Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 01: Mental Health and Mental Illness Instructor’s Manual Thoughts About Teaching the Topic The instructor will probably devote an hour or less to this material and will probably emphasize (1) the mental health–mental illness continuum; (2) the mental health assessment, using both the factors that influence mental health and the five criteria of mental health; and (3) the importance of becoming conversant with the DSM-5. The learning activities found on the Evolve Web site will assist students to operationalize this general knowledge. Activities can be used in class or assigned as independent work. Key Terms and Concepts clinical epidemiology co-morbid condition Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) electronic health care epidemiology evidence-informed practice incidence mental health mental illness Nursing Interventions Classification (NIC) Nursing Outcomes Classification (NOC) prevalence resilience Objectives Describe the two conceptualizations of mental health and mental illness. Explore the role of resilience in the prevention of and recovery from mental illness, and consider your own resilience in response to stress. Identify how culture influences our view of mental illnesses and behaviours associated with them. Define and identify attributes of positive mental health. Discuss the nature/nurture origins of psychiatric disorders. Summarize the social determinants of health in Canada. Explain how findings of epidemiological studies can be used to identify areas for medical and nursing interventions. Identify how the DSM-5 can influence a clinician to consider a broad range of information before making a diagnosis. Describe the specialty of psychiatric mental health nursing. Compare and contrast a DSM-5 medical diagnosis with a NANDA nursing diagnosis. Chapter Outline Teaching Strategies Mental Health and Mental Illness The validity of several concepts is explored, beginning with the idea that mental illness is what a culture regards as unacceptable and that mentally ill individuals are those who violate social norms. This is shown to be an inadequate definition by pointing out that political dissidents are not necessarily mentally ill. Another misconception to be discussed is that a healthy person must be logical and rational, with the point being made that each of us has irrational dreams and experiences irrational emotions. All human behaviour lies somewhere along a continuum of mental health and mental illness. Mentally healthy persons are those who are in harmony with themselves and their environment. Such individuals may possess medical deviation or disease, as long as this does not impair reasoning, judgement, intellectual capacity, and the ability to make harmonious personal and social adaptations. Instead of a definition of mental health, traits possessed by the mentally healthy are identified as happiness, control over behaviour, appraisal of reality, effectiveness in work, and a healthy selfconcept. The misconception that mental illness is incurable or treatment is unsuccessful is refuted by contrasting people with cardiovascular disease with people with mental illness. Contributing Factors Many factors can affect the severity and progression of a mental illness, as well as the mental health of a person who does not have a mental illness (Figure 1-3). If possible, these influences need to be evaluated and factored into an individual’s plan of care. Resilience Resilience is associated with adaptation and means that rather than falling victim to negative emotions, resilient people recognize their feelings, readily deal with them, and learn from experience. Accessing and developing resilience assists people to recover from painful experiences and difficult events. It is characterized by optimism and a sense of mastery and competence. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) (2011), a recovery process includes the following components: self-directed, individual, empowering, holistic, nonlinear, strengthsbased, peer-supported, respect, responsibility, and hope. Culture In determining the mental health or mental illness of an individual, we must consider the norms and influence of culture. Cultures differ in their views of mental illness, the meaning ascribed to experiences of health or illness, and the behaviour categorized as mental illness. Although some disorders such as bipolar disorder and schizophrenia are found throughout the world, other syndromes are culture bound (e.g., running amok, pibloktoq, and anorexia nervosa). The DSM-5 provides information about cultural variations for each of the clinical disorders, a description of culture-bound syndromes, and an outline of cultural formulations for evaluating and reporting the impact of the individual’s cultural context. Perceptions of Mental Health and Mental Illness Mental Illness Versus Physical Illness A distinction between mental and physical illnesses is often made. It frequently implies that psychiatric disorders are all “in the head,” whereas the majority of physical illnesses are considered to be beyond personal responsibility. Nature Versus Nurture The most prevalent and disabling mental disorders have strong biological influences. Examples are schizophrenia, bipolar disorder, major depression, obsessive-compulsive and panic disorders, post-traumatic stress disorder, and autism. Nurses are cautioned to remember that we do not treat diseases; rather we care holistically for people. Factors that affect a person’s mental health include support systems, family influences, developmental events, cultural or subcultural beliefs and values, health practices, and negative influences impinging upon one’s life. Each must be evaluated and factored into a plan of care. Figure 1-3 identifies some influences that can affect a person’s mental health. Currently, the diathesis–stress model, in which diathesis represents biological predisposition, and stress represents the environmental aspect, is the most accepted explanation for mental illness. Social Influences on Mental Health Care Self-Help Movement Groups of people with mental illnesses began to advocate for their rights and the rights of others with mental illness; they fight stigma, discrimination, and forced treatment. Decade of the Brain The last decade of the 1900s was designated as the Decade of the Brain” by then U.S. president George H.W. Bush. The goal was to make legislators and the general public aware of the advances that had been made in neuroscience and brain research (Tandon, 2000). Mental Health for Canadians: Striking a Balance One of the first national reports, Mental Health for Canadians: Striking a Balance (Epp, 1988), sought to review mental health–related policies and programs. Three challenges in mental health were identified at that time: (1) reducing inequities, (2) increasing prevention, and (3) enhancing coping. These challenges continue, and the more recent Mental Health Commission of Canada strategy (2012) identified similar challenges: (1) promoting mental health across the lifespan; (2) fostering recovery and well-being for people while upholding their rights; (3) providing timely access to treatment and supports; (4) reducing disparities; (5) recognizing the distinct circumstances, rights, and cultures in addressing mental health needs of individuals and communities; and (6) ensuring effective leadership and collaboration across sectors, agencies, and communities. Human Genome Project This project lasted from 1990 to 2003 and strengthened biological and genetic explanations for psychiatric conditions (Cohen, 2000). Although researchers have begun to identify strong genetic links to mental illness (as you will see in the chapters on clinical disorders), it will be some time before we understand the exact nature of genetic influences on mental illness. Changing Directions, Changing Lives: The Mental Health Strategy for Canada The Mental Health Commission of Canada released a report titled Toward Recovery & Well-Being: A Framework for a Mental Health Strategy for Canada in 2009. Up to this time, Canada did not have a national plan for the development of a mental health strategy. This put forward the vision and broad goals for the strategy that was released in 2012: Changing Directions, Changing Lives: The Mental Health Strategy for Canada. The aim of the strategy is to improve the mental health and well-being for all Canadians. Six key strategic directions (see Box 1-2) were outlined in the report. Epidemiology of Mental Disorders The epidemiology of mental disorders may be defined as the quantitative study of the distribution of mental disorders in human populations. Epidemiologists can identify high-risk groups and high-risk factors associated with illness onset, duration, and recurrence. The further study of risk factors for mental illness may then lead to important clues about the causes of various mental disorders. Incidence—the number of new cases of mental disorders in a healthy population within a given period—and prevalence—the total number of cases, new and existing, in a given population during a specific period of time, regardless of when the subjects became ill—provide information that can be used to improve clinical practice and plan public-health policies. Applications of Epidemiology Clinical epidemiology is briefly explained as a broad field that addresses what happens to people with illnesses once they are seen by providers of clinical care. Classification of Mental Disorders Presently there are two major classification systems for mental disorders in Canada: the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10-CA) (WHO, 2011). DSM-5 In the DSM-5, each of the over 350 mental disorders is conceptualized as a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. DSM-5 supports accurate diagnostic assessment by providing information about culturally diverse populations. ICD-10-CA This document helps to identify epidemiological trends among populations in an effort to report and manage the global burden of disease. What is Psychiatric Mental Health Nursing? Psychiatric mental health nurses work with knowledge, skill and compassion alongside people throughout the lifespan. They assist healthy people who are in crisis or who are experiencing life problems, as well as those with long-term mental illness. Their patients may include people with concurrent disorders (e.g., a mental disorder and a coexisting substance disorder), homeless people and families, people in jail, individuals who have survived abusive situations, and people in crisis. Psychiatric mental health nurses work with individuals, couples, families, and groups in every nursing setting: in hospitals, in patients’ homes, in halfway houses, in shelters, in clinics, in storefronts, on the street—virtually everywhere. Nursing Classifications/NIC/NOC The Nursing Interventions Classification (NIC) is a tool used to standardize, define, and measure nursing care. The Nursing Outcomes Classification (NOC) is a reference that provides standardized outcomes, definitions, and measures to describe patient outcomes influenced by nursing practice (Moorhead, 2008, p. 15). Evidence-Informed Practice The nursing diagnosis classification systems form a foundation for the novice or experienced nurse to participate in evidence-informed practice— that is, care based on the collection, interpretation, and integration of valid, important, and applicable patient-reported, clinician-observed, and research-derived evidence. Levels of Psychiatric Mental Health Clinical Nursing Practice Levels of psychiatric mental health nursing clinical practice are differentiated by educational preparation, professional experience, and certification. Basic Level A psychiatric mental health registered nurse holds a diploma or baccalaureate degree in nursing or psychiatric nursing and may become certified. Certification demonstrates that the nurse has met the profession’s standards of knowledge and experience in the specialty. Advanced Practice An advanced-practice registered nurse–psychiatric mental health (APRN-PMH) will have preparation at the master’s degree or higher level in psychiatric nursing and will have the designation clinical nurse specialist or nurse practitioner. Future Challenges and Roles for Psychiatric Mental Health Nurses Future trends for psychiatric nursing indicate the need to strengthen current roles and develop novel approaches to patient care. Key trends will affect the future of psychiatric nursing: the aging of the population, increasing cultural diversity, ever-expanding technology, and advocacy for broader social determinants of mental health. The growing number of older Canadians with Alzheimer’s disease and other dementias will require increased skilled nursing care in institutions. Healthier older adults will need services at home, in retirement communities, or in assisted-living facilities. Cultural diversity is steadily increasing in Canada. Recent immigrants represent about 16% of Canada’s population (Ali, 2002). These new Canadians add to and form an important part of our social, cultural, and economic institutions. Going forward, psychiatric mental health nurses will need to increase their cultural competence—that is, their relational practice and awareness of the unique experiences and views of their patients regarding mental health, illness, and response to treatment. Technology is also important in areas of the nurse’s communication, patient care, and patient teaching. The Internet and telehealth can provide individuals with health lines to care from a totally new perspective. This will mean that psychiatric nurses must remain current and become more active in providing patient care in new and innovative ways. Psychiatric nurses will also need to remain current with technological advances that can shape their practice. There will be an increased need for nurses to understand research and help promote and propose research areas that addresses prevention of mental illness and early treatment and intervention, as new methodologies become available. Finally, the psychiatric nurse will have an advocacy role in protecting the rights of patients with psychiatric disabilities, particularly those rights that concern the broader social determinants of health and mental health. This role needs to continue to evolve. The nurse must be vigilant about provincial or territorial and national legislation affecting health care to identify potential detrimental effects on the mentally ill. We know that mental health care looks much different today from how it looked a half century ago. We have more and better services for more individuals, but we also know that we still have individuals who do not receive decent mental health care. As concerned professionals, we need to continue to make required improvements toward the goal of serving those who are in need of mental health care in local, rural, and remote geographical areas. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 02: Historical Overview of Psychiatric Mental Health Nursing Instructor’s Manual Thoughts About Teaching the Topic The instructor will incorporate this historical overview in an introduction to a course as a prereading and to set the context for topics to follow (e.g., ethics, therapeutic relationships, care in acute and community settings, and so on). The learning activities found on the Evolve Web site will assist students to operationalize this general knowledge. Activities can be used in class or assigned as independent work. Key Terms and Concepts advanced-practice nursing (APN) Chapter Outline Teaching Strategies Trends in approaches to the treatment of mental illness have contributed to the emergence and evolution of the role of psychiatric nursing. These trends stem largely from societal values, politics, culture, and economics. Early Mental Illness Care Early asylums were eighth-century Middle Eastern asylums Canadian Federation of Mental Health Nurses custodial care deinstitutionalization Dorothea Dix moral treatment Philippe Pinel Registered Psychiatric Nurses of Canada Weir Report William Tuke Objectives Identify the sociopolitical, economic, cultural, and religious factors that influenced the development of psychiatric mental health nursing. Summarize the influence of psychiatric treatment trends on the role of the nurse. Identify the factors that led to the separate designations of registered nurse and registered psychiatric nurse. Analyze the factors that have enhanced and delayed the professionalization of psychiatric mental health nursing. Consider the future potentials and challenges for psychiatric mental health nursing in Canada. retreats from society, with the view that after several months of rest, people with mental illness could be cured (Weir, 1932). These early treatment centres, guided by Islamic beliefs, provided a compassionate and peaceful environment in which to care for people with mental illnesses. In medieval Western Europe, strong religious influences inspired the belief that mental illness was the cause of spiritual failings or sin, resulting in treatments that were punitive. By the fifteenth century, several asylums had been built across Europe, and patients were often chained or caged, and cruelty or neglect was the norm (Digby, 1983). In late-1700s France, more humane treatments were developed—literally removing the chains of the patients, talking to them, and providing a calmer, soothing environment. In England, similarly, the use of social and psychological approaches emerged as “moral treatment” (Digby, 1983). This revolutionary way of treating people with mental illness swept across Europe and influenced the design of early asylums in North America. Early Canadian Mental Health Care Canada’s context draws on this history but is uniquely influenced by the history, immigration patterns and the land itself. Canada’s Aboriginal peoples had a variety of holistic approaches to treating mental illness—treating mind, body, and soul—and included sweat lodges, animistic charms, potlatch, and Sundance (Kirkmayer, Brass, & Tait, 2000). Sixteenth-century colonial settlers from France and England brought their own approach, with responsibility for care falling upon the family and religious orders, such as the Grey Nuns, who provided early care in Canada (Hardill, 2006). By the 1800s, migration to Canada increased alongside urbanization, and the European model of asylums was established. Early Canadian Asylums Asylums were built in country-like settings, providing occupational therapies such as farming. Toward the end of the nineteenth century, asylum care became more acceptable, with family support systems becoming diluted due to rapid urbanization (Cellard & Thifault, 2006). The lack of success in treating mental illnesses, combined with overcrowding in many asylums, meant that minimal—or custodial—care was the norm. Many sought to reform these approaches, among them Dorothea Dix, a retired school teacher from New England who was the superintendent of nurses during the American Civil War. Dix was educated in the asylum reform movements in England while she was there recuperating from tuberculosis. Passionate about social reform, she began advocating for the improved treatment and public care of people with mental illness. Early Psychiatric Treatments By the end of the nineteenth century, the new field of psychiatry sought medical cures for mental illness. With few medications available other than heavily alcoholbased sedatives, doctors used many experimental treatments—for example, leeching (using bloodsucking worms), spinning (tying the patient to a chair and spinning it for hours), hydrotherapy (forced baths), and insulin shock treatment (injections of large doses of insulin to produce daily comas over several weeks). By the mid-twentieth century, treatment choices expanded to include electroconvulsive therapy (see Chapter 14) and lobotomies, through which nerve fibres in the frontal lobe were severed. With these more invasive treatments, more patient monitoring beyond custodial care led to the recruitment of nurses to work in these experimental medical institutions. Bringing Nurses to Asylums No nurses were working in Canadian psychiatric settings prior to the late 1800s. Asylums used predominantly male attendants to provide custodial care for patients. The increased medicalization of psychiatry prompted a need for more specially trained providers, especially for female patients (Connor, 1996). The first psychiatric institution in Canada offered a 2-year diploma (to women only) in Kingston, Ontario, in 1888 (Kerrigan, 2011). The curriculum, which was taught by physicians, included courses in physiology, anatomy, nursing care of the sick, and nursing care of the insane (Legislature of the Province of Ontario, 1889). Shifts in Control Over Nursing In the early 1900s, the Canadian Nurses Association’s (CNA) desires to professionalize nursing were contentious, mostly because physicians wanted control over nursing education; patriarchal society structures devalued nursing knowledge; nursing skills were seen as natural women’s work; and hospitals relied on the economical service hours of nursing students (Anthony & Landeen, 2009). In 1932, a joint Canadian Medical Association and CNA report—the “Weir Report ”—concluded that drastic changes were needed in nursing education programs, including standardization of curriculum, work hours, instructor training, and that care of people with mental illnesses needed to be integrated into all generalist programs (Fleming, 1932). A split between Western and Eastern Canada in training programs occurred, with the western provinces creating the specialty-focused psychiatric nursing training programs and the registered psychiatric nurse designation separately, and the eastern and Atlantic provinces offering a generalist training. Deinstitutionalization and the Role of Psychiatric Nursing Psychiatric nursing continued to take place predominantly in hospital settings until the 1960s, when deinstitutionalization shifted care into communities. Since then, a wide range of community-based mental health services eventually developed (e.g., crisis management, consultation-liaison, primary care psychiatry), creating new settings and skill requirements for psychiatric mental health nurses. University Education The first shift from hospital to university education occurred in the 1930s, with the first degree offered at the University of Toronto in 1942. In Western Canada, the shift to the role of registered psychiatric nurse, and the increased range of practice settings into community settings brought about radical changes in educational programs over the past 20 years. Psychiatric nurse diploma training continued until 1995, when Brandon University began its baccalaureate program in psychiatric mental health nursing. Registered Psychiatric Nurses of Canada (RPNC) issued a position statement in 2008 advocating for baccalaureate degree entry to practice for RPNs due to the increasingly complex needs and roles of the registered psychiatric nurse (Registered Psychiatric Nurses of Canada, 2008a). Further, the first graduate program in psychiatric nursing for registered psychiatric nurses began at Brandon University in January 2011. National Certification Since 1995, the Canadian Nurses Association has offered registered nurses certification in psychiatric mental health nursing; this certification exam is one of the most commonly written (CNA, 2011b) Advanced Practice Advanced-practice nursing (APN) includes the roles of nurse practitioner and clinical nurse specialist (CNA, 2008). Each province has its own regulations guiding the licensing and scope of practice for APN. The clinical nurse specialist (CNS) role has been well established in psychiatry since the 1970s. CNSs can provide psychotherapy and have worked as consultants, educators, and clinicians in inpatient and outpatient psychiatry throughout Canada. Nurse practitioners, on the other hand, work as consultants or collaborative team members and can diagnose, prescribe and manage medications, and can also provide psychotherapy. While the role of psychiatric nurse practitioner has been well established in the United States, the role has remained virtually nonexistent in Canada. Future Directions Based on its success in the United States, the role of advanced-practice nurse in psychiatric mental health care is another one that is certain to develop in Canada in the future. The changes in public perception of mental illness and decreases in stigma are beginning to increase the role of mental health promotion and illness prevention in schools and workplace settings. Evidence-informed approaches to treatment have led to the creation of related nursing roles, education, and research. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400
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