SCOPE OF PSYCHIATRIC MENTAL HEALTH NURSING Page 1

SCOPE OF PSYCHIATRIC MENTAL HEALTH NURSING

INTRODUCTION:

The nursing profession, by developing and articulating the scope and standards of professional nursingpractice, defines its boundaries and informs society about the parameters of nursing practice. The scope andstandards also guides the development of state level nurse practice acts, rule and regulations governing nursepractice. Because each state develops its own laws regulating nursing, the designated limits, functions, and titles fornurses, particularly at the Advanced Practice level, may differ significantly from state to state. Nurses must ensure thattheir practice remains within the boundaries as defined by their state practice acts. Individual nurses are accountablefor nursing that they practice within the limits of their own competency, professional code of ethics and professionalpractice standards. The National Council of State Boards of Nursing (NCSBN) has made some progress (Compact andModel Practice Acts) to support standardization across states, recognizing that new trends in health care, includingtelehealth, require that nurses move more seamlessly between states to promote access to care.

Psychiatric mental health nursing is a specialized area of nursing practice committed to promoting mental healththrough the assessment, diagnosis, and treatment of human responses to mental health problems and psychiatricdisorders. Psychiatric mental health nursing, a core mental health profession, employs a purposeful use of self as itsart and a wide range of nursing, psychosocial, and neurobiological theories and research evidence as its science.Psychiatric mental health nurses provide comprehensive, patient-centred mental health and psychiatric care andoutcome evaluation in a variety of settings across the entire continuum of care. Essential components of this specialtypractice include health and wellness promotion through identification of mental health issues, prevention of mentalhealth problems and care and treatment of persons with psychiatric disorders.

Psychiatric mental health nursing is necessarily holistic and considers the needs and strengths of the individual, family,group and community. It is within the scope of Psychiatric Mental Health Nursing Practice to provide primary mentalhealth care to patients seeking mental health services in a wide range of delivery settings. Primary mental health careinvolves overall health promotion, universal, selective, and preventive interventions (Mrazek & Hagerty, 1994),general health teaching, health screening and appropriate referral for treatment of general or complex healthproblems and a specialization in the evaluation and management of those with psychiatric disorders and those at riskfor them, including psychiatric rehabilitation (Haber and Billings 1995). The psychiatric mental health nurse’sassessment is a synthesis of the information obtained from interviews, behavioural observations and other availabledata from which a diagnosis is derived and validated with the patient. The psychiatric mental health nurse usesdiagnoses and standard classifications of mental disorders such as North American Nursing Diagnosis Association(NANDA, 1999), The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association(APA cite latest edition) or the International Classification of Diseases (WHO, 1993) to develop a treatment planbased on assessment data and theoretical premises. The nurse then selects and implements interventions andperiodically evaluates patient outcomes, revising the plan of care as needed, to achieve optimal results. Suchclassification systems enhance communication and permit the data to be used for research purposes.

Psychiatric Mental Health Nurses are concerned about:

Promotion of optimal mental and physical health and well-being and prevention of mental illness Impaired ability to function related to psychiatric, emotional and physiological distress Alterations in thinking, perceiving and communicating due to psychiatric disorders or mental health problems. Behaviours and mental states that indicate potential danger to self or others Emotional stress related to illness, pain, disability and loss Symptom management, side effects/toxicities associated with self-administered Drugs, psychopharmological intervention and other treatment modalities. The barriers to treatment efficacy and recovery posed by alcohol and substance abuse and dependence Self-concept and body image changes, developmental issues, life process changes, and end of life issues.

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Physical symptoms that occur along with altered psychological status Psychological symptoms that occur along with altered physiological status Interpersonal, organizational, sociocultural, spiritual or environmental circumstances or events which have an

effect on the mental and emotional well-being of the individual and family or community. Elements of recovery including the ability to maintain housing, employment and social support that help

individuals re-engage in the seeking of meaningful lives.

LEVELS OF PSYCHIATRIC MENTAL HEALTH NURSING PRACTICEPsychiatric mental health nurses are registered nurses who are educationally prepared in

nursing and licensed to practice in their individual states. Levels of practice are differentiated by educationalpreparation, complexity of practice, and performance of certain nursing functions. (SERPN, 2005)

The Psychiatric Mental Health Registered NurseA psychiatric mental health registered nurse is a registered nurse who demonstrates

competence, including specialized knowledge, skills, and attitudes, obtained through education or experience, incaring for persons with mental health issues, mental health problems and psychiatric disorders.

Nurses from a number of educational backgrounds participate and practice in psychiatric nursing settings. Due to thecomplexity of care in the specialty the preferred educational preparation is at the baccalaureate level. The science ofnursing is based on a critical thinking framework, known as the nursing process, composed of assessment, diagnosis,outcomes identification, planning, implementation and evaluation. These steps serve as the foundation for clinicaldecision-making and are used to provide an evidence base for practice (ANA, 2004, pp. 11-12).

Psychiatric mental health registered nursing practice is characterized by the use of the nursingprocess with persons with actual or potential mental health problems or psychiatric disorders to promote and fosterhealth and safety, assess dysfunction, assist persons to regain or improve their coping abilities, maximize strengths,and prevent further disability. Data collection at the point of contact involves observational and investigativeactivities, which are guided by nurse’s knowledge of human behaviour and the principles of the psychiatricinterviewing process.The work of psychiatric mental health nurses is accomplished through the nurse-client relationship and therapeuticintervention skills. These skills include but are not limited to self awareness, empathy and moral integrity which enablepsychiatric mental health nurses to practice the use of self artfully in therapeutic relationships. Some characteristicsof artful therapeutic practice are respect for the client, availability, spontaneity, hope, acceptance, sensitivity, vision,accountability, advocacy and spirituality.

Psychiatric mental health registered nurses practice in a variety of clinical settings across the care continuum andengage in a broad array of clinical activities including, but not limited to, health promotion and health maintenance;intake screening, evaluation and triage; case management; provision of therapeutic and safe environments; promotionof self care activities; administration of psychobiological treatment regimens and monitoring response and effects;crisis intervention and stabilization; and psychiatric rehabilitation.Psychiatric mental health registered nurses maintain current knowledge of advances in genetics and neuroscience andtheir impact on psychopharmacology and other evidence- based treatment modalities. Psychiatric mental healthnurses provide leadership in identifying mental health issues and problems and developing strategies, in partnershipwith consumers, patients, communities and other health professionals, to ameliorate or prevent them.

The Psychiatric Mental Health Advanced Practice Registered NurseThe psychiatric mental health advanced practice registered nurse (APRN-PMH) is a licensed

registered nurse who is educationally prepared at the master’s or doctorate level in the specialty of psychiatric mentalhealth nursing. The Psychiatric Mental Health Advanced Practice Registered Nurse builds on the practice of registerednurses by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexityof skills and interventions, and significant role autonomy (ANA 2004, p. 14).

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The American Nurses Association (ANA) identifies Advanced Practice Registered Nurses (APRNs)as professional nurses who have successfully completed a graduate program of study in a nursing specialty thatprovides specialized knowledge and skills that form the foundation for expanded roles in health care. The ANA’s useof APRN as an umbrella term for all advanced practice nurses has been a successful political strategy to educateregulators and legislators regarding the contributions that APRNs make in providing access to high quality care.

The APRN-PMH is professionally qualified to assume autonomous responsibility for the clinical rolefunctions. They are accountable for their own practice and are prepared to perform services independent of otherdisciplines in the full range of delivery settings. The educational preparation of advanced practice psychiatric mentalhealth nurses in both the biological and social sciences gives them a unique ability to differentiate various aspects ofthe patient’s functioning and to make appropriate judgments about the need for interventions, referral or consultationwith other clinicians (ANA, 2001, p.20).

Additional functions practiced by the APRN-PMH include advanced practice level practice ofpsychopharmacological interventions, complementary interventions, various forms of psychotherapy, communityinterventions, case management, consultation- liaison, clinical supervision, and expanded advocacy activities.

Psychotherapy:Psychotherapy interventions include all generally accepted methods of brief or long-term therapy,

specifically including individual therapy, group therapy, couple/marital therapy and family therapy using a broad arrayof therapy models including, but not limited to, insight-oriented, cognitive, behavioural and interpersonal therapies.

Psychotherapy denotes a formally structured contractual relationship between the therapist(APRN-PMH) and patient(s) for the explicit purpose of effecting negotiated outcomes. This treatment approach tomental disorders is intended to alleviate emotional distress and/or symptoms, reverse or change maladaptivebehaviours, and facilitate personal growth and development. The contract with the patients(s) or client(s), usuallyverbal but may be written, includes the well-accepted elements such as purpose of the therapy, time, place, fees,confidentiality and privacy components, and access to emergency after hours contact information.

Psychopharmacological Interventions:Psychopharmacology interventions include the prescribing of pharmacologic agents and the

ordering and interpretation of diagnostic and laboratory testing. In utilizing any psychobiological intervention,including the prescribing of psychoactive medications, the APRN-PMH intentionally seeks specific therapeuticresponses, anticipates common side effects, safeguards against adverse drug interactions, and is alert for unintendedor toxic responses.

Case Management:Case Management for the APRN-PMH involves population specific nursing knowledge coupled with research,

knowledge of the social and legal systems related to mental health and expertise to engage a wide range of servicesfor the patient, regardless of setting. The APRN-PMH may oversee or directly engage in case management activities.The APRN- PMH analyzes barriers to care and intervenes to change or improve systems to mobilize therapeuticresources needed by the patient for maximum positive outcomes. Case management activities may be with a singleclient or with a specific population such as the seriously and persistently mentally ill. In the community, the APRN-PMHmay focus on the mental health needs of the population as a whole. The APRN-PMH may design programs to meet themental health needs of a population (such as the seriously and persistently mentally ill) or to target a population atrisk for developing mental health problems through health and wellness promotion, identification and ameliorationof risk factors, screening and early intervention. These activities are informed by the full range of nursing knowledgewhich includes a holistic approach to individuals, families, communities that is cognizant and respectful of culturaland spiritual norms and values.

Consultation Liaison:Consultation-liaison activities take place in general (non-psychiatric) health care arenas such as hospitals,

extended care facilities, rehabilitation centres, schools, nursing homes and outpatient clinics. The role of the

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consultation-liaison psychiatric-mental health nurse focuses on providing mental health specialist consultation ordirect care psychiatric mental health nursing services.The clinical aspect of the role ranges from mental health promotion to illness rehabilitation. The APRN-PMH focuses

on the emotional, spiritual, developmental, cognitive, and behavioural responses of patients who enter any setting ofthe health care system with actual or potential physiological dysfunction (client-centred consultation). Thepsychiatric-mental health consultation may include consultee-centered consultation with nurses and clinicians inother specialty areas to increase their bio psychosocial knowledge and skills. Such consultation may also assist theconsultee to recognize and manage their own reactions to patients that, undetected and unaddressed couldadversely affect their patient care. Psychiatric-mental health consultation may also include assessment andrecommendations for action focusing on the health care delivery organization as the client (administrative-consultation) (Caplan & Caplan, 1993).

Clinical Supervision:The APRN-PMH provides clinical supervision to assist other PMH clinicians to further develop their clinical

practice skills, to meet the standard requirement for ongoing peer consultation and for essential peer supervision. Thisprocess is an educative process focused on professional growth and development rather than staff performanceevaluation. Through education, preparation and clinical experience, the APRN-PMH is qualified to provide clinicalsupervision at the request of other mental health clinicians and clinician-trainees. The APRN-PMH as a clinicalsupervisor is expected to be involved in providing direct patient care and serve as a clinical role model as well as aclinical consultant.

FOCUSED AREAS OF PRACTICESpecialty programs in psychiatric-mental health nursing generally focus on adult and/or child-

adolescent psychiatric-mental health nursing and certifications are currently available for these two specialties. Areasof focus within psychiatric-mental health nursing has emerged based on current and anticipated societal needs. Theseareas of focus may be organized according to a developmental period (geriatric), a specific mental/emotionaldisorder (depression, severe and persistent mental illness, developmental disability), a particular practice focus(forensics, addictions, community, family, couple, individual) and/or a specific role or function (case management,consultation-liaison).

Psychiatric-Mental Health Nursing Clinical Practice SettingsThe settings and arrangements for psychiatric-mental health nursing practice vary widely in purpose, type,

location, and the auspices under which they are operated. Psychiatric- mental health nurses may work in organizedsettings and may be paid for their services on a salaried, contractual or fee for service basis. In addition, the APRN-PMH may be self-employed, practice autonomously and bill clients for services provided. Today, because of theadvances in brain research and pharmacological treatments, as well as the current focus on cost effective treatment,most clients in need of mental health are cared for in community settings. Acute, intermediate and long-term caresettings still admit and care for psychiatric patients but lengths of stay, especially in acute and intermediate settingshave decreased in response to fiscal mandates, the availability of community-based settings, and consumerpreference.

Crisis Intervention/Psychiatric Emergency Services:Crisis intervention units may be found in the emergency department of a general or psychiatric hospital or

within centres in the community. In crisis patients demonstrate severe symptoms and require a high intensity ofnursing services.

Acute Inpatient Care:This setting involves the most intensive care and is reserved for acutely ill patients who are at high

risk for harming themselves or others, and/or are unable to care for their basic needs. This treatment is often “shortterm”. These units may be in a psychiatric hospital, within a general hospital or a state mental hospital.

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Intermediate and Long Term Care:Intermediate and long-term care facilities may admit patients but more often they receive patients

transferred from acute care settings. Intermediate and long-term care provides treatment and rehabilitation forpatients who are at chronic risk for harming themselves or others due to mental illness. Long-term inpatient careusually involves a minimum of three months. Both public and private psychiatric facilities provide this type of care.However, trends in psychiatric mental health care delivery continue to shift the locus of care to community settings.This is, in part, financially driven as state budgets continue to reduce funding for mental health care as part of theirinitiatives to balance their budgets and as reimbursement for intermediate and long term care for private institutionsis consistently reduced. This trend increases the risk of homelessness and inadequate housing for persons whoexperience chronic symptoms of psychiatric illness.

Partial Hospitalization/Intensive Outpatient Treatment:The aim of partial hospitalization and Intensive Outpatient Programs is acute symptom

stabilization for patients with safe housing options or employment.Residential Services:

A residential facility provides care for patients over a twenty-four hour period. Services in typicalresidential treatment facilities include psycho education around symptom management and medications, assistancewith vocational training, and sometimes with the severely and persistently mentally ill, may include activities of dailyliving training. Rehabilitation is often a goal for residential treatment facilities.Community-based Care:

Psychiatric-mental health nurses provide care within the community as an effective method ofresponding to the mental health needs of individuals, families and groups. Community-based care refers to caredelivered in partnerships with clients/consumers in their homes, worksites, mental health clinics and programs,health maintenance organizations, shelters and clinics for the homeless, crisis centres, senior centres, group homes,and other community settings.Assertive Community Treatment (ACT):

The Assertive Community Treatment model is an interdisciplinary team approach providing services in the individual’snatural setting including homeless shelters. The ACT approach provides a comprehensive range of treatments. Thegoals of ACT are to help patients meet the requirement s of community living after discharge from another morerestricted form of care, and to reduce recurrences of hospitalization (Boyd, 2005) .Telehealth:

The practice of telehealth is the removal of time and distance barriers for the delivery of health care services andrelated health care activities through telecommunications technologies (Farrell & McKinnon, 2003), and is anexpanded means of communication that promotes access to health care. The psychiatric-mental health nurse mayutilize electronic means of communication such as telephone consultation, computers, electronic mail, imagetransmission and interactive video sessions to establish and maintain a therapeutic relationship with patients bycreating an alternative sense of the nursing presence that may or may not occur in “real time”. Psychiatric mentalhealth nursing care in telehealth incorporates practice and clinical guidelines that are based on empirical evidence andprofessional consensus. Telehealth encounters carry with them particular issues especially related to confidentialityand regulation. Because telehealth technology can cross state and even national boundaries, it must be practiced inaccordance with all applicable state, federal, and international laws and regulations. Particular attention must bedirected to confidentiality, informed consent, documentation, and maintenance of records and the integrity of thetransmitted information.Self-employment:

Self-employed advanced practice psychiatric-mental health nurses offer direct services in solo privatepractice and group practice settings, or through contracts with employee assistance programs, health maintenanceorganizations, managed care companies, preferred provider organizations, industry health departments, home healthcare agencies, or other service delivery arrangements. In these settings, the APRN provides primary mental healthcare to clients in the nurse’s caseload. In the consultation-liaison role, the PMH-APRN may also contract forconsultation services focused either on the needs of the organization and its staff, or the needs of patients in a

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variety of health care settings (nursing homes, medical units, home health care). Self-employed nurses also may formnurse-owned corporations or organizations that would provide mental health service contracts to industries oremployers.

CONCLUSION:Mental health nursing is a developing field in the practice of nursing. New arenas are coming forth in this dynamic

field making nurse to assume a wide variety of roe in the community.

BIBILIOGRAPHY:1. Dr (Mrs).k. Lalitha. Mental health and psychiatric nursing: An Indian perspective. Bangalore: V M G book

house publications: 2009. Page no: 90- 1102. www.ispn-psych.org3. www.amazon.com