INTRODUCTION TO PSYCHIATRIC NURISNG

PSYCHIATRIC NURSING IN YOUR COMMUNITY

• Interpersonal process whereby a professional nurse through • What are the daily challenges for persons with mental,
the therapeutic use of self, assist an individual, family, group neurological and substance use disorders?
or community:
• To promote mental health • Employment?
• To prevent mental illness and suffering o People with mental, neurological and substance
• To participate in the treatment and rehabilitation of the use disorders may be denied work opportunities.
mentally ill and if necessary to find meaning in these o Studies have shown that people with mental,
experiences. neurological and substance use disorders
• Uses the NURSING PROCESS experience unemployment rates of up to 90% in
many countries.
WHY CONSIDER MENTAL HEALTH?
• Education?
• MENTAL HEALTH is a precondition to active ageing and o Children with mental disorders are excluded from
quality of life educational opportunities.
o In many countries children with mental or
MENTAL HEALTH intellectual disorders are INSTITUTIONALIZED in
facilities that do not offer education.
• Psychological, social and emotional well being
• Refers to our ability to manage thoughts, feelings and
• Marriage? Civil / Family Right
behavior so that we can
o People experience restrictions in the right to marry
• experience satisfaction and happiness
and start a family
• cope with stress and sadness
o In some countries, people can be placed under
• achieve our goals and potentials guardianship which prevent them from marrying or
• maintain positive connections with others filing for divorce without approval.
• Changes over time
• Social life? Political
AGEING AND MENTAL HEALTH
o People also experience restrictions in the right to
• Most older people face life challenges with equanimity, good vote.
humor and courage and manage transition and stressors with o In some countries, people cannot vote if deemed of
resilience, resourcefulness and hardiness. “unsound mind or mental infirmity” (eg.Thailand) or
if under guardianship (eg.Hungary).
MENTAL HEALTH PROBLEMS
• Abuse?
• Barrier to active and satisfying ageing/negative impact on o 1 in 6 Children are sexually abused.
quality of life o 75% don’t tell
• Prolongs stays in general hospital and increases recovery o Sexual abuse
time from physical health problems o Physical abuse
• Negative impact on motivation and compliance with o Emotional abuse
rehabilitation (e.g., Diabetes, medication, diet) o Etc
• Increases mortality from natural compliance
• SUICIDE in older age a major problem
STIGMA & DISCRIMNATION

• A stigma is a negative and often unfair social attitude attached

to a person or group, often placing shame on them for a
perceived deficiency or difference to their existence

• Many individuals with mental, neurological or substance use

disorders are perceived by the community as weak, inhuman,
dangerous or inferior because of their symptoms.
• As a result of stigma, these people are excluded or they
exclude themselves

• A father about his intellectually challenged daughter. “Girls

like her are only for house work, bringing her to your clinic is
a waste of my time”
• “I can’t come to see a doctor. If someone sees me I’ll never
get married”

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 INTRODUCTION TO PSYCHIATRIC NURISNG

HISTORY AND BENCHMARKS IN PSYCHIATRIC NURSING 4. Renaissance Period (1300 -1600)

• People with mental illness were distinguished from
1. ANCIENT TIMES to 800 BC: criminals in England.
• people believed that any sickness indicated displeasure of the • Mental illness - caused by demons. Witch hunts were
gods and in fact was punishment for sins and wrongdoings. common.
• Considered harmless - wander the countryside or live in
• TREPHINING - drill hole in the head to let evil spirits out rural areas.
of the body • Dangerous lunatics - imprisoned, chained and starved.

• 1547
o Hospital of St. Mary of Bethlehem was
declared hospital of the insane. (The 1st
mental asylum).
o Private hospitalization for the wealthy who
could pay

• Insane were treated like animals than humans because

• Depending on behavior mental disorder was viewed as being: they were thought to have no feelings and were believed
o Divine - worshipped and adored to lack understanding.
o Demonic – ostracized, punished or sometimes • Men and women were not given separate quarters.
burned at the stake. • Violent inmates were placed with those who are
convalescing or tranquil.
2. PERIODS OF INQUIRY 800BC to 1 CE
• Egypt and Greek Periods of inquiry. • Inhabitants were poorly clothed and fed, often chained
• Physical and mental health viewed as interrelated. and caged and deprive of heat and sunlight.
• Hippocrates argued abnormal behaviors were due to brain • Attendants taking care of the patients were also ill-
disturbances. treated, wages were less than the amount paid to
domestic workers and laundresses.
• Counselling, work, music was provided in temples by priest to • Mentally ill individuals were often placed in display for
relieve the distress of those with mental disorders amusements of caretaker and the public

• ARISTOTLE 5. Colonial period (1700 – 1790)

• Attempted to relate mental disorders to physical • 1751
disorders and developed his theory that the amounts of • BENJAMIN FRANKLIN established Pennsylvania
4 substances: blood, water, and yellow and black bile in Hospital (in Philadelphia) the 1st institution in United
the body controlled the emotions. States to receive with those with mental disorders
• 4 substances (or humors)- controlled for treatment and cure
o Calmness
o Happiness • 1752.
o Anger • A portion of this hospital was set apart for the
o Sadness. mentally ill, and the first patients were admitted in
• Imbalances of the 4 humors were believe to cause 1752.
mental disorders so treatment was aimed at restoring
balance through bloodletting, starving, and purging. • The beginning of mental diseases viewed as illness to be
treated.
3. Early Christian and Early Medieval times
(1-1000CE) • 1773
• Power of Christian church grew. • Eastern State Hospital was the first psychiatric
• St. Augustine pronounced all diseases ascribed to institution to be founded in the United States in
demons Wiliamsburg, Virginia.
• Priests performed exorcism to get rid of evil spirits and o custodial care provided by non-nursing
when they fail more brutal measures were used such as attendants
incarceration in dungeons, flogging and starving. o Florence Nightingale stressed the
significance of emotional support.

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6. 1790’s - Period of Enlightenment (Age of Reason) - 7. Nineteenth Century: The Evolution of the Psychiatric
BENCHMARK I Nurse
• 1817- Mclean Asylum in Massachusettes became the first
• Benjamin Rush institution to provide humane treatment to the mentally ill.
o Became the father of American psychiatry. • 1882 – first training school for nursing of the mentally ill was
o advocated for human treatment. established at Mclean Asylum
o In 1783 began treatment of mental disorders
with medical interventions • DOROTHEA DIX
• BECAME AN INSTRUMENTAL IN OPENING 32 STATE
• TRANQUILAZER CHAIR HOSPITALS IN U.S. THAT OFFERED ASYLUM TO
o The belief at the time was that "madness" was THE SUFFERING.
an arterial disease, an inflammation of the • SHE PROMOTED ADEQUATE SHELTER,
brain. The patient’s extremities are strapped NUTRITIOUS FOOD, AND WARM CLOTHING
down and reduces motor and pulse rates,
thought to have calming effect. • Mentally challenged forced to live in jails
• Dorothea dix fought to educate the general pubic of this
• Insane asylums created to house people with mental
• GYRATING CHAIR disorders
o a form of shock therapy consisting of a • Dix started a movement that would lead to modern
rotating, swinging platform onto which the advances in mental health care
person is strapped and moved at high
speed.Thought to increase cerebral • LINDA RICHARDS
circulation. • The first American psychiatric nurse
o It is used to calm people with mania. • Graduate of new England hospital for women
• Developed nursing care in state hospitals and also
directed a school of psychiatric asylum in 1880
• Her efforts resulted to the development of school for
nurses in more than 30 asylums
• CRIB – to restrain violent patients

8. 20TH CENTURY: THE ERA OF PSYCHIATRY (Period of Scientific

Study) – Benchmark II

• Exploration of the reasons for mental disease accelerated with

• PHILIPPE PINEL in France and WILLIAM TUKES of England
contributions from numerous theorist and researchers who
formulated the concept of asylum.
laid the foundation of understanding and demystifying mental
o ASYLUM MOVEMENT DEVELOPED
illness.
• In 1792 Pinel became the chief physician at the Bicêtre
• Treatment was provided in large mental hospitals(state or
Hospital.
private) usually located away from the well populated areas.
• Before his arrival, inmates were chained in cramped cell-like
• Length of stay was typically prolonged: few mechanisms for
rooms where there was poor ventilation, led by a man named
follow up care after discharge existed.
Jackson 'Brutis' Taylor.
• Clients commonly became institutionalized: they were not
• Jackson was then killed by the inmates leading to Pinel's
active participants in their health care and treatment.
leadership.
• Family members were not part of the treatment team.
• Pinel proved that releasing the insane from chains and
• FREUD
providing moral treatment (use of kindness, compassion and
o Emphasized the importance of early life
a pleasure environment) improved their prospect.
experience.
• Declared that these people are sick and a cure must be found.
o Development of psychoanalysis,psychosexual
o HUMAN DIGNITY UPHELD
theories and neurosis.
• WILLIAM TUKE
• HARRY STACK SULLIVAN (1892 – 1949)
o an English businessman, philanthropist was
o Postulated the hypothesis of interpersonal theory
instrumental in the development of more humane
and the development of multidisciplinary
methods in the custody and care of people with
approaches to psychiatric and milieu therapy
mental disorders.
o He surmised that anxiety could be reduced through
a meaningful interpersonal relationship that
• FRANZ MESMER
stresses the process of effective communication
o renewed the art of suggestive healing that stemmed
from the use of ancient trances which became the
basis of hypnosis

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 INTRODUCTION TO PSYCHIATRIC NURISNG

9. Period of Psychotropic Drugs – 10. 1960’s Community Mental Health - Benchmark IV

Benchmark III
• The Civil Rights movement of the 1960’s served as a catalyst for
• 1950s - development of psychotropic drugs(drugs used to treat mental focusing on the rights of the mentally ill.
illness. • The Community Mental Health Centers Act (1963) dramatically
• 1949 - Lithium - antimanic drug affected delivery of the mental health services.
• 1950 - Chlorpromazine (Thorazine )- antipsychotic • People have the right to be treated in their community
• 1952 - MAOIs
• 1958 - TCAs • DEINSTITUTIONALIZATION
• 1960 – Benzodiazepines o depopulating state mental hospitals and transferring
patients to community mental health centers that provides
• CHEMICALS COULD RESTORE CHEMICAL BALANCE – PEOPLE less restrictive treatment located closer to homes, families
WOULD NO LONGER NEED TO BE CONFINED and friends.
• DESTIGMATIZATION OF MENTAL ILLNESS OCCURRED
o  HOSPITAL STAY OF PATIENTS= 80%
• FIRST PSYCHIATRIC NURSING TEXTBOOK o  HOSPITAL ADMISSION= 90%
o “ Nursing Mental Diseases” o Patients with severe and persistent mental illness are
o Written by Harriet Bailey in 1920 admitted more frequently.
o REVOLVING DOOR EFFECT
• 1937 – psychiatric nursing became a part of the curriculum of general
nursing programs • Between 1955 -1980 population of mental health hospitals dropped
558,000 to 140,000.
• FIRST PSYCHIATRIC NURSING THEORIST • Funds from the states that were supposed to follow patients from the
o Hildegard Peplau hospitals into the community did not provide sheltered housing and
o developed a model for psychiatric nursing practice treatment.
o emphasize the interpersonal dimension of practice. • Poverty, homelessness, and criminalization resulted
o wrote a history of psychiatric nursing
• 1963
o Focus and funding for treatment shifted from large mental
DSM –Diagnostic and Statistical Manual of Mental Disorders hospitals to newly established community health centers
(Deinstitutionalization) that provided the following health
• Outlines the S/S required in order for clinicians to assign a specific services:
diagnosis to a patient
• Diagnostic Bible of Psychatry a. Emergency care:
• DSM 1 1952 = 105 DIAGNOSES • immediate assessment and initiation of appropriate
• DSM II 1968 = 185 DIAGNOSES treatment.
• DSM III 1980 = 265 DIAGNOSES
• DSM IIIR (Revised) 1987 = 292 DIAGNOSES b. 24-hour inpatient care:
• DSM IV 1994 = 361 DIAGNOSES • hospital based care for symptom stabilization (short
• DSM IV TR (Text Revision) 2000 = 361 DIAGNOSES term care)
• DSM 5 2013 = 376 DIAGNOSES
c. Partial hospitalization:
• treatment programs for individuals requiring daily support
DEINSTITUTIONALIZATION – LATE 1950S but not 24 hour hospital care; allowed clients to participate
in various therapies (group or individual therapy, social
• Many factors led to deinstitutionalization: skills training) for 6-8 hours/day.
• Journalistic exposes
• Introduction of chlorpromazine (Thorazine) which initiated the d. Outpatient care:
psychopharmacologic revolution • assessment, psychotherapeutic support and
• President Eisenhower’s major study of the care of the mentally ill management: clients seen for 1-2 hours/week.
population:
▪ Mental institutions were often viewed as inhuman e. Consultation and education:
“snake pits” factories for the manufacture of madness • outreach programs for community groups on mental
▪ Evidence of social and functional deterioration health topics( training for police on handling
following long-term care reinforced the notion that
institutions caused chronic disorder • 1980 – 1990:
o The high cost of health care and the need for cost
Life Magazine Expose – Bedlam 1946 containment became national issues, leading to the
establishment of managed care systems, which oversee
• Pennsylvania’s Byberry the relationship among payers, providers, and consumers
• Ohio’s Cleveland state of health care.
• “all of a sudden America sees these photos that look like concentration
camp photos. You see people huddled naked along walls, strapped to ❖ Types of managed care systems include:
benches… and it really is this descent into this shameful moment.” –
Robert Whitaker, author of “Mad in America” a. Health maintenance organizations (HMOs)
▪ offer a preset fee for clients in a particular
population in exchange for delivery of health
World War 2 care services during a given period of time.
b. Independent practice organizations
• Several new ideas emerged with military psychiatry: ▪ in which group of health care providers contract
o Proximity with HMO
▪ Treatment should occur as close as possible to
where symptoms were exhibited c. Preferred provider organizations (PPOs)
o Immediacy ▪ in which an HMO approves provider groups to
▪ Early identification and treatment lead to better provide services to its to its client population.
outcomes
o Simplicity
▪ The major part of intervention should consist of rest,
nourishment, and social support
o Expectancy
▪ Return to former functioning was possible

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 INTRODUCTION TO PSYCHIATRIC NURISNG

11. 1990’s Decade of the brain - Benchmark V NOTES:

• 50 million Americans are affected of brain disorders.

• medical advances and genetic research led to the profound
knowledge about the workings of the brain, reshaping our
understanding of the cause and treatment of mental illness.
- Ex.- neuroimaging
- Increase in brain research, increased interest in
biologic explanations for mental disorders.

• 21st Century: Neuroscience and Genetics

• more consumers use the Internet to learn about their health
concern

Managed care incorporated several new structures: (1990 – 2000)

a. Case management
• assigned case manager coordinates services for
individual clients and collaborate with a multidisciplinary
team.

b. Critical pathways and care maps

• serve as a clinical management tool to designate the
organization, sequence, and timing of interventions
provided by a treatment team for an identified client
disorder.

c. Population-based community care:

• focuses on primary preventive services and not just
illness-based care; includes identification of high-risk
groups and education for lifestyle changes to prevent
illness.

• Alternative settings were designed to provide treatment and

tertiary prevention in the least restrictive environment
including:
a. Mental Health Centers
b. Short-term inpatient psychiatric located in community
hospitals
c. Mobile crisis units and homeless shelters.
d. Prisons
e. Nursing homes

• Americans Disability Act (1990)

o helped ensure that people with disabilities,
including mental illness, can fully participate in the
economic and social mainstream of society.

• National Alliance of the Mentally Ill

o helped remove the stigma of mental illness and
provided local community support for mentally ill
people and families

12. 2000-2010- DECADE OF THE BEHAVIOR

• focus in improving health, safety and education

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 INTRODUCTION TO PSYCHIATRIC NURISNG

Chronicles of Philippine Psychiatry in Four Decades • 1935

o the City Sanitarium closed prompting all of its
1. The Pre-Spanish Era existing patients to be transferred to the
Psychopathic Hospital and exaggerating the
• Preceding the Spanish era, there was not much information already overfilled hospital wards. In response to the
available regarding the phenomenon of mental illness, more said predicament, additional pavilions were put up
so how it was managed. subsequently expanding its total bed capacity from
• All maladies psychiatric or otherwise were simply believed to an initial 400 to 1,600
be instigated by natural and supernatural occurrences.
• The Japanese occupation
o With the eruption of World War II in December
2. the Spanish Era (1521 – 1898) 1941, the progress of psychiatry in the country was
placed into a halt. Majority of the families of
• mental illness were attributed to religious factors and mentally ill patients felt compelled to bring them
supernatural forces. home despite the continued operation of the
o have offended or displeased dieties National Psychopathic Hospital.
o have incensed witches or mangkukulam who would
get back at them by casting wicked chants and 4. The Era of Liberation
incantations or pricking mystic dolls with a needle
and devilmen or manggagaway who would make • End of World War II, there was an extensive expansion and
them mentally ill by praying to the dark forces rehabilitation of the existing psychiatric facilities together with
the subsequent training of the workforce.
• Management - mentally ill individuals were brought to • 1945
o churches for purification and exorcism. o the University of the Philippines College of Medicine
o folk healers or herbolarios who would subject them started to teach psychiatry as a subject, then
to physical and psychological distress in an attempt conducted by a professor of anatomy and
to chase off their mental illness. neuroanatomy, Marciano Limson.
▪ wrap in a mat and subsequently • July 1946
flagellated with a dried tail of a stinger fish o the National Psychopathic Hospital was renamed
or a bamboo stick. National Mental Hospital (NMH)
▪ drink herbal and other plant potions while • 1946
hot pots were steadied at the top of their o the Victoriano Luna General Hospital established
heads. its own 100-bed neuropsychiatric unit. The
following year, the first ever prefrontal lobotomy
• Hospicio de San Jose, the first Roman Catholic social welfare was performed by Major Romeo Gustilo using his
institution in the country founded in 1782 which also operated own improvised leucotone on a violent
as a foster care agency to orphans, the abandoned, those with schizophrenic patient who failed to respond to
special needs, and the elderly. electroconvulsive therapy and other available
• Around 1810, upon the appeal of the Spanish naval treatments.
authorities for confinement of its mentally ill seafarers, the • 1947
institution started to take into its fold the mentally ill as well o University of Santo Tomas, the Section of
Neurology and Psychiatry was structured under the
Department of Medicine as headed by Leopoldo
Pardo
3. The American Regime (1898 – 1946)
• 1949
• when mental disability began to be recognized just as any o Toribio Joson of the National Mental Hospital and
other medical illness. Thus, an advocacy towards a more Manuel Arguelles founded the PMHA with the aim
humane approach towards the mentally ill was fostered. of promoting the mental health activities in the
country through the provision of clinical services
• November 1904 - the Insane Department of San Lazaro
Hospital (first ever hospital unit specifically dedicated for the and public education
mentally ill) was established. • 1972
• Dr. Elias Domingo = department head, the first Filipino o Philippine Psychiatric Association was formed with
psychiatrist (psychiatric training Pennsylvania, U.S.A.) Lourdes Ignacio as its founding president.

• 1910 • NOV. 12, 1986

o Philippine General Hospital was opened during o National Mental Hospital was given its present
which two American physicians, Almond T. Gough name National Center For Mental Health thru
and Samuel Tretze, began to teach psychiatry to Memorandum Circular no.48 of the office of the
the medical students president
o The National Center for Mental Health (NCMH)
(Filipino: Pambansang Sentro ng Pangkaisipang
• 1918
Kalusugan), is a 4200-bed psychiatric hospital
o another psychiatric institution, the City Sanitarium,
occupying 47 hectares of land in the city of
was established at San Juan del Monte.
Mandaluyong
• December 18, 1928
• April 27, 2017
o Insular Psychopathic Hospital, the first hospital
o passage of the Senate Bill 1354, otherwise known
exclusively dedicated for the treatment of patients
as the Philippine Mental Health Act of 2017 to
afflicted with mental and nervous disorders was
address at the national level the Filipinos’ mental
formally opened and inaugurated. It was called the
health needs and ensuring that the rights of such
Insular Psychopathic Hospital, a 64-hectare estate
individuals are protected and secured.

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 INTRODUCTION TO PSYCHIATRIC NURISNG

GENERAL PRINCIPLES OF MENTAL HEALTH NURSING 3. CONSISTENCY IS USED TO CONTRIBUTE TO PATIENT’S

SECURITY
• these principles are based on the concept that each individual
has an intrinsic worth, dignity, and has potentialities to grow • There should be a consistency in the attitude of staff, ward
• the following principles are general in nature and from routine and in defining the limitation placed on the patient
guidelines for emotional care of patients
4. REASSURANCE SHOULD BE GIVEN IN A SUBTLE AND
1. PATIENT IS ACCEPTED EXACTLY AS HE IS ACCEPTABLE MANNER

• acceptance conveys the feeling of being loved and cared • To give reassurance, the nurse needs to understand and
• acceptance means being non judgmental analyze the situation as to how it appears to the patient
• acceptance does not mean complete permissiveness but
setting of positive behaviors to convey to him the respect as 5. PATIENT BEHAVIOR IS CHANGED THROUGH EMOTIONAL
an individual human being EXPERIENCE AND NOT BY RATIONAL INTERPRETATION

acceptance is expressed in following ways: • Major focus in psychiatry is on feelings and not on the
intellectual aspects
a. being non-judgmental and non-punitive: • Advising or rationalizing with patients is not effective in
changing behavior
• the patient behavior is not judged as right or wrong or bad
• the patient is not punished for his undesirable behavior 6. UNNECESSARY INCREASE IN PATIENT’S ANXIETY SHOULD BE
• all direct and indirect methods of punishment must be avoided AVOIDED
• a nurse whose shows acceptance does not reject the patient
• The following approaches may increase the patient’s anxiety
even when he behaves contrary to her expectations
and should therefore avoided:
b. being sincerely interested in the patient: ✓ Showing nurse’s own anxiety
✓ Showing attentions to the patient’s deficits
• this can be demonstrated by: ✓ Making the patient to face repeated failures
• studying patient’s behavior ✓ Placing demands on patient which he cannot meet
• allowing him to make his own choices and decision as far as ✓ Direct contradiction on psychotic ideas
possible
7. OBJECTIVE OBSERVATION OF PATIENT TO UNDERSTAND HIS
• being aware of his likes and dislikes
BEHAVIOR
• being honest with him
• taking time and energy to listen what he is saying • It is the ability to evaluate exactly what the patient wants to
• avoiding sensitive subjects and issues say and not mix up one’s own feelings, opinion, or judgement
c. recognizing and reflecting on feeling which patient may express 8. MAINTAIN REALISTIC NURSE PATIENT RELATIONSHIP
• when the patient talks, it is not the content is important to note, • It focuses on the personal emotional needs of the patient and
but the feeling behind the conversation which has to be not on what the patient needs
recognized and reflected
9. AVOID PHYSICAL AND VERBAL FORCE AS MUCH AS
d. talking with a purpose POSSIBLE

• the nurse’s conversation with a patient must resolves around • All methods of punishment must be avoided
his needs, wants and interest
10. NURSING CARE IS CENTERED ON THE PATIENT AS A PERSON
e. listening AND NOT ON THE CONTROL OF SYMPTOMS
• the nurse should take time and energy to listen to what the • Analysis and study of the symptoms is necessary to reveal
patient is saying their meaning and their significance to the patient
• she must be a sympathetic listener and show genuine interest • Two patients showing the same symptoms may be expressing
two different needs
f. permitting patient to express strongly held feelings
11. ALL EXPLANATION OF THE PROCEDURE AND OTHER
• strong emotions bottled up are potentially explosive and ROUTINES ARE GIVEN ACCORDING TO THE PATIENT’S LEVEL OF
dangerous
UNDERSTANDING
• it is better to permit the patient to express his strong feelings
without disapproval or punishment • The extent of explanation that given to a patient depends on
this attention span, level of anxiety, and level of ability to
decide
2. USE SELF UNDERSTANDING AS A THERAPEUTIC TOOL
• It should never be withheld
• a psychiatric nurses should have a realistic self-concept and 12. MANY PROCEDURES ARE MODIFIED BUT BASIC PRINCIPLES
should be able to recognize one’s own feeling
REMAIN UNALTERED
• her ability to be aware and to accept her own strengths and
limitations should help her to see the strengths and limitation • In psychiatry many procedures are modified but the
in other people underlying nursing principles remain the same
In the Philippines, statistics are harder to come by because society still treats the Depression is a condition that knows no social class; it could strike
topic as taboo. Most suicides are placed under the category of death by “intentional
anyone regardless of intelligence, educational attainment and
self-harm.” A 2007 study from the Asia Pacific Journal of Public Health reported
that about 150 people die of suicide per month while 15 out of 900 teenagers would financial standing.” – Jeanne Goulbourn
attempt it. Since then, no further studies have revealed how the situation is being
resolved.

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 INTRODUCTION TO PSYCHIATRIC NURISNG

LEGAL ISSUES CRIMINAL DEFENSES

PSYCHIATRY AND THE LAW criminal defense

• Relationship between psychiatry and the law reflects a tension • is a strategic argument that attempts to challenge the validity and
between individual rights and social needs sufficiency of the prosecutions evidence.
• MENTAL HEALTH AND THE LEGAL SYSTEM • The prosecution is the party trying to prove the criminal charges
o GUIDED BY ETHICAL PRINCIPLES AND STATE against the defendant.
AND FEDERAL LAWS • For conviction, prosecutor must establish defendant committed act
beyond a reasonable doubt
ETHICAL PRINCIPLES APPLICABLE TO NURSING • Responsibility:
o People who argue they are not responsible for their
• Autonomy
actions because of some issue with their minds.
o is the client’s freedom to make choices in his life.
• Justification/excuse:
• Beneficence
o People who have no issues mentally, but who have a
o means acting in ways that benefit the client
reason why they did what they did.
• Non-maleficence
o means acting in a manner to avoid causing harm to Insanity defense
a client (A nurse questions the meds being too
extreme for patient) • also known as the mental disorder defense, is an
• Veracity affirmative defense by excuse in a criminal case, arguing that the
o is the practice of telling the truth defendant is not responsible for his or her actions due to an
• Confidentiality episodic or persistent psychiatric disease at the time of the criminal
o nondisclosure of information with which one is act.
entrusted • A defendant cannot stand trial
• Justice o in a criminal case because a mental disease prevents
o acting in a fair, equitable and appropriate manner them from effectively assisting counsel
Obligation to be fair; equal treatment to all patients o from a civil finding in trusts and estates where a will is
• Fidelity nullified because it was made when a mental disorder
o faithfulness and the practice of keeping promises prevented a testator from recognizing the natural objects
of their bounty,
ETHICAL CONSIDERATION FOR PSYCHIATRIC NURSES • Defendant must show insanity at trial by offering expert testimony
to the fact. In some states, when found not-guilty by reason of
• ETHICAL DILEMMAS insanity, defendant is committed to a mental institution until it is
• WHAT IS THE RIGHT THING TO DO? confirmed that defendant no longer poses a danger to society.
• WHEN IS APPROPRIATE FOR SOCIETY TO REGULATE • Civil commitment hearings are often conducted to determine
PERSONAL BEHAVIOR? defendant’s danger to society
• SENSITIVITY TO PATIENT’S RIGHTS AND NEEDS
• Temporary insanity argues that a defendant was insane during
• Nurses are constantly faced with the challenge of making the commission of a crime, but they later regained their sanity after
difficult decisions regarding good and evil or life and death. the criminal act was carried out. This legal defense is commonly
• Legislation determines what is “right” or “good” within a used to defend individuals that have committed crimes of passion.
society. • The defense was first successfully used by U.S
Congressman Daniel Sickles of New York in 1859 after he had
SOURCES OF LAW killed (gunned down in broad daylight) his wife's lover, Philip Barton
Key a U.S. Attorney.
• the origins of law, i.e. the binding rules governing human conduct.
• any premise of a legal reasoning such sources may be
• DANIEL SICKLES
international, national, regional or religious.
o Demographic representatives from New York, 1857 –
1861 and 1893 – 1895
• Legislature
o First person to successfully use the temporary insanity
o passed by Congress (Constitution) ex.:Nurse
defense in the USE
practice act
o Only one of the 52 generals in Gettysburg to not receive
a statue
• Executive
o passed by administrative agencies
• The Insanity Defense
o Ex. BON – licensure exam (practice)
o If D can show he was insane at the time he committed a
criminal act, he may be entitled to the verdict “not guilty
• Judiciary by reason of insanity.”
o COMMON LAW- court cases
o If D succeeds with the insanity defense, he does not walk
o derived from decisions made in previous cases out of the courtroom free. In virtually every state, any D
o for reviewing legal disputes who succeeds with the insanity defense will be
involuntarily committed to a mental institution.

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 INTRODUCTION TO PSYCHIATRIC NURISNG

M’NAGHTEN TEST NOTES:

• The M'Naghten Rule (or test) focuses on whether a criminal

defendant knew the nature of the crime or understood right from
wrong at the time it was committed.
• defendant is NOT GUILTY if, because of a defect of reason due to
a mental disease, the defendant did not know either the nature or
quality of the act or the wrongfulness of the act

• M'Naghten Rule
o A defence to criminal law liability developed in England;
if, at the time of the offence, the accused had a disease
of the mind such that he was unable to know that his act
was wrong.

• Daniel M'Naghten (extreme paranoia) attempted to kill the Prime

Minister, Sir Robert Peel, but instead shot and killed Edward
Drummond, the Prime Minister's Secretary

INSANITY DEFENSE: TEST / EXAMPLE

The M'Naghten Rule -The client (with mental disorder)

• strangles his wife believing he was squeezing a lemon

• Shots a cop believing he is a russian spy.

• The insanity defense can be heartbreaking, difficult to prove or

disprove.
• EXAMPLE: Naperville mother Marilyn Lemak murdered her three
children, pled insanity.

• Lashuan Harris threw her 3 kids (6, 2, 16 mos.) into SF bay in

2005.
• Paranoid schizophrenic; laughing, talking to herself, rocking,
smiling to self, etc.
• Thought God told her to do it; felt they were in heaven.

• Jeffrey Dahmer also known as the Milwaukee Cannibal or the

Milwaukee Monster, was an American serial killer and sex offender
who committed the rape, murder, and dismemberment of 17 men
and boys from 1978 to 1991.
• He killed and ate parts of victims, kept bodies, parts as trophies.

• John Wayne Gacy THE KILLER CLOWN (March 17, 1942 – May
10, 1994) was an American serial killer who raped, tortured and
murdered at least 33 teenage boys and young men between 1972
and 1978 in Cook County, Illinois (a part of metropolitan Chicago).

INSANITY DEFENSE IN PHILIPPINE LAW

• Article 12 of the Revised Penal Code exempts an insane person

from criminal liability, except if the person "acted during a lucid
interval.“

• 2011-Supreme Court acquitted S. Verdadero for the crime of

homicide.
• On March 12, 2009, at around 3:00 o'clock in the afternoon,
Maynard Plata (Maynard) and his father Rom were at the Baggao
Police Station. Together with R.Elaydo they went there to report
that Verdadero had stolen the fan belt of their irrigation pump.7
• After a confrontation with Verdadero at the police station, the three
men made their way home on a tricycle but stopped at a drugstore
as Maynard intended to buy some baby supplies. Rom proceeded
towards a store near the drugstore while R.Elaydo stayed inside
the tricycle. From the drug store, Maynard saw Verdadero stabbing
Rom, after he was alerted by the shouts of R.Elaydo

• The SC ruled that there was enough evidence to prove Verdadero

was having a relapse of schizophrenia when he stabbed to death a
man who had reported him to the police for stealing the fan belt of
their irrigation pump.

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 INTRODUCTION TO PSYCHIATRIC NURISNG

2 KINDS OF UNLAWFUL ACTS 1. UNINTENTIONAL TORT

a. NEGLIGENCE
1. Criminal Law • failure to do or not to do what a reasonably careful person
• provides protection from conduct deemed injurious to the public would do under the circumstances.
welfare. It provides for punishment of those who have found to be
engaged in such conduct, which commonly includes imprisonment, • 4 elements that must be present for a plaintiff to recover
parole conditions, loss of privilege (such as license), a fine or any damages
combination of these. 1. Duty to care
• Ex. Theft of a hospital employee of supplies or drugs. • A legal obligation of care, performance, or observance
imposed on a person who is in a position to safeguard
2. Civil Law the rights of others.
• protects the private and property rights of individuals and o Nurse and patient relationship
businesses o Physician and patient relationship
• torts
• contract 2. An obligation or reasonable care (i.e. standard of care)
• In patient care nurses use the standard of care (SKA)
A. Contracts
▪ Is legally binding exchange of promises or agreement 3. Breech of duty
between parties that the law will enforced • A duty of care is breached when someone is injured
because of the action (or in some cases, the lack of
▪ Elements of contract action) of another person when it was reasonably
✓ Agreement should state; what each must or must not do foreseeable that the action could cause injury, and a
✓ Mutual understanding of the terms reasonable person in the same position would not have
✓ Payment or consideration given for actions taken or not taken acted that way.

4. Injury proximately caused by a breach of duty

B. Torts
• relation that holds between two temporary simultaneous
▪ A violation of civil law in which an individual has been wronged.
or successive events when the first event (the cause)
▪ One party asserts the wrongful conduct on the part of the other has
brings about the other (the effect).
caused harm and seeks compensation for harm suffered.
• is an event sufficiently related to an injury that the courts
deem the event to be the cause of that injury.
▪ Unintentional = negligent
• The act of omission/commission harm/injury
▪ Intentional, Quasi-intentional = willfully committed without just
cause
▪ Is a legal wrong committed against a person, his or her rights or • Proximate cause relates to concepts such as the predictability or
property remoteness of an event
o i.e. suppose a physician prescribes a patient a
medication, which is consumed later at home by the
▪ Can be any of the following:
✓ Denial of person’s legal right patient’s child, who dies as a result.
o A court may find that prescribing the medication was the
✓ Failure to comply with a public duty
cause in fact, but not the proximate cause, of the child’s
✓ Failure to perform a private duty that results in harm to another
death
• Legal cause exists only when both cause in fact and proximate
cause have been proven

Negligence cases

• Giving drugs to the wrong patient

• Wrong medicine, wrong route, wrong concentration wrong dosage
• Using defective equipment
• Omission or failure to report or record his nursing observations in
the nurse’s chart
• Errors in executing a physician’s order

b. MALPRACTICE
• occurs when a nurse fails to competently perform his or her
medical duties and that failure harms the patient.

• Examples:
o Medication error
o Failure to get informed consent
o Failure to follow physician’s orders.
o Delaying patient care/or failure to monitor a patient

• CONTRIBUTING FACTORS:
1. Nurse who works excessively long shift may suffer from
fatigue, making them more prone to commit an error.
2. Hospitals/facilities may hire inadequately trained nurses.
The less training a nurse has, the greater the risk of
medical error.

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 INTRODUCTION TO PSYCHIATRIC NURISNG

2. INTENTIONAL TORT 3. QUASI-INTENTIONAL TORT

• are wrongful acts done on purpose. The person does not need • wrongful act based on speech committed by a person or entity
to actually mean harm, but the other person ends up hurt against another person or entity that causes economic harm or
anyway damage to reputation – defamation of character, invasion of privacy
A. Assault a. defamation of character
• is an act that results in a person’s genuine fear and • sharing of information that is detrimental to the patient’s reputation.
apprehension that he/she will be touched without consent. Communication that is malicious and false.
• Deliberate threat coupled with the apparent ability to do I. Slander – oral defamation
physical harm a. A nurse spreads a rumor that a patient is a
• No actual contact is necessary compulsive gambler
b. A nurse who comments to her coworkers that her
• Examples: patient with sexually transmitted disease has been
o Verbally threatening a patient to force him sexually active in the community
o to take his medications against his will c. A nurse tells a co-worker that she believes the
o Threatening to slap an elderly patient has been unfaithful to her spouse
o patient who refuses to clean up after herself
o Threatening to place a nasogastric tube in a client II. Libel – made in writing
who is refusing to eat. a. A nurse circulates a petition among her coworkers
in an attempt to remove her coworker from her unit
B. Battery who has engaged in inappropriate behavior with a
• unconsented intentional touching of another person that patient.
causes injury
• Example: b. invasion of privacy / breech of confidentiality
o Force used in unlawful detention of a patient • charge made for revealing aspects about a client’s case or for
o Nurse physical attacks a patient who complains that revealing that he has been hospitalized which resulted to harm to
she is not being cared for properly the patient.
o Administering an injection against her wishes
• Example:
C. False imprisonment o A nurse releases the medical diagnosis of a patient to
• unlawful restraint or confinement of an individual against his members of the press
wishes and outside an emergency situation.
Duty to Warn
• Example
o Excessive force used to restrain a patient
• Healthcare providers’ responsibility to disclose information
o Preventing a patient from leaving a health care
about a patient who is potentially violent or dangerous
facility
• Duty to warn a third party is an exception to client
o Wrongfully committing a patient in a psychiatric
confidentiality
facility
• Clinicians must warn identifiable third parties of threats made
o Locking an individual in a room
by a client
o Taking his/her clothes for the purpose of
o Is client dangerous to others?
detainment
o Is the danger the result of serious mental illness?
o Is the danger serious?
D. Invasion of privacy
o Are the means to carry out the threat available?
• a lawsuit against an individual who unlawfully intrudes into his
o Is the danger targeted at identifiable victims?
or her private affairs, discloses his or her private information,
o Is the victim accessible?
publicizes him or her in a false light, or appropriates his or her
name for personal gain.
• Example:
o A charge that may result when a client is searched
without a probable cause. Conducting body
searches in mentally ill patients as a routine
intervention should have a physician’s orders and
written rationale showing probable cause of the
intervention.
o Recording an interview with a patient without his
knowledge

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 INTRODUCTION TO PSYCHIATRIC NURISNG

TYPES OF HOSPITAL ADMISSION\ CONSERVATORSHIP

A. Voluntary • A court case where a judge appoints a responsible person or

o the client willingly enters and consent to treatment organization (called the “conservator”) to care for -
o too young to be autonomous ( child) / another adult (called
o Characteristics of voluntary hospital admission the “conservatee”)
o mentally or physically incapacitated and unable on their own
• Written direct application of the patient
to make proper legal, medical, and financial decisions.
• Justification: patient voluntarily seeks help
• Sign consent to treatment • Conservatorships
• Evaluation takes 48-72 hours o are designed to assist with financial needs.
• Civil rights are fully retained by the patient
• (Right to vote, hold a driver ‘s license, buy and sell • Guardianships
property, o are designed to assist with personal and health-related
• hold office, practice a profession, engage in a business). o gives an individual the authority to decide on matters relating
• Discharge is initiated by the patient to the physical and mental well-being of a person
• Assessment shows client may be harmful to self or
o duties include:
others- admission status may be changed to involuntary
▪ deciding where the person will live
▪ caring for clothing, furniture, vehicles, etc
B. Involuntary
▪ consenting or withholding consent to medical
• the client is institutionalized against his will care
▪ providing care, comfort and overall well-being for
• Characteristics of involuntary hospital admission the individual
• State laws define which persons can be committed and
generally include those who pose a threat in self and
others LEGAL RESPONSIBILITIES OF PSYCHIATRIC NURSES
• Admission did not originate with patient
• Report pertinent information to co-workers
o Evaluation/emergency care form filled out by
• Keep accurate records.
the police or others
• Maintain confidentiality
o Assessment – 48 to 72 hours
• Aware of the current knowledge of law
o Extended care (long term) – 3,6,12 months
• Respect rights of individual
• Obtain informed consent
• Discharge is initiated by the hospital or court • Vigilant and watchful
• Patient loses only the right to freedom; all other rights are
intact • DO’S
• Document all unusual incidences
• Reasons for admission • Report all unusual incidences
• In an emergency situation (client may be dangerous to • Follow policies and procedures of the institution
self or others) • Keep current year license to practice
• For observation and treatment of mentally ill persons. • Perform procedures that you have been taught (within the
• When there is risk of harm through self-neglect, grave
standard of practice)
• Protect patients from injuring themselves
disability or failure to meet basic needs.
• DON’TS
• Remove side rails on patients bed, unless there is an order or
LENGHTS OF HOSPITAL STAY hospital policy to do so.
• Allow patients to leave the hospital or nursing home unless there
1. Emergency is an order to signed release.
a. to control an immediate threat to self or others. • Accept money or gifts from patients
• Give advice contrary to doctors orders or NCP
2. Short term or Observational • Witness a patient’s will
a. to diagnose and for short term therapy. • Take medications that belong to patients.

3. Long term
a. for an indefinite time or until the patient is ready for COMMON AREAS OF LIABILITY IN PSYCHIATRI SERVICES
discharge. Periodic reviews may be made every
3,6, or 12 months • Sexual contact with a patient
• Preventing patient suicide
• Medication errors
• Problems related to ECT
o Electroconvulsive therapy (ECT) is a procedure used to treat
certain psychiatric conditions.
o It involves passing a carefully controlled electric current
through the brain, which affects the brain's activity and aims
to relieve severe depressive and psychotic symptoms.

• Breach of confidentiality
• Failure to refer a patient
• Failure to obtain informed consent
• Failure to report abuse

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 INTRODUCTION TO PSYCHIATRIC NURISNG

Senate Bill No 1354 or the Mental Health Act of 2017 ADVANCE DIRECTIVES

• To enhance the Delivery of Integrated Mental Health Services, • Are legal documents that tell others what your treatment
promoting and protecting Persons utilizing Psychiatric, preferences are
Neurologic and Psychosocial Health Services, appropriating • They are directions for others to follow, made in advance of
Funds therefor and for other purposes. an illness or injury
• Generally state law governs their use

RIGHTS FOR THE MENTALLY ILL • Advance directive can exist in both the physical health and
mental health context
• Right to be treated with dignity and respect
• The majority of states with advance directives statuses
• Right to communicate with persons outside the hospital
expressly or by implication apply to mental health
• Right to keep clothing and personal effects with them.
• Some states have passed specific psychiatry advance
directive laws
• Right to religious freedom
• Right to be employed
• Right to manage property
• Right to execute wills TYPES OF ADVANCE DIRECTIVE

• Right to enter into contractual agreements A. HEALTH CARE PROXY DIRECTIVE / POWER OF ATTORNEY
• Right to make purchases • Allows you to choose who will make decisions on your behalf
if you become
• Right to education
• Agent driven (power of attorney)
o Gives another individual the power to make
• Right to habeas corpus(written request for the release from
decisions for you when you are deemed incapable
the hospital)
of making decisions for your self
• Right to an independent psychiatric examination
▪ i.e. who you would want to make
decisions for you
• Right to civil service status, including the right to vote
▪ also called a surrogate decision maker or
• Right to retain licenses, privileges or permits proxy

• Right to sue or to be sued B. INSTRUCTION DIRECTIVE (“LIVING WILL”)

• Right to marry or divorce • Provides specific instructions for how your representative
should make decisions
• Right to treatment in the least restrictive setting • Instructional
• Right not to be subject to unnecessary restraints o Refers to a person’s treatment wishes
▪ i.e. what you want in the way of treatment
• Right to privacy and confidentiality or services and also what you don’t want
• Right to informed consent ▪ also know as living will

• Right to treatment and refuse treatment

• Right to refuse participation in experimental treatments or
research WHO CAN I APPOINT AS MY HEALTH REPRESENTATIVE?

• Spouse / domestic partner

PATIENTS RIGHTS • Family member (adult only)
• Friends
• Right to treatment in the least restrictive setting • Religious / spiritual advisor
• Maintain the greatest amount of personal freedom, autonomy, • Any adult EXCEPT your physician, employees / administrator
dignity, and integrity in determining treatment of a healthcare institution where you are a patient / resident
• Restrictions includes the nature of the choices being restricted unless they are related to you
and the method by which choices are restricted

MENTAL ILLNESS

• A mental health condition that has a negative effect on the

way an individual:
o Think
o Feels
o Behaves

MENTAL HEALTH MATTERS!

YOU ARE NOT ALONE!

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