Psychiatric and mental health nursing

For specific information about these professionals in the United States, see Psychiatric and mental health Nurse Practitioner

Psychiatric nursing or mental health nursing is the specialty of nursing that cares for people of all ages with mental illness or mental distress, such as psychosis, depression or dementia. Nurses in this area receive additional training in psychological therapies, building a therapeutic alliance, dealing with challenging behavior, and the administration of psychiatric medication.

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Therapeutic relationship

Main article: Therapeutic relationship

As with other areas of nursing practice, psychiatric mental health nursing works within nursing models, utilising nursing care plans, and seeks to care for the whole person. However, the emphasis of mental health nursing is on the development of a therapeutic relationship or alliance.^[1] In practice, this means that the nurse should seek to engage with the person in care in a positive and collaborative manner that empowers them to draw on their inner resources in addition to any other treatment they may be receiving.^[1]

Development of the therapeutic relationship can be challenging, not just due to the nature of the person's mental illness or distress, but also because the person may be detained in a psychiatric hospital and be receiving treatment against their will under mental health law. It also requires a level of self-awareness on the part of the nurse to help understand and properly utilise the relationship.

Interventions

Nursing interventions may be divided into the following categories:

Physical and biological interventions

Psychiatric medication

Psychiatric medication is a commonly used intervention and many psychiatric mental health nurses are involved in the administration of medicines, both in oral (tablet) form or by intramuscular injection. Nurses will monitor for side effects and response to these medical treatments by using assessments. Nurses will also offer information on medication so that, where possible, the person in care can make an informed choice, using the best evidence available.

Electroconvulsive therapy

Psychiatric mental health nurses are also involved in the administration of the treatment of electroconvulsive therapy and assist with the preparation and recovery from the treatment, which involves an anesthesia. This treatment is only used in a tiny proportion of cases and only after all other possible treatments have been exhausted.

Physical care

Along with other nurses, psychiatric mental health nurses will intervene in areas of physical need to ensure that people have acceptable levels of personal hygiene, nutrition, sleep etc as well as tending to any concomitant physical ailments.

Psychosocial interventions

Psychosocial interventions are increasingly delivered by nurses in mental health settings and include psychotherapy interventions such as cognitive behavioural therapy, family therapy and less commonly other interventions such as milieu therapy or psychodynamic approaches. These intervention can be applied to broad range of problems including psychosis, depression and anxiety. Nurses will work with people over a period of time and use psychological methods to teach the person psychological techniques that they can then use to aid recovery and help manage any future crisis in their mental health. In practice, these interventions will be used often, in conjunction with psychiatric medications. Psychosocial interventions are based on evidence based practice and therefore the techniques tend to follow set guidelines based upon what has been demonstrated to be effective by nursing research. There has been some criticism^[2] that evidence based practice is focused primarily on quantitative research and should reflect also a more qualitative research approach that seeks to understand the meaning of people's experience.

Spiritual interventions

The basis of this approach is to look at mental illness or distress from the perspective of a spiritual crisis. Spiritual interventions focus on developing a sense of meaning, purpose and hope for the person in their current life experience.^[3] Spiritual interventions involve listening to the person's story and facilitating the person to connect to God, a greater power or greater whole, perhaps by using meditation or prayer. This may be a religious or non-religious experience depending on the individual's own spirituality. Spiritual interventions, along with psychosocial interventions, emphasise the importance of engagement, however, spiritual interventions focus more on caring and 'being with' the person during their time of crisis, rather than intervening and trying and 'fix' the problem. Spiritual interventions tend to be based on qualitative research and shares some similarities with the humanistic approach to psychotherapy.

Organization of mental health care

Psychiatric mental health nurses work in a variety of hospital and community settings.

• People generally require an admission to hospital, voluntarily or involuntarily if they are experiencing a crisis that means they are dangerous to themselves or others in some immediate way. However, people may gain admission for a concentrated period of therapy or for respite. Despite changes in mental health policy in many countries that have closed psychiatric hospitals, many nurses continue work in hospitals though patient length of stay has decreased significantly.

• Community nurses in mental health, work with people in their own homes (care in the community) and will often emphasise work on mental health promotion. Psychiatric mental health nurses also work in rehabilitation settings where people are recovering from a crisis episode and the where the aim is social inclusion and a return to living independently in society.

• Psychiatric mental health nurses also work in forensic psychiatry with people who are detained as they have committed a crime or are particularly dangerous.

• People in the older age group who are more prone to dementia tend to be cared for in separate places than younger adults and there are also specialist services for the care of adolescents with mental health problems. Occasionally there have been efforts to integrate psychiatric units across the age spectrum.

UK, US, and Canada

In the UK, the term psychiatric nurse has now largely been replaced with mental health nurse.

In the UK, mental health nurses undergo a 3-4 year training programme at either diploma or degree level, in common with other nurses. However, most of their training is specific to caring for clients with mental health issues.

In North America, there are three levels of psychiatric nursing.

• The licensed vocational nurse (licensed practical nurse in some states) and the licensed psychiatric technician may dispense medication and assist with data collection regarding psychiatric and mental health clients.

• The registered nurse or registered psychiatric nurse has the additional scope of performing assessments and may provide other therapies such as counseling and milieu therapy.

• In Canada the Registered Psychiatric Nurse is a distinct nursing professional in one of the four western provinces (with some practising elsewhere by special mandate). Such nurses carry the designation "RPN" (note: in Ontario this designation refers to a practical nurse and should not be confused with a registered psychiatric nurse). In addition to various mental health therapies RPNs also provide physical nursing care similar to registered nurses.

• The advanced practice psychiatric registered nurse is prepared at the masters or doctoral degree level and functions as a clinical specialist and/or psychiatric nurse practitioner encompassing all of these and may additionally include prescribing medication and providing psychiatric diagnosis (under direct supervision by a physician).

Mental health nurses may work in inpatient settings or in the community as community psychiatric nurses (the term psychiatric has been retainedbut is being gradually replaced with the title "Community Mental Health Nurse" or CMHN)). They may also specialise in areas such as drug and alcohol rehabilitation, or child and adolescent mental health.

Further levels of practice in US

The clinical practice of psychiatric-mental health nursing occurs at two levels: basic and advanced. At the basic level, registered nurses work with individuals, families, groups and communities, assessing mental health needs, developing a nursing diagnosis and a plan of nursing care, implementing the plan and finally evaluating the nursing care. Basic level nursing practice is characterized by interventions that promote and foster health and mental health, assist clients to regain or improve their coping skills or abilities, and prevent further disability.

In working with psychiatric clients or patients, basic level nurses assist them with self care, administer and monitor biopsychosocial treatment regimens, teach about health and mental health individually or in groups, including psycho-education. Basic level nurses are also prepared to assist with crisis intervention, counseling and work as case managers.

Advanced practice registered nurses (APRN) have a Master’s degree in psychiatric-mental health nursing and assume the role of either clinical nurse specialist or nurse practitioner. Psychiatric-mental health nursing (PMHN) is considered a specialty in nursing. Specialty practice is part of the course work in a Master’s degree program. In addition to the functions performed at the basic level, APRN’s assess, diagnose, and treat individuals or families with psychiatric problems/disorders or the potential for such disorders. They provide a full range of primary mental health care services to individuals, families, groups and communities, function as psychotherapists, educators, consultants, advanced case managers, and administrators. In many states, APRN’s have the authority to prescribe medications. Qualified to practice independently, psychiatric-mental health APRN’s offer direct care services in a variety of settings: mental health centers, community mental health programs, homes, offices, HMOs, etc.

Because of their broad background in both the biological, including pharmacological, sciences as well as the behavioral sciences, APRNs in PMHN are a rich resource as providers of psychiatric-mental health services and are advocates of and partners with the consumers of their services.

Psychiatric nurses who earn doctoral degrees (PhD, DNSc, EdD) often are found in practice settings, teaching, doing research, or as administrators in hospitals, agencies or schools of nursing.

See also

• Psychiatric and mental health Nurse Practitioner
• Mental health professional
• List of counseling topics
• Hildegard Peplau - psychiatric nurse theorist
• Tidal Model - model developed for mental health nursing
• Bob the Psychiatric Nurse comprehensive site offering links to websites on mental health and mental health nursing.

Notes and references

• Boyd, M.A.; Nihart, M.A. (eds.) (1998). Psychiatric Nursing: Contemporary practice. Philadelphia: Lippincott. ISBN 0-397-55178-9.