Psychiatric and mental health nursing

Psychiatric nursing or mental health nursing is the branch of nursing that cares for people of all ages with mental illness or mental distress, such as psychosis, depression or dementia. Nurses in this area of practice will have received specialist training to assist with these problems and consequently there are differences in the way that psychiatric mental health nurses work compared to other branches of nursing.

Different levels of practice
The clinical practice of Psychiatric-Mental Health Nursing occurs at two levels: Basic and Advanced. At the basic level, registered nurses work with individuals, families, groups and communities, assessing mental health needs, developing a nursing diagnosis and a plan of nursing care, implementing the plan and finally evaluating the nursing care. Basic level nursing practice is characterized by interventions that promote and foster health and mental health, assist clients to regain or improve their coping skills or abilities, and prevent further disability.

In working with psychiatric clients or patients, basic level nurses assist then with self care, administer and monitor psychobiologic treatment regimens, teach about health and mental health individually or in groups, including psycho-education. Basic level nurses are also prepared to assist with crisis intervention, counseling and work as case managers.

Advanced Practice Registered Nurses (APRN) have a Master’s degree in psychiatric-mental health nursing and assume the role of either Clinical Nurse Specialist or Nurse Practitioner. Psychiatric-Mental Health Nursing (PMHN) is considered a “Specialty” in nursing. Specialty practice is part of the course work in a Master’s Degree Program. In addition to the functions performed at the basic level, APRN’s assess, diagnose, and treat individuals or families with psychiatric problems/disorders or the potential for such disorders. They provide a full range of primary mental health care services to individuals, families, groups and communities, function as psychotherapists, educators, consultants, advanced case managers, and administrators. In many states, APRN’s have the authority to prescribe medications. Qualified to practice independently, Psychiatric-Mental Health APRN’s offer direct care services in a variety of settings: Mental Health Centers, community mental health programs, homes, offices, HMOs, etc.

Because of their broad background in both the biological, including pharmacological, sciences as well as the behavioral sciences, APRNs in PMHN are a rich resource as providers of psychiatric-mental health services and are advocates of and partners with the consumers of their services.

Psychiatric Nurses who earn doctoral degrees (PhD, DNSc, EdD) often are found teaching, doing research, or as administrators in hospitals, agencies or schools of nursing.

Therapeutic relationship
As with other branches of nursing practice, psychiatric mental health nursing works within nursing models, utilising nursing care plans and seeks to care for the whole person. However, the emphasis in mental health nursing is on the development of a therapeutic relationship. In practice this means that the nurse should seek to engage with the person in a positive and collaborative manner that empowers them to draw on their inner resources to recover. The therapeutic relationship can be divided into three phases. Development of the therapeutic relationship can be challenging, not just due to the nature of the person's mental illness or distress, but also because the person may be detained in a psychiatric hospital and be receiving treatment against their will under mental health law.
 * Orientation phase - getting to know each other and clarifying purpose of relationship
 * Working phase - essentially the time when the bulk of the therapeutic work is done
 * Resolution phase - this is where the patient becomes more independent and eventually is able to end the therapeutic relationship with the nurse.

Interventions
Nursing interventions may be divided into the following categories :

Physical and biological interventions
Psychiatric medication, is a commonly used intervention and many psychiatric mental health nurses are involved in the administration of medicines, both in oral (tablet) form or by intramuscular injection. Nurses will monitor for side effects and response to these medical treatments by using assessments. Nurses will also offer information on medication so that, where possible, the person in care can make an informed choice, using the best evidence available.

Psychiatric mental health nurses are also involved in the administration of the highly controversial treatment of electroconvulsive therapy and assist with the preparation and recovery from the treatment, which involves a general anaesthetic.

Along with their colleagues in other branches of nursing, they will also intervene in areas of physical need to ensure that people have acceptable levels of self-care, nutrition, sleep etc.

Psychosocial interventions
Psychosocial interventions are increasingly delivered by nurses in mental health settings and include psychotherapy interventions such as cognitive behavioural therapy for depression, anxiety and psychosis and, less commonly, psychodynamic approaches. Nurses will work with people over a period of time and use psychological methods to teach the person psychological techniques that they can then use to aid recovery and help manage any future crisis in their mental health. In practice, these interventions will be used often, in conjunction with psychiatric medications. Psychosocial interventions are based on evidence based practice and therefore the techniques tend to follow set guidelines based upon what has been demonstrated to be effective by nursing research. There has been some criticism that evidence based practice is focused primarily on quantitative research and should refect also a more qualitative research approach that seeks to understand the meaning of people's experience.

Spiritual interventions
There has been increasing interest in recent years in spiritual interventions. The basis of this approach is to look at mental illness or distress from the perspective of a spiritual crisis. Spiritual interventions focus on developing a sense of meaning, purpose and hope for the person in their current life experience. Spiritual interventions involve listening to the person's story and facilitating the person to connect to God, a greater power or greater whole, perhaps by using meditation or prayer. This may be a religious or non-religious experience depending on the individual's own spirituality. Spiritual interventions, along with psychosocial interventions, emphasise the importance of engagement, however, spiritual interventions focus more on caring and being with the person during their time of crisis, rather than intervening and trying and fix the problem. (see also humanistic approach). Spiritual interventions tend to be based on qualitative research.

Organization of mental health care
Psychiatric mental health nurses work in a variety of hospital and community settings.
 * People generally require an admission to hospital, voluntarily or involuntarily if they are experiencing a crisis that means they are unable, currently, to live safely in society. However, people may gain admission for a concentrated period of therapy or for respite. Despite changes in mental health policy in many countries that have closed psychiatric hospitals, many nurses continue work in hospitals.
 * Community nurses in mental health, work with people in their own homes (care in the community) and will often emphasise work on mental health promotion. Psychiatric mental health nurses also work in rehabilitation settings where people are recovering from a crisis episode and the where the aim is social inclusion and a return to living independently in society.
 * Psychiatric mental health nurses also work in forensic psychiatry with people who are detained as they have committed a crime or are particularly dangerous.
 * People in the older age group who are more prone to dementia tend to be cared for in separate places to younger adults and there are also specialist services for the care of adolescents with mental health problems.