Principles of Psychiatric Nursing

Introduction

Health is a state of complete physical, mental, social and spiritual well-being and not
merely the absence of disease or infirmity. Both physical and mental health are
interdependent. A nurse who is responsible for total health care of a person must take
care of both physical and emotional needs; therefore she should develop a basic
understanding and skill in psychiatric nursing to achieve total health care.

Definition

PSYCHIATRY- It is a branch of medicine that deals with the diagnosis, treatment and
prevention of mental illness.

PSYCHIATRIC NURSING- It is a specialized area of nursing practice, employing

theories of human behavior as it is a science, and the purposeful use of self as it is an
art, in the diagnosis and treatment of human responses to actual or potential mental
health problems. (American Nurses Association, 1994) Thus psychiatric nursing deals
with the promotion of mental health, prevention of mental illness, care and
rehabilitation of mentally ill individuals both in hospital and community.

CURRENT ISSUES AND TRENDS IN CARE (SCOPE)

A psychiatric nurse faces various challenges because of changes in patient care

approach. Some of these changes that affect her role are as follows:

Demographic Changes
• Type of family (increased number of nuclear families)
• Increasing number of the elderly group

Social Changes
The need for maintaining intergroup and intra group loyalties
• Peer pressure

Economic Changes
• Industrialization
• Urbanization
• Raised standard of living

Technological Changes
• Mass media
• Electronic systems
• Information Technology

Mental Health Care Changes

• Increased awareness in the public regarding mental health
• Need to maintain mental stability
• Increased mental health problems

The above changes set the current trends in mental health care. Some of these are:

Educational Programs for the Psychiatric Nurse

• Diploma in Psychiatric Nursing (The first program was offered in 1956 at NIMHANS,
Bangalore).
• M.Sc. in Psychiatric Nursing (The first program was offered in 1976at Raj kumari
Amrit Kaur College of Nursing, New Delhi).

• M.Phil in Psychiatric Nursing (1990, M.G. University, Kottayam).

• Doctorate in Psychiatric Nursing (offered at MAHE, Manipal; RAK College of Nursing,
Delhi; NIMHANS, Bangalore).
• Short-term training programs for both the degree and diploma holders in nursing.

Standards of Mental Health Nursing

The development of standards for nursing practice is a beginning step towards the
attainment of quality nursing care. The adoption of standards helps to clarify nurses'
areas of accountability, since the standards provide the nurse, the health agency, other
professionals, clients, and the public, with a basis for evaluating practice.

Definition of Standard

Standards also define the nursing profession's accountability to the public.

Development of Code of Ethics

This is very important for a psychiatric nurse as she takes up independent roles in
psychotherapy, behavior therapy, cognitive therapy, individual therapy, group therapy,
maintains patient's confidentiality, protects his rights and acts as patient's advocate.

Legal Aspects in Psychiatric Nursing

Knowledge of the legal boundaries governing psychiatric nursing practice is necessary

to protect the public, the patient, and the nurse. The practice of psychiatric nursing is
influenced by law, particularly in its concern for the rights of patients and the quality
of care they receive. The client's right to refuse a particular treatment, protection from
confinement, intentional torts, informed consent, confidentiality and record keeping
are a few legal issues in which the nurse has to participate and gain quality knowledge.

Promotion of Research in Mental Health Nursing

The nurse contributes to nursing and the mental health field through innovations in
theory and practice and participation in research.

Cost Effective Nursing Care

Studies need to be conducted to find out the viability in terms of cost involved in
training a nurse and the quality of output in terms of nursing care rendered by her.

Focus of Care

A psychiatric nurse has to focus care on certain target groups like the elderly, children,
women, youth, mentally retarded and chronic mentally ill.

New Trends in Role of a Psychiatric Nurse

Primary Mental Health Nursing-

Psychiatric nurses are moving into the domain of primary care and working with other
nurses and physicians to diagnose and treat psychiatric illness in patients with somatic
complaints. Cardiovascular, gynaecological, respiratory, and gastrointestinal and
family practice settings are appropriate for assessing patients for anxiety, depression
and substance abuse disorders.

Collaborative Psychiatric Nursing Practice

Patients who are having difficulty being stabilized on their medications or who have co
-morbid medical illnesses are seen in a psychiatric nursing clinic where nurses and
physicians collaborate to provide high quality patient care.

Registered Psychiatric Nurse (RPN)

A Registered Psychiatric Nurse provides psychiatric mental health nursing care to

individuals, families and groups to enable them to function at an optimal level of
psychological wellness through more effective adaptive behaviors and increased
resilience to stress. She must be able to provide safe, basic physical care, have a wide
understanding of psychological and developmental problems and their treatment and
have a highly developed level of communication skills.

She works with children, adolescents, adults and elderly with dysfunctional behavior
patterns, and developmental handicaps. A registered psychiatric nurse works as an
independent entity. She works in various kinds of inpatient facilities and community
settings.

Clinical Nurse Specialist (CNS)

The Clinical Nurse Specialist provides consultative services to nursing personnel. She
attends clinical teaching programs, demonstrates therapies, conducts in-service
education programs, initiates and participates in curriculum revision/ changes and
nursing research.

Case Management

Using case management a psychiatric mental health nurse is responsible for assessing
needs, identifying services, and monitoring and evaluating client status. A case
manager coordinates care through collaboration with all involved health professionals
ensuring accessibility and availability of care.

Nurse Psychotherapist

The psychiatric nurse can take up psychotherapy roles as in individual therapy, group
therapy, counselling, etc.

Psychiatric Nurse Educator

The main function of psychiatric nurse educator is planning and changing the
curriculum according to the needs of the society and learner. The Indian Nursing
Council included psychiatric nursing as compulsory for the qualifying examination in
B.Sc. Nursing program in 1965, and from 1986 it became a component in General
Nursing and Midwifery course as well. The number of nurses in the field of teaching
psychiatric nursing needs to be enhanced. This is a big challenge for nursing
curriculum planners.

Psychosocial Rehabilitation Nursing

It is concerned with helping people with chronic mental illness to lead more
independent and satisfactory lives in the community.

Child Psychiatric Nursing

In child psychiatric nursing the nurse identifies emotional and behavioral problems of
the children and provides comprehensive care.

Gerontological and Geriatric Nursing

Gerontological nursing provides emotional support to those people who have retired
from services, who have no financial sources and helps them in understanding the
situation, and developing new coping mechanisms.Geriatric nursing is expanding the
psychiatric nursing practice to aged people who have been affected by emotional and
behavioral disorders such as dementia, chronic schizophrenia, delirium, etc.

De-addiction Nursing

A psychiatric nurse in these units identifies psychosocial problems and maintaining

factors in addicts. She also provides various therapies to the addicts and their family
members.

Neuropsychiatric Nursing

Psychiatric nursing practice is extended to patients who are suffering from

neuropsychiatric disorders such as dementia, epilepsy, brain tumor, head injury with
behavioral problems, HIV infection with behavioral problems, etc

Community Mental Health Nursing

Community mental health nursing is the application of knowledge of psychiatric

nursing in preventing mental illness, promoting and maintaining mental health of the
people. It includes early diagnosis, appropriate referrals, care and rehabilitation of
mentally ill people.

Advanced Practice Roles

These include: Nursing leadership in forensic health units, crisis intervention, risk
assessment and management in community settings.

PSYCHIATRIC NURSING SKILLS

Mental health nursing is the practice of promoting mental health as well as caring for
people who have mental illness, potentiating their independency and restoring their
dignity. In order to fulfil this arduous occupation, a mental health nurse must possess
a sound knowledge base and the requisite skills for good nursing practice.

Prerequisites for a Mental Health Nurse

Personal Skills

Self-awareness It is a key component of psychiatric nursing experience. It is an answer

to the question, "who am I". The nurse must be able to examine personal feelings,
actions and reactions as a provider of care. A firm understanding and acceptance by
the nurse allows acknowledging a patient's differences and uniqueness.

Adaptability

A mental health nurse needs to be adaptable to different settings and cultures.

Working within residential settings, for example, may demand attitudes and roles
which are different from working in a community, as in a residential setting the nurse
may have an authoritative or a supervisory role which she necessarily does not have in
a community. A mental health nurse also needs to cope with a variety of social and
cultural settings. Social settings involve the class and status of the individuals while
cultural settings involve race, ethnicity and gender. Therefore she may need to be
familiar with the issues that arise in cross-cultural mental health nursing.

Care values and attitudes

These include:
• Self-awareness and self-esteem
• Respecting the person's rights
• Listening
• Responding with care and respect
• Supporting with trust and confidence
• Reassuring with explanation and honesty
• Physically nursing the helpless with compassion
• Carrying out procedures skilfully
• Working within personal and ethical boundaries.

Counselling Skills

These include:
• Unconditional positive regard/non-judgemental approach
• Empathy
• Warmth and genuineness
• Confidentiality
• Non-verbal sensitivity, non-verbal attending, non-verbal responding
• Other interpersonal skills required are paraphrasing, reflecting, clarifying,
summarizing.

Behavioral Skills

These are based on Pavlovian principles and Skinner's principles. They include:
1. To increase adaptive behavior
• Positive reinforcement
• Negative reinforcement
• Token economy

2. To decrease maladaptive behavior

• Extinction
• Timeout
• Restraining
• Over correction

3. To teach new behavior

• Modelling
• Shaping
• Chaining
• Cueing.

Supervisory Skills

Supervision is an integral necessity for any worker in the caring profession, to ensure
the best quality service for clients and best quality developmental opportunities for
workers. A good supervisor requires interpersonal and professional skills, technical
knowledge, leadership qualities and human skills.
Crisis Skills

Aggressive and assaultive behavior of violent patients, self-harm, acute alcohol

intoxication are some of the cases a nurse is likely to encounter in the course of her
practice. Such situations may cause the nurse to feel overwhelmed with feelings of
helplessness, powerlessness and inadequacy. Exercise of self-control, calm, rational
thinking and identifying ways of obtaining help from the other people are some of the
skills to be cultivated by the psychiatric nurse when confronted with such crises
situations.

Teaching Skills

This relates to the nurse's ability to explain, enabling full understanding on the part of
the client. It also involves enhancing the client's environment in order to maximize his
awareness of the things around him. It is necessary for the nurse to be enthusiastic
about activities and choices of the clients and also give the client every opportunity to
use his power of judgment in order to make decisions.

STANDARDS OF MENTAL HEALTH NURSING

The purpose of Standards of Psychiatric and Mental Health Nursing practice is to fulfil
the profession's obligation to provide a means of improving the quality of care. The
standards presented here are a revision of the standards enunciated by the Division on
Psychiatric and Mental Health Nursing Practice in 1973.

Professional Practice Standards

Standard I: Theory
The nurse applies appropriate theory that is scientifically sound as a basis for
decisions regarding nursing practice.
Standard II: Data Collection
The nurse continuously collects data that are comprehensive, accurate and
systematic
Standard Ill: Diagnosis
The nurse utilizes nursing diagnoses and/ or standard classification of mental
disorders to express conclusions supported by recorded assessment data and
current scientific premises.
Standard IV: Planning
 The nurse develops a nursing care plan with specific goals and interventions
delineating nursing actions unique to each client's needs.
Standard V:Intervention
The nurse intervenes as guided by the nursing care plan to implement nursing
actions that promote, maintain or restore physical and mental health, prevent
illness and effect rehabilitation.
(a) Psychotherapeutic interventions The nurse uses psychotherapeutic interventions to
assist clients in regaining or improving their previous coping abilities and to
prevent further disability.

(b) Health teaching- The nurse assists clients, families and groups to achieve satisfying
and productive patterns of living through health teaching.
(c) Activities of daily living- The nurse uses the activities of daily living in a goal
directed way to foster adequate self-care and physical and mental well being of
clients.

(d) Somatic therapies- The nurse uses knowledge of somatic therapies and applies
related clinical skills in working with clients
(e) Therapeutic environment- The nurse provides, structures and maintains a
therapeutic environment in collaboration with the client and other health care
providers.

(f) Psychotherapy- The nurse utilizes advanced clinical expertise in individual, group
and family psychotherapy, child psychotherapy and other treatment modalities to
function as a psychotherapist and recognizes professional accountability for
nursing practice.

Standard VI: Evaluation

The nurse evaluates client responses to nursing actions in order to revise the
database, nursing diagnoses and nursing care plan.

Professional Performance Standards

Standard VII: Peer Review

The nurse participates in peer review and other means of evaluation to assure
quality of nursing care provided for clients.
Standard VIII: Continuing Education
The nurse assumes responsibility for continuing education and professional
development and contributes to the professional growth of others.
Standard IX: Interdisciplinary Collaboration
The nurse collaborates with other health care providers in assessing, planning,
implementing and evaluating programs and other mental health activities.
Standard X: Utilization of Community Health Systems
The nurse participates with other members of the community in assessing,
planning, implementing and evaluating mental health services and community
systems that include the promotion of the broad continuum of primary,
 secondary and tertiary prevention of mental illness.
Standard XI: Research
The nurse contributes to nursing and the mental health field through innovations
in theory and practice and participation in research.

GENERAL PRINCIPLES OF PSYCHIATRIC NURSING

The following principles are general in nature and form guidelines for emotional care
of a patient. These principles are based on the concept that each individual has an
intrinsic worth and dignity and has potentialities to grow.

1. Patient is Accepted Exactly as He is

Accepting means being non-judgmental. Acceptance conveys the feeling of being

loved and cared. Acceptance does not mean complete permissiveness but setting of
positive behaviors to convey to him the respect as an individual human being. A nurse
should be able to convey to the patient that she may not approve everything what he
does, but he will not be judged or rejected because of his behavior. Acceptance is
expressed in the following ways:
(a) Being Non-judgmental and Non-punitive The patient's behavior is not judged as
right or wrong, good or bad. Patient is not punished for his undesirable behavior.
All direct (chaining, restraining, putting him in a separate room) and indirect
(ignoring his presence or withdrawing attention) methods of punishment must be
avoided. A nurse who shows acceptance does not reject the patient even when he
behaves contrary to her expectations.
(b) Being Sincerely Interested in the Patient
Being sincerely interested in another individual means considering the other
individual's interest. This can be demonstrated by:
• Studying patient's behavior pattern.
• Allowing him to make his own choices and decisions as far as possible.
• Being aware of his likes and dislikes.

• Being honest with him.

• Taking time and energy to listen to what he is saying.
• Avoiding sensitive subjects and issues.
(c) Recognizing and Reflecting on Feelings which Patient may Express When patient
talks, it is not the content that is important to note, but the feeling behind the
conversation, which has to be recognized and reflected.
(d) Talking with a Purpose- The nurse's conversation with a patient must revolve
around his needs, wants and interests. Indirect approaches like reflection, open-
ended questions, focusing on a point, presenting reality are more effective when
the problems are not obvious.
(e) Listening- Listening is an active process. The nurse should take time and energy to
listen to what the patient is saying. She must be a sympathetic listener and show
genuine interest.
(e) Permitting Patient to Express Strongly-held Feelings
Strong emotions bottled up are potentially explosive and dangerous. It is better
to permit the patient to express his strong feelings without disapproval or
punishment. Expression of negative feelings (anxiety, fear, hostility and
anger)may be encouraged in a verbal or symbolic manner. The nurse must accept
the expression of patient's strong negative feelings quietly and calmly.
2. Use Self-understanding as a Therapeutic Tool

A psychiatric nurse should have a realistic self concept and should be able to recognize
one's own feelings, attitudes and responses. Her ability to be aware and to accept her
own strengths and limitations should help her to see the strengths and limitations in
other people too. Self understanding helps her to be assertive in life situations without
being aggressive and feeling guilty.

3. Consistency is used to Contribute to Patient's Security

This means that there should be consistency in the attitude of the staff, ward routine
and in defining the limitations placed on the patient.

4. Reassurance should be given in a Subtle and Acceptable Manner

Reassurance is building patient's confidence. To give reassurance, the nurse needs to

understand and analyze the situation as to how it appears to the patient. False
reassurance can also reflect a lack of interest and understanding or unwillingness on
the part of the nurse to empathize with the patient's life situation.

5. Patient's Behavior is Changed through Emotional Experience and not by Rational

Interpretation

Major focus in psychiatry is on feelings and not on the intellectual aspect. Advising or
rationalizing with patients is not effective in changing behavior. Role-play and socio-
drama are a few avenues of providing corrective emotional experiences to a patient
and facilitating insight into his own behavior. Such experiences can truly bring about
the desired behavioral changes.

6. Unnecessary Increase in Patient's Anxiety should be Avoided

The following approaches may increase the patient's anxiety and should therefore, be
avoided:
• Showing nurse's own anxiety.
• Showing attention to the patient's deficits.
• Making the patient to face repeated failures.
• Placing demands on patient which he obviously cannot meet.

• Direct contradiction of patient's psychotic ideas.

• Passing sharp comments and showing indifference.

7. Objective Observation of Patient to Understand his Behavior

Objectivity is an ability to evaluate exactly what the patient wants to say and not mix
up one's own feelings, opinion or judgment. To be objective, the nurse should indulge
in introspection and make sure that her own emotional needs do not take a
precedence over patient's needs.

8. Maintain Realistic Nurse-Patient Relationship

Realistic or professional relationship focuses upon the personal and emotional needs
of the patient and not on nurse's needs. To maintain professional relationship the
nurse should have a realistic self-concept and should be able to empathize and
understand the feelings of the patient and the meaning of behavior.

9. Avoid Physical and Verbal Force as Much as Possible

All methods of punishment must be avoided. If the nurse is an expert in predicting

patient behavior, she can mostly prevent an onset of undesirable behavior.

10. Nursing Care is Centred on the Patient as a Person and not on the Control of
Symptoms

Analysis and study of symptoms is necessary to reveal their meaning and their
significance to the patient. Two patients showing the same symptoms may be
expressing two different needs.

11. All Explanations of Procedures and other Routines are Given According to the
Patient's Level of Understanding

The extent of explanation that can be given to a patient depends on his span of
attention, level of anxiety and level of ability to decide. But explanation should never
be withheld on the basis that psychiatric patients are not having any contact with
reality or have no ability to understand.

12.Many Procedures are Modified but Basic Principles Remain Unaltered

In psychiatric nursing field, many methods are adapted to individual needs of the
patients, but the underlying nursing scientific principles remain the same. Some
nursing principles to be kept in mind are: safety, comfort, privacy, maintaining
therapeutic effectiveness, economy of time, energy and material.

FUNCTIONS OF A PSYCHIATRIC NURSE

• Assessing the client and planning nursing care.

• Providing safe nursing care, including medication administration and participation in
various therapies, individual interactions, formal and informal group situations,
role playing, advocating on behalf of the client, and so forth.
• Providing a safe environment, including protecting the client and others from injury.
• Accurately observing and documenting the client's behavior.
• Providing feedback to the client based on observations of his behavior.
• Teaching the client and significant others.
• Involving the client and the client's significant others in the nursing process.
• Providing opportunities for the client to make his own decisions and to assume
responsibility for his emotions and life.
• Cooperating with other professionals in various aspects of the client's care; thereby,
facilitating an interdisciplinary approach to care.
• Continuing nursing education and the exploration of new ideas, theories, and
research.
QUALITIES OF A PSYCHIATRIC NURSE

Certain attitudes are necessary for a psychiatric nurse to deal with psychiatric patients.
These include:
1. Self-awareness
2. Self-acceptance
3. Accepting the Patient
4. Being Sincerely Interested in Patient Care
5. Being Available
6. Empathizing with the Patient
7. Reliability
8. Professionalism
9. Accountability
10.The Ability to Think Critically

THERAPEUTIC ROLES OF A PSYCHIATRIC MENTAL HEALTH NURSE

Psychiatric nurses have many roles that will continue to change and evolve as the
health care environment changes. The roles of the nurse meet client and family needs,
guide, assist, and teach the client and family; and provide an environment that
facilitates client and family growth and development.

1. Direct Care Provider

2. Provider of Therapeutic Environment for the Patient
3. Teacher I Educator
4. Coordinator
5. Patient Advocate
6. Provider of Preventive Care
7. Collaborator
8. Case Manager
9. Professional Role
10. Researcher