Hi class, it's Professor Gasparro and in this lecture we're going to cover professional practice and the role of the mental health nurse. You may find yourself thinking, I'm not really interested in the specialty of mental health nursing or that you just really couldn't picture yourself ever working in a mental health facility. So maybe you think that a lot of this information won't be applicable to your practice, but I'm here to tell you that it absolutely will. I think that the skills and the concepts we learn in our mental health nursing course are going to be some of the most broad and general things that we can apply to a wide variety of patients.
You may never care for a client that's on a ventilator. You may never work in the realm of pediatrics, but no matter where you end up, I promise you, you will take care of clients. that have underlying psychiatric diagnoses, whether that is their main presenting problem or not. So for example, maybe you are taking care of a client who needs a hip replacement surgery because they had a fall at home due to a substance misuse problem.
Maybe on your medical surgical unit, you have a client who is in liver failure and kidney disease. Maybe they also have bipolar and an underlying substance misuse problem. Maybe you're taking care of a client who has none of those, but there's family at the bedside who is having some erratic behaviors, and maybe there's a history of schizophrenia there. So as you can see, these behaviors and these concepts, they show up in many ways, whether we are truly working in a mental health facility or not. Registered nurses in a variety of settings provide care for clients with medical illnesses who may also be experiencing concurrent mental health disorders.
Nurses who specialize in psychiatric mental health nursing, they promote clients'well-being through prevention strategies and patient education, while also using the nursing process to provide care for clients with mental health and substance use disorders. Psychiatric mental health. health nursing is a recognized specialty area of nursing and therefore the nurse can be board certified in this area. So when a nurse is board certified, it demonstrates that they hold a minimum level of education, usually a bachelor's degree. They have a minimum amount of experience working in the mental health setting.
They've completed a certain amount of continuing education and they've passed a certification exam. Overall, nurses who work in psychiatric mental health settings, some of their main interventions or things that they do every day is that they partner with individuals to achieve their recovery goals. They provide health promotion and maintenance education.
They conduct intake screenings, evaluations, and triage patients. They provide case management and they teach their clients self-care activities. They administer and monitor psychobiological treatments. They practice things like crisis intervention, stabilization.
They have really strong therapeutic communication skills. They help coordinate care and they overall work within an interdisciplinary team. There's also an opportunity to be an advanced practice nurse within the specialty of psychiatric mental health nursing. Now advanced practice nurses, these are registered nurses with a master's of science and nursing degree. They may be nurse practitioners.
They may also have a doctorate of nursing degree. And overall their scope of practice is going to differ. They are able to prescribe medications for acute and chronic illnesses. They can provide psychotherapy for individuals, groups, families, couples.
They provide more comprehensive assessments. They provide clinical supervision and they diagnose, treat, and manage chronic or acute illnesses. They provide therapy interventions. They're able to order and perform and interpret certain labs and other diagnostic studies. They can perform certain procedures and even make referrals for health problems outside of their scope of practice.
Now professional organizations related to psychiatric nursing practice. We have the American Psychiatric Nurses Association. This association establishes standards of practice in psychiatric mental health nursing that are built on the ANA scope and standards of practice.
The standards are published in the psychiatric mental health nursing scope and standards of practice document. They're very similar to the ANA scope and standards of practice that you've reviewed previously. They just have additional activities that are within the interventions of the standards of care.
And then again, there's also the American Nurses Association, which provides support and even continuing education in certain topics within mental illness. Next, we'll talk about the Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM-5. So that's a lot easier to say, so we'll call it that.
This manual is published by the American Psychiatric Association. It's the handbook used by healthcare professionals in the United States and much of the world, and it's considered the authoritative guide to the diagnosis of mental disorders. The DSM-5 describes all mental disorders. It outlines specific diagnostic criteria for each disorder based on clinical experience and research.
In general, there are three purposes to the DSM. One, to provide a standardized nomenclature and language for all mental health professionals. Two, it's to present defining characteristics or symptoms that differentiate specific diagnoses.
And then three, it assists in identifying the underlying cause of disorders. The number five refers to the fact that we are on the fifth version of the DSM. So it gets updated every few years. So currently we're on the fifth version of it.
For each disorder in the DSM, there will be a diagnostic classification, criteria set, and a descriptive text. The diagnostic classification, this is the official list of all the mental health disorders recognized in the DSM and then each diagnosis is going to have a diagnostic code called the ICD-10 code. All you need to know about this is that this code is just used for billing and reimbursement purposes.
Looking at the criteria sets for each disorder included in the DSM, there's a set of diagnostic criteria which indicates the symptoms that must be present and for how long those symptoms have been present in order to diagnose a particular diagnosis. It's going to list any conditions that must be met and anything that must be ruled out in order to make a diagnosis. And then the descriptive text, this is going to provide information regarding each disorder. And it's going to include things like the diagnostic features of the disorder, the prevalence of the disorder, any risk factors, sex and gender related diagnostic issues, differential diagnoses, and also comorbidity.
Alright, so how do nurses help our clients to prevent mental health disorders? Well, we have to look at the client's protective factors versus their risk factors. Protective factors refer to characteristics, conditions, or behaviors that help that individual mitigate the risk of negative outcomes, and it also helps to enhance their ability to cope with challenges. So these are positive or good things in the patient's life. that are going to help them overcome those normal day-to-day stresses and cope in a positive way to hopefully again mitigate that risk for developing any mental illness.
Protective factors play a crucial role in promoting mental health and well-being and they buffer the individuals from potential adverse effects in their environment. So some examples of protective factors are developing problem-solving skills throughout life, having overall resilience, being aware of and having access to health services, having positive peer relationships, having family support, having a safe and stable living environment, and being connected to the community around them. Conversely, risk factors, these are conditions, characteristics, or behaviors that increase the likelihood of experiencing negative outcomes or adverse effects.
These play a significant role in the development of mental health disorders. So this highlights the importance of identifying and addressing these factors as part of the mental health nurse's preventative strategies. Examples of risk factors include trauma. exposure to adverse childhood events, having a family history of certain disorders, let's see, brain chemistry, having negative habits or lifestyle choices, not having positive peer relationships, or not having a strong family support system around them. Additionally, nurses use health promotion and prevention strategies to help their clients.
I'm hoping this is a review from your previous nursing courses but we're going to just briefly talk about primary, secondary, and tertiary promotion and prevention strategies. So remember primary prevention, this is reducing the risk factors for developing certain disorders and strengthening those protective factors. So at this point there is no mental health. disorder or there's no mental illness.
So our interventions are really aimed at, again, reducing that risk of them developing. So some examples of primary prevention focuses are substance abuse programs in school, right? Like D.A.R.E. programs, having the access to after-school clubs and extracurricular groups, even parenting classes for adults. Secondary strategies, these are early detection of and prompt intervention for mental health concerns.
Examples of secondary measures include screening tools for depression and suicide, the availability of crisis centers, and suicide hotlines. Finally, tertiary prevention targets for advanced recovery and the reduction of relapse risk. All right, so this is where we are helping our client recover after an illness.
We're trying to prevent any further complications and provide support after the diagnosis has already happened or after a mental health crisis has happened. Support groups for families after a loved one has completed suicide. Psychopharmaceutical therapy and outpatient services. and counseling following a mental health event or hospitalization are examples of tertiary measures. Now let's look at where psychiatric mental health nurses provide treatment.
There are various types of treatment settings. Today, inpatient units provide rapid assessment, stabilization of symptoms, and discharge planning, and they must accomplish their goals quickly. The first thing that we see is that the patient is not in a state of mental illness.
A client-centered, multidisciplinary approach to a brief stay is essential. Clinicians help clients recognize symptoms, identify their coping skills, and help to choose discharge support. When the client is safe and stable, the clinicians and the client identify long-term issues for the client to pursue in outpatient therapy. Now the trend is in healthcare if the client doesn't need an inpatient stay we do try to avoid it just because of the limited resources that we have. It's not uncommon for a patient to present to an emergency room in crisis and they could potentially be staying in that emergency room for days to weeks simply waiting for an inpatient center to be available to them because they're not safe to go back into the community but Again, there's just not the space or the resources to really help everybody that needs help with mental health disorders.
So in general, with inpatient stays, there are two classifications. There's the short stay. These are usually intended just for emergency care, and safety is the priority.
So this may be a client presenting in crisis for risk of suicide. In the short stay, we are trying to identify as many resources as possible to help them. Now a long stay, these are for clients with severe mental illnesses who continually require acute care services despite the emphasis on providing them resources and really trying to keep them out of the hospital. They don't have a good hold on their disease, right? It's unmanaged and they continue to present with needs and so they may need more of a long stay in patient care.
Some examples of this would be like our state hospital, mental health state hospital. Within the inpatient treatment settings, case management and discharge planning are two very important concepts. Inpatient case managers follow the client from admission to discharge, and they serve as liaisons between the client and any resources that they can help connect them with within their community, like home care. In the community, they work with clients on a broad range of issues, anything from accessing needed medical and psychiatric services to helping them carry out tasks of daily living, such as helping them be able to use public transportation, or managing their money, or helping them pay bills, etc. When it comes to discharge planning, this really is based on individual needs and discharge planning.
always begins with admission. Environmental supports like housing and transportation, access to community resources and services, these are very very crucial to successful discharge planning so your case manager is very involved in this process. Discharge plans that are based on the client's individual needs including medication management, education, helping them set up timely outpatient appointments and helping them set up telephone follow-up calls. These are all strategies that are going to help make the client more successful in their recovery. In fact, the adequacy of discharge plans is a better predictor of how long that person can remain in the community without any problems than other clinical indicators.
So that's really interesting. Remember discharge planning really important to identify those needs and resources that the client needs to be as independent and as functional as possible within their community. Some other treatment settings, there's also partial hospitalization programs.
These help the patient transition from inpatient to independent living. These can look like day or evening treatment programs and each client has their individual plan and goals. During day programs the client is receiving treatment for a good part of the day but then they're able to leave that facility and they return home at night. Evening programs are the opposite where they present at night time and receive overnight care. The services vary at different treatment programs, but most programs include groups for building communication and social skills, problem solving, medication monitoring, education on coping skills, and skills for everyday living.
Some individual services are available like vocational and occupational and recreation services. Again, each plan is really individualized to that client and what they need. It also focuses on stabilizing their living environment, improving their activities of daily living, they're learning to structure their time in a more healthy and therapeutic way, developing social skills, and obtaining meaningful work, hopefully paid employment, or some kind of volunteer position. In residential settings, the client is living within a community setting where they are receiving treatment.
These settings really vary in structure, the level of supervision that the client has, and even the services provided. So some examples of this may include a group home, this may look like a supervised apartment setting, board and care homes, assisted living, respite or crisis housing. Some are designed as a temporary or transitional housing. with the expectation that the resident will be able to progress to more of an independent living situation. Other programs are there really to serve the client for as long as they have a need, you know, sometimes years.
And then there's intensive outpatient programs. These are very high touch programs that offer group therapy and life skill classes. Intensive meaning that the schedule of treatment is, they have a lot of meetings with clinicians over the course of a week.
So usually they do about 10 hours per week either meeting with their doctors or attending support groups. This is outpatient, so the client does go home at night, but they're structured programs that follow a very rigid schedule and routine. These are pretty common for treatment for substance use disorders and for co-occurring mental health disorders.
All right, so who makes up the interdisciplinary team in mental health settings? Well, we have a lot of players here. We're going to go through them.
The pharmacist helps to manage medications and monitor for side effects or interactions with non-psychiatric medications that the client is taking. The psychiatrist is the physician that is certified in psychiatry. Their primary function is to diagnose and prescribe the medical treatments.
The psychologist is going to help participate in the design of the therapy programs. The psychiatric nurse helps provide care in that holistic way. The social worker or the case manager again they help with discharge planning and connecting the client to outside resources.
The occupational therapist is going to focus on the functional abilities of the client and find ways to improve their functioning, like working with arts and crafts and focusing on psychomotor skills. The recreational therapist is going to help the client achieve a balance of work and play in his or her life. They help provide activities and promote constructive use of leisure time or unstructured time.
the vocational rehabilitation specialist. Their job includes determining the client's interests and their abilities and helping match them to a vocation or a job that would really suit them. And then you have the behavioral health tech.
This is similar to a nursing assistant in the medical facility. They help the patient with personal grooming, activities of daily living, they work with the nurse to help provide care within their scope of practice. They're also going to be able to identify and report any pertinent behavioral, medical, or psychosocial concerns to the nurse who can then relate that information to the physician or psychiatrist. To get a better idea of what the psychiatric mental health nurse really focuses on with their client. This is the APNA phenomena of concern for the mental health nurse.
So you'll notice that the nurse is really promoting that optimal mental and physical health and well-being to help prevent any illness for their client. They're looking for alterations in the thinking, perceiving, and communicating. of psychiatric disorders or mental health problems. They're looking for emotional stresses related to illness, pain, disability, and loss. Some overall themes of this phenomena of concern are maximal level of functioning for the client with fewest symptoms as possible, We want to help our client be autonomous and we want them to have the ability to make safe decisions for themselves.
We want to help the client maintain their safety, so we're assessing all the time for any danger that they may present to themselves or to others. And we're helping to identify barriers to treatment, so again that goes back to those societal factors like violence, poverty, substance misuse. and we're helping address any issues related to body image, major life changes, or end-of-life events.
So that concludes this part of the lecture and I'll see you in the next one.