Developments in neuroscience during the past 3 decades have led to a better understanding of psychiatric illnesses and their treatment (Preskorn, 2010). These advances have contributed to a greater reliance on the use of psychotropic medications, sometimes at the expense of other treatment modalities. What does this mean for nurses providing psychiatric care?
Nurses have played an important role in the use of psychotropic medication in the treatment of psychiatric illnesses. This involvement has included providing education to patients and their families about pharmaceutical treatments, administering and monitoring medications for safety and efficacy, and, in the case of advanced practice nurses (APNs), prescribing therapeutic drugs. Due to the central role that medications have assumed in the treatment of psychiatric illnesses, health care organizations, administrators, educators, and even nurses themselves may overlook other significant therapeutic modalities in the treatment of psychiatric illnesses. There is no question that psychotropic medications have transformed treatment for psychiatric patients but, as nurses, we must promote a holistic approach that addresses the psychological and social needs—as well as the biological needs—of the individual.
Fortunately, mental health clinicians of all disciplines increasingly recognize the importance of balance in treating patients with regard to their psychological, social, and physiological needs (Grant, 2011; Hyun & Alfonso, 2011; Lüllmann, Berendes, Rief, & Lincoln, 2011). In a recent article published in the New York Times, Daniel Carlat (2010), a leading psychiatrist and writer on mental health issues, lamented the fact that the psychiatrist’s role is now primarily to medicate psychiatric patients, while the psychotherapy component is carried out by another nonprescribing clinician, referred to as the split treatment model. He asserts that even if the psychiatrist’s role is primarily pharmacological, it is still important to provide some level of psychotherapy within this framework. It is imperative that we, as psychiatric nurses, avoid assuming a similar limited role. We need to be cautious not to overemphasize the use of pharmacotherapy, while overlooking other therapeutic interventions. Nursing theory is grounded in viewing the patient as a biological, psychological, and social being and emphasizes the interplay between these three spheres (McFarlane, 1980). Theory guides the practice of nursing, and it is essential that in our practice we do not limit our focus solely to the biological aspects of psychiatric illness (Colley, 2003).
Many nurse theorists have identified the importance of seeing the patient as one who interacts with the environment to achieve and maintain psychological, social, and physical health. For example, the nurse theorist Martha Rogers identified the primary purpose of nursing as promoting the overall health and wellness of the patient. She proposed that nursing practice is an art and a science and should entail noninvasive modalities, such as therapeutic touch, humor, guided imagery, and use of color, light, music, and meditation, focusing on the person’s health potential. Rogers (1992) believed pain management, supportive psychotherapy, and motivation for rehabilitation are areas that nursing practice should emphasize. Sister Callista Roy, founder of the Adaptation Model of Nursing, saw the person holistically as a biopsychosocial being who needs to adapt to the environment to maintain wellness (Roy & Andrews, 1976). Another major nurse theorist, Virginia Henderson (1966), emphasized the idea of biophysiology, culture, communication, and human needs as central to the care of patients.
Hildegard Peplau (1962), the foremost theorist and leader of psychiatric nursing and advocate for individuals with mental illness, considered interpersonal techniques as the “crux of psychiatric nursing.” She believed the counseling role was the heart of psychiatric nursing practice. While she also identified nurses as technical experts, which would seem to apply to the role of psychotropic prescriber, administer, and educator, the roles of resource person, counselor, and surrogate were perceived as the most important.
Bedside nurses, nurse educators, APNs, and nurse administrators have a responsibility to promote and practice holistic care based on nursing theory. Steps to prevent a myopic focus on medication interventions need to be identified. For example, nurse educators should continue to include psychology, ethics, nutrition, wellness, and sociology components along with core nursing and life sciences curriculum requirements. At the graduate level, educators should preserve the didactic and clinical components of psychotherapy of the individual, family, and group in addition to psychiatric assessment, psychopathology, and pharmacology. Even if nurses are primarily involved in administering or prescribing medication, this broad education will aid them in more fully understanding the patient and promote therapeutic interactions with patients and families. Postmaster and postdoctoral training in psychotherapy should be encouraged for nurses who plan to work in private practice, as is customary with other psychiatric professionals.
In practice, APNs should apply psychological, social, and family theory in their work with patients, in addition to pharmacotherapy and biological theory. Certainly, if the APN is in the role of psychotherapist this would be the case. However, even if the APN’s role is primarily prescribing medication, a therapeutic approach based on these theories will improve outcomes. Patients are more likely to benefit from medication if it is incorporated into a holistic treatment plan. For example, APNs need to assess and address how the family is reacting to the patient’s need for medication. The family’s support of pharmacological treatment is often vital in a achieving medication adherence. Without knowledge of family system theory, APNs are not prepared to provide optimum treatment to support the best outcomes for the patient. Furthermore, the importance of understanding the cultural identities of patients and their families and how these influence their understanding of medication cannot be overstated. How does the patient feel about taking the medication? What is the family’s and cultural beliefs about medication? These are important questions nurses need to explore with patients and their families.
While economic changes and managed care organizations are influencing patient care, nurse leaders need to make sure that the care nurses provide represents the full caliber of nursing capabilities, as recommended in the Future of Nursing report from the Institute of Medicine (2011). Nurse managers should provide a dynamic, therapeutic environment on inpatient and partial hospitalization units, despite staffing cuts. Since an integral part of the nurse’s role is to interact therapeutically with patients and their families, nurses should continue to be involved in running patient and family groups on the unit as part of an interdisciplinary team. Additionally, nurses need to continue to educate patients and families about medications. The ability to do so needs to be supported with ongoing education related to social, psychological, and biological theory.
Nurse administrators need to remember that the nurse’s most powerful tool is the use of self. When critical decisions are made regarding staffing levels and educational preparation and experience in the planning for patient care, the value of the nurse as a therapeutic tool should not be underestimated. Nurses are much more than medication administrators and prescribers. In this day of cost-consciousness, nurses’ capabilities should be used to the fullest. We should be asking, in addition to prescribing medication, what else can nurses do to improve patients’ health? Nurses are well prepared to educate patients about the benefits of exercise, healthy eating, and stress management; nurse administrators and managers should capitalize on this for the benefit of patients. These significant factors influence health and should not be overlooked, particularly in those with chronic mental illness, as they have significantly greater morbidity and mortality than the general population.
As nurses, we are well equipped to provide integrated holistic care to psychiatric patients. Because of our core beliefs and education, we view the person as a biopsychosocial being. Although we incorporate psychotropic medications in the care of our patients, it doesn’t reflect the essence of what we do. Despite external forces that may contribute to a limited perspective on how psychiatric care is provided to individuals and their families, we need to maintain our own vision of what constitutes excellence in psychiatric nursing care.
Mary Cullen-Drill, DNP, APN-BC, DCC
Assistant Professor of Clinical Nursing
Columbia University School of Nursing
Private Psychotherapy and
Montclair, New Jersey
Kathleen M. Prendergast, MSN, PMH-NP, BC
Clinical Adjunct Faculty
School of Nursing
Newark, New Jersey
Advanced Practice Nurse
Care Plus NJ
Paramus, New Jersey
Private Psychotherapy and
Caldwell, New Jersey
- Carlat, D. (2010, April23). Mind over meds. New York Times. Retrieved from http://www.nytimes.com/2010/04/25/magazine/25Memoir-t.html
- Colley, S. (2003). Nursing theory: Its importance to practice. Nursing Standard, 17(46), 33–37.
- Grant, A. (2011). A critique of the representation of human suffering in the cognitive behavioural therapy literature with implications for mental health nursing practice. Journal of Psychiatric and Mental Health Nursing, 18, 35–40. doi:10.1111/j.1365-2850.2010.01623.x [CrossRef]
- Henderson, V. (1966). The nature of nursing: A definition and its implications for practice, research, and education. New York: MacMillan.
- Hyun, A. & Alfonso, C.A. (2011). Epilogue: Conversations between a psychoanalyst and a psychiatry resident. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 39, 221–227. doi:10.1521/jaap.2011.39.1.221 [CrossRef]
- Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Retrieved from the National Academies Press website: http://www.nap.edu/catalog.php?record_id=12956
- Lüllmann, E., Berendes, S., Rief, W. & Lincoln, T.M. (2011). Benefits and harms of providing biological causal models in the treatment of psychosis–An experimental study. Journal of Behavioral Therapy and Experimental Psychiatry, 42, 447–453. doi:10.1016/j.jbtep.2011.03.003 [CrossRef]
- McFarlane, E.A. (1980). Nursing theory: The comparison of four theoretical proposals. Journal of Advanced Nursing, 5, 3–19. doi:10.1111/j.1365-2648.1980.tb00206.x [CrossRef]
- Peplau, H.E. (1962). Interpersonal techniques: The crux of psychiatric nursing. American Journal of Nursing, 62(6), 50–54.
- Preskorn, S.H. (2010). CNS drug development: Part II: Advances from the 1960s to the 1990s. Journal of Psychiatric Practice, 16, 413–415. doi:10.1097/01.pra.0000390760.12204.99 [CrossRef]
- Rogers, M.E. (1992). Nursing science and the space age. Nursing Science Quarterly, 5(1) 27–34. doi:10.1177/089431849200500108 [CrossRef]
- Roy, C. & Andrews, H.A. (1976). The Roy Adaptation Model. Upper Saddle River, NJ: Prentice Hall.