Psychiatric nursing in The United states is currently so strongly integrated wiyh the rest of nursing practice it may be hard to believe that 100 years ago general nursing ang care of the mentally ill were completely separated. Today, we have come to value the basic skills of mental health nursing as important for the nurse in the general hospital or clinic; and we have come to value the basic skills of physical assessment ang management of physical health needs as important skills for nurses in both inpatient and outpatient psychiatric setting.
CARE OF MENTALLY
Early Civilization
Throught history, those who were mentally ill have attracted the attention of other. In some societies the mentally ill or the insane were viewed with reverence, in some they were viewed with repulsion and anger. In primitive cultures where medicine, magic, and religion were not distinct, the insane were treated through magical rituals, prayer and exorcism. Belief in the causes of mentally illness ranged from the idea that the ill person was possessed by demons or was ill because of breaking some taboo to the notion that the affected person had had some harmful substance enter his body. Early civilizations, such as the Greek and Roman cultures, developed ideas of body “humors” –blood, black bile, yellow bile and phlegm- which could influence emotional stability. Hipocrates believed that excesses of black bile caused melancholy and that bloodletting could remove this excess.
Middle Ages and Renaissance
In europe during this time period. Treatment of the mentalli ill was influenced by beliefs that the mentally ill were evil, witchs or heretics. The mentally ill were excluded from community life, and evetually in order to secure such seclusion, the mentally ill were confined to institutions that housed all those deemed not fit to live in society. Persons were treated as criminals and punished for their behaviors. Care was custodial, and inmates were poorly fed and clothed and were frequently restrained.
Eighteenth and early Nineteenth Centuries
Throught the latter part of the eighteenth and early nineteenth centuries, mentally ill persons who were insane were commtied to asylums; those who commited crimes were put in prison. Care of the mentally ill, by and large, was provided by persons without training or interest in helping others and was often lacking in compassion. In both the Unite states and england, however, there were a few physicians who began to view the insane as persons suffering from disease and needing some kind of treatment. For example, English physician Willian Battie had a scientific background ang a high social position. His interset in work with the insane ultimatelyserved to elevate mental services to something respectable physicians could do. He believe that there is something powerful about a caring environment and recommended that those who work as attendants and nurses to the insane be carefully selected and trained (Nolan, 1993). Given the very positive influence of his work. It is somewhat ironic that the phrase “going batty” was derived from his name. During the time period, there were several theories regarding the cause of mental illness. No oe theory was widely accepted, and the views of the physician in charge of an asylum dictated the nature of the care and treatment provided within (nolan. 1993). Important, however, was the medicalization of the care of the insane. Physicians became those in charge og the care: insanity was increasingly viewed as a disease, not a condition of character. In the nineteenth century physicians began their first attempts to classify mental disordes, and they so described both moral causes of illness (such as jealoisy, religious excitement, and disappointment in love) and physical causes (such as epilepsy, injury to the hea, overwork and intemperance or drunkenness) (Nolan. 1993).
In 1846, the term psychiatry was first used by asylum doctors in England to identify their work and to further define the medical role in the treatment and cure of the insane. These physicians began to publish The Journal Of Mental Science to further the legitimacy of psychiatry as a medical speciality (Nolan, 1993).
Nineteenth Century
Before long, however, the optimistic idea that the mentally ill would recover quickly and return to society broke down. The asylums required productive workers. Therefore, inmates who were “good” workers were not likely to be let go: they were needed to maintain the institution. Those who could not participate in the vigorous schedules had to be “controlled” by the asylum attendants. In many cases, physical restraints were used as the only mans of controlling inmates. It became increasingly difficult to find persons willing to work in asylums, and many who did were not of sound character. Inmates were ill-treated, neglected, and taken advantage of by those who were supposed to care for them. Also the asylums soon became overcrowded, making matters of control even more difficult.
Many individuals-physicians, private citizens, and recuvered patients alike-called for reform. In the United States, Dorothea Dix, a private citizen who had provided nursing care to soldiers during the Civil war, became a crusader for reform in the treatment of the mentally ill. She advocated for humane treatment as well as safe and comfortable environments (which included heat in the winter. She fought for activities, such as dances, that would relieve the monotony of asylum life. Through her efforts, care was improved throught the United States and in Canada and Scotland as well (Dolan, Fitzpatrick, & Herrmann, 1983).
With the establishment of a reformed approach to care, it became increasingly clear that persons working in asylums (or what were then beginning to be called hospitals) needed training, a certain willingness to care for others, and a strong sense of compassion. How were such persons to be found? One physician wrote that women were to be more highly valud in this work than men, for womenwho were “of a kind and sensible disposition could not fail to be of great comfort to those patients who require gentle and sympathetic attention” (Maudley, 1879, as quoted in Nolan, 1993). Still, how were women to be required into such work? One way was to set up training schools for persons to attend to the mentally ill and to provide education for respectablewomen and men who were willing and able to enter such schools.
Nursing Education
Eighteenth and Nineteenth Centuries
In 1882 the Mclean Asylum in Somerville, Massachusettts, opened the first training school in the world for mental health nurses (Church, 1987). This school graduated its first class of 15 students in 1886. Edward Cowles was the physician superintendent of Mclean, and his effort to train nurses was part of his campaign to medicalize care of the insane. He proclaimed that inmates would be called “patients” and that ward attendants would be called “ nurses”. He believed that the presence of a “nurse” indicated not only that the patient was ill but also that there was a hope for recovery.
During this same time period, other schools of nursing were opening in the United states. The most notable of these were the Bellevue Training School in New York and the Conecticut Training School in New Haven. These were the first in the country to operate primarily under the Nightingale model, where the training of nurses was accomplished via the tutelage of nurses (rather than physicians). These programs were granted autonomy from the hospital itself, and the education was securely in the hands of the matron of superintendent, who was herself a “trained nurse”.
The programs to train the mental nurses were not autonomous in this way. Physicians like Dr. Cowles were incharge of the programs and established the curiculum. Dr. Cowles believed that these nurses needed skills in both physical and mental care and attempted to prepare nurses who could provide both. Ultimately, he designed a program where nurses studied physical nursing for the first year of training and studied skills in mental care in the second year (Church, 1987).
The year 1893 marked the first meeting of organized nursing in the United states. Nursing leaders met in Chicago at the World’s Fair and Participated in a formal conference on the state of nursing and nursing training. Various individuals presented papers on these topics, and speakers included national leaders such as Isabel Hampton and Lavinia Dock. These women called for clear standards for nursing education and for a clear definition of waht it meant to be a “trained nurse” (Hampton, 1949/1893; Dock, 1949/1893). However, care of the mentally ill was not adderesed the issues of asylum nursing (May, 1949/1893), and nurses providing care to the physically ill and those providing care to the mentally ill seemed to focus more on their differences than on any similaraties that could be identified.
Mental health nurses continued to be trained at asylums, and their trained at asylums, and their training evolved to keep up with new approaches in psychiatric care. These nurses had to care for a wide range of patients. Much of the work still included custodial care and supervision of ward attendants. Staff had to make sure that patients did not harm themselves and did not escape. Treatments such as cold dressings, poultices (hot packs, often made with herbs, applied to a sore or inflamed part of the body). Fomentations (lotion or compresses), and enemas were given. Manic behaviors were managed by packing patients in wet sheets (Nolan, 1993). Baths of different kinds were popular treatments: hot baths were used for melancholy. Cold for mania. And various positive claims were made about Turkish baths. Few drugs were available; however, sedatives such as alcohol and opium might be used sparingly for violent patients (Nolan, 1993).
Twentieth Century
The American Psychiatric Association established a commitee on Training Schools for Nurses. This commitee submitted a report in 1907 outlining the standards required for nursing, thus marking the physicians official assumption of control over mental nursing care. In 1913, however, the Johns Hopkins hospital School, under the leadershi of Effie J. Taylor, the nursing director of the Phipps Clinic, insluded psychiatric nursing in the training of general nurses. This was the first time a hospital program offeres training in psychiatric care to all of its students. Taylor’s goal was to provide a standard knowledge base for all nursing so that there would be no arbitary division of the patient’s mind and body (Church, 1987). Her reasoning today comes across as the foundation of holistic care.
Over time, other nursing programs adopted a similar model to that of the John Hopkins program. Also, other programs developed exchanges where students who were studying to be mental health nurses spent a certain amount of time studying and practicing various aspects of general nursing. The time during and immadiately after World War I increased the demand for nurses to provide care to mentally stressed persons. Mental hospitals were overcrowded and understaffed, and the national attitude was to develop increased services to meet the needs of veterans undergoing “shell shock” and other sychiatric disturbance. By 1920, the first psychiatric nursing textbook was published, Nursing Mental Disease.
In 1930s, new approaches to psychiatric care were emerging: mostly somatic therapies that involved treatments sch as deep sleep therapy, insulin shock therapy, and ultimately electroshock therapy. The need for nurses trained in the physical care of patients became clearer, and by 1937 the National League for Nursing recommended that all nurses obtain education in psychiatric nursing as part of their basic nursing coursework.
In 1946, the U.S Congress passed the National mental Health Act, which established the national Institutes of Mental Health (NIMH). This act provided federal funds for research and education in all areas of psychiatric care. This act also provided funds for graduate nursing, assisting universities to establish graduate programs for psychiatric nurses.
During the late 1940s, nursing leaders joined together in a council of 14 nursing organizations and commissioned a study regarding the status of nursing education. Esther Lucille Brown, director of The Departement of Studies in the Profeesions at the Russell Sage Foundation, was selected to carry out thi work. She published her findings in 1948 in a document called “ The Future of Nursing” better known through the years as the Brown Report. Among other recommendations, she advised that psychiatric hospitals be used as agencies for affiliation in nursing programs, rather than having psychiatric was not until 1955, however, that the National Lague for Nursing required that nursing programs include classroom and clinical experiences in psychiatric nursing in order to receive national accreditation.
The coming of age for psychiatric nursing as a speciality occured simultaneously with changes in the way those with mental illness were viewed and treated. The mid-twentieth century marked a mental health movemnt that progressed from the notion of treatment as confinement to treatmgislation was passed that empahasized prevention and rehabilitation.
Congress passed the Community Mental Health Centers Act in 1963, which provided the framework for “deinstitutionalization” or the movement of individuals from psychiatric hospitals to community settings. The idea was to provide treatment for the client in the etting that was the least restrictive alternative. Individualswho could be managed at home, in board-and-care facilities, or who could be supported with day treatment programs could be released from state mental hospitals and returned to their communities. This period also marked the era of new perspectivees on civil rights and the rights of persons with mental illness. Nursing approaches during this time expanded from exclively hospital-based serveices to include community mental health services.
The Role Of Nursing Theor and Scholarship
Nursing science and scholarship continued to advance in all aspects of nursing. In 1952 nurse theoriest Hildegard Peplau publihed Interpersonal Relations in Nursing . this text presented the first nursing theoretical framework for the practice of psychiatric care. The framework is grounded in the interpersonal philosophy of psychiatry and is discussed in some detail in cahpter 3 of this text. Other nursing theoriest followed, and some emphasied the interpersonal nature of all nursing care. Ida Jean Orlando published The Dynamic Nurse-Patient rRelationship in 1961. This work was the result of a five-year project funded by the NIMH that attempted to identify factors that enchaed or impeded the integration of mental health principles into basic nursing curricula (Leonard & George, 1995). Orlando’s theory suggests that all nursing care must be concerned with a patiet’s need for help (real or received) in an immadiate situation. She suggested further that nurses help patients through disciplined interaction.
Psychiatric nurses establihed their own jounals to furthes their work and to share their developing ideas. Two new journals were establihed in the early 1960s:Perspectives in Psychiatric Care and Journal of Psychiatric Nursing and Mental Health Services. Both are still published today, with the latter having changed its title to Journal of Psychosocial Nursing and Mental Health services. In 1970s specialitycertification in psychiatric nursing became available through the American Nurses Association (ANA). With the establishment of certification, the ANA published the first standards of psychiatric and mental health nursing practice.
Current Trends and Isuues
Today, scholarship, research, and evaluation of psychiatric nuring have advanced to the point where there is no question that psychichiatric nursing is a speciality within nursing. Other, more modern, nursing theories all addess the holistic nature of people and emphasize the need to care for a person’s mind and body. The ANA issued the current Standards of Psychiatric-Mental Health Clinical Nursing Practice in 2000. These standards document the scope of current practice and two levels of practice (basic and advanced). The accompanying display summariezes the scope of practice at these two levels. At the basic level of practice, the nurse works with individuals, families, communities, and groups to promote health, asses dysfunction, assist clients to regain or improve coping, and prevent further disability. At the advanced level, the nurse may focus on the full range of activities from mental health promotion to illness care, with additional skills in the diagnosis and treatment of mental disorders.
In the definition of psychiatric nursing, the ANA standards state that “psychiatric-mental health nursing is the diagnosis and treatment of human responses to actual or potential mental health problems. Psychiatric-mental nursing is a specialized area of nursing practice, employing theories of human behavior as its science and purposeful use of self as its art” (ANA, 2000). The accompaying display lists psychiatric mental health nursing’s phenomena of concern.
Early Nineteenth Century Theories on Causes of Mental Illness
| Theory | Premise |
| Inheritance theory | Beliefe that “insanity” is transmitted from one generation to another |
| Moral degenarcy theory | Belief that persons are mentall ill by virtue of having bad character |
| Mismic theory | Belief thet dirt and putrefaction are the principal causes of ill health. This theory provided justification for removing the ill and insane from the rest of society |
| Germ theory | Belief that tose who are ill can contaminate others; the insane, therefore, should b segregated |
| Septic foci theory | Belief that there is a source of infection that causes insanity; removal of the infection (frequently through surgery) can cure the person |
| Psychiatric Mental Health Nursing’s Phenomena Of Concern Actual or potential mental health problems of clients pertaining to :
|
Community-based Roles In Psychiatric Nursing
Home Health Psychiatric Care
Case management for persons who live alone and are in need of supervision; care of elderly and demented
Care for individuals with medical illness for which there is a strong emotional response
Ongoing care for the chronic mentally ill who live at home or in alternative care settings such as group homes/halfway haouses
Participation in crisis response teams
Community-Based care
Family preservation, care of families at risk for violence, abuse, and dysfunction
Care of the homeless
Care of the incarcreated
Psychiatric nursing in the community
Future Directions
In an directory statement on the contemporary issues in psychiatric nursing, the ANA addresses the fact that the 1990s became a atime of increasing interest and knowledge in biological, genetic, and pharmalogical treatments of psychiatric disease (ANA, 2000). These advances have paralleled an increase in autonomy and professionalization of psychiatric nursing (Bolling, 2004). These advances hold great promise for treatment; however, they have also raised concerns that advancing medical treatments could minimize the recognitions. Clements (2004) has commented that even though the increasing technology has provided obvious benefits to clients, there is a concern that our emphasis is shifting away from the recognition that there is a person needing care. Thus, one must recall our nursing mandate to treat the whole being and take necessary actions to maintain the “art” of nursing in our practice. Nurses in psychiatric care are called on to lead the way for reintegration of physical and psychosocial care for persons with mental illness. Furter, there is an unquestioned and rather urgent need for nurses with psychiatric nursing skills to provide service to individuals coping with acute and chronic illnesses, terminal diagnoses, effects of stress, societal problem (such as violence), and problems associated with aging, grief, and other serious illnesses or stressful events.
Many believe the major challenge for psychiatric nursing in the twenty-first centur is keeping a nursing focus in a field that is rapidly changing on the basis of new discoveries of science, genetics, and technology (McCrone, 1996). Psychiatric nursing must include neuroscience as well as behavioral science. The focus of nursing may shift due to an explosion of scientific knowledge. Leading to highly sophisticated technology, diagnotics and pharmacologic treatments (Cukr, Jones, Wilberger, Smith & Stopper, 1998). These challenges are coming at a time when there are fewer students enrolled in graduate programs in psychiatric-mental health nursing (McCabe,2000). However, the future provides challenging work for those interested in combining knowledge of neuroscience with an understanding of human behavior and their relationship to social and environmental conditions affecting people.
Mental health services are delivred today within a developing philosophy of managed care and cost containment. Today, many persons may be underdiagnosed and untreated. For example, current data show that barely half of the persons with depression receive treatment, and that less than half of that treatment is judged to be adequate based on nember and timing of follow up visits (Kessler et al.,2003).
