Mental Health Nursing II
NURS 2310
Unit 1
Basic Concepts of Mental
Health and Mental Illness
Objective 1
Exploring the historical overview of
care of the mentally ill client
In the Beginning

No known treatment for the mentally ill
before 1840
– Mental illness perceived as incurable
– Only “reasonable” intervention was removing
mentally ill persons from the community
The Birth of Community Mental Health
Provided for reimbursement of mental
health services through Medicare and
Medicaid
 Resulted in the “deinstitutionalization” of
the mentally ill

Deinstitutionalization of the Mentally Ill

The deinstitutionalization movement
occurred throughout the late 1950’s and
early 1960’s
– 500,000 people lived in state mental hospitals
in 1955
– Right to freedom at issue

Communities unable to sustain care for
mentally ill
– Insufficient planning
– Budget cuts reduced mandated services
– Mentally ill became homeless
– Outcome is “revolving door” syndrome
The Problems That Remain
The mentally ill comprise a great majority
of the homeless population
 Many person with chronic mental illness
end up in jails and emergency rooms
 Not enough community services/facilities to
provide adequate care for mental illness
 Medicaid, Medicare, and other 3rd-party
payers do not reimburse mental health
services at the same rate as medical
services
 Continuing stigma of mental illness

Objective 2
Reviewing concepts related to
mental health and mental illness
Mental health
The successful adaptation to stressors from the
internal or external environment, evidenced by
thoughts, feelings, and behaviors that are ageappropriate and congruent with local and
cultural norms.
Mental illness
Maladaptive responses to stressors from the
internal or external environment, evidenced by
thoughts, feelings, and behaviors that are
incongruent with local and cultural norms, and
interfere with the individual’s social,
occupational, and/or physical functioning.
Self-esteem
One’s opinion of oneself; a confidence and
satisfaction in oneself.
Self-awareness
An awareness of one’s own personality or
individuality.
Sanity
Soundness or health of mind; one’s ability to
bear legal responsibility for one’s actions.
Resilience
Ability to recover from or adjust easily to
misfortune or change.
Well-being
The state of being happy, healthy, or
prosperous.
Empowerment
To promote the self-actualization or
influence of.
Assertiveness
The expression of opinions, needs, and
feelings without negating the opinions,
needs, and feelings of others.
Objective 3
Identifying members of the mental
health team and their roles
Psychiatrist
Medical doctor with special training in mental illness
and behavioral/emotional problems
 Diagnoses conditions and prescribes medical
treatment

Clinical psychologist
Provides individual and group therapy
 Performs psychiatric testing

Therapist
Provides individual therapy
 Conducts group therapy sessions

Social worker
Community resource education
 Discharge planning

Recreation therapist

Incorporates leisure activities in group settings to
demonstrate healthy coping mechanisms
Nurse
Administers medications
 Conducts group education sessions
 Provides patient support and directs patient care

Psychiatric technician
Assists nursing staff
 Provides support to client

Objective 4
Reviewing the ANA Standards
of Psychiatric and Mental
Health Nursing Practice
The American Nurses’ Association (ANA) has
identified five standards of psychiatric and
mental health nursing practice:
Standard I –
Assessment
Standard II –
Diagnosis
Standard III –
Outcome Identification
Standard IV –
Planning
Standard V –
Implementation
Standard V includes milieu therapy,
promotion of self-care activities,
psychobiological interventions, health
teaching, case management, health
promotion and health maintenance
Objective 5
Describing the
composition of
the Board of
Mental Health
in Nebraska
and Iowa
Iowa’s mental health committals are handled
by the county court in which the ill individual
resides.
The Board of Mental Health in Nebraska
consists of:





2
2
2
2
2
licensed mental health practitioners
certified marriage and family therapists
certified master social workers
certified professional counselors
public members
Members of the BOMH serve for 5 years, with
no more than 2 consecutive 5-year terms.
At least one member of the board must be a
member of a racial or ethnic minority.
The professional members of Nebraska’s
BOMH must meet the following
requirements:

Be actively engaged in the practice of his/her
profession

Be working in his/her profession within the State of
Nebraska

Be working under a license issued in this state

Have a 5-year history of working in his/her
profession just preceding the appointment
The public members of Nebraska’s BOMH must
meet the following requirements:

Be a resident of this state

Attained the age of majority

Represent the interests and viewpoints of
consumers

Not be a present or former member of a
credentialed profession, an employee of a member
of a credentialed profession, or an immediate
family or household member of any person
presently regulated by such board
Objective 6
Examining psychiatric client rights
Universal Bill of Rights for Mental Health
Patients
Mental Health Systems Act of 1980

Right to the least restrictive treatment
alternative

Right to informed consent

Right to refuse treatment

Right to confidentiality

Right to keep personal items
Right to the least restrictive treatment
alternative

The nurse must attempt to provide
treatment in a manner that least restricts
freedom
Right to informed consent
Informed consent is the client’s permission
to perform treatment
 Legal liability for informed consent lies with
the physician
 The nurse acts as the client’s advocate to
ensure informed consent was obtained

Right to refuse treatment

The patient has the right to refuse treatment
to the extent permitted by law, and to be
informed of the medical consequences of his
or her action
Right to confidentiality
Pt’s privacy is protected by Amendments IV,
V, and XIV
 Protection of client records and
communications per state statute

Right to keep personal items
People in a hospital or other treatment
facility retain the right to keep their personal
possessions
 Items must be protected and returned upon
release from the facility
 Exceptions include:

– the belonging poses a serious threat to self or
others
– items that may be dangerous would be held in a
secure place during hospitalization
– personal items must be returned to the client
upon release from the facility
– (each facility has own guidelines regarding
confiscated illegal items)
Psychiatric patients have the right to freedom
from restraint or seclusion except in an
emergency situation:
Restraints or seclusion are used for an
individual whose behavior is out of control
and who poses an inherent risk to the
physical safety and psychological well-being
of the individual and staff or others.
Restraints or seclusion are never used for
punishment or for the convenience of staff.
 Mechanical Restraints
– set of leather straps
 5-point maximum use
 2-point minimum use

– used to restrain the extremities of the individual
– individual is always in seclusion if in restraints
Physical Restraints
– Seclusion (solitary confinement in a locked room)
– Holding (used with smaller children)

Requires 1:1 supervision
Restraints and Seclusion Guidelines
Restraints or seclusion can be initiated
without a physician’s order in an emergency

Physician must be notified for an order
within 1 hour of initiation


Renewal of restraint or seclusion orders
– Every 4 hours for adults
– Every 2 hours for children 9 years and older
– Every 1 hour for children younger than age 9
Restraints and Seclusion Guidelines (cont’d)
In-person evaluation of individual in
restraints or seclusion by the physician

– Within 4 hours of initiating restraints or
seclusion for an adult
– Within 2 hours of initiating restraints or
seclusion for a child
In-person re-evaluation of individual in
restraints or seclusion by the physician

– Every 8 hours for an adult
– Every 4 hours for a child
The nurse must assess and document
circulation, respiration, nutrition, hydration,
and elimination every 15 minutes

Concepts related to the Right to Freedom
False imprisonment = the deliberate and
unauthorized confinement of a person within
fixed limits (can be verbal or physical)

– may include taking a client’s clothes for
purposes of detainment against his or her will
Assault = an act that results in a person’s
genuine fear and apprehension that he or she
will be touched without consent
 Battery = the touching of another person
without consent (harm or injury may or may
not occur

Major Elements of Informed Consent
Knowledge
 Competency
 Free will
Treatment may be performed without obtaining
informed consent under these conditions:

The client is mentally incompetent to make a
decision and treatment is necessary to preserve life or
avoid serious harm
 Refusal endangers the life or health of another
 An emergency situation
 Client is a minor
 Therapeutic privilege (full disclosure would
complicate treatment, cause severe psychological
harm, or be so upsetting as to render a rational
decision impossible)

Objective 7
Discussing confidentiality in
psychiatric care
Health Insurance Portability and Accountability
Act (HIPAA) of 1996
 The individual has the right to access his/her
medical records
 The individual has the right to have corrections
made to his/her medical records
 The individual has the right to decide with whom
his/her medical information may be shared
Breach of Confidentiality
Revealing aspects about a client’s case
 Revealing that an individual has been hospitalized

Defamation of Character
Sharing of malicious and false information that is
detrimental to an individual’s reputation
 Client may seek legal restitution if making the
information known resulted in harm
 Libel = information shared in writing
 Slander = information shared orally

Invasion of Privacy

Searching a client without probable cause
Objective 8
Discussing criteria for
hospitalization of a mentally ill
client
In order to be considered eligible for
admission to an acute inpatient psychiatric
unit, an individual must meet one or more of
the following criteria:
 The client is an imminent threat to
himself/herself
 The client poses an imminent threat to the
safety and/or well-being of others
 The client is unable to provide for his/her
basic needs in spite of having adequate
resources
 The client is out of control
Objective 9
Comparing voluntary
hospitalization, involuntary
hospitalization, and involuntary
commitment
Voluntary Hospitalization
Admission process similar to medical hospitalization
 Patient may stay as long as treatment is deemed
necessary
 Patient can leave at any time

Involuntary Hospitalization
Client is hospitalized without consent
 Situation must be considered an emergency
 Client receives observation and treatment for mental
illness
 May occur when an individual is unable to take care
of his/her basic needs in spite of having adequate
resources to do so

Involuntary Commitment
In the State of Nebraska, an individual can be
involuntarily committed subject to due process
and as a result of being a danger to self or
others as manifested by:

Recent threats or acts of violence
Substantial risk of serious harm evidenced by
inability to provide for basic human needs,
including food, clothing, shelter, essential
medical care, or personal safety

Types of Involuntary Commitment

“Voluntary” commitment via a guardian

Emergency Protective Custody (EPC)

Physician hold

Board of Mental Health hold

Board of Mental Health commitment
“Voluntary” Commitment via a Guardian
Guardian may voluntarily commit ward to a mental
health treatment facility
 No due process required

Emergency Protective Custody (EPC)
Police custody
 36-hour time limit
 Terminates automatically or by county attorney
intervention

Physician Hold
May follow EPC or voluntary admission
 48-hour time limit

Board of Mental Health (BOMH) Hold
Petition can be filed by anyone at any time
 Petition must include sufficient documentation that
an individual is at imminent risk of harming self/others
 Once approved, client brought to hospital/psychiatric
facility

– BOMH hearing set for 7 calendar days
– Client served with copy of BOMH petition
– Client has the right to attend hearing and be represented
by an attorney
Physician can drop petition after assessment of
client with approval from the county attorney

Board of Mental Health (BOMH) Commitment
BOMH determines whether a client should be
involuntarily committed to inpatient or outpatient
treatment during the BOMH hearing following the
filing and approval of the petition
 BOMH treatment plan must be approved during the
process of the hearing as this directs client’s care
throughout his/her commitment
 Committal must be reviewed periodically, as well as
upon appeal by client/client’s attorney or physician
 Ultimate goal of the BOMH is to use the least
restrictive means possible to ensure the client receives
necessary treatment
