PSYCHIATRIC-MENTAL HEALTH NURSING ACROSS THE CONTINUUM OF CARE
Patricia Smythe Matos
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Define the continuum of care
2. Describe available treatment options and community-based resources for psychiatric-mental health patients
3. Correlate the adequacy of care settings as they relate to patient acuity and needs
4. Explain how the psychiatric-mental health nurse (PMHN) applies the nursing process throughout the diverse settings within continuum of care
5. Discuss the specialized roles that PMHNs may assume within the continuum of care
Continuum of care
Least restrictive environment
Psychiatric-mental health nursing is a specialized area of nursing practice committed to promoting mental health through the assessment, diagnosis, and treatment of patients presenting with mental health problems and psychiatric disorders along a CONTINUUM OF CARE (an integrated system of settings, services, health care clinicians, and care levels spanning illness to wellness states [Boyd, 2005]) in a variety of health care settings (American Nurses Association [ANA], American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nursing Practice, 2014). The practice of psychiatric-mental health nursing is based on the nursing process and operationalized through the scope and standards outlined by the ANA, the American Psychiatric Nurses Association, and the International Society of Psychiatric-Mental Health Nurses (2014; see Chapter 1 for a description of the scope and standards of practice). These standards provide a firm basis for psychiatric-mental health nursing practice across all levels of care and span diverse settings, including inpatient units and community mental health clinics.
This chapter describes the various levels of care in which the psychiatric-mental health nurse (PMHN) practices and the principles of practice are appropriate for each level of care. It also integrates the nursing process as the primary method for PMHNs in providing care to patients. The chapter concludes with a discussion of some of the specialized roles for PMHNs along the continuum of care.
PSYCHIATRIC-MENTAL HEALTH NURSING ACROSS THE CONTINUUM OF CARE
As stated earlier, the continuum of care spans from illness to wellness. It maximizes the coordination of care and services including nursing, medical, psychological, and social services. This coordination ensures that patients receive all appropriate services necessary for optimal health.
Psychiatric-mental health nursing employs the purposeful use of self as its art, based on Peplau’s theory (1991). The science is based in nursing, psychosocial, and neurobiological theories and research evidence. PMHNs promote and provide the delivery of holistic, patient-centered, interpersonal, and comprehensive primary mental health services to patients and families within their communities. The nurse always remains cognizant of the need to practice evidence-based care, thereby avoiding the use of untested alternative therapies. The advanced practice nurse should not recommend or prescribe treatments that are not grounded in solid research.
The PMHN’s role is diverse and encompassing. For example, PMHNs provide care in hospitals, outpatient clinics, and day treatment programs. They also develop health and wellness promotion programs addressing mental health issues, advocate for the prevention of mental health problems, and provide direct care and treatment to persons with psychiatric disorders. In addition, PMHNs may be employed in research, act as expert consultants, be self-employed and practice autonomously, or practice within a group practice.
PMHNs integrate the interpersonal process, incorporating the therapeutic use of self and the collaborative partnership between the nurse and patient (Peplau, 1991), and the nursing process to develop a plan of care for the patient with a psychiatric-mental health problem. In doing so, the PMHN is able to assist patients, their families, and their communities at all levels on the continuum of care, from the acutely unstable to the chronic, long-term care patient.
The continuum of care covers the range from illness to wellness and requires coordination of care and services for the patient to achieve optimal health.
Goal of the Least Restrictive Environment
The continuum of care is designed to ensure that treatment provided to a patient is one that allows the patient the highest level of functioning in the LEAST RESTRICTIVE ENVIRONMENT, that is, in the safest environment with the minimum restrictions on personal liberty necessary to maintain the safety of the patient and the public, and to allow the patient to achieve independence in daily living as much as possible. Least restrictive environments respect the individual’s personal needs for dignity and privacy while enhancing personal autonomy. In 1999, with the Olmstead decision, the Supreme Court affirmed that the unjustified institutionalization of a person with disabilities is discriminatory. The decision also affirmed that such an action violates the Americans with Disabilities Act. As a result, psychiatric-mental health treatment is more often delivered in community settings rather than in highly restrictive inpatient hospital settings (ANA, 2014).
When a patient requires psychiatric-mental health care in a setting other than a psychiatric service setting, such as a medical hospital unit, nursing home, and rehabilitation facility, a PMHN, typically at the advanced level of practice, may be called on to provide consultation-liaison services. In this role, the nurse assesses the patient’s mental health needs and makes recommendations for nursing interventions in the setting in which the patient is being treated. These recommendations are carried out by the staff in that medical setting. The consultation-liaison nurse also provides education for the staff as needed, provides follow-up visits to assess the patient’s response to the nursing intervention, and/or makes recommendations to modify the interventions based on this evaluation.
LEVELS OF CARE
Care is provided in a variety of different settings along the continuum of care and ranges from acute emergency treatment to long-term chronic care. Many factors, including current research findings, cost-effectiveness, level of reimbursement, social factors, and the availability of pharmacological treatments, influence which level of care is appropriate for the patient.
Psychiatric Emergency Care
Psychiatric emergency care is similar to medical emergency care. Both often involve life and death situations. Patients may be a danger to themselves or others. Their thinking or judgment may be so impaired that they cannot safely care for themselves.
If a patient is receiving individual treatment with an advanced practice nurse such as a nurse practitioner or other mental health practitioner, the first step is to ensure that the patient and those around him or her are safe. The nurse assesses the patient for suicidal or homicidal ideation and for the ability to maintain control. Once the nurse has identified the problems, the nurse must then decide which setting is most appropriate and develop a plan for providing that level of care. Some communities have mobile crisis teams that come to the setting and provide emergency treatment to the patient in crisis. These teams also may transport the patient to a safer setting. Other communities may depend on 911 or police emergency systems. The nurse considers the urgency of the situation as well as community resources in developing the plan.
Communicating pertinent clinical information (diagnosis, psychiatric history, current medications, current concern/risk, etc.) to the providers at the next level of care is essential, especially in an emergency situation. In addition, the nurse remains available to those providers throughout the patient’s care and discharge. Following any patient emergency, the nurse reviews the case with the collaborating physician and/or treatment team to evaluate the treatment plan and develop new interventions if needed on the patient’s return to outpatient care.
Like medical emergency care, psychiatric emergency care often involves life and death situations. The safety of the patient and those around him or her is the priority.
Acute Inpatient Care
Inpatient care for the psychiatric-mental health patient is most often acute and short term. The inpatient unit may be in a general medical hospital or psychiatric hospital. The goal of inpatient care is stabilization of symptoms and discharge to a safe and therapeutic living environment with the appropriate level of outpatient treatment. Inpatient treatment is reserved for patients who cannot be safely treated outside of the hospital setting and require a 24-hour nursing supervision and care.
On admission, the nurse completes a full assessment of the patient. Assessment tools, although variable from facility to facility, generally incorporate medical, nursing, and social assessments. Based on these assessments, an interdisciplinary treatment plan is developed and shared with the patient and family as appropriate. Behavioral outcomes that are clear and measurable are included. Inclusion of the patient’s preferences based on ethnic, cultural, and family values ensures that the nurse is providing patient-centered care that is respectful of diversity. For instance, primary language must be assessed and a plan for a professional interpreter services developed.
The PMHN develops a plan of care that includes interventions addressing the biological, psychosocial, and spiritual needs of the patient. Patient and family education about the diagnosis, treatment, and strategies to improve and maintain health are an essential part of this plan.
Typically, a THERAPEUTIC MILIEU is created on the inpatient unit. A therapeutic milieu involves a focus on creating a climate and environment that is therapeutic and conducive to psychiatric healing within a structured group setting that encompasses the elements of trust, safety, peer support, and repetition of recovery psychoeducation to enable patients to work through psychological issues. This milieu is designed to promote healing for all of the patients on that unit. The nurse is responsible for providing the structure necessary to maintain this environment. In collaboration with other health care providers, families, and patients, groups and activities are prescribed based on the patient’s assessment and cultural background. The nurse provides orientation and education for expected behaviors and interpersonal relationships. The nurse also ensures that safety for all is maintained in the least restrictive environment.
The PMHN continuously communicates an evaluation of the patient’s response to treatment and progress toward goals to other members of the interdisciplinary team. This communication is a collaborative process and is ongoing throughout the patient’s inpatient stay. Changes in treatment and interventions are based on the patient’s response and are used to develop appropriate discharge plans.
When a patient is admitted to an acute inpatient facility, discharge planning begins on admission. Collaboration occurs among all parties involved, such as the patient, family, interdisciplinary team, and outpatient provider. The nurse is a leader in the discharge planning process and coordinates the care needed to ensure that the patient is discharged to a safe living environment and has adequate resources for care and support.
Intermediate- or Long-Term Inpatient Care
Intermediate- or long-term inpatient care is required for patients who cannot be stabilized in an acute setting; for example, patients who are chronically self-destructive, psychotic, or unsafe to others in the community. These patients may spend many months or years in a chronic care facility such as a state hospital. However, over the past 20 years, the trend has been toward discharging these patients to the community. In some cases, patients may require a specialized treatment program, such as drug or alcohol rehabilitation, necessitating a longer length of stay (typically 28 days but it may be up to 6 months), or an eating disorder program. Although the length of stay may be different than acute inpatient hospitalization, application of the nursing process, the interpersonal process, and standards of practice remain the same.
Partial Hospitalization/Day Treatment
Partial hospitalization is an intense, ambulatory mental health program for patients who require a structured treatment program during the day, but are stable enough to return to their living environment at night. These programs can be designed for treatment ranging from 3 to 5 days per week. The time frame for the program can be for a full or half day. Patients appropriate for this setting generally cannot function autonomously on a daily basis. However, with the structure and the support of this type of program, the patient is deemed safe to be in treatment outside of an inpatient setting. Partial hospitalization may be used as an alternative to inpatient admission or as a transition from inpatient to outpatient care. Treatment provided includes individual and group therapy, psychopharmacological treatment as needed, and education. Individualized plans are developed by the interdisciplinary treatment team and may include social skills groups, illness and relapse prevention education, time management classes, and expressive and supportive psychotherapy. The nurse implements the nursing process for each patient, incorporating it into the interdisciplinary treatment plan.
The PMHN is involved in discharge planning and coordination of care, ensuring that the patient’s medical, financial, and housing needs are met. He or she also provides education to the family or nighttime caregiver as needed. Discharge to a less intensive level of care, such as an outpatient mental health clinic or private practitioner, is usually the goal. Unfortunately, some patients may require inpatient treatment if symptoms worsen or the living environment becomes unstable.
A partial hospitalization program provides a structured treatment program during the day, with the patient returning to his or her living environment at night.
The search for nonhospital-based options for psychiatric patients requiring acute care has become a focus in light of current efforts to control medical costs. Residential facilities combine and provide mental health treatment and residential care to the seriously and persistently mentally ill population who may be diagnosed with persistent and unremitting psychotic and mood disorders and/or substance use disorders. These facilities may be publicly or privately owned and funded. Intensive residential services provide patients with a place to stay in conjunction with supervised care over a 24-hour period. Length of stay may be brief (ranging from days to weeks) or extended (ranging from months to years). Medical, nursing, psychosocial, recreational, and other support services are available. In addition, assistance with vocational training and activities of daily living training are provided.
The PMHN is in a unique position and plays an important role in the care of persons with severe and persistent mental illness who require residential services. The Scope and Standards of Psychiatric Mental Health Nursing provides a guide for nurses in the delivery of patient care in this setting (ANA, 2014). PMHNs assess and provide supportive services to patients and provide psychoeducation about diagnosis, symptom management, anger management, and prescribed medication. The PMHN also assesses the patient’s level of motivation to treatment and tailor appropriate interventions while emphasizing the importance and benefit of adherence to treatment. Supervised self-administration and management of medication also is provided.
Rehabilitation is often a goal for residential treatment facilities. A return to independent living and work life with psychosocial supports in place has been achieved for many persons diagnosed with mental illness.
Residential services are used for patients experiencing seriously persistent mental illness, such as persistent and unremitting psychotic or mood disorders.
Community-based psychiatric-mental health care covers a wide range of services. PMHNs provide care in partnership with patients within the community as an effective method of responding to the mental health needs of individuals, families, and groups. Care may be delivered in the patient’s home, on the worksite, or at a school mental health clinic. Community mental health care is also provided in clinics, health maintenance organizations (HMOs), day treatment programs, homeless shelters, crisis centers, senior centers, group homes, and churches. Regardless of where the community mental health care is delivered, it is provided in a manner that respects the cultural and spiritual diversity of the patient and the community.
The PMHN assumes various roles within community-based care. In general, PMHNs identify and assess the mental health needs of the group and design programs and educational health and wellness outreach activities to target vulnerable populations. In the school setting, PMHNs engage in primary prevention and early intervention to promote good future health. They provide psychoeducation to students, parents, and teachers; assess and evaluate students for mental health difficulties; and provide psychiatric services, such as therapy and psychopharmacological interventions, to students.
Psychiatric Rehabilitation Programs
Psychiatric rehabilitation, also known as psychosocial rehabilitation or psych rehab, is a collaborative, patient-centered approach that promotes individual empowerment, community integration, and improved quality of life for patients diagnosed with mental health conditions. Recovery is a critical component of outpatient and psychiatric rehabilitation treatment programs and focuses on helping individuals develop the skills to assist them in sustaining relationships, employment, and housing (Anthony, Cohen, Farkas, & Cagne, 2002). Services provided include psychopharmacological management, social skills, vocational training, and access to leisure activities. Physicians, nurse practitioners, social workers, nurses, and other mental health workers work collaboratively with patients toward, the goals of empowerment, social inclusion, decreased stigma, and psychosocial recovery. The roles of the PMHN in these programs include psychopharmacological management, psychoeducation, group facilitation, and case management.
Assertive Community Treatment
Assertive community treatment (ACT) offers services that are customized to the individual needs of the consumer, delivered by a team of practitioners to the patients where they live, and are available 24 hours a day. The goal of ACT is to prevent hospitalization and to develop skills for living in the community. The constant availability of practitioners provides support and assistance to patients and families whenever a crisis arises. Patients are provided emergency contact numbers; when a crisis occurs, mobile treatment teams provide outreach crisis prevention services. Linkage to appropriate services are negotiated and arranged. ACT teams have been effective in reducing service costs and decreasing inpatient hospital admissions (Kane & Blank, 2004).
The clubhouse model was created in 1947 by a group of patients recovering from mental illness. They believed that they could support each other through recovery and return to productive lives in society. This group, “We Are Not Alone” or WANA, eventually developed and became the Fountain House in Manhattan (www.fountainhouse.org). The clubhouse model differs from day treatment programs in that it is primarily a self-help model. The members hire the professional staff and partner with them to provide daily structure and support services as needed. The role of the PMHN in this setting differs from other health care settings in that the nurse does not directly care, but rather partners with the patients to encourage usage of coping techniques and interpersonal skills. The PMHN assists the patient to develop independent skills for problem solving and provides health care teaching as needed. Patients are considered as club members and share chores and duties. They may join work units within the clubhouse. As they become more skilled and socially adept, the members may transition to paid employment. There is no time limit on membership (Clubhouse model, n.d.).
Respite care is available to families who are the primary caregivers of a person with a psychiatric-mental illness, and who endure high levels of stress in the caregiving role. It provides short-term relief to families by supplying short-term housing for the patient. This type of service can dramatically lower stress for the family. PMHNs act as family advocates, assisting families in connecting with available services and providing psychological support. Unfortunately, accessing respite care can be problematic due to several obstacles, such as expense, a shortage of trained providers and quality programs, restrictive eligibility, and fragmented, duplicative systems.
Downsizing of psychiatric institutions in the 1970s combined with the aging of the United States population have resulted in increased numbers of patients with psychiatric-mental health disorders residing in nursing homes. After deinstitutionalization, many psychiatric-mental health patients were unable to live independently. Thus, they were discharged from state hospital facilities to intermediate and skilled-care nursing facilities. Nursing homes and equivalent settings have become an increasingly common residence for patients with mental illness in the later stages of life.
Facilities primarily engaged in the assessment, diagnosis, treatment, and care of mental health disorders are designated by the federal government as an institution of mental disease (IMD).
The holistic care and treatment of patients in intermediate and skilled nursing facilities incorporates the physical, emotional, social, and spiritual aspects of patient care. Generalist PMHNs working in these settings are in a unique position to advocate for patients in need of increased services for psychiatric-mental health issues. Advanced practice PMHNs assess, diagnose, and provide psychopharmacological and psychotherapeutic treatments to psychiatric-mental health residents in intermediate and skilled nursing facilities.
Along the continuum of care, patients discharged from inpatient settings are generally referred for outpatient follow-up. Outpatient services promote optimal symptom management and patient functioning while integrating the patient back into the community. This follow-up care and treatment, which may be intensive, daily, weekly, or monthly, involves supportive services including individual and/or group psychotherapy, medication management, substance abuse treatment, and skills training. In addition, many outpatient programs have developed specific tracts to address diagnostic and symptom-specific problems such as depression, anxiety, posttraumatic stress disorder (PTSD), and substance abuse.