Psychiatric-Mental Health Nursing

Meriwhen, ASN, BSN, MSN, RN

Overview

Psychiatric nursing, also known as Mental-Health nursing, is the provision of nursing care to patients with mental illnesses. Mental illness is a wide range of medical conditions that affect mood, thinking, and behavior. These conditions often result in a detrimental effect on a person's daily functioning.

Examples of Mental Illnesses (not all-inclusive)

The schizophrenias
Depression
Anxiety disorders
Bipolar disorder
Substance dependence and other addictions
Post-traumatic stress disorders
Personality disorders

The Stigma

Unfortunately, mental illness is still stigmatized in society, with illnesses and those suffering from them often seen in a negative light. Patients are viewed in terms of stereotypes: the maniac, the neurotic, the sad one. Or patients are viewed in terms of their illness: the borderline, the bipolar, the schizo. Terms such as "crazy", "cuckoo" and "lunatic" are readily used to describe psych patients. If someone shares that they are on a psychotropic medication, others question if they are truly stable, or they see the person in terms of liability. These patients are seen as being untreatable and incurable, destined to be dependent on hospitalization and/or medications forever.

In addition, mental illnesses often do not display physical signs or symptoms, and so some may discount mental illness as not being significant. Patients who try to reach out for help are brushed off with, "it's all in your head; suck it up and get over it" or other useless tidbits of advice.

The stigma crosses over to psychiatric nursing as well. Psychiatric nurses are not seen as the life-savers that nurses in other specialties may be viewed as. Instead, psych nurses are seen as pill pushers who are quick to restrain a patient or give an injection for any real or imagined infraction. They may be seen as being "as crazy as their patients are." Psych nursing is seen as the specialty for nurses who couldn't hack it in other specialties. Or it's the specialty for nurses who want to "take it easy", yet psychiatric nursing is seen as being very violent. And of course, the rumor is that once you're in psychiatric nursing, you will lose all of your nursing skills and be stuck there forever.

Inaccurate Portrayals

It does not help that the media tends to portray psych and its patients in a negative (and often not quite accurate) light. The term "psych nurse" conjures up Nurse Ratched as its poster child. Movies frequently show psychiatric hospitals as part prison, part torture-chamber; its staff is portrayed as barbaric, if not sadistic individuals. In fact, psychiatric hospitals are a frequent setting for many horror movies. Television shows use mental illness as the catalyst for a character's violent behavior, such as the veteran going on a homicidal rampage due to his PTSD. We see and read news reports about a suspect who recently admitted to depression, insinuating that this was the trigger for the criminal actions. And, very often, movies and television may use mental illnesses for a comic effect instead.

The Reality

The reality of mental illness and psychiatric nursing is very different. The best way to describe psychiatric patients is like this: whenever nursing students come to do clinicals on my unit, one of the first things they will say to me is that most of the patients look so "normal". And to that I reply, "they ARE normal. Most are just regular people experiencing a psychiatric crisis and need help." It is true that there are very acute and unstable patient populations out there, but the reality is that many psychiatric patients are not that much different than you or I. Psychiatric facilities are not that much different than other hospital facilities, though there are extra precautions taken to ensure the safety of patients and staff.

As far as psychiatric nursing practice goes, while medications are one major nursing intervention, they are not the only nursing intervention. Psychiatric nurses do perform physical assessments and interventions. Psychiatric nurses may not use skills such as Foleys and IV placements as often as their non-psychiatric nursing counterparts. Instead, psychiatric nurses develop a different skill set where therapeutic communication and relationship building are key, and a nurse who fails to develop this skillset will struggle. While the tight job market may make this more difficult to do, nurses have been able to transition out of psych into other specialties.

Psychiatric nursing does have a higher risk of violence than you would find on a regular hospital unit. However, nursing and clinical staff are trained in de-escalation and crisis intervention, with the end result of heading off many situations before they get out of control. Measures such as seclusion (chemical or physical restraint) are not used with abandon, but only as a last resort. In addition, many patients in non-psych units/settings often have concurrent psychiatric disorders so essentially, you will find psych patients anywhere and everywhere.

Mental illness does not discriminate based on age, race, gender or income level; psychiatric patients can be anyone.

Duties (not all-inclusive)

Utilize therapeutic communication
Conduct comprehensive initial clinical assessment
Rapid on-going assessment; recognize deviations from initial presentation
Provide safe environment
Develop nursing diagnoses and plans of care
Administer medication
Provide patient education

Advanced practice psychiatric nurses provide primary care mental health services such as diagnosis and psychotherapy treatment including prescription of medication.

Psychiatric patients frequently have medical comorbidities such as diabetes, hypertension, or hepatitis. While the focus is on the psychiatric illness presentation, psychiatric nurses cannot neglect the patient's medical conditions and must provide nursing care for them as well.

Practice Settings

Freestanding psychiatric hospitals
Psychiatric units within medical hospitals
Partial hospitalization/outpatient facilities
Community settings
- Clinics
- Private practices
- Home health
- Correctional facilities
- Out-patient education
Research facilities

Subspecialties (not all-inclusive)

Geropsych
Child and adolescent psych
Chemical dependency and rehab
Addictions
Emergency psych
Electroconvulsive therapy (ECT)
Forensic psychiatric nursing

Professional Organizations

The American Psychiatric Nurses Association (APNA) is the, "largest professional membership organization committed to the practice of psychiatric-mental health (PMH) nursing and wellness promotion, prevention of mental health problems, and the care and treatment of persons with psychiatric disorders".

The mission of the International Society of Psychiatric-Mental Health Nurses (ISPN) is, "to support advanced-practice psychiatric-mental health nurses in promoting mental health care, literacy, and policy worldwide".

There are also professional organizations for several subspecialties in psychiatric nursing such as advanced practice psych nursing, child and adolescent psych nursing and addictions nursing as well as individual U.S. state organizations.

Education

Graduate from an accredited RN (Registered Nurse) nursing program (Diploma, ADN, BSN, MSN) or LPN/LVN (Licensed Practical/Vocational Nurse) nursing program (Diploma, Certificate, Degree)
Successfully pass the NCLEX-RN or NCLEX-PN examination
Current, unencumbered U.S. license as an RN or LPN/LVN

To become an Advanced Practice Psychiatric Nurse, the individual will need to graduate from an accredited master's or doctoral program with an emphasis in psychiatric-mental health nursing. Licensed Psychiatric/Mental Health Nurse Practitioners sit for the certification examination and are certified by the American Nurses Credentialing Center (ANCC) as required by their individual Boards of Nursing (BON) in the U.S. state of practice.

Certifications (ANCC)

1 - Registered Nurse (RN): Psychiatric-Mental Health Nursing Certification (RN-BC)

The Accreditation Board for Specialty Nursing Certification (ABSNC) accredits this ANCC certification for the RN. This examination is offered to the RN who meets eligibility requirements.

Eligibility (not all-inclusive)

Current, unencumbered RN* license in state or territory of the U.S.
Practiced the equivalent of 2 years full-time as an RN
Minimum 2,000 hours clinical practice in psychiatric–mental health nursing within last 3 years
Completed 30 hours continuing education in psychiatric–mental health nursing within last 3 years

*Note: Certification is not offered to the LPN/LVN

2 - Nurse Practitioner (NP): Psychiatric-Mental Health Nurse Practitioner (Across the Lifespan) Certification (PMHNP-BC)

The ABSNC also accredits this ANCC certification for the NP. This examination is offered to the NP who meets eligibility requirements.

Eligibility* (not all-inclusive)

Current, unencumbered RN license in state or territory of the U.S. or hold the professional, legally recognized equivalent in another country
Hold a master's, post-graduate, or doctoral degree from accredited psychiatric-mental health NP Program (minimum 500 faculty-supervised clinical hours must be included in the program)

*see ANCC's eligibility requirements for complete information

Other Certifications

Pediatric Nursing Certification Board (PNCB): Pediatric Primary Care Mental Health Specialist (PMHS) certification for the Advanced Practice Registered Nurse (APRN)*

Eligibility** (not all-inclusive)

Current, unencumbered APRN license in U.S. state of practice
Current Certification (one of the following):
- Primary Care Pediatric Nurse Practitioner
- Family Nurse Practitioner
- Child/Adolescent Psychiatric & Mental Health CNS
- Psychiatric-Mental Health NP
Clinical practice hours completed within past 5 years
- Minimum 2,000 hours pediatric developmental, behavioral, and mental health clinical practice experience while holding APRN license
Education or CE completed within the past 5 years
- Either 30 hours of DBMH CE or 1 graduate level DBMH course of at least 2 credits

*Note: The PMHS certification does not replace primary APRN certification required for licensure

**see PNCB's eligibility requirements for complete information

Salary (2020)

RN - According to salary.com, the salary is $76,277 and falls between $69,754 and $86,111.

NP - According to salary.com, the salary is $107,390 and falls between $95,990 and $117,800.