Professional Documents
Culture Documents
Mental Health
o State of well-being
o Able to recognize own potential
o Cope with normal stress
o Work productively
o Make a contribution to community
o Ability to
Think rationally
Communicate appropriately
Learn
Grow emotionally
Be resilient
Have a healthy self-esteem
Realistic goals and reasonable function within the individual’s role
Mental Illness
o Disorders with a definable diagnosis
DSM-5
o Culturally defined
o Significant dysfunction in mental functioning
o Causes
Developmental
Intellectual disability
Autism
Biological
Prenatal exposure to alcohol
Oxygen deprivation at birth
Psychological Disturbances
Bipolar disorders
Schizophrenia
o Continuum
Everyone falls somewhere on the spectrum
Sections
Well-Being
Emotional Problems or Concerns
o Temporary
o Mild-to-moderate distress
o Minor or temporary impairment
Mental Illness
o Chronic
o Marked distress
o Moderate-to-disabling or chronic impairment
o Causes serious dysfunction in daily life
Recovery
o Process of change
o Improvement of health and wellbeing
o Living a self-directed life
o Striving to reach full potential
Influencing Factors
o Individual
Management of thoughts and feelings
Ability to navigate life
Management of everyday stress and pressures
Responses to social cues
Participation in social activities
Resilience
Ability and capacity to secure resources needed to support
wellbeing
Characterized by
o Optimism
o Sense of mastery
o Competence
Essential to recovery
Resilient people are effective are regulating their emotions and not
falling victim to negative thoughts
o Social and Economic Circumstances
Family
Can promote confidence and coping skills
Can instill anxiety and feelings of inadequacy
School and Peer Groups
Socioeconomic Status
Dictates access to resources
Basic needs
Educational advancement
o Environmental Factors
Policies
Insurance
o Mental health coverage is slim
o Low reimbursement
Healthcare Systems
Lack of Mental Health Resources and Providers
Culture
Ex. Scientology denies mental illness
Diathesis-Stress Model
o Most accepted explanation for mental illness
o Diathesis
Biological predisposition
o Stress
Environmental stress or trauma
o Combination of genetic vulnerability and negative environmental stressors
o Most psychiatric disorders result from a combination of genetic vulnerability and
negative environmental stressors
DSM-5
o Official medical guidelines of the APA for diagnostic psychiatric disorders
o Identifies disorders based on specific criteria
Influenced by multi-professional clinical field trials
Psychiatric Mental Health Nurses
o Promote mental health through assessment, diagnosis, and treatment of behavioral
and mental disorders
o Assist people in crisis, those experiencing life problems, and those with long-term
mental illness
o Work with people throughout the lifespan
o Employed in a variety of settings and among varied populations
o Levels of Practice
Basic
Psychiatric Mental Health RN (PMH-RN)
2 years full-time work, 2000 clinical hours, 30 hours CE, and a
certification exam for the BC title
Advanced Practice
Psychiatric Mental Health Advanced Practice RN (PMH-APRN)
Requires a MSN or DNP
Treatment Settings
Outpatient Care
o Primary Care Providers
Often the first point of contact
Treat uncomplicated psychiatric problems
Mild depression
Anxiety
Sleep problems
Most people do not venture beyond this level of care
More comfortable
Familiar setting
Decreased stigma
Disadvantages
Time constraints
o 15-minute appointments are inadequate for a mental health
assessment
Limited training in psychiatry
Lack of expertise in diagnosis and treatment of psychiatric
disorders
o Oftentimes refer patients to specialty mental health care
o Specialized Psychiatric Care Providers
Educational background and experience in psychiatric problems and
mental health
Types of Providers
Psychiatrists
o Can diagnose and prescribe medicine
PMH-NP
o Can diagnose and prescribe medicine
Psychologists
Social Workers
Counselors and Therapists
All providers are educated to use psychotherapy (talk therapy) and lead
group therapy
Many providers have sub-specialties
PTSD
Child and Adolescent Care
Homeless Care
o Patient-Centered Health/Medical Homes
Provides access to physical, behavioral, and community health, as well as
social services
Comprehensive care
All levels (preventative, acute, and chronic) of mental and physical
care are addressed
Developed in response to fragmented care
o Community Health Centers
Federally funded
Provide mental health care to those who can’t afford it
Free or low-cost slide scale
Utilize multidisciplinary teams
Services
Patient intake
Medication management and administration
Psychotherapy
Case management
o Psychiatric Home Care
Community-based treatment model
Requirements per Medicare
Homebound status
Presence of psychiatric diagnosis
Need for skills of PMH-RN
Plan of care ordered by MP/PMH-NP
Medicare allows for 2 types of health care providers
MSW
o Provide counseling
o Link patients with services
PMH-RN
o Provide evaluation, therapy, and teaching
o Visit patient 1-3 times weekly
Limited time period
Allows nurse to address access to services and
adherence with treatment
Must assess agitation and potential for violence
o Assertive Community Treatment
Intensive type of case management
Developed for severely mentally ill patients who would not participate in
traditional forms of treatment
Meeting the patient in their homes, agencies, clinics, etc.
Attempting to prevent unnecessary and expensive repeat
hospitalizations and ED use
Multidisciplinary team
RN is usually the case manager
Visits patients 3-5 times weekly
Supervised by MD/PMH-NP
o Intensive Outpatient Programs/Partial Hospitalization
Held M-F for 4-6 hours
Include medication management, therapy, and nursing intervention
o Other
Telephone Crisis Counseling
Telephone Outreach
Internet
Telepsychiatry
o Role of the Nurse
Strong problem-solving and clinical skills
Cultural competence
Flexibility
Knowledge of community resources
Autonomy
Promoting recovery and continuation of treatment
Emergency Care
o Primary Goals
Triage
Determining the severity of the problem and the urgency of a
response
Stabilization
Resolution of the immediate crisis
o Often provides a bridge from the community to more intensive psychiatric
services
Inpatient care
Inpatient Care
o Reserved for those who are suicidal, homicidal, or extremely disabled
The top five diagnoses for inpatient patients are mood disorders, substance
use disorders, neurocognitive disorders, anxiety disorders, and
schizophrenia
o Settings
Crisis Stabilization/Observation Units
Rapid stabilization and short-length stay
General and Private Hospitals
State Hospitals
Serve the most severely ill patients
Uninsured patients
o Entry to Inpatient Care
Direct admission on referral
Emergency department or crisis service
Voluntary
Involuntary
o Patients’ Rights
Hospitalized patients retain their rights as citizens
Patients’ need for safety must be balanced against their rights as citizens
Mental health facilities have written statements of patient rights and
applicable state laws
o Teamwork and Collaboration
Treatment Team
Team of professionals and staff who work together to provide care
o Includes the patient
o Provider, MSW, RN, PharmD, etc.
Meet 1-2 times weekly
Nurse leads the meetings
o Only discipline that is represented on the unit at all times
o Contributes valuable information
Continuous assessments
Patient’s adjustment to the unit
Health concerns
Psychoeducational needs
Deficits in self-care
Treatment plan provides a guideline for the patient’s care during their stay
Based on goals for hospitalization
Defines how goals will be measured
Members of each discipline are responsible for gathering data and
participating in the plan of care
o Therapeutic Milieu
Surroundings and physical environment
Patients
Staff
Structure
o Activities
o Rules
o Reality orientation practices
o Environment
Emotional climate
Well-managed milieu offers patients a sense of security and promotes
healing
Managing crises
Behavioral crises can lead to patient violence
Staff practice crisis prevention and management techniques
Special teams that respond to psychiatric emergencies practice
crisis management
Seclusion, restraint, and emergency medication are actions of last
resort
Safety
Safe environment is essential to any inpatient setting
Staff members check all personal property and clothing for
potentially harmful items prior to taking the patient on the unit
Staff track patients’ whereabouts
Staff monitor visitation
o Nursing Role
Complete comprehensive data collection
Includes patient, family, and other health care workers
Develop, implement, and evaluate plans of care
Assist or supervise workers
Maintain a safe and therapeutic environment
Facilitate health promotion through teaching
Monitor behavior, affect, and mood
Maintain oversight of restraint and seclusion
Coordinate care with the treatment team
o Specialty Settings
Pediatrics
Geriatrics
Veterans
Forensics
Alcohol and Drug Abuse
Self-Help
Prevention Strategies
o Primary
Occurs before any problem manifests
Aim is teaching coping strategies and providing psychosocial support
o Secondary
Aim is to reduce the prevalence of psychiatric disorders
Aim is early identification, screening, and prompt treatment
o Tertiary
Treatment of disease
Aim is to prevent progression to a severe state, disability, or death
Cultural Implications
World Views
o Scientific frameworks that guide nursing and psychological theories, as well as
the understanding of mental health and illness
o Based on Western cultural ideals, beliefs, and values
o Nurses should consider how a patient’s culture and/or belief system might affect
their nursing care
o Western Tradition
Identity found in individuality
Values
Autonomy
Independence
Self-reliance
Mind and body are separate entities
Disease has a cause, and treatment is aimed at eradicating that cause
o Eastern Tradition
Family is the basis for identity
Family interdependence
Group decision-making
Body-mind-spirit is one entity
No separation between a physical and psychological illness
Disease is caused by fluctuations in opposing forces
Ex. Yin-yang energies
People are born into an unchangeable fate
One must simply comply
o Indigenous Tradition
Places significance on the place of humans in the natural world
Basis of identity is that of the tribe
Person is an entity only in relation to others
Disease is caused by a lack of harmony between the individual and the
environment
Impact of Culture on Mental Health
o Each culture has different patterns of nonverbal communication
o Each culture follows different rules of etiquette
o Beliefs and values
Their culture defines what is within the range of normal and what is
outside that range
Culture defines normality and mental health
o Nurses should strive to be sensitive to one’s culture and belief system
Avoid ethnocentrism
Believing your way of thinking and behaving is the only correct
and natural way
Cultural Barriers to Quality Mental Services
o Communication barriers
Language differences
o Stigma of mental illness
o Misdiagnosis
o Cultural concepts of distress
At-Risk Populations
o Immigrants
o Refugees
o Cultural “minorities”
Cultural Competence
o 5 Constructs
Cultural Awareness
Recognizes the enormous impact culture makes on patients’ health
values and practices
Examine beliefs, values, and practices of own culture
Understands that EBP guidelines may NOT be applicable to all
people
o Derived from studies involving people primarily of
European descent
Recognize that during a cultural encounter, three cultures are
intersecting
o Culture of patient
o Culture of nurse
o Culture of setting
Cultural Knowledge
Learn by attending cultural events and programs
Forge friendships with diverse cultural groups
Learn by studying and/or asking questions
Learning cultural differences helps the nurse
o Establish rapport
o Understand behaviors and avoid misunderstandings
o Ask culturally relevant questions
o Identify cultural variables to be considered
Cultural Encounters
Deter nurses from stereotyping
o Can NOT assume that every member of a group is like all
other members
Help nurses gain confidence in cross-cultural interactions
Help nurses avoid or reduce cultural pain
o Occurs when nurses cause the patient discomfort or offense
by a failure to be sensitive to cultural norms
o If you do offend someone, take measures to recover trust
and rapport by apologizing and expressing willingness to
learn from the patient
Cultural Skill
Ability to perform a cultural assessment in a sensitive way
o Use professional medical interpreters to ensure meaningful
communication
o Use culturally sensitive assessment tools
Goal
o A mutually agreeable therapeutic plan
Culturally acceptable
Capable of producing positive outcomes
Cultural Desire
Genuine concern for patient’s welfare
Willingness to listen and understand a patient’s viewpoint
Nurses exhibit cultural desire through patience, consideration, and
empathy
DO NOT behave like you know what is best for the patient
DO NOT impose the “correct” treatment on the patient
Inspires openness to meet the patient’s cultural needs
Therapeutic Relationships
Concepts of the Nurse-Patient Relationship
o Basis of all psychiatric nursing treatment approaches
o To establish that the nurse is
Safe
Confidential
Reliable
Consistent
o Relationship with clear boundaries
Goals and Functions
o Facilitates communication of distressing thoughts and feelings
o Assist patient with problem solving
o Help patient examine self-defeating behaviors and test alternatives
o Promote self-care and independence
o Provide education
o Promote recovery
Social Relationships
o Initiated for the purpose of friendship, socialization, enjoyment, or
accomplishment of a task
o Mutual needs are met
o Communication to give advice, give, or ask for help
o Content of communication is superficial
Therapeutic Relationships
o Needs of patient are identified and explored
o Clear boundaries are established
o Problem-solving approaches are taken
o New coping skills are developed
o Behavioral change is encouraged
Necessary Behaviors for Nurses
o Accountability
o Focus on patient’s needs
o Clinical competence
o Delaying judgement
o Supervision
Boundaries
o Establishment
Social
Physical
Psychological
o Blurring
When the relationships slips into a social context
When the nurse’s needs are met at the expense of the patient’s needs
Transference
Patient unconsciously and inappropriately displaces onto the nurse
feelings and behaviors related to significant figures in the patient’s
past
Intensified in relationships of authority
May be positive or negative
Countertransference
Nurse displaces feelings related to people in the nurse’s past onto
the patient
Patient’s transference to the nurse often results in
countertransference in the nurse
Common sign of countertransference in the nurse is
overidentification with the patient
Values, Beliefs, and Self-Awareness
o Nurse’s values and beliefs
Reflect own culture or subculture
Derived from a range of choices
Chosen from a variety of influences and role models
o Must respect patients’ values and reliefs
Peplau’s Model of the Nurse-Patient Relationship
o Preorientation Phase
Preparing yourself for your assignment
Viewing the chart
Researching the patient’s illness
Discussing the patient’s case with staff
Recognizing one’s own thoughts and feelings
o Orientation Phase
Introduction
Establishing rapport
Parameters of the relationship are set
Confidentiality is discussed
o Working Phase
Maintain relationship
Gather further data
Explore problem areas in the patient’s life
Patient education
Promote patient’s
Problem-solving skills
Self-esteem
Use of language
Evaluate progress
o Termination Phase
Final phase
Summarize goals and objectives achieved
Discuss ways for the patient to incorporate new coping strategies
Factors that Promote Patient Growth
o Genuineness
o Empathy
NOT sympathy
o Positive Regard
Actions
Attending
Suspending value judgements
Helping patients develop resources
Attitudes
Therapeutic Communication
Factors that Affect Communication
o Personal Factors
o Environmental Factors
o Relationship Factors
Verbal Communication
o All the words a person speaks
o Communicates
Values and beliefs
Perceptions and meaning
o Can convey
Interest and understanding
Insult and judgement
Clear or conflicting messages
Honest or distorted feelings
Nonverbal Communication
o Tone of voice
o Emphasis on certain words
o Physical appearance
o Facial expressions
o Body language/posture
o Amount of eye contact
o Hand gestures
Interaction of Verbal and Nonverbal Communication
o Messages can appear to be one thing when they are, in fact, another
o People are often less aware of their nonverbal messages and behaviors
o Effective communicators pay attention to both verbal and nonverbal cues
o Double-Bind Messages
A contradictory message
The recipient of the message is caught inside a contradictory statement in
which they cannot win
Therapeutic Communication Techniques
o Tools for enhancing communication
o Using Silence
o Active Listening
o Clarifying Techniques
Paraphrasing
Restating
Reflecting
Exploring
Open-ended questions
Closed-ended questions
Projective questions
The “Miracle” question
o Attending Behaviors
Eye contact
Body language
Proxemics
The study of personal space
US Standards
o Intimate Distance
0-18 inches
o Personal Distance
18-40 inches
o Social Distance
4-12 feet
o Public Distance
12+ feet
Vocal quality
Nontherapeutic Communication Techniques
o Excessive questioning
o Giving approval or disapproval
o Giving advice
o Asking “why” questions
o Arguing, minimizing, or challenging the patient
o Giving false reassurance
o Interpreting or speculating
o Probing into sensitive areas the patient doesn’t want to discuss
o Trying to “sell” the patient on accepting treatment
o Joining in attacks patients launch on others
o Participation in criticizing other staff members
Preparing for the Clinical Patient Interview
o Pace
o Setting
Quiet room
Sense of security is important
o Seating
Be sure to sit at eye level
Always be between the patient and the door
o Introductions
AIDET
Confidentiality
o Initiating the interview