1.

ISSUES IN MENTAL HEALTH:

Issues in mental health develop with in a social context and need to be examined within the same.
Consumerism, questioning of the insanity defence, decrease in funding for mental health research,
and independent nursing practice are issues that affect and are affected by such social factors as
inflation, political activism, and community attitudes. As these issues evolve and ramify,
implications for the future are suggested.

1.1. CONSUMERISM: Consumer power:

A philosophy is emerging that encourages equal participation in decision making between
consumers and providers of mental health care. The trend toward increased involvement of and
power for consumers is moving ahead on two levels - individuals and communities.
On the first level, individuals are being given knowledge that will make them educated consumers of
and effective participants in the therapeutic process. Clients have a right to and are being given,
explanations about their psychiatric conditions, treatment plans, alternative types of treatment and
their costs, and any untoward reactions that might occur as a consequence of treatment. Within the
therapeutic relationship, mutuality between clients and nurses is also being encouraged. Clients
have more autonomy in contractual than in status relationships.

Many clients are turning for assistance to self-help groups composed of people who have recovered
from specific psychosocial problems. Alcoholic anonymous, Gamblers anonymous, and Overeaters
anonymous are examples of such groups. In many instances, these self-help groups constitute the
major treatment modality. In other instances, self-help groups are used in conjunction with other
therapies or to prevent the development of psychosocial problems (for e.g. Compassionate Friends
are a support group for bereaved parents). Client's decisions to utilize the therapeutic properties of
self-help groups by some recovered clients exemplify the increasing autonomy of consumers in the
mental health delivery system.

The second level of the trend in consumerism is characterized by collaboration between the
community and nurses and other professionals in community mental health centres. Community
mental health boards thereby become a point of articulation between community residents and care
providers. Such collaboration between community representatives and mental health professionals
is a potentially educational experience. Community representatives may learn firsthand information
about the community mental health movement- its philosophy, goals, and problems. This
educational process helps to demystify mental health and mental illness, to teach consumers (and
potential consumers) about treatment modalities and the roles and functions of members of the
mental health team, and to sensitize residents to the mental health problems in their community.
Community residents may become aware of the influence their involvement and support
can have on community mental health program. Community representatives may develop an
increased understanding of their sources of power and of how power relationships affect budgeting,
service priorities, and programming.
Nurses and other mental health professionals can better view clients within the socio-
cultural context of the community. The value, ideologies, and traditions of subgroups (such as ethnic
groups and classes) within the community may be better identified and understood. Nurses and
other mental health professionals can also increase their awareness of perceptions that subgroups
within the community have about the definition, cause, and treatment of mental illness.

1
Implications for the future: The role of consumers in the mental health delivery system will
probably continue to expand. Presently people who have recovered from specific psychosocial
problems (such as alcoholism, drug abuse, and compulsive eating) are effectively intervening in the
treatment of people who have not yet recovered. Gonzalez (1976) suggests that this trend may grow
to include other psychosocial problems (for e.g. depression, phobias, and compulsive working). In
addition, consumers are becoming more vocal about their perceptions of effective treatment for
mental illness, and nurses and other mental health professionals are becoming more responsive to
the ideas of consumers.

1.2. QUESTIONS OF THE INSANITY DEFENSE: Current attitudes:

An increase of the violence in the United States, underscored by the recent history of violent acts
against public figures, has precipitated an outcry against the verdict "not guilty by the reason of
insanity." Although the insanity defence has recently become the focus of much attention, it should
be noted that most violent people are not mentally ill and most mentally ill people are not violent.
People with a history of mental illness who commit violent acts usually have a history of criminal
activity that predates their mental illness. Forensic psychiatry is that speciality in psychiatry that
deals with the legal facets of mental illness (sadoff, 1975). People accused of crimes can be found
incompetent to stand trial because of a mental condition, or they can plead not guilty on the basis on
the insanity and be so found by a jury. A determination that a person is incompetent to stand trial is
based up on his or her inability to understand the charges and to participate with a lawyer in his or
her own defence because of mental disorder.
Many of our laws and legal procedures have developed English common law. This is true of one of
the more frequently invoked rules in cases involving the insanity plea- The Mc Naughton Rule. This
rule, which was handed down in England in 1834, holds that a person is not guilty of a crime if the
person did not understand the nature and quality of the act or did not know that the act was wrong
(stine, 1975). Although the Mc Naughton Rule has been criticized by legal scholars and members of
the psychiatric profession, it has remained an important aspect of the insanity defence in many
jurisdictions in the United States.

Another defence that is valid in some states is Irresistible Impulse Test, which was introduced in
Alabama in 1887 and has since been adopted by many states. The irresistible impulse test expanded
upon the Mc Naughton Rule by adding criteria for determining people's ability to control their
behaviour. Then, in 1954, the Durham Rule, which is still used in the district of Columbia, stated
that accused people are not responsible for their unlawful behaviour if that behaviour is the result of
mental illness or mental defect. Both Mc Naught on Rule and the Irresistible Impulse Test have
been criticized by legal scholars and members of the psychiatric profession because of their
moralistic quality and because they do not reflect current knowledge of human psychology. A recent
attempt to develop a test or rule governing responsibility for criminal acts in relation to mental
disorders resulted in the American Law Institute Test. According to this test, a person is not
responsible for criminal behaviour if at the time of committing a crime the person lacked substantial
capacity either to appreciate the criminality of the act or to control his or her behaviour so that it
confirmed to the law.

Implications for the future: Central to any discussion of the insanity defence is concern about
the lack of criteria for assessing and, in effect, predicting whether individuals will be dangerous to
themselves or others because of mental disease or disorder.
In many, if not in most instances, a prediction of violence is very difficult to make.
Although such situational and environmental factors as poorly functioning family, peer, or
occupational support systems seem to contribute to violent behaviour, the common denominator

2
among people who are violent appears to be simply a history of violent behaviour. This is an area in
which nurses and other mental health professionals should develop proposals, write grants and
otherwise engage in research.
1.3. DECREASE IN FUNDING FOR RESEARCH:

In the United States, The National Institute of Mental Health (NIMH) is the major source of funding
for mental health research over the past decade, the combination of budgetary cuts and inflation has
resulted in a 5o% decrease in the purchasing power of money invested in mental health research.

Status of mental health research: Because trained researchers are having difficulty obtaining
research grants, many researchers are entering other fields of mental health, such as practice or
teaching. Brown (1976) predicts that not only will the scarcity of research grants affect the current
level of mental health research, but because young scientists have limited research opportunities,
there will be a dearth of prepared researchers for the next 10 or 20 years. There is also a trend in
American society toward evaluating the worth of a program in terms of its cost effectiveness. Mental
health researchers translating their results in to a dollar amount, While dollar savings can be
attached to decreases in the number of people hospitalized for mental illness, similar cost
effectiveness cannot as readily be demonstrated for such improvements in human functioning as
increased sense of well being or more effective coping behaviour. The difficulty of translating
research results into cost effectiveness formulae plus, the stigma that, much of the general public
still attaches to mental illness result in a lack of public support for mental health research.

Implications for the future: Nurses and other mental health professionals will need to become
more politically active and politically effective in educating legislators and the general public about
the importance of mental health research. Public support will be essential if mental health
professionals are to successfully complete for scarce research resources. Serving on advisory
committees may increase the opportunities for mental health professionals to influence legislation
concerning research in mental health.

In addition to becoming politically active in advancing the cause of mental health research, nurses
also will need to actively engage in research. One area of nursing research that often overlooked is
the evaluation of outcome effectiveness. Connolly (1982) suggests that the resistance of nurses and
other mental health professionals to conducting outcome research studies can be explained in
several ways. First, there are few reliable and valid instruments available with which to evaluate
mantel health outcomes. For instance, who should determine that the mental health of a client has
improved- the client, the mental health professional or both? The difficulty in finding adequate
research tools can often serve as an excuse for not conducting outcome research.

The reluctance of nurse-researchers to report their findings when no statistical significance is found
may also contribute to the paucity of published outcome research studies. The human behaviour
cannot be reduced to a unifactorial, cause-and -effect explanation, because many factors interrelate
and contribute to human behaviour, nurse-researchers should report both their positive and
negative findings and they should discuss the many possible reasons why statistical significance was
not found. Finally, because quality assurance programs are operative in mental health agencies,
nurses may assume that their work is already being evaluated and that there is no further need to
professional responsibility for documenting outcome effectiveness. Thus, nurses will need to
recognize that they have a professional responsibility for conducting outcome research studies that
are separate from the evaluations done by quality assurance programs.

3
The American Nurses' Association, in its Standards of Psychiatric and Mental Health Nursing
Practice (1982), states that nurses have a responsibility to engage in research so that knowledge in
the field of mental health will be advanced. To help nurses achieve this aim, the ANA has
enumerated the following process criteria:

1. Nurses should maintain inquisitiveness and open-mindedness in their practice of nursing.

2. They should apply research findings of others to their own nursing practice.
3. They should participate in the development, implementation and evaluation of research
projects appropriate to their levels of education.
4. They should use responsible investigative standards whenever engaging in research.
5. They should ensure that the rights of human subjects are protected.
6. They should consult with and/or seek the supervision of experts whenever necessary.
1.4. INDEPENDENT NURSING PRACTICE: Current issues:
In the past few decades, mental health nursing has expanded both its clinical base and its range of
clinical practice. Recently, nurses have departed from the medical model and have developed
nursing process. Nurses are now making nursing diagnosis, writing nursing orders, treating human
responses to illness, and evaluating outcome effectiveness.
Nurse practitioners and clinical nurse specialists have thus become legally able to practice in an
expanded or autonomous role. However autonomy in practice should not be interpreted as an
unsupervised or unregulated practice of nursing. Instead, nurses collaboration with other nurses
and with other professionals in the giving and receiving of professional supervision. The expanded
role of nurse has provided an opportunity for many psychiatric nurses to become direct providers of
mental health care.
Implications for the future: Third party reimbursement for state-licensed nurse-practitioners is
beginning to occur. In December, 1981, the US Defence Department's Civilian Health and Medical
Program for Uniformed Services(CHAMPUS) approved the reimbursement of state licenced nurse-
practitioners and certified Psychiatric nurses as CHAMPUS-authorized care providers.
Some progress is being made in reorganizing Nurse-practitioners and Psychiatric clinical nurse-
specialists as autonomous providers of mental health care. Yet much work still needs to be done to
promote the autonomy and credibility of psychiatric nurses engaged in independent practice.
The Need for Nursing in a Transformed Mental Health Care System:
Major changes in the health care delivery system, practice patterns of health professionals, and
funding continue to have a profound effect on mental health care and psychiatric –mental health
nursing practice. Nationally, health care delivery systems, educational institutions, policy makers,
and health professionals have been challenged to create a vision for mental health care delivery that
reduces health disparities and embeds quality safety evidence-based practice, interprofessional
practice, and cultural competence as essential dimensions of consumer-focused 21st century mental
health care delivery and professional practice.

1.5. CARE IN THE COMMUNITY:

Community care has a better effect than institutional treatment on the outcome and quality of life of
individuals with chronic mental disorders. Shifting patients from mental hospitals to care in the community is
also cost-effective and respects human rights. Mental health services should therefore be provided in the
community, with the use of all available resources. Community-based services can lead to early intervention
and limit the stigma of taking treatment.
1.6. EDUCATION OF THE PUBLIC
Public education and awareness campaigns on mental health should be launched in all countries. The main
goal is to reduce barriers to treatment and care by increasing awareness of the frequency of mental disorders,
their treatability, the recovery process and the human rights of people with mental disorders. The care choices
available and their benefits should be widely disseminated so that responses from the general population,

4
professionals, media, policy-makers and politicians reflect the best available knowledge. This is already a
priority for a number of countries, and national and international organizations. Well-planned public
awareness and education campaigns can reduce stigma and discrimination, increase the use of mental health
services, and bring mental and physical health care closer to each other.
1.7. INVOLVING COMMUNITIES, FAMILIES AND CONSUMERS:
Communities, families and consumers should be included in the development and decision- making of
policies, programmes and services. This should lead to services being better tailored to people’s needs and
better used. In addition, interventions should take account of age, sex, culture and social conditions, so as to
meet the needs of people with mental disorders and their families.
1.8. LINKING WITH OTHER SECTORS
Sectors other than health, such as education, labour, welfare, and law, and nongovernmental organizations
should be involved in improving the mental health of communities. Nongovernmental organizations should be
much more proactive, with better defined roles, and should be encouraged to give greater support to local
initiatives.
1.9. ETHICAL DECISIONS
Some ethical dilemmas are specific to mental health nursing and are seen rarely in other areas of practice. An
involuntary commitment to care, or a decision made by a family member on behalf of the patient, is often
made to protect the patient from harming herself or others. The patient might contest this decision. This
presents an ethical dilemma because psychiatric patients have the same legal rights as other citizens. The
decision is often made by administration for the organization, but the mental health nurse is the person who
must care for the patient.
1.10. CONFIDENTIALITY AND PRIVACY:
Health care organizations have strict codes of confidentiality. If a mental health patient divulges information
to a nurse that is potentially harmful to himself or someone else, the nurse faces a dilemma in reporting the
information. A psychiatric patient cannot have a stable frame of mind for the information to even be truthful.
A mental health nurse faces difficult decisions by caring for psychiatric patients who reveal sensitive
information that might end up harming others.
It is important for the nurse to constantly protect the privacy of the patients and to avoid revealing any
information about them except when permission has been given or when the state mental health code covers
the information involved.
1.11. SUPERVISORY LIABILITY:
Supervisory liability may be incurred if nursing duties are delegated to the persons who cannot safely
perform these duties. The nurse who does not verify that the assistive personnel can safely and appropriately
provide the care being delegated will be liable to for any harm or injury the client suffers. Supervision of
assistive personnel is essential.
1.12. WORKFORCE ISSUES IN MENTAL HEALTH NURSING:
Short staffing issues have raised concerns about client safety. Hospitalized patients have better outcomes with
high ratio of nurses. Nurses should not perform the tasks for which they are not prepared, including the
assumptions of responsibility for the safety and care of an unreasonable number of clients. They must not
work outside the scope of their license.
The problems of establishing sufficient numbers of adequately skilled mental health nurses with the
motivation to work in this field over the long term are well known. Recruitment and retention remain
problematic particularly in light of the ageing workforce. Nursing workloads, stress and burnout, workplace
violence and aggression, for example are frequently identified as major contributors to these problems. While
these factors have been identified and articulated, the relationship between them has received significantly less
attention. More effective and sustainable workforce planning will be facilitated through recognition of the
complexity of mental health nursing rather than by artificially reducing it to component parts. (HAPPELL B.,
2008)
1.13. ISUUES REGARDING SECLUSIONS AND RESTARINTS:
Psychiatric-mental health nurses provide leadership to create a culture that minimizes the use of seclusion or
restraint while promoting a safe environment for persons served as well as staff. Organizational leaders

5
working toward realizing the vision of seclusion and restraint free environments must assure sufficient
resources as well as effective administrative and clinical structures and processes to prevent behavioural
emergencies and to support the implementation of alternatives.
Any staff providing care to persons at risk for harming themselves or others and who participate in seclusion
and restraint shall have received training and demonstrate current competency in all aspects of dealing with
behavioural emergencies.

2. TRNDS IN PSYCHIATRI MENTAL HEALTH NURSING:

2.1. ROLE EMERGENCE:

The role of psychiatric nursing began to emerge in the early 1950s. In 1947 Weiss published an
article in the American Journal of Nursing that emphasized the shortage of psychiatric nurses and
outlined the differences between psychiatric and general duty nurses. She described "attitude
therapy" as the nurse's directed use of attitudes that contribute to the patients' recovery. In
implementation the patient for small and fleeting changes, demonstrates acceptance, respect, and
understanding of the patient, and promotes the interest and participation in reality. An article by
Bennet and Eaton in the American Journal of Psychiatry in 1951 identified the following problems
affecting psychiatric nurses:
1. Scarcity of qualified psychiatric nurses
2. Underuse of their abilities
3. The fact that "very little real psychiatric nursing is carried out in otherwise good psychiatric
hospitals and units"
Those psychiatrists believed that the psychiatric nurse should join mental health scientists, consult
with welfare agencies, work in outpatient clinics, practice preventive psychiatry, engage in research,
and help educate the public. They supported the nurses participation in individual and group
psychotherapy and stated ,"despite the fact that most psychiatrists seem to ignore the role of the
psychiatric nurse in psychotherapy, all nurses in psychiatric wards do psychotherapy of one kind or
another by their contacts with patients"(Bennet & Eaton, 1951).
Also in 1951 Mellow wrote of the work she did with schizophrenia patients. She called these activities
"nursing therapy". A year later, Tudor (1952) published a study in which she described the nurse-
patient relationships she established, which were characterized by unconditional care, few demands,
and the anticipation of her patients' needs. These articles were some of the earliest descriptions by
psychiatric nurses of the nurse-patient relationship and the nature of its therapeutic process. As
nurses engaged in these kinds of activities, many questions arose. Are these activities therapeutic or
are they therapy? What is a therapeutic relationship or a one-to-one nurse-patient relationship?
How does it differ from psychotherapy? These questions were addressed by Dr. Hildegard Peplau, a
dynamic nursing leader whose ideas and beliefs shaped psychiatric nursing.

In 1952 Peplau published a book, Interpersonal Relations in Nursing, in which she described the
skills, activities and role of psychiatric nurses. It was the first systematic, theoretical framework
developed for psychiatric nursing. Peplau defined nursing as a "significant, therapeutic process".
While she studied the nursing process, she saw nurses emerge in various roles: as a recourse person;
a teacher; leader local, national, and international situations; a surrogate parent; and a counsellor.
She wrote, "counselling in nursing has to do with helping the patient remember and to understand
fully what is happening to him in the present situation, so that the experience can be integrated
with, rather than dissociated from other experiences in life"(Peplau, 1952).

Finally two significant developments in psychiatry in the 1950s also affected nursing's role for years
to come. The first was Jones' publication of The Therapeutic Community: A New Treatment
Method in Psychiatry in 1953. It encouraged using the patient's social environment to provide a

6
therapeutic experience. The patient was to be an active participant in the care and become involved
in the daily problems of the community. All patients were to help solve problems, plan activities and
develop the necessary rules and regulations. Therapeutic communities became the preferred
environment for psychiatric patients. The second significant development in psychiatry in the early
1950s was the use of psychotropic drugs. With these drugs more patients became treatable, and
fewer environmental constraints such as locked doors were required. Also more personnel were
needed to provide therapy and the roles of various psychiatric practitioners were expanded,
including the nurse's role.

2.2. EVOLVING FUNCTIONS:

In 1958 the following functions of psychiatric nurses were described (Hays, 1975):
 Dealing with patients' problems of attitude, mood and interpretation of reality.
 Exploring disturbing and conflicting thoughts and feelings.
 Using the patients' positive feelings toward the therapist to bring about
psychopharmacological homeostasis.
 Counselling patients in emergencies, including panic and fear.
 Strengthening the well part of patients.
The nurse-patient relationship was referred to by a variety of terms, including "therapeutic nurse-
patient relationship", "psychiatric nursing therapy", "supportive psychotherapy"," rehabilitation
therapies", and "non directive counselling". Because of the distinction between these terms, the
exact nature of the nurse's role remained hazy. Once again Peplau clarified psychiatric nursing's
position and directed its future. In "Interpersonal Techniques: The Crux of Psychiatric Nursing",
published in 1962, she identified the heart of psychiatric nursing as the role of counsellor or
psychotherapist. In her article Peplau differentiated between general practitioners who were staff
nurses working on psychiatric units and psychiatric nurses who were specialists and expert clinical
practitioners with graduate degrees in psychiatric nursing. Thus from an undefined role involving
primarily physical care, psychiatric nursing was evolving into a role of clinical competence based on
interpersonal techniques and use of the nursing process.

In the 1960s the focus of psychiatric nursing began to shift to primarily prevention and
implementation of care and consultation in the community. Representatives of these changes were
the shift in the name of the field from psychiatric nursing to psychiatric and mental health nursing.
This focus was stimulated by The Community Mental Health Centres Act of 1963, which made
federal money available to states to plan, construct and staff, community mental health centres. This
legislation was prompted by growing awareness of the value of treating people in the community
and preventing hospitalization whenever possible. It also encouraged the formation of
multidisciplinary treatment teams by combining the skills of many professions to alleviate illness
and promote mental health. This team approach continues to be negotiated. The issues of territory,
professionalism, authority structure, consumer rights, and the use of paraprofessionals are still
being debated.

The 1970s gave rise to the further development of the speciality. Psychiatric nurses became the pace
setters in speciality nursing practice. They were the first to:
Develop standards and statements on scope of practice
Establish generalist and specialist certification.

At this same time, the nursing profession was defining caring as a core element of all nursing
practice, and the contributions of psychiatric nurses were embraced by nurses of all speciality
groups. Partly as a result of this broader definition of psychiatric nursing and the perceived skill of

7
psychiatric nurses, nursing education reorganized its curriculum and began to integrate psychiatric
nursing content into non-psychiatric courses. This beginning of content was evident in the second
change in the name of the field in the 1970s from psychiatric and mental health nursing to
psychosocial nursing. Clinical rotations focusing on the psychiatric illness of patients in psychiatric
settings were often replaced by clinical rotations integrating psychosocial aspects of the care of
physically ill patient's in general medical surgical units. Unfortunately, this trend often did not
provide students with an opportunity to care for patients with psychiatric illness and learn about
new information that was emerging in the field of psychiatric and broader behavioural sciences.

The 1980s were years of exciting scientific growth in the area of psychobiology. Advancements
occurred in five basic areas:

Brain imaging techniques

Neurotransmitters and neuronal receptors
Psychobiology of emotions
Understanding the brain
Molecular genetics related to psychobiology.
Although this information explosion advanced knowledge in the field, it lacked integration and was
often of limited clinical usefulness. It has also been observed that psychiatric nurses in the 1980s
were slow to make the shift away from primarily psychodynamic models of the mind to more
balanced psychobiological models of psychiatric care.
Psychiatric nurses thus entered the 1990s faced with the challenge of integrating the expanding
bases of neuroscience in to the holistic bio-psychosocial practice of psychiatric nursing. Advances in
understanding the relationships of the brain, behaviour, emotion and cognition offered new
opportunities for psychiatric nursing (Hays, 1995). Psychiatric nurses saw the need to become
realigned with care and caring which represent the art of psychiatric nursing and complement the
high technology of current health care practices (Mc Bride, 1996).

The new millennium brings with it issues of balance, differentiation and integration. The knowledge
base of the speciality is rooted in the integration of the biological, psychological, spiritual, social and
environmental realms of the human experience. As Flaskerud and Wuerker (1999) note "the
physiological and ethical challenge to nursing is to the nursing care of mentally ill people while
remaining cantered in the nursing domain and maintaining our focus on caring and our sensitivity
to the human condition.

2.3. PSYCHIATRIC MENTAL HEALTH NURSING TODAY:

The nursing shortage has stuck just about everywhere in the United States and there's no relief in
sight- but its effects vary by region and speciality, its clear that experienced nurses are in short
supply in all areas of nursing. The Bureau of labour statistics predicts that more than one million
nurses will be needed by the year 2010. This predicted need is based on several factors. Nurses are
retiring or leaving the profession for several reasons, such as low wages for physically demanding
work, mandatory overtime, burnout, job dissatisfaction, nurse to-increased client ratios, and work
related injuries.(American Nurse, 2002).

2.3.1. EDUCATION:
A paradigm shift is taking place in education, moving from the traditional classroom to the
presentation of knowledge via distance education, multimedia centres, and cyberspace. The
beginning nurse needs to have basic competencies related to computer science, information science
to manage and communicate data, information and knowledge in nursing practice (Reavis &

8
Brykczynski, 2002; Newbold, 2001). Schools of nursing offer a variety of programs to prepare
students for the practice of psychiatric-mental health nursing.
Licensed practical or vocational nursing programs
Associate's degree nursing programs
Baccalaureate degree nursing programs
Master's degree nursing programs
Continuing education.

2.3.2. CAREER OPPURTUNITIES:

Currently, the field of psychiatric-mental health nursing offers a variety of opportunities for
specialization. Examples include nurse liaison in the general hospital, therapist in private practice,
consultant, educator, expert witness in legal issues, employee assistance counsellor, mental health
provider in long-term care facilities, and work in association with mobile psychiatric triage unit. In
addition, psychiatric-mental health nursing experience as a student provides a valuable foundation
for career opportunities after graduation.

2.3.3. EXPANDED ROLE OF THE NURSE:

The role of nurses continues to expand. For example, the American Board of Managed care Nursing
(ABMCN), formed in 1998, promotes excellence and professionalism in managed care nursing by
recognizing individuals; who, through voluntary certification, demonstrate an acquired knowledge
and expertise in managed health care. The managed care nurse's role is to advocate for all the clients
enrolled in managed health care plans, to administer benefits within the confines of the managed
care plan, and to provide customer service during all the nurse's encounters with members of the
managed care programs. The nurse's role in managed-care moves along the continuum from direct
client care to administrator.

Another area of expansion is parish nursing, which developed in the early 1980s in the Midwest.
Parish nursing is a program that promotes health and wellness of body, mind and spirit using the
community health nursing model as its framework. The church congregation is the client. The
parish nurse is a member of the church congregation, spiritually mature, and is a licensed registered
nurse with a desire to serve the members and friends of his or her congregation. Although parish
nurses are volunteers, some are paid by grants, the hospital or the congregation. In 1998, the
American Nurses Association recognized parish nursing as a speciality focusing on disease
prevention and health promotion.

Additionally nurses have recently become subject to the privilege process that physicians have
enjoyed for years. Nurses provide comprehensive services, acute and chronic illness management.
And management of psychiatric disorders for hospitalized clients and those admitted to sub-acute
and long-term care facilities. The role of nurse is also expanding in the area of tele-health, or
telephone nursing. It is an effective method to teach clients and consumers about health care and
disease management. As technology becomes cheaper and more reliable, and demand for this
convenient delivery method grows, experts predict more dramatic changes in the delivery of health
care in the 21st century after legislative, technical, and practice barriers are overcome.
Confidentiality issues, imperfect software, faulty equipment, and reimbursement issues present
challenges.

Finally forensic nursing is expected to become one of the fastest growing nursing specialities of 21st
century. Forensic nursing focuses on advocacy for the ministration to offenders and victims of

9
violent crime and the families of both. In 1995, The Scope and Standards of Nursing Practice in Co-
relational Facilities was published, recognizing forensic nursing as a significant recourse in forensic
psychiatric practice and in the treatment of incarcerated persons. In 1997, the American Nurses
Association published The Scope and Standards of Forensic Nursing Practice.

2.4. FUTURE TRENDS IN PSYCHIATRIC-MENTAL HEALTH NURSING:

The future of psychiatric-mental health nursing will be affected by many influences. Thus , flexibility
will be an essential characteristic of the psychiatric mental health nurses.
In addition to the above mentioned changes in the field , nurses will also experience changes in
other areas:
Emphasis on psychobiology
Computer assistance
New educational demands
Biologic
holistic
Societal demands and stressors
Scientific, geographic, sociopolitical and economic factors.

Emphasis on psychobiology:
The past decade has seen an explosion of psychobiologic information. Research focused on
neurobiology has focused on the structure and function of the brain and nervous system, and how
these systems affect health and illness. Research findings support a biological basis for many mental
disorders. This emphasis on the biologic aspect of mental illness greatly affects client care and
treatment. Pharmacological interventions are emphasized and new technologies are applied as
assessment and treatment measures.
Computer technologies:
Few psychiatric setting currently function without assistance from computers. As a rule, the larger
the agency the more complex the system. There may come a time when clients will be able to turn to
a computer computer assisted instruction programs or interactive videodisca to input symptoms
and effect diagnoses and self-treatment without leaving home.
At the 32nd biennial Convention of The Sigma Theta Tau National Honor Society, a video was
presented to show how nursing is changing (AJN, 1993). The video showed that in a time when
more instructors are needed, it may soon be posiible to provide safe clinical experiences for student
nurses working in multiple community settings by giving each student technological aids that can
communicate to one instructor in a designated setting. With the use of individual computers,
students may safely reach community destinations via explicit instructions, send symptoms back to
the base, receive laboratory values, answer clients' questions, and teach them about disorder or
treatment modalities.

Educational demands:
A nurse's education consists of multiple courses in natural, physical, and behavioural sciences, the
humanities, and the art and science of nursing. The task force on the psychiatric-mental health
nursing psychopharmacology project of 1994 recommends that nurses include and add additional
componants in their education where necessary (ANA, 1994a).these componants are:
Neuroanatomy
Physiology
Biochemistry
Psychiatry
Psychology

10
 Physics
Genetics/family correlates
Neurology
Neurosurgery
Psychoimmunology
Psychopharmacology
Neuroimaging
Computer sciences
Psychoendocrinology
Biologic rhythms
Psychobiologic dysfunction
Biologic theories of major disorders
Chronobiology
Psychiatri nurses are faced with new educat ional challenges. They will integrate biologic content for
safe and effective care, while still forging the proven basis for optimum client wellness- the art and
science of the nurse-client relationship. It must all work together for comprehensive client care.
Psychiatric nurses are also responding to holistic methods of treating clients. These methods(for
example, healing touch, nutrition, herbal medicine, massage, accupuncture and accupressure) are
becoming increasingly popular in the United States, and the trend will continue. Increased numbers
of mental health care providers espouse a combination of western and eastern methods for most
comprehensive client care.
Societal demands and stressors:
Genetics and bilogical vulnability have beed scientifically implicated in seversl mental disorders. As
previously described, these findings have affected major changes in thinking, and the pendulum of
causality has swung far in the biologic direction. Psychiatric-mental health nurses do well to
maintain balanced thinking, to avoid minimizing the part that psychosocialstressors play in mental
well-being or mental disorder. Biology is influnced by environment and can not function in a
vaccuum. For example; a genetically vulnerable individual who may be predisposed to substance
dependence will not become dependant if he or she never has access to or chooses not to use mind-
altering substances. On the other hand, a person who is faced with intolerable stressors may find
drug use a viable alternative. In these instances, stressors and choice are important, as is biological
vulnerability. As our society becomes more and more complex, it is safe to predict that occurences of
mental disorders may also increase. It seems evident that intolerance of increased societal demands
has contributed to psychiatric diagnosis.
Secientific, geographic, sociopolitical, and economic factors:
The United States continually becomes more homogenous. Geographic distances have shortened,
and scientific discoveries instantly reach around the world. Present sociopolitical and economic
factors remain a constant remainder of the degree to which countries are interdependent. The
International Classification of Mental Disorders is very similar to the U.S publication of the
Diagnostic and Statistical Manual of Mental Disorders. Perhaps one answer to a reduction of
symptoms of mental illness and treatment success lies in diverse cultures looking more to reach
other for common answers and solutions.
Psychiatric nursing and all other nursing disciplines face many changes that depend in large part on
the government leaders who will direct and guide health care decisions and the allocation of funds
for maintaining health care. In 1994 a major health care reform bill was defeated that included,
among others, areas for prevention, maintainance,and restoration concerning the mental health
issues. Politics greatly affect the outcomes for mental health care. The current administratior has

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invested psychiatric nurse leaders to give input to this important subject, but the result remains
unpredictable and will depend on priorities of future political leaders.

3. MAGNITUDE OF PSYCHIATRIC NURSING:

Mental health nursing is concerned with the care of patients who are suffering from mental illnesses
such as dementia, schizophrenia and bipolar disorder, or from emotional distress. Its particular
focus is the development of a special relationship between nurses and patients. This relationship
encourages patients to learn to do what they can to help manage their condition, as opposed to one
in which a dependency between patient and caregiver is established.

3.1. RESPONSIBILITIES

The scope of nursing has evolved from the early role of a nurse carrying out orders at a doctor's
bidding. According to Jennifer Wilson-Barnett, contributor for the Journal of Medical Ethics, the
role of a nurse has expanded, and nurses are now more involved in contributing to patient
outcomes. Some treatments associated with psychiatric care might cause ethical dilemmas for a
nurse involved with treatment decisions for a patient.

3.2. MEETING THE PSYCHOLOGICAL AND PSYCHIATRIC NEEDS OF PATIENTS:

Nursing constitutes the largest professional health care group, comprising 45% of full time public
hospital staff and 60% of private hospital staff (Australian Bureau of Statistics 2001). Therefore,
nurses are the group most in direct and indirect contact with people experiencing a mental illness
and potentially play an important role in the detection of mental health problems and subsequent
care (Sharrock and Happell 2000). Furthermore, as nurses aspire to a holistic model of care, they
may help to balance the scales between biomedical and psychosocial support, in a complementary
fashion, towards the provision of optimal quality care.

4. CONTEMPORARY PRACTICE:
Psychiatric nursing is an independant process that promotes and maintains patient behaviour that
contributes to integrated functioning. The patient may be an individual, family, group, organization
or community. The American Nurses Association Scope and Standards of Psychiatric-Mental Health
Nursing Practice defines psychiatric nursing as "a specialized area of nursing practice, employing
the wide range of explanatory theories of human behaviour as its science and purposeful use of self
as its art" for Mental Health Services officially recognizes psychiatric nursing as one of the five core
mental health disciplines. The other four disciplines are marriage and family therapy, psychiatry,
psychology and social work.
The current practice of psychiatric nursing is
based on a number of underlying premices or
beliefs. The psychiatric nurse uses knowledge
from the psychosocial and biophysical sciences
and theories of personality and human
behaviour. From these sources the nurse derives
a theoritical frame work on which to base
nursing practice. The contemporary practice of
psychiatric nursing occurs within the social and
environmental context. Thus the nurse patient
relationship has evolved into a nurse-patient
relationship that expands the dimensions of the

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professional psychiatric role. These elements include clinical competence, patient- family advocacy,
fiscal responsibility, interdisciplinary collaboration, social accountability, and legal-ethical
parameters.
One question that is often raised when nurses talk about the health care environment is
wether psychiatric nurses will be vulnerable to being replaced as expensive and out-dated providers
or be valued as competent clinicians who can function in a world of changing needs, processes, and
structures. Potential areas of vulnerability have been identified and include the following (stuart,
2001):
Fewer nurses are attracted to psychiatric nursing as compared with other speciality areas.
Content devoted to understanding psychiatric illness and working with psychiatric patients
in nursing educational programs has decreased steadily during the past decade.
Graduate programs are moving toward the preperation of nurse practitioners who have
significantly less course work related to the diagnosis and treatment of psychiatric illnesses.
Biopsychosocial skills and expertise of psychiatric nurses are often underused in mental
health care systems.
Psychiatric nurses often are viewed as expensive health care providers who can be replaced
by two or more less costly personnel.
There are increased threats to nursing autonomy as state boards of nursing and other
regulatory bodies attempt to establish seperate advanced practice licensure ane
examinations, and require advanced practice nurses to be under the full supervision of
physicians.
There are few outcome studies that doccument the nature, extent, and effectiveness of care
delivered by psychiatric nurses.
The speciality is struggling with the education and certification of advanced practice
psychiatric mental health nurses in clinical nurses specialist, nurse practitioner, and
combined roles.
Role differentiation from psychiatric nurses based on education and experience is often
lacking in the position description, job responsibilities, and reward programs of the health
care system in which nurses practice.
Each of these issues must be addressed if psychiatrc nursing is to continue to develop as a speciality
area. Nurses need to move in to the continuum of care and clearly articulate their skills , functions
and abilities. They must also demonstrate their cost effectiveness and establish differentiated levels
of practice based on education, experience, and credentials, other survival skills needed by
psychiatric nurses in the future include managment of negative emotionality,achievement of
collegial unity, understanding the nature of transactions, receiving career trajectories, and
marketting skills and functions (Thomas, 1999). Such strategies will position psychiatric nurses as
visible, interdependent, central and collaborating professionals who have much to offer a reformed
health care system.
No longer can psychiatric nurses focus exclusively on bedside care and the immediacy of patient
needs. Today they must broaden the context of their care and their responsibility and understanding
they bring to the care giving situation.the current practice of psychiatric nursing requires greater
sensitivity to the social environment and the advocacy needs of the patients and their families. Is
also requires thoughtful consideration of complex legal and ethical dilemmas that arise from a
delivery system that often discriminates against those with mental illness.
New models of mental health care also require skill in interdisciplinary collaboration that is built on
the psychiatric nurse's clinical competence and professional self-assertion and balanced by a clear
understanding of the costs of psychiatric nursing care in general and psychiatric nursing care in

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particular. Each of these issues must influnce the
education, research, and clinical aspects of contemporary
psychiatric nursing practice.
4.1. CONTINUUMO F CARE:
Tiaditional settings for psychiatric nurses include
psychiatric facilities, community mental health centers,
psychiatric units in general hospitals, residential
facilities, and private practice. Many psychiatric hospitals
also have become integrated clinical systems that provide
inpatient care, partial hospitalization or day treatment,
residential care, home care, and outpatient or ambulatory care.
Psychiatric nurses are also moving into the domain of primary care and working with other nurses
and physicians to diagnose and treat psychiatric illness in patienrs with somatic complaints (Saur et
al,2002). Cardiovascular gynecological, respiratory gastrointestinal, and family practice settings are
appropriate,for assessing patients for anxiety, depression, and substance abuse disorders. As health
care initiatives continue to move into schools and other community settings, psychiatric nurses are
assuming leadership roles in providing expertise through consultation and evaluation.
Psychiatric nurses are very well suited to provide comprehensive health care to patienrs in both
psychiatric settings, and primary care environments. In particular, advanced practice psychiatric
nurses acting as consultants to nonpsychiatric providers in hospital-based or outpatient clinics are
in a unique position to assess and triage these patients. Early assessment and triage can minimize
the length of time between psychiatric referral and intervention and enhance the efficacy of
treatment.
4.2. Competent caring:
There are three domains of contemporary
psychiatric nursing practice: direct care,
communication, and management. Within
these overlapping domains of practice, the
teaching, coordinating, delegating, and
collaborating functions of the nursing role
are expressed. Often the communication and
management domains of practice are
overlooked when discussing the psychiatric
nursing role. However, these integrating
activities are critically important and very
time consuming aspects a nurses's role. They
have become even more important in a
reformed health care system that places
emphasis of efficient patient triage and
managment.

The following list gives specific psychiatric nursing activities that reflect the current nature and
scope of competent caring functions performed by psychiatric nurses. Not all nurses perform all of
these activities. Psychiatric nurses participate in these activities based on their education and
experience.

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psychiatric nurses need to be able to explain both the general and the specific aspects of their practice to
patients, families and other professionals, administrators and legislators. Only when such skills are identified
will psychiatric nurses be able to ensure their appropriate roles, adequate compensation for the nursing care
provided and the most efficient use of scarce human resources , in delivery of mental health care.
BIBLIOGRAPHY:
1. Shives Rebraca Louise. Basic Concepts of Psychiatric-Mental Health Nurisng. 6th ed. Philadelphia:
Lippincott Williams & Wilkins; 2005. P.18-20.
2. Pasquali Anne Elaine. Et al. Menatl Health Nursing: A Holistic Approach. 2nd ed. St Louis: The C.V
Mosby Company; 1985. P. 60-66.
3. Fortinash M Katherine. Worret Holodag. Psychiatric Mental Health Nursing. St Louis: Mosby
Elsevier;2996. P. 23-25.
4. Stuart W Gail. Laraia T Michele. Principles & Practice of Psychiatric Nursing. 8th ed. St Louis:
Mosby Elsevier;2005. P. 6-8.
5. The World Health Report 2001: Mental Health; New Understanding, New Hope. Geneva: WHO;
2001. P.23-25. Available from:
URL: http://www.who.int/whr/2010/en/index.html
6. 2011 WORLD MENTAL HEALTH DAY; THE GREAT PUSH: INVESTING IN MENTAL
HEALTH. Geneva: WHO. Available from:
URL: http://www.who.int/whr/2010/en/index.html

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