Mental health nursing, unit-I

MENTAL HEALTH & MENTAL ILLNESS, HISTORICAL PERSPECTIVES,

TRENDS ISSUES AND MAGNITUDE

UNIT-I
SUBJECT- MENTAL HEALTH NURSING

SUBMITTED TO
DR. SAILAXMI GANDHI,
ADDITIONAL PROFESSOR &,
HOD, DEPARTMENT OF NURSING
NIMHANS

SUBMITTED BY
Ms ANAMIKA VERMA
MSc. NURSING 1 YEAR,
NIMHANS

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1. MENTAL HEALTH

It is a state of balance between the individual and the surrounding world, a state of harmony
between oneself and others, a co-existence between the realities of the self and that of other
people and the environment.

1.1 Definitions

 Karl Menninger (1947) defines mental health as "An adjustment of human beings to
the world and to each other with a maximum of effectiveness and happiness."
 The American Psychiatric Association (APA 1980) defines mental health as:
"Simultaneous success at working, loving and creating with the capacity for mature
and flexible resolution of conflicts between instincts, conscience, important other
people and reality".

Thus, mental health would include not only the absence of diagnostic labels such as
schizophrenia and obsessive-compulsive disorder, but also the ability to cope with the
stressors of daily living, freedom from anxieties and generally a positive outlook towards
life's vicissitudes and to cope with those.

1.2 Components of Mental Health

The components of mental health include:

• The ability to accept self: A mentally healthy individual feels comfortable about himself.
He feels reasonably secure and adequately accepts his shortcomings. In other words, he has
self-respect.

• The capacity to feel right towards others: An individual who enjoys good mental health
is able to be sincerely interested in other's welfare. He has friendships that are satisfying and
lasting. He is able to feel a part of a group without being submerged by it. He takes
responsibility for his neighbours and his fellow members.

• The ability to fulfil life's task: The third important component of mental health is that it
bestows on an individual the ability to meet the demands of life. A mentally healthy person is
able to think for himself, set reasonable goals and take his own decision. He does something
about the problems as they arise. He shoulders his daily responsibilities, and is not bowled
over by his own emotions of fear, anger, love or guilt.

1.3 Criteria for Mental Health

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• Adequate contact with reality.

• Control of thoughts and imagination.

• Efficiency in work and play.

• Social acceptance.

• Positive self-concept.

• A healthy emotional life.

1.4 Indicators of Mental Health

Jahoda (1958) has identified six indicators of mental health which include:

I. A positive attitude towards self This includes an objective view of self, including
knowledge and acceptance of strengths and limitations. The individual feels a strong
sense of personal identity and security within the environment.
II. Growth, development and the ability for self-actualization This indicator correlates
with whether the individual successfully achieves the tasks associated with each level
of development.
III. Integration includes the ability to adaptively respond to the environment and the
development of a philosophy of life, both of which help the individual maintain
anxiety at a manageable level in response to stressful situations.
IV. Autonomy Refers to the individual's ability to perform, in an independent self-
directed manner; the individual makes choices and accepts responsibility for the
outcomes.
V. Perception of reality This includes perception of the environment without distortion,
as well as the capacity for empathy and social sensitivity- a respect and concern for
the wants and needs of others.
VI. Environmental mastery This indicator suggests that the individual has achieved a
satisfactory role within the group, society or environment. He is able to love and
accept the love of others.
a.5 Characteristics of a Mentally Healthy Person
• He has an ability to make adjustments.
• He has a sense of personal worth, feels worthwhile and important.\
• He solves his problems largely by his own effort and makes his own decisions.

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• He has a sense of personal security and feels secure in a group, shows understanding of
other people's problems and motives.
• He has a sense of responsibility.
• He can give and accept love.
• He lives in a world of reality rather than fantasy.
• He shows emotional maturity in his behaviour, and develops a capacity to tolerate
frustration and disappointments in his daily life.
• He has developed a philosophy of life that gives meaning and purpose to his daily
activities.
• He has a variety of interests and generally lives a well-balanced life of work, rest and
recreation.
2. MENTAL ILLNESS

Mental illness is maladjustment in living. It produces a disharmony in the person's ability to

meet human needs comfortably or effectively and function within a culture. A mentally ill
person loses his ability to respond according to the expectations he has for himself and the
demands that society has for him. In general, an individual may be considered to be mentally
ill if:

• The person's behaviour is causing distress and suffering to self and or others

• The person's behaviour is causing disturbance in his day-to-day activities, job and
interpersonal relationships.

2.1. Definition

“Mental and behavioural disorders are understood as clinically significant conditions

characterized by alterations in thinking, mood (emotions) or behaviour associated with
personal distress and/ or impaired functioning.” (WHO, 2001)

2.2. Characteristics of Mental Illness

• Changes in one's thinking, memory, perception, feeling and judgment resulting in changes
in talk and behaviour which appear to be deviant from previous personality or from the
norms of community.

• These changes in behaviour cause distress and suffering to the individual or others or both.

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• Changes and the consequent distress cause disturbance in day-to-day activities, work and
relationship with important others (social and vocational dysfunction).

2.3 Features of Mental Illness

The features of mental illness are classified under four headings:

a) Disturbances in bodily functions.

b) Disturbances in mental functions.
c) Changes in individual and social activities.
d) Somatic complaints

a) Disturbances in Bodily Functions

 Sleep: Disturbed sleep throughout the night, or no sleep at all, or difficulty in
falling asleep, or waking up in the middle of night and failing to fall asleep again.
In addition, the individual may experience lethargy and lack of freshness in the
morning.
 Appetite and food intake: Increased appetite or decreased appetite, weight loss or
weight gain, nausea, vomiting.
 Bowel and bladder movement: Diarrhoea or constipation, increased micturition,
bed-wetting.
 Sexual desire and activity: Decreased interest in sex, premature ejaculation,
impotence or lack of sexual satisfaction. In some conditions there can be
excessive sexual desire or lack of social inhibitions.
b) Disturbances in Mental Functions
 Behaviour: The patient may exhibit over activity, restlessness, irritability, may be
abusive to others for trivial or no reasons at all, or the patient may become dull,
withdrawn and not respond to external or internal cues. At times the patient may
behave in a bizarre way which the family members may find irritating. Sometimes
the patient's behaviour can be dangerous to self or others.
 Speech: Patient talks excessively and unnecessarily or talks very little or stays
mute. The talk becomes irrelevant and un-understandable (incoherent).
 Thought: Patient expresses peculiar and wrong beliefs which others do not share.

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 Emotions: Patient may exhibit excessive emotions like excessive happiness,

anger, fear or sadness. Sometimes emotions can be inappropriate to situations. He
may laugh to self or weep without any reason.
 Perception: The patient may perceive without any stimulus. There can be
misinterpretation of perception. For example, a mentally ill person can see things
or hear sounds or feel objects which do not exist or which others do not see. This
is known as hallucinations. A patient who is hallucinating is seen talking to self,
laughing or weeping to self, wandering in the streets and behaving in a manner
which others may find abnormal.
 Attention and concentration: Patient may have decreased attention and
concentration; he may get distracted easily, or have selective inattention.
 Memory: Patient may lose his memory and start forgetting important matters.
 Intelligence and judgment: In some mental illnesses, intelligence and the ability to
take decisions deteriorate. Patient loses reasoning skills and abilities, may not be
able to perform simple arithmetic, or commits mistakes in routine work.
 Level of consciousness: In some mental illnesses due to possible brain damage
there may be changes in the level of consciousness. Patient fails to identify his
relatives. He can be disoriented to time and place. He may remain confused or
become unconscious.
c) Changes in Individual and Social Activities
Patients may neglect their bodily needs and personal hygiene. The patient may also
lose social sense. They behave in an inappropriate manner in social situations and
embarrass others. They behave strangely with their family members, friends,
colleagues and others. They may insult, abuse/ assault them.
d) Somatic Complaints
Patient may complain of aches and pains in different parts of the body, fatigue,
weakness, involuntary movements, etc.

2.4. Common Signs and Symptoms of Mental Illness

 Disturbances in Motor Behaviour

Motor retardation, stupor, stereotypes, negativism, waxy flexibility, echopraxia,
restlessness, agitation and excitement.
 Disorders of thought, language and communication

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Pressure of speech, poverty of speech, dysarthria, flight of ideas,

circumstantiality, loosening of association, tangentiality, incoherence,
perseveration, neologism, clang association, thought block, thought insertion,
thought broadcasting, echolalia, delusions, obsessions and phobias.
 Disorders of perception
Illusions, hallucinations, depersonalization, derealization.
 Disorders of emotion
Blunt affect, labile affect, elated mood, euphoria, ecstasy, dysphoric mood,
depression, anhedonia.
 Disturbances of consciousness
Clouding of consciousness, delirium and coma.
 Disturbances in attention
Distractibility, selective inattention.
 Disturbances in orientation
Disorientation of time, place or person.
 Disturbances of memory
Amnesia, confabulation.
 Impaired judgment
 Disturbances in biological function
Persistent deviations in temperature, pulse and respiration, nausea, vomiting,
headache, loss of appetite, increased appetite, loss of weight, pain, fatigue, weight
gain, insomnia, hypersomnia and sexual dysfunction.

2.5. Illness-wellness continuum

The Illness-Wellness Continuum is a graphical illustration of a wellbeing concept first

proposed by John W. Travis in 1972. It proposes that wellbeing includes mental and
emotional health, as well as the presence or absence of illness.

As shown in the Continuum. The right side reflects degrees of wellness, while the left
indicates degrees of illness. The model has been used to describe how, in the absence of
physical disease, an individual can suffer from depression, anxiety or other conditions.

He contends that medicine typically treats injuries, disabilities, and symptoms, to bring
the individual to a "neutral point" where there is no longer any visible illness. However,

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the Wellness Paradigm requires moving the state of wellbeing further along the
continuum towards optimal emotional and mental states. The concept assumes that
wellbeing is a dynamic rather than a static process.

The Illness-Wellness Continuum proposes that individuals can move farther to the right,
towards greater health and wellbeing, passing through the stages of awareness, education,
and growth. Worsening states of health are reflected by signs, symptoms and disability.

The Illness-Wellness Continuum has been viewed as promoting preventive treatment,

which improves wellbeing before an individual present with signs or symptoms of illness,
as well as educating people to be aware of and avoid risk factors, in order to protect
against pathology and premature death.

Figure.1- Illness-Wellness Continuum

3. EVOLUTION OF MENTAL HEALTH SERVICES, EDUCATION & RESEARCH

As the late 1700s approached, a day of enlightenment dawned: the establishment of
asylum. Four different periods stand out as benchmarks in evolution of modern
psychiatric care:
 Benchmark I: enlightenment ~1790s
 Benchmark II : Scientific study ~late 1800s
 Benchmark III : psychotropic drugs~1950s
 Benchmark IV: community mental health~1960s
 Period of enlightenment

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The modern era of psychiatry has began with two men, Philippe Pinel in France and
William Tuke in England. In 1793 Pinel became the superintendent of the France
institution. Pinel unchained the shackled, clothed the naked, fed the hungry and
abolished the whips and other instruments of cruel treatment. Simultaneously in
England, Willam Tuke was planning a private facility that would ensure moral
treatment for the mentally ill after he had witnessed the deplorable conditions in
public facilities. Pinel and Tuke were responsible for this first benchmark of modern
psychiatry. The concept of asylum developed from humane efforts of Pinel and Tuke.
The first asylum in US was the Eastern Lunatic Asylum in Williamsburg, Virginia,
founded in 1773. The period of enlightenment was short-lived. Within 100 years of
establishment of first asylum, the reformers were being assailed as misusers and
abusers of their charge.
 Period of scientific study
Toward the last third of nineteenth century, several scientist devoted themselves to
understanding the mind and mental illness. Although Freud had the greatest impact on
the world’s view of mental illness, he neither thought nor work in vacuum. Emil
Kraepelin (1856-1926) made tremendous contributions to the classification of mental
disorder. He was a true scientist who’s descriptions of schizophrenia are classical and
valuable reading. Eugene Bleuler (1857-1939) coined the term schizophrenia and
added a note of optimism to its treatment.

Freud’s contribution still influences psychiatric care, although for a number of years,
belittling his accomplishments was popular. He described human behaviour in
psychologic terms. He developed theory of motivation, established the usefulness of
talking(catharsis), explained importance of dreams, and proposed to unlock the
hidden parts of mind.

 Period of psychotropic drugs

From this milieu of theory and scientific thought came the third benchmark, which
began approximately in 1950 with the discovery of psychotropic drugs.
Chlorpromazine, an antipsychotic drug , and lithium, an antimanic agent, were
introduced first, and imipramine, an antidepressant, was introduced a few year later.
The impact of these drug has been powerful. Hospital stays was shortened and
hospital environments improved. The widely held belief was that psychotropic drugs
were truly miracle drugs.

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 Period of community mental health

As the various treatment approaches were being developed in the milieu derived from
Freud’s theories, criticism grew, and the state hospital system continued in plunge
into “psychiatric Siberia”.
Eventually community mental health programs were build to meet the need of all
people living within boundaries of a designated area. There programmes had
following goals:
 Emergency care
 24 hr inpatient care
 Partial hospitalization care
 Outpatient care
 Consultation and education for the population
 Screening services

The community mental health movement broadened the scope of psychiatric nursing.
A whole range of opportunities became available to the psychiatric nurse to work in
community and concentrating on individual treatment.

3.1. Some important milestones

 1773 The first mental hospital in the US was built in Williamsburg, Virginia.
 1793 Phillip Pinel removed the chains from mentally ill patients confined in Bicetre, a
hospital outside Paris, thus bringing about the first revolution in psychiatry.
 1812 The first American textbook in psychiatry was written by Benjamin Rush, who
is referred to as the Father of American Psychiatry.
 1908 Clifford Beers, an ex-patient of a mental hospital, wrote the book, 'The Mind
That Found Itself' based on his bitter experiences in the hospital. He founded the
American Mental Health Association, which made a major contribution towards the
improvement of conditions in mental hospitals.
 1912 Eugene Bleuler, a Swiss psychiatrist coined the term 'schizophrenia'. -The
Indian Lunacy Act was passed.
 1927 Insulin shock treatment was introduced for schizophrenia.
 1936 Frontal lobotomy was advocated for the management of psychiatric disorders.
 1938 Electro Convulsive Therapy (ECT) was used for the treatment of psychoses.

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 1939 Development of psychoanalytical theory by Sigmund Freud led to new concepts

in the treatment of mental illness.
 1946 The Bhore Committee presented the situation with regard to mental health
services. Based on its recommendations, 5 mental hospitals were set up at Amritsar
(1947),Hyderabad (1953),Srinagar (1958), Jamnagar (1960)and Delhi (1966).An All
India Institute of Mental Health was also set up at Bangalore (currently known as
National Institute of Mental Health and Neurosciences or NIMHANS).
 1949 Lithium was first used for the treatment of mania.
 1952 Chlorpromazine was introduced which brought about a revolution in
psychopharmacology and changed the whole picture of mental health care.
 1963 The 'Community Mental Health Centres’ Act was passed.
 1978 The Alma-Ata declaration of "Health for All by 2000AD." posed a major
challenge to Indian mental health professionals. In order to achieve mental health for
all (as a part of the achievement of Health for All by 2000 AD.), in 1980 the
Government of India called for experts in the field for assessing the mental health
needs of the people and recommended steps for providing mental health care.
 1981 Community psychiatric centres were set up to experiment with primary mental
health care approach at Raipur Rani, Chandigarh and Sakalwara, Bangalore.
 1982 The Central Council of Health, India's highest health policy making body
accepted the National Mental Health Policy and brought out the National Mental
Health Program in India.
 1987 The Indian Mental Health Act was passed. The Government of India passed two
acts, Mental Health Act 1987, and Person with Disability Act (PWD) 1995 to protect
rights of person with mental illness.
 1990 The Government of India formed an Action Group at Delhi to pool the opinions
of mental health experts about the National Mental Health Program. National Institute
of Mental Health and Neurosciences (NIMHANS), Bangalore, has taken up the
leadership in orienting health care professionals about the mental health programs of
our country. A number of innovative approaches for the treatment and rehabilitation
of mental illness have been initiated, and the most important ones are:
 Integration of mental health care with general health care.
 School mental health programs.

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 Promotion of child mental health through the involvement of Anganwadis

(ICDS program).
 Crisis intervention for suicide prevention.
 Halfway homes for mentally ill individuals for social skills training,
vocational training.
 Education and involvement of the general public through the activities of non-
governmental organizations.
 Media materials for public education.
 Training for non-professionals to work with mentally ill individuals.
 1997 National human right commission prepared a plan of action of improving the
conditions in mental hospitals in the country.
 2001 Current situation analysis (CSA) was done to evolve a comprehensive plan of
action to energize the NMHP.
Advance centre for Ayurveda in Mental Health Neuroscience at the NIMHANS,
initiated research studies in areas like epilepsy, mental retardation, schizophrenia, etc.
 2002 National survey of mental health resources carried out by directorate general of
health services, ministry of health & family welfare.
 2008 WHO mental health gap action program was launched.
 2013 the mental health care bill was introduced in the Rajya Sabha on 19 august
2013. The bill abolishes the Mental Health Act, 1987.
 2016 The Rights of Persons with Disabilities Bill was passed by Rajya Sabha on 14
December 2016 (amendment done in 2018) , the bill abolishes the PWD act 1995.
 2017 the Mental Health Care Act 2017 was passed on 7 April 2017. Following
revisions made from the Mental Health Act 1987 –
1. The Mental Healthcare Act 2017 aims at decriminalising the Attempt to Commit
Suicide by seeking to ensure that the individuals who have attempted suicide are
offered opportunities for rehabilitation from the government as opposed to being
tried or punished for the attempt.
2. The Act seeks to fulfill India's international obligation pursuant to the Convention
on Rights of Persons with Disabilities and its Optional Protocol.
3. It looks to empower persons suffering from mental illness, thus marking a
departure from the Mental Health Act 1987. The 2017 Act recognises the agency

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of people with mental illness, allowing them to make decisions regarding their
health, given that they have the appropriate knowledge to do so.
4. The Act aims to safeguard the rights of the people with mental illness, along with
access to healthcare and treatment without discrimination from the government.
Additionally, insurers are now bound to make provisions for medical insurance
for the treatment of mental illness on the same basis as is available for the
treatment of physical ailments.
5. The Mental Health Care Act 2017 includes provisions for the registration of
mental health related institutions and for the regulation of the sector. These
measures include the necessity of setting up mental health establishments across
the country to ensure that no person with mental illness will have to travel far for
treatment, as well as the creation of a mental health review board which will act
as a regulatory body.
6. The Act has restricted the usage of Electroconvulsive therapy (ECT) to be used
only in cases of emergency, and along with muscle relaxants and anaesthesia.
Further, ECT has additionally been prohibited to be used as viable therapy for
minors.
7. The responsibilities of other agencies such as the police with respect to people
with mental illness has been outlined in the 2017 Act.
8. The Mental Health Care Act 2017 has additionally vouched to tackle stigma of
mental illness, and has outlined some measures on how to achieve the same.
3.2. Some important milestone in development of psychiatric nursing
 1872 First training school for nurses, based on the Nightingale system was
established by the New England Hospital for Women and Children, USA. Linda
Richards, the first nurse to graduate from the one-year course, developed 12
training schools in the USA.
 1882 First school to prepare nurses to care for the mentally ill was opened at Mc
Lean Hospital in Waverly. A two-year program was started but few psychological
skills were addressed and much importance was given to custodial care such as
personal hygiene, medication, nutrition, etc.
 1913 Johns Hopkins became the first school of nursing to include a fully
developed course for psychiatric nursing in the curriculum.
 1921 short training courses of 3-6 months were conducted in Ranchi.

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 1943 Psychiatric nursing course was started for male nurses.

 1946 Health Survey Committee's report recommended preparation of nursing
personnel in psychiatric nursing also. The existing institutions like, mental
hospitals in Bangalore and Ranchi should start the training.
 1952 Dr. Hildegard Peplau defined the therapeutic roles that nurses might play in
the mental health setting. She described the skills and roles of the psychiatric
nurse in her book 'Interpersonal Relations in Nursing'. It was the first systematic
theoretical framework developed for psychiatric nursing.
 1953 Maxwell Jones introduced therapeutic community.
 1954 Nur Manzil Mental Health Centre, Lucknow, started psychiatric nursing
orientation courses of 4-6 weeks duration.
 1956 One-year post-certificate course in psychiatric nursing was started at
NIMHANS, Bangalore.
 1958 All the wards of Agra mental hospital were ordered to be kept open. Nurses
took an active role in patient care and handled their newer responsibilities with
great consciousness and devotion.
 1960 The focus began to shift to primary prevention and implementing care and
consultation in the community. The name 'psychiatric nursing' was changed to
'psychiatric and mental health nursing,' and a second change was made in the
1970s when it was known as 'psychosocial nursing'.
 1963 Journal of Psychiatric Nursing and Mental Health Services was published.
 1964 Mudaliar committee felt the need for preparing a large number of
psychiatric nurses and recommended inclusion of psychiatry in the nursing
curriculum (as per International Council of Nursing).
 1965 The Indian Nursing Council included psychiatric nursing as a compulsory
course in the [Link] Nursing program.
 1967 The Trained Nursing Association of India (TNAI), formed a separate
committee for psychiatric nursing to improve the perception of psychiatric
nursing as well as to set guidelines for nursing teachers to conduct theory classes
and clinical training in psychiatric nursing.
 1973 Standards of Psychiatric and Mental Health Nursing practice were
enunciated to provide a means of improving the quality of care.

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 1975 Psychiatric Nursing was offered as an elective subject in [Link] Nursing at

the Rajkumari Amrit Kaur College of Nursing, New Delhi. Now various colleges
offer psychiatric nursing as an elective subject in [Link] Nursing. These are PGI
Chandigarh (1978), SNDT College of Nursing, Mumbai (1980), CMC Vellore
CMC Ludhiana (1987), NIMHANS, Bangalore (1988).
 1980 Scientific advances in the area of psychobiology, in imaging techniques,
knowledge about neurotransmitters and neuronal receptors, molecular genetics
related to psychiatry, etc, emerged. These contributed to the shift from
psychodynamic models to more balanced psychobiological models of psychiatric
care.
 1986 The Indian Nursing Council (INC) made psychiatric nursing a component of
General Nursing and Midwifery course. American Psychiatric Nurses Association
was established.
 1990 During these years’ integration of neurosciences into holistic
biopsychosocial practice of psychiatric nursing occurred. Advances in
understanding the interrelationships of brain, behavior, emotions and cognition
offered many new opportunities for psychiatric nurses.
[Link]. started in M.G. university Kottayam
 1991 Indian Society of Psychiatric Nurses formed at NIMHANS.
 1994 The above-mentioned changes led to the revision of Standards of Psychiatric
and Mental Health Nursing.
 1995 Journal of American Psychiatric Nurses Association was established.
 2000 The scopes and standard of psychiatric nursing was published by American
Psychiatric Nurses Association.
 2003 American Psychiatric Nurses Association began certifying Psychiatric
mental health practitioners.
 2010 ISPN published journal titled Indian Journal of Psychiatric Nurses.
4. Trends, issues and magnitude
4.1. Trends in mental health nursing
4.1.1. 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

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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 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.

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4.1.2. 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 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.

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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.
4.1.3. 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, it’s 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).
4.1.4. 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 & Brykczynski, 2002; Newbold, 2001). Schools of nursing offer a variety of
programs to prepare students for the practice of psychiatric-mental health nursing.

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 Licensed practical or vocational nursing programs

 Associate's degree nursing programs
 Baccalaureate degree nursing programs
 Master's degree nursing programs
 Continuing education.

4.1.5. Career opportunity:

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.
4.1.6. Extended roles 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 violent crime and the families of both. In 1995, The Scope and Standards of

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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.
4.1.7. Future trends in psychiatric nuring:
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
o Biologic
o 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

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 Biochemistry
 Psychiatry
 Psychology
 Physics
 Genetics/family correlates
 Neurology
 Neurosurgery
 Psychoimmunology
 Psychopharmacology
 Neuroimaging
 Computer sciences
 Psychoendocrinology
 Biologic rhythms
 Psychobiologic dysfunction
 Biologic theories of major disorders
 Chronobiology
Psychiatric 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

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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 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.
4.2. Issues in mental health nursing

S.N. Issues Solution

1. Lack of mental health care at primary WHO recommends that mental

level health care should be part of or
integrated into primary health care.
Education is necessary to improve
the recognition of mental disorders
in primary health care, increase the
referral to more specialized health
providers and enhance the
initiation of supportive therapies.
In addition, ongoing supervision
and support from specialist mental
health services are needed to assist
nurses to care for people with more
complex mental health needs.
2. Lack of qualified psychiatric nurses in High priority should be given to
psychiatric centres place qualified psychiatric nurses.
Mental health concepts should be
introduced early and should be part
of the ongoing curricula. Also,
there should be opportunities for
experiential learning. Ongoing
education is also needed to assist
nurses to further develop their

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knowledge and skills, foster

changes in attitudes and beliefs and
reorient them from custodial
models of mental health care to
community-based treatment.
3. Lack of mental health care provider As per the National Survey of
Mental Health Resources carried
out by the Directorate General of
Health Services, between May and
July 2002, against the required
11,500 psychiatrists in the country,
only 3800 existed. Like other
countries, the concept of
Psychiatric Nurse Practitioner can
be implemented in India especially
at primary level.
4. Lack of mental health care in Community care has a better effect
than institutional treatment on the
community
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.

5. Lack of awareness and education Public education and awareness

regarding mental health in public campaigns on mental health should
be launched in all over country.
The main goal should be to reduce
barriers to treatment and care by
increasing awareness of the
frequency of mental disorders,
their treatability, the recovery

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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,
professionals, media, policy-
makers and politicians reflect the
best available knowledge.

4.3. 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.
4.3.1 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.
4.3.2. Meeting 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.

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Conclusion
Mental health is the level of psychological well-being or an absence of mental illness.
It is the state of someone who is "functioning at a satisfactory level of emotional and
behavioural adjustment". mental health includes "subjective well-being, perceived
self-efficacy, autonomy, competence, inter-generational dependence, and self-
actualization of one's intellectual and emotional potential, among others”.
References
1. R Sreevani, a guide to mental health & psychiatric nursing, 4 th edition , jaypee
publication, page no 1-10
2. M.S. Bhatia, a concised tesxtbook on psychiatric nursing, 4 th edition, cbs
publishers, page no- 5-8
3. Health and illness continuum, from-
[Link]
[Link]
4. Fortinash M Katherine. Worret Holodag. Psychiatric Mental Health Nursing.
St Louis: Mosby Elsevier;2996. P. 23-25.
5. Stuart W Gail. Laraia T Michele. Principles & Practice of Psychiatric Nursing.
8th ed. St Louis: Mosby Elsevier;2005. P. 6-8.
6. Developing Nursing Resources for Mental Health, from-
[Link]
7. Keltner N.L., Psychiatric Nursing, 4th edition, Mosby Elsevier,P.2-7

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