Ch. 1, 3, 4 Current Theories and Practice

complementary vs alternative therapies

-Complementary: used together with conventional medicine -Alternative medicine: used stead of conventional medicine

crisis intervention

-Directive interventions are designed to assess the person's health status and promote problem-solving, such as offering the person new information, knowledge, or meaning; raising the person's self-awareness by providing feedback about behavior; and directing the person's behavior by offering suggestions or courses of action. -Supportive interventions aim at dealing with the person's needs for empathetic understanding, such as encouraging the person to identify and discuss feelings, serving as a sounding board for the person, and affirming the person's self-worth. Techniques and strategies that include a balance of these different types of intervention are the most effective.

therapeutic nurse-patient relationship tasks

-Orientation Patient's problems and needs are clarified. Patient asks questions. Hospital routines and expectations are explained. Patient harnesses energy toward meeting problems. Patient's full participation is elicited. -Identification Patient responds to persons he or she perceives as helpful. Patient feels stronger. Patient expresses feelings. Interdependent work with the nurse occurs. Roles of both patient and nurse are clarified. -Exploitation Patient makes full use of available services. Goals such as going home and returning to work emerge. Patient's behaviors fluctuate between dependence and independence. -Resolution Patient gives up dependent behavior. Services are no longer needed by patient. Patient assumes power to meet own needs, set new goals, and so forth.

therapeutic communications techniques

-Using silence --> allows client to take control of the discussion, if they desire -Accepting --> conveys positive regard -giving recognition --> acknowledges, indicating awareness -offering self --> making oneself available -giving broad openings --> allows client to select the topic -offering general leads --> encourages client to continue placing the event in time or sequence --> clarifies the relationship of events in time -making observations --> verbalizing what is observed or perceived -encouraging description of perceptions --> asking client to verbalize whats being perceived -encouraging comparison --> asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships -restating --> lets client know whether an expressed statement has or has not been understood -reflecting --> directs questions or feelings back to client so that they may be recognized and accepting -focusing --> taking notice of a single idea or even a single word -exploring --> delving further into a subject, idea, experience, or relationship -seeking clarification and validation --> striving to explain what is vague and searching for mutual understanding -presenting reality --> clarifying misconceptions that client may be expressing -voicing doubt --> expressing uncertainty as to the reality of the client's perception -verbalizing the implied --> putting into words what client has only implied -attemptinh to translate words into feelings --> putting into words the feelings the client has expressed indirectly -formulating a plan of action --> striving to prevent anger or anxiety from escalating to an unmanageable level the next time the stressor occurs

interpersonal communication

-a transaction between the sender and the receiver. -Both persons participate simultaneously. -verbal and nonverbal communication Social Factors -both sender and receiver bring certain preexisting conditions to the exchange that influence both the intended message and the way in which it is interpreted -

psychoanalytic theory

-all human behavior is cause and can be explained -repressed sexual impulses and desires motivates human behavior -personality comprised of id (pleasure seeking), superego (morality), ego (balance) -person's dreams reflect the subconscious and have meaning -ego uses defense mechanisms to protect self and cope -oral, anal, phallic, latency, and genital stages -transference and countertransference -still practiced but on a limited basis

ancient perspective of mental illness

-any sickness indicated displeasure with the gods -punishment for sins and wrongdoings

how to avoid nonacceptance and avoidance

-be aware of client behavior from the beginning --> explore possibility with colleague -be aware of prejudice

group therapy

-clients participate in sessions with a group of people. -The members share a common purpose and are expected to contribute to the group to benefit others and receive benefit from others in return. -Group rules are established results: •Gaining new information, or learning •Gaining inspiration or hope •Interacting with others •Feeling acceptance and belonging •Becoming aware that one is not alone and that others share the same problems •Gaining insight into one's problems and behaviors and how they affect others •Giving of oneself for the benefit of others (altruism)

clubhouse model

-community-based rehabilitation -an "intentional community" based on the belief that men and women with serious and persistent psychiatric disability can and will achieve normal life goals when given the opportunity, time, support, and fellowship -provides members with many opportunities, including daytime work activities focused on the care, maintenance, and productivity of the clubhouse; evening, weekend, and holiday leisure activities; transitional and independent employment support and efforts; and housing options -focused on health not illness

orientation (introductory) phase of therapeutic nurse-client relationship

-create an environment for trust and rapport -establish contract for intervention -gather assessment data -identify client strengths and weaknesses -formulate nursing diagnoses -set mutually agreeable goals -develop a realistic plan of action -explore feelings of both client and nurse

enlightenment period perspective of mental illness

-created first mental institutions -movement for moral treatment of mentally ill -short-lived, attendants began abusing residents -hospitals became insane asylums

Partial hospitalization programs (PHPs)

-designed to help clients make a gradual transition from being inpatients to living independently and to prevent repeat admissions -important to include the client in an active role in identifying rehabilitation goals Goals: •Stabilizing psychiatric symptoms •Monitoring drug effectiveness •Stabilizing living environment •Improving activities of daily living •Learning to structure time •Developing social skills •Obtaining meaningful work, paid employment, or a volunteer position •Providing follow-up of any health concerns

Cost Containment/Managed Care

-designed to purposely control the balance between the quality of care provided and the cost of that care -receiving care you need, not what you request -can cover mental health treatment but cant guaranty substance abuse treatment

conversion

-expression of emotional conflict through the development of a physical symptom, usually sensorimotor -Example: -teenager forbidden to see X-rated movies goes with friends and develops blindness but is unconcerned with it

client-centered therapy

-focuses on role of the client •Unconditional positive regard—a nonjudgmental caring for the client that is not dependent on the client's behavior •Genuineness—realness or congruence between what the therapist feels and what he or she says to the client •Empathetic understanding—in which the therapist senses the feelings and personal meaning from the client and communicates this understanding to the client

Nontherapeutic Communication Techniques

-giving reassurance --> may discourage client from further expression of feelings if client believes the feelings will only be belittled -rejecting --> refusing to consider client's ideas or behavior -giving approval or disapproval --> implies that the nurses has the right to pass judgement on the goodness or badness of client's behavior -giving advice --> implies the nurse knows what is best for the client and that cliet is incapable of any self direction -probing --> pushing for answers to issues that client doesn't wish to discuss causes the client to feel used and valued only for what is shared with the nurse -defending --> to defend what client has criticized implies that the client has no right to express ideas, opinions, or feelings -requesting an explanation --> asking "why" implies that the client must defend their behavior or feelings -indicating the existence of an external source of power --> encourages the client to project blame for their thoughts or behaviors on others -belittling feelings expressed --> causes the client to feel insignificant or unimportant -Making stereotyped comments, cliches, and trite expressions --> these are meaningless in a nurse-client relationship -using denial --> blocks discussion with the client and avoids helping them identify and explore areas of difficulty -interpreting --> results in the therapists telling client the meaning of his or her experience -introducing an unrelated topic --> causes the nurse to take over the direction of the discussion

how to avoid crossing inappropriate boundaries

-maintain boundaries -define boundaries clearly at beginning -act warmly and empathetically but don't attempt friendship -dont accept gifts -dont give out personal info -keep feelings in check -focus on client's interests and needs •Realize that all staff members, whether male or female, junior or senior, or from any discipline, are at risk for overinvolvement and loss of boundaries. •Assume that boundary violations will occur. Supervisors should recognize potential "problem" clients and regularly raise the issue of sexual feelings or boundary loss with staff members. •Provide opportunities for staff members to discuss their dilemmas and effective ways of dealing with them. •Develop orientation programs to include how to set limits, how to recognize clues that the relationship is losing boundaries, what the institution expects of the professional, clearly defined consequences, case studies, how to develop skills to maintain boundaries, and recommended reading. •Provide resources for confidential and nonjudgmental assistance. •Hold regular meetings to discuss inappropriate relationships and feelings toward clients. •Provide senior staff to lead groups and model effective therapeutic interventions with difficult clients. •Use clinical vignettes for training. •Use situations that reflect not only sexual dilemmas but also other boundary violations, including problems with abuse of authority and power.

working phase of therapeutic nurse-client relationship

-maintain trust and rapport -promote client's insight and perception of reality -use problem solving model to work towards goals -overcome resistance behaviors -continuously evaluate progress toward goal attainment -transference may occur

psychotherapy groups

-members learn about their behavior and to make positive changes in their behavior by interacting and communicating with others as a member of a group. -Open groups are ongoing and run indefinitely, allowing members to join or leave the group as they need to. -Closed groups are structured to keep the same members in the group for a specified number of sessions

pre-interaction phase of therapeutic nurse-client relationship

-obtain info about the client from the chart, significant others, or other health team members -examine one's own feelings about working with a particular client

what are the boundaries of a nurse-client relationship?

-professional boundaries limit and outline expectations for appropriate professional relationships -concerns commonly include issues i.e.: --> self-disclosure --> gift-giving --> touch --> friendship or romantic association -relationship should always be centered on helping client meet goals

termination phase of therapeutic nurse-client relationship

-progress has been made toward attainment of the goals -pattern of adaptive coping with stressors has been established -plan for dealing with future stressors -feelings about termination of the relationship are recognized and explored

psychiatric rehabilitation

-providing services to people with severe and persistent mental illness to help them to live in the community -assist clients with activities of daily living, such as transportation, shopping, food preparation, money management, and hygiene -important to include the client in an active role in identifying rehabilitation goals

sigmund freud/mental disorder treatment perspective of mental illness

-psychiatry began to focus more on diagnosis and treatment -psychotropic drugs began development in 1950

individual psychotherapy

-psychological treatment in which a therapist sees a troubled person one-on-one -bringing about change in a person by exploring his or her feelings, attitudes, thinking, and behavior -therapist client relationship is key

Conditions Essential to Development of a Therapeutic Relationship

-rapport -trust -respect -genuineness -empathy

the 6 subroles of within the role of psych nurse

-stranger -resource person -teacher -leader -surrogate -counselor

Transference vs Countertransference

1. transference: occurs when the client unconsciously displaces to nurses feelings formed toward a person from the past 2. Countertransference: nurse's behavioral and emotional response to the client

Components of Therapeutic Relationship

1. trust -Behaviors the nurse can exhibit to promote trust: caring, interest, understanding, consistency, honesty, keeping promises 2. congruence: words & actions match (essential to forming trust) 3. genuine interest: can disclose past experiences related to the client's current concerns 4. empathy: ability of nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client; NO sympathetic comments 5. acceptance: no judgements 6. positive regard: unconditional nonjudgmental attitude -Call the client by name, spend time with the client, and listen and respond openly -Consider client's ideas and preferences when planning care 7. Self-Awareness and Therapeutic Use of Self: understand one's own thoughts and beliefs and how they affect others -reevaluate beliefs and attitudes -use aspects of self to establish relationships with clients -avoid preconceptions

Piaget's stages of cognitive development

1.Sensorimotor—birth to 2 years: The child develops a sense of self as separate from the environment and the concept of object permanence, that is, tangible objects do not cease to exist just because they are out of sight. He or she begins to form mental images. 2.Preoperational—2 to 6 years: The child develops the ability to express self with language, understands the meaning of symbolic gestures, and begins to classify objects. 3.Concrete operations—6 to 12 years: The child begins to apply logic to thinking, understands spatiality and reversibility, and is increasingly social and able to apply rules; however, thinking is still concrete. 4.Formal operations—12 to 15 years and beyond: The child learns to think and reason in abstract terms, further develops logical thinking and reasoning, and achieves cognitive maturity.

introjection

Acceptance of another's values and opinions as one's own Example: -person who dislikes guns becomes a hunter because of best friend

rationalization

Attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors Example: -student blames failure on teacher being mean

dissociation

Dealing with emotional conflict by a temporary alteration in consciousness or identity Example: -Amnesia that prevents recall of auto accident

undoing

Exhibiting acceptable behavior to make up for or negate unacceptable behavior Example: -person who cheats on spouse brings spouse bouquet

fixation

Immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage Example: -Never learning to delay gratification

sullivan's life stage

Infancy Birth to onset of language Primary need exists for bodily contact and tenderness. Prototaxic mode dominates (no relation between experiences). Primary zones are oral and anal. If needs are met, infant has sense of well-being; unmet needs lead to dread and anxiety. Childhood Language to 5 years Parents are viewed as source of praise and acceptance. Shift to parataxic mode; experiences are connected in sequence to each other. Primary zone is anal. Gratification leads to positive self-esteem. Moderate anxiety leads to uncertainty and insecurity; severe anxiety results in self-defeating patterns of behavior. Juvenile 5-8 years Shift to the syntaxic mode begins (thinking about self and others based on analysis of experiences in a variety of situations). Opportunities for approval and acceptance of others. Learn to negotiate own needs. Severe anxiety may result in a need to control or in restrictive, prejudicial attitudes. Preadolescence 8-12 years Move to genuine intimacy with friend of the same sex. Move away from family as source of satisfaction in relationships. Major shift to syntaxic mode occurs. Capacity for attachment, love, and collaboration emerges or fails to develop. Adolescence Puberty to adulthood Lust is added to interpersonal equation. Need for special sharing relationship shifts to the opposite sex. New opportunities for social experimentation lead to the consolidation of self-esteem or self-ridicule. If the self-system is intact, areas of concern expand to include values, ideals, career decisions, and social concerns.

anxiety levels

Mild Sharpened senses Increased motivation Alert Enlarged perceptual field Can solve problems Learning is effective Restless Gastrointestinal "butterflies" Sleepless Irritable Hypersensitive to noise -Moderate Selectively attentive Perceptual field limited to the immediate task Can be redirected Cannot connect thoughts or events independently Muscle tension Diaphoresis Pounding pulse Headache Dry mouth Higher voice pitch Increased rate of speech Gastrointestinal upset Frequent urination Increased automatisms (nervous mannerisms) -Severe Perceptual field reduced to one detail or scattered details Cannot complete tasks Cannot solve problems or learn effectively Behavior geared toward anxiety relief and is usually ineffective Feels awe, dread, or horror Doesn't respond to redirection Severe headache Nausea, vomiting, diarrhea Trembling Rigid stance Vertigo Pale Tachycardia Chest pain Crying Ritualistic (purposeless, repetitive) behavior -Panic Perceptual field reduced to focus on self Cannot process environmental stimuli Distorted perceptions Loss of rational thought Personality disorganization Doesn't recognize danger Possibly suicidal Delusions or hallucination possible Can't communicate verbally Either cannot sit (may bolt and run) or is totally mute and immobile

identification

Modeling actions and opinions of influential others while searching for identity, or aspiring to reach a personal, social, or occupational goal Example: -Nursing student becoming critical care nurse because this is the occupation of the instructor she admires

regression

Moving back to a former stage to escape conflict or fear Example: -5 year old asks for bottle when baby sibling is being fed

Components of nonverbal communication

Physical appearance and dress Body movement and posture Touch Facial expressions Eye behavior Vocal cues or paralanguage

goals of psych rehab

Recovery from mental illness Personal growth Quality of life Community reintegration Empowerment Increased independence Decreased hospital admissions Improved social functioning Improved vocational functioning Continuous treatment Increased involvement in treatment decisions Improved physical health Recovered sense of self

denial

Refusing to acknowledge the existence of a real situation or the feelings associated with it Examples: -diabetic eating candy -spending money freely when broke

substitution

Replacing the desired gratification with one that is more readily available Example: -woman who wants kids opens day care

Active Listening (SOLER)

S - Sit squarely facing the client O - Observe an open posture L - Lean forward toward the client E - Establish eye contact R - Relax

intellectualization

Separation of the emotions of a painful event or situation from the facts involved; acknowledging the facts but not the emotions Example: -person shows no emotion when discussing car accident

Nurse-Client Contracts

The contract should state the following: •Time, place, and length of sessions •When sessions will terminate •Who will be involved in the treatment plan (family members or health team members) •Client responsibilities (arrive on time and end on time) •Nurse's responsibilities (arrive on time, end on time, maintain confidentiality at all times, evaluate progress with client, and document sessions)

suppression

The voluntary blocking of unpleasant feelings and experiences from one's awareness Example: -student focuses on studying instead of parent's illness

Erickson's stages of psychosocial development

Trust vs. mistrust (infant) Hope Viewing the world as safe and reliable; relationships as nurturing, stable, and dependable Autonomy vs. shame and doubt (toddler) Will Achieving a sense of control and free will Initiative vs. guilt (preschool) Purpose Beginning development of a conscience; learning to manage conflict and anxiety Industry vs. inferiority (school age) Competence Emerging confidence in own abilities; taking pleasure in accomplishments Identity vs. role confusion (adolescence) Fidelity Formulating a sense of self and belonging Intimacy vs. isolation (young adult) Love Forming adult, loving relationships, and meaningful attachments to others Generativity vs. stagnation (middle adult) Care Being creative and productive; establishing the next generation Ego integrity vs. despair (maturity) Wisdom Accepting responsibility for oneself and life

evolving consumer household (ECH)

a group-living situation in which the residents make the transition from a traditional group home to a residence where they fulfill their own responsibilities and function without on-site supervision from paid staff

reaction formation

acting opposite of how you feel Example: -woman who never wants kids becomes supermom

projection

attributing one's own unacceptable feelings or impulses to someone else Example: -man who has gay tendencies beats up an openly gay man

therapeutic community/milieu

beneficial environment; interaction among clients is seen as beneficial, and treatment emphasizes the role of this client-to-client interaction -clients' interactions with one another, including practicing interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems.

compensation

covering up a real or perceived weakness by emphasizing a trait one considers more desirable Examples: -Napoleon complex -nurse with low self-esteem working double shifts

repression

excluding uncomfortable thoughts, feelings, and desires from consciousness Example: -woman has no memory of mugging

cognitive therapy

focuses on immediate thought processing—how a person perceives or interprets his or her experience and determines how he or she feels and behaves

Adaptive coping mechanisms

helps you deal with stress in a healthy way --> i.e. exercise, meditation, talking to someone, listening to music

psychosocial interventions

nursing activities that enhance the client's social and psychological functioning and improve social skills, interpersonal relationships, and communication

Bridging Staff (transitional care)

overlap between hospital and community care; hospital staff do not terminate their therapeutic relationship with the client until a therapeutic relationship has been established with the community care provider

resistance

overt or covert antagonism towards remembering or processing anxiety-producing info Example: -Nurse too busy to talk with dying client

how to avoid feelings of sympathy and encouraging client dependency

reassess professional behavior and refocus on the client's needs and therapeutic goals

maladaptive coping mechanisms

relieve stress temporarily but can also cause harm --> i.e. excessive worrying, binge eating, smoking

types of relationships

social: -purpose of friendship -communication focused on sharing ideas -acceptable but should be limited between nurses and clients intimate: -emotional and/or sexual commitment -unacceptable therapeutic: -focuses on client only -nurse uses communication skills, personal strengths, and understanding of human behavior to interact with the client

sublimation

substitution a socially acceptable activity for an activity that is unacceptable Example: -person quitting smoking sucks on hard candy instead

dual diagnosis

the client with both substance abuse and another psychiatric illness

displacement

ventilation of intense feelings toward persons less threatening than the one who aroused those feelings Example: -Person mad at boss yells at spouse instead

Points to consider when working on self awareness

• Keep a diary or journal that focuses on experiences and related feelings. Work on identifying feelings and the circumstances from which they arose. Review the diary or journal periodically to look for patterns or changes. • Talk with someone you trust about your experiences and feelings. This might be a family member, friend, coworker, or nursing instructor. Discuss how he or she might feel in a similar situation, or ask how he or she deals with uncomfortable situations or feelings. • Engage in formal clinical supervision. Even experienced clinicians have a supervisor with whom they discuss personal feelings and challenging client situations to gain insight and new approaches. • Seek alternative points of view. Put yourself in the client's situation and think about his or her feelings, thoughts, and actions. • Do not be critical of yourself (or others) for having certain values or beliefs. Accept them as a part of yourself, or work to change those values and beliefs you wish to be different.

characteristics of later recovery

•Accepting illness •Managing symptoms effectively •Being actively engaged in the community •Having meaningful social contact •Coping with family relationships •Valuing self and others

Types of complementary and alternative therapies

•Alternative medical systems include homeopathic medicine and naturopathic medicine in Western cultures, and traditional Chinese medicine, which includes herbal and nutritional therapy, restorative physical exercises (yoga and tai chi), meditation, acupuncture, and remedial massage. •Mind-body interventions include meditation, prayer, mental healing, and creative therapies that use art, music, or dance. •Biologically based therapies use substances found in nature, such as herbs, food, and vitamins. Dietary supplements, herbal products, medicinal teas, aromatherapy, and a variety of diets are included. •Manipulative and body-based therapies are based on manipulation or movement of one or more parts of the body, such as therapeutic massage and chiropractic or osteopathic manipulation. •Energy therapies include two types of therapy: biofield therapies, intended to affect energy fields that are believed to surround and penetrate the body, such as therapeutic touch, qi gong, and Reiki, and bioelectric-based therapies involving the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, and alternating current or direct current fields. Qi gong is part of Chinese medicine that combines movement, meditation, and regulated breathing to enhance the flow of vital energy and promote healing. Reiki (which in Japanese means "universal life energy") is based on the belief that when spiritual energy is channeled through a Reiki practitioner, the patient's spirit and body are healed.

Assertive Community Treatment (ACT)

•Having a multidisciplinary team that includes a psychiatrist, psychiatric-mental health nurse, vocational rehabilitation specialist, and social worker for each 100 clients (low staff-to-client ratio) •Identifying a fixed point of responsibility for clients with a primary provider of services •Ameliorating or eliminating the debilitating symptoms of mental illness •Improving client functioning in adult social and employment roles and activities •Decreasing the family's burden of care by providing opportunities for clients to learn skills in real-life situations •Implementing an individualized, ongoing treatment program defined by clients' needs •Involving all needed support systems for holistic treatment of clients •Promoting mental health through the use of a vast array of resources and treatment modalities •Emphasizing and promoting client independence •Using daily team meetings to discuss strategies to improve the care of clients •Providing services 24 hours a day that would include respite care to deflect unnecessary hospitalization and crisis intervention to prevent destabilization with unnecessary emergency department visits •Measuring client outcomes on the following aspects: symptomatology; social, psychological, and familial functioning; gainful employment; client independence; client empowerment; use of ancillary services; client, family, and societal satisfaction; hospital use; agency use; rehospitalization; quality of life; and costs

core practice skills for interdisciplinary functioning

•Interpersonal skills, such as tolerance, patience, and understanding •Humanity, such as warmth, acceptance, empathy, genuineness, and nonjudgmental attitude •Knowledge base about mental disorders, symptoms, and behavior •Communication skills •Personal qualities, such as consistency, assertiveness, and problem-solving abilities •Teamwork skills, such as collaborating, sharing, and integrating •Risk assessment and risk management skills

3 types of crises

•Maturational crises, sometimes called developmental crises, are predictable events in the normal course of life, such as leaving home for the first time, getting married, having a baby, and beginning a career. •Situational crises are unanticipated or sudden events that threaten the individual's integrity, such as the death of a loved one, loss of a job, and physical or emotional illness in the individual or family member. •Adventitious crises, sometimes called social crises, include natural disasters like floods, earthquakes, or hurricanes; war; terrorist attacks; riots; and violent crimes such as rape or murder.

interdisciplinary team for a psychiatric exam

•Pharmacist: The registered pharmacist is a member of the interdisciplinary team when medications, management of side effects, and/or interactions with nonpsychiatric medications are complex. Clients with refractory symptoms may also benefit from the pharmacist's knowledge of chemical structure and actions of medications. •Psychiatrist: The psychiatrist is a physician certified in psychiatry by the American Board of Psychiatry and Neurology, which requires a 3-year residency, 2 years of clinical practice, and completion of an examination. The primary function of the psychiatrist is diagnosis of mental disorders and prescription of medical treatments. •Psychologist: The clinical psychologist has a doctorate (Ph.D.) in clinical psychology and is prepared to practice therapy, conduct research, and interpret psychological tests. Psychologists may also participate in the design of therapy programs for groups of individuals. •Psychiatric nurse: The registered nurse gains experience in working with clients with psychiatric disorders after graduation from an accredited program of nursing and completion of the licensure examination. The nurse has a solid foundation in health promotion, illness prevention, and rehabilitation in all areas, allowing him or her to view the client holistically. The nurse is also an essential team member in evaluating the effectiveness of medical treatment, particularly medications. Registered nurses who obtain master's degrees in mental health may be certified as clinical specialists or licensed as advanced practitioners, depending on individual state nurse practice acts. Advanced practice nurses are certified to prescribe drugs in many states. •Psychiatric social worker: Most psychiatric social workers are prepared at the master's level and are licensed in some states. Social workers may practice therapy and often have the primary responsibility for working with families, community support, and referral. •Occupational therapist: Occupational therapists may have an associate degree (certified occupational therapy assistant) or a baccalaureate degree (certified occupational therapist). Occupational therapy focuses on the functional abilities of the client and ways to improve client functioning, such as working with arts and crafts and focusing on psychomotor skills. •Recreation therapist: Many recreation therapists complete a baccalaureate degree, but in some instances, persons with experience fulfill these roles. The recreation therapist helps the client to achieve a balance of work and play in his or her life and provides activities that promote constructive use of leisure or unstructured time. •Vocational rehabilitation specialist: Vocational rehabilitation includes determining clients' interests and abilities and matching them with vocational choices. Clients are also assisted in job-seeking and job retention skills as well as in pursuit of further education, if that is needed and desired. Vocational rehabilitation specialists can be prepared at the baccalaureate or master's level and may have different levels of autonomy and program supervision based on their education.

phenomena of concern for psych nurses

•Promotion of optimal mental and physical health and well-being and prevention of mental illness •Impaired ability to function related to psychiatric, emotional, and physiologic distress •Alterations in thinking, perceiving, and communicating because of psychiatric disorders or mental health problems •Behaviors and mental states that indicate potential danger to self or others •Emotional stress related to illness, pain, disability, and loss •Symptom management, side effects, or toxicities associated with self-administered drugs, psychopharmacologic intervention, and other treatment modalities •The barriers to treatment efficacy and recovery posed by alcohol and substance abuse and dependence •Self-concept and body image changes, developmental issues, life process changes, and end-of-life issues •Physical symptoms that occur along with altered psychological status •Psychological symptoms that occur along with altered physiologic status •Interpersonal, organizational, sociocultural, spiritual, or environmental circumstances or events that have an effect on the mental and emotional well-being of the individual and family or community •Elements of recovery, including the ability to maintain housing, employment, and social support, that help individuals reengage in seeking meaningful lives •Societal factors such as violence, poverty, and substance abuse Areas of Practice: Basic-Level Functions •Counseling •Interventions and communication techniques •Problem-solving •Crisis intervention •Stress management •Behavior modification •Milieu therapy •Maintain therapeutic environment •Teach skills •Encourage communication between clients and others •Promote growth through role modeling •Self-care activities •Encourage independence •Increase self-esteem •Improve function and health •Psychobiologic interventions •Administer medications •Teach •Observe •Health teaching •Case management •Health promotion and maintenance Advanced-Level Functions •Psychotherapy •Prescriptive authority for drugs (in many states) •Consultation and liaison •Evaluation •Program development and management •Clinical supervision

Possible Warnings or Signals of Abuse of the Nurse-Client Relationship

•Secrets; reluctance to talk to others about the work being done with clients •Sudden increase in phone calls between nurse and client or calls outside clinical hours •Nurse making more exceptions for client than normal •Inappropriate gift-giving between client and nurse •Loaning, trading, or selling goods or possessions •Nurse disclosure of personal issues or information •Inappropriate touching, comforting, or physical contact •Overdoing, overprotecting, or overidentifying with client •Change in nurse's body language, dress, or appearance (with no other satisfactory explanation) •Extended one-on-one sessions or home visits •Spending off-duty time with the client •Thinking about the client frequently when away from work •Becoming defensive if another person questions the nurse's care of the client •Ignoring agency policies

points to consider when working in community-based settings

•The client can make mistakes, survive them, and learn from them. Mistakes are a part of normal life for everyone, and it is not the nurse's role to protect clients from such experiences. •The nurse will not always have the answer to solve a client's problems or resolve a difficult situation. •As clients move toward recovery, they need support to make decisions and follow a course of action, even if the nurse thinks the client is making decisions that are unlikely to be successful. •Working with clients in community settings is a more collaborative relationship than the traditional role of caring for the client. The nurse may be more familiar and comfortable with the latter.