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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing: Mental Health and Community Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

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Nursing: Mental Health and Community Concepts [Internet].

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Chapter 1 Foundational Mental Health Concepts

1.1. INTRODUCTION

Learning Objectives

  • Describe basic concepts related to mental health care
  • Establish a safe environment for clients, nurses, and other staff
  • Discuss psychiatric-mental health nursing and associated standards of care
  • Apply principles of patient-centered care while considering client diversity across the life span

Mental health is an important part of everyone’s overall health and well-being. Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make healthy choices. Mental health is important at every stage of life, from childhood to adolescence and through adulthood. [1] This chapter will provide an overview of mental health, mental illness, and mental health nursing. As with all areas of nursing, when caring for a person with a mental health diagnosis, it is important to focus on patient-centered care and evaluate the effectiveness of care in terms of the highest level of functioning that person is able to achieve.

Reflective Questions

As we begin this chapter, reflect on the following questions:

1.

How do you define mental health?

2.

How do you define mental illness?

3.

How do you differentiate between the two with everyday functioning?

4.

Consider how you communicate with clients. Which therapeutic techniques have you found work best? What interferes with effective communication?

5.

How does ineffective communication impact client care? How can it affect your nursing license or create legal implications?

References

1.
Centers for Disease Control and Prevention. (2021, July 20). Mental health. https://www​.cdc.gov/mentalhealth/index​.htm.

1.2. MENTAL HEALTH AND MENTAL ILLNESS

Mental health is an essential component of health. The World Health Organization (WHO) defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Mental health is a state of well-being in which an individual realizes their own abilities, copes with the normal stresses of life, works productively, and contributes to their community. The promotion, protection, and restoration of mental health is a vital concern of individuals, nurses, communities, and societies throughout the world. [1]

According to the American Psychiatric Association, mental illness is a health condition involving changes in emotion, thinking, or behavior (or a combination of these) associated with emotional distress and problems functioning in social, work, or family activities. [2] Mental illness is common in the United States. Nearly one in five (19 percent) of adults experience some form of mental illness, one in twelve (8.5 percent) have a substance use disorder, and one in 24 (4 percent) have a serious mental illness. [3]

Poor mental health increases the risk of chronic physical illnesses, such as heart disease, cancer, and strokes, and can lead to thoughts and intentions of suicide. Suicide is a common symptom associated with mental illness and is the second leading cause of death in Americans aged 15-34. [4]

View the following YouTube video on WHO’s Special Initiative on Mental Health (2019-2023) [5]: WHO Special Initiative on Mental Health (2019-2023)

Mental Health Continuum

Mental health fluctuates over the course of an individual’s life span and can range from well-being to emotional problems and/or mental illness as indicated on the mental health continuum illustrated in Figure 1.1. [6],[7],[8]

Figure 1.1 . Mental Health Continuum (Used with permission.

Figure 1.1

Mental Health Continuum (Used with permission.)

Well-being is on the “healthy” range of the mental health continuum in which individuals are experiencing a state of good mental and emotional health. They may experience stress and discomfort resulting from occasional problems of everyday life, but they are able to cope effectively with these stressors and experience no impairments to daily functioning.

On the other end of the mental health continuum are mental health problems where individuals have progressively more difficulty coping with serious problems and stressors. Within this range are two categories: emotional problems/concerns and mental illness. For individuals experiencing emotional problems, discomfort has risen to a level of mild to moderate distress, and they are experiencing mild or temporary impairments in functioning, such as insomnia, lack of concentration, or loss of appetite. As their level of distress increases, they may seek treatment and often start with visiting their primary health care provider.

Emotional problems become classified as “mental illness” when an individual’s level of distress becomes significant, and they have moderate to severe impairment in daily functioning at work, school, or home. Mental illness includes relatively common disorders, such as depression and anxiety, as well as less common disorders such as schizophrenia. Mental illness is characterized by alterations in thinking, mood, or behavior. The term serious mental illness refers to mental illness that causes disabling functional impairment that substantially interferes with one or more major life activities. The Americans With Disabilities Act defines major life activities as, “caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.” [9] Examples of serious mental illnesses that commonly interfere with major life activities include major depressive disorder, schizophrenia, and bipolar disorder. [10] Individuals with serious mental illnesses may experience long-term impairments ranging from moderate to disabling in nature, but many can lead productive lives with effective treatment. Roughly half of schizophrenia patients recovered or significantly improved over the long-term, suggesting that functional remission is possible. [11],[12]

Mental health providers, such as psychiatrists, psychologists, therapists, social workers, or advanced practice mental health nurses, use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) published by the American Psychiatric Association to assess a client’s signs and symptoms and determine a mental health diagnosis. The manual lists diagnostic criteria including feelings, behaviors, and time frames to be officially classified as a mental health disorder. [13]

There are more than 200 types of mental illness. People can experience different types of mental health disorders, and different disorders can occur at the same time or vary in intensity over time. Mental illness can be ongoing, occur over a short period of time, or be episodic (i.e., it comes and goes with discrete beginnings and ends). [14]

Read more information about specific mental health disorders at the Medline Plus Mental Health and Behavior webpage.

Assessing Dysfunction and Impairment

Mental health disorders have been defined as a type of dysfunction that causes distress or impaired functioning and deviates from typical or expected behavior according to societal or cultural standards. This definition includes three components referred to as dysfunction, distress, and deviance. [15]

Dysfunction includes disturbances in a person’s thinking, emotional regulation, or behavior that reflects significant dysfunction in psychological, biological, or developmental processes underlying mental functioning. In other words, dysfunction refers to a breakdown in cognition, emotion, and/or behavior. For instance, an individual experiencing a delusion that they are an omnipotent deity has a breakdown in cognition because their thought processes are not consistent with reality. An individual who is unable to experience pleasure has a breakdown in emotion, and an individual who is unable to leave home and attend work due to fear of having a panic attack is exhibiting a breakdown in behavior. [16]

Distress refers to psychological and/or physical pain. Simply put, distress refers to suffering. For example, the loss of a loved one causes anyone to experience emotional pain, distress, and a temporary impairment in functioning. Impairment refers to a limited ability to engage in activities of daily living (i.e., they cannot maintain personal hygiene, prepare meals, or pay bills) or participate in social events, work, or school. Impairment can also interfere with the ability to perform important life roles such as a caregiver, parent, or student. [17]

Deviance refers to behavior that violates social norms or cultural expectations because one’s culture determines what is “normal.” When a person is described as “deviant,” it means they are not following the stated and unstated rules of their society (referred to as social norms). [18]

Nurses complete and document initial and ongoing assessments of dysfunction, distress, and behavior associated with an individual’s diagnosed mental health disorder. The World Health Organization Disability Assessment Scale (WHODAS) is a tool recommended in the DSM-5 to assess impairments resulting from mental illness. [19] The WHODAS is a generic assessment instrument that provides a standardized method for measuring health and disability across cultures. [20] The WHODAS assesses functioning in six domains: cognition, mobility, self-care, getting along, life activities, and participation. [21]

The Global Assessment of Functioning (GAF) was historically used to rate the seriousness of a mental illness and measure how symptoms affect an individual’s day-to-day life on a scale of 0 to 100. It is an overall (global) measure of how clients are doing and rates psychological, social, and occupational functioning on the continuum from mental well-being to serious mental illness. The higher the score, the better the daily functioning. The GAF was omitted from the DSM-5 because it had questionable validity and reliability, but some government agencies and insurance companies continue to include it in paperwork to assess client functioning. [22]

Recovery

Mental illness is treatable. Research shows that people with mental illness can get better, and many recover completely. [23] The majority of individuals with mental illness continue to function in their daily lives. Recovery refers to a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. [24] Dimensions that support a life in recovery include the following:

  • Health: Overcoming or managing one’s disease(s), as well as living in a physically and emotionally healthy way
  • Home: Having a stable and safe place to live
  • Purpose: Participating in meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society
  • Community: Enjoying relationships and social networks that provide support, friendship, love, and hope

Early Signs of Mental Health Problems

Mental health problems are common. We all experience problems and stressors from daily living at the milder end of the mental health continuum, and at some point in our lives, we are likely to experience emotional problems or concerns. Mental illness, though less common, is nevertheless a frequent occurrence, and it is estimated that approximately one in five Americans will personally experience a mental illness in their lifetime. [25],[26]

Nurses in all care settings must recognize signs and symptoms of diagnosed and undiagnosed emotional and mental health problems in clients. Each mental health disorder has specific signs and symptoms, but common signs of mental health problems in adults and adolescents are as follows [27]:

  • Excessive worrying or fear
  • Excessive sad or low feelings
  • Confused thinking or problems concentrating and learning
  • Extreme mood changes, including uncontrollable “highs” or feelings of euphoria
  • Prolonged or strong feelings of irritability or anger
  • Avoidance of friends and social activities
  • Difficulty understanding or relating to other people
  • Changes in sleeping habits or feeling tired and low energy
  • Changes in eating habits, such as increased hunger or lack of appetite
  • Changes in sex drive
  • Disturbances in perceiving reality referred to as hallucinations (i.e., when a person senses things that don’t exist in reality)
  • Inability to perceive changes in one’s own feelings, behavior, or personality (i.e., lack of insight)
  • Misuse of substances like alcohol, drugs, or prescription medications
  • Multiple physical ailments without obvious causes (such as headaches, stomachaches, or vague and ongoing “aches and pains”)
  • Thoughts of suicide
  • Inability to carry out daily activities or handle daily problems and stress
  • Intense fear of weight gain or being overly concerned with appearance

Mental health disorders can also be present in young children. Because children are still learning how to identify and talk about thoughts and emotions, their most obvious symptoms are behavioral or complaints of physical symptoms. Behavioral symptoms in children can include the following [28]:

  • Changes in school performance
  • Excessive worry or anxiety, for example fighting to avoid going to bed or school
  • Hyperactive behavior
  • Frequent nightmares
  • Frequent disobedience or aggression
  • Frequent temper tantrums

View the following YouTube video about warning signs of mental health problems [29]: 10 Common Warning Signs of a Mental Health Condition

Cultural Impact

Cultural values and beliefs impact how a person views certain ideas or behaviors. In the case of mental health, it can impact whether or not the individual seeks help, the type of help sought, and the support available. Every individual has different cultural beliefs and faces a unique journey to recovery. In general, historically marginalized communities in the United States are less likely to access mental health treatment, or they wait until symptoms are severe before seeking assistance. [30]

Four ways that culture can impact mental well-being are the following [31]:

  • Cultural stigma. Every culture has a different perspective on mental health, and most cultures have a stigma surrounding mental health. Mental health challenges may be considered a weakness and something to hide, which can make it harder for those struggling to talk openly and ask for help.
  • Describing symptoms. Culture can influence how people describe or feel about their symptoms. It can affect whether someone chooses to recognize and talk openly about physical symptoms, emotional symptoms, or both. For example, members of the Amish community are typically stoic and endure physical and emotional pain without complaining.
  • Community support. Cultural factors can determine how much support someone gets from their family and community when it comes to mental health. Because of existing stigma, it can be challenging for individuals to find mental health treatment and support.
  • Resources. When looking for mental health treatment, it can be difficult to find resources and treatment options that take into account a specific culture’s concerns and needs.

Nurses can help clients by understanding the role culture plays in their mental health. If potential signs of undiagnosed or poorly managed mental health disorders are present, nurses should make appropriate referrals for further assessment and follow-up.

Read more about cultural diversity and providing culturally responsive care in the “Diverse Patients” chapter of Open RN Nursing Fundamentals.

Causes of Mental Illness

Mental health researchers have developed several theories to explain the causes of mental health disorders, but they have not reached consensus. One factor in which they all agree is that an individual is not at fault for the condition, and they cannot simply turn symptoms on or off at will. There are likely several factors that combine to trigger a mental health disorder, including environmental, biological, and genetic factors. [32]

Environmental Factors

Individuals are affected by broad social and cultural factors, as well as by unique factors in their personal environments. Social factors such as racism, discrimination, poverty, and violence (often referred to as “social determinants of health”) can contribute to mental illness.

Read more about addressing social determinants of health in the “Advocacy” chapter of Open RN Nursing Management and Professional Concepts.

Additionally, it is estimated that 61% of adults have experienced early adverse childhood experiences (ACEs) such as abuse, neglect, or growing up in a household with violence, mental illness, substance misuse, incarceration, or divorce. Chronic stress from ACEs can change brain development and affect how the body responds to stress. ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood. [33],[34] See Figure 1.2 [35] for an image of adverse childhood experiences.

Figure 1.2

Figure 1.2

Adverse Childhood Experiences (ACEs)

Individual trauma resulting from an event, series of events, or set of circumstances that is experienced as physically or emotionally harmful can have lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. [36] Read more about ACEs and addressing individual trauma in the “Introduction to Trauma-Informed Care” section of this chapter.

Take the Adverse Childhood Experiences Questionnaire for Adults to better understand how previous experiences can affect one’s well-being.

Current stressors such as relationship difficulties, the loss of a job, the birth of a child, a move, or prolonged problems at work can also be important contributory environmental factors. [37]

Read more about stress in the “Stress, Coping, and Crisis Intervention” chapter.

Biological Factors

Scientists believe the brain can have an imbalance of neurotransmitters, such as dopamine, acetylcholine, gamma-aminobutyric acid (GABA), norepinephrine, glutamate, and serotonin, resulting in changes in behavior, mood, and thought. While causes of fluctuations in brain chemicals aren’t fully understood, contributing factors can include physical illness, hormonal changes, reactions to medication, substance misuse, diet, and stress. [38]

Read more about neurotransmitters and the central nervous system in the “Psychotropic Medications” chapter.

Some studies also suggest that depressive and bipolar disorders are accompanied by immune system dysregulation and inflammation. [39]

Genetics

There appears to be a hereditary pattern to some mental illnesses. For example, individuals with major depressive disorder often have parents or other close relatives with the same illness. Research continues to investigate genes involved in specific disorders so that treatment can be effectively targeted to the individual. [40]

View the following YouTube video on causes of mental illness [41]: Understanding the Biology of Mental Illness

WHO Guidelines for Mental Health Care

It is vital for nurses to protect and promote the mental well-being of all individuals and address the needs of individuals with diagnosed mental disorders. [42] The World Health Organization (WHO) published the Mental Health Intervention Guide for nurses and primary health care providers that provides evidence-based guidance and tools for assessing and managing priority mental health and substance use disorders using clinical decision-making protocols. Essential principles for providing mental health care include promoting respect and dignity for the individuals seeking care; using effective communication skills to ensure care is provided in a nonjudgmental, nonstigmatizing, and supportive manner; and conducting comprehensive assessments. [43]

Promoting Respect and Dignity

Individuals with mental health and substance use conditions should be treated with respect and dignity in a culturally appropriate manner. Health care professionals should promote the preferences of people with mental health and substance use disorders and support them, their family members, and their loved ones in an inclusive and equitable manner. These are some tips discussed in the WHO Mental Health Intervention Guide [44]:

Do:

  • Treat people with mental health and substance use conditions with respect and dignity.
  • Protect confidentiality.
  • Ensure privacy.
  • Provide access to information and explain the proposed treatment risks and benefits in writing when possible.
  • Make sure the person provides consent to treatment.
  • Promote autonomy and independent living in the community.
  • Provide access to decision-making options.

Don’t:

  • Discriminate against people with mental health and substance use conditions.
  • Ignore individual preferences.
  • Make decisions for or on behalf of individuals.
  • Use overly technical language when explaining proposed treatment.

Using Effective Communication Skills

Using effective communication skills promotes quality mental health care. Tips for effective communication from the WHO Mental Health Intervention Guide include the following [45]:

  • Create an environment that facilitates open communication.
    • Meet the person in a private space, if possible.
    • Be welcoming and conduct introductions in a culturally appropriate manner.
    • Use culturally appropriate eye contact, body language, and facial expressions that facilitate trust.
    • Explain to adults that information discussed during the visit will be kept confidential. (Special considerations regarding “conditional confidentiality” and mandatory reporting for minors are discussed in the “Childhood and Adolescence Disorders” chapter.)
    • If caregivers are present, suggest speaking with the client alone (except for young children) and obtain consent from the client to share clinical information.
    • When interviewing a young person, consider having another person present who identifies with the same gender to maintain feelings of a psychologically safe environment.
  • Involve the person.
    • Include the person (and with their consent, their caregivers and family members) in all aspects of assessment and management as much as possible. This includes children, adolescents, adults, and older adults.
  • Start by listening.
    • Actively listen. Be empathic and sensitive. (Read more about active listening in the “Therapeutic Communication and the Nurse-Client Relationship” chapter.)
    • Allow the person to speak without interruption.
    • Be patient and ask for clarification of unclear information.
    • For children, use language that they can understand. For example, ask about their interests (toys, friends, school, etc.).
    • For adolescents, convey that you understand their feelings and situation.
  • Be friendly, respectful, and nonjudgmental.
    • Always be respectful.
    • Be nonjudgmental about an individual’s behaviors and appearances.
    • Remain calm and professional.
  • Use good verbal communication skills.
    • Use simple language. Be clear and concise. Avoid medical terminology only understood by health care professionals.
    • Use open-ended questions and other therapeutic communication techniques. (Read more about specific techniques in the “Therapeutic Communication and the Nurse-Client Relationship” chapter.) For example:
      • Use open-ended questions: “Tell me more about what happened?”
      • Summarize: “So, your brother pushed you off your bike and then laughed when you fell and started crying?”
      • Clarify: “To clarify, were you at home or a neighbor’s house when this happened?”
    • Summarize and repeat key points at the end of the conversation.
    • Allow the person to ask questions about the information provided. For example, “What questions do you have about what we have discussed today?”
  • Respond with sensitivity when people disclose traumatic experiences (e.g., sexual assault, violence, or self-harm).
    • Thank the person for sharing this sensitive information.
    • Show extra sensitivity when discussing difficult topics.
    • Remind the person that what they tell you will only be shared with the immediate treatment team to provide the best possible care.
    • Acknowledge that it may have been difficult for the person to disclose the information.

Therapeutic Relationship

In all nursing care, the therapeutic relationship with the client is essential. This is especially so in psychiatric care, where the therapeutic relationship is considered to be the foundation of client care and healing. [46] Although nurse generalists are not expected to perform advanced psychiatric interventions, all nurses are expected to engage in compassionate, supportive relationships with their patients and use therapeutic communication as part of the “art of nursing.” [47]

The nurse-client relationship establishes trust and rapport with a specific purpose. It facilitates therapeutic communication and engages the client in decision-making regarding their plan of care. Read more about therapeutic communication and the nurse-client relationship in the “Therapeutic Communication and the Nurse-Client Relationship” chapter.

Conducting Comprehensive Assessments

Clients undergo comprehensive assessments related to their disorder, including mental status examination, psychosocial assessment, physical examination, and review of laboratory results. Specific nursing assessments are further discussed in the “Application of the Nursing Process in Mental Health Care” chapter as well in each “Disorder” chapter. Persons with severe mental health and substance use disorders are two to three times more likely to die of preventable disease like infections and cardiovascular disorders, so it is also important for nurses to advocate for the medical treatment of existing physical disorders. [48]

References

1.
World Health Organization. (2018, March 30). Mental health: Strengthening our response. https://www​.who.int/news-room​/fact-sheets​/detail/mental-health-strengthening-our-response.
2.
American Psychiatric Association. (n.d.). What is mental illness? https://www​.psychiatry​.org/patients-families​/what-is-mental-illness.
3.
American Psychiatric Association. (n.d.). What is mental illness? https://www​.psychiatry​.org/patients-families​/what-is-mental-illness.
4.
Centers for Disease Control and Prevention. (2021, July 20). Mental health. https://www​.cdc.gov/mentalhealth/index​.htm.
5.
World Health Organization (WHO). (2020, July 20). WHO special initiative on mental health (2019-2023) [Video]. YouTube. All rights reserved. https://youtu​.be/ti7OIMq7V9I.
6.
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William S. The continuum between temperament and mental illness as dynamical phases and transitions. Frontiers in Psychiatry. 2021 January 18;11:1617. [PMC free article: PMC7848037] [PubMed: 33536952] [CrossRef]
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Office of Federal Contract Compliance Programs. (2009, January 1). ADA Amendments Act of 2008 frequently asked questions. U.S. Department of Labor. https://www​.dol.gov/agencies​/ofccp/faqs/americans-with-disabilities-act-amendments.
10.
American Psychiatric Association. (n.d.). What is mental illness? https://www​.psychiatry​.org/patients-families​/what-is-mental-illness.
11.
Vita A., Barlati S. Recovery from schizophrenia: Is it possible? Current Opinion in Psychiatry. 2018;31(3):246–255. [PubMed: 29474266] [CrossRef]
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Rakitzi S., Georgila P., Becker-Woitag A. P. The recovery process for individuals with schizophrenia in the context of evidence-based psychotherapy and rehabilitation: A systematic review. European Psychologist. 2021;26(2):96–111. [CrossRef]
13.
American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5.
14.
Centers for Disease Control and Prevention. (2021, July 20). Mental health. https://www.cdc.gov/mentalhealth/index.htm 
15.
Culture and Psychology by Worthy, Lavigne, and Romero is licensed under CC BY-NC-SA 4.0.
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Culture and Psychology by Worthy, Lavigne, and Romero is licensed under CC BY-NC-SA 4.0.
17.
Culture and Psychology by Worthy, Lavigne, and Romero is licensed under CC BY-NC-SA 4.0.
18.
Culture and Psychology by Worthy, Lavigne, and Romero is licensed under CC BY-NC-SA 4.0.
19.
Office of Federal Contract Compliance Programs. (2009, January 1). ADA Amendments Act of 2008 frequently asked questions. U.S. Department of Labor. https://www​.dol.gov/agencies​/ofccp/faqs/americans-with-disabilities-act-amendments.
20.
World Health Organization. (2012). Measuring health and disability: Manual for WHO disability assessment schedule (WHODAS 2.0). [Manual]. https://www​.who.int/publications​/i/item/measuring-health-and-disability-manual-for-who-disability-assessment-schedule-(-whodas-2.0)
21.
National Academies of Sciences, Engineering, and Medicine. (2016). Measuring specific mental illness diagnoses with functional impairment: Work-shop summary. J. C. Rivard and K. Marton, Rapporteurs. Committee on National Statistics and Board on Behavioral, Cognitive, and Sensory Sciences, Division of Behavioral and Social Sciences and Education. Board on Health Sciences Policy, Institute of Medicine. The National Academies Press. http://elibrary​.pcu.edu​.ph:9000/digi/NA02/2016/21920.pdf. [PubMed: 27227211]
22.
Smith, M. (2021, February 6). What is the global assessment of functioning (GAF) scale? WebMD. https://www​.webmd.com​/mental-health/gaf-scale-facts.
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Centers for Disease Control and Prevention. (2021, July 20). Mental health. https://www​.cdc.gov/mentalhealth/index​.htm.
24.
Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https://www​.ncbi.nlm​.nih.gov/books/NBK207201/ [PubMed: 24901203]
25.
William S. The continuum between temperament and mental illness as dynamical phases and transitions. Frontiers in Psychiatry. 2021 January 18;11:1617. [PMC free article: PMC7848037] [PubMed: 33536952] [CrossRef]
26.
National Alliance on Mental Illness (NAMI). (2022, June). Mental health by the numbers. https://www​.nami.org​/mhstats#:~:text=21%25%20of%20U​.S.%20adults​%20experienced,represents​%201%20in%2020%20adults.
27.
National Alliance on Mental Illness. (n.d.). Warning signs and symptoms. https://nami​.org/About-Mental-Illness​/Warning-Signs-and-Symptoms.
28.
National Alliance on Mental Illness. (n.d.). Warning signs and symptoms. https://nami​.org/About-Mental-Illness​/Warning-Signs-and-Symptoms.
29.
NAMI. (2015, February 2). 10 common warning signs of a mental health condition [Video]. YouTube. All rights reserved. https://youtu​.be/zt4sOjWwV3M.
30.
Mental Health First Aid USA. (2019, July 11). Four ways culture impacts mental health. National Council for Mental Wellbeing. https://www​.mentalhealthfirstaid​.org/2019​/07/four-ways-culture-impacts-mental-health/
31.
Mental Health First Aid USA. (2019, July 11). Four ways culture impacts mental health. National Council for Mental Wellbeing. https://www​.mentalhealthfirstaid​.org/2019​/07/four-ways-culture-impacts-mental-health/
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National Human Trafficking Training and Technical Assistance Center. (n.d.) The original ACE study. https://nhttac​.acf.hhs​.gov/soar/eguide/stop​/adverse_childhood_experiences.
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U.S. Department of Health & Human Services. (2020, January 24). Strategic goal 3: Strengthen the economic and social well-being of Americans across the lifespan. https://www​.hhs.gov/about​/strategic-plan​/strategic-goal-3/index.html.
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Kraybill, O. (2019, May 31). Inflammation and mental health symptoms. Psychology Today. https://www​.psychologytoday​.com/us/blog/expressive-trauma-integration​/201905/inflammation-and-mental-health-symptoms.
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Alabama Department of Health. (2011, July 29). Understanding the biology of mental illness [Video]. YouTube. All rights reserved. https://youtu​.be/LLUoG9Se77w .
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World Health Organization. (2018, March 30). Mental health: Strengthening our response. https://www​.who.int/news-room​/fact-sheets​/detail/mental-health-strengthening-our-response.
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Ross C. A., Goldner E. M. Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: A review of the literature. Journal of Psychiatric and Mental Health Nursing. 2009;16(6):558–567. [PubMed: 19594679] [CrossRef]
47.
Centers for Disease Control & Prevention. (2021, July 22). Coping with stress. https://www​.cdc.gov/mentalhealth​/stress-coping​/cope-with-stress/index.html.
48.

1.3. INTRODUCTION TO TRAUMA-INFORMED CARE

Many individuals experience trauma during their lifetimes that can have a lasting impact on their mental health. Trauma results from an event, series of events, or set of circumstances that are experienced by an individual as physically or emotionally harmful and can have lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being. Events may be human-made, such as war, terrorism, sexual abuse, violence, or medical trauma, or they can be the products of nature (e.g., flooding, hurricanes, and tornadoes). Nurses must keep in mind to not interject their own experiences or perspectives because something minor to them may be major to the client.

It’s not just the event itself that determines if it is traumatic, but the individual’s experience of the event. Two people may be exposed to the same event or series of events but experience and interpret these events in vastly different ways. Various biopsychosocial and cultural factors influence an individual’s immediate response and long-term reactions to trauma. For most individuals, regardless of the severity of the trauma, the effects of trauma are met with resilience, defined as the ability to rise above circumstances or meet challenges with fortitude. Resilience includes the process of using available resources to negotiate hardship and/or the consequences of adverse events. [1]

Trauma can affect people of any culture, age, gender, or sexual orientation. Individuals may also experience trauma even if the event didn’t happen to them. A traumatic experience can be a single event, a series of events, or adverse childhood experiences (ACEs). Review information about ACEs in the “Mental Health and Mental Illness” section of this chapter. There has been an increased focus on the ways in which trauma, psychological distress, quality of life, health, mental illness, and substance misuse are linked. For example, the terrorist attacks of September 11, 2001, the wars in Iraq and Afghanistan, disastrous hurricanes, and the COVID pandemic have moved traumatic experiences to the forefront of national consciousness. Trauma can affect individuals, families, groups, communities, specific cultures, and generations. It can overwhelm an individual’s ability to cope; stimulate the “fight, flight, or freeze” stress reaction; and produce a sense of fear, vulnerability, and helplessness. [2]

Read more information about the stress reaction in the “Stress, Coping, and Crisis Intervention” chapter.

For some people, reactions to a traumatic event are temporary, whereas other people have prolonged reactions to trauma with enduring mental health consequences, such as post-traumatic stress disorder, anxiety disorder, substance use disorder, mood disorder, or psychotic disorder. Others may exhibit culturally mediated physical symptoms referred to as somatization, in which psychological stress is expressed through physical concerns such as chronic headaches, pain, and stomachaches. Traumatic experiences can significantly impact how an individual functions in daily life and how they seek medical care. [3]

Individuals may not recognize the significant effects of trauma or may avoid the topic altogether. Likewise, nurses may not ask questions that elicit a client’s history of trauma. They may feel unprepared to address trauma-related issues proactively or struggle to effectively address traumatic experiences within the constraints of their agency’s policies. [4]

By recognizing that traumatic experiences are closely tied to mental health, nurses can provide trauma-informed care and promote resilience. Trauma-informed care (TIC) is a strengths-based framework that acknowledges the prevalence and impact of traumatic experiences in clinical practice. TIC emphasizes physical, psychological, and emotional safety for both survivors and health professionals and creates opportunities for survivors to rebuild a sense of control and empowerment (i.e., resilience). [5] TIC acknowledges that clients can be retraumatized by unexamined agency policies and practices and stresses the importance of providing patient-centered care rather than applying general treatment approaches. [6]

TIC enhances therapeutic communication between the client and the nurse. It decreases risks associated with misunderstanding clients’ reactions or underestimating the need for referrals for trauma-specific treatment. TIC encourages patient-centered care by involving the client in setting goals and planning care that optimizes therapeutic outcomes and minimizes adverse effects. Clients are more likely to feel empowered, invested, and satisfied when they receive TIC. [7]

Implementing TIC requires specific training, but it begins with the first contact a person has with an agency. It requires all staff members (e.g., receptionists, direct patient-care staff, nurses, supervisors, and administrators) to recognize that an individual’s traumatic experiences can greatly influence their receptivity and engagement with health services. It can affect their interactions with staff, as well as their responsiveness to care plans and interventions. [8]

View the following YouTube video on trauma-informed approach to health care [9]: Dr. Pickens Explains Trauma-Informed Approach

Read more details about trauma-informed care (TIC) in the “Trauma, Abuse, and Violence” chapter.

References

1.
Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https://www​.ncbi.nlm​.nih.gov/books/NBK207201/ [PubMed: 24901203]
2.
Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https://www​.ncbi.nlm​.nih.gov/books/NBK207201/ [PubMed: 24901203]
3.
Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https://www​.ncbi.nlm​.nih.gov/books/NBK207201/ [PubMed: 24901203]
4.
Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https://www​.ncbi.nlm​.nih.gov/books/NBK207201/ [PubMed: 24901203]
5.
Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https://www​.ncbi.nlm​.nih.gov/books/NBK207201/ [PubMed: 24901203]
6.
Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https://www​.ncbi.nlm​.nih.gov/books/NBK207201/ [PubMed: 24901203]
7.
Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https://www​.ncbi.nlm​.nih.gov/books/NBK207201/ [PubMed: 24901203]
8.
Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https://www​.ncbi.nlm​.nih.gov/books/NBK207201/ [PubMed: 24901203]
9.
Washington State Health Care Authority. (2019, June 24). Dr. Pickens explains trauma-informed approach [Video]. YouTube. All rights reserved. https://youtu​.be/6syEFO4OSFU.

1.4. STIGMA

Despite a recent focus on mental health in the United States, there are still many harmful attitudes and misunderstandings surrounding mental illnesses that can cause people to ignore their mental health and make it more difficult for them to reach out for help. [1],[2] Stigma has been defined as a cluster of negative attitudes and beliefs that motivates the general public to fear, reject, avoid, and discriminate against people with mental health disorders. [3]

It estimated that nearly two-thirds of people with diagnosable mental health disorders do not seek treatment due to the stigma of mental illness. The U.S. Surgeon General’s Report in 1999 was a milestone report that sought to dispel the stigma of mental illness and its impact on those seeking care. [4] The National Alliance on Mental Illness (NAMI) seeks to improve the lives of those with mental illness and reduce stigma through education, support, and advocacy. NAMI encourages people to share their stories to discredit stereotypes, break the silence, and document discrimination. [5]

Take a quiz in the following box to separate facts from myths about mental illness.

Take the CDC’s Mental Health Quiz.

However, stigma and negative attitudes toward mental illness can still be found among nurses. A review of nursing literature by Ross and Golder explored negative attitudes and discrimination towards mental illness in the nursing profession. Several studies from a variety of countries indicated that health care professionals can be classified in three categories in relation to stigma, including “’stigmatizers,” “the stigmatized,” and “de-stigmatizers.” “Stigmatizers” refer to nurses in medical settings with stereotypical attitudes towards clients with mental illnesses, psychiatric-mental health nurses, and/or psychiatry. Nurses classified as “the stigmatized” have mental health disorders or perceive stigma regarding their roles as psychiatric-mental health nurses. “De-stigmatizers” actively work to reduce stigma surrounding mental health disorders. The authors found that many nurses share commonly held stereotypical beliefs portrayed in the media. For example, clients with mental health disorders have been portrayed in the media as dangerous, unpredictable, violent, or bizarre, and these portrayals can cause fearful attitudes. Nurses in the studies were also concerned about inadvertently saying or doing “the wrong thing” or “setting off” uncontrollable behavior. Many nurses in general medical settings felt they lacked the skills to confidently and competently manage behavioral symptoms of clients with mental health disorders. The authors of the review reported that nursing literature supports additional mental health education for entry-level nurses and practicing nurses to enhance their knowledge base on mental health. [6]

Nurses can reduce stigma and advocate for a client’s needs and dignity by establishing a therapeutic nurse-client relationship. A therapeutic nurse-client relationship is essential in all settings, but it is especially important in mental health care where the therapeutic relationship is considered the foundation of client care and healing. Although nurse generalists are not expected to perform advanced psychiatric-mental health nursing interventions, all nurses are expected to engage in compassionate, supportive relationships with their clients. [7] In fact, in Nursing: Scope and Standards of Practice (2021), the American Nurses Association states, “The nursing profession, rooted in caring relationships, demands that nurses reflect unconditional positive regard for every patient.” [8]

Read more about establishing a therapeutic nurse-client relationship in the “Therapeutic Communication and the Nurse-Client Relationship” chapter.

The first step in resolving stigma is to become aware of one’s personal beliefs. Take the survey in the following box to become more aware of your own attitudes and biases toward mental health care.

Take the Personal Attitudes Survey (page 8) from the Canadian Mental Health Association.

References

1.
Centers for Disease Control and Prevention. (2021, July 20). Mental health. https://www​.cdc.gov/mentalhealth/index​.htm.
2.
Corrigan P. W., Watson A. C. Understanding the impact of stigma on people with mental illness. World Psychiatry: Official Journal of the World Psychiatric Association (WPA). 2002;1(1):16–20. https://www​.ncbi.nlm​.nih.gov/pmc/articles/PMC1489832/ [PMC free article: PMC1489832] [PubMed: 16946807]
3.
4.
Hegner R. E. Dispelling the myths and stigma of mental illness: The surgeon general’s report on mental health. Issue Brief. 2000;754  https:​//www​.ncbi.nlm.nih.gov/books/NBK559750/ [PubMed: 11010620]
5.
Abderholden, S. (2019, March 7). It’s not stigma, it’s discrimination [Blog]. National Alliance on Mental Illness. https://www​.nami.org​/Blogs/NAMI-Blog/March-2019​/It-s-Not-Stigma-It-s-Discrimination.
6.
Ross C. A., Goldner E. M. Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: A review of the literature. Journal of Psychiatric and Mental Health Nursing. 2009;16(6):558–567. [PubMed: 19594679] [CrossRef]
7.
Ross C. A., Goldner E. M. Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: A review of the literature. Journal of Psychiatric and Mental Health Nursing. 2009;16(6):558–567. [PubMed: 19594679] [CrossRef]
8.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.

1.5. BOUNDARIES

Boundaries are limits we set as individuals that define our levels of comfort when interacting with others. Personal boundaries include limits in physical, sexual, intellectual, emotional, sexual, and financial areas of our lives. Boundaries promote psychological safety in relationships at work, home, and with partners by protecting one’s well-being and limiting the stress response. For example, if you come away from a meeting or conversation with someone feeling depleted, anxious, or tense, consider if your boundaries were crossed. A lack of healthy personal boundaries can lead to emotional and physical fatigue. [1]

Five major types of personal boundaries include the following [2]:

  • Physical: Physical boundaries refer to one’s personal space, privacy, and body. For example, some people are comfortable with public displays of affection (hugs, kisses, and hand-holding), while others prefer not to be touched in public.
  • Sexual: Sexual boundaries refer to one’s comfort level with intimacy and attention of a sexual nature. This can include sexual comments and touch, not just sexual acts.
  • Intellectual: Intellectual boundaries refer to one’s thoughts and beliefs. Intellectual boundaries are not respected when someone dismisses another person’s ideas and opinions.
  • Emotional: Emotional boundaries refer to a person’s feelings. For example, an individual might not feel comfortable sharing feelings with another person and prefer to share information gradually over time.
  • Financial: Financial boundaries refer to how one prefers to spend or save money.

When caring for clients with mental health disorders, it is common to notice problems with setting appropriate boundaries. For example, a client experiencing bipolar disorder may exhibit a lack of financial and sexual boundaries. When they are experiencing a manic episode, they may spend thousands of dollars on a credit card over a weekend or have sexual relations with someone they just met. Another example of boundary issues is an individual with a depressive disorder who is treated poorly by their partner but does not leave or assert boundaries because they don’t feel that they deserve to be treated any better.

Nurses must establish professional boundaries with all clients while also maintaining a respectful and caring relationship. Due to their professional role, nurses have authority and access to sensitive information that can make clients feel vulnerable. A Nurses Guide to Professional Boundaries by the National Council of State Boards of Nursing (NCSBN) states that it is the nurse’s responsibility to use clinical judgment to determine and maintain professional boundaries. Nurses should limit self-disclosure of personal information and avoid situations where they have a personal or business relationship with a client. The difference between a caring nurse-client relationship and an over-involved relationship can be difficult to discern, especially in small communities or in community health nursing where roles may overlap. In these circumstances, it is important for the nurse to openly acknowledge their dual relationship and emphasize when they are performing in a professional capacity. Signs of inappropriate boundaries include the following [3]:

  • Self-disclosing intimate or personal issues with a client
  • Engaging in behaviors that could be interpreted as flirting
  • Keeping secrets with a client
  • Believing you are the only one who truly understands or can help the client
  • Spending more time than is necessary with a particular client
  • Speaking poorly about colleagues or your employment setting with the client and/or their family
  • Showing favoritism to a particular client
  • Meeting a client in settings outside of work
  • Contacting a client and/or their family members using social media

Establishing professional boundaries with clients diagnosed with mental health disorders is essential due to the vulnerability of the client population, as well as the behavioral manifestations of some disorders. For safety purposes, nurses and nursing students should keep their last name, home address, personal telephone number, and social media handles private.

View the NCSBN video: “Professional Boundaries in Nursing.”

Read A Nurse’s Guide to Professional Boundaries PDF from the National Council of State Boards of Nursing (NCSBN)

References

1.
Pattemore, C. (2021, June 2). 10 ways to build and preserve better boundaries. PsychCentral. https:​//psychcentral​.com/lib/10-way-to-build-and-preserve-better-boundaries#types.
2.
Pattemore, C. (2021, June 2). 10 ways to build and preserve better boundaries. PsychCentral. https:​//psychcentral​.com/lib/10-way-to-build-and-preserve-better-boundaries#types.
3.
National Council of State Boards of Nursing. (2018). A nurse's guide to professional boundaries. https://www​.ncsbn.org​/ProfessionalBoundaries_Complete.pdf.

1.6. ESTABLISHING SAFETY

Suicidal thoughts are a common symptom of mental health disorders and typically resolve with effective treatment. However, despite a recent increased focus on mental health care, there has been no documented decrease of suicide rates in the United States, and suicide remains the tenth leading cause of death in the country. [1]

Warning Signs of Suicide

Everyone can help prevent suicide by recognizing warning signs of suicide and intervening appropriately. Warning signs of suicide include client statements or nurse observations of the following [2]:

  • Feeling like a burden
  • Being isolated
  • Increasing levels of anxiety
  • Feeling trapped
  • Being in unbearable pain
  • Increasing substance use
  • Looking for a way to access lethal means
  • Increasing anger or rage
  • Exhibiting extreme mood swings
  • Expressing hopelessness
  • Sleeping too little or too much
  • Talking or posting about wanting to die
  • Making plans for suicide

See Figure 1.3 [3] for five action steps for anyone to take to prevent suicide in someone experiencing suicidal thoughts or ideations. Nurses can educate others to take the following steps if they believe someone may be in danger of suicide [4]:

Figure 1.3

Figure 1.3

Preventing Suicide

  • Call 911 if danger for self-harm seems imminent.
  • Ask the person if they are thinking about killing themselves. Although asking this question can feel invasive, it is common for individuals with mental health problems to share their thoughts and plans regarding suicide. Asking them about suicide will not “put the idea into their head” or make it more likely that they will attempt suicide. In fact, by responding appropriately, you can help save their life by asking this question.
  • Listen without judging and show you care.
  • Stay with the person or make sure the person is in a private, secure place with another caring person until you can get further help.
  • Remove any objects that could be used in a suicide attempt.
  • Call or text 988 to reach the new nationwide Suicide and Crisis Line for a direct connection with compassionate, accessible care and support for anyone experiencing mental health-related distress.

Establishing a Safe Care Environment for Clients

In addition to encouraging these general action steps to prevent suicide, nurses can further prevent suicide by establishing a safe care environment. Establishing a safe care environment is a priority nursing intervention.

Reducing the risk for suicide is one of the National Patient Safety Goals for Behavioral Health Care established by The Joint Commission. New requirements were established in 2020 that apply to patients in psychiatric hospitals, patients being evaluated or treated for behavioral health conditions as their primary reason for care in general hospital units or critical access hospitals, and all patients who express suicidal ideation during their course of care. [5] These requirements include performing an environmental risk assessment, screening for suicidal ideation, assessing suicide risk, documenting risk of suicide, following evidence-based written policies and procedures, providing information on follow-up care on discharge, and monitoring effectiveness of these actions in preventing suicides. These requirements are discussed in further detail in the following subsections. [6]

Read more about suicide prevention at Joint Commission’s Suicide Prevention webpage.

Perform Environmental Risk Assessmen

An environmental risk assessment identifies physical environment features that could be used by clients to attempt suicide. Nurses implement actions to safeguard individuals identified at a high risk of suicide from environmental risks, such as continuous monitoring, routinely removing objects from rooms that could be used for self-harm, assessing objects brought into a facility by clients and visitors, and using safe transportation procedures when moving clients to other parts of the hospital.

In psychiatric hospitals and on psychiatric units within general hospitals, additional measures are taken to prevent suicide by hanging by removing anchor points, door hinges, and hooks. The Veteran’s Health Administration showed that the use of a Mental Health Environment of Care Checklist to facilitate a thorough, systematic environmental assessment reduced the rate of suicide from 4.2 per 100,000 admissions to 0.74 per 100,000 admissions. [7]

Read more about the VA Mental Health at the Mental Health Environment of Care Checklist (MHEOCC) webpage [8]

Screen for Suicidal Ideation With a Validated Tool

Clients being evaluated or treated for mental health conditions often have suicidal ideation (i.e., thoughts of killing themselves). Additionally, clients being treated for medical conditions often have coexisting mental health disorders or psychosocial issues that can cause suicidal ideation. Therefore, all patients aged 12 and older admitted for acute health care should be screened for suicidal ideation with a validated tool. An example of a validated screening tool is the Patient Safety Screener. [9],[10] View more information about the Patient Safety Screener tool in the following boxes.

Visit the Suicide Prevention Resource Center’s webpage to read more about the The Patient Safety Screener: A Brief Tool to Detect Suicide Risk [11]

View the following YouTube video on administering the Patient Safety Screener: [12] The Patient Safety Screener 3

Assess Suicide Risk

An evidence-based suicide risk assessment should be completed on patients who have screened positive for suicidal ideation. Patients with suicidal ideation vary widely in their risk for a suicide attempt depending upon whether they have a plan, intent, or past history of attempts. An in-depth assessment of patients who screen positive for suicide risk must be completed to determine how to appropriately keep them safe from harm. Assessment for suicide risk includes asking about their suicidal ideation (i.e., thoughts of suicide), if they have a plan for committing suicide, their intent on completing the plan, previous suicidal or self-harm behaviors, risk factors, and protective factors. [13] When assessing for a suicide plan, notice if the plan is specific and the method they plan to use. The risk of acting on suicide thoughts increases with a specific plan. The risk also increases if the plan includes use of a lethal method that is accessible to the client.

An example of an evidence-based suicide risk assessment tool that anyone can use with anyone, anywhere is the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS). Read more about the C-SSRS in the following box. The C-SSRS uses a series of simple, plain-language questions that anyone can ask. The answers help identify if a person is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs. Examples of questions include the following [14]:

  • Have you had thoughts of killing yourself?
  • Have you thought about how you might do this?
  • Have you done anything, started to do anything, or prepared to do anything to end your life?

Columbia Suicide Severity Rating Scale (C-SSRS) [15]

Read more about using the C-SSRS at Columbia Lighthouse Project web site.

View the following YouTube video on C-SSRS [16] at Saving Lives Worldwide – A Call to Action – The Columbia Lighthouse Project

Develop a Safety Plan

If a client is assessed as high risk for suicide, a safety plan should be created in collaboration with the client. A safety plan is a prioritized written list of coping strategies and sources of support that clients can use before or during a suicidal crisis. The plan should be brief, in the client’s own words, and easy to read. After the plan is developed, the nurse should problem solve with the client to identify barriers or obstacles to using the plan. It should be discussed where the client will keep the safety plan and how it will be located during a crisis. [17],[18]

Read the Safety Planning Guide PDF by the Western Interstate Commission for Higher Education. [19]

Document Level of Risk for Suicide

After suicide screening and suicide risk are assessed, it should be documented and communicated with the treatment team, along with the plan to keep the client safe. It is vital for all health care team members caring for the client to be aware of their level of risk and plans to reduce that risk as they provide care. [20] Nurses complete documentation regarding the level of a client’s suicide risk and associated interventions every shift or more frequently as needed, depending upon the client status.

Follow Written Policies and Procedures

Nurses must strictly follow agency policies and procedures addressing the care of individuals who are identified at risk for suicide to keep them safe. For example, in some suicide cases reported to The Joint Commission, the root cause was a failure of staff to adhere to agency policies, such as a period of time when one-to-one monitoring was in place for a client identified as high risk for suicide. [21]

Provide Information for Follow-Up Care on Discharge

Nurses should provide written information at discharge regarding follow-up care to clients identified at risk for suicide and share it with their family members and loved ones as appropriate. Studies have shown that a patient’s risk for suicide is high after discharge from psychiatric inpatient or emergency department settings. Developing a safety plan with the patient and providing the number of crisis call centers can decrease suicidal behavior after the patient leaves the care of the organization. [22]

Monitor Effectiveness of Suicide Prevention Interventions

The effectiveness of policies and protocols regarding suicide prevention should be evaluated on a periodic basis as part of overall quality improvement initiatives of the agency. [23] Research demonstrates implementation of the Zero Suicide Model results in lower suicidal behaviors.

Zero Suicide Toolkit [24]

Read the American Psychiatric Association Psych News Alert, “‘Zero Suicide’ Practices at Mental Health Clinics Reduce Suicide Among Patients“.

View the following WHO video on preventing suicide by health care workers [25]:

Establishing a Safe Care Environment for Nurses and Other Health Care Team Members

The American Nurses Association states, “No staff nurse should have to deal with violence in the workplace, whether from staff, patients, or visitors.” [26] Workplace violence is the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty. The impact of workplace violence can range from psychological issues to physical injury or even death. Violence can occur in any workplace and among any type of worker, but the risk for nonfatal violence resulting in days away from work is greatest for health care workers. [27] Research indicates the rate of physical assaults on nurses is 13.2 per 100 nurses per year, and 25% of psychiatric nurses experienced disabling injuries from client assault. Many experts believe these figures represent only the tip of the iceberg and that most incidents of violence go unreported. [28] See Figure 1.4 [29] for an illustration of safety first.

Figure 1.4

Figure 1.4

Safety First

Safety strategies for nurses and nursing students providing client care include the following [30]:

  • Dress for Safety
    • Tuck away long hair so that it can’t be grabbed
    • Avoid earrings or necklaces that can be pulled
    • Avoid overly tight clothing that can restrict movement or overly loose clothing or scarves that can be caught
    • Use breakaway safety lanyards for glasses, keys, or name tags
    • Do not wear your stethoscope around your neck
  • Be Aware of Your Work Environment
    • When in a room with a client or visitor who is demonstrating warning signs of escalation, position yourself between the door and the client so you can exit quickly if needed
    • Note exits and emergency phone numbers, especially if you float to other areas
    • Recognize that confusion, background noises, and crowding can increase clients’ stress levels
    • Be aware that mealtimes, shift changes, and transporting patients are times of increased disruptive behaviors
  • Be Attuned to Patient Behaviors
    • Most violent behavior is preceded by warning signs, including verbal cues and nonverbal cues. The greater the number of cues, the greater the risk for violence. Be aware of these verbal and nonverbal cues indicating a client’s potential escalation to violence:
    • Verbal Cues
      • Speaking loudly or yelling
      • Swearing
      • Using a threatening tone of voice
    • Nonverbal and Behavioral Cues
      • Evidence of confusion or disorientation
      • Irritability or easily angered
      • Boisterous behavior (i.e., overly loud, shouting, slamming doors)
      • Disheveled physical appearance (i.e., neglected hygiene)
      • Holding arms tightly across chest
      • Clenching fists
      • Heavy breathing
      • Pacing or agitated restlessness
      • Looking terrified (signifying fear and high anxiety)
      • Staring with a fixed look
      • Holding oneself in an aggressive or threatening posture
      • Throwing objects
      • Exhibiting sudden changes in behavior or signs of being under the influence of a substance
  • Use Violence Risk Assessment Tools
    • Use risk assessment tools to evaluate individuals for potential violence, enabling all health care providers to share a common frame of reference and understanding. This minimizes the possibility that communications regarding a person’s potential for violence will be misinterpreted. These tools can be used as an initial assessment upon admission to determine potential risk for violence and repeated daily to assist in predicting imminent violent behavior within the next 24 hours. See sample risk assessment tools in the box at the end of this section.
  • Be Attuned to Your Own Responses
    • Be aware of your own feelings, responses, and sensitivities and pay attention to your instincts. For example, your “fight or flight” response can be an early warning sign of impending danger to get help or get out.
    • Be aware of how you express yourself and how others respond to you. Those who know you well may respond differently than do strangers. Effective therapeutic communication skills are an essential tool in preventing violence.
    • Use self-awareness and acknowledge if you have a personal history of abuse, trauma, or adverse childhood experiences (ACEs) that can affect how you respond to situations.
    • If coworkers are engaging in abusive behaviors, consider if you are exhibiting similar behaviors.
    • Be aware that fatigue can diminish your alertness and your ability to respond appropriately to a challenging situation.
  • Check Your Cultural Biases
    • A key aspect of self-awareness is recognizing how our own particular cultural heritage, values, and belief systems affect how we respond to our clients and coworkers and how they, in turn, respond to us.

If travelling to a home setting as a home health nurse, additional safety strategies are as follows [31]:

  • Review agency files to confirm that a background check was done on a patient regarding any history of violence or crime, drug or alcohol abuse, and mental health diagnoses. Also, check to see if a patient’s family member has a record of violence or arrest.
  • If entering a situation assessed as potentially dangerous, you should be accompanied by a team member who has training in de-escalation and crisis intervention.
  • Always carry a charged cell phone.
  • Make sure someone always knows where you are.
  • Have a code word to use with your office or coworkers to let them know you’re in trouble if you can’t call the police.

The CDC offers a free, online course called Workplace Violence Prevention for Nurses to better understand the scope and nature of violence in the workplace. Access the free CDC course on workplace violence with nurse videos at the Workplace Violence Prevention for Nurses webpage

References

1.
The Joint Commission. (2021). 2021 Behavioral health care and human services: National patient safety goals. https://www​.jointcommission​.org/-/media/tjc​/documents/standards​/national-patient-safety-goals​/2021/simplified-2021-bhc-npsg-goals-final-11420.pdf.
2.
Centers for Disease Control and Prevention. (2021, July 20). Mental health. https://www​.cdc.gov/mentalhealth/index​.htm.
3.
“5actionsteps_t.jpg” by unknown author for National Institute of Mental Health is licensed in the Public Domain. Access for free at https://www​.nimh.nih​.gov/health/topics/suicide-prevention.
4.
Substance Abuse and Mental Health Services Administration. (2021, November 29). Help prevent suicide.https://www​.samhsa.gov/suicide.
5.
The Joint Commission. (2021). 2021 Behavioral health care and human services: National patient safety goals. https://www​.jointcommission​.org/-/media/tjc​/documents/standards​/national-patient-safety-goals​/2021/simplified-2021-bhc-npsg-goals-final-11420.pdf.
6.
7.
8.
U.S. Department of Veterans Affair. (2021, April 1). VHA national center for patient safety. https://www​.patientsafety​.va.gov/professionals​/onthejob/mentalhealth.asp.
9.
10.
Suicide Prevention Resource Center. (n.d.). The patient safety screener: A brief tool to detect suicide risk. https://sprc​.org/micro-learning​/patientsafetyscreener.
11.
Suicide Prevention Resource Center. (n.d.). The patient safety screener: A brief tool to detect suicide risk. https://sprc​.org/micro-learning​/patientsafetyscreener.
12.
SPRC. (2018, April 26). The Patient Safety Screener 3 [Video]. YouTube. All rights reserved. https://youtu​.be/4GmGiRBMnYc.
13.
14.
The Columbia Lighthouse Project. (n.d.). Identify risk. Prevent suicide. https://cssrs​.columbia.edu/
15.
The Columbia Lighthouse Project. (n.d.). Identify risk. Prevent suicide. https://cssrs​.columbia.edu/
16.
The Columbia Lighthouse Project. (2016, October 19). Saving lives worldwide - A call to action - The Columbia Lighthouse Project [Video]. YouTube. All rights reserved. https://youtu​.be/csPPsstf2og.
17.
Western Interstate Commission for Higher Education. (2008). Safety planning guide [Handout]. https://www​.sprc.org​/sites/default/files​/SafetyPlanningGuide​%20Quick%20Guide%20for%20Clinicians.pdf.
18.
Schuster H., Jones N., Qadri S. F. Safety planning: Why it is essential on the day of discharge from in-patient psychiatric hospitalization in reducing future risks of suicide. Cureus. 2021;13(12):e20648. [PMC free article: PMC8786576] [PubMed: 35106206] [CrossRef]
19.
Western Interstate Commission for Higher Education. (2008). Safety planning guide. https://www​.sprc.org​/sites/default/files​/SafetyPlanningGuide​%20Quick%20Guide%20for%20Clinicians.pdf.
20.
21.
22.
23.
24.
Zero Suicide. (n.d.). Zero suicide toolkit. https://zerosuicide​.edc​.org/toolkit/zero-suicide-toolkitsm.
25.
World Health Organization (WHO). (2019, October 8). Preventing suicide: Information for health workers [Video]. YouTube. Licensed in the Public Domain. https://youtu​.be/Fy7n8SfwS_A.
26.
27.
Centers for Disease Control and Prevention. (2021, August 11). Occupational violence. https://www​.cdc.gov/niosh​/topics/violence/default.html.
28.
Centers for Disease Control and Prevention. (2021, August 11). Occupational violence: Workplace violence prevention for nurses. https://www​.cdc.gov/niosh​/topics/violence/training_nurses​.html.
29.
“Safety-First--Arvin61r58.png” by unknown author at freesvg.org is licensed under CC0 1.0. Access for free at https://freesvg​.org/safety-first.
30.
Centers for Disease Control and Prevention. (2021, August 11). Occupational violence: Workplace violence prevention for nurses. https://www​.cdc.gov/niosh​/topics/violence/training_nurses​.html.
31.
Centers for Disease Control and Prevention. (2021, August 11). Occupational violence: Workplace violence prevention for nurses. https://www​.cdc.gov/niosh​/topics/violence/training_nurses​.html.

1.7. PSYCHIATRIC-MENTAL HEALTH NURSING

What is Psychiatric-Mental Health Nursing?

Registered nurses (RNs) 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 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. [1] According to the American Psychiatric Nurses Association, psychiatric-mental health nurse specialists perform the following activities [2]:

  • Partner with individuals to achieve their recovery goals
  • Provide health promotion and maintenance
  • Conduct intake screening, evaluation, and triage
  • Provide case management
  • Teach self-care activities
  • Administer and monitor psychobiological treatment regimens
  • Practice crisis intervention and stabilization
  • Engage in psychiatric rehabilitation and intervention
  • Educate patients, families, and communities
  • Coordinate care
  • Work within interdisciplinary teams

Within the specialty of psychiatric-mental health nursing, there is an opportunity to become board certified. Eligibility requirements include a bachelor’s degree, two years of full-time work, 30 hours of continuing education, and passing a certification exam. The nurse earns the credential of PMH-BC (Psychiatric-Mental Health-Board Certified) or RN-BC.

Psychiatric-mental health advanced practice registered nurses (PMH-APRN) and nurse practitioners (PMHNP-BC) are registered nurses with a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) degree in psychiatric nursing. PMH-APRNs perform the following activities:

  • Provide individual, group, couples, and/or family psychotherapy
  • Prescribe medication for acute and chronic illnesses
  • Conduct comprehensive assessments
  • Provide clinical supervision
  • Diagnose, treat, and manage chronic or acute illness
  • Provide integrative therapy interventions
  • Order, perform, and interpret lab tests and other diagnostic studies
  • Provide preventative care, including screening
  • Develop policies for programs and systems
  • Make referrals for health problems outside their scope of practice
  • Perform procedures

Standards of Psychiatric-Mental Health Nursing

The American Psychiatric Nurses Association establishes standards of practice in psychiatric-mental health nursing that are built on the ANA Scope and Standards of Practice (2021). These standards are published in the Psychiatric-Mental Health Nursing: Scope and Standards of Practice document. [3] The standards are very similar to the ANA Scope and Standards of Practice, with additional activities included in the Intervention standard of care. These interventions will be further discussed in the “Implementation” section of the “Application of the Nursing Process in Mental Health Care” chapter.

Read the About Psychiatric-Mental Health Nursing webpage to learn more about the American Psychiatric Nursing Association.

There are specific legal and ethical considerations that apply to caring for clients with mental illness. See the “Legal and Ethical Considerations in Mental Health Care” chapter for further information.

Treatment Settings

There are many settings where psychiatric-mental health nurses collaboratively provide services to clients with mental health disorders, ranging from outpatient settings to inpatient care to state mental hospitals.

Outpatient Services

Clients often initially visit their primary care provider when concerned about their mental health. If a client has a more severe disorder, they are typically referred to specialized psychiatric care providers such as psychiatrists, psychiatric-mental health advanced practice registered nurses/nurse practitioners, psychologists, social workers, counselors, or other licensed therapists.

There are many different types of mental health services offered in the community:

  • Patient-centered medical homes that are comprehensive, coordinated, patient-centered models of primary care. [4]
  • Community mental health centers that offer free, low-cost, or sliding scale care for those who lack funding for mental health care.
  • Country programs, such as Comprehensive Community Services (CSC) or Community Support Programs (CSP).
  • Psychiatric mental health care in correctional facilities.
  • Psychiatric home care that provides community-based treatment for clients who are homebound.
  • Certified peer specialists.
  • Telepsychiatry that provides therapy and prescription services through videoconferencing. [5]

Inpatient Care Settings

Clients with acute mental health symptoms, or those who are at-risk for hurting themselves or others, may be hospitalized. They are often initially seen in the emergency department for emergency psychiatric care. Clients may seek voluntary admission, or in some situations, may be involuntarily admitted after referral for emergency evaluation by law enforcement, schools, friends, or family members. Read more about involuntary admissions in the “Patient Rights” section of the “Legal and Ethical Considerations in Mental Health Care” chapter.

Acute-care psychiatric units in general hospitals are typically locked units on a separate floor of the hospital with the purpose of maintaining environmental safety for its clients. State-operated psychiatric hospitals serve clients who have chronic serious mental illness. They also provide court-related care for criminal cases where the client was found “not guilty by reason of insanity.” This judgment means the client was deemed to be so mentally ill when they committed a crime that they cannot be held responsible for the act, but instead require treatment. [6]

Terminology Used in Psychiatric-Mental Health Nursing

Specific terminology is used in psychiatry and mental health nursing to document and describe signs, symptoms, and behaviors related to mental health disorders. Using specific mental health terminology when documenting and communicating with interprofessional health care team members is vital to ensure continuity of care. See the definitions of common terms in the “Assessment” section of the “Application of the Nursing Process in Mental Health Care” chapter, as well as in chapters related to specific mental health disorders.

References

1.
American Psychiatric Nurses Association. (n.d.). About psychiatric-mental health nursing. https://www​.apna.org​/about-psychiatric-nursing/
2.
American Psychiatric Nurses Association. (n.d.). About psychiatric-mental health nursing. https://www​.apna.org​/about-psychiatric-nursing/
3.
American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.
4.
AHRQ. (n.d.). Defining the PCMH. https://pcmh​.ahrq.gov/page/defining-pcmh.
5.
Halter, M. J. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders.
6.
Halter, M. J. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders.

1.8. LEARNING ACTIVITIES

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Image ch1learning-Image002.jpg

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I. GLOSSARY

Adverse childhood experiences (ACEs)

Traumatic circumstances experienced during childhood such as abuse, neglect, or growing up in a household with violence, mental illness, substance use, incarceration, or divorce.

Boundaries

Limits that we set as individuals that define our levels of comfort when interacting with others. Personal boundaries include limits in physical, sexual, intellectual, emotional, sexual, and financial areas of our lives.

Deviance

Behavior that violates social norms or cultural expectations because one’s culture determines what is “normal.”

Distress

Psychological and/or physical pain.

Dysfunction

Disturbances in a person’s thinking, emotional regulation, or behavior that reflects significant dysfunction in psychological, biological, or developmental processes underlying mental functioning.

Environmental risk assessment

Identification of physical environment features that could be used to attempt suicide in clients identified as at a high risk for suicide.

Health

A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

Impairment

A limited ability to engage in activities of daily living (i.e., they cannot maintain personal hygiene, prepare meals, or pay bills) or participate in social events, work, or school.

Major life activities

Activities of daily living such as caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. [1]

Mental health

A state of well-being in which an individual realizes their own abilities, copes with the normal stresses of life, works productively, and contributes to their community. [2]

Mental health continuum

A continuum of mental health, ranging from well-being to emotional problems to mental illness.

Mental illness

A health condition involving changes in emotion, thinking, or behavior (or a combination of these) associated with emotional distress and problems functioning in social, work, or family activities. [3]

Recovery

A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. [4]

Resilience

The ability to rise above circumstances or meet challenges with fortitude. [5]

Safety plan

A prioritized written list of coping strategies and sources of support that clients can use before or during a suicidal crisis. The plan should be brief, in the client’s own words, and easy to read. After the plan is developed, the nurse should problem solve with the client to identify barriers or obstacles to using the plan. It should be discussed where the client will keep the safety plan and how it will be located during a crisis.

Serious mental illness

Mental illness that causes disabling functional impairment that substantially interferes with one or more major life activities. Examples of serious mental illnesses that commonly interfere with major life activities include major depressive disorder, schizophrenia, and bipolar disorder. [6]

Social norms

Stated and unstated rules of an individual’s society.

Stigma

A cluster of negative attitudes and beliefs that motivates the general public to fear, reject, avoid, and discriminate against people with mental health disorders.

Suicidal ideation

Thoughts of killing oneself.

Suicide risk assessment

Identifying the risk of a client dying by suicide by assessing suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.

Trauma

An event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful and can have lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being.

Trauma-informed care (TIC)

A strengths-based framework that acknowledges the prevalence and impact of traumatic experiences in clinical practice. TIC emphasizes physical, psychological, and emotional safety for both survivors and health professionals and creates opportunities for survivors to rebuild a sense of control and empowerment referred to as resilience. [7]

Well-being

The “healthy” range of the mental health continuum where individuals are experiencing a state of good mental and emotional health.

Workplace violence

The act or threat of violence, ranging from verbal abuse to physical assaults, directed toward persons at work or on duty.

World Health Organization Disability Assessment Scale (WHODAS)

A generic assessment instrument that provides a standardized method for measuring health and disability across cultures.

References

1.
Office of Federal Contract Compliance Programs. (2009, January 1). ADA Amendments Act of 2008 frequently asked questions. U.S. Department of Labor. https://www​.dol.gov/agencies​/ofccp/faqs/americans-with-disabilities-act-amendments.
2.
World Health Organization. (2018, March 30). Mental health: Strengthening our response. https://www​.who.int/news-room​/fact-sheets​/detail/mental-health-strengthening-our-response.
3.
American Psychiatric Association. (n.d.). What is mental illness? https://www​.psychiatry​.org/patients-families​/what-is-mental-illness.
4.
Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https://www​.ncbi.nlm​.nih.gov/books/NBK207201/ [PubMed: 24901203]
5.
Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https://www​.ncbi.nlm​.nih.gov/books/NBK207201/ [PubMed: 24901203]
6.
American Psychiatric Association. (n.d.). What is mental illness? https://www​.psychiatry​.org/patients-families​/what-is-mental-illness.
7.
Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https://www​.ncbi.nlm​.nih.gov/books/NBK207201/ [PubMed: 24901203]
Copyright Notice

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/.

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