Psychiatric Nursing: Issues and Challenges - Essay Example

?Psychiatric Nursing: Issues and Challenges Understanding psychiatric nursing practice requires various lenses because mental illness, the profession, and the professional interact within a given social context that is influenced by intermingling factors (socio-cultural, economic, and political) that constantly undergo changes and in turn effect changes. Understanding these changes will clarify the issues and challenges confronting psychiatric nursing practice and at the same time will help define the needs of the profession. Basic to understanding psychiatric nursing practice is to define what psychiatric nursing is? How is it different from other nursing practices? Is it really needed? How should it operate – with autonomy or under the auspices of doctors? With those issues and challenges confronting psychiatric nursing practice, what then could be the future of psychiatric nursing? Defining the Profession Defining psychiatric nursing alone is proven difficult and controversial for two major reasons. First, nursing itself to which psychiatric nursing is part of the nursing practice continuum (Ballard, 2008) cannot also be defined without difficulty. What made defining nursing difficult, Brenner (1984) argues, is the lack of a well-defined theory that embodies the unique and rich knowledge of the nursing clinical practice, while nursing is being taught to include both theory (‘knowing that’) and practice (‘knowing how’); but until today, it is through practice – the least studied area – that nursing is being pursued. This theoretical deficiency in nursing, she furthers, is due to the failure of nurses themselves to chart their own practices and clinical observations, which should have been rich sources of theoretical knowledge. (As cited in Ellis & Hartley, 2004, p. 150) This holds true in psychiatric nursing. Zauszniewski, Bekhet, and Haberlein (2012) note that “Current psychiatric nursing practice is still grounded in tradition, unsystematic trial and error, and authority” (p. 2). Second, the very raison d'etre of psychiatric nursing – mental illness – is being questioned of its existence. For example, Szasz (2010) perceives psychiatric illness a fiction. From a sociological perspective, the sociology of deviant behaviors views mental illness not as illness but more as a manifestation of unjust social order as clearly illustrated in the correlation between social status and mental illness. For example, people who live below poverty threshold or the most deprived, who belong to the marginalized racial minority, and who belong to the most vulnerable group, specifically women and children are those who suffer most, thus under too much stress, making them more vulnerable to mental illness, because the crueler, unkinder, and ruthless environment greatly threatens mental health. Furthermore, the labeling of eccentric behavior as mental illness is differentiated by the individual’s social status. It is easier for society to label eccentric behaviors as mental illness when exhibited by poor, marginalized and discriminated people than when exhibited by the socio-economically affluent. Specifically, the functionalist theory view mental illness as society’s clever way of emphasizing the normative behavior that is congruent to the existing social order; the symbolic theory sees those labeled as mentally ill not necessarily sick but rather victims of being stigmatized by the labeling, because according to the labeling theory, labels have powerful social effects. (Andersen & Taylor, 2011) Furthermore, even among psychiatrists and psychiatric nurses themselves, the classification systems being used in identifying and treating mental illnesses, specifically DSM, is also being criticized for over labeling “minor mental difficulties or understandable reactions to stressful situations” (Kalat, 2011, p. 545) as mental illnesses. These undermine the need for psychiatry, consequently psychiatric nursing. Against this difficulty, it is time to turn to the definition of the American Nurses Association’s (ANA) of its profession. ANA’s (2007) definition of psychiatric nursing can be broken down into three chunks of interdependent concepts. First, it is “a specialized area of nursing practice committed to promoting mental health through the assessment, diagnosis, and treatment of human responses to mental health problems and psychiatric disorders” (ANA, 2007, as cited in Ballard, 2008, p. 21). This implies expertise on the promotion of mental health, which means two things – the centrality of client care to the practice (Clarke, 1999, p. 1) and the imperative of the practice for a higher theoretical level of knowledge to provide the specialized care of the special client. Thus it is categorized under the advanced practice registered nurses (APRN), typified under the clinical nurse specialist (CNS) – which focuses on providing nursing care either to a particular population, a specialized setting, a peculiar clinical problem, or an exclusive type of care, and they are authorized to “provide direct care to patients, assist with delineating best practices in care, and teach nurses and other healthcare workers how to improve the care they deliver to a population” (Mason, 2011, p. 15). Second, it “employs a purposeful use of self as its art and a wide range of nursing, psychosocial, and neurobiological theories and research evidence as its science” (ANA, 2007, as cited in Ballard, 2008, p. 21). This implies three interdependent points: (1) vital to psychiatric nursing practice is the therapeutic use of self – the nurse as an agent of healing; (2) it utilizes a wide range of care in promoting mental health in various settings – i.e. hospitals, private practices, corrections, substance abuse centers; and (3) its practice is grounded on a strong theoretical and research-based knowledge from diverse scientific fields (Jones, Rogers, & Fitzpatrick, 2008, p. 10) – meaning collaboration with other medical profession and non-medical professions relevant to the practice. Third, psychiatric nursing practice includes the provision of “comprehensive, patient-centered mental health and psychiatric care and treatment and outcome evaluation in a variety of setting across the entire continuum of care” (ANA, 2007, as cited in Ballard, 2008, p. 21). This emphasizes the professional integrity of psychiatric nursing, far from the traditional view of being the simple handmaiden of the doctor. In doing so, this definition asserts the autonomy of the profession. Given this definition, psychiatric nurses are obligated to fulfill the following responsibilities and capabilities: to be able to execute quick but comprehensive assessment; to be able to make use of effective problem-solving skills in coming-up with difficult clinical decisions; to perform psychiatric nursing practice with autonomy but giving equal regard to working collaboratively with other professionals; to be conscious and responsive to issues of ethical dilemmas, cultural diversity, and accessibility of psychiatric care to underserved populations; to be able to work efficiently in decentralized settings; and to be knowledgeable regarding the costs and benefits of providing care limited by fiscal constraints (Shives, 2008). Brief Analytic Review of the History of the Evolution of Psychiatric Nursing The historical development of psychiatric nursing cannot be viewed independent from that of nursing in general, because psychiatric nursing is a product of the proactive response of the nursing profession to new emerging needs and demands (McKenna & Slevin, 2008). Whether this is something that the nursing profession should be proud of, whether this is a positive development to mental health care, or whether this is a manifestation of health care failure shall be answered later. Furthermore, psychiatric nursing has not evolved neither exist in a vacuum but within a given social context which is shaped by intermingling economic, sociocultural and political realities (Austin, 2010). The usefulness of history is not simply to go back to past events and past decisive figures, decisions, policies, but more important is to understand the implications of the past to the present. It is not only the ‘what’, but rather the ‘how’ and the ‘why’ that should be understood, because from this lens the issues and challenges confronting psychiatric nursing can be best understood. Along these frameworks, the evolution of psychiatric nursing shall be reviewed here. The first point that can be gleaned from the historical evolution of psychiatric nursing is the single thread that has not only propelled nursing practice to continuously evolve but more has kept the nursing practice humanized even in the midst of the gruesome realities of world wars. It is this single thread that strongly connects nursing practice in the past, in the present and in the future. This single thread is no other than patient care, and this single thread is dynamic and volatile. Suffice it to say then that the presence of nurses during wars symbolizes the care for life. For one, the evolution of various nursing practices is driven by this cause. For example, following Mason’s (2011) narrative, ‘public health nursing’ – the term Lilian Wald coined in the late 1800’s for nurses who served the deprived and middle class families in their homes oftentimes going through health hazardous environments – was a product of Isabel Hampton Robb’s altruistic idea of nursing as a moral responsibility of caring for other’s health anytime, anywhere. It is also their concern for the health of others that has professionalized nursing as a result of their courageous involvement in various wars. According to Mason, the skills and knowledge that they inevitably learned and became adept to in attending casualties of World Wars I and II had greatly expanded, which later would be transmitted to civilian nursing practice. The roles and responsibilities nurses undertook during the Vietnam War further expanded nursing, as they ‘became essential providers of emergency, trauma and rehabilitative care’ (Mason, 2011, p. 9). This development implies that nursing in general, and psychiatric nursing in particular will always be needed because healthcare in general and mental healthcare in particular will always be an issue that humanity and society will confront. Perhaps, what will change are the interventions. Second, the evolution of psychiatric nursing unsurprisingly went along with the evolution of mental healthcare. Following Jones et al.’s (2012) narrative, the availability and accessibility of nurses to care for the mentally ill in whatever way had been constant from the sanitarium where they provide custodial care (from 1890s to post World War II) to hospitals where they were obliged to practice medical-surgical nursing care to psychiatric patients (first half of the 20th century). As the understanding of mental illness broadened, came also the discovery of new interventions, which consequently redefined the role of psychiatric nursing. For example, during the time that mental illness was poorly understood, the role of the nurse was basically caregivers. They are limited to making the environment conducive for healing and to executing the patient’s medical regimen. But as mental illness was understood broadly from different perspectives, the role of nurses was also broadened. For example, with the development of the interpersonal models near mid-20th century as spearheaded by Harry Stack Sullivan and others, nursing practice was then attuned to interpersonal models, which became prominent in 1952 and continued until today. Jones et al.’s (2012) note, “Regardless of the treatment modality, the energy expended by the nurse in the delivery of psychiatric care revolved around the development and maintenance of a therapeutic relationship and the promotion of a therapeutic environment” (p. 10). In fact, it was within this theoretical paradigm that Hildegard Peplau (1952) refined nursing as a profession, defining nursing as “a significant, therapeutic, interpersonal process… functions cooperatively with other human processes that make health possible for individuals and communities… is an educative instrument, a maturing force that aims to promote forward movement of personality…” (as cited in Jones et al., 2012, p. 9). With the discovery of antipsychotic drugs for the severely mentally ill, medication administration and monitoring were added to the psychiatric nurse regimen but also transferred psychiatric care from hospitals to communities. Then when brain chemistry exploded, medical somatic interventions became the fad, resulting to lesser funding for mental health treatment. The role of the psychiatric nurse became more of a case manager of care. This development implies that the role of the psychiatric nurse is dependent on the understanding of expert researchers on mental health and on the interventions they found effective. It was not clear how were the therapeutic experiences of psychiatric nurses with patients treated as source of new higher knowledge to better understand mental illness and the patient. So, if the view that mental illness is a lie, perhaps then psychiatric nursing will no longer be needed. But before that, the question is: will the sociological perspective on mental illness prevail over the medical view, especially the pharmacological view? Unless psychiatric hospitals and pharmaceuticals found new illnesses to venture in better than mental illness, then perhaps that may happen; if not, then the possibility is very, very slim, because whether one admits it or not, mental illness means business with big profits. In fact, “nursing care is the core business of hospitals” (Mason, 2011, p. 16) Third, the historical evolution of psychiatric nursing as a profession and nursing in general has proven the necessity of well trained nurses in healthcare promotion. This statement may appear irrelevant, because it can be argued simply that the professionalization of nursing and the various specialization of nursing have proven it more than enough. However this statement is meant to present the nursing profession as a co-equal in importance of the medical profession. The evolution of the nursing from being viewed as the handmaiden of the doctor to a medical professional today has consistently shown the presence of nurses whenever care is needed with or without the doctor. The question is if the roles nurses play in the medical field can be taken over by doctors, then why would not the doctors do it? Perhaps, the answer here is obvious. Because doctors have undergone training different from the training that nurses undergo, which only tells that they are distinct professions with distinct roles, yet being in the same medical field, their roles though distinct are interdependent. In short, doctors and nurses are supposed to be partners, not superiors and subordinates. In fact, “nurses have been key to making modern, high-tech hospitals more hospitable” (Mason, 2011, p. 10). Fourth, the evolution of psychiatric nursing and nursing in general is a story of the emancipation of women masked as the struggle for the recognition of the autonomy of the nursing profession. It should be noted that by the late 1800s the impetus for the professionalization of nursing came into motion with New York City’s Bellevue Hospital having initiated a program of nursing education grounded on the Nightingale model. The years that followed witnessed the opening of hundreds of training schools for nurses. Working as apprentice, nursing students were exploited having to work long hours 6 days/week. During this time nursing is a job meant for women; whereas medicine is meant for men. This also shows the low-regard of doctors of nurses. But Jones et al. (2012) clarify that the consistent participation of psychiatric nurses with the use of therapies made them reassess the broadening roles they were ordered to undertake, which led them to struggle for a redefinition of their role. Since during that time (mid-20th century) women were still widely viewed inferior to men, this did not prosper. Moreover, Boschma (2003) highlighted the important impact of the women’s movement to the development of psychiatric nursing. The women movement had changed the social status of women, who due to their perceived superior moral capabilities were then regarded by society as the ideal caregivers rather than men (De Ruiter, 2004). Suffice it to say then that the nursing profession is also a political act, because its emergence and development is essentially a struggle for power – the power to be empowered not only as a nurse, but also as a woman. As such, Lanza (1997) correctly argues that nurses should be engaged politically. Why this is so? This will be better explained in the issues and challenges confronting the nursing profession, specifically psychiatric nursing. Issues and Challenges Psychiatric nursing is confronted with and is influenced by many issues and trends (Ballard, 2008) which are driven by the same forces which in the past have been impinging on psychiatric nursing. Perhaps, what only changed today are the approaches and tools being used. Among the many issues and challenges confronting psychiatric nursing practice, those that will be focused on here pertain to the ethical dilemmas psychiatric nursing commonly confront and the healthcare system that structurally disregards the vital role of nurses to make healthcare provision efficient and affordable. Psychiatric Nursing Ethical Value System: Dealing with Moral Conflict Everyday Every profession, organization, institution, and individual has its own ethical value system. For individuals this serves as their conscience in determining what is right and what is wrong. For organizations, institutions and professions, this serves as the anchor that aligns actions and decisions along their defined vision, mission, and goals. The importance of ethical value system may vary among different organizations and professions depending on the nature and on the implication of what they do. For instance, the business act of overpricing commodity for greater profit may not necessarily be seen unethical because profit is the being of business. Remove that and business will die. But if the overpricing has resulted into the death of the consumer, the act will become unethical. In short, if even in the business world the ethical value system matters, how much more in psychiatric nursing, which task is to promote mental health and to care for life. However, the ethical value system is influenced by various factors. Thus the question that should be answered is the ‘who’ – who defines the ethical value system of psychiatric nursing? Is it the psychiatric nurse, the patient and its family, the community, the doctor, or the state? The answer to this question will reveal the powerful forces that influence psychiatric nursing. Aroskar (1994) argues that in reality, the ethical value system of nursing in general (psychiatric nursing included) is historically dependent on bureaucratic institutions, specifically hospitals and nursing schools. What is the problem then if this is the case? Can they not define the ethical value system appropriate for psychiatric nursing? This can be answered from two different areas of concern: the motive and the practice. On the motive, most private hospitals, if not all, are being run as business enterprise; whereas, public hospitals are being run not out of altruism that had motivated Wald’s ‘public health nursing’ in the late 1800s but rather out of political expediency. On practice, the best entity to speak for the ethical conduct of psychiatric nursing is no other than the psychiatric nurses themselves, because they are those who are immersed in the practice. It is they who come in regular contact with the dilemmas that come with the therapeutic relationship. It is they who come in contact the patient’s families. As Lundy and Janes (2009) conclude in their study, “Because of the special relationship nurses have as care providers to their patients, they are the frequent participants in ethical decision making relating to patients, families, and the community” (p. 265). Thus it is they who are in the position to define the ethical value system of psychiatric nursing, yet, just like before, they are not heard. It may be argued that the ANA which is the main force in establishing the standards for nursing practice is a professional organization that represents registered nurses in the United States. However, the role of ANA in defining the ethical value system of psychiatric nursing compared with the other forces outside the nursing profession has yet to be studied. It is worthy to note here that the medical and nursing profession is actually operating within the auspices of the ideology of the free market. Meaning, various market forces such as the pharmaceutical companies, the hospitals and clinics, the medical and nursing schools and universities, and the food and beverage companies are all directly and indirectly dictating the practice of psychiatric nursing. Meaning, what is ethical in actual operation is defined not necessarily by the need of the patient’s mental health and well-being, but rather by the interest of these market forces – no other than profit and big profit. One study (Duncan, 1992) finds that the clinical situations which have subjected psychiatric nursing practice in a dilemma involve ‘patient’s rights’ (i.e. right to treatment, right to refuse treatment, and right to informed consent), ‘system interaction’ (i.e. ‘problematic situations between nurses and consumers and problems with inadequate resources’), and ‘nurses’ rights’ (i.e. ‘employment contracts, high case loads, and limited resources’) (as cited in Lundy & Janes, 2009, p. 263). Hamrick (2000) explains, it is common for nurses to first experience moral uncertainty and later on will worsen into moral distress as they witness the disregard of patient’s rights or as institutional constraints prevent them from doing what they believe is right. Other ethical dilemma that psychiatric nurse ordinarily confront are those instances that calls for practical solutions yet may come in conflict with abstract ethical principles usually revolve around issues regarding “the allocation of scarce resources to various people with similarly pressing needs; the care of vulnerable populations, such as mentally ill clients who need additional considerations; or the rights and entitlements of people with conflicting interests” (Katims, 1995, p. 68). The Healthcare System: The Need for Psychiatric Nursing Leadership In her article, Delaney (2011) explains why the current healthcare reform movement can become a turning point to psychiatric nursing that it should rethink its role and a make well-thought of choice. According to her, the United States healthcare system is compelled to undergo dramatic reforms in response to the troubling findings of healthcare policy analysts that the expenditure of the state for health care is unjustifiably high compared to its meager result. The reform movement pushes for greater access to health care, prevention and wellness; focuses on recovery as the center of mental health treatment; and directs future innovation following the explosion of neurobiological research, which means more pharmacological intervention. For the last decade, McCabe (2009) argues that psychiatric mental health care in the United States has been undergoing a paradigm shift “from mindfulness to pharmacopeia; from relational to prescriptive” (McCabe, 2009, p. 6) as a result of neurobiological research explosion. This unsurprisingly is funded by pharmaceutical companies which have ensured the availability of these drugs in the market. The roles considered as advance practice psychiatric nursing which development can be compared to treading the rough and steep road is now being supplanted by psychiatric drugs. According to the National Institute of Health Care Management [NIHCM] (2002), the substantial growth of the pharmaceutical companies – which according to the Kaiser Foundation (2003) topped $304 billion in 2002 – corresponds with the country’s increasing national expenditure on drugs for health care. The NIHCM furthers that US expenditures on prescription drugs tripled every decade for the last three decades (1980 = $12 billion, 1990 = $40 billion, 2001 = $154 billion) (as cited in McCabe, 2009, p. 7). The growing dependence of psychiatric care on drugs, McCabe (2009) furthers, can be seen in the cost explosion of five types of drugs which are common psychotropic agents (antidepressants, antipsychotics, and anti-epileptics), gastroesophageal reflux disease (GERD) drugs, and antihistamines. Suffice it to say then that “psychiatric disorders are about pharmacology” (McCabe, 2009, p. 7). Such dramatic changes, Delaney (2011) argues, will push the role of psychiatric mental health nursing to the edge, thus the danger of the profession and the professional to be marginalized. Other than this, she notes, is the on-going major change in the certification and licensure of APNs. From APNs, psychiatric nursing is being moved to a life-span nurse practitioner, which is an NP role. Essentially the importance of psychiatric nursing as part of the whole continuum of the nursing practice is being diminished. Against these annoying implications, Delaney argues, psychiatric nursing is now at a crossroad which could either push for a future vision of the profession or could quietly go with the flow and allow the profession to be marginalized, just like in the past. Kalish and Kalish (1982) note that nurses have been historically reactive rather than proactive, and they do not fully recognize the power play that operates in nursing practice. This they further is the primary reason why nurses do not influence the healthcare system. If they could have been proactive they could have envisioned future innovations because they will be able to foresee changes in the healthcare system. (As cited in Lanza, 1997, p. 8) “The key drivers of change set the context of PMH nurses’ decision since it is these dynamics that are shaping the service delivery landscape” (Delaney, 2011, p. 42). Therefore, the future of psychiatric nursing depends on psychiatric nurses themselves, because as Delaney rightly says, they can choose to become the subject of change or the master of change. To this, Lanza correctly notes the necessity for a psychiatric nursing leadership, because the historical development of psychiatric nursing has proven how power play impinges on the practice of psychiatric nursing. Conclusion Psychiatric nursing is a specialized advanced nursing practice which emergence was grounded on the need for professionalized mental health care. Within the psychiatric nursing practice are various issues and challenges which illustrate power play as to who will define the course of development of the profession. At the core of this power play are issues of feminism, capital dominance, paid science, professional autonomy, and professionalism. At the back of this power play are various forces benefitting from these changes, specifically hospitals, pharmaceuticals companies and nursing schools. Today, psychiatric nursing is facing the greatest challenge because the healthcare reform movement is marginalizing the profession. This challenge poses a question that has essentially characterized the development of psychiatric nursing until today: Do psychiatric nurses prefer to be subject of change rather than be masters of change? If the former, then the search for professional autonomy becomes irrelevant; if the latter, then there is the urgent need for a psychiatric nurse leader. References Andersen, M. L. & Taylor, H. F. (2011). Sociology: The Essentials. Belmont, CA: Wadsworth. Aroskar, MA. (1994). Ethics in Nursing and Health Care Reform: Back to the Future? The Hastings Center Report, 24(3), 11-12. Austin, MA. B. (2010). Psychiatric & mental health nursing for Canadian practice. Philadelphia, PA: Lippincott Williams & Wilkins Ballard, K. (2008). Chapter 2: Issues and trends in psychiatric-mental health nursing. In O’Brien, P. G., Kennedy, W. Z., & Ballard, K. A. (eds.), Psychiatric-mental health nursing: An introduction to theory and practice (pp. 21-38). Sudbury, MA: Jones and Bartlett Publishers. Clarke, L. (1999). Challenging ideas in psychiatric nursing. New Fetter Lane, London: Routledge. Delaney, K. R. (2011). Psychiatric mental health nursing: why 2011 brings a pivotal moment. Journal of Nursing Education and Practice, 1(1), 42-50. De Ruiter, PH. (2004, Fall). The rise of mental health nursing: A history of psychiatric care in Dutch asylums, 1890-1920 (review). Bulletin of the History of Medicine, 78(3), 727-728. Ellis, R. & Hartley, CL. (2004). Nursing in today’s world: Trends, issues & management (8th ed.). Philadelphia, PA: Lippincott_Raven Publishers. Hamrick, A. B. (2000). Moral distress in everyday ethics. Nursing Outlook, 48(5), 199-201. Kalat, J. W. (2011). Introduction to psychology. Belmont, CA: Wadsworth. Katims, I. (1995). Response to "An analysis of some dimensions of the concept of moral sensing exemplified in psychiatric care." Scholarly Inquiry for Nursing Practice, 9(1), 67-70. Jones, J. S., Rogers, V., & Fitzpatrick, J. (2012). Psychiatric-mental health nursing: an interpersonal approach. New York, NY: Springer Publishing. Lanza, M. L. (1997). Power and Leaderships in Psychiatric Nursing: Directions for the Next Century. Perspectives in Psychiatric Care, 33(2), 5-13. Lundy, K. S., & Janes, S. (2009). Community health nursing: caring for the public’s health (2nd ed.). Sudbury, MA: Jones and Bartlett Publishers. Mason, D. J. (2011). Review of the nursing field. In Mason, D. J., Isaacs, S. L. & Colby, D. C. (eds.). The nursing profession: Development, challenges, and opportunities (pp. 3-82). San Francisco, CA: Jossey-Bass. McCabe, S. (2009). The Perspective of Mystery: Threading the Connection between Patient and Nurse. Perspectives in Psychiatric Care, 40(1), 5-12 McKenna, H. & Slevin, O. (2008). Vital notes for nurses: Nursing models, theories and practice. West Sussex, UK: John Wiley & Sons. Shives, L. R. (2008). Basic concepts of psychiatric mental-health nursing (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Szasz, T. (2010). Coercion as cure: A critical history of psychiatry. New Brunswick, NJ: Transaction Publishers. Zauszniewski, J. A.; Suresky, M. J.; Bekhet, A. K.; & Kidd, L. (2007). Moving from Tradition to Evidence: A Review of Psychiatric Nursing Intervention Studies. Online Journal of Issues in Nursing, 12(2), 1-9. Read More