NLE Foundations of Psychiatric & Mental Health Nursing — Foundations of Mental Health & Psychiatric NursingRevision Notes

Exam Tips

• If the NLE asks 'Which best describes mental health?', choose the answer that includes positive functioning and well-being, NOT just 'no mental illness'.
• Remember the three domains of mental health factors: Biological, Psychological, Sociocultural (BPS model) – useful for nursing assessment questions.
• Philippine-context items may ask about barriers to mental health care – always consider stigma and cultural beliefs as priority answers.
• Link to Maslow: Mental health addresses all levels of the hierarchy; a mentally ill client may have unmet safety, love/belonging, and esteem needs simultaneously.

Key Points

• Mental health is defined by the WHO as a state of emotional, psychological, and social well-being in which a person realises his own abilities, copes with normal stresses of life, works productively, and contributes to his community.
• Mental health is NOT simply the absence of mental illness – this distinction is frequently tested on the NLE.
• Mental illness refers to clinically significant disturbances in cognition, emotional regulation, or behaviour that cause distress or impairment in daily functioning.
• Mental health and mental illness exist on a CONTINUUM – a person moves along this continuum based on stressors, coping resources, and available support.
• Characteristics of a mentally healthy person: positive self-concept, capacity for satisfying interpersonal relationships, autonomy, accurate perception of reality, environmental mastery, and adaptability to change.
• Biological factors influencing mental health include genetics, neurochemistry (dopamine, serotonin, norepinephrine, GABA imbalances), physical health, and nutrition.
• Psychological factors include temperament, self-concept, past experiences, and coping skills.
• Sociocultural factors include family structure, poverty, education, culture, and spirituality. In the Philippine context, the extended family (pamilya) and strong religiosity (relihiyosidad) serve as PROTECTIVE factors.
• Stigma is a major barrier to help-seeking in the Philippines – terms like 'baliw' and attributing psychiatric symptoms to spiritual causes (kulam, usog) delay treatment and are culturally significant nursing concerns.
• Under RA 9173 (Philippine Nursing Act of 2002), nurses have the legal and ethical obligation to provide care without discrimination, which includes psychiatric clients facing stigma.

Definitions

Section Title

Concepts of Mental Health and Mental Illness

Common Mistakes

• Defining mental health only as the absence of mental illness – the NLE may give this as a wrong answer option.
• Forgetting that stigma is identified as a BARRIER rather than a protective factor in Philippine psychiatric nursing care.
• Confusing protective sociocultural factors (family, spirituality) with barriers (stigma, attribution to spiritual causes) – both are present in Filipino culture simultaneously.

Exam Tips

• For Erikson NLE items: First identify the CLIENT'S AGE, then match to the stage and its conflict. Example: 'A 70-year-old retired teacher reviews her life with satisfaction' → Ego Integrity vs. Despair (older adult).
• A Filipino clinical example: A toddler hospitalised for bronchopneumonia begins clinging to mother and refusing to feed independently → regression AND struggle with Autonomy vs. Shame/Doubt.
• Remember the acronym for Erikson's virtues in order: Hope, Will, Purpose, Competence, Fidelity, Love, Care, Wisdom (HWPCFLCW) – create a Filipino mnemonic to remember this.
• For Freud items: If the question mentions 'unconscious', 'pleasure', or 'immediate gratification' → ID. If it mentions 'rational', 'mediates', or 'defense mechanisms' → EGO. If it mentions 'guilt', 'conscience', or 'morality' → SUPEREGO.
• Peplau's nursing theory (phases: Orientation, Identification, Exploitation, Resolution) is the psychiatric nursing extension of Sullivan – expect at least one NLE item on this.

Key Points

• Freud's psychoanalytic theory describes three personality structures: ID (unconscious, pleasure principle, present at birth), EGO (largely conscious, reality principle, mediator, seat of defense mechanisms), and SUPEREGO (moral conscience, develops age 3–6, strives for perfection, produces guilt).
• Freud's levels of awareness: Conscious (current awareness), Preconscious (retrievable memories), Unconscious (repressed material that drives behaviour without the person's awareness).
• MOST TESTED Freud content: The id–ego–superego structure and the concept of the unconscious.
• Freud's psychosexual stages (Oral, Anal, Phallic, Latency, Genital) – fixation at any stage produces characteristic adult personality traits, but these are less NLE-emphasised than Erikson.
• Erikson described 8 psychosocial stages spanning the ENTIRE LIFESPAN, each with a core CONFLICT and a resulting VIRTUE if successfully resolved.
• Stage 1: Infancy (0–18 mo) – Trust vs. Mistrust → Virtue: Hope
• Stage 2: Toddler (18 mo–3 y) – Autonomy vs. Shame/Doubt → Virtue: Will
• Stage 3: Preschool (3–6 y) – Initiative vs. Guilt → Virtue: Purpose
• Stage 4: School Age (6–12 y) – Industry vs. Inferiority → Virtue: Competence
• Stage 5: Adolescence (12–20 y) – Identity vs. Role Confusion → Virtue: Fidelity
• Stage 6: Young Adult (20–40 y) – Intimacy vs. Isolation → Virtue: Love
• Stage 7: Middle Adult (40–65 y) – Generativity vs. Stagnation → Virtue: Care
• Stage 8: Older Adult (65+ y) – Ego Integrity vs. Despair → Virtue: Wisdom
• Sullivan's Interpersonal Theory emphasises the importance of relationships and the 'self-system'; Peplau applied Sullivan's work to nursing to define the phases of the nurse–patient therapeutic relationship.
• Maslow's Hierarchy of Needs (Physiologic → Safety → Love/Belonging → Esteem → Self-Actualisation) guides nursing prioritisation in psychiatric settings.
• In psychiatric nursing, Maslow's hierarchy means: SAFETY needs (e.g., suicidal ideation) are prioritised OVER psychological/social needs.

Definitions

Section Title

Personality Theories – Freud and Erikson

Common Mistakes

• Confusing the id's pleasure principle with the ego's reality principle – the ID wants immediate gratification; the EGO considers reality.
• Mismatching Erikson's stages with age groups, especially Toddler (18 mo–3 y) vs. Preschool (3–6 y) – a common NLE trick.
• Forgetting that Erikson covers the ENTIRE lifespan, not just childhood – the last three stages (Intimacy, Generativity, Ego Integrity) are frequently tested.
• Confusing the virtue/quality associated with each stage – remember: Trust→Hope, Identity→Fidelity, Ego Integrity→Wisdom.
• Thinking the conscious mind is larger than the unconscious – in Freudian theory, the unconscious is the largest repository of mental content (like an iceberg).

Exam Tips

• NLE classic question: 'A client who is angry at her doctor complains that the doctor is angry at her.' → This is PROJECTION (attributing her own anger to the doctor).
• NLE classic question: 'A nurse who is furious at her head nurse goes home and shouts at her children.' → This is DISPLACEMENT (redirecting anger to a safer target).
• NLE classic question: 'Which defense mechanism is conscious?' → SUPPRESSION. Always.
• NLE classic question: 'Which defense mechanism is most mature/adaptive?' → SUBLIMATION. Always.
• NLE classic question: 'Which is the cornerstone/basic defense mechanism?' → REPRESSION. Always.
• Use client scenarios to identify the mechanism: Ask yourself 'Is the client denying reality? Projecting? Redirecting feelings or impulses?' then match to the definition.
• Remember: Defense mechanisms exist on a spectrum from PRIMITIVE (denial, regression, projection) to MATURE (sublimation, humour, suppression).

Key Points

• Defense mechanisms are UNCONSCIOUS strategies used by the EGO to protect itself from anxiety, manage internal conflict, and maintain psychological equilibrium.
• They become MALADAPTIVE only when overused, used exclusively, or when they replace healthy problem-solving.
• CRITICAL EXCEPTION: SUPPRESSION is the ONLY CONSCIOUS defense mechanism.
• SUBLIMATION is the MOST MATURE and most adaptive defense mechanism.
• REPRESSION is considered the CORNERSTONE or most fundamental defense mechanism – it is the involuntary blocking of painful thoughts or memories from conscious awareness.
• DENIAL: Refusing to accept a painful reality (e.g., newly diagnosed cancer patient who says 'The doctor must be wrong').
• PROJECTION: Attributing one's own unacceptable feelings or impulses to another person (e.g., 'She hates me' when the client actually feels hatred).
• DISPLACEMENT: Transferring feelings from a threatening target to a safer substitute target (e.g., scolded by supervisor, then shouts at family members at home).
• RATIONALISATION: Providing logical, acceptable reasons to justify unacceptable behaviour or feelings (e.g., 'I failed the NLE because the questions were ambiguous').
• REACTION FORMATION: Behaving in a manner exactly opposite to one's true feelings (e.g., being excessively kind to someone you intensely dislike).
• REGRESSION: Reverting to behaviours characteristic of an earlier developmental stage under stress (e.g., a school-age child begins bedwetting after hospitalisation).
• SUBLIMATION: Channelling unacceptable impulses into socially acceptable and often productive activities (e.g., redirecting aggression into competitive sports or artistic expression).
• UNDOING: Performing an act intended to cancel out or negate a previous unacceptable act (e.g., bringing a gift to apologise after an argument).
• COMPENSATION: Covering a real or perceived weakness by excelling in another area (e.g., a student with poor social skills excels academically).
• IDENTIFICATION: Modelling oneself on an admired person, adopting their characteristics.
• CONVERSION: Converting emotional conflict or anxiety into a physical symptom that has no organic/physiological basis (e.g., sudden blindness or paralysis with no neurological cause).
• SUPPRESSION (conscious): Deliberately choosing to postpone thinking about a stressful matter (e.g., 'I won't worry about the NLE results until tomorrow').
• INTROJECTION: Internalising the values, beliefs, or characteristics of another person.
• INTELLECTUALISATION: Using abstract, intellectual reasoning to emotionally distance oneself from a stressful situation.

Definitions

Section Title

Defense Mechanisms

Common Mistakes

• Stating that ALL defense mechanisms are unconscious – SUPPRESSION is the one conscious exception.
• Confusing Repression with Suppression: Repression is INVOLUNTARY/UNCONSCIOUS; Suppression is VOLUNTARY/CONSCIOUS.
• Confusing Projection with Displacement: Projection attributes your OWN feelings to others; Displacement transfers feelings from one TARGET to another.
• Confusing Reaction Formation with Undoing: Reaction Formation is ongoing opposite behaviour; Undoing is a specific corrective act after an unacceptable one.
• Forgetting that Sublimation is the MOST MATURE defense mechanism – students often choose 'compensation' by mistake.

Exam Tips

• MOOD vs. AFFECT memory trick: Mood = 'Me report' (client reports it); Affect = 'A nurse watches' (nurse observes it).
• NLE item pattern: A scenario describes an observation made by the nurse (e.g., 'The nurse observes that the client shows no facial expression') → this is FLAT AFFECT (objective/observed).
• NLE item pattern: A scenario says 'The client states he feels happy' → this is MOOD (subjective/reported).
• Always remember: Auditory hallucinations = most common in SCHIZOPHRENIA. Visual hallucinations = more common in organic conditions and substance withdrawal (e.g., delirium tremens in alcohol withdrawal).
• The MSE follows a logical head-to-toe-like pattern: observe APPEARANCE first (what you see when the client walks in), then SPEECH, then explore MOOD/AFFECT, THOUGHT, PERCEPTION, and lastly test COGNITION and assess INSIGHT/JUDGMENT.
• For MMSE: A score of 24–30 = normal; 18–23 = mild cognitive impairment; below 18 = moderate to severe impairment.

Key Points

• The MSE is the psychiatric equivalent of the physical examination – a structured, systematic assessment of the client's current mental functioning documented at a specific point in time.
• The MSE is primarily an OBSERVATIONAL tool used during the nursing assessment phase of the nursing process.
• APPEARANCE: Grooming, hygiene, dress, posture, and whether apparent age matches stated age.
• BEHAVIOUR/PSYCHOMOTOR ACTIVITY: Eye contact, gait, degree of psychomotor agitation or retardation, tics, tremors, and level of cooperation.
• SPEECH: Rate (fast/slow), volume (loud/soft), quantity (talkative/mute), and articulation. Pressured speech is associated with MANIA; poverty of speech is associated with DEPRESSION and SCHIZOPHRENIA.
• MOOD vs. AFFECT (critical distinction): MOOD is the client's SUBJECTIVE, SELF-REPORTED sustained emotional state (what the client says they feel – 'I feel sad'). AFFECT is the OBJECTIVE, NURSE-OBSERVED external expression of emotion.
• Affect descriptors: broad (normal range), restricted/constricted, blunted (significantly reduced), flat (absent), or labile (rapid shifts). Affect can be congruent (matches mood) or incongruent with mood.
• THOUGHT PROCESS: The FORM or structure of thinking – how ideas are linked. Examples: logical/coherent (normal), circumstantial (eventually gets to the point but with excessive detail), tangential (never gets to the point, goes off on tangents), flight of ideas (rapid, loosely connected thoughts – mania), loose associations (thoughts with minimal logical connection – schizophrenia), word salad (completely incoherent combinations of words).
• THOUGHT CONTENT: WHAT the client actually thinks – delusions (fixed false beliefs), obsessions, phobias, suicidal ideation, homicidal ideation. Suicidal ideation MUST be assessed directly.
• PERCEPTION: Hallucinations (false sensory perceptions without external stimuli) – Auditory (most common in schizophrenia), Visual, Tactile, Olfactory, Gustatory. Illusions are misinterpretations of real external stimuli.
• COGNITION/SENSORIUM: Level of consciousness, orientation (person, place, time – assessed in that order), attention and concentration, memory (immediate, recent, remote), abstract thinking (proverb interpretation), and fund of knowledge.
• The Mini-Mental State Examination (MMSE) is a validated tool used within the MSE to quantify cognitive functioning (scored out of 30; scores below 24 suggest cognitive impairment).
• INSIGHT: The client's awareness and understanding of their own illness and its effects.
• JUDGMENT: The client's ability to make sound, realistic decisions in everyday situations.
• The nurse documents MSE findings using objective, behavioural, and non-judgmental language.

Definitions

Section Title

The Mental Status Examination (MSE)

Common Mistakes

• Confusing MOOD (subjective/reported by client) with AFFECT (objective/observed by nurse) – this is one of the most frequently tested distinctions in psychiatric nursing.
• Confusing THOUGHT PROCESS (form/how) with THOUGHT CONTENT (what) – process is HOW thoughts are connected; content is the IDEAS themselves.
• Confusing HALLUCINATIONS (no external stimulus) with ILLUSIONS (misinterpretation of a real external stimulus).
• Not including suicidal ideation assessment in thought content – always directly assess for SI during the MSE.
• Describing flat affect and blunted affect interchangeably – blunted means significantly reduced; flat means virtually absent.

Exam Tips

• NLE item pattern: 'Which law protects the rights of persons with mental illness in the Philippines?' → RA 11036.
• NLE item pattern: 'Which body was created by RA 11036 to oversee mental health policy?' → Philippine Council for Mental Health (PCMH) under the DOH.
• NLE item pattern: 'A psychiatric client refuses medication. What should the nurse do first?' → Respect the right to refuse (RA 11036), explain the purpose, explore reasons for refusal, and inform the psychiatrist – do NOT forcibly administer except in emergencies.
• Remember the year: RA 11036 was enacted in 2018 – the FIRST national mental health law in Philippine history.
• The NCMH Crisis Hotline number (1553) may appear in community/mental health context questions.
• Connect RA 11036 to your nursing documentation responsibilities: confidentiality of psychiatric records is a legal obligation under this law.

Key Points

• Republic Act No. 11036, known as the PHILIPPINE MENTAL HEALTH ACT, was signed into law in 2018. It is the FIRST national mental health legislation in the Philippines.
• RA 11036 is RIGHTS-BASED: It affirms the rights of mental health service users to the best available care, confidentiality, informed consent, treatment in the least restrictive environment, and freedom from discrimination, torture, and inhumane treatment.
• KEY MANDATE: Integration of mental health services into the general health system, including at the COMMUNITY and BARANGAY level and into the basic health services of Local Government Units (LGUs).
• RA 11036 created the PHILIPPINE COUNCIL FOR MENTAL HEALTH (PCMH), an inter-agency body under the Department of Health (DOH), tasked with overseeing implementation and coordination of mental health programs.
• RA 11036 requires mental health programs in EDUCATIONAL INSTITUTIONS and WORKPLACES.
• RA 11036 mandates SUICIDE PREVENTION programs and public education initiatives to reduce stigma.
• Clients have the right to REFUSE TREATMENT except in specifically defined circumstances (e.g., imminent danger to self or others).
• RA 11036 includes provisions for SUPPORTED DECISION-MAKING and ADVANCE DIRECTIVES for mental health care.
• The NATIONAL CENTER FOR MENTAL HEALTH (NCMH), located in Mandaluyong City, is the country's premier psychiatric institution and operates the NCMH CRISIS HOTLINE for suicide and mental health emergencies (1553).
• The National Mental Health Program is led by the DOH and is integrated into the UNIVERSAL HEALTH CARE ACT (RA 11223) benefit package.
• RA 9165 (Comprehensive Dangerous Drugs Act) is the relevant law for clients with substance use disorders – nurses apply this within the psychiatric nursing framework.
• Under RA 9173 (Philippine Nursing Act of 2002), Filipino nurses have the legal and ethical duty to provide care that upholds all provisions of RA 11036, including patient rights and non-discrimination.
• The LEAST RESTRICTIVE ENVIRONMENT principle means the nurse should use the lowest level of intervention necessary – prioritise therapeutic communication and de-escalation before restraints.
• CONFIDENTIALITY under RA 11036 protects psychiatric clients' information from unauthorised disclosure, supporting their dignity and encouraging help-seeking.

Definitions

Section Title

Philippine Mental Health Act – RA 11036

Common Mistakes

• Confusing RA 11036 (Philippine Mental Health Act, 2018) with RA 9173 (Philippine Nursing Act, 2002) – both are tested on the NLE but address different domains.
• Stating that a client with mental illness has NO right to refuse treatment – RA 11036 grants this right EXCEPT in specified circumstances (imminent danger to self or others).
• Forgetting that mental health services under RA 11036 must be integrated at the BARANGAY and community level, not only in tertiary hospitals.
• Mixing up the NCMH (National Center for Mental Health) with the PCMH (Philippine Council for Mental Health) – NCMH is the hospital; PCMH is the policy-making inter-agency body.
• Failing to connect RA 11036 to RA 11223 (Universal Health Care Act) – mental health is included in the UHC benefit package.

Exam Tips

• NLE prioritisation question: 'A nurse has four psychiatric clients. Client A is delusional but calm; Client B is anxious and crying; Client C is verbalising suicidal ideation with a specific plan; Client D is refusing medication.' → ALWAYS prioritise Client C (safety: risk of self-harm).
• Maslow's hierarchy in psychiatric nursing: Safety (suicidal/homicidal risk) > Physiologic needs (if acutely compromised by psychiatric illness) > Love/Belonging > Esteem > Self-Actualisation.
• NLE therapeutic communication question: If one option includes 'Don't worry' or 'You'll be fine' → this is the WRONG (non-therapeutic) answer.
• Connect Peplau's phases to nursing process: Orientation = Assessment; Identification = Nursing Diagnosis + Planning; Exploitation = Implementation; Resolution = Evaluation.
• RA 9173 scope: Remember that psychiatric nursing is within the independent practice of a professional nurse in the Philippines – you do not need a physician's order to perform therapeutic communication, MSE documentation, or milieu management.

Key Points

• SAFETY is the absolute FIRST PRIORITY in all psychiatric settings. Assessing for risk of harm to self or others must occur at every client contact.
• A client with suicidal ideation + a specific plan + means to carry it out is the HIGHEST PRIORITY among all psychiatric clients – safety overrides all other concerns (Maslow: Safety > all psychological needs).
• The THERAPEUTIC USE OF SELF is the primary tool of the psychiatric nurse – using one's own personality, insights, perceptions, and verbal/non-verbal communication deliberately to facilitate the therapeutic relationship.
• ESTABLISHING TRUST is foundational: achieved through consistency, honesty, acceptance, empathy, and a non-judgmental presence.
• SETTING THERAPEUTIC LIMITS: The nurse sets clear, consistent limits on harmful or disruptive BEHAVIOURS while simultaneously communicating unconditional acceptance of the PERSON.
• MAINTAINING A THERAPEUTIC MILIEU: Creating and sustaining a safe, structured environment that promotes healing, includes clear rules, supportive staff relationships, and client involvement in decision-making.
• SELF-AWARENESS: The nurse continuously examines her own feelings, values, biases, and countertransference reactions to prevent them from intruding on therapeutic care.
• COUNTERTRANSFERENCE: The nurse's emotional reactions to the client (can be positive or negative); must be recognised and managed through supervision and self-reflection.
• THERAPEUTIC COMMUNICATION: Use open-ended questions, active listening, reflection, clarification, and silence therapeutically. Avoid false reassurance ('Don't worry, everything will be fine'), moralising, and advising.
• NANDA nursing diagnoses commonly applied in psychiatric nursing foundations: Risk for Self-Directed Violence; Ineffective Coping; Disturbed Thought Processes; Disturbed Sensory Perception; Anxiety; Social Isolation; Impaired Social Interaction; Powerlessness.
• The Nursing Process (ADPIE) is fully applicable in psychiatric nursing: Assessment (MSE, history), Diagnosis (NANDA), Planning (priority-based goals), Implementation (therapeutic interventions), Evaluation (client outcomes).
• Peplau's Four Phases of the Nurse-Patient Relationship: Orientation (establishing rapport, identifying needs), Identification (client begins to work with nurse), Exploitation (client uses nurse's services and resources), Resolution (goals met, relationship ends therapeutically).
• Under RA 9173 (Philippine Nursing Act), the nurse practices within the scope defined for professional nurses, which includes independent, dependent, and interdependent psychiatric nursing functions.

Definitions

Section Title

Nursing Management and Priority Interventions in Psychiatric Nursing

Common Mistakes

• Prioritising medication administration over safety assessment – ALWAYS assess safety FIRST before any other intervention.
• Using false reassurance ('Everything will be okay') which is a non-therapeutic communication technique and invalidates the client's feelings.
• Confusing transference (client's feelings toward the nurse) with countertransference (nurse's feelings toward the client).
• Failing to include self-awareness and countertransference management as part of the nurse's professional role.
• Forgetting that setting limits is about BEHAVIOUR, never about rejecting the PERSON – the therapeutic relationship must be maintained while redirecting harmful behaviour.