Learning Objectives
By the end of this section, you will be able to:
- Understand the holistic approach to mental health care
- Describe the physical needs of the mental health client in a community environment
- Understand the social-emotional needs of the mental health client in a community environment
The specific needs of mental health clients will vary depending on their diagnosis, treatment plan, and individual circumstances. Nursing is a holistic discipline that treats mental health from a whole person perspective; nurses should consider the physical, emotional, and spiritual aspects of the person when developing a community care treatment plan. Personalized care and ongoing assessment are crucial to meet the unique physical and social-emotional needs of each client in a community setting.
Understanding the Holistic Approach to Mental Health Care in the Community
The holistic approach is person-centered and considers all the determinants of health, such as economic stability, access to health care, education and spiritual expression, safe neighborhoods, and social networks in the community. Holistic care is integrated, combining resources for physical and psychosocial needs, and approaching the whole person, not simply the diagnostic category. Collaboration between the person and the health-care team can address symptom management as well as individualized outcomes of care.
Mental health conditions can impact physical health, manifesting as poor nutrition, increased risk of comorbidities, and medication side effects. Basic physical needs, such as food and housing, must be addressed as part of any effective mental health-care plan. Physical needs also include transportation and work accommodations.
Similarly, physical health issues can affect mental health, causing anxiety, depression, stress, and fear. Additionally, mental health clients may struggle to express their emotions and communicate their needs effectively, which can lead to feelings of frustration and isolation.
Socialization and interpersonal relationships in the community provide a sense of connection, support, and purpose, which can positively impact mental health outcomes. Social support can enhance a sense of belonging, reduce feelings of isolation, improve overall health, and provide opportunities for skill building, engagement, and personal growth.
Clinical Judgment Measurement Model
Using the CJMM to Create a Nursing Plan of Care
Davis, BSN RN, is working with Beatrice A., eighty-two years old, who was hospitalized after a fall with no fractures. Her discharge is planned in the next twenty-four hours. Davis reviews the electronic health record (EHR) and learns that Beatrice experiences orthostatic hypotension, consumes approximately one-half of her diet each day, is continent of bowel and bladder. Medications include lisinopril, metformin, omeprazole, simvastatin. Beatrice has health insurance through Medicare with a supplemental policy. She is financially secure with a retirement income.
During interdisciplinary rounds, the physical therapy staff has reported Beatrice remains at risk for falls due to low vision and weakened physical strength and recommends discharge to short-term rehab. The social services representative reports that Beatrice was hospitalized last year after a motor vehicle accident and refused rehab at that time, not wanting to leave her home. Beatrice lives alone in her own apartment, attends weekly church with a neighbor, and has her groceries delivered. She no longer drives a car, has no history of substance use, and watches television programs two to four hours each day.
Davis meets with Beatrice to discuss the discharge plan. Davis knows that the local community has the following services available:
- ambulatory care programs
- support groups, mental health clinics
- home visiting services, medication management
- partial hospitalization or day treatment
- personal-care assistance, case management and services coordination
- transportation services
- telehealth
Davis follows the CJMM steps and involves the client throughout the process.
| Step | Nursing Plan of Care |
|---|---|
| Recognizing Cues | Objective data: wears hearing aids and eyeglasses; seated in a chair by the window; wearing hospital gown, slippers, and a sweater; hair is combed Subjective data: acknowledges the nurse’s greeting appropriately and agrees to talk Primary data: client verifies the information the nurse relates about her living situation, medications, and insurance coverage; client states “Yes, I had a fall. I know I get up too fast,” “I don’t check my blood sugar, I don’t have that kind of diabetes,” “I have been alone since my sister died two years ago, sometimes I wish I had someone to talk to. I still have her computer, but I don’t how to use it.” Secondary data: reports from interdisciplinary rounds and nurse’s review of electronic health record (EHR) |
| Analyzing Cues | Objective data: sensory impairment; capable of, or amenable to, hygiene and grooming Subjective data: alert and oriented, social awareness Primary data: orthostasis, diabetes, loneliness, potential learning need Secondary data: identified fall risk, past reluctance for rehab, medication list—any side effects, reduced nutritional intake |
| Prioritizing Hypotheses |
|
| Generating Solutions | Review with client slow position change to prevent orthostatic changes in blood pressure. Review lower extremity exercises taught by physical therapy staff. Share with client available resources in the community, such as transportation services, in-home physical therapy, nursing care, medication monitoring and nutrition services, socialization opportunities and education, specifically computer training, potentially for telehealth. |
| Taking Actions | Present client with a list of community services and case management/care coordination. Answer questions, set meeting time for tomorrow to discuss client’s choices and make arrangements. |
| Evaluating Outcomes | On discharge day, review plan with client, clarify as needed, share contact information for follow-up. |
Physical Needs of Mental Health Clients in the Community
In one sense, the physical needs of the mental health client are the same as those of anyone: to have secure housing, food, transportation, and potential work accommodations. But mental health clients seeking treatment in community or community environments may encounter stigma, and they have specific needs that involve how they seek and access treatment, and how well they are able to continue their treatment. In essence, this means, for instance, that accessible public transportation is, in part, a mental health issue. There are also a number of comorbidities that can appear alongside many mental health illnesses; depression, for example, often accompanies substance use disorder and physical illnesses like cancer, and is a significant and leading cause of disability in adults of all ethnicities (Khodyakov et al., 2018).
Health and Medical Care
Mental health clients have been shown to have a higher incidence of certain medical issues than the general population. Take cardiovascular disease, for example. Mood disorders, anxiety disorders, post-traumatic stress disorder (PTSD), and chronic stress are among those most studied in relation to cardiovascular disease; however, other behavioral health disorders, including substance misuse, may be related to cardiovascular disease as well (CDC, 2020). This correlation means that a client with a mental illness, such as depression, anxiety, and PTSD, may be more likely to experience a stroke, heart failure, or myocardial infarction. Physical manifestations may be found across the life span and are not necessarily specific to a particular age group. This is especially true of depression. Research has found that clients with depression may experience increased inflammation, changes in heart rate control and blood circulation, stress hormone abnormalities, and metabolic changes. These changes may lead to cardiovascular disease, pain, stroke, diabetes, and even Alzheimer’s disease (National Institute on Mental Health [NIMH], 2021). Research has revealed that women, veterans, people with PTSD, and racial or ethnic minorities have higher rates of heart disease that are related to mental health conditions (Gross et al., 2022).
Health-care providers can support these clients by working as multidisciplinary teams, providing resources to mental health clients on risks, or using electronic health records to coordinate the care the client needs. Clients should look for physical signs and symptoms of heart disease, determine any family history or genetic predisposition, and try to keep a healthy lifestyle. This last point is of particular importance; an unhealthy routine, as a result of anxiety or depression, can lead to smoking, being sedentary, or not taking necessary medications as they should be taken. Unfortunately, medications used to treat mental health illnesses may have undesirable side effects such as “obesity, insulin resistance, diabetes, heart attacks (myocardial infarctions), atrial fibrillation, stroke … death,” sexual side effects, and hyperglycemia (U.S. Department of Health and Human Services, 2022b), making compliance even more difficult for some mental health clients.
Clients with mental health disorders sometimes experience difficulties with basic physiological and safety needs that increase the challenge to maintain their overall well-being. For example, clients with mental health illnesses may also experience food insecurity, which is limited or inconsistent access to the amount of food required to live a healthy lifestyle. Food insecurity has strong physical and emotional effects on an individual and can have serious negative effects on mental health. Those who have a mental health illness are at increased risk for food insecurity and may have to choose between food or treatment for their mental health (NAMI, 2023d). Clients across the life span may qualify for Supplemental Nutrition Assistance Program (SNAP), and those who are pregnant or with children age five or younger may also qualify for the Women, Infants, and Children (WIC) program. NAMI states that “it is critical to address food insecurity and related social determinants of health to allow people with mental health conditions to focus on getting and staying well” (NAMI, 2023d, para 13).
Link to Learning
The federal government website ChildCare.gov provides more information on government financial assistance and benefits for families.
Housing
Housing instability or neighborhood violence can affect clients across the life span, and potentially influence the physical health and safety of a client. According to NAMI, a significant barrier to recovery from mental illness is the lack of stable and/or affordable housing; if this need is not met, then the mental health client can end up unhoused, in jail, in a shelter, or back in the hospital (NAMI, 2023d). Therefore, a client may need assistance with housing upon discharge from a hospital. According to the National Alliance to End Homelessness, more than one in ten people who seek substance misuse or mental health treatment in the public health system are homeless (2023). It is important to collaborate with the client to determine the appropriate type of housing that the client may need to support recovery. One option is group housing, a type of small-scale living facility that, in addition to housing, provides support, supervision, and other types of assistance. Group housing can be supervised or partially supervised. Other options in the community can include supportive housing, rental housing, or home ownership. Supervised group housing can provide mental health clients with a higher level of care, but still allow the independence of living in the community. This type of housing may assist the client with meals, medications, activities of daily living, paying bills, transportation, and treatment. Partially supervised group housing allows for more independence, but gives the mental health client access to help if needed; supportive housing combines living space with services.
Link to Learning
Nurses and clients can find more information on government financial assistance and benefits at the federal government’s benefits site.
The client may also need support in obtaining the finances for housing. Often clients with serious mental illnesses are living on Supplemental Security Income (SSI), and may not be able to afford sufficient housing. A client with a mental health illness may qualify for Section 8, which provides vouchers to low-income individuals and families, or Section 811, the Supportive Housing for People with Disabilities Program, for which a client with a chronic mental health illness may qualify. Be mindful of the fact that many housing options have age and/or income qualifications.
Work Accommodations and Transportation
Clients with mental health disorders may also need employment or work accommodations. These clients need to be informed of their rights regarding discrimination under the Americans with Disabilities Act and/or the Rehabilitation Act of 1973. Under these laws, clients who qualify may request an extended leave of absence, flexible work/break schedules or start times, work/break environment with reduced distractions or noise, telework, regular feedback, written directions and/or task lists, and/or use of a job coach. While these accommodations can be requested and granted, stigma remains a significant concern in the workplace, and it often prevents employers from considering options and exceptions that assist individuals to maintain employment.
There are several community resources for workers with mental health-related disabilities. Disability-specific nonprofit organizations specialize in supporting individuals with job placement services, support groups, and training programs. Job training programs can provide training in skills that are in demand in the job market, such as computer skills or customer service skills. Disability employment services are often offered through state or local government agencies and can provide job placement services, vocational training, and other types of support for individuals with disabilities. Additionally, there are disability-friendly employers who specifically seek out individuals with disabilities for employment opportunities. These employers are committed to expanding their applicant pool toward a diverse workplace and have accommodations in place for individuals with mental health-related disabilities.
Transportation, or the lack thereof, can be a significant barrier to mental health treatment or services. Clients with mental health illnesses may require the support of another person to drive them to appointments or to pick up medications, while others may be too anxious to drive themselves. Sometimes, a client cannot get to the treatment location or to the pharmacy for medications. Depending on where the client lives, public transportation may or may not be an option. Even when public transportation is an option, the client may not be able to afford the transportation. Being familiar with other options within the community allows the nurse to help clients resolve transportation barriers.
Social and Emotional Needs of Mental Health Clients in the Community
When seeking mental health care in the community, clients will have a range of social and emotional needs. Social and emotional support is a crucial aspect of mental health care, particularly for clients in the community. Mental health-care clients can face stigma, discrimination, and isolation, which contribute to feelings of loneliness, anxiety, and depression. Social and emotional support help to alleviate these negative emotions and improve the client’s mental well-being.
The purpose of emotional support is to help clients to feel less isolated and stigmatized, and provide them with a sense of belonging and connectedness (U.S. Department of Health and Human Services, 2022c). Emotional support helps clients to feel valued and appreciated, which can boost their self-esteem and self-confidence. It can also help clients to stay motivated and engaged in their treatment, which can reduce their risk of relapse (SAMHSA, 2013). Local and online peer support groups can offer emotional support to clients, as can public or private counseling services. Family and friends can be an important source of emotional support for individuals with mental health issues. They can provide a listening ear, offer encouragement and support, and help individuals access resources and services that can support their mental health.
Clients may require support in developing coping skills to deal with some of the emotional challenges of their mental health condition. Meditation and mindfulness workshops and seminars can provide clients with techniques to help manage emotional distress. Therapists or support groups can offer other relaxation techniques, problem-solving strategies, or communication skills. Participating in community activities, such as volunteer work, sports, or hobbies, can help clients feel more connected, reduce stress, and provide a sense of purpose.
Some clients may need additional emotional support in the form of developing specific skills to regulate their emotions. Emotional regulation skills are important for mental health clients because they can help reduce stress and improve overall function in the community. The ability to recognize, understand, and regulate one’s emotions in a healthy and adaptive way is considered emotional regulation. Good emotional regulation leads to increased self-awareness, improved coping skills, better decision-making, improved relationships, and reduced risk of relapse. In addition to therapy and support groups, clients can also self-educate by finding resources on emotional regulation online or at their local library.
The concept of empowerment is central to good mental health. Empowerment can motivate clients to take an active role in their treatment and recovery. The World Health Organization considers empowerment to refer to “the level of choice, influence and control that users of mental health services can exercise over events in their lives” (Baumann, 2011, para 1). Empowerment means giving individuals the tools, resources, and support they need to make decisions, take action, and create positive change in their lives. Empowerment is essential for mental health clients in the community because it allows them to take control of their lives and regain a sense of agency and self-determination. Here are a few reasons why empowerment is important for mental health clients:
- Increased self-efficacy: This can help them feel more confident and capable of managing their mental health challenges, and can lead to improved mental health outcomes.
- Increased engagement: When people feel empowered, they are more likely to engage in their treatment and take an active role in managing their mental health.
- Increased sense of control: Empowerment can help people regain a sense of control and agency, which can lead to increased feelings of autonomy, independence, and self-esteem.
- Reduced stigma: Empowerment can help reduce the stigma surrounding mental health by encouraging people to speak up and advocate for themselves. This can lead to increased awareness, understanding, and acceptance of mental health issues in the community.
For mental health-care clients, it can also be critical in supporting recovery and wellness for them to feel a sense of social belonging, which is the feeling of being connected to and valued by others. This connection can come from a variety of sources, including family, friends, peers, and community groups. When individuals feel like they belong, they are more likely to experience positive emotions, have a sense of purpose, and feel supported in times of stress or challenge. A sense of social belonging can help combat isolation and loneliness, improve self-esteem, and increase motivation. A sense of social belonging can also provide emotional support, practical assistance, and advice or guidance from others in the community who have shared similar experiences (U.S. Department of Health and Human Services, 2021a). Community resources, such as social clubs, art classes, sports teams, or other activities, can provide opportunities for clients to connect with others and engage in activities they enjoy. By providing a supportive, nonjudgmental, and empowering environment, mental health professionals can help clients develop the skills and resources they need to manage their condition and lead fulfilling lives.
Link to Learning
Mental health clients need to be surrounded by a safety net of support in the community. One such resource is suicide risk assessment standards, which connects callers with the National Suicide Prevention Lifeline.