UNIT XXI: PSYCHOLOGICAL REHABILITATION

Tertiary Prevention
Services aimed at reducing the residual defects that are associated with severe and persistent mental illness.

Tertiary prevention is accomplished in two ways:

1. Preventing complications of the illness.

2. Promoting rehabilitation that is directed toward achievement of each individuals maximum level of
functioning. Sadock and Sadock (2003) suggest that the term chronic mental illness, which historically
has been associated with long hospitalizations that resulted in loss of social skills and increased
dependency, now may also refer to clients from the deinstitutionalized generation. These individuals
may never have experienced hospitalization, but they still do not possess adequate skills to live
productive lives within the community. Nursing in tertiary prevention focuses on helping clients learn
or relearn socially appropriate behaviors so that they may achieve a satisfying role within the
community.

Examples include:
Consideration of the rehabilitation process at the time of initial diagnosis and treatment planning.
Teaching the client daily living skills and encouraging independence to his or her maximum ability.
Referring clients for various aftercare services (e.g., support groups, day treatment programs, partial
hospitalization programs, psychosocial rehabilitation programs, group home or other transitional
housing).
Monitoring effectiveness of aftercare services (e.g., through home health visits or follow-up
appointments in community mental health centers).
Making referrals for support services when required (e.g., some communities have programs linking
individuals with serious mental disorders to volunteers who serve to develop friendships with the
individuals and who may assist with household chores, shopping, and other activities of daily living
with which the individual is having difficulty, in addition to participating in social activities with the
individual). Nursing care at the tertiary level of prevention can be administered on an individual or
group basis and in a variety of settings, such as inpatient hospitalization, day or partial hospitalization,
group home or halfway house, shelters, home health care, nursing homes, and community mental
health centers.

THE ROLE OF THE NURSE

One emphasis of the National Mental Health Act of 1946 was to increase the supply of mental health
professionals.
This Act named four major mental health disciplines: psychiatry, clinical psychology, social work, and
nursing. To increase the numbers of trained mental health professionals, grants were provided to institutions,
and stipends and fellowships were awarded to individuals. Nurses who work in the field of psychiatry may
practice at one of two levels: the psychiatric-mental health registered nurse or the psychiatric-mental health
advanced practice registered nurse. These two levels have been differentiated in the Psychiatric-Mental Health
Nursing Scope and Standards of Practice published by the American Nurses Association (ANA) in 2007.
The Psychiatric-Mental Health Registered Nurse (RN-PMH)
Definition: A registered nurse (RN) who demonstrates competence, including specialized knowledge, skills,
and abilities, obtained through education and experience in caring for persons with mental health issues,
mental health problems, and psychiatric disorders. (ANA, 2007, p. 16). Education: The ANA (2007) states,
Nurses from a number of educational backgrounds participate and practice in psychiatric nursing settings.
Due to the complexity of care in the specialty, the preferred educational preparation is at the baccalaureate
level with credentialing by the American

Nurses Credentialing Center (ANCC) (p. 16). Additional In addition to professional licensure by
credentialing: the state, psychiatric-mental health RNs may apply to sit for examinations that certify them as
basic level psychiatric-mental health nurses. Employment Inpatient psychiatric hospital unit, day settings:
treatment and partial hospitalization programs, community health centers, home health care, long-term care
centers. Professional Health promotion and health responsibilities: maintenance; intake screening, evaluation,
and triage; case management; provision of therapeutic and safe environments; promotion of self-care
activities; administration of psychobiological treatment regimens and monitoring response and effects; crisis
intervention and stabilization; and psychiatric rehabilitation (ANA, 2007, p. 18).

The Psychiatric-Mental Health Advanced Practice Registered Nurse (APRN-PMH)

Definition: A professional nurse who has successfully completed a graduate program of study in a
[psychiatric-mental health] nursing specialty that provides specialized knowledge and skills that form the
foundation for expanded roles in health care. The ANA (2007) states, The APRN-PMH expands the practice
of a registered nurse by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data,
increased complexity of skills and interventions, and significant role autonomy. Education: A masters or
doctorate degree in the specialty of psychiatric-mental health nursing, with an advanced practice specialty
certification from ANCC. Additional: Masters- or doctorate-prepared nurses may sit for credentialing:
examination that certify them as a psychiatric mental health clinical nurse specialist or nurse practitioner. In
addition, some states have special licensure that may be granted to nurses with advanced education that permits
them to practice at a more independent level (e.g., Advanced Practice Registered Nurse [APRN] or Advanced
Registered Nurse Practitioner [ARNP]) and that makes them eligible for prescriptive.

Authority, inpatient admission privileges, third-party reimbursement, and other specific privileges.
Employment Inpatient psychiatric hospital units; settings: day treatment and partial hospitalization programs;
community mental health centers; private mental health facilities; individual private practice; crisis
intervention services; or in the capacity of mental health consultant, supervisor, educator, administrator, or
researcher. Professional In addition to those required at the responsibilities: basic RN level, functions of the
APRN-PMH include prescribing psychopharmacological agents, integrative therapy interventions, various
forms of psychotherapy, community interventions, case management, consultation and liaison, clinical
supervision, expanded advocacy activities, education, and research (ANA, 2007, p. 20).

CASE MANAGEMENT

Because of the rising costs of hospitalization and in keeping with the concept of deinstitutionalization, there
has become a need for managing the care of clients (particularly those with severe and persistent illnesses) in
an outpatient setting. Case management at the secondary level of prevention strives to organize client care so
that specific outcomes are achieved within an allotted time frame. Commonly, this time frame is determined
by the established protocols for length of stay as defined by the DRGs. Ideally, case management incorporates
concepts of care at the primary, secondary, and tertiary levels of prevention. Various definitions have emerged
and should be clarified.

Managed care is a concept designed to control the balance between cost and quality of client care. In a
managed care program, individuals receive health care based on need, as assessed by coordinators of the
provider. Managed care exists in many settings, including (but not limited to):

Insurance-based programs
Employer-based medical provider programs
Social service programs
The public health sector

Managed care may exist in virtually any setting in which healthcare provision is a part of the service; that is,
in any setting in which an organization (whether it be private or government-based) is responsible for payment
of healthcare services for a group of people. Examples of managed care are health maintenance organizations
(HMOs) and preferred provider organizations (PPOs). Case management is the method used to achieve
managed care. It is the actual coordination of services required to meet the needs of the client. The Case
Management Society of America (CMSA) defines case management as a collaborative process of
assessment, planning, facilitation, and advocacy for options and services to meet an individuals health needs
through communication and available resources to promote quality cost-effective outcomes (CMSA, 2007).
Types of clients who benefit from case management include (but are not limited to):
The frail elderly
Those who are developmentally disabled
Those who are physically handicapped
Those who are mentally handicapped
Individuals with long-term medically complex problems that require multifaceted, costly care
(e.g., high-risk infants, persons with human immunodeficiency virus or AIDS, and transplant
patients).
Individuals who are severely compromised by an acute episode of illness or an acute
exacerbation of a sever and persistent illness (e.g., schizophrenia).

The case manager is responsible for negotiating with multiple health care providers to obtain a variety of
services for the client. The very nature of nursing that incorporates knowledge about the biological,
psychological, and sociocultural aspects related to human functioning makes nurses highly appropriate as case
managers. The American Nurses Credentialing Center (ANCC) now offers accreditation by exam for nursing
case management.
The applicant must hold a current license as a registered nurse with two years of full-time nursing practice
experience. In addition, he or she must have functioned as a nursing case manager for a minimum of 2000
other professional agencies also now offer programs of accreditation or certification for case management
(e.g., Accreditation Commission for Health Care, National Committee for Quality Assurance, American Case
Management Association). Some case management programs prefer clinical nurse specialists who have
experience working with the specific populations for whom the case management service will be rendered.
Case management is becoming a recommended method of treatment for individuals with a severe and
persistent mental illness. This type of care enhances functioning by increasing the individuals ability to solve
problems, improving work and socialization skills, promoting leisure time activities, and endeavoring to
diminish dependency on others.
General responsibilities of the rehabilitation nurses:

Possesses the specialized knowledge and clinical skills necessary to provide care for people with
physical disability and chronic illness
Coordinates educational activities and uses appropriate resources to develop and implement an
individualized teaching and discharge plan with clients and their families
Performs hands-on nursing care by utilizing the nursing process to achieve quality outcomes for clients
Provides direction and supervision of ancillary nursing personnel, demonstrates professional
judgment, uses problem solving techniques and time-management principles, and delegates
appropriately
Coordinates nursing care activities in collaboration with other members of the interdisciplinary
rehabilitation team to facilitate achievement of overall goals
Coordinates a holistic approach to meeting patient's medical, vocational, educational, and
environmental needs
Demonstrates effective oral and written communication skills to develop a rapport with clients, their
families, and health team members and to ensure the fulfilment of requirements for legal
documentation and reimbursement
Acts as a resource and a role model for nursing staff and students and participates in activities such as
nursing committees and professional organizations that promote the improvement of nursing care and
the advancement of professional rehabilitation nursing
Encourages others to become CRRN certified, obtain advance degrees, participate on committees,
and/or join professional organizations
Facilitates community education regarding acceptance of people with disabilities
Actively engages in legislative Initiatives affecting the practice of rehabilitation nursing or the people
in their care
Applies nursing research to clinical practice and participates in nursing research studies

Roles and functions of the rehabilitation staff nurse

Teacher

Shares information about the disease processes underlying disabilities and teaches nursing techniques
to help clients and their families develop the self-care skills necessary to move toward wellness on the
illness-wellness continuum
Prepares clients and their families for future self-management and decision-making responsibilities by
fostering clients' independence and goal achievement
Reinforces the teaching done by specialists in rehabilitation and other healthcare disciplines, provides
resource materials for clients' changing needs, and provides on-going patient education after discharge
Provides in-service education for healthcare team members and members of the community regarding
the prevention of disabilities
Caregiver

Assesses the physical, psychological, sociocultural, and spiritual dimensions of clients and their
families, as well as their educational and discharge needs in order to formulate nursing diagnoses
Plans nursing care while acknowledging that rehabilitation nursing is practiced within a dynamic,
therapeutic, and supportive relationship that is constantly changing, as nurses and clients influence
one another
Implements a plan of care by providing nursing care and education directly or through ancillary
personnel, as needed, to maintain and restore function and prevent complications and further loss
Evaluates the nursing care that is being provided and modifies the plan, as needed, to achieve
measurable goals and objectives.

Collaborator

Develops goals, in collaboration with clients, their families, and the rehabilitation team, that are
oriented to wellness behavior and are reality based and that encourage socialization with others,
and promote maximal independence for patients with disabilities or chronic disabling conditions
Participates in the interdisciplinary team process at team conferences and other team meetings and
offers input into team decision making
Intervenes with team members and other healthcare professionals to ensure that the optimal
opportunity for recovery is made available to the client, the most significant member of the
rehabilitation team
Collaborates with team members to achieve cost-effective care by utilizing appropriate clinical
measures to meet emergent physical, psychosocial, and spiritual situations

Client advocate

Actively listens, reflects, and guides clients and their families through the stages of the grieving
process to mourn the loss of abilities and roles while also "instilling hope"
Advocates for policies and services that promote the quality of life for individuals with disabilities
and participates in activities that will positively influence the community's awareness of disabilities
Contributes to a safe and therapeutic environment and supports activities that promote the clients'
return of function and prevent complications or chronic illness
Intervenes on behalf of clients to ensure that medical professionals and nonmedical professionals
work to maximize clients' success when they return to work or school

Conclusion

The goal of rehabilitation nursing is to assist individuals with disability and/or chronic illness to attain and
maintain maximum function. The rehabilitation staff nurse assists clients in adapting to an altered lifestyle,
while providing a therapeutic environment for client's and their family's development. The rehabilitation staff
nurse designs and implements treatment strategies that are based on scientific nursing theory related to self-
care and that promote physical, psychosocial, and spiritual health. The rehabilitation staff nurse works in
inpatient and outpatient settings that can be found in a range of acute to sub-acute rehabilitation facilities. This
role description has been developed by staff nurses to clarify and specify the responsibilities of the staff nurse
in a rehabilitation setting and to promote professionalism based on the established scope and standards of
rehabilitation nursing practice.
REFERENCES
Townsend, M.C., Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practice, Sixth
Edition, Philadelphia: F. A. Davis Company.
Mohr, Wanda K. Psychiatric-Mental Health Nursing, Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins, 2013.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock's synopsis of psychiatry: Behavioral
sciences/clinical psychiatry (Third edition.). Philadelphia: Wolters Kluwer.