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Mental health nursing, also called psychiatric nursing, is among the newest of the recognized fields within the nursing profession. While cases of "possession" and "witchcraft" date back from the beginning of written record, cases of nurses caring for the mentally ill only date back a few centuries. Even then, psychiatric-mental health nursing only began to become the legitimized profession that it is today in the 1800s. This paper explores the history of mental health nursing with specific emphasis on the post-Florence Nightingale era. This paper will also delve into what it means to be a psychiatric-mental health nurse today and the impact that different cultures can have on the view of mental health to medical professionals.
History of Mental Health Nursing
Mental health nursing focuses on those patients who have mental distresses. Patients come from all ages and economic backgrounds. Psychiatric nursing is a specialty that has changed throughout history and has drastically changed through time. Mental health nursing originally dates back to the 8th Century. In 13th century Europe, psychiatric hospitals were used to house the insane, but were not run by psychiatric nurses (Neugebauer, 1979). Compassionate care for the mentally ill was seldom given. These psychiatric hospitals were used simply as living quarters. During the climax of Christianity in Europe, hospitals suggested religious interventions. The patients were partnered with "soul friends" to help patients adjust to exist within society. Soul friends are considered the first modern psychiatric nurses (Neugebauer, 1979).
In the early United States, witchcraft and devil possession were considered an explanation for mental illness, which resulted in hangings or burnings at the stake. In the 1700s, people with mental illnesses were considered dangerous and kept in cages or jailed. These people were pronounced as lunatics possessed by the devil. Many times, relatives would hide their "insane" family member or hire someone to care for them. Some mentally ill were sold into slavery, while others were forced out of their communities (Leupo, 2009).
In 1752, the first "lunatic ward" opened its doors at the Pennsylvania Hospital in Philadelphia. The treatment of mentally ill patients was comparable to the other patients of the hospital with clean rooms and fresh air. The modern medicine at the time included ice baths until patients lost consciousness or shocks to the brain. Purging the afflicted meant driving out crisis from the patient. Bleeding was also an infamous form of treatment for patients. Bad blood was drained from the patient, which usually ended up in death (Leupo, 2009).
Dorothea Dix was a major contributor in reforming the treatment of the mentally ill. In 1841, she first visited prisons and was shocked to see the horrid conditions in which prisoners lived. She was also horrified to see mentally ill living amongst the felons (Hurd, Drewry, Dewey, Pilgram, Blumer, & Burgess, 1916). Dix traveled to different states gathering information regarding the treatment of prisoners and reported back to the state's government to request improvements in their conditions. Many psychiatric hospitals were built due to Dix's efforts. Dix also insisted on a humane setting for the incurable and therapy for those deemed curable (Hurd et al., 1916). However, there was still a resistance in training women to help care for mentally ill patients.
After the Civil War, many soldiers who fought experienced mental traumas. These soldiers were placed into mental hospitals for treatment. No new treatments had yet been discovered so shock therapy treatments were still used. More hospitals were needed to treat these chronically ill patients. Unfortunately, treatment and care began to deteriorate. The over abundance of patients stretched the care to pitiful conditions once again. Soon, mental hospitals began opening across the country. By the mid 1800s, there were over 20 hospitals available for treating the mentally ill (Hurd et al., 1916).
Psychiatric nursing wasn't official in the United States until 1878, with the opening of Boston College. Boston College was the first outside source to formally train nurses in psychiatric care in the United States (Doona, 2007). McLean Hospital, founded in 1811 in Massachusetts, was originally an insane asylum. In 1880, McLean became home to the first hospital-housed training school for mental health nurses (Hurd et al., 1916). Prior to 1913, psychiatric nursing was not a required course by nursing standards and was mainly taught in nursing programs based in psychiatric hospitals. Gradually, psychiatric education infiltrated all nursing curriculum until it was required for all nursing programs.
Formal psychiatric nursing care became recognized with the publication of Handbook for Attendants of the Insane in 1885 (Hurd et al., 1916). Kindness and compassion were the most important aspects of patient care. During the 1900s, caregivers were known as attendants of the insane before they became accepted as nurses because of their training and experience. According to Peter Nolan (1993), the role of the attendant varied from institute to institute and was not clearly defined. Attitudes towards patients had changed but there was still little knowledge of causes of mental illness and how to treat it.
In the 1930s, The Mental Treatment Act allowed patients to sign themselves into psychiatric facilities voluntarily with the understanding that after treatment, a patient would be well enough to be released. Patients had the choice for treatment or against it. A physician would be involved to help treat the patient as well as any other psychiatric personnel to take any stigma off of psychiatric facility.
America's first trained nurse, Linda Richards, is often viewed as the first noted psychiatric nurse. In 1899, Richards began training schools in several different hospitals for mental health nurses (Richards, 1915). During this time, there were already many nurses working in mental health hospitals, but Richards felt that their training was not on par with the training nurses received in regular hospitals (Richards, 1915). She began to educate both nurses and doctors on the value of psychological nursing (Richards, 1915). Her work paved the way for future mental health nurse Hildegard Peplau and all of the psychiatric nurses of today.
Around the year 1900, theories on mental health began to abound. Sigmund Freud transformed public opinion on mental health by taking a new view on personality (Varcarolis, Carson, & Shoemaker, 2006). His overriding theory was that mental disorders arose in people who had unresolved issues regarding their childhood (Varcarolis et al., 2006). American psychologist Harry Stack Sullivan theorized that human behavior is based on the desire to get one's needs met through interaction with others and to avoid discomfort (Varcarolis et al., 2006). This theory would later inform Hildegard Peplau's interpersonal relationship theory and approach to nursing (Varcarolis et al., 2006). With the development of such a vast number of different psychological theories came a growing public interest in the field of mental health and a much more apparent need for mental health professionals.
On July 3, 1946, President Harry Truman signed the National Mental Health Act into law (Grob, 1994). This act came on the heels of years of the United States government not playing a major role in the field of mental health and the startling realization that up to half of hospital beds were taken up by patients with psychiatric illnesses (Grob, 1994). The goals of the National Mental Health Act were to subsidize research into psychiatric illness, to help states set up clinics and treatment centers, and to train more qualified mental health professionals (Grob, 1994). This acknowledgement by the federal government of a legitimized nursing organization to deal only with the mentally ill began to cement mental health nursing as the profession it is today.
In 1963, President John F. Kennedy began the "deinstitutionalization" of mental health care with the passage of the Community Mental Health Act (Grob, 1994). This act was designed to take mental health patients out of psychiatric hospitals by providing funding for community-based mental health centers (Grob, 1994). This led to fewer restrictions for mental health nurses in the places in which they could be employed (Grob, 1994). However, the standards of care, which were already very ill-defined at this time, began to lapse in the face of patients being taken from the hospitals and put into community settings (Grob, 1994).
In the 1970s, the American Nurses Association began to develop standards of care that would be used by all mental health nursing professionals. These standards were precursors to the ones which are in place today. The standards provide for safe and effective care for all patients within the care of mental health nurses. In 1973, the American Nurses Association officially established a certification program in mental health nursing so that nurses could receive specialized training in the practices and standards of care of psychiatric nursing (Grob, 1994).
The field of psychiatric nursing was influenced most by the work of Hildegard Peplau. Using the philosophy of psychologist Harry Stack Sullivan, Peplau fought to promote her belief that the interpersonal nurse-client relationship should be the basis of psychiatric nursing practice (Callaway, 2002). Peplau is considered the mother of current psychiatric nursing because her interpersonal relationship philosophy was considered revolutionary at the time and is still used as the basis for current practice (Callaway, 2002). Like Florence Nightingale, Peplau understood that environment was important and believed that psychological disorders would respond to a "giving, supportive, caring, and thoughtful environment." (Callaway, 2002, p. 445). Though she passed away on March 17, 1999, Peplau's theories continue to overwhelmingly guide the practice of mental health nurses today.
It is important to understand how other cultures view mental health because we live in a society made up of many different cultures. Merriam-Webster's Medical Dictionary (2006) defines culture as the customary beliefs, social forms, and material traits of a racial, religious, or social group. An individual might find identity across multiple cultures. In order to understand and diagnose a patient with a mental disorder a clinician should be aware of the cultural background of the patient (Corey, Corey, & Callahan, 1993). Cultures, for example, could include gang behaviors, the culture of physicians or medical practitioners, or the culture of religious factions. The cultural background of an individual influences not only the cause and development of the disease, but also plays a role in the definition and socio-cultural meaning of the illness. (Hwang , Myers, Abe-Kim, & Ting, 2008)
Somatization, or the degree to which people express their distress through physical symptoms, can vary across cultural groups, affect different parts of the body, and carry different social meanings (Chun, Enomoto, & Sue, 1996). For example, in Asian cultures, research suggests that somatic expression of distress is very common; whereas in western cultures, there is a greater emphasis on talking about problems and expressing oneself verbally and emotionally (Chun et al., 1996). These differences influence the diagnostic accuracy of the mental health professional. Accurate clinical diagnoses are essential for providing appropriate services to the individual. Practitioners should be aware of the cultural background of the patient to determine if the symptoms expressed are normal to the patient's culture (Hwang, Lin, Cheung, & Wood, 2006).
The stigma associated with mental illness is a factor that needs to be addressed as well. Stigma towards mental health is a worldwide phenomenon that operates by motivating the general public to reject, avoid, fear, and discriminate against those with mental illness (Corrigan, 2004). Coupled with this, there is a general mistrust in the mental health care system for fear of being mistreated, misdiagnosed and discriminated by the providers and the system (Smedley, Smith, & Nelson, 2003).
The American Psychological Association (APA) published "Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists" (American Psychological Association, 2003). These guidelines reinforce the idea that culture and diversity should be taken into account when treating diverse clients (Hwang et al., 2008). Better integration of indigenous and alternative health care services (e.g., herbal medicine, prayer, and Traditional Chinese Medicine) may help facilitate the patient's therapy because it establishes a cultural bridge that links the patient's cultural beliefs to the treatment (Hwang et al., 2008). Mental Health Professionals need to be given training to internalize and conceptualize the skills that makes them culturally competent. Adaptation of treatments is especially important since the concept of therapy and the rationale behind therapeutic treatment may be culturally unfamiliar or foreign to those who have little exposure or experience with mental illness, and to cultures where mental illness can be especially stigmatizing (Hwang et al., 2006).
Since the early 1900s, mental health nursing has progressed. Mental illness is thought of as a continuum because any dividing line is based on how long symptoms last as well as how they affect a patient's life (Doebbeling, 2007). Today, there are many more issues in the psychiatric nursing field with regards to events in society such as September 11th and Post Traumatic Stress Disorder since troops are coming back from war. Although tremendous advances have been made in the understanding and treatment of mental illnesses, the stigma surrounding them persists (Doebbeling, 2007). For example, people with mental illness may be blamed for their illness or viewed as lazy or irresponsible (Doebbeling, 2007). In recent decades there has been a push to bring mentally ill people out of institutions which has been made possible by the development of effective drugs, along with some change in attitude about the mentally ill (Doebbeling, 2007).
With the deinstitutionalization movement, greater emphasis has been placed on viewing mentally ill people as members of families and communities (Doebbeling, 2007). Today, family members and doctors use techniques to help improve the life of a chronically ill patient without simply putting him or her into an institution (Doebbeling, 2007). The goal is to keep these people on a treatment plan that involves group therapy (Doebbeling, 2007). Support and self-help groups have been researched and are starting to be used more frequently to help with the mentally ill. The National Alliance for the Mentally Ill is one of these groups which provide support for not only the patient, but the family members as well (Doebbeling, 2007). Many people who have a mental illness are not being put into institutions and hospitals in order to keep costs down as well as provide better treatment for the person. However, a stigma still exists today surrounding mental illness that causes people to turn away and want nothing to do with someone who is affected by a mental illness.
Psychiatric-mental health nurses (PMHNs) deliver nursing care to people with mental disorders (Melville, 2008). Along with the regular duties of a registered nurse, a PMHN works closely with the family to ensure that the patient is getting the right care (Melville, 2008). There are two different types of PMHNs; basic and advanced. In order to become a basic PMHN you must go to high school then become a Registered Nurse through a Bachelor's Degree program, a Hospital Diploma, or an Associate Degree program. The salary of a basic PMHN can vary depending on location to be about thirty to forty thousand dollars a year. To become an advanced PMHN, the nurse needs to further his or her education by getting a Master's Degree or a Doctorate. The annual salary for an advanced practice registered nurse is about sixty thousand dollars. There are many different specialties within mental health nursing such as child, adult, geriatric, substance abuse and forensic mental health nursing. These nurses need to be very caring, compassionate, and understanding when working with these types of patients because of the types of illnesses they have.
Like most different practices of nursing, PMHNs have a journal: The Journal of the American Psychiatric Nurses Association. This journal helps nurses to promote psychiatric nursing as well as improve health care for the mentally ill. Nurses can join the association as well as subscribe to the journal in order to stay current on all the latest details on Mental Health Nursing.
Since the time of Florence Nightingale, much has changed about mental health nursing. Psychiatric nursing is considered a legitimate profession, a change that was just beginning to happen in the time of Nightingale. Hildegard Peplau promoted Nightingale's theories as they pertained to the mentally ill and showed that environment could have a vast influence in the success of psychiatric treatment. With the correct education, training, and certification, and thanks to the mental health nurses who have come before, any nurse today may train to become a psychiatric nursing professional. Through the stigma and the trying times throughout history, mental health nurses have cemented themselves as a profession within nursing which deserves both recognition and respect.