Unit one…Introduction to mental health and psychiatric nursing science
Unit two…The theoretical basis underlying mental health and psychiatric nursing science
Unit three…Mental health and psychiatric nursing science theories
Unit four…The general response to loss-grieving
Unit five…Anxiety disorders
Unit six…personality disorders
Unit seven…eating disorders
Unit eight…sexual disorders
Unit nine…psychotic disorders
Unit ten…psychiatric treatment methods
Unit eleven…lifestyle effects on mental health
1.3...What is mental illness?.............
3...The historical aspects of psychiatric illness....
1.4....Development of the Psychiatric Nursing Field....
Introduction to mental health and Psychiatric nursing science
e welcome students of mental health and psychiatric nursing science into the exciting empire of
nursing. Psychiatric nursing fully recognises the interdependability of body systems; that the
pathophysiological manifestations of one organ system not only disrupts normal functioning of the
target organ, but disrupts all the other organ systems including even those several points away;
people, buildings, polluted environment and numerous other things that at first glance might appear distant so
as to not influence him and yet are the source and aetiology of ill-health so prevalent.
The systems theory suggests that anything working as an entity has components termed ‘subsystems’; that in a
system with subsystems none of those systemic parts should operate below par of its capacity if efficiency and
maximum output of the whole system is to be achieved. If only one of components is deficient in the system, so
will be the whole. The human being, more like a machine than anything else possesses components known
organs, which form organ systems. The organs are finally intricately linked and coordinated to function as a
The human being stays not in a vacuum or emptiness too. He has in his vicinity buildings or people, which at
face value appear quite distant and unrelated to him and yet still affect him. Is it not in the environment that we
get seasonal depression arising from the severe cold spells with temperatures plummeting to minus 30 degrees
occurring in Europe or the Americas during winter period? Are our senior colleagues at work so bossy that
sleepless nights become the norm for subordinates to end-up being diagnosed with sleeplessness? What has
caused that insomnia? The presiding information reminds one that to talk of a sick mind only without saying it is
the whole organism that is pathological makes little sense or logic. It is so because a person is the sum total of
his parts which are biological, sociological, psychological as well as spiritual subsystems or realms.
The module will attempt to show with current evidence-based information from reputable centres of higher
learning and core knowledge of the related disciplines how we can maintain our mental health so we can enjoy
life and benefit from our God-given resources. It will open our eyes as to how one tragic event in the course of
life such as death of a loved one or any loss of a treasured object in one family can produce mental disorder in
one or more individuals in that family whereas the same misfortune produces resilience and other mature
coping skills in another family set up.
Mental illness is feared, abhorred, and rightfully so. Which other disease affects our relationships in the
community as well as personality and our worldview like it? Do individuals with mental illness or mental disorder
truly become "normal" like others ever again even with advanced psychotropic treatment developed today?
When a person behaves in a way society is convinced at the time that it is abnormal such as removing all clothes
and becoming naked without seemingly being ashamed of it...does that person know what he is doing at that
time? How does a nurse or doctor conclude that the person is aware or unaware of his actions? Is mental illness
the same in different individuals? Does a normal person who believes the altered perceptions and cognitive
functions of a mentally ill client also becoming mentally ill himself? Do nurses, doctors and other clinicians
become mentally ill simply by treating patients or interacting with them at therapy sessions? These are some of
the questions this module will share with the student and try to remove the myth and mystery behind mental
illness so stigmatised as a pathology of the so called insane.
-describe and use the nursing process as a significant component of nursing science’s conceptual framework including
mental health and psychiatric nursing science:
-perform psychosocial and physical assessment of a patient/ client:
-describe the structure of personality according to the Freudian proposition as well as other theorists:
-discuss defence mechanisms and show how they affect mental health:
-describe the normal stages of development of an individual:
-classify mental disorders according to the DSM 4 classification:
-classify mental disorders according to the ICD-10 classification
-differentiate major psychiatric syndromes from the minor and manage selected conditions using a given standard format;
-discuss the effects and negative impact on mental health of certain lifestyles and how to change lifestyle to prevent mental
disorders in the community.
-- discuss food groups and food additives of special interest to mental health.
-diagnose patients, prescribe medications against tailor-made psychiatric nursing interventions and evaluate the overall
clinical management provided.
-manage psychiatric patients correctly with confidence.
n this unit our thrust is to understand the historical developments that shaped present-day mental health and
psychiatric nursing science. It is vital to note that what we are having as patients in our units, hospitals and
institutions today were previously regarded as individuals unworthy of care and attention and therefore were
thrown or cast away from society to live solitary lives in various filthy dwellings and being supervised by illiterate
people who did not care much about them or their treatment.
By the end of this unit, the student should be able to:
⃝ define the terms 'mental health' and ' mental/psychiatric illness'.
⃝ state the early warning signs of mental illness
⃝ describe the various changes that mental and psychiatric nursing science has gone through.
⃝ list the factors that affect the mental health of a person.
⃝ discuss the relationship between mental health, psychiatric nursing science and other social
ental health is the emotional state we possess when we enjoy life in its fullest form. It is not
measured by wealth for its fulfillment. It has less to do with acquiring worldly possessions, for
there are countless numbers of very unsatisfied and sorrowful billionaires out there. It is an
inescapable state for any person who strives to live in equilibrium with the ego ideal and others in
this world. When a party in full swing tickles its audients to the dance-floor, many eagerly mount on their
muscles and respond accordingly. This is a good barometer for identifying those among us possessing what is
termed ‘good mental health’. At a funeral congregation, everyone uniformly saddens. Some may pretend to be
somber in the process of course but that is all that is required for the situation. This is a state taken for granted
by most of us that it remains eternal and is achieved effortlessly. When we refer to people as ‘normal’, we agree
that they exhibit acceptable behaviour traits we have come to terms with in our community.
Mental health, like a desert sand dune, is always on the move and not staying the same. Therefore, no one
possesses all attributes of good mental health all the time. We go and squander our hard-earned income as we
gamble on slot machines and drown our sorrows in liquor overnight. The following morning, one rightfully comes
to terms with the reality that it was all wrong and wasteful. It would be a bitter but timely lesson learnt. Now, we
can stretch further our imagination as to how many are living homeless, pitiful and destitute lives because such
savings were all drained by repeated acts of antisocial behaviour. The sixth sense dictates that we do learn from
our past mistakes and make amends in the future, but are such people showing signs of good mental health by
not learning from the past, one asks.
Mental health has been defined in myriad ways. The definitions may appear different due to the syntax as well
as the abstractness of the subject matter but critically look for the basic message being conveyed by each mental
Defining mental health
is a state of emotional and psychological wellbeing in which an individual is able to use his or
her cognitive and emotional capabilities, function in society and meet the ordinary demands of life. ‘American
is a branch of medicine that deals with achievement and maintenance of psychological
wellbeing. ‘American Heritage Dictionary’.
is not only the absence of a mental disorder. It is defined as a state of wellbeing in which
every individual realises his or her own potential, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to contribute to his or her community. ‘World Health Organisation’.
a person’s overall psychological and emotional condition.’Mentalhealthnet.org’.
You may have observed the close relationship between general health and mental health. It is only fair that
we also pay homage to defining what health really is.
Definition of Health
is a state of complete physical, mental and social wellbeing and not merely the absence of disease
or infirmity. ‘WHO’
What is your own definition of mental health? (2marks).
Select only one definition that you think best explains your understanding of mental health from those listed.
Give two (2) reasons why you think so. (2marks).
All the above definitions have one thing in common. What is it? (1mark)
he following red flags may occur to a person who was previously pretty stable. It is vital to note that not
all of these features may occur to a particular person all at once. However, one or two signs and
symptoms may be noticed.
In psychotic disorders such as , it will be common for one to begin of people not
physically present in the environment where the person is. Nevertheless, these voices are so real to the recipient
that if the content is a command to perform an action, that order makes itself so believable as to be carried out
as a real life event. Consider this, if one is hearing commanding voices telling him to laugh all the way to the
bank, he will likewise laugh all the way to the bank.
In , a tendency to commit will manifest, some expressing a wish to die, others feelings
of and prolonged will be observed.
Repeating activities already performed such as or thinking the same idea
repeatedly, thought process where one feels powerless to stop these ideas from coming to the surface into
consciousness is common in
In , a person will believe positively at all that they have arisen in reality.
An individual may accuse a colleague of sorcery and causing illness in his own family without basis or will point
out that one is stealing items in the house without evidence to back this up.
In , the mood swings at different intervals from periods of agitation ,elation and high
energy or to low energy and deep sadness . Usually the mood in
the morning may be found to change as the day progresses and may be quite the opposite in the afternoon or
evening. Thus, the person who in the morning presented with excitement and verve will often become low in
energy, sad and disheartened in the later part of the day.
Figure 1.Only a thin line exists to separate what is normal and abnormal behaviour. Competing perspectives, Cultures,
religion, academic background, among other factors are all important in deciding what is and what is not normal. Why
then are so many people overnight experts at labelling others as ‘normal’ and ‘not normal?’ Here, senior high school
students pose for a photo to show they are simply doing what any common group with common interests do; relaxing
after a busy study day at college.
here are many variables directly having a bearing on the mental health of a person. The mental Health
Act of1996 (Zimbabwe) was enacted by the president and parliament of Zimbabwe for the purpose of
treatment, care and prevention of mental disorders. This awareness bears testimony to the fact that
mental illness is of tremendous concern to the health of the population. The government provides both
material and human resources in the form of psychiatric nurses, hospitals and treatment centres across the
country to enable proper management of patients and clients. There is a new trend in treatment of psychiatric
illness where treatment in psychiatric institutions and hospitals is gradually being replaced by establishing
community mental health centres where treatment and care is provided to those in need of care close to their
families and homes. This is a new phenomenon of what is now termed as the global health movement that
also promotes mental health. The government is cash strapped having so many needs and so requires the
hand of well-wishers such as churches and voluntary organisations to assist in meeting up this void.
Here is a list of factors that may play a significant role in mental health. Please note that this is not an exhaustive
Self-criticism or negative view of the self including other cognitive distortions.
Including but not limited to large ventricles.
poor living conditions and crime riddled societies.
-wars and natural calamities.
he most pertinent aspect to maintain mental health is self-awareness. It is defined as the capacity of an
individual to have introspection as well being able to reconcile with oneself as an entity detached from
the environment and other people. There are situations where you feel distressed and uneasy. There are
environments where you feel excited and at peace with everything. You can greatly improve your own
mental health and psychological state by monitoring your feelings against situations that cause you discomfort.
Know your purpose in life so that you know what you are capable of and then make personal choices yourself
rather than passively accepting what others say or dictate to you willy-nilly.
Figure 2. The soft Socrates… if all happy people needed approval from others for their
happiness to materialise and then suddenly the world runs short of those who approve happiness how many of us then
would be happy to laugh and smile? The bottom-line? Happiness starts and grows from within you before others amplify
it. It is a personal choice to be or not to be happy.
nger, like sadness and fear is one of what we term unpleasant or negative emotions. Many people realised how
painful this emotion is and therefore attempt to evade their anger by denial. In so doing, one expects that the pain
will simply melt away just like that without actively acknowledging that it actually is real. Negative emotions must
not be wished away because they must first be accepted for them to then be resolved and therefore eliminated
from continuously causing physicopsychosocial harm on an individual. It is believed to be normal to experience
unpleasant emotions sometimes (Atkinson). When somebody steps his feet on our toes mostly the response we give is not
true since most people say, ‘No it is alright with me’ while in fact we are boiling like hot water inside our minds. Rather
than pretending, express exactly how you feel about a situation and the mental health benefits in the long run will out-
weigh the temporal relief you get as you attempt in vain to please the crowds surrounding your life.
We should as matters of principle accept the way we feel at all times without being ashamed of it or thinking
that we are inadequate in some way.
any people become anxious in situations they feel they cannot cope or control especially if it
involves judgment by peers. if one feels that he has little preparation and may possibly make errors
due to insufficient subject matter when giving a presentation, he exposes himself by his quivering
voice and sweating palms. Examination anxiety is an unwelcome frequent emotion during
examination period to those preparing to write or already writing tests. You could perhaps see examinations in a
new light by getting well prepared by prior reading material covered in the syllabus. In the event that you feel
you cannot avoid the other distresses accompanying you in life, you could reappraise the situation or see it in a
different way. At the work place it is not uncommon to hear managers bellowing instructions, commands and
insults to subordinates all day, all year round; some are amused by such antics but there are those with big egos
who feel belittled and undervalued. You may not enjoy the comfort zone of such a boss but the truth of the
matter is that you will still need to work together in your uneasy relationship of convenience. Therefore, you
may try to understand your manager as someone who has a skewed view of proper human interaction. Careful
planning and preparation can also assist in lessening anxiety associated with feelings of being overwhelmed by a
Figure 4 Fight the temptation of being a ‘couch potato” and be actively involved in activities
taking place in your environment. A Sedentary lifestyle with little or no physical activity is detrimental to your general as
well as mental well being.
An old English proverb goes thus, ‘an idle mind is the devil’s workshop’. Even in the ancient times, our
ancestors were clever a mile ahead of their time to realise the negative effects of idleness. It clearly shows daily
how boredom quickly settles and sadness worsening into depression sets the tone to the one who stays put like
a rock doing no activity at all. It is believed by experts that the sources of many emotional disorders is loneliness
and therefore follow your instincts and develop your taste for life and mix with others in life. If you love soccer,
so be it! Go and watch with others. Bring relatives or friends instead into your dwellings and watch the soccer on
television if for any reason you are unable to go there physically yourself. If you are for the scenic fresh
outdoors, enrich your eyes, freshen your nostrils with panoramic views, the aroma of fresh flora, and admire the
well-clothed environment. After all, they say you only live once in this world!
Figure 5 The concept of believing in our inert abilities…to convince our own souls that we are capable of doing
what we are supposed to do despite the odds against us… before an outside voice says so as a motivational tool…What is needed to throw oneself into
the thick of the action without the usual push?
Low self-esteem is the belief that one is worthless, a failure in life, not suitable to be loved and the
overall negative appraisal of the self. Such people always have the ever-lurking notion that they are not
good enough and inferior to all others they compare themselves with.
A person who is shy may find it very trying to ask for help when help is needed with disastrous consequences if
time is of the essence. The one without confidence cannot take new tasks or try new ways of doing things
resulting in others losing confidence in him or her. Such are the behaviour resulting in one not being hired or
promoted since you need to market yourself as a product of value to those around you and no one does this
better than yourself. By developing your self-esteem, you will not only make yourself visible to colleagues and
the community that you are serving, but you will to your advantage project a favourable image of respect and
attractiveness. This alone makes you a much sought after and therefore expensive product incomparable to
even much senior, worthy or stronger competition putting the race beyond the reach of many.
Figure 6. The usual length of sleep cycle for an adult human is eight (8) hours. What is the effect on mental and general
health of less or more sleep duration?
There is no substitute for it. It demands its own prerequisites for less sleep is as inadequate interrupted sleep. In
our sleep, we are rejuvenated and tired body functions restored to their optimum level of function. The
environment conducive for sleep demands low stimuli and therefore bedrooms may be lit with switch deeming
lighting as well as keeping noise to the bare minimum. Avoid ruminating about your problems by trying to think
the good time you cherish all the time.
Experts believe we recover our memories and even organise current memories in our sleep. When we are
learning something new, it is in sleep that we are able to retain the knowledge of the day in question. The
second sleep cycle of Rapid eye movement (REM) stage of sleep is responsible for moderating the bad mood of
the passing day and social interaction enabling our emotions, decision-making capacity to slow and rest at night
thus allowing us to start the following day in a pleasant mood as others view us.
The immune system weakens when sleep is deprived making us vulnerable to diseases and infections. It is
during sleep where the growth hormone important in both physical and mental growth is se
creted. The nerve cells (neurons) responsible for our perceptual wonders grow and repair themselves as one
sleeps. A study conducted at Chicago medical institute in 2001 has shown that sleep deprivation results in
pathology ranging from heart disease, psychosis and bipolar disorder.
The sleep cycle
here are two stages in sleep physiology namely the non rapid eye movement sleep (NREM) and rapid eye
movement sleep (REM).
In non-rapid eye movement sleep eyes do not move, muscles including the heart relax and the brain some
The opposite occurs in rapid eye movement (REM) sleep. Eye movements occur in quick succession with the
heart, smooth muscles, as well as brain activity behaving as if someone is awake. Dreams are common in REM
sleep and their content is some-what life-like but with important feature of being illusionary and not as in real
How much sleep is enough?
he amount of sleep each of us requires is not uniform. It is different for different age groups too. It is said
to be different for different populations as well. No matter the differing needs, too little sleep of four to
five hours for an adult is said to be as unhealthy as sleeping for over nine hours. Sleeping for longer than
ten hours result in increased morbidity (accidents, illness) and mortality (death).Therefore research
suggests an average of six to eight hours of sleep a night to be adequate.
Three to five year olds require more time of 11 to 13 hours while school going children need 10 to 11 hours a
night if sleep is to be adequate. However, it is also true that academic demands are more pressing for such age-
groups making it practically difficult to sleep that much without getting late for classes.
s a mother of three in her thirties Sithembile sacrifices her own sleep requirements for that of her
family’s. She entertains a busy day at the clothing shop all day and come evening she has more to do
at the house, not to mention time for her children and her husband. Sithembile feels exhausted at the
end of the day but still does not want to sleep. She still has ironing and dishes to do and continues to
do these. When it appears she must retire to bed for the day it dawns to her that she forgot to
prepare the food prepacks for school children and jumps straight away to do this. When she finally sleeps, it
is well after midnight. Behind her mind as she is slowly drifting into deep sleep she remembers that she must
not forget to wake up and bath the school going children at 4 0’clock in the morning.
Does it appear to you that Sithembile is getting enough sleep. Support your answer (2marks).
1.2 (b) How much sleep do you recommend for mental health and why? (5marks).
What should change in Sithembile’s routine so that she gets enough sleep. (5marks).
Depending on the cumulative number of nights missed by a person research shows that the basal
sleep need-(actual amount of sleep the body requires for optimum function) and sleep debt-(cumulative
amount of sleep lost due to unhealthy sleep behaviour, sickness, disturbances while sleeping such that waking
up is inevitable and other such causes) the 8 hours each adult needs may be increased or reduced. How much
sleep need would you advise Sithembile during her visit to your consulting rooms if she missed 3 nights? What
would be her sleep debt and what would you recommend to bring back her sleep cycle to normal? (7marks).
1.2 (e) Write short notes on the following sleep disorders:
Figure 10. ( 20 marks).
Mental health is affected by host of things other than those listed above. Your task is to research which other
variables directly affect the mental health of a person other than the listed. Try to find not less than four (4)
n the absence of good mental health, the opposite happens to a person. The individual behaviour becomes a
source of remarkable attention to neighbours due to its unacceptability or curious nature. Where one used
to be outgoing, charming as well creatively exciting, suddenly he mutates into a dull introvert who has
become suspicious because of his newly found capability to read the mind which has enabled him also to be
aware that there are people about to poison him. These he now avoids, only to visibly recoiling away if cornered.
He no longer greets or identifies with any of them for that reason. They are now his guaranteed eternal foes.
ravelling takes a remodeled format. The usual road is now treacherous and so changes roads or travels in
the same road with hyper-alertness if there is no choice because there are enemies also there in the
foliage hiding to put his life in peril. As he drives, his normally relaxed composure transforms his heart
into a replica energised V6 Toyota engine of torque and function. He truly agrees within himself he is
more than ready for the unforeseen eventuality that might unfold any time sooner rather than later.
Why has his belief system so suddenly changed? What in him reveals such realistic images he obediently
follows with docility? In addition, in reasoning…so impenetrable and hard as concrete to convince?
When one begins to perceive presence of real life images and yet they are physically absent….when one begins
to hear loud speeches from a president or church minister hundreds of kilometres away so clearly he even
answers in unison to the speech also loudly himself while others hear utterly nothing since there is nothing
there… when one has now found out only Jesus as his ‘real’ brother while all family members are from other
families according to the new belief…then we may be persuaded to say that mental health is no longer there and
mental illness has or is settling in him.
Mental illness, like physical injury is classified. It can be a minor mental disorder like posttraumatic stress
disorder or a major one such as schizophrenia and depressive psychosis. Some with mental illness can go and
perform various activities, as normal people would do. They do not need prompting to go to the bathroom to
bath and groom. There are patients so sick that to them there is no real difference in them between putting on
attire and walking stark naked about while among others. There are also people well aware they are mentally ill
and seek treatment themselves. There are many without insight into their mental state and will vigorously
defend this ‘normalcy’ that they think they have. They may need to be taken to treatment centres and hospitals
for care against their wish especially if they become a danger to themselves or others for involuntary care and
The mental status examination determines the mental state of a person. It is one of the most important
undertakings that a psychiatric nurse will be called upon to perform from time to time….determining presence of
mental disorder…assessing efficacy of therapeutic interventions and whether a person is now well enough to be
discharged from custodial or institutional care. It is done on admission, during treatment, as a basis for
discharging patients and as a way of ensuring that mental disorder is not recurring during reviews.
.4 (a) From the discussion presented previously, see if you are able to define the term ‘mental illness’.
.4 (b) List eight (8) bizarre behaviour that may persuade you to say that someone is having mental illness or
mental disorder. (4marks).
⃝ Mental illness is a medical condition that disrupts a person’s thinking, feeling, mood, and ability to relate to
others and daily functioning (National Alliance On mental illness, 2012).
⃝ Mental illness refers to… (Fill this space with your own words).
ome groups of mental illnesses have common signs and symptoms shared among them. One such common
psychiatric symptom is anxiety. Anxiety is defined as a feeling of fear or apprehension whose source may or may
not be specific. In other words, one may be worried that he has lost his job and therefore is aware of why he is in
fear. The same individual may get another job and is now employed but for no apparent reason he still finds that,
he is still worried and fearful. This is free-floating anxiety and not directed at any specific cause. Many levels of
anxiety exist concerning the different types of psychiatric conditions.
It is important to remember that anxiety in any of the psychiatric disorders can be mild, moderate or severe depending
on the nature of the illness identified. Anxiety can become so severe that it may warrant its own psychiatric classification
as a stand-alone mental or psychiatric disorder.
This is the case with organic anxiety syndrome, which is actually panic attack or generalised anxiety taking effect in a
subject who has a normal level of consciousness. Let us see how many psychiatric disorders have anxiety presenting as a
feature amongst them.
ORGANIC ANXIETY SYNDROME
Figure 8. Psychiatric conditions where anxiety features prominently as a dominating presenting symptom. Note the diversity of
Figure 9. Anxiety
in any psychiatric disorder is managed in the same manner as the diagrammatic presentation linking Fear with inability to cope makes
daily coping the aim of treatment.
fear maintained at intolerable level
coping with daily demands is made impossible
aim of anxiety management is therefore to allow individual coping
Figure 10. Psychiatric conditions where hallucinations predominate
Figure11. Psychiatric conditions with delusions as a major clinical picture
qualified mental health expert does diagnosis of mental illness. The process is complicated however
by the ever-present common signs and symptoms that overlap among the disorders as shown above.
Nevertheless, there still exist telltale signs as well as symptomatology that even with a shared feature
like delusions in both depressive psychosis and schizophrenia, the content in the belief system in these
two quite clearly sets them apart. While schizophrenics believe that televisions that are in their houses are
broadcasting messages from broadcasting stations specifically for their ears only as the content is meant for
them, depressed patients do not think along such lines. Instead, the minds of those depressed make them to
believe that they are poverty-stricken or so useless that they are unworthy of living and therefore view their
future fearfully and pessimistically to the point that they want kill themselves and actively seek ways and means
to achieve this objective of committing suicide.
Diagnostic classification literature and Rating scales are used to achieve universality of diagnosis of mental
illness. These are summarised below.
● Diagnostic and Statistical Manual of Mental Disorders (DSM)
● ICD-10 Chapter 5: Mental and Behavioural disorders
● Feighner Criteria
●Research Diagnostic Criteria
●Chinese Classification of Mental Disorders
●Structured Clinical interview for DSM (SCID)
●World Health Organisation Composite International Diagnostic Interview (CIDI)
● Schedule for Affective Disorders and Schizophrenia (SADS)
●Schedule for Clinical Assessment in Neuropsychiatry (SCAN)
●Mini-International Neuropsychiatric Interview (MINI)
There are many rating scales available for each psychiatric condition and only a few for the given disorders is
●Altman self-rating Mania Scale
●Young Mania Rating Scale
●Beck Hopelessness Scale
●Hospital Anxiety and Depression Scale
●Beck Anxiety Inventory
●Social Phobia Inventory
●Positive and negative Syndrome Scale (PANSS)
●Scale for The Assessment of Positive Symptoms (SAPS)
●Binge Eating Scale
●Anorectic Behaviour Observation Scale
●Hare Psychopathic Checklist
●Narcisstic Personality Inventory
●Clinical Global Impression
●Global Assessment of Functioning
●Barnes Akathisia Scale
●Adult ADHD Self Report Scale
ursing is widely acknowledged as a profession that has vastly travelled in its knowledge base that is also
considered an art and a science. The art component draws from experienced practitioners who develop
knowledge based on daily interactions with clients and patients. Therefore, we now know more of the
vital role played by a close relationship that builds up between a newly born with its mother if this baby
is put close to the mother immediately at birth and early rather than later in life. This is termed ‘bonding’ and
without good bonding, a child might grow to become a loner, develop problems when interacting or even
forming relationships later in life. Nursing is credited in being the pioneer in identifying this very special clinical
Nursing is a science by virtue of its ability to form its own unique brand of knowledge using a systematic,
verifiable and reliable set of principled steps using the nursing process. Within psychiatric nursing generally,
there is a corpus of activity in competence, pedagogy and evidence based quality clinical interventions and
outcome evaluation going on all the time.
The field draws extensively from related disciplines such as medicine, psychiatry, psychology and sociology
FIGURE 12. THERAPEUTIC ENVIRONMENT HAS BEEN SHOWN TO POSITIVELY INFLUENCE PSYCHIATRIC PATIENT
PROGNOSIS THE SAME WAY AS OTHER RELEVANT TREATMENTS. ONLY IN THE LATE NINETEENTH CENTURY WAS THE CONCEPT OF A SUITABLE TREATMENT
ENVIRONMENT FOR PATIENTS GIVEN ATTENTION. WHAT DO WE MEAN BY THE TERM ‘THERAPEUTIC ENVIRONMENT’ AND WHAT DOES IT TAKE TO CREATE
ental illness was previously considered a disease emanating from evil spirits and the devil. Many ancient
societies including Hebrews as well Egyptians and the Chinese believed that psychotic disorder was due to
possession by evil spirits. It was the norm then in ancient times to experience sessions where rituals were
performed or casting out of demons was done among some religious groups to cleanse the possessed
person of the evil causing mental disorder. The mentally ill person was also considered fit for punishment
since it was believed he was responsible in part for the disordered behaviour he was experiencing. It was common to flog a
patient as part of the psychiatric treatment; an inhuman and cruel way of managing mental illness. Some were kept isolated
from the general population while others were chained to trees and left there without proper treatment. Some religious
groups and cultural societies all over the world to this day still practice casting out evil spells and spirits as a way of treating
Cities of the ancient times demarcated special zones during the middle ages and built shacks known then as asylums where
the mentally ill were supposedly treated. In reality, asylums were terrifying prison environments infamous for exactly the
opposite of what treatment imply. These often wet, filthy unlit cells were the epicentres of beatings, torture, all forms of
ill-treatment and it was quite remarkable they were thought of as places of care.
redit goes to Hippocrates (460-377 B.C.), the father of medicine, Greek and Roman doctors who pioneered
scientific methods and therefore proper treatment of mental disorders. Hippocrates also did not subscribe to the
notion that demons were the cause of mental illness; to him mental illness appeared to be caused by an imbalance
in body fluids. Of all Hippocratic methods used for psychiatric treatment such as proper nutrition, bathing and
grooming, body massage and empathy, only purging patients and application of restraints on them are
considered negatively in modern psychiatric care or treatment.
It is now well established that mental illness is no different from other pathological processes affecting the human body
save that it mainly affecting the brain, thought process and emotions.
Mental illness is now managed and treated in well-equipped hospitals with professionals of the following categories;
psychiatrists, psychiatric nurse practitioners, psychiatric nurses, clinical psychologists and various rehabilitation
personnel, and medication provided on a daily basis. Mental illness is treated using a special class of drugs called
psychotropics or antipsychotics that were discovered in the early fifties. These drugs are effective in managing psychotic
symptoms and patients do so well that while on treatment some are able to return to employment and to perform activities
that are deemed basic normal human functions. Either patients who remain admitted in psychiatric hospital are a danger to
themselves or to the community; otherwise, they are discharged for home care and given review dates by psychiatrists.
Some delay being discharged due to slow response to treatment.
Treatment is shifting from admission into psychiatric hospital in-patient care to treatment centres situated near clients’
homes or communities and day centres. This trend in treatment that ensures patients gain interaction skills in the
community, the comfort of a home environment, family support system was started in the sixties, and it is most effective
means of preventing institutionalisation of patients. When patients over stay in hospital, they feel being a part of it and
prefer to remain admitted in that hospital forever even if they recover well unlike short-stay hospital admissions that tend
to quickly feel home sick and want to be discharged. Long-stay admissions create a dependence syndrome among patients
and are expensive to manage in the end.
Deinstitutionalisation works well where community resources are adequate. There should exist enough day-care centres,
clinics and treatment facilities in the environment of the discharged psychiatric patient other wise without this after-care
relapse would occur within the community. Patients should be reviewed regularly also to prevent relapse. Medication must
be continuously supplied and the troublesome side effects of psychotropic drugs called extra pyramidal side effects
managed satisfactorily. Figure 13. The Catholic church, home to a billion
world-wide passionate followers is depicted in its age-old tradition of exorcising demons to cleanse followers with mental
disorder in this action thriller film by Dan Brown’s Angels and Demons. Why is this age-old tradition difficult to shake off
even in the present-day evidence-based scientific environment on mental health?
Figure13. The methodology of psychiatric treatment has
since largely shifted from hospital-based long-stay management to the community setting. What advantages and disadvantages are
associated with this new shift in psychiatric patient management?
Discuss the important changes psychiatric nursing science has undergone over the
years putting emphasis on the cause and treatment perspectives (20 marks).
Figure 14. The
normal major brain anatomical structure (Diagram after ADAM).
Frontal lobe functions
It reaches full maturity only after 20 years in humans
Emotional control centre
Has most of the dopamine-sensitive neurones of cerebral cortex
Dopamine system is associated with attention, motivation, reward, planning and short-term memory
Emotional disorders including schizophrenia affect this region if it is damaged by eg. Stroke, injury, parkinsonism and
Parietal lobe functions
Integrates sensory information from various parts of the body, knowledge of numbers and objects
Processing information on the sense of touch
Enables a person to read, write and solve mathematical problems
Temporal lobe functions
Retention of visual memories
Comprehending language, storing new memories, emotion and deriving meaning
Occipital lobe functions
Figure15. The Dopaminergic areas .Overproduction of the neurotransmitter dopamine and over activity of dopamine neurones produce
features of psychosis (Diagram after ADAM).
reduced Dopamine neurons causes Parkinson’s disease and Parkinson-like disorders
is a neurotransmitter made in the terminal bulbs of brain neurones.
Figure 16. Problems of Addictive disorders are thought to occur due to overproduction of Dopamine in mesocortical region of the brain
(Diagram after ADAM).
●Areas responsible for forming memories, making decisions and solving problems
● The neurones in these regions are excitatory in nature
● Disorders affecting these areas therefore cause indecision, irrational decision-making, forgetfulness and
● sites for Addiction theory
● Made up of hippocampus, hypothalamus, thalamus and amygdala
Hippocampus…converts short-term memory to long-term memory> if damaged no new memories will
form making daily events unable to be recorded or remembered.
Thalamus…regulates motor function and sensory perception;- pain relay from regions down up to
cerebrum; auditory relays, visual relays, vestibular relays, taste relays, thermal relays.
Amygdala…stores episodic biographic memory unlike hippocampus, which stores spatial memory
Damage to the amygdala causes akinesia (lack of movement).
Limbic system is the site for pleasurable activities…eating, sex and hobbies
● SITE FOR SEX ADDICTION AND EATING DISORDERS
Damage to the limbic system will result in Alzheimer’s disease and anterograde amnesia
Figure . The limbic system… The pleasure and reward centre of the brain
Figure. The Fear centre…Amygdala is part of the Limbic system responsible for defining whether any signal or image is an
immediate threat to the self. Without the amygdala the emotion of fear to anything including dangerous situations no
longer exist to the self. When does fearlessness appear and why?
Figure. The amygdala closely connected to the Hippocampus which is the site responsible for memory. Why is this close
relationship so important to the survival of an organism?
Figure. Like the centre of the spokes of a wheel, the brain is connected to the amygdala area of the limbic system. Scientists
have been able to map the amygdala in relation to other parts of the brain. It has been said that without the amygdala
human beings would become as fearless as animals. In which disorder (s) is fear not observed?
1. Atkinson Rita L (Hilgard’s introduction to Psychology 1996).
2. www.currentnursing.net ( 2012-03-12).
3. www.mentalhealth.net ( 2011).
4. Townsend Mary C (Nursing diagnoses in psychiatric nursing).
5. American psychiatric association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
DSM-IV-TR. Washington, DC : 2000.
Figure 17. Let there be evidence based clinical practice to direct all nursing interventions without which no new
treatments and better methods of care are envisioned. How does research develop current methods of patient care to
their ultimate best?
By the end of this unit, the student should be able to:
tandardisation of nursing practice is important in the provision of consistent quality nursing care and to
prevent gray areas during hand over and take over periods among nursing shifts as well as when working
with other health-care professionals.
One way is to develop or formulate common terminology and the use of diagnostic categories and nursing
classification in line with the urgent demands of clinical nursing practice. This led to the development of the
‘Nursing diagnoses to guide nursing interventions. To date the North American Nursing Diagnosis Association
(NANDA, 1988) has a published list of 98 Nursing Diagnoses. It is noteworthy to view this not as an exhaustible
list since new categories come in for clinical testing in nursing practice when available all the time.
define the nursing process with special reference to its application in
psychiatric nursing science.
develop relevant standard psychiatric nursing diagnoses from given
describe each of the stages of the nursing process.
Describe the components of the Nursing diagnosis.
Figure 18. Patients come to a treatment facility because they feel they are in need of care. This may be an immediate
problem, long-standing problem or simply an anticipated problem. The belief system some health workers harbour to the
point of telling a person seeking care that they do not need care at this time therefore does not materialise, or does it?
There are three aspects in the making of a psychiatric nursing diagnosis namely;
● the health problem that resulted in someone seeking psychiatric treatment.
● contributing factors causing the health problem.
● Defining characteristics that represent the signs and symptoms.
he health problem can be actual or potential depending on an individual and can be identified by the
nurse during assessment of the patient. The contributing factors can be considered as the cause or
aetiology and could be genetic, negative life experiences or psychopathic processes. The defining
characteristics then become what is verbalised by the patient or the nurse’s observations with regards to
the patient condition.
The psychiatric nursing diagnoses are used in the formulation of individualised nursing care plans. The point to
note is that without a nursing diagnosis no care plan is possible. Nursing care plans are an essential shift from
the treatment of patients considering them only as people with a common health problem and therefore
common treatment requirements to tailor-made psychiatric nursing interventions suited for each individual
patient needs. There is no hard and fast rule where and when a psychiatric nursing diagnosis appears to have
come from medical diagnostic categorisation as in a depressed person having depressive psychosis. The only
shift is that nursing diagnosis will include in its diagnostic criteria the phrase ‘evidenced by’ referring to
symptoms or signs associated with the health problem that would have been identified.
The psychiatric nursing diagnosis also points direction as to what would be evaluated during outcome derivation
and therefore whether our intended goals have been achieved or not in the management of the patient. The
goals must be structured in a way making them achievable, measurable and it should be clear right from the
onset whether these are short-term or long-term goals. Short-term psychiatric nursing goals are those nursing
outcomes where results are possible in moments, hours or a few days while the long-term goals could be the
overall intended broad objective of treatment.
The patient is the central figure in the treatment arena and must have input into what will become nursing
interventions targeted at him. He must therefore not to be a passive recipient of nursing care. His arguments
and input must be carefully weighed and all pros and cons critically looked into before drafting the nursing care
plan that as a matter of principle include his personal contribution. After-all it is his treatment plan meant for his
benefit and he would gain more in supporting it than sabotaging the interventions and this most likely happens if
patient input is ignored or not included by the psychiatric nursing staff .
azvinei has not been eating well of late. The last time she ate was yesterday, and she took only
three mouthfuls before dejectedly remarking, “I do not feel hungry any more. I do not even see the
value of life. I would be better dead than alive.”
She no longer associates with her friends preferring to stay alone inside the house. Most of the time
she is sleeping especially during the day-time, but at night she hardly sleeps, always gazing into the ceiling
as if in a trance and she complains, “I cannot find sleep at night no matter how hard I try”.
When treatment time comes and Hazvinei is given her drugs she accepts, however as soon as the psychiatric
nurse leaves she shoves them in her pocket for hoarding purposes.
From what is happening to Hazvinei, it is clear that all the following become psychiatric nursing diagnoses;
Hazvinei has lost appetite and is in danger of becoming anorexic and in the extreme cachexic (loss of appetite
related to verbal cues as evidenced by not keen to eat).
●Hopelessness related to present physical complains as evidenced by verbalisations of having lost interest in
● Helplessness related to the physical complains as evidenced by decreased interest in all activities of daily
● Insomnia related to verbal cues as evidenced by patient finding it difficult to fall asleep
●Social isolation related to anxiety, as evidenced by withdrawal behaviour from activities involving others.
he psychiatric nurse decides the outcome of individualised psychiatric nursing care beforehand during the
period when formulating the psychiatric nursing diagnosis. It is a deliberate, methodical process with
input of nursing interventions and processing them so that the desired outcome of psychiatric care are
realised. The desired outcome measures range from a change in hostile to preferred behaviour or inability
to follow a treatment protocol to following treatment routines without prompting by psychiatric nursing staff.
When desired outcome measures have not been achieved, either the nursing interventions fell short of the
required input into care or the commitment on the part of the psychiatric patient seeking care was lacking and
therefore inadequate for the targets to be reached. In either case, a review of the whole process from the
psychiatric nursing diagnosis, psychiatric nursing interventions right up to outcome criteria measure must be
carefully assessed and redone. Nothing must be left to chance as this as about patient’s improvement as it
psychiatric nursing’s reputation.
American Nurses Association has defined nursing as:
The diagnosis and treatment of human responses to actual or potential health problems (ANA, 1980).
The nursing process has been and is the nursing yardstick for performance methodology and outcome
he nursing process is a deliberate, methodical problem solving process whose objective is to attain the
goal of nursing care. It is scientific and therefore eliminating subjective biases related to clinical
phenomena of interest that we would objectively want to assess at the end of the day. As a scientific
Endeavour nursing postulates hypotheses of clinical interest such as while treating a ward full of patients
diagnosed with schizophrenia, it catches the eye of a clever psychiatric nurse that only a certain number of such
patients appear to be relieved of both positive and negative symptoms while a fraction again do not improve or
even do not have anything of it to show that they were on treatment after all. Actually, it would equate to a
roller coaster in deterioration of the mental state. The psychiatric nurse would be persuaded to ask, ‘If
antipsychotic drugs work, why do they seem not to among some patients? ’
Many ideas crop up. Maybe the class of the antipsychotic drug used was not suitable for some of the patients
rendering it ineffective as a result. It could probably well be genetic differences among the patients not
improving during treatment from those who improve. It could be due to antipsychotic drug efficacy problems;
bringing into question the quality and metabolism issues of the drugs administered. It may also involve dosing
problems, as different patients require different regimens.
The approach and interest garnered in the clinical observation by the psychiatric nurse decides the hypothesis
to be formulated as well as the developed theory that would predict, explain and describe the phenomena of
interest to the nurse. Thus, the stage would be set for the clinical experiment to be conducted to help find
The nursing process ensures that the nurse and psychiatric patient are partners in treatment and without the
other, no outcome is achievable. This is made possible by the belief that the patient is a mature individual with
the capacity to make informed choice. The relationship is developed through mutual trust taking advantage of
patient-strengths and utilising these in body system maintenance and value addition in adaptive responses to
illness by the patient.
There are hosts of challenges awaiting the psychiatric nurse when fared with other nursing sub-specialties in
using the nursing process. It is so mainly due to inability to self-express themselves that many psychiatric
patients with emotional problems are short-changed. Unlike pathophysiological conditions which can be graded
and observed as ‘deep suppurating wound’ or ‘extensive superficial burn’ with clear-cut charts, pictorials and
guides nothing of the sort exists in psychiatry other than the ICD 10 and DSM 1V classification.
The photograph of the face of a schizophrenic patient may not show much unless you observe the behaviour
over time. Picture this too. At a roadside carnage involving a pile-up of four burning cars and screaming voices
seeking help with cars soon reduced to unrecognisable twists of burnt-out steel and a number of severe burns,
broken limbs and you happen to find yourself there. The instinct is to go and offer much needed assistance right
away. Contrast this to a person who has just developed brief psychotic reaction on his way home from work
spotting designer wear right from head to toe and leaning on a gleaming C-class Mercedes and singing alone at
the top of his voice. Would you or anyone for that matter be as quick to go and assist this client with a psychotic
illness as in the accident example narrated earlier? Of-course not! All of them are emergencies requiring similar
speed of attention but many would dare not go to the singing man preferring to assist at the accident scene.
Psychiatric patients may display disturbed behaviour for varied reasons. They may be responding to vague
emotional problems, feeling powerless or simply out of touch with reality. It is the task of the psychiatric nurse
to formulate corresponding nursing diagnoses and nursing interventions and outcome criteria fit the individual
patient to enable recovery and resultant discharge back into the community where the patient came from.
he nursing process is continuous being aware that objectives that were not achieved in earlier nursing
interventions must be revisited and a post mortem conducted to rectify these mishaps. The nursing
process goes through five and in some texts six stages as follows;
ight from the time of admission the psychiatric nurse must observe patient behaviour, conduct
interviews of patient as well as any accompanying relatives, significant others and perform baseline
observations of temperature, Blood pressure, pulse rate, respiratory rate and general head to toe
physical examination to exclude lesions likely due to abuse, disease or neglect. The mental status
examination must be done on admission to establish baseline for future progress in the evaluation of mental
● The reason in the patient’s own words why he is in need of care at this particular time.
● Patient expectations as to the care going to be rendered.
● past health history including medications taken and still being used by the patient.
● Family history of disorders genetic in origin including mental illness.
● Socio-cultural belief system including religious practices.
● Substance abuse history with special reference to drugs available in the locality of the patient.
● Usual coping mechanisms employed in times of distress.
● Medical and other investigations conducted including full blood counts, urea, electrolytes, and ESR.
● Mental status examination including mental health and psychotropic medication being used.
obtained via the patient or relatives to include, name, address employment status,
social relationship patterns and general behaviour.
obtained by way of nurse’s actual observation on the patient such as head to toe
physical examination, blood pressure reading, temperature reading, respiratory count, mood, current
behaviour laboratory findings, perception and appearance.
aving collected all health information both subjective and objective, the psychiatric nurse then uses it to
come up with the nursing diagnosis. A nursing diagnosis may be an actual or an anticipated health
problem affecting the patient and includes both adaptive as well as maladaptive patient responses. The
patient requires assistance from psychiatric nurses with regard to the identified problems and the
commonly used nursing diagnoses are those derived from the North American Nurses Diagnosis Association
A standard nursing diagnosis has three characteristics and these are;
The defining characteristics are significant especially in that they suggest what nursing activities to employ
and how these would be evaluated. As said earlier, outcome considerations must involve that which the
patient considers important.
In the clinical exemplified above, it is clear that what the patient views by verbalising to the nurse such as
not being able to sleep and wanting to die, will direct how we develop our nursing diagnosis and in this
instance it is;
●helplessness, related to physical complains as evidenced by decrease in appetite and verbalisation showing
despondency or it could also be;-
●social isolation, related to anxiety as evidenced by being withdrawn and not communicating.
In all instances note how the wording is constructed so that it is considered standard.
The goals of psychiatric nursing interventions or outcome need to be clear and well defined as to whether
they are short-term or long-term.
are expected outcome of short duration like a fortnight such as;
●at the end of the week, the patient will be able to mix with others and participate in daily ward chores or
●at the end of three weeks the patient will be able to bath and groom himself unprompted.
range from the psychiatric nurse’s overall aim of treatment to what is to
be achieved in a long period of time such as;-
●At the end of treatment, it is expected that the patient will remember always to take his medication
without fail or
●In six months-time, the patient will be able to participate well in sheltered employment.
lanning involves setting the priorities together with the patient, making nursing intervention as well
as creating nursing care plans. Here, plan also your short and long-term interventions, which are the
urgent problems to be acted on first and the problems, interventions and nursing goals are recorded
ere, the actual nursing activities are executed by performing nursing functions. The important task
of documenting all nursing actions for both legal and continuity of care purposes is done too. The
psychiatric nurse depends on her scope of practice to function. These are the functions; -
where the psychiatrist derived management is carried out by
the nurse including administering prescriptive antipsychotic medications.
●Independent psychiatric nursing actions where the nurse takes responsibility for diagnosis, management
and outcome of nursing care as required in her scope of practice.
his is an on-going process bearing in mind the dynamic nature that is psychiatric nursing. New
problems arise during treatment. Old problems may not have given desired outcomes and so
modifications are always necessary here. Revisit all the stages of the nursing process with meticulous
care to determine if what was supposed to be done was done. If the patient is better than he was
before treatment, we would say we achieved our objective, but if it is to the contrary it then points to
a problem which needs to be managed again. As a feedback mechanism, this stage shows the needs for
reassessment, replanning, reimplementation and re-evaluation.
How many times should a patient be evaluated in a day? The duration and frequency depends on the
situation and policy or procedure guidelines of the institution one is working on. Generally, the psychiatric
nurses on day duty get their hand-over take-over report of the treatment outcome of patients from the night
staff at 1845 Hours. This is a report of what condition the psychiatric patient was at night in terms of
behaviour. The improvement or deterioration in the patient in exact terms and not using jargon should be
conveyed both in writing and verbally. The morning shift will make new assessment of the patient starting
with interviewing the patient (subjective information), taking temperature, blood pressure, respirations and
observing behaviour(objective information).The information is then used to define the state of Health
(assessment) and what will be done as treatment (planning).The doctor’s round that was done and any new
collaborative interventions must be said and noted that they have been done and what has been the patient’s
response. Any thing that was planned by the treatment team and not done must be handed over to be
continued by the night staff as nursing is a continuous process.
include facial expressions
agitated, relaxed, hyperactive, gait, gestures, mannerisms, tics, argumentative,
interactive, cooperative, friendly, bizarre, articulate, monotonous, confabulatory, circumstantial,
poverty of speech, poverty of thought, pressured speech, slow speech, repetitive speech.
depressed, anxious, sad, apprehension, angry, happy, excited, ambivalent, ecstatic,
blunted affect, euphoric, labile, apathy, appropriate, inappropriate.
illusions, hallucinations, depersonalisation, derealisation, logical or
illogical thoughts, autistic, neologisms, thought block, thought broadcasting, thought insertion,
word salad, rumination, abstract and concrete thoughts , obsessions, delusions.
●cognitive aspect and sensation;- Glasgow coma scale, short and long-term memory, information
processing and intelligence, attention span, comprehension.
rational and irrational decision-making, ability to take responsibility for
own decisions, ability to judge, assess and evaluate, awareness of whether mental illness is present
or absent and knowledge of its effect on other people.
-internal causation… psychiatric or medical illness, loss of self-concept
;-external causation or loss… actual loss of a treasured object, can be loss of a spouse, family
dysfunction, loss of employment or income.
ability to adapt to life’s challenges, use of functional and dysfunctional coping
patterns, management methods on the activities of daily living.
●culture and relational aspects;-ability to maintain a relationship appropriate for age group and sex,
ability to conform to societal expectations and norms.
heories, as said earlier are concepts put together to help explain, predict and describe that situation
which has gripped our attention and is of interest to us. They are the bedrock of our knowledge
development and the core of research because research without a theoretical base is near impossible if
not unheard of. They cannot just be made however; both deductive and inductive reasoning methods
must be employed to develop them. Thus we speak of mental health and psychiatric nursing science
since as nurse scientists we use knowledge derived from our researches, utilising real observable facts on
clinical grounds and not guesswork to reach our conclusions or outcomes. Anyone in doubt as to the
authenticity of such claims can repeat the researches and experiments that were done. Research is on going to
assist patients to heal quicker (applied research). Therefore, scientists do not become emotional or sing any
much louder about their knowledge base because as a scientific playing field, it is evidence based, verifiable as
well as repeatable by any other scientist interested in any phenomenon that has been described, predicted and
explained here as well as elsewhere where researches have been done or are on going.
1. Atkinson Rita L (Hilgard’s introduction to Psychology 1996).
2. www.currentnursing.net ( 2012-03-12).
3. www.mentalhealth.net ( 2011).
4.Townsend Mary C (Nursing diagnoses in psychiatric nursing).
5. American psychiatric association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
DSM-IV-TR. Washington, DC : 2000.
Here is a list of the theories used in mental health and psychiatric nursing
by Florence Nightingale
y by Ida Jean Orlando
by John Bowlby
by Imogene King
by Virginia Henderson
by Hildegard E. Peplau
by Eric Erikson
by Dorothy Johnson
by Sigmund Freud
by Dorothea Orem
by Martha Rogers
by Sister Calista Roy
by Jean Watson.
By the end of this unit, the student should be able to:
ental health and psychiatric nurses are keen to study those aspects of the human being that cause
emotional distress and try in the process to find explanations as to their aetiology. This is performed
in the hope that better or even faster clinical outcomes result after using interventions from this
new gained knowledge. In this endeavour, they engage in both qualitative as well as quantitative
research methods. At the backbone of it all is nursing theory.
3.1 Defining nursing theory
It refers to a set of interrelated concepts that give a systematic view of a phenomenon. The phenomenon can
be a clinical situation or event. Theories are made up of concepts, definitions, models, propositional
statements and are based on a set of preconceived assumptions.
define nursing theory with special reference to mental health and psychiatric nursing science.
describe each of the mental health theories.
select any three theories and apply them to a clinical situation.
. The development of new knowledge derives from theory. To what extent is this statement true? (2marks).
. Many Nurse Theorists such as Betty Neumann and Hildegard Peplau among others have produced models
with important clinical application. Which nurse theorist appeals to you most and why? (5marks).
. Not long ago a psychiatric nurse reported for work as usual. Then suddenly something gripped her
attention…two fully-grown and heavily built male patients were fighting each other for as yet unclear reasons.
The nurse summoned assistance from other nurses and auxiliary staff and finally managed to subdue the
fighting patients. On further inquiry as to the cause of the scuffle, it emerged that each of these patients was
responding to commanding voices instructing each patient to defend himself from the other’s supposed hostile
body movements. Hearing commanding voices is common in many psychiatric conditions including
schizophrenia and your task is to try to develop a hypothesis (the initial phase of theory development) to help
describe this clinical example of aggression (5marks).
(Hint: Create a relationship between the two variables of aggressive behaviour impulses and the symptoms of
hearing voices of command).
Figure 19. Sooner rather than later, we are even more attached to those close to us, as we stay longer together than if
we had only a brief stint with each other in a relationship. Why does this happen in any given long-held relationship?
He theory of attachment suggests that individuals in a relationship are attached to each other the longer
they remain together in that relationship. This theory, which was improved by Mary Ainsworth, was
initially developed from observations made by British psychiatrist, psychologist and psychoanalyst Edward
Bowlby (1907-1990). These observations emanated from the severe distress he noticed being experienced
by those infants who were separated from their parents. Bowlby was particularly interested in child
development. He therefore wrote his observations in the form of textbooks. Three volumes of attachment
theory were published as follows; attachment-1969, Separation-1973 and loss-1983.
sustained emotional ties that develop between them
and the parent or caregiver.
Even short duration separation of children from parents or significant caregivers is considered detrimental to
the children’s long-term health.
The theory highlights the significant role of the mother in child development as compared to that of the father
figure who in this case plays the role of second best.
-the caregiver is attracted to the baby by baby’s innate signals.
-after that, the caregiver will be willing to remain close to the baby because the baby is responding positively to
-Baby develops trust that caregiver will respond when so required.
-infant respond more positively to the familiar face of caregiver.
-Babies do not show signs of protest if separated from caregiver at this stage.
-baby displays separation anxiety when separated from caregiver.
-baby can protest if care giver is leaving.
-the child’s knowledge of objects and situation around him increases.
-child has become aware that the caregiver/parent will return even though he or she is going away
at the moment.
t has been shown that just like in children. It is believed that attachment occurs in
romantic relations involving adults as studies done from the beginning of 1980 show. Important differences are
observed when comparing attachment in children to that of adults. However, principles governing attachment remain
the same for both adults and children. This means that the emotional bond that causes security in times of distress
when a child retreats to the comfort zone of the care giver also develops among adults who become attached to one
another. An adult in times of insecurity will be more at emotional equilibrium, develop means and ways to later confront
the psychological issue at hand and then cope with stressful environment if there is a another supporting adult with whom
trust has developed than if he were unsupported and therefore on his own.
Cindy Hazan and Phillip Shaver in the late 1980s noticed that the relationship pattern of adults in romantic relationships
were quite similar to relationships children developed with their caregivers. This means that adults in romantic
relationships feel insecure if separated from their lovers and therefore prefer to remain together at all cost because during
periods of emotional discomfort or pain they retreat to the comfort of their partners who then offer this comfort in return.
This explains why some spouses who are abused repeatedly never appear willing to leave their marriages or partners no
matter the amount of battering or advice from well-wishers they may get.
. Jealousy is an important emotional aspect in both child and adult attachment theory. Differentiate child
jealousy from that of adults and state the term ascribed to this form of jealousy in children (5marks).
. Pathological jealousy also occurs in adults and yet not so in children. What is pathological jealousy and what
are its effects on a normal relationship such as marriage (6marks)?
. Romance or established marriages may survive and outlive their problems. There are also similarly romance
and marriages that abruptly end in separation or divorce because of reasons even far less important to those
problems occurring in surviving relationships. Explain this observation in terms of attachment theory (4marks).
. Differentiate attachment in adults from that of children (4marks).
he theory was developed by the French-speaking Swiss developmental-psychologist Jean Piaget (1952-
1980) after performing epistemological studies with children. His theory of cognitive development and
epistemological perspective are together called genetic epistemology. Piaget noticed at one point while
marking examination papers of his schoolchildren that children appeared to make certain common
mistakes in their answers, which adults would not normally do. This he reasoned as being due to their cognitive
processes that were immature and different from that of adults. He therefore proposed the theory of cognitive
developmental stages where persons exhibit common patterns of reasoning at various stages of development.
was the term coined by Piaget to represent mental images we create and organise so that we derive
sense of the real world objects.
refers to adapting and moulding usual schemes in the mind to accept new knowledge.
refers to an innate ability of a person to adjust to assimilation and accommodation.
is the process of making sense of new experience by using old schemes stored in mind.
is the joining of old schemes into complex mental images.
is the normal progressive changes across the lifespan.
- Learning via all senses (sight, auditory, tactile, taste and smell)
- Child extremely egocentric
-develops purposeful actions
-develops object permanence capability
-dominated by magical thinking
-acquires motor skills
-cannot conserve or use logical thinking
-egocentrism dies away
-develops conservation or logical thinking
-thinking is still concrete
-logical thinking made possible with model aids assistance
11 years to adult>
-develops abstract thinking
-easily conserves and thinks logically
-some individuals may not reach this stage
he Russian psychologist Lev Vygotsky put emphasis on culture as an important element in shaping child
development and this was not considered or included in the theory of cognitive development. Many
cultures put effort in certain tasks for special age stages as milestones to be achieved by their growing
children and this may not necessarily be hierarchical in succession as is suggested in the Piagetian
. The proverb requires one to have achieved what level of cognitive
development to understand it (2marks)?
(a) What are and
(b)Why should they
(c) In which mental disorder is it difficult or impossible for one to understand the meaning conveyed here in this
he Hungarian physician Hans Selye (1907-1982) for the biological basis of stress developed this theory in
scientific terms by way of explanation of what is known to occur in a biological system subjected to strain.
Hans Selye’s stress theory used psycho physiological developments that normally occur in the body to
describe what he termed the general adaptation syndrome (GAS).
The model states that anything that threatens the wellbeing of the individual person (which he called a
stressor) leads to a three stage response by the body chiefly;-
He explained the bodily response that happens to confront stress by way of the Hypothalamic-
pituitary-adrenal Axis (HPA-Axis). This is the process which the body normally uses to cope with a
stressful situation and be able to return the person to the original functional state.
He also described the local inflammatory response as well as repair process that happen around a
damaged tissue area like minor topical lacerations which he called local adaptation syndrome and
explained that this minor injury that is localised had the potential also to lead to GAS if for any
reason it became severe enough.
ccurs when the body encounters a stressor or situation it considers threatening. The body activates
the sympathetic nervous system to prepare the person for fight or flight. The fight- or –flight
response mechanism is put into action. Hormones such as cortisol and adrenaline are released to
increase body energy production. The body resources are now all mobilised for the threat.
he body activates the parasympathetic nervous system which returns some body functions back to
normal while the body devotes some resources to deal or control the stressor. Blood levels of
circulating adrenaline, glucose and cortisol are maintained at high levels as are blood pressure, heart
and respiratory rate. The alertness level remains heightened too. Outwardly though, the individual
he last stage is exhaustion, disease or death and this will happen if body resources were inadequate or
individual was unable to manage the stressor.
. What practical
activities must a psychiatric nurse practitioner plan for a community with a high incidence of alcohol abuse that
is leading to teenage pregnancies and suicide (10marks)?
Should we blame psychiatric nurses, psychiatrists and relatives of
psychiatric patients when these patients die after failing to follow medical advice by not honouring review dates
or taking their medicines as required? Support your answer (6marks).
(a) Physical (biological) stressors
(b) Social stressors
(c) Psychological stressors (15marks).
THE HEARTBEAT OF PSYCHIATRIC NURSING…PSYCHIATRIC NURSES ON NIGHT DUTY, RUNDU HOSPITAL NAMIBIA.
he American-born Theorist Hildegard E Peplau (1909-1999) published this theory in 1952 and was
influenced in developing this theory by Harry Stack Sullivan; who himself also developed his theory of
interpersonal relations in 1953. Other theorists who influenced her included Abraham Maslow, Percival
Symonds and Neal Elger Miller. Peplau studied education, personal psychology and psychiatric nursing;
was professor emeritus at Rutgers University, worked with the National Institute of Mental health (NIMH), the
world health organisation (WHO) and in 1968 published interpersonal techniques-the crux of psychiatric
nursing. She was also at one time president of the American nurses Association and is credited in starting the
post baccalaureate programme in nursing.
The theory explains nursing’s aim as that of assisting others to pinpoint or identify their needs.
Nursing is because it is an art form that heals a person.
Nurses should to manage every day issues and challenges.
Nursing is an because it occurs as an interaction between two or more persons
with a common objective.
Goal attainment is arrived at by way of a
Both the because they are in this process together.
is a valuable therapeutic interpersonal process where its interaction with other human processes
make health feasible for both individual and the community.
is an image we create to mean forward movement of human processes and personality in the direction
of constructive, creative, useful, personal and community life.
is a maturing being attempting to reduce anxiety caused by felt needs.
are the outside forces surrounding the organism in the form of culture.
THE ROLES OF THE NURSE TO THE PATIENT
the nurse will at first see patient as a stranger similar to any other stranger she can meets in daily life
at the first encounter.
the nurse is regarded as one in possession of much needed health information to help
patient understand his health problem.
the nurse will impart appropriate knowledge within the confines of immediate demands of the
the nurse provides an understanding and clarifies environment to assist patient see his situation
●Surrogate: the nurse assists patient see his responsibilities and acts as a patient advocate where the patient
cannot speak for himself.
●Leader: nurse helps patient to own up to his responsibilities in treatment outcome achievement.
There are four clearly defined interlocking phases in the interpersonal process and these are:
ere both the nurse and the client or patient define the problem(s) of the patient or client. This occurs as the nurse
encounters the patient in the form of a stranger at their initial meeting. The client comes in looking for assistance,
asking that which she wants the nurse to clarify. The nurse in turn provides resources in the form of knowledge and
other services that assists the patient to clear any misconceptions that might have been there and in the process,
they share experience. Their specific roles are also spelt out at this time.
ue to the clarification done by the nurse the patient starts developing trust in his own capacities unlike earlier when
he came as a helpless person.
he nurse uses professional intervention methods to manage the identified problems. Various services are used and
availed to advance the goals of the patient’s needs. The patient may display various negative behaviour attributes
such as attention seeking. They may also display capacities showing independence in some functions due to the
nursing interventions employed. Many methods of communication are utilised at this juncture and the nurse is better
prepared if he is aware and uses these methods in interacting with the patient.
his is the stage where the professional relationship is terminated between the nurse and patient. The link between
nurse and the patient is broken and there must be no further communication between them. This is easier said than
done since many may have developed psychological and emotional ties between them. However, the patient must
bud off from this psychological dependence and this is what develops healthy coping as continuous clinging will stall
and prevent future growth.
he theory cannot be utilised on patients who have no felt needs such as those with depressive
disorders and the unconscious patients as such individuals cannot express their immediate needs.
Health maintenance and health promotional aspects are not fully covered by the theory.
. The theory of interpersonal relations is one of the most significant theories ever developed for mental health
and psychiatric nursing science. Suggest why it has achieved such a feat against competing equally good models
(a) Why is it necessary to handle a new admission into a unit as a stranger (2)?
(b) What is the effect of handling a patient you have not met before as if you know the patient perfectly well (3
(c) Compare and contrast handling a new psychiatric patient as a stranger with handling the same new patient as
someone you are already familiar with (10marks).
Figure 8. Sometimes looks can be deceiving. People with ‘smiling
depression’ wear smiles on their faces yet in fact, internally they are sad. How can we with certainty decode the true meaning of a
It is the cognitive science of investigating how we ascribe mental states to other persons as well as how we
use the mental states to predict and explain the actions of those other people or persons (Marraffa, 2001).
Theory of the mind is a term reserved to explain awareness of beliefs, desires, aspirations, motivations and
emotions as mental states that are ascribed to the self and others. In a way we are saying that anyone is
capable reading someone’s mind if the right environment to make those predictions exists.
Theory of the mind says that we are able to represent the mental states of others; thus if one is angry we can
tell that emotional state and not wait for the person to actually say it in words. This ability enables us to make
inferences of other people’s actions such as their motives or intentions.
For us to be able to read other people’s intentions and drives, requires of us to be in possession of high order
cognitive capacities within us and not merely the anatomical brain that all people are born with but the
abstract brain as well which unfortunately others may be unable to develop up to that level.
Theory of mind says that we can infer the complete mental picture of the mental state of another
person if we want to. It means that we have the ability to infer other people’s intent ions, belief
system, emotions, desires, imaginations, aspirations and any behaviour that cause action.
ndividuals with this disorder are not able to infer the needs of others. Thus, your anger may go
unnoticed or does not get attention from an autistic person. The person cannot ‘see’ that you
are angry so to speak. If you are shy to speak about your hunger expecting such a person to
realise that you are both shy and hungry, you may as well forget that you will get a plate of
food on the table from such a person since he can neither ‘read’ your shyness nor your need of food
to satisfy the hunger. This is not like selfishness however, here we speak of a person who is truly
unaware of the immediate demands required by the next person and there does not assist since we
help others only after realising that the next person requires that specific assistance we are going to
offer. A selfish person cannot offer assistance to someone suffering due to certain deficiencies in his
environment despite capacity in resources and awareness of the next person’s requirement of
. Some people in the community always run to the rescue of those not able to help themselves; others wonder
why someone should be assisted at all. Write short notes on why kindness in relation to someone in distress may
not be shown and why (6 marks).
. Theory of the mind believes that we can infer when the next person needs assistance from us. State any two
disorders where one cannot tell whether the next person must be helped without the affected person even
voicing it verbally to us (2marks).
his is one of the best known and yet one of the most controversial Theories derived from Sigmund Freud. The
theory puts emphasis on biological developments that happen around one’s sexual orientation and awareness as
being male or female as important turning points of personality. The theory also says that a child undergoes
through stages of development where pleasure-seeking energies of the id are directed at certain erogenous zones
of the child’s body. This is what Freud referred to as psychosocial energy and he said this is what drives behaviour.
The other name coined for this psychosocial energy was libido or libidinal energy. So to put it in other terms, to Freud
behaviour was caused by energy from the libido.
Sigmund Freud believed that an individual’s personality is fully established at the age of five years. The child at the age of
five has as part of his personality acquisition source in the form of past personal experience lived during the same period. As
the child continues to develop, the personality is expected to develop also. However, the personality that this child had at
the age of five will still influence his behaviour in later periods of his life.
Personality is said to develop through childhood stages where pleasure-seeking energies of the id become concentrated in
specific special erogenous zones of the body.
Any person expecting to have a healthy normal personality must complete each of the psychosexual stages successfully.
If any stage fails to be completed as expected, the result is a fixation at that stage which was not completed by the person.
A fixation is a situation where a person consistently focuses on an earlier psychosexual stage that is expected to have been
passed already by that person. The conflict that caused that fixation must be resolved otherwise the individual will stay-put
at that stage. According to the theory, those who did not successfully complete their oral stage of development will be
behaving as follows in their daily lives: smoking tobacco, sucking their thumbs, pens, other objects, drinking alcohol, over
eating and are seen to be over-dependent on others in daily functioning.
Stages of psychosexual development
his occurs during infancy. Libidinal energy is focused in the mouth. An infant develops by way of interacting with the
world by using its mouth. Therefore, the infant through the sucking-reflex derives pleasure as well other beneficial
outcomes like tasting new types of foods from the oral stimulation. The infant by virtue of being totally dependent
on the caregiver for feeding and all its needs, will develop trust as well as comfort when these oral needs of feeding
The conflict area is weaning period when the infant must be removed from the breast-feeding process to feed as other
siblings and be less dependent on the caregiver. Freud believed that a person who does not pass this stage and is fixated at
it would show aggression, nail-biting, dependence, smoking and over-eating behaviour.
1 to 3 years
he erogenous zone is bladder and bowel control at the anal stage. Freud thought that the main focus of libido was
controlling bowel and bladder movements. The child derives pleasure when he uses the toilet with own control.
The conflict area is toilet-training. The child must learn to control bodily needs leading to a sense of
accomplishment as well as independence.
Freud believed this stage depended largely on parents as a parent’s style of toilet-training depends
on the approach used. Parents who reward and praise their children when they used the toilet well
encourage positive results as children feel capable and confident. Freud believed that it was the
positive experiences obtained from parents these children had earlier in life which served as the
cornerstone for competency, creativity, productivity and ability later in life.
It is unfortunate that some parents are not supportive of their children as depicted above. Instead
they ridicule their children at every opportunity, shame them and even punish children. Such
inappropriate parenting model produces experiences that result in negative outcome later in life
among children, according to Freud.
Freud thought that an anal-expulsive personality results if the parents’ style of toilet-training is too
lenient. Here, the personality would be wasteful or messy and even destructive while strict or too
early toilet-training would produce an anal-retentive personality where a person is rigid, stringent,
orderly and obsessive.
3 to 6 years
ere the erogenous zone is the genitals or sexual organs. Children become aware that males
and females have different sexual organs from each other.
Freud believed boys begin to see their fathers as rival for attention and love of the mothers.
This is what he referred to as the Oedipus complex where the male child develops feelings of
wanting to possess the mother and the desire to replace his own father with himself.
The Electra complex is the same as the Oedipus complex except that it is now referring to feelings
of attraction little girls develop towards their fathers and wanting to replace their mothers with
themselves. However, Freud believed as well that these little girls develop penis envy when they
realised that they do not possess one like their male counterparts.
Gradually, the child will begin to identify with the same-sex parent as a way of vicariously winning
over the other parent. This happens as the child becomes aware that he or she cannot replace the
same sex parent with herself/himself or compete successfully to be able to win the love and
control of the opposite sex parent. For the females however, Freud thought that this penis envy
was never fully resolved and that all women remain somehow fixated at this stage throughout life.
The female then would not be in a position to forego this jealousy of men even in adulthood for
behind her brain the penis should have been on her and not otherwise.
6 years to puberty
uring this period, the libidinal energy zones are suppressed by the development of the Ego
and Super Ego which all help to bring calmness to the person. This is the stage also where
peer relationships, school, and hobbies as well as other competing interests come into the
picture and so take preferential attention compared to the erogenous zones. It is important
to note that sexual energy is still present although now directed to other areas like social
interaction and academic pursuit. It is also believed to be an important period for the development
of proper communication skills and self esteem.
puberty to death
his is the final stage of psychosexual development where the individual develops sexual
attraction to the opposite sex. It begins at puberty and progresses throughout the person’s
entire life. The interests and wellbeing of other people take centre-stage as compared to self
interests of an individual. The goal here is to achieve a balance between the different areas of
aren Horney and other psychologists dispute the penis envy theory. They think that it is both
inaccurate and demeaning to women. Instead, Horney formulated a competing parallel
version of her own arguing and proposing that men experience feelings of inferiority also
since they cannot give birth to children just like women and envy women for it. This Horney
called womb envy theory.
● Focuses almost entirely on male development mentioning little of female psychosexual development.
● The concept of libido is difficult to measure and therefore untestable. Scientifically this is a drawback, as
theories need to be verified by testing empirically. The research done so far tends to discredit Freud’s theory
● Freud’s theory is purely and not on empirical Furthermore, Freud based his
theory on recollections of his who and real observation and study on
● Future predictions are vague and not easy. It is not possible to tell if current behaviour is exactly caused by
previous experiences. The period between cause and effect is very long for making assumptions between
these two variables of study.
. Toilet training is required when bedwetting appear not to stop at a certain stage of a child’s development. Describe
what Freud believed would have happened to an adult who is bedwetting and plan a toilet training schedule for this adult
patient of between two to three months planning your treatment in weekly intervals (8 marks).
.Freud believed that women are permanently enviously in need of the male penis. According to Freud, they
are said to be fixed at that stage. This is an interesting observation. Give your own view with supporting
factual evidence (5marks).
. At what stage human development are females aware that they are quite unlike their male counterparts
anatomically in the theory of psychosexual development (2marks)?
. Suggest 3 (three) behaviour modes where some women appear to do or prefer male-related activities or
behave just like men (3marks).
. Are there males also who envy woman-hood? How do they behave if you have seen or heard about them
and which theory applies to such men (5marks)?
(a) What does it mean to say,” women are equal to men?”
(b) In real life, are women considered equal to men? Support your answer with true-life scenarios (10 marks).
1. Atkinson Rita L (Hilgard’s introduction to Psychology 1996).
2. www.currentnursing.net ( 2012-03-12).
3. www.mentalhealth.net ( 2011).
4.Townsend Mary C (Nursing diagnoses in psychiatric nursing).
5. American psychiatric association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
DSM-IV-TR. Washington, DC : 2000.
6. www. About.com Psychology
THE GENERAL RESPONSE TO LOSS-GRIEVING
Figure 10. Grieving when one has lost a treasured object is a normal process. It happens spontaneously and resolves likewise. Why then
do some people grieve for what might appear to all and sundry, an eternity?
By the end of this unit, the student should be able to:
veryday people all over the spectrum of life lose treasured objects. In the most unfortunate scenario, one
person may have to endure or succumb to a succession of losses without even having time to ponder over
the tragedy or recover fully from its effects. Such is the way of life that natural disasters and accidents
claim loved ones while one is unaware…while one is unprepared for it at all. Thieves come in people’s
sleep to vandalise and ransack all and sundry at home as well as in cars leaving dejected souls.
How do we respond to a loss of a loved object like loss of a spouse in an untimely vehicle accident? We take it as
an example since research has it that this is the item of highest order of things treasured in life. The way one
● describe healthy coping
●describe unhealthy coping
●describe the grief reaction
● discuss the types of grief reactions