Roles and Functions of Psychiatric–Mental Health Nurses: Competent Caring

Roles and Functions of Psychiatric–Mental Health Nurses

Competent Caring

Gail W. Stuart

Nursing, or caring for the sick, has existed since the beginning of civilization. Before 1860 nursing care for those with emotional problems was mainly custodial; it focused on the patients’ physical needs, such as medications, nutrition, hygiene, and ward activities. Psychiatric nurses had limited training in psychiatry, and they mostly applied the principles of medical-surgical nursing to the psychiatric setting. Psychological care consisted of kindness and tolerance toward the patients. Nursing as a profession began to emerge in the late nineteenth century, and by the twentieth century it had evolved into a specialty with unique roles and functions (Bowling, 2003) (Table 1-1).



  1882 First school to prepare nurses to care for mentally ill opened at McLean Hospital in Massachusetts
American Journal of Nursing first published 1900  
Florence Nightingale died 1910  
  1913 Johns Hopkins was first school of nursing to include a course on psychiatric nursing in its curriculum
Electroconvulsive therapy developed 1937  
National Mental Health Act passed by Congress, creating National Institute of Mental Health (NIMH) and providing training funds for psychiatric nursing education 1946  
  1950 National League for Nursing (NLN) required that to be accredited schools of nursing must provide an experience in psychiatric nursing
  1952 Hildegard Peplau published Interpersonal Relations in Nursing
Maxwell Jones published The Therapeutic Community 1953  
Development of major tranquilizers 1954  
Community Mental Health Centers Act passed 1963 Perspectives in Psychiatric Care published; Journal of Psychiatric Nursing and Mental Health Services published
  1973 Standards of Psychiatric–Mental Health Nursing Practice published; certification of psychiatric–mental health nurse generalist established by American Nurses Association (ANA)
Report of the President’s Commission on Mental Health 1978  
  1979 Issues in Mental Health Nursing published; certification of psychiatric–mental health nurse specialists established by ANA; first edition of Principles and Practice of Psychiatric Nursing published (Stuart and Sundeen)
Nursing: A Social Policy Statement published by ANA 1980  
National Center for Nursing Research (renamed National Institute of Nursing Research [NINR]) created in National Institutes of Health (NIH) 1985 Standards of Child and Adolescent Psychiatric and Mental Health Nursing Practice published by ANA
  1986 American Psychiatric Nurses Association (APNA) established
  1987 Archives of Psychiatric Nursing published; Journal of Child and Adolescent Psychiatric and Mental Health Nursing published
  1988 Standards of Addictions Nursing Practice published by ANA
  1990 Standards of Psychiatric Consultation Liaison Nursing Practice published by ANA
Center for Mental Health Services created 1992  
  1994 Revised Standards of Psychiatric–Mental Health Clinical Nursing Practice published by ANA
Revised Nursing Social Policy Statement published by ANA 1995 Journal of the American Psychiatric Nurses Association (JAPNA) published
Report of the Surgeon General on Mental Health 1999 Hildegard Peplau died
  2000 Revised Scope and Standards of Psychiatric–Mental Health Clinical Nursing Practice published by ANA
Report of the President’s New Freedom Commission on Mental Health 2003 Certification of psychiatric–mental health nurse practitioners by ANA
Improving the Quality of Health Care for Mental and Substance-Use Conditions published by the Institute of Medicine 2006  
  2007 Revised Psychiatric–Mental Health Nursing Scope and Standards of Practice published by ANA
Patient Protection and Affordable Care Act 2010  

Historical Perspectives

In 1873 Linda Richards graduated from the New England Hospital for Women and Children in Boston. She developed better nursing care in psychiatric hospitals and organized nursing services and educational programs in state mental hospitals in Illinois. She said, “It stands to reason that the mentally sick should be at least as well cared for as the physically sick” (Doona, 1984). For these activities, Linda Richards is called the first American psychiatric nurse. One of her most important contributions was her emphasis on assessing both the physical and the emotional needs of the patients. In this early period of nursing history, nursing education separated these two needs; nurses were taught either in the general hospital or in the psychiatric hospital. It was not until the late 1930s that nursing education recognized the importance of psychiatric knowledge in general nursing care for all illnesses (Box 1-1).

An important factor in the development of psychiatric nursing was the emergence of various somatic therapies, including insulin shock therapy (1935), psychosurgery (1936), and electroconvulsive therapy (1937). These techniques required the medical-surgical skills of nurses. Although these therapies did not help patients understand their problems, they did control behavior and make the patients more open to psychotherapy. Somatic therapies also increased the demand for improved psychological treatment for patients who did not respond. As nurses became more involved with somatic therapies, they began the struggle to define their role as psychiatric nurses. An editorial in the American Journal of Nursing in 1940 described the conflict between nurses and physicians as nurses tried to implement what they considered appropriate care for psychiatric patients (Editorial, 1940). This conflict continued in later nursing practice (Box 1-2).


I have spent all of my professional career in close association with, and close dependency on, nurses, and like many of my faculty colleagues, I’ve done a lot of worrying about the relationship between medicine and nursing.

The doctors worry that nurses are trying to move away from their historical responsibilities to medicine (meaning, really, to the doctors’ orders). The nurses assert that they are their own profession, responsible for their own standards, coequal colleagues with physicians, and they do not wish to become mere ward administrators or technicians.

My discovery as a patient is that the institution is held together, glued together, enabled to function as an organism, by the nurses and by nobody else. The nurses make it their business to know everything that is going on. They spot errors before errors can be launched. They know everything written on the chart. Most important of all, they know their patients as unique human beings, and they soon get to know the close relatives and friends. Because of this knowledge, they are quick to sense apprehensions and act on them.

The average sick person in a large hospital feels at risk of getting lost, with no identity left beyond a name and a string of numbers on a plastic wristband, in danger always of being whisked off on a litter to the wrong place to have the wrong procedure done, or worse still, not being whisked off at the right time. The attending physician or the house officer, on rounds and usually in a hurry, can murmur a few reassuring words on his way out the door, but it takes a confident, competent, and cheerful nurse, there all day long and in and out of the room on one chore or another through the night, to bolster one’s confidence that the situation is indeed manageable and not about to get out of hand.

Knowing what I know, I am all for the nurses. If they are to continue their professional feud with the doctors, if they want their professional status enhanced and their pay increased, if they infuriate the doctors by their claims to be equal professionals, if they ask for the moon, I am on their side.

Lewis Thomas, MD

The Youngest Science, New York, 1983, Viking Press

The period after World War II was one of major growth and change in psychiatric nursing. Because of the large number of military service–related psychiatric problems and the increase in treatment programs offered by the Veterans Administration, psychiatric nurses with advanced preparation were in demand. The content of psychiatric nursing had become a standard part of the generic nursing curriculum. Its principles were applied to other areas of nursing practice, including general medical, pediatric, and public health nursing. By 1947 eight graduate programs in psychiatric nursing had been started.

Role Emergence

The role of psychiatric nursing began to emerge in the early 1950s but it was not a smooth path. An article by Bennett and Eaton in the American Journal of Psychiatry in 1951 identified the following problems affecting psychiatric nurses:

These psychiatrists believed that the psychiatric nurse should join mental health societies, consult with welfare agencies, work in outpatient clinics, practice preventive psychiatry, engage in research, and help educate the public. They supported the nurse’s 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” (Bennett and Eaton, 1951).

Also in 1951 Mellow (Mellow, 1968) wrote of the work she did with schizophrenic patients. She called these activities “nursing therapy.” One year later, Tudor published a study in which she described the nurse-patient relationships she established, which were characterized by unconditional care, few demands, and anticipation of her patients’ needs (Tudor, 1952). These articles were some of the earliest descriptions of the nurse-patient relationship and 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 first theoretical framework for psychiatric nursing and the specific skills, activities, and roles of psychiatric nurses. Peplau defined nursing as a “significant, therapeutic process.” While she studied the nursing process, she observed nurses functioning in various roles, such as those listed in Box 1-3. She wrote, “Counseling 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).

Two other significant developments in psychiatry in the 1950s also affected nursing’s role. The first was Jones’ publication of The Therapeutic Community: A New Treatment Method in Psychiatry in 1953. This method encouraged using the patient’s social environment to provide a therapeutic experience. The basis of the therapeutic community was that each patient was to be an active participant in care, become involved in the daily problems of the unit, and help solve problems, plan activities, and develop the required unit rules. 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 and straitjackets were required. Also, more personnel were needed to provide therapy, and the roles of various psychiatric clinicians were expanded, including nursing.

Evolving Functions

In 1958 the following functions of psychiatric nurses were described (Hays, 1975):

Peplau further clarified psychiatric nursing’s position and directed its future growth. In Interpersonal Techniques: The Crux of Psychiatric Nursing, published in 1962, Peplau identified the heart of psychiatric nursing as the role of counselor or psychotherapist. She clarified the differences 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. For her contributions to the specialty, Hildegard Peplau is often called the mother of psychiatric nursing (Figure 1-1).

In the 1960s the focus of psychiatric nursing began to shift to primary prevention and implementation of care and consultation in the community. These changes lead to a shift in the name of the specialty from “psychiatric nursing” to “psychiatric and mental health nursing.” The Community Mental Health Centers Act of 1963 made federal money available to states to plan, construct, and staff community mental health centers and resulted in a growing awareness of the value of treating people in the community and preventing hospitalization whenever possible. It also encouraged the use of multidisciplinary treatment teams by combining the skills of many professions to treat illness and promote mental health. This team approach continues to be negotiated as issues of territoriality, professionalism, authority structure, consumer rights, and the use of peer counselors are still being debated.

The 1970s saw psychiatric nurses emerging as the pacesetters in specialty nursing practice. They were the first to do the following:

Feb 25, 2017 | Posted by in NURSING | Comments Off on Roles and Functions of Psychiatric–Mental Health Nurses: Competent Caring
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