1.1 Mental Health and Mental Illness

Psychiatric-Mental Health

The promotion, protection, and restoration of mental health is a vital concern of individuals, nurses, communities, and societies throughout the world (Figure 1.2).

Figure 1.2 Mental health and mental illness exist on a continuum. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Mental health fluctuates over the course of an individual’s life span and can range from well-being to emotional problems and/or mental illness, as indicated on the mental health continuum. Well-being is on the “healthy” range of the mental health continuum, where individuals are experiencing a state of good mental and emotional health. They may experience stress and discomfort resulting from occasional problems of everyday life, but they are able to cope effectively with the stressors and experience no impairments to daily functioning.

Psychiatric-Mental Illness

Mental illness is common in the United States. Nearly one in five (19 percent) of adults experience some form of mental illness, one in twelve (8.5 percent) have a substance use disorder, and one in twenty-four (4 percent) have a serious mental illness (American Psychiatric Association, 2022). Poor mental health increases the risk of chronic physical illnesses, such as heart disease, cancer, and strokes, and can lead to thoughts and intentions of suicide. Suicide is a common symptom associated with mental illness and is the second leading cause of death in Americans aged fifteen to thirty-four (Centers for Disease Control and Prevention, 2021a).

Emotional problems become classified as mental illness when an individual’s level of distress becomes significant, and they have moderate to severe impairment in daily functioning at work, school, or home. Mental illness includes relatively common disorders, such as depression and anxiety, as well as less common disorders, such as schizophrenia. Mental illness is characterized by alterations in thinking, mood, or behavior. The term serious mental illness refers to that which causes disabling functional impairment that substantially interferes with one or more major life activities.

History of Psychiatric Nursing

In the late 1800s, Edward Cowles, a physician at McLean Asylum in Massachusetts, began the first program to train nurses to care for psychiatric clients (APNA, 2022). Prior to that, the caregivers were called “keepers” (p. 8). In the early 1900s, Effie Jane Taylor at Johns Hopkins Hospital organized the first nurse-taught course to train psychiatric nurses. Before that time, physicians trained nurses. The first psychiatric nursing textbook was published in 1920 (p. 8). World War II expanded the need for psychiatric nurses as veterans returned from war with combat-related mental health problems.

It was in the 1950s that Hildegard Peplau rose to prominence as the “mother of psychiatric nursing” with her development of the theory of interpersonal relations, a theory and model of the therapeutic nurse-client relationship that focused on the “therapeutic use of self in promoting the well-being of individuals, families, groups, and communities” (Haber, 2000, p. 56) (Figure 1.3). Her theory not only helped nurses to become self-aware in their therapeutic relationships, but also assisted clients to build autonomy in problem-solving due to the support they received from the nurse while moving forward toward better mental health. Peplau’s mission was to redefine the scope of work of the psychiatric nurse as a collaborative part of the health-care team and not just as the physician’s “handmaiden” (p. 57).

Figure 1.3 Hildegard Peplau’s model for the therapeutic nurse-client relationship shows what the nurse and the client bring to the therapeutic relationship. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Current Scope of Psychiatric Nursing Practice

All nursing practice is based on theory and a caring philosophy toward the provision of holistic care. Psychiatric-mental health nursing is a specialty practice focused on the client’s psychological and emotional responses, level of risk, and coping abilities. The client’s recovery is the goal, with individualized care as the process. The therapeutic nurse-client relationship is key to this process.

Mental health nursing takes place across settings, in the emergency room, in the community, in schools, in jails, in medical offices, in person, and through telehealth. Psychiatric nurses not only assess and provide care for the client’s health-care needs, but are also involved in education, administration, and research (APNA, 2023, p. 40). When evaluating a client’s mental health, the nurse uses a variety of assessments in addition to the traditional physical examination:

• performing a mental status examination
• completing a psychosocial assessment
• reviewing the client’s use of psychotropic medications (drugs that treat psychiatric symptoms) and/or other medications that can cause psychiatric symptoms as side effects
• screening for suicidal ideation, exposure to trauma or violence, and substance misuse
• incorporating a spiritual assessment while assessing the client’s coping status
• incorporating life span, developmental, and cultural considerations
• reviewing specific laboratory results related to the client’s use of psychotropic and other medications

Nursing assessments related to mental health disorders differ from physiological assessments because they have a greater focus on collecting subjective data: information provided by the client from the client’s point of view or a description of their experience. For example, prior to administering a cardiac medication to a client with a heart condition, a nurse will assess objective data, such as blood pressure and an apical heart rate, to determine the effectiveness of the medication treatment.

Prior to administering an antidepressant, however, a nurse uses therapeutic communication to ask questions and gather subjective data about how the client is feeling in order to determine the effectiveness of the medication. The nurse will also observe client behaviors, speech, mood, and thought processes as part of the assessment. Nurses cannot directly measure a neurotransmitter to determine the effects of an antidepressant, for instance, but they can ask questions to determine how the client is feeling emotionally and perceiving the world, two factors influenced by neurotransmitter levels. An example of a nurse using therapeutic communication to perform subjective assessment is, “Tell me more about how you are feeling today.” The nurse may also use general survey techniques, such as simply observing the client, to assess for cues of behavior. Examples of data collected by a general survey could be evaluating the client’s mood, hygiene, appearance, or movement.

Nurses in any setting holistically observe and process their clients’ physical, emotional, and mental health, as well as any impairments affecting their functioning. They must recognize subtle cues of undiagnosed or poorly managed physical and mental disorders and follow up appropriately with other members of the interprofessional health-care team (Figure 1.4).

Figure 1.4 The QSEN model includes six competencies, along with knowledge, skills, and attitudes (KSAs) for each competency. (credit: "Core Competency Framework for Undergraduate Nursing Student" by Dena Attallah and Abd Alhadi Hasan/Nursing Reports, CC BY)