A registered psychiatric nurse (RPN) is a nurse that specialises in holistic physical and mental health promotion. RPNs are often licensed as registered nurses that work in psychiatric-mental health settings. Depending on their regulatory body's requirements, they may have additional training, education and/or experience in psychiatric-mental health nursing. The exception being in Canada, where the western provinces regulate registered psychiatric nurses (RPNs) separately from registered nurses (RNs). Nurses there that have completed a diploma or bachelor's degree program in psychiatric nursing receive the title RPN, but both RNs and RPNs may work in psychiatric-mental health and substance use roles. [1] [2]
RPNs provide mental health care through the bio-psycho-social model of health and well-being. The care provided by these nurses focus on addressing the complex determinants of health of each patient. Research has shown individuals with significant mental health issues are disproportionately at risk for poor physical health outcomes. RPNs as a result take a person-centered approach to assessment, treatment and advocacy for their patients. Meaning, they individualise physical and mental health care they provide to patients. This ensures that the patient is connected with the most appropriate resources. RPNs are also specialized in therapeutic communication and interpersonal techniques to provide safe and therapeutic nursing care. [3]
Often RPNs work in collaboration with a team of health professionals, such as family physicians, psychiatrists, other nurses and social workers. This may be in a hospital setting, long-term care centre, primary community clinic or mental health outreach team. Diagnosing patients using the medical model is beyond the scope of practice for RPNs. However, in some jurisdictions RPNs are permitted to practice independently. This is different from nurses that have completed a masters degree in nursing, which allows a wider, independent scope of practice. [3]
Psychiatry in Australia has been historically influenced by the colonial origins of the states since the first penal colony settlements. [4] The first psychiatric insitution in Australia was established in 1838 and many more appeared of the 100 years following. [4] However, care for psychiatric patients was not generally haphazard and not recognized seriously as nursing care, it was not until the 1930's that psychiatric nursing was registered. At that time psychiatric nursing regulation was up to the states, with formal psychiatric nursing training at Royal Dewent Hospital in Tasmania starting in 1935 and opening nursing registration in 1936. For Western Australia however, they did not have registered mental health nurses regulated by the nursing board until 1944. [5] Victoria also struggled to professionalize psychiatric nurses during this time, which operated up to this point mental institutions in deplorable conditions for both the patient and attendants. With the Mental Hygiene Act of 1933 Victoria hospitals of psychiatric patients became mental hospitals with the trained attendant renamed as a Mental Nurse. This signalled a changing tone in how patients were treated and seen as a step towards professionalizing mental health nursing in Victoria. [5]
Australia developed a private health care system, which during the 70's underwent a move towards deinsitutionalization of psychiatric health care. [4] Under the 3-step National Mental Health Strategy plan between 1993 to 2008 psychiatric nursing care moved more into the community. Mental health nurses became involved in specialized community services such as assertive community treatment, crisis intervention teams and social recovery services. [4]
Psychiatric nursing in New Zealand originated in prisons. However, from 1850, psychiatric patients were then treated in mental asylums. [6] At first, non-qualified supervisors had the authority to assess and treat any patients. [6] The New Zealand approach for psychiatric care of patients in mental asylums then adopted the structure of the British mental health system. [6] In 1905, under the Mental Hygiene Division of the Department of Health, psychiatric nursing training commenced. [6] By 1948, registration of psychiatric nursing became recognised by the Nurses’ and Midwives’ Board. [7] The history of care between psychiatric patient and psychiatric nurse morphed from a physical care to more of a personal and interactive relationship. [8]
The inpatient model in the United States before the 1950s was considered the most effective way of treating mental illnesses. [9] However, there was a push for de-institutionalisation as there was a belief that patients would receive better care outside of these psychiatric hospitals. [9] By the 1960s many patients were moved from the hospitals to local facilities or mental health homes where they received personalised care by qualified psychiatric nurses. The number of institutionalised mentally ill patients fell from 560,000 in the 1950s to 130,000 by 1980. [9]
Finland built its biggest hospitals during the 1920s and 30s. From the start, psychiatric nurses were the primary staff responsible for the care of the mentally ill. [10] The treatment in Finland was mostly institutionalised and during the 1970s, more psychiatric hospitals were being built and psychiatric nurses remained the biggest group within these facilities. [10]
In 1833, one of the first mental hospitals, which were called lunatic asylums at the time was established in Ballinasloe. [11] There were no significant differences between a general nurse and a psychiatric one, they both provided care to their patients. [12] However, psychiatric nursing roles were typically untrained and were former patients themselves in these asylums. Once their treatment was fulfilled, they were allowed to stay and continue to deliver care to other patients in these institutions. [12] These origins made psychiatric nursing less respected and had a substandard reputation, this was until Florence Nightingale's professional treatment of patients became the gold standard for nursing. [12] As nursing in general became more professionalised by the skills and training they were now required to have, psychiatric nursing, however, still had a stigma of being seen as an inferior field of nursing. [12] As time went on, training became an important part of psychiatric nursing and it allowed these nurses to specialise in the treatment of mental illnesses. [12] In Ireland today, psychiatric nursing is seen as a more respected career choice and are essentially intermediaries between patient and doctor with both sides depending on a trusting relationship to accurately treat a patient's mental illness. [13]
There is an east-west split in Canada of how nurses in psychiatric and mental health work are educated and regulated. At the beginning of the 20th century care for psychiatric patients in Canada was performed in asylums, which rebranded themselves into mental institutions. It was typical across the country that care was provided by the untrained attendants under the strict control of psychiatrists and other institution leadership.
Ontario hospitals in 1909 began offering 3-year mental health nursing curriculum training, shifting the workers in institutions from untrained to trained mental health nurses. There were changes however, inspired by the american nursing system and mental hygiene movement, to cross-train mental health nurses with generalist nurses. By the 1930's there were established affiate training in both mental and general hospitals for psychiatric nurses and generalist nurses. Further shift towards an integrated, balanced nursing education standard occured in a phased approach negotiated by nursing leadership, the government, and psychiatric institution leaders. The eastern provinces have since taken the approach of regulating nurses engaged in mental health care work as registered nurses, which can specialize in mental health and substance use with additional certification. [14]
Western provinces have retained the specialized psychiatric nurse role, licensed as regulated as registered psychiatric nurses (RPNs). [15]
RPNs and mental health nurses work with patients to improve their overall physical and mental health. These patient populations often struggle with mental illnesses and/or substance use issues to varying degrees. Psychiatric nursing care is specialized in developing therapeutic relationships with patients that may otherwise be misunderstood and/or mistreated. It is through understanding the patient's goals, strengths and challenges/barriers that RPNs form assessment and treatment plans. In comparison, registered nurses working in other medical fields do not specialize in therapeutic communication and interpersonal techniques in this way.
RPNs are also skilled in motivating interviewing, risk assessments and resource planning. These nurses use the combination of patient assessment and specialized nursing theory to inform appropriate nursing interventions. In this field of nursing patient interactions and conversations are important in continually assessing for changes to illness, as well as treatment efficacy and tolerability. Sometimes keeping an open line of communication with close family members is a helpful strategy for RPNs looking to strengthen the patients support system. [16]
RPNs utilize their therapeutic relationship with the patient to reduce any barriers they may face accessing treatment to improve health outcomes. This is an important part of safe, effective psychiatric nursing care, as a large proportion of patients may have persistent and/or disabling mental health issues. They also help educate the patient about medications they may be taking, including its effects and side effects profile, as well as any potential interactions with other medications or foods. RPNs may be tasked with dispensing, administering and prescribing medications within their scope of practice. Changes to medication tolerability, illness symptoms and concordance are also monitored by psychiatric nurses.
Brain stimulation through ECT (electro convulsive therapy) and TMS (transcranial magnetic stimulation) are common biological therapies for mental health issues such as major depression. As with other biological therapies, RPNs provide counselling prior to and monitoring during the course of treatment for patients undergoing these procedures. Nurses specialized in psychiatric nursing care work with the patient to express their treatment preferences when exploring treatment options, especially for procedures. This involves exploring the patient's beliefs, values and culture whenever possible. Psychiatric nursing interventions like engaging with the patient in their own treatment promotes health and reduces harm to the patient.
Patients with mental health issues may have or develop co-morbid physical health conditions. This can make treatment more complicated, so psychiatric nurses assess, plan and provide nursing care inclusive of both the patients mental and physical health needs. RPNs communicate with the patient's health care team to ensure the patient receives the most appropriate treatment. Psychiatric nursing care prevents harm caused by medication interactions through the effective coordination of patient health care. Common co-morbidities RPNs may see in clinical practice are diabetes, coronary heart disease, respiratory conditions, as well as liver and kidney diseases.
There are two different types of diabetes. Type 1 diabetes is where the pancreas does not have the ability to produce any insulin. Whereas type 2 diabetes is a condition where there is a reduced sensitivity to insulin. [17] An example of how it affects the patient is that psychotropic medications will generally have a side effect of weight gain. It is important for people, especially people with type 2 diabetes to have control over their weight. It is also shown that psychotropic medication is known to have links to impaired glucose metabolism thus prescribing the right medication and dose is essential to have all medications working how they are prescribed. Psychiatric nurses need to be aware that chronic conditions such as diabetes can only be managed with a mental illness if there is a combination of self-management with the patient and monitoring by the psychiatric nurse.
Psychiatric medications can affect the rhythm of the heart, so people who have a pre-existing heart condition need to have the psychiatric nurse aware of this issue before administering of any psychiatric medications. An electrocardiogram can help detect a heart condition prior to dispensing of psychiatric drug. So, patients need to have the psychiatric nurse aware of any heart problems, so precautions can be taken.
Asthma is a respiratory condition that people who struggle with mental health may neglect and if they do not attend to this, the condition will worsen and sometimes may be fatal. Psychiatric nurses are important to frequently monitor symptoms and encourage the use of asthma related medications such as inhalers.
Smoking is a habit that will exacerbate chronic respiratory conditions, and this will increase the patient's susceptibility in developing infections. Psychiatric nurses will need to observe patients whenever there are signs of respiratory illnesses because psychiatric medications can decrease the respiratory rate of patients and in some cases reduces the effectiveness of the doses.
Liver and kidney problems tend to occur either with alcohol and drugs being abused, or when an individual has a genetic liver problem. People that have a mental health issue tend to misuse alcohol and drugs as a coping mechanism. A study found that ten per cent of psychiatric patients that are prescribed antipsychotic medication have livers that are impaired and not functioning at full capacity. For psychiatric nurses, they need to be aware that some diseases that are liver related might not show in initial liver scans, so they need to be knowledgeable of certain medications that have the potential to further damage the kidney or the liver. An example of this is lithium, this medication can significantly damage an organ, even if it is a minor impairment.
In order to become a mental health nurse in Australia you must first graduate with an undergraduate degree in nursing. After graduation they must apply to Australian Health Practitioner Regulation Agency (AHPRA) to practice as a registered nurse. To begin working as a mental health nurse, registered nurses must be in progress or completed a post-graduate mental health nursing certificate. Working then as a provisionally credentialed mental health nurse is recommended to demonstrate committment to the specialized field of mental health work. Additional education in mental health nursing is required, either completion of a diploma or masters program approved by the Australian College of Mental Health Nurses (ACMHN). Further specialization into specific mental health and substance use populations and therapeutic modalities are available, but optional. Once these steps are completed, registered nurses can become a credentialed mental health nurse.
The New Zealand requirements to work as a qualified psychiatric nurse is a postgraduate certificate in Health Sciences specialising in Mental Health Nursing. This certificate can be attained if the entry requirements have been satisfied, which is an undergraduate degree at either a recognised university or an institution that offers a degree within a health sciences discipline such as nursing, social work, pharmacy and so forth. A current registration with the Nursing Council in New Zealand is also a requirement
To become a psychiatric-mental health nurse in the United States you must complete a nursing program eligible to take the NCLEX-RN exam, such as an associate, diploma bachelor of nursing or accelerated bachelor of nursing degree. Once passing the NCLEX-RN, new graduates can obtain licensure as a registered nurse (RN). In the United States RNs can start working in entry-level mental health care roles, such as in hospitals or agencies without additional education. However, cerifications in psychiatric-mental health nursing are available to RNs with additional experience and training, demonstrating their commitment to the field of mental health nursing. [1]
Some RNs working as psychiatric-mental health nurses opt to take a master's program in psychiatric-mental health nursing. Nurses can then practice as a psychiatric-mental health nurse practitioner (PMH-NP), which further specialize in diagnosing and treating both acute and chronic mental illnesses using the medical model. This means they have greater scope in prescribing, ordering diagnostics and performing advanced procedures in the mental health context. [1]
In Britain, it is possible to qualify as a Registered Mental Nurse (RMN) by completing a BSc in Mental Health Nursing. There are four fields of nursing in the UK: Adult, Mental Health, Learning Disability, and Child (https://www.nmc.org.uk/registration/your-registration/statement-of-entry/registration-and-qualification-codes/).
To qualify as a psychiatric nurse in South Africa, a 4-year nursing science diploma at a recognised nursing college will then open up the possibility for further training in mental health, with a postgraduate degree specialising in Psychiatric Nursing Science. Also, registration with the South African Nursing Council will certify an individual wanting to pursue a career in psychiatric nursing.
A prospective registered psychiatric nurse (RPN) must complete one of the eight approved diploma or bachelor of psychiatric nursing degree programs available in western Canada. RPNs are regulated nursing professionals in the provinces of British Columbia, Alberta, Saskatchewan, Manitoba, and territories of Yukon, Northwest Territories and Nunavut. [18] [2] The Registered Psychiatric Nurse Regulators of Canada (RPNRC) sets the national registered psychiatric nurse competency standards in Canada. New graduates of psychiatric nursing programs must pass the RPNCE exam and become licensed with their provinicial regulatory body to start working as a RPN. [2]
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