Physical health problems of the psychiatric client

The psychiatric nurse can make significant contributions to the client's overall state of health by attending to the physical health care needs of clients in psychiatric settings. Psychiatric clients die at a younger age than the general population and their incidence of physical health problems tends to be higher. As major providers of psychiatric care, especially to the chronically mentally ill, nursing skills are crucial to the physical and mental health of vulnerable clients. The case reports provide examples of how the interaction between physical and psychological states influence care.     

Independent living for the chronically mentally ill

1. Many of the systems problems faced by the chronically mentally ill and their caregivers could be ameliorated by applying the principles of primary nursing. 2. Psychiatric nurses as primary caregivers of the chronically mentally ill can intervene at the client level (assessment, education, medication monitoring, family counseling) and at the systems level (networking, boundary-spanning, advocacy). 3. Psychiatric nurses are a natural and largely untapped resource for improving the care of the chronically mentally ill in the community.     

Factors in the transition to homelessness in the chronically mentally Ill

Although there is a great deal of literature on homelessness and mental illness, few studies have examined the factors which may lead to homelessness in the mentally ill. The objective of this research was to examine the factors in the length of time between when a client of the Los Angeles County Department of Mental Health entered the system and when he or she was first homeless on admission to a service (time before homelessness, TBH). Past psychiatric records of 142 currently homeless clients were examined through the Automated Information System of LACDMH. Results showed that total admissions to any service and total admissions to prison services were predictors of shorter TBH; being younger and being both African-American and female were predictors of longer TBH. TBH shortened dramatically from 1973 to 1993; mental health funding levels for theprevious year were significantly correlated with TBH. Results show that demographic, clinical, and system variables all impact on homelessness in the chronically mentally ill.     

Factors in the Transition to Homelessness in the Chronically Mentally III

Although there is a great deal of literature on homelessness and mental illness, few studies have examined the factors which may lead to homelessness in the mentally ill. The objective of this research was to examine the factors in the length of time between when a client of the Los Angeles County Department of Mental Health entered the system and when he or she was first homeless on admission to a service (time before homelessness, TBH). Past psychiatric records of 142 currently homeless clients were examined through the Automated Information System of LACDMH. Results showed that total admissions to any service and total admissions to prison services were predictors of shorter TBH; being younger and being both African-American and female were predictors of longer TBH. TBH shortened dramatically from 1973 to 1993; mental health funding levels for the previous year were significantly correlated with TBH Results show that demographic, clinical, and system variables all impact on homelessness in the chronically mentally ill.     

Services for the underserved. A nurse-managed center for the chronically mentally ill

1. A university-based, nurse-managed center for the chronically mentally ill enhanced the experiences of baccalaureate nursing students with this underserved population. 2. The course objectives included psychosocial rehabilitation for chronic illness and provided a good fit between client's needs, course objectives, and the behavioral-ecological model. 3. The project positively changed the attitudes of nursing students. Changing attitudes of professionals and motivating student interest toward the chronically mentally ill is an imperative for meeting their needs.     

Strategies for improving education

1. An extensive curriculum is required to prepare mental health professionals to adequately assess, plan, and implement the necessary comprehensive treatment plan and to sufficiently develop relevant social policy. 2. A majority of professionals believe they were not adequately trained in the care of the chronically mentally ill; this may be a result of the trend of integrating the teaching of mental health nursing concepts into the baccalaureate curriculum. 3. Frequently there is a lack of mental health professional role models. Nursing faculty are in an excellent position to implement innovative practice models. 4. Learning from a multidisciplinary team may increase the likelihood that students will apply these approaches to the chronically mentally ill.     

Deinstitutionalization: a public policy perspective

1. Deinstitutionalization was initiated in an era of social reform to protect the rights of the mentally ill; however, a strong research base was absent and led to major flaws in the policy's implementation. 2. The chronically mentally ill are frequently poor advocates for themselves and, without even the most simple needs fulfilled, end up homeless. 3. The homeless mentally ill require comprehensive support systems with assured continuity of care. An emerging concept to deal with this issue is that of case management. 4. The mental health professional can strive to influence future public policy as patient advocate and nonpartisan educator.     

Factor structure of quality of life: The Lehman interview

This study of 67 chronically mentally ill outpatients with psychotic disorders examined subjective quality of life scores from Lehman's Quality of Life (QOL) interview. Factor analyses identified ‘Affiliative’ and ‘Instrumental’ dimensions which accounted for 67% of the variance in subjective satisfaction ratings. The results suggest a model in which instrumental and affiliative needs comprise significant portions of subjective life satisfaction and that global QOL satisfaction is related more to instrumental than affiliative needs. These findings further clarify the concept of life satisfaction in this population of severely mentally ill individuals and suggest modifications in how quality of life information is evaluated.     

A proposal for change to achieve competence in long-term psychosocial nursing care

Psychiatric nursing in a large institutional setting presents challenges to the nursing staff, who must remain competent in the specialized areas of psychiatric and medical nursing. Chronically mentally ill individuals present complex and continuing nursing care needs that must be addressed using a holistic approach to nursing assessment and care. The complex needs of nursing staff and patients in an institutional setting have been described. Methods of assisting the nurse to achieve competence using education and experience have been implemented and described with the goal of improving holistic nursing care to chronically institutionalized individuals.     

Promoting public/academic linkage.

1. Collaborative linkages between public mental health/mental retardation service systems and academic institutions have evolved in response to several problems: increasing numbers of individuals requiring long-term mental health care; the nursing shortage; and a decline in enrollment and students graduating from psychiatric mental health nursing programs. 2. Evidence suggests that a public/academic linkage in the form of a multidisciplinary training course in the care of seriously mentally ill patients promotes a recruitment of mental health professionals to work with these patients. 3. The establishment of academic/health care system linkages can enhance client care, expand and improve clinical experiences and education for students, and provide opportunities for collaborative research among clinical staff, faculty members, and graduate students.     

Learning to laugh: humor as therapy

Use of humor may indicate a person's mental health status, may reveal psychosocial problems and conflicts, and may indicate ability to cope with those problems and conflicts. Humor may also be one way of helping people more effectively cope with the stresses and strains of living in a complex world. Humor may be incorporated into psychotherapy, either as part of the therapist-client relationship or as a humor program. The humor used by the author in a humor program with chronically mentally ill clients is the laughing with, not the laughing at, type. It deals with problems of life and of people living life. The stories, jokes, comic strips, and songs selected show how people perceive and laugh at the ironies and absurdities in their predicaments and are able to cope with, and frequently transcend, them.     

Psychiatric nursing in the 1990s & beyond.

In the decade of the '90s, psychiatric mental health nursing will need to take stock of itself--its practice, its education, and its research--if it is to successfully prepare for the changes in care of the mentally ill. Like psychiatrists, we will need to rethink our agendas in light of new science and technology and rationalize the mental health delivery system and our role in it through systematic research and advocate for a system that provides quality care for the chronically ill and the poor. In the next century, we will need to rethink the basics of nursing care and the leadership roles of nurses as hospitals and the doctor's role within them changes. Psychiatric mental health nurses will need to be at the forefront in advocating for a delivery system that listens to patients and families, that humanizes the dehumanizing experience of hospitalization. The challenges before us are formidable.     

A psychiatric nurse's role

1. Homelessness in America is a result of complex social, political, and economic forces; approximately one third to one half of the homeless have severe emotional problems. 2. The person with chronic mental illness who is also homeless will face numerous obstacles when the need for psychiatric care arises. 2. The person with chronic mental illness who is also homeless will face numerous obstacles when the need for psychiatric care arises. 3. The federal government is beginning to address the problems of the homeless chronically mentally ill population by establishing pilot programs in Veterans Administration hospitals. 4. The psychiatric nurse is in a unique position to provide services to those who are homeless and mentally ill.     

Characteristics of the Homeless Mentally III in Case Management: Differentiation Using Major Diagnostic Categories

The homeless mentally ill are more disabled than other homeless people and require more services, but important variations exist. This study examined relationships between broad Axis I diagnostic clusters and demographic and service variables for 328 clients receiving case management at a community program for the chronic mentally ill homeless. Demographic characteristics, medical history, educational, psychological, and marital history, and case management variables were examined for psychotic, affective, and miscellaneous other clients. Differences were found in such areas as suicide attempts and current suicide status, psychiatric treatment history, education, overall impairment of functioning, length of time homeless, and time in case management but not in status at termination or number of senlices required. Psychotics had lower adaptive functioning, spent less time in case management, but had as successful outcomes as affective clients. Psychiatric diagnosis provides information that might assist case management for the homeless mentally ill.     

The expanded role of nurse case managers

1. Effective nursing practice is responsive to the changing needs of clients. The community, rather than the hospital, has become the primary treatment setting in which the long-term mentally ill manage their daily activities. 2. The professional role of rehabilitative nurse case management can provide an opportunity for nurses to expand their roles and develop new career directions. 3. The primary nursing model provides an excellent foundation for acquiring the attitudes and skills necessary in the delivery of a comprehensive rehabilitative model of case management.     

Simple measures of case mix in mental health services.

The concept of Case Mix in community mental health service program evaluation can be useful in mental health program evaluation if the definition of case mix is expanded beyond Diagnostic Related Groups (DRG), where DRG is solely based upon diagnosis and length of hospitalization stay. A case mix definition based upon two principal characteristics is offered. One characteristic is clinical status defined in terms of diagnostic signs and symptoms, level of functioning, and age. The other characteristic is typical treatment strategy for a given period of time (e.g., 13 weeks). Two cases mixes typical of services designed for the chronically mentally ill are discussed.     

The history, economics, and financing of mental health care. Part 2: The 20th century

1. To understand how mental health nursing practice was affected by the financing and policy changes occurring rapidly in the second part of the 20th century, sources can only be found in the literature in psychiatry, the social sciences, and economics. There was no psychiatric nursing journal until the 1950s, and no article by a nurse in the general nursing literature about finances. 2. Deinstitutionalization was really transinstitutionalization. Changes in regulations in Medicaid allowed the shifting of mentally ill people who were older than age 65 to nursing homes. 3. Community mental health centers never developed programs to serve people who were seriously mentally ill. Rather than serving clients who were psychotic, the community mental health centers marketed their treatment programs to people with anxieties, who were undergoing divorce, or who had mildly troubled children.     

Nurse entrepreneurs

1. Supervised Environmental Living Facility (SELF) is a nurse-developed, non-profit, community-based, supervised apartment program for the chronically mentally ill. It provides comprehensive supportive and rehabilitative services to the chronically mentally ill, allowing them to re-establish themselves as part of the community. 2. SELF is based on the philosophy that a person needs assistance according to the extent that the illness affects the individual's ability to live safely and optimally. 3. Nurses can be entrepreneurs by seeking and creating innovative models for the delivery of services to specialized populations.     

Labeling theory and community care of the mentally ill in California: the relationship of social theory and ideology to public policy

The practical merit of a labeling theory approach to mental illness is examined and assessed through an exploration of its application in terms of public policy, i.e., community mental health policy in the state of California since 1968. Primary focus is placed on the impact of the deinstitutionalization of mental health services in that state, and the release of former mental patients into the community. Similarities in the fundamental ideological underpinnings of labeling theory, an associated conspiratorial model of mental illness, and contemporary California mental health policy, are presented and examples of policy input by labeling theorists and researchers are detailed. The impact of the California policy on the mentally ill is generally negatively assessed in terms of three major criteria: (1) rehabilitation; (2) reintegration; and (3) quality and continuity of care. The "translation" of several theoretical misconceptions regarding mental illness, caused by putting labeling theory into official policy, is suggested to lie at the root of many of the policy's implementation problems. The uses of social science theory and research are discussed, and caution is advised in the translation and application of social scientific theory and research to public policy proposals and programs.     

Reframe your outlook on recidivism

1. Deinstitutionalization has placed many chronically mentally ill people in communities that are not prepared to care for them. A lack of fit between clients and the programs provided often results in repeated visits to psychiatric emergency services. 2. Repeated visits to a community program can be viewed positively: community services carry less stigma than hospital admissions, they are less expensive, and they are directly linked with the community. 3. By encouraging a return to a community program before decompensation necessitates a hospital admission, it becomes possible to focus on how a client can cope with, rather than simply react to, the illness.