Psychiatric nursing in the 1990s requires integrating an expanding biological focus into nursing practice to accommodate both the growing biological knowledge base and changing patients needs. The term biological psychiatry is used to convey biological causation and psychophysiological change (Babich, 1992).
Knowledge of the biological bases for psychiatric problems and treatment has expanded greatly in the past decade (McKeon, 1990). From this expansion, new medications have been developed and more uses are made of existing medications. There is ever increasing documentation of the role of circadian rhythms, nutrition, exercise, sleep, environment, and touch in psychiatric illness trajectories (Babich, 1992; McEnany, 1991).
Congress labeled the 1 99Os the Decade cfthe Brain. The neuroscience knowledge expansion is reflected in the creation of such terms as neuroanatomy, neurophysiology, neurobiology, neuroendocrine -immune system and neuropharmacology.
As the population of inpatient psychiatric units reflects the aging of the American population, the multiple chronic, complex illnesses prevalent in the older population are found increasingly in psychiatric patients. As with other inpatients, psychiatric patients are increasingly ill on admission and remain hospitalized for increasingly shorter stays.
Perhaps more than any other nursing specialty, the field will change because science and technology are revolutionizing the way we think about our patients and ourselves. We will face a special challenge as psychiatry becomes more "medicalized" (Lowery, 1991).
Purpose and Methodology of the Present Study
The purpose of this study was to describe the current practice and identify the perceived learning needs of practicing psychiatric nurses regarding the biological (rather than intra- or interpersonal) aspects of practice. The research design was a descriptive study using participant observation and interview methodology for data collection, and qualitative analysis of the data. Participant observation involved a visit to and involvement in a setting with data collected through observation, interaction, and experience. The interviews were semistructured with some set questions and the pursuit of emerging themes (Table). Qualitative analysis was used to organize the data by discovering patterns of relationships and themes within the data.
Data were collected from 23 units in 12 inpatient psychiatric facilities chosen purposively for diversity. The 5 public hospitals (2 federal, 2 state, 1 county) and 7 private hospitals (2 for profit, 5 nonprofit) were located in four counties of the San Francisco Bay area. Two of the settings were long-term and 10 were acute. The patient population was both voluntary and involuntary, and represented a variety of diagnoses in the DSM-HI-R (American Psychiatric Association, 1987).
The sample comprised 83 registered nurses who were willing and available to be interviewed during the participant observation visit. The nurses interviewed worked full-time, part-time or per them and had worked in psychiatric nursing from less than 3 months to more than 30 years. Educational preparation included a nursing diploma, associate, baccalaureate, master's, and doctoral degrees in nursing. Each of the 12 participant observation visits lasted 7 to 9 hours and included at least 2 1/2 hours of both the day and evening shifts. Institutional approval was obtained. A letter was sent to the nurse manager of each unit prior to the visit to acquaint the nurses with the purpose of the visit.
Each open-ended interview began with an explanation of the researchers' interest in understanding what currently practicing psychiatric nurses did and thought they needed to know regarding the biological side of psychiatric nursing. Six miscellaneous questions that emerged during the study were asked of about 30 nurses.
Analysis of the data was qualitative. Repetitive themes were sought from the data and developed through constant comparison (Glaser, 1967). Validity was sought by having participating nurses read and validate (or correct) this description as reflective of their experience (Reason, 1981).
The responses of participating nurses were validation of specific experiences by some and of the overall experience by others. Nurses on one unit expressed concern that biological knowledge was needed but not actively sought by some practicing nurses. An additional comment was that all the biological content should be known by new graduates.
The findings focus on the two major components shaping nursing practice (patient needs described and the nurse's response to these patient needs) and identified learning needs for nurses. Evident in all 12 psychiatric settings was the inpatient population trend of older patients who have concomitant chronic and acute medical problems, physical limitations, and cultural and language diversity. The following examples illustrate this finding:
* A late middle-aged male patient who seemed to be responding to auditory hallucinations was admitted. A staggering gait was evident as he came into the unit and he was minimally responsive to direction through the admission process; he sometimes repeated the directions given. Admitting information included a history of atherosclerosis, a recent head injury from a fall, and partial deafness.
* The team was updating the care plan for a 53-year-old male post-lobotomy patient with severe psychotic disorganization and seizures. Problems noted included lack of safety awareness (eg, walking backwards, unaware of obstacles in pathway, inattention while smoking), the need for supervision of personal care, messy eating habits, insufficient nutritional intake, excessive water drinking, constipation, and incontinence. Additional problems included emotional lability, obstinate behavior, assaultive behavior, and inappropriate touching and grabbing of patients and staff members. He was identified as being at risk for wandering. Further physiological problems noted included insufficient calcium hi his bones, hypertension, a lump in his lateral chest wall, poor dentition, and erythema on both arms.
The nurses interviewed in the study were consistent in noting a perceived need for practicing psychiatric nurses to steadily increase their knowledge about medications, physical care, and environment. The need to integrate this expanding knowledge base in working with a changing patient population was generally perceived positively and as a challenge by those with recent medical experience. One respondent stated,
I can get close to patients and increase their trust by attending to their medical needs. Physical care is a great tool for developing a relationship. IfI listen to somatic complaints, they either get fewer and fewer, or I find a real physical problem that needs attention.
A second nurse gave this example:
Last night in report I heard that Mr. Y. was agitated, cranky, and refusing his medications. When I reminded him that it was time for medication, he simply lay there and said no. I went over and touched him, and I then took his temperature. [It was] 1030F. We transferred him to a medical unit where he is being treated for an acute infection . . . That's what I like - seeing the patient holistically.
For those whose practice was based primarily on therapeutic use of self and communication, the changing population and practice were eliciting feelings ranging from unpreparedness to alarm. Said one nurse, "Eight years ago we rejected patients with an IV; now we get patients with new transplants."
Another nurse summarized her concerns as follows:
Other nurses refuse to be in charge here because they feel vulnerable legally. I'm considering going to parttime to avoid charge duties because I feel so vulnerable. The psychiatrist refers [he medical problems to the internist, but the psychiatric nurse has to do all the nursing. I have no deficit in my psychiatric background, but I need a crash course in medicalsurgical nursing to practice safely. I don't want it, but I need it to practice safely.
The qualitative analysis of the interviews and the current practice described and observed was used to identity the following five areas of learning needs for practicing psychiatric nurses:
* Knowledge of medications;
* Recognition of interactions of patient physical conditions and medications with other substances ingested (eg, prescribed medications, nicotine, illicit drugs, and over-the-counter medications);
* Obtainment of skills to manage acute and chronic medical problems in the psychiatric milieu, and to differentiate medical and psychiatric concerns (eg, anxiety versus myocardial infarction, psychosis versus toxicity, manipulation versus incontinence);
* Maintenance of safety and management of the impact of environmental factors, such as light, color and noise, on the patients status; and
* Achievement of self-care for the caregiver.
Knowledge of Medications. Nurses consistently described knowledge about medications as their major knowledge deficit. Not only are there new drugs and new classifications of drugs, but also known drugs are given in a wider range of dose, both lower and higher, and there are increasingly more combinations (eg, haloperidol [Haldol] with lorazepam [Ativan], haloperidol with lithium, haloperidol with and without benztropine [Cogentin]). All these advances have led to an increasing number of desired and undesired effects and consequences of interaction.
Nurses described their practice related to medications as increasingly autonomous. This was true not only of nurse practitioners with prescriptive authority, but also of staff nurses. Often, many p.r.n.s are ordered; so nurses have multiple choices of what to give when. Clinical judgment centers on the ability to select the best p.m. for the person/ situation and to assess the effectiveness. For example, the nurse might have to determine if the restless, agitated patient needs a p.r.n. dose of fluphenazine (Prolixin) or if the next scheduled dose of fluphenazine should be held; whether p.m. trihexyphenidyl (Aitane) is indicated or if lorazepam is the p.m. of choice for this situation. In this case, the nurse needs the ability to differentiate among agitation, akathisia and anxiety, and assess the effectiveness of the p.m. choice.
A patient approached a nurse during our interview and asked for benztropine for his stiff neck; his head was noticeably to one side. She said, "No, go join in with your group." As he walked away with head upright, she said she had learned from experience with him that he only wanted the high. This was one of many demonstrations of the need for clinical judgment in giving p.r.n. medications.
Nurses increasingly participate in treatment team planning and discussion in which they have the opportunity to recommend the selection of a medication based on awareness of individual patient responses. Nurses need to know what to recommend for a given goal (eg, when the individual patient complains of an extra dry mouth, blurred vision, or nightmares). They need to know how to teach patients, how to encourage the continuing use of medication after discharge, and how to present the perspective that medication is a way of maintaining independence - particularly in situations in which impotence, weight gain, or akathisia have been major problems.
The nurses' descriptions of what they need to know about medications were extensive. The following is a summary of what they said they need to know:
* The desired effect of the medication and the time line within which this effect should happen, if there is a difference in the effectiveness of the brand name(s) of the drug and generic version, and, if the drug is used as a p.r.n., when it is used for what purpose. They want an understanding of the basic neuroanatomy, physiology, and biochemistry involved.
* The effects to be expected in elderly or very young patients and variations that are predictable with different ethnic groups. Several nurses said they noted extrapyramidal side effects (EPS) to be most common in young noncaucasian males. They wondered if this finding was true generally or scientifically documented, or if it was coincidental.
* The side effects, adverse reactions, signs of toxicity and overdose, and appropriate nursing response to manage such situations. They also wanted to know how and why side effects occur, from the perspective of understanding how the medications affect the body's systems.
When asked what medication side effects were of greatest concern, nurses consistently identified EPS. However, nurses did not describe a consistent knowledge base in how they looked for EPS. When asked how they recognized EPS, nurses gave varying responses; akathisia, cogwheeling, stiff jaw and neck, salivation, and slurred speech were mentioned most frequently. One nurse indicated knowledge of a time factor in saying, "Restlessness and distonia are the early signs; later I see cogwheeling." Another nurse indicated an erroneous understanding in her description: "If the patient complains of stiffness, I check for cogwheeling; it is not EPS if there is no cogwheeling."
* The impact of medications on the patient's life (eg, weight gain, body image, sexuality, menstrual cycle) and how to educate the patient to manage these effects.
Nurse Biological Learning Needs Interview/Observation Guide
* An awareness of medications and drugs that precipitate or mimic psychiatric symptoms (eg, excessive insulin precipitating hypoglycemia with its irritability, anxiety, and/or confusion; cortisone inducing depression, psychosis, or euphoria; phencyclidine (PCP) initiating anxiety, agitation, and even violence).
Interaction of the Patient's Condition and Medications With Other Substances Ingested. Nurses said they need to understand the interactions of psychiatric drugs with other prescribed drugs, over-the-counter medications, alcohol and illegal drugs, caffeine, nicotine, specific foods, sugar, and additives. The desire was to understand which of these potentiate and which diminish the effectiveness of the psychiatric drugs and what combinations produce new concerns beyond potentiation and diminished effectiveness.
Nurses said their practice often included giving several different psychiatric medications to the same patient and that knowing the interactive effects was important. However, the need to understand interactive effects went beyond understanding the interactions of psychiatric drugs prescribed by the patient's psychiatrist. Nurses commented that it was not uncommon to have patients on five or more prescribed medications prescribed by three or more physicians for acute and chronic medical and psychiatric problems.
About 75% of respondents were unaware that nicotine interfered with the absorption of antipsychotic drugs. Many of the nurses who were aware commented that the same was true of caffeine. This topic often elicited thought provoking questions from the nurses about the implications for practice. If smoking was limited on the inpatient unit and the patient was stabilized on medication, and then resumed heavy smoking after discharge, had the patient been stabilized on the "wrong" dose of medication? When a chronic but stable patient embarks on a program to quit smoking, what must be done with the stable medication dosage?
Skills to Manage Acute/Chronic Medical Problems, Differentiate Medical from Psychiatric Problems. Nurses described patients with acute and chronic heart disease, lung disease, gastrointestinal problems, and renal problems; thus, the nurses were involved with pacemakers, implanted defibrillators, aerosols, ileostomies, and catheters. Patients with cancer, AIDS, organ failure, diabetes, and self-inflicted trauma brought to psychiatric units central lines, tube feeding pumps, and elaborate dressing changes. Seizure disorders, and impairment of sight, hearing, and mobility brought additional equipment and concerns about patient safety and staff ability.
Patents who are acutely and chronically ill psychiatrical Iy and medically must be assessed on admission and repeatedly thereafter to ensure awareness of rapidly changing conditions. Nurses agreed that their assessment must include mental status examination, including the neurologic component, and an assessment of the activities of daily living (eg, ability to walk and read, continence, nutritional status, pain perception).
Practicing psychiatric nurses varied widely in their description of the level of physical assessment they believed appropriate for nurses to do. This finding was consistent with the diversity of opinion about the appropriateness of the acute and chronic medical problems on psychiatric units.
Many nurses who have practiced only traditional psychiatric nursing say they want to practice only psychiatric nursing and believe medical problems should be limited on psychiatric units. This belief was attributed both to the limited biomédical background of psychiatric nurses and also to the inability of medically needy patients to participate in the milieu. Others saw the inclusion of more medical problems as inevitable and wondered aloud what to do to bridge the increasing gap between the skills with which they were comfortable and the skills they perceived as needed for assessment, developing care plans, and delivering complex medical nursing care to psychiatric patients.
In 3 of the 12 facilities visited, vital signs were not routinely monitored after admission. When asked how they watch for signs of neuroleptic malignancy syndrome (NMS), the frequent response was elevated temperature. Less frequent responses included pulse and blood pressure, rigidity, sweating, delirium, catatonic behavior, and failure to respond to neuroleptics. It was while discussing NMS that concern often was expressed that vital signs were not taken routinely on all patients.
Even knowing what is "psychiatric" and what is "medical" is often difficult. Some medical illnesses appear to be psychiatric illness (eg, lupus), some medical problems precipitate psychiatric symptoms (eg, organ failure), and some medical illnesses have a psychiatric component (eg, AIDS dementia). Discussing these realities led nurses to describe patient examples of learning needs for complex assessment and intervention skills:
* Assessing incontinence at the change of shift to differentiate accidents from attempted communication;
* Planning care for a diabetic patient with schizophrenia with an above the knee amputation, Catapres (clonidine) patch, and leg ulcers; and
* Responding helpfully to a patient's complaint of difficulty breathing (her diagnoses included anxiety disorder and COPD secondary to heavy smoking) or epigastric pain (his diagnoses included anxiety disorder, atrial fibrillation, and a history of gastrointestinal bleeding).
While talking with the researcher, one nurse pointed out a young female patient who was arguing loudly and wanting to leave:
She is anorexic, which has precipitated psychosis. She is being nourished now, but it will still take 5 to 10 days for the psychosis to clear. Reading her lab reports and taking care of her nutrition and her psychosis are all part of her care - you can't separate out what is 'medical.'
The learning needs identified were for depth and integration of psychiatric and medical nursing knowledge, and for knowledge of resources and boundaries.
Maintenance of Safety and Management of the Impact of Environmental Factors. The number one environmental concern identified by nurses was safety; nurses frequently discussed concerns for safety of patients and also of staff members. The need most often stated was for nurses to practice what they had already learned.
The most frequently mentioned problem was falls, with the comment that determining who was at risk must be part of initial and ongoing assessment. Nurses speculated that falls occurred because of medications, lack of call lights, and insufficient staff number. On one unit the needs of the aging and mobility impaired population were reflected by hand rails on all walls in the day room, halls, bathrooms, and patient rooms.
Dealing with agitated and assaultive behavior was identified as a safety threat; nurses consistently thought they needed to be able to deal with agitated and assaultive behavior and, when early intervention was unsuccessful, with restraint and seclusion. The widespread presence of small objects (eg, table or floor lamps) that could be used as projectiles was perceived by some nurses as unsafe practice.
The physical environment of the psychiatric unit reflected changes initiated in the past decade. No unit visited allowed smoking at all times in all places. All units had restrictions on where smoking could occur, often outside or in a smoking room. About one third restricted the number of cigarettes patients could have; the most stringent restriction was one cigarette after each meal.
Units often were lighted with softer fluorescent lighting and the noise level was often under the conscious control of the nursing staff. The management of environmental stimuli was described as part of the nurse managed milieu. Nurses expressed a need/desire to know theory that would guide them in the deliberate manipulation of lighting, color, and sound in psychiatric nursing practice.
Many nurses mentioned the need to know of, and hopefully assess, the home environment of the patient. The environment to which the patient will be discharged is a major determinant of behavior and must be considered realistically in planning and teaching.
The care of the larger environment also was brought up by nurses. The need for staff members and patients to be aware of recycling, waste, and disposal of toxic materials was a concern expressed.
Self-Care of Nurses. Nurses wondered how their peers were faring in their personal lives and to what extent they were able to care for themselves. They wondered about the incidences of divorce and substance abuse in psychiatric nursing. They questioned if others were able to develop and maintain a personal program of nutrition, exercise, healthy relaxation, and selfdiscovery. These questions were related to an awareness that being able to care for oneself is essential in order to teach effective self-care to patients.
"Self-care gets an 'F' in this environment," said one nurse. "Even humor is frowned upon."
Discussion and Conclusion
What practicing psychiatric nurses said they need to know is congruent with what psychiatric nursing leaders say: Biological psychiatry is a reality. The challenge for this decade is to integrate biological science and behavioral science into the practice of psychiatric nursing (McBride, 1990).
The present study is important because practicing nurses have identified competency requirements and current learning needs of their occupational roles. This identification and recognition is the essential point of adult readiness to learn (Knowles, 1978).
That some biological knowledge is to be learned and not already known is a reflection of developmental reality for practicing psychiatric nurses. The criticism of self and others described by some nurses who are aware of a knowledge deficit is sad to note because criticism and other negative feelings inhibit learning. Embarrassment, shame, and low self-esteem have no helpful function in professional development.
Openness about and respect for nurses' identification of learning needs is appropriate. A positive response and enthusiasm were expressed for practice incorporating biological psychiatry in a survey of Journal of Psychosocial Nursing readers (What are your feelings, 1988).
There was widespread interest from the nurses participating in this study in knowing what nurses in other settings were experiencing in their practice and the learning needs they perceived. Both commonality of and individuality in needs and experiences were evident. This article was written to help psychiatric nurses see themselves within a larger context and then help self and peers formulate learning goals to pursue.
How to meet the biological learning needs for practicing psychiatric nurses is a challenge to be addressed jointly by practicing nurses, their nurse managers, and the nursing education staff in the practice setting. Adult learning principles and strategies make clear that adult learners enjoy planning and carrying out learning exercises and evaluating progress towards goals (Knowles, 1975).
One possible approach is to use the outline of this article and the Jacobsma (1991) article for a needs assessment. Jacobsma focused on the interpersonal aspects of psychiatric nursing in outlining continuing education to assist the generalist graduate nurse and already practicing nurses to develop competency in practicing the specialty of psychiatric-mental health nursing. Together these two articles outline the potential broad learning needs in psychiatric nursing and offer a framework of selecting curriculum for professional development.
Nurses in a small or moderate size geographic area might combine resources by using the same assessment tool and identifying priority learning needs within each setting. All interested nurses might choose a segment of interest to them and develop a short (eg, one hour) learning segment. Nurses within the geographic area could be invited to classes, the segment could be videotaped and shared, or the presenter could become the local expert and repeat the segment in participating settings.
Nurses with learning needs will see many other avenues for learning. Regardless of the venue, it is important to involve the adult learner in the identification and meeting of their learning needs.
The need to update prelicensure programs and master's programs to incorporate biological psychiatry is evident and noted by both McBride (1990) and Pothier ( 1 990). McBride ( 1 990) advocated reintegration of neurological and psychiatric nursing because both focus on maximizing adjustment with central nervous system impairment. She specifically noted the need for inclusion in graduate programs of biological theories of panic, neuroanatomy of memory, circadian rhythm, and psychopharmacologyand immunology.
The list of knowledge needed must be an open one as we seek to incorporate the continually emerging results of research and new knowledge into all levels of education and practice. Appreciating this reality and developing skill in the process of updating ourselves will facilitate our practice through this decade and into the next.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd. ed., rev. Washington, DC: Author, 1987.
- Babich, K., Tolbert, R.B. Professionally speaking: What is biological psychiatry? J Psychosac Nurs Ment Health Ser\' 1992; 30(1):3338.
- Glaser, B.G.. Strauss, A.L. The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine, 1967.
- Jacobsma, B. A balancing act: Continuing education for staff nurses. J Psychosoc Nurs Ment HealthServ 1991; 29(2):15-21.
- Knowles, M. M. Self directed learning: A guide for learners and teachers. New York: Cambridge, 1975.
- Knowles, M.M. The aduli learner: A neglected species, 2nd ed. Houston: Gulf. 1978.
- Lowery, B.J. Psychiatric nursing in the 1990s and beyond. J Psychosoc Nurs Mem Health Sm'1992;30(l):7-13.
- McBride. A.B. Psychiatric nursing in the 1990s. Arch Psychiatr Nurs 1990; 4(l):21-28.
- McEnany, G.W. Psychobiological indices of bipolar mood disorder: Future trends in nursing care. Arch Psychiatr Nurs 1 990; 4< 1 ):29-38.
- McKeon, K.L. Introduction: A future perspective on psychiatric mental health nursing. Arch Psychiatr Nurs 1990; 4(1):19-20.
- Pothier, P.C. Toward a bio/psycho/social synthesis. Arch Psychiatr Nurs 1990; 4(2):77.
- Reason, P.. Rowan, J. Human inquiry: A sourcebook of new paradigm research. New York: John Wiley & Sons, 1981.
- What are your feelings about the trend toward the biomedicalization of psychiatry? [Your turn]. J Psychosoc Nurs Ment Health Sen· 1988: 26<f):40-41.
Nurse Biological Learning Needs Interview/Observation Guide