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Psychiatric-Mental Health Nursing

1.1 Mental Health and Mental Illness

Psychiatric-Mental Health Nursing1.1 Mental Health and Mental Illness

Learning Objectives

By the end of this section, you will be able to:

  • Compare and contrast psychiatric-mental health to psychiatric-mental illness
  • List standard nursing practices in psychiatric mental health

It is important for nurses to understand the line between mental health and mental illness. The human body has physical and psychological responses to stress that psychiatric-mental health nurses are trained to observe in their clients. The nurse’s role is to assess, plan, implement, and evaluate, all while collaborating with the client. Collaboration between the nurse and the client is an essential part of the mental health-care nursing process.

Psychiatric-Mental Health versus Psychiatric-Mental Illness

The term mental health refers to a state of well-being in which individuals realize their own abilities, cope with the normal stresses of life, work productively, and contribute to their community. Mental health is an essential component of overall health. The World Health Organization (WHO) defines overall health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Conversely, according to the American Psychiatric Association, mental illness is a health condition involving changes in emotion, thinking, or behavior (or a combination of these) associated with emotional distress and problems functioning in social, work, or family activities (American Psychiatric Association, n.d.).

It is important that “health services . . . devote as much attention to mental health as they do to physical health care” (Happell et al., 2021, p. 560). The World Health Organization’s slogan agrees: “There is no health without mental health.” Yet attitudes toward choosing mental health nursing as a specialty are ambivalent. Nurses should receive education that reduces stigma surrounding mental health and its treatment, increases their knowledge about mental health/illness, and exposes them to caring for clients with mental health problems in all nursing settings.

As a note, medical orientation to mental health treatment may refer to recipients of care as patients where the person is receiving acute treatment or assistance from a medical provider. Client is more often used in the community setting in which a person is in a collaborative solution-based relationship with a therapist (Spector, 2016). In the 1990s, nurses began to use the term client more regularly in an effort to show that the person was working in collaboration with their health-care team (American Psychiatric Nurses Association [APNA], 2022). This text will, for the most part, use the word client.

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).

A color graph showing a continuum from Mental Health (left) to Mental Illness (right). From left to right the text includes "Occasional, mild stressors with adequate coping ability," "Mild to moderate stressors with occasional or temporary challenges to coping," and "Moderate to extreme stressors with disabling or chronic inability to cope."
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.

Psychosocial Considerations

Stress and Physical Response

The body’s response to stress, often called the fight-or-flight response, can initiate both physical and psychological symptoms. The fight-or-flight response is triggered when a stressful situation puts hormones into overdrive. Even if the stress is not life-threatening, this response has evolved over the years as a survival mechanism against situations deemed dangerous (Harvard Health Publishing, 2020). This response can entail a person sweating, enduring chest pain, panic, stomach upset, headache, and an overall sense of doom. Chronic stress can lead to high blood pressure, insomnia, anxiety, depression, poor appetite or overeating, and substance use. Stress, of course, does not equal mental illness.

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.

Standards of Psychiatric-Mental Health Nursing Practice

The American Psychiatric Nurses Association (APNA), the International Society of Psychiatric-Mental Health Nurses (ISPN), and the American Nurses Association (ANA) have established standards of care for psychiatric-mental health nursing practice. These standards include that individuals with mental health and substance use conditions should be treated with respect and dignity in a culturally appropriate manner. Health-care professionals should consider the preferences of people with mental health and substance use disorders and support them, their family members, and their loved ones in an inclusive manner.

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).

A graphic showing the Hildegard Peplau model for the therapeutic nurse-patient relationship. The graphic shows two overlapping boxes. In the first box are the nurse contributions. These include: values, culture race, beliefs, past experiences, expectations, preconceived ideas. In the second box are the patient contributions. The include: values, culture race, beliefs, past experiences, expectations. At the overlapping area is text that reads: "Nurse-Patient Relationship."
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)

Clinical Judgment Measurement Model

What Is the Clinical Judgment Measurement Model (CJMM)?

Designed by the National Council of State Boards of Nursing (NCSBN), the CJMM measures a nursing licensure candidate’s ability to exercise sound clinical judgment and decision-making. Grounded in the nursing process, the CJMM includes six components: (1) recognize cues, (2) analyze cues, (3) prioritize hypotheses, (4) generate solutions, (5) take actions, and (6) evaluate outcomes. Built in layers, the CJMM provides a framework for thought processes and actions to take in exercising clinical judgment in a nursing scenario.

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).

A graphic showing the QSEN model. The graphic is made up of seven circle icons within a larger circular pattern. At the center of the graphic is a circle icon with the label "person-centered care." The other six circle icons are arranged in a circle surrounding this center icon. They are organized into pairs with a category for each pair. Under the category of "Knowledge" is the icon of "Quality Care and Patient Safety" flowing to "Evidence-Based Practice." The knowledge pair flows into the next pair with the category "Skills." The Skills pair has "Professionalism and Leadership" flowing to "Communication and Teamwork." The "Skills" category then flows into the "Attitudes" category. In this portion there is "Informatics and Technology" flowing into "System-Based Practice." The "Attitudes" category then flows back into the "Knowledge" category.
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)

Clinical Safety and Procedures (QSEN)

Competency: Description of QSEN Competencies

The references to Quality and Safety Education for Nurses (QSEN) competencies throughout this text refer to the educational repository created through funding by the Robert Wood Johnson Foundation to provide evidence-based teaching resources for nursing curricula. This was in response to the Institute of Medicine’s call to improve the quality of healthcare in its report on healthcare safety in 1999. QSEN competencies are aligned with concepts that can be expected to be tested on the NCLEX Next Gen, and with concepts presented in National Patient Safety Goals published annually by the Joint Commission.

The overall goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health-care systems within which they work. QSEN helps nurses to identify and bridge the gaps between nursing school and nursing practice. QSEN includes six core QSEN competencies, KSAs, teaching strategies, and faculty development resources. The competencies arose after the Institute of Medicine (IOM) released a report in 2000 that highlighted the need for health-care system redesign. The six QSEN competencies are:

  • patient-centered care
  • teamwork and collaboration
  • evidence-based practice (EBP)
  • quality improvement (QI)
  • safety
  • informatics

These competencies align with both the components of the NCLEX and the Joint Commission 2024 Behavioral Health Care National Patient Safety Goals (Table 1.1). The QSEN Competency of EBP aligns with the NCLEX Integrated Process of clinical judgment.

QSEN Competencies Components of NCLEX Test Plan 2023, Client Needs The Joint Commission
2024 Behavioral Health Care National Patient Safety Goals
Quality improvement (QI)
Safe and Effective Care Environment
Management of Care
Safety and Infection Control
Reduction of Risk Potential
Identify individuals served correctly
Use medicines safely
Prevent infection
Patient-centered care
Teamwork and collaboration
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Adaptation
Identify individuals served safety risks
Improve health care equity
Table 1.1 QSEN Competencies (Sources: Ferro & Yoder, 2023; Joint Commission, 2024; QSEN Institute, 2022; Stanley et al., 2023)

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