COMMUNITY MENTAL HEALTH NURSING

Presented to: Dr. Sandhya Ghai Presented by: Mukta M.Sc.Nursing 1st yr

INTRODUCTION
The methods of treating mental illness have changed dramatically in the past century. The overall goal of community mental health as outlined by Mrs. Indira Gandhi in may 1981 while addressing the world health assembly is as : In India, we would like to go homes instead of large numbers gravitating towards centralized hospitals. Services must begin where people are and where problems arise.

Community mental healthpsychiatric nursing

DEFINITION
Community mental health- psychiatric nursing is
the application of specialized knowledge to populations and communities to promote and maintain mental health, and to rehabilitate populations at risk that continue to have residual effects of mental illness.

Community mental healthpsychiatric nursing

Psychiatric nursing in the community setting differs markedly from its hospital counterpart. The community setting requires that the psychiatric nurse possess knowledge about the community resources. She should be flexible in approaching problems related to individual psychiatric symptoms, family and support systems and basic living needs such as housing and financial support.

HISTORY
Before 1840, there was no known treatment for individuals who were mentally ill because mental illness was perceived as incurable. The intervention was thought to be removing these ill persons from the community to a place where they would do no harm to themselves or others. With establishment of the National Mental Health Act of 1946, the U.S. government awarded grants to the states to develop mental health programs outside of state hospitals.

HISTORY
Outpatient clinics and psychiatric units in general hospitals were inaugurated. In 1949, National Mental Health (NIMH) was established. Deinstitutionalization movement started as the care of the client in the hospital became cost prohibitive whereas care for client in community is cost effective.

HISTORY
Deinstitutionalization means closing of state

mental hospitals and discharging of mentally ill individuals.

Provision of outpatient mental health services not only is the wave of the future but also has become a necessity today.

Provision of health promotion, early intervention, and to ensure rehabilitation or prevention of longterm disability.

PRINCIPLES OF COMMUNITY MENTAL HEALTH

PRINCIPLES OF COMMUNITY MENTAL HEALTH

(A) General principles: The home and community environment help clients sustain social, family, and self - care functions. Keeping clients in their usual environments is preferred, as long as it is medically, socially and economically feasible to do. A health problem is a manifestation of several related problems and issues, residual or ongoing, in various aspects of life. A holistic approach is necessary.

Principles Cont
Cost- effectiveness can be achieved only through well coordinated and integrated services & close monitoring. Home health care is delivered in a clients place of residence. When entering a clients home, the nurse is in that persons cultural surroundings and must respect them, as well as integrate cultural preferences and expectations into services.

High quality client care is an indisputable goal, regardless of changes in policy and regulation of home care services.

Principles Cont
(B) Specific principles Each person has an unique psychological makeup. Nurses must tailor an individualized care plan to the persons particular circumstances and consider his or her home and community surroundings. Goals for improving health status and developing personal resources must be realistic based on the clients condition.

Principles Cont
A clients or familys reaction to an alteration in mental health status, mental disability or mental illness is often influenced by whether the condition is permanent, temporary, or degenerative. Empathy for emotional reactions from clients and families to various mental illnesses can help establish a positive therapeutic relationship. Nurses base client care on the therapeutic relationship. Therapeutic rapport is the foundation for providing appropriate psychiatric home care nursing services.

THE PUBLIC HEALTH MODEL

THE PUBLIC HEALTH MODEL

The model of public health is based largely on the concepts set forth by Gerald Caplan (1964) during the initial community mental health movement. Concepts include:

1. Primary prevention 2. Secondary prevention 3. Tertiary prevention

PRIMARY PREVENTION
Services aim at reducing the incidence of mental disorders within the population. Primary prevention targets both individuals and the environment. Emphasis is twofold: 1. Assisting the individuals to increase their ability to cope effectively with stress.

2. Targeting and diminishing harmful forces (stressors) within the environment.

Nursing Interventions in primary prevention

Focused on the targeting of groups at risk and the

provision of educational programmes.

Examples include:

1. Teaching parenting skills and child development to prospective new parents. 2. Teaching physical and psychosocial effects of alcohol/drugs to elementary school students.

Nursing Interventions in primary prevention

3. Teaching techniques of stress management to virtually anyone who desires to learn. 4. Teaching groups of individuals ways to cope with the changes associated with various maturational stages.
5. Teaching concepts of mental health to various groups within the community.

Nursing Interventions in primary prevention

6. Providing education and support to unemployed or homeless individuals. 7. Providing education and support to other individuals to various transitional periods (e.g. Widows and widowers, new retirees, and women entering the work force in middle life.)

8. Antenatal care to the mother and educating her regarding the adverse effects of irradiation, certain drugs and pre-maturity.

Nursing Interventions in primary prevention

9. Ensuring timely, efficient, obstetrical assistance to guard against the ill effects of anoxia and injury to new born at birth. 10. Providing dietary corrections to those infants suffering from metabolic disorders. 11. Correction of endocrinal disorders. 12. Training programs for mentally and physically handicapped children like blind, deaf and mute.

Nursing Interventions in primary prevention

13. Rendering crisis counseling to the parents of physically and mentally handicapped children. 14. Identifying the problems of scholastic performance and emotional disturbances among school going children and giving timely intervention. 15. Ensuring harmonious relationship among the members of the family, and teaching healthy adaptive techniques at the time of stress producing events.

Nursing Interventions in primary prevention

These services can be offered in a variety of settings that are convenient for the public (e.g. churches, schools, colleges, community centres, YMCAs and YWCAs, work place of employee organizations, meetings of womens group, or civic or social organizations such as PTAs health fairs, and community shelters.

SECONDARY PREVENTION
Services aimed at reducing the prevalence of psychiatric illness by shortening the course (duration) of the illness. (Sadock & Sadock, 2003)
Secondary prevention is accomplished through early identification of problems and prompt initiation of effective treatment.

Nursing in secondary prevention

Focuses on recognition of symptoms and provision
of, or referral for, treatment.
Examples include: 1. Ongoing assessment of individuals at high risk for illness exacerbation (e.g. during home visits, at day care, in community health centres, or in any setting where screening of high- risk individuals might occur.)

Nursing in secondary prevention

2. Provision of care for individuals in whom illness symptoms have been assessed. Example: Individual or group counseling, medication administration, education and support during period of increased stress( crisis intervention), staffing rape crisis centres, suicide hotlines, homeless shelters, shelters for abused women, or mobile mental health units.

Nursing in secondary prevention

3. Referral for treatment of individuals in whom illness symptoms have been assessed. Referrals may come from support groups, community mental health centres, emergency services, psychiatrists or psychologists, and day or partial hospitalization.

 The salient features of secondary prevention

include:

1. Early diagnosis and case finding 2. Early referral 3. Screening programmes 4. Early and effective treatment for patient and, if necessary, to relevant family members. 5. Mental health education 6. Crisis intervention 7. Consultation services.

TERTIARY PREVENTION
Services aimed at reducing the residual defects that are associated with severe or chronic mental illness. Tertiary prevention is accomplished in two ways: 1. Preventing the complication of the illness. 2. Promoting rehabilitation that is directed toward achievement of each individuals maximum level of functioning.

Nursing Interventions 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: 1. Consideration of the rehabilitation process at the time of initial diagnosis and treatment planning. 2. Teaching the client daily living skills and encouraging independence to his or her maximum ability.

Nursing Interventions in tertiary prevention

3. Referring clients for various after-care services like support groups, day treatment programs, psycho social rehabilitation programs.

4. Monitoring effectiveness of after-care services through home health visits or follow-up 5. Making referrals for support services when required.

Nursing Interventions in tertiary prevention

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 community mental health centers.

THE COMMUNITY AS CLIENT

PRIMARY & SECONDARY PREVENTION

Lancaster (1980) states:

The term community refers to a group of people living in close proximity and having some dependency on each other.
Community encompasses the place where people live, work, raise children, and in general carry on the activities necessary for daily living.

Lancaster (1980) states:

A given community is composed of individuals who are engaged in some degree of social interaction within a defined geographic area and who have one or more common ties. The community is the social environment in which hazards are experienced and supports are provided.

PRIMARY PREVENTION
Primary prevention within communities encompasses the twofold emphasis, i.e.:
Identifying stressful life events that precipitate crisis and targeting the relevant populations high risk. Intervening with these high-risk populations to prevent or minimize harmful consequences.

POPUATION AT RISK
1. Adolescence
2. Marriage 3. Midlife 4. Retirement

{1}. ADOLESCENTS
It is a transition into young adulthood and is a volatile time in most families. Commonly there is conflict over issues of control. It seems that the adolescent is 25 yrs old one day and 5 yrs old the next. An often quoted definition of an adolescent, by an anonymous author, is A toddler with hormones and wheels. Most frequent precipitant to adolescent suicide is loss, or threat of loss, or abandonment by parents or closest peer relationship.

PRIMARY LEVEL
It focused on providing support and accurate information to ease the difficult transition they are undergoing. Educational offerings can be presented in schools, churches, youth centers, or any location in which group of teenagers gather. Programmes that inform about and validate bodily changes and emotional feelings about which they may be some concerns.

NURSING INTERVENTIONS

 Educational programmes that inform about sexuality, pregnancy, contraception and sexually transmitted diseases. Educational programmes that inform about the use and abuse of alcohol and other drugs. Educational programmes that inform about the nutritional needs specific for this age group.

NURSING INTERVENTIONS AT PRIMARY LEVEL

NURSING INTERVENTIONS AT SECONDARY LEVEL

The need for intervention occurs when disruptive and age-inappropriate behaviors become the norm, and the family can no longer cope adaptively with the situation.

All levels of dysfunction are considered, from dysfunctional family coping to the need for hospitalization of the adolescent. Do interventions at community mental health centers, physicians offices, schools, public health departments, and crisis intervention centers.

NURSING INTERVENTIONS AT SECONDARY LEVEL

Work with families to problem solve and improve coping and communication skills Or they may work on a one-to-one basis with the adolescent in an attempt to modify behavior patterns. Focus on problem identification and stabilizing a crisis situation.

{2}. MARRIAGE
No two people can possibly coordinate all their developmental crises.

Additional conflicts sometimes also arise when the marriage is influenced by crossovers in religion, ethnicity, social status, or race, although these types of differences have become more individually and societal acceptably than once were.

PRIMARY LEVEL
It involves education regarding what to expect at carious stages in the marriage. Nurses could offer courses in marriage and family living in community through role-play. Encouraging honest communication. Determining what each person expects from the relationship.

NURSING INTERVENTIONS

NURSING INTERVENTIONS AT PRIMARY LEVEL

Ascertaining whether or not each individual can accept compromise. Can be done effective in individual or couple therapy or in support/educational groups of couples experiencing similar circumstances.

Parenthood causes developmental crisis precipitated by the birth of a child.

NURSING INTERVENTIONS AT PRIMARY LEVEL

Anticipatory guidance is the term used to describe the interventions used to help new parents to know what they might expect.

Information is given about :

parent-infant bonding changing husband-wife relationships, clothing and equipment feeding and other expectations, prepared childbirth classes stages of growth and development.

NURSING INTERVENTIONS AT SECONDARY LEVEL

Nursing interventions at this level with individuals encountering marriage problems may include one or more of the following:
Counseling with the couple or with one of the spouses on a one-to-one basis. Referral to a couples support group.

NURSING INTERVENTIONS AT SECONDARY LEVEL

Identification of the problem and definite solutions. Support and guidance as changes are undertaken.
Referral to a sex therapist. Referral to a financial advisor. Referral to parent effectiveness.

NURSING INTERVENTIONS AT SECONDARY LEVEL

PARENTHOOD: nurse should be able to recognize the following problems of parents & signs of abuse:

1. 2. 3. 4. 5.

Physical, emotional or sexual abuse of a child. Birth of an imperfect child. Physical or emotional neglect of a child. Diagnosis of a terminal illness in a child. Death of a child.

NURSING INTERVENTIONS AT SECONDARY LEVEL

Teaching effective methods of disciplining children, aside from physical punishment. Positive reinforcement.

Committed to consistent use of the adapted behavior.

{3}. MIDLIFE
The occurrence of middle crisis is not defined by a specific number. This is very individual but classified as: An altercation in perception of self. An altercation in perception of others. An altercation in perception of time.

NURSING INTERVENTIONS

NURSING INTERVENTIONS AT PRIMARY LEVEL

Providing accurate information regarding changes occurring during this time of life and support for adapting to these changes effectively.

Nutrition classes to avoid obesity, exercise and good nutrition. Assistance with ways to improve health. E.g. quit smoking, cease or reduce alcohol consumption, reduce fat intake.

NURSING INTERVENTIONS AT PRIMARY LEVEL

Regular physical examinations. Classes on menopause. Support and information R/T physical changes occurring in body in this time. Support and information related to care of ageing parents

SECONDARY LEVEL
Nursing care becomes necessary when the individual is unable to integrate all the changes. An inability to accept the physical and biological changes; Changes in relationships between themselves and their adult children and ageing parents; The loss of the perception of youth may result in depression for which the individual may require help to resolve.

{4}. RETIREMENT
Retirement is regarded as an achievement in principle but is dreaded as a crisis when it actually occurs.

Retirement can result in depression and lowered self-esteem.

It involves providing information and support to individuals who have retired or are considering retirement.

NURSING INTERVENTION AT PRIMARY LEVEL

Support can be one-to-one basis to assist to sort out their feelings regarding retirement.
Group support of individuals undergoing same experiences.

Information about Medicare, social security, and Medicaid; information regarding ways to use newly acquired free time constructively.

NURSING INTERVENTION AT SECONDARY LEVEL

Inpatient and outpatient settings both. Close observation Medicine supervision. Activity scheduling. Exploring about suicidal plan if severe depression. Providing information about medicine, sideeffects and compliance.

TERTIARY PREVENTION

NURSING INTERVENTIONS AT TERTIARY LEVEL

In 1955, more than half a million individuals resided in public mental hospitals.
Deinstitutionalization of chronically mentally ill persons began in the 1960s as national policy change and with a strong belief in the individuals right to freedom.

BARRIERS IN PROVIDING HEALTH SERVICES IN COMMUNITY

Community based mental health system is not working for the chronically mentally ill because of the following barriers:

Public attitudes Fragmented systems Poverty and race Private insurance Public findings.

ESSENTAIL SERVICES REQUIRED

Primary care mental health services Universal access to a basic mental health package (both OPD & inpatient). Long-term care Managed care

HEALTH SERVICES AVAILABLE AT COMMUNITY LEVEL

Group homes Half-way homes Boarding homes

Mobile outreach clinics: outreach

programmes literally reach out to the homeless individuals in their own environment in an effort to provide health care.

HEALTH SERVICES AVAILABLE AT COMMUNITY LEVEL

Store-front clinics: these operate under poor working conditions under budgetary constraints with inadequate staffing, supplies & equipments. Administering medicines, vital signs, screening for communicable diseases, health education & supportive counseling. Foster homes Day care centers

HEALTH SERVICES AVAILABLE AT COMMUNITY LEVEL

Sheltered care facilities: provide a safe and supportive environment Transitional housing Independent living programmes Social-rehabilitation centers

POPULATION REQUIRING TERTIARY PREVENTION

The elderly
The chronically mentally ill Homeless mentally ill Those with acute mental health problems.

CONCLUSION
Mental health care within the community targets primary prevention (reducing the incidence of mental disorders within the population), the secondary prevention (reducing the prevalence of psychiatric illness by shortening the course of illness), and tertiary prevention (reducing the residual defects that are associated with severe or chronic mental illness)

REFERENCES
1. Lalitha K. Mental health and psychiatric nursing. (First edn). Gajanana book publishers and distributors. Bangalore; 2006. 2. Shives L. R. Basic concepts of psychiatric mental health nursing. (7th edn) Lippincott Williams and Wilkins. 3. Mohr W K. Psychiatric mental health nursing. (6th edn). Lippincott Williams and Wilkins. Philadelphia.

CONCLUSION
Nurses are unique in their ability to bridge the gap between the hospital and the community, between the psychiatrist and the community care given, and between the public and other health care providers. Therefore, nurses role in community support service is primary.

REFERENCES
4. http./www.googles.com 5. Benjamin J. Sadock, Virginia A. Sadock, Menas S. Gregory; comprehensive textbook of psychiatry, 8th edition. 6. Merry C. Townsend, psychiatry mental health nursing, 5th edition, jaypee publications, page no 76-88. 7. Steuart W.Gail; Laraia T Michele, principles of psychiatry nursing, 8th edition, Mosby publication, page no 140-168.