r.sreevani - seminar presentation

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EXPANDED ROLE OF A PSYCHIATRIC NURSEGUIDEDr.K.ReddemmaProfessor & HODDept. of NursingNIMHANS,Bangalore

PRESENTERMrs.R.SreevaniPh.D Nursing

Student

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INTRODUCTION

During recent years, the development of health services in the world, much emphasis has been placed on the expanding role of the nurse.

Expanded role emphasizes on health promotion and illness prevention as well as a concern for the client as a whole.

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ROLE

A role is a set of expected and actual behaviors associated with a position in a social structure.

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PSYCHIATRIC NURSE The American Nurses Association defines

psychiatric nursing as a specialized area of nursing practice using theories of human behavior as its scientific base and the planned use of self as its art. Psychiatric nursing includes the prevention and treatment of mental illness. It also includes the promotion of optimal mental health for society, the community and individuals.

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EXPANDED ROLE Expanded role of a nurse is one that the nurse

assumes by virtue of education and experiences. It goes beyond the traditional nursing roles with additional responsibilities in a practice area and in most cases, practices with greater autonomy.

It implies any enlargement of the nurse's role within the boundaries of nursing education, theory and practice, thereby expanding her role around the needs of the patient rather than simply taking on a delegated medical task.

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APPROACHES TO AN EXPANDED NURSING ROLE

Nursing philosophers perceive expansion of nursing in one of the two ways – as a replacement function or as a complemental function, relative to the knowledge and skills of other health professionals, e.g. the physician.

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APPROACHES TO AN EXPANDED NURSING ROLE Contd…

In the replacement function, the expansion is based in increasing the medical knowledge and skills of the nurse so that her understanding of the pathological processes, diagnosis and treatment closely parallels that of the medical person.

The function of nursing expands as it moves from the assistant to the physician role to the replacement of a major part of the physician work.

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APPROACHES TO AN EXPANDED NURSING ROLE Contd…

In complemental function the expanded role is enacted in primary care settings where emphasis is on the development and maintenance of family health.

In this expansion it does not replace that of other health professionals but adds another dimension to health care service.

It is an expansion of nursing into areas of need which are unmet and unfulfilled at this time; it is also an expansion of the core of what nursing basically is.

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HISTORY OF EVOLUTION OF EXPANDED ROLE IN PSYCHIATRIC NURSING

1873 1882

1930

1930s

1960

First American Psychiatric Nurse First training program in America for

psychiatric nurses Sullivan emphasized interpersonal

interactions with patients Development of somatic therapiesThe Community Mental Health

Centers Act

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HISTORY OF EVOLUTION OF EXPANDED ROLE IN PSYCHIATRIC NURSING contd…

1960s

1973

Peplau’s work on interpersonal theory, Mellow’s work on nursing therapy The American Nurses' Credentialing Centre (ANCC) offered the first certification examination for Psychiatric Mental Health Clinical Nurse Specialist. The American Nurses Association (ANA) developed standards of care

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HISTORY OF EVOLUTION OF EXPANDED ROLE IN PSYCHIATRIC NURSING contd…

1974

1990

2000

The Massachusetts Board of Registration in nursing developed regulations for advanced practice

Advances in Neurobiology, psychopharmacology

Increase in alternative and non-traditional treatment settings

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FACTORS INFLUENCING THE ROLE SHIFT IN PSYCHIATRIC NURSING

1. Economic Issues and trends From To

Physician directed Diverse decision-makers

Independent decisions

Protocol / guidelines

New technologies Cost – effectivenessPaper records, medical charts

Information system - computer

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FACTORS INFLUENCING THE ROLE SHIFT IN PSYCHIATRIC NURSING contd…

2. Change in care orientation From To

Illness Prevention Specific Holistic

Quantity of care Quality of care

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3. Change in care delivery From To

Institutional service Community services

Genetic services Counseling servicesNurse-patient relationship

Nurse-patient partnership

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4. Other trends Nurses are pressured to

demonstrate excellent clinical care with less cost that satisfies the customer’s requirements.

Population diversity and ageing Consumer empowerment Inter-disciplinary collaboration

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Schreiber et al (2003) explained the following converging trends that led to the advanced nurse practice role:

Physician shortage Gaps in service Political climate

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LEVELS OF PSYCHIATRIC NURSE

Basic Level Psychiatric nurses

Advanced Level Psychiatric nurses

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BASIC LEVEL FUNCTIONS OF A PSYCHIATRIC NURSE

Counseling Milieu therapy Self-care

activities Psycho-biological

interventions Health teaching

Case management

Health promotion and maintenance

Crisis intervention Community based

care

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ADVANCED LEVEL FUNCTIONS OF A PSYCHIATRIC NURSE

Psychotherapy Prescription of drugs Clinical supervision /

Consultation

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EXPANDED ROLES OF A

PSYCHIATRIC -MENTAL HEALTH NURSE

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ADVANCED PRACTICE REGISTERED NURSE

In the psychiatric nursing, advanced practice applies to either the clinical nurse specialist or the nurse practitioner, who is a licensed registered nurse educationally prepared at the master or doctoral level specialized in psychiatric mental health nursing and meets criteria established by the profession. (Bjorklund, 2003)

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ADVANCED PRACTICE REGISTERED NURSE contd…

Advanced practice nurse is usually a primary health care provider; functions autonomously, often works in a semi-isolated situation, has limited medication prescription privileges (depending upon individual state laws), manages the overall care of people with emotional and psychiatric problems, and usually has a consultative arrangement with a psychiatrist (Burgess, 1998).

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In Canada, registered psychiatric nurses are fully prepared for expanded roles in the following areas: Acute care hospitals and clinics Child and adolescent geriatric psychiatric care settings Long term psychiatric facilities Crisis teams and suicide prevention programs Substance abuse programs Forensic psychiatry Other community outreach programs

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Psychiatric Mental Health Clinical Nurse Specialists (PMHCNS) were the first advanced practice nurses in the US.

The scope of the PMHCNS role can include psychotherapy practice as well as a focus on staff development and the systems that support patient care.

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Empirical evidenceResearch suggests that consumer satisfaction with Nurse Practitioners (NPs) is generally higher than with general practitioners (Horrocks et al 2002; Kinnersley et al 2000, Mundinger et al 2000, Shum et al 2000; Venning et al 2000). Longer time spent in consultation, more frequent follow-up visits, the provision of information and health teaching, and a superior quality care, were specific characteristics in which NPs were considered to perform favorably compared with General Practioners (GPs).

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COMMUNITY MENTAL HEALTH NURSE (CMHN)

The central role of the community mental health nurse is to assist people experiencing a mental illness to achieve and maintain their highest level of function and independence within the community (Fortinar'n & Holoday Worret, 2004).

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COMMUNITY MENTAL HEALTH NURSE (CMHN) contd…

Community psychiatric nursing developed at Walingham Park hospital, Croydon in 1954, when ward-based nurses were sent out into the community to follow up patients who had received treatment for schizophrenia (Greene, 1968).

De-institutionalization in the 1960s gave more opportunities for community psychiatric nurses.

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Care Provider Counselor Advocate

Case Manager

Educator Researcher

Crisis Worker

Developer

Roles of Communit

y Psychiatric

Nurse

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Many additional roles in the community are: Psychiatric home health care Prevention of mental illness and stress Direct services

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In Ireland community mental health nurses were given the responsibility for helping discharged clients to remain well in their homes. Community mental health care model in Ireland is the "Cavan Monaghan exemplar" where resources become available to provide a community based service, with early intervention and community based responses. This model comprises of specialist teams and clinical nurse specialist.

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PSYCHIATRIC HOME CARE NURSE

Psychiatric home care nurses provide holistic psychiatric nursing care on a visiting basis to people needing assistance. These nurses provide comprehensive care which include:Assessment Direct Nursing CareBehavioral Management Crisis InterventionPsycho-education Case ManagementIn-home Detoxification ConsultationMedication Management

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PSYCHIATRIC HOME CARE NURSE contd…

Under the Japanese system of nursing license, there are two kinds of certification for making home visits - Registered Nurse (RN) - Public Health Nurse (PHN) In 1992 a revised health and medical insurance system launched the system of a Visiting Nurses Service Station (VNSS)

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Empirical Evidence An investigation by Barker, Robinson & Brantigan (1999) showed that psychiatric clients with depression who have been discharged from inpatient units can benefit from home care visits. Readmission rates at 60 days post discharge were substantially reduced for clients receiving home care follow up, when compared with those who did not receive home visits.

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At NIMHANS, Bangalore, India, a home care program for schizophrenia patients was carried out by a trained nurse.

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FORENSIC PSYCHIATRIC NURSE

The forensic psychiatric nurse works with

individuals who have mental health

needs and who have entered the legal

system.

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FORENSIC PSYCHIATRIC NURSE contd…

Basic level forensic

psychiatric nurses

responsibilities

Self care activities Administration of

medications Monitor the

effectiveness of treatment

Promote coping skills Improve mental health

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Advanced level forensic

psychiatric nurses

responsibilities

Diagnosis Treatment Prescription of

medications Psychotherapist Consultant

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Otherfunctions

offorensic

psychiatric nurses

Forensic evaluation for legal sanity Assessment of potential for

violence Parole / probation considerations Assessment of racial / cultural

factors during crime Sexual predator screening and

assessment Competency therapy Formal written reports to court Review of police reports On-scene consultation to law

enforcement

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Community based out patient clinics

Secure units in general hospitals

State psychiatric hospitals

Hospitals for the criminally insane

Custodial type settings such as young offender facilities, jails and prisons

Forensic Nursing Settings

(ANA, 1995)

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Empirical evidence Burnout and job satisfaction : a

comparative study of psychiatric nurses from forensic and a mainstream mental health service. Forensic nurses displayed lower burnout and higher job satisfaction than their counterparts from the mainstream services (Happell B, Martin T, Pinikahana J 2003).

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PSYCHIATRIC CONSULTATION – LIAISON NURSE (PCLN)

PCLN has arisen in response to the increased recognition of the importance of psycho-physiological inter-relationships and their impact on physical illness, recovery and wellness (Minarik & Neese, 2002).

Consultation liaison nursing began at Duke University, North Carolina, US in the 1960s when psychiatric nurses made their skills and expertise available to assist nurses working on other hospital units (Johnson 1963).

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PSYCHIATRIC CONSULTATION – LIAISON NURSE (PCLN) contd…

Psychiatric consultation – Liaison nurse is an advanced practice nurse who practices psychiatric and mental health nursing in a medical setting / non-psychiatric setting providing consultation and education to patients, families, and health care team and the community.

PCLN may provide assessment, recommendations and supportive therapy to patients who are anxious, depressed or experiencing other psychological problems or emotional distress (Chase et al 2000).

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Practice Setting

s for

PCLN

Emergency room nursing Inpatient units Home-health care Hospice care / Oncologic

nursing Physician clinics Criminal justice system Obstetric nursing Industrial nursing

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Empirical evidence Use of psychiatric consultation liaison

nurses ensures that the patient’s emotional needs are met. Patients and families feel more cared for and respected, patient satisfaction is increased (Chase P, Gage J 2000).

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NURSE CASE MANAGER Nurse case manager acts as advocate for

clients and their families by coordinating care and linking the client with the physician, other members of the health-care team, resources and the payers.

Assesses, plans, implements, coordinates, monitors, and evaluates patient care options and services to meet health needs through communication and promotes high quality, cost-effective outcomes and decreases the duplication and fragmentation of care.

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NURSE CASE MANAGER

Onset of illness

Collaborates withPatient and

family

Resolution of

illness

Collaborates withHealth team

members

Co-ordinatesCommunity

services

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NURSE CASE MANAGER contd…

Factors indicating need for nurse case manager A complex treatment plan An injury or illness that may permanently

prevent the client from returning to a previous level of health

Pre-existing medical condition that may complicate or prolong recovery

A need for assistance in accessing health-care resources

Environmental stressors

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Case management can be provided by an individual or a team. It may include both face-to-face and telephone contact with the patient, as well as contact with other service providers.

One of the most valuable assets case managers possess is their ability to synthesize patient data and act as conduits between patients and the health care system (William, 2001)

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Empirical evidence Implementation of case management –

access to care is increased through coordinated efforts that reduce fragmentation of care and diminished health care costs (Chans, et al 2000).

Proactive telephone contact with clients in the community, helped to address client’s immediate concerns and avoided relapse and re-hospitalization (Beebe LH, 2002).

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GERONURSE

Geronursing is expanding the psychiatric nursing practice to aged people who have been affected by emotional and behavioral disorders such as dementia, chronic schizophrenia, delirium etc.

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GERONURSE contd…

Basic functions

of aGeronurs

e

Assess cognitive, affective function, physical and behavioral status

Assess family dynamics Provides direct care Case management Consults with other case

providers

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GERONURSE contd…

Advanced functions

of aGeronurs

e

Provides individual and group psychotherapy

Prescribes medications Takes leadership in

program development

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PARISH NURSE

Parish nursing is a program that promotes health and wellness of body, mind and spirit. The parish nurse is a pastorally called, spiritually mature, licensed registered nurse with a desire to serve the members and friends of his or her congregation. It is a non-invasive type of nursing in which no hands-on nursing care is provided.

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PARISH NURSE contd…

Parish nurse serves as the community link between health institution and home by providing physical and mental health screenings, outreach education and visits to the home, hospital or long term care facility (Hamlin L 2000).

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TELENURSE

Nurses engaged in tele-nursing practice use technologies such as internet, computers, telephones, digital assessment tools and tele-monitoring equipments to deliver nursing care.

- Tele-Nursing in India

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TELENURSE contd…

Empirical Evidence Tele-nursing intervention increased

psychiatric medication adherence in

schizophrenia (Humphrey L 2008).

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EXPANDED ROLES OF A PSYCHIATRIC NURSE IN ALTERNATIVE THERAPIES

The American Holistic Nurses Association has the following licensed certificate programs in Alternative therapies. Licensed massage therapy Therapeutic touch Guided imageryThe most frequently employed therapies used by nurses have recently been reported to include massage, music, exercise, diet, prayer and counseling.

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NURSE RESEARCHER

Nurse researchers are scientists who seek to find answers to questions through methodical observations and experimentation.

They are doctorally or post-doctorally prepared persons who initiate or participate in all phases of the research process.

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NURSE RESEARCHER contd…

Nurse Research

er

Design studies Conduct research Disseminate

findings at professional meets and in peer reviewed journals

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PSYCHIATRIC NURSE EDUCATOR

The psychiatric nurse educator works in educational institutions, staff development department of health care agencies, client education department.- Educational Qualification- Functions

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NURSE ADMINISTRATOR / MANAGER

Has the responsibility to provide nursing leadership to ensure that an appropriate therapeutic milieu is maintained. Responsibilities Support and development of nurses Representing nursing views to senior managers Negotiating and allocating nursing resources

within clinical directorates.

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BARRIERS TO EXPANDED ROLES

According to Stephen Elsom et al 2007 potential barriers to expanded practice were :

Doctors and professional medical organizations who resisted the perceived encroachment on their professional territory

Mental health services that did not wish to invest the resources to employ nurse practitioners

Shortage of appropriately qualified mental health nurses

Lack of clarity about expanded roles in mental health nursing

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EXPANDED ROLES OF THE PSYCHIATRIC NURSE IN INDIA

In India the role of psychiatric nurse is largely confined to institutional care. There are developments in the form of community mental health care role and nurse educator role. Nurses with experience in mental health care or having special training in psychiatry with diploma or masters degree work in community mental health programs.

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NEED FOR THE EXPANDED ROLE OF A PSYCHIATRIC NURSE IN INDIA

Mental illness prevalence rate is high Lack of available resources to treat

mental illness Shortage of psychiatrists, psychiatric

nurses and other paramedical professionals

Gaps in delivering care to the patients

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MENTAL HEALTH PROBLEMS IN INDIA

Analysis of fifteen epidemiological studies shows prevalence rates as follows (Ganguli H.C,2000) All mental disorders – 70.5 per 1000 population Schizophrenia is - 2.5 per 1000 population Affective disorder (depression) – 34 per 1000 population Anxiety neurosis – 16.5 per 1000 population Hysteria – 3.3 per 1000 population Mental retardation – 5.3 per 1000 population

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MENTAL HEALTH SERVICES AVAILABLE IN INDIA

There are just 3,500 psychiatrists 1000 psychologists 600 psychiatric social workers 1000 psychiatric nurses 40 rehabilitation professionals 80% of our districts do not have

even one psychiatrist in public service

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MENTAL HEALTH SERVICES AVAILABLE IN INDIA

Most of the 75% mentally ill patients live in villages, where access even to basic health care is difficult

Half of the state-run psychiatric hospitals (53%) do not have a rehabilitation program

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STRATEGIES TO MINIMIZE OR SOLVE PROBLEMS

The Atlas : Nurses in Mental Health 2007 was launched on 11th September 2007 with a seven country video conference involving 133 participants.

The Atlas was developed by the WHO’s department of mental health and substance abuse to raise public awareness of the inadequacies of existing mental health care resources and the inequities in their distribution at the national and global level.

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STRATEGIES TO MINIMIZE OR SOLVE PROBLEMS contd…

The main discussion was on

The roles of the mental health nurse Education and curriculum Barriers to care Innovative recommendations

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INNOVATIVE STRATEGIES SUGGESTED BY EXPERTS

Mental health and development model Medications prescribing rights and standard protocols Training of village based community mental health workers Nurse mental health officer

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VARIOUS STRATEGIES FOR FACILITATING THE IMPLEMENTATION OF EXPANDED ROLES OF PSYCHIATRIC NURSES

Nurses in the first place should receive adequate training in mental health.

Regular in-service education.

Developing post-certificate courses.

Basic and graduate nursing curriculum should include more exposure to mental health issues.

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VARIOUS STRATEGIES FOR FACILITATING THE IMPLEMENTATION OF EXPANDED ROLES OF PSYCHIATRIC NURSES contd…

Regulating professional practice, including defining practice, licensure and certification and developing standards for practice.

A supportive research environment as a need at the institutional, community, national, regional and international levels.

Improving community participation

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Nurses is long and wide

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BIBLIOGRAPHY Allen MF. Comparative theories of

the expanded role in Nursing and implications for Nursing practice:A working paper. Canadian Journal of Nursing Research 1999; 30(4):83-89.

Cherry B, Jacob S. Contemporary Nursing. Philadelphia: Mosby 2002.

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BIBLIOGRAPHY Schreiber K, Boyd M, Williams CA, Head K.

Blending specialist and practitioner roles in psychiatric nursing. Journal of American Psychiatric Nurses Association 2003;9(4):136-144.

Bjorklund P. The certified psychiatric nurse practitioner advanced practice psychiatric nursing reclaimed. Archives of Psychiatric Nursing 2003; 17(2) : 77-87.

Burgess AW. Advanced Practice Psychiatric Nursing. Standford: Appleton & Lange; 1998.

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BIBLIOGRAPHY Horrocks S, Anderson E, Salisbury C.

Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal 2002; 324(7341):819-823.

Kinnersley P, Anderson E, Parry K, Randomized controlled trial of nurse practitioner versus general practitioner care for patients requesting same day consultations in primary care. British Medical Journal 2000; 320(7241):1043-48.

Mundinger MO, Kane RL, Lenz ER. Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial. Journal of the American Medical Association 2000; 283:59-68.

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BIBLIOGRAPHY contd..

Shum C, Humphreys A, Wheeler D, Cochrane MA, et al. Nurse management of patients with minor illnesses in general practice : Multicentre, randomized controlled trial. British Medical Journal 2000;320(7241):1038-1043.

Venning P, Durie A, Roland M, Roberts C, Leese B. Randomized controlled trial comparing cost effeciveness of general practitioners and nurse practitioners in primary care. British Medical Journal 2000; 320(7241):1048-1053.

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Fortinash KM, Holoday Worrett PA. Psychiatric Mental Health Nursing. St.Louis:Mosby, 2004.

Greene J. The psychiatric nurse in the community nursing service. International Journal of Nursing studies 1968;5:175-184.

Barker E, Robinson D, Brantigan, R. The effect of psychiatric home nurse follow-up on readmission rates of patients with depression. Journal of the American psychiatric Nursing Association 1999;5(4):111-116.

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Pai S, Nagarajaiah. Treatment of schizophrenic patients in their homes through a visiting nurse- some issues in the nurses training. International Journal of Nursing 1982;19:167-172.

Hufft A.Forensic nursing and multidisciplinary care of the mentally disordered offender. London:Jessica Kingsley Publishers 2000

Happell B, Martin T, Pinikahana J. Burnout and job satisfaction: a comparative study of psychiatric nurses from forensic and a mainstream mental health service. International Journal of Mental Health Nursing 2003;12(1):39-47

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Minarik PA, Neese JB. Essential educational content for advanced practice nurses in psychiatric consultation liaison nursing Archives of psychiatric nursing 2002;9(1):3-15

Johnson BS. Psychiatric nurse consultant in a general hospital. Nursing Outlook 1963;11:728-729.

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Chase P, Gage J, Stanley KM, Bonadonna JR. The psychiatric consultation / liaison nurse role in case management. Nurse Case Management 2000;5(2):73-77.

William D. Connections in case management. Lippincott’s case management 2001; 6(5):183.

Chan S, Mackenzie H, Tin-Fu Ngd, Ka-yi-lenng J. An evaluation of the implementation of case management in the community of psychiatric nurse service. Journal of Advanced Nursing 2000;31(1):144-156

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Beebe LH. Problems in community living identified by people with schizophrenia. Journal of Psychosocial Nursing 2002;40(2):38-45

Hamlin L. Parish nursing: Ties faith and healing. Vital Signs 2000;10(23):6-7

Humphrey L, Smith K, Crye C. Telenursing intervention increases psychiatric medication adherence in schizophrenia. Journal of American Psychiatric Nurses Association 2008; 14(3): 217-224

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Elsom S, Hapell B, Manias E. Exploring the expanded practice roles of community mental health nurses. Issues in Mental Health Nursing 2007;28:413-429

Ganguli HC. Epidemiological findings on prevalence of mental disorders in India. Indian Journal of Psychiatry 2000; 42(1):14-20

Government of India. Health information of India 2005, Ministry of health and family welfare, New Delhi 2006.

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Kumar S. Indian mental health care reviewed after death of asylum patients. Lancet 2001; 358(9281):569

Atlas:Nurses in Mental Health 2007. Geneva, World Health Organization, 2007

r.sreevani - seminar presentation

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