INTRODUCTION
The
phases of the nursing process as described by the Standards of Practice in Psychiatric–Mental Health Nursing: Scope and
Standards of Practice are assessment, diagnosis, outcomes identification,
planning, implementation, and evaluation. Validation is part of each step, and all phases may overlap or occur simultaneously. The nursing conditions and related to each of these phases are shown
in. Each of these phases, as it applies to psychiatric nursing practice, is now
described.
STANDARDS OF PRACTICE:
1. Standard
1: Assessment
2. Standard
2: Diagnosis
3. Standard
3: Outcome identification
4. Standard
4: Planning
5. Standard
5: Implementation
Standard 5A: Coordination of care
Standard 5B: Health teaching and health promotion
Standard 5C: Milieu therapy
Standard 5D: Pharmacological, Biological, and integrative
therapies
Advance Practice Interventions 5E to 5G
Standard 5E: Prescriptive Authority and treatment
Standard 5F: Psychotherapy
Standard 5G: Consultation
6. Standard
6:Evaluation
7. Standard
7:Quality of practice
8. Standard
8:Education
9. Standard
9:Professional Practice Evaluation
10.
Standard 10: Collegiality
11.
Standard 11: Collaboration
12.
Standard 12: Ethics
13.
Standard 13: Research
14.
Standard 14.Resource Utilization
15.
Standard 15:Leadership
STANDARD:1 ASSESSMENT
The
psychiatric–mental health registered nurse collects comprehensive
health data that
are pertinent to the patient’s health or situation.
A Systematic, dynamic process by which the nurse, through interaction
with the client, significant others, and health care provides collectives &
analyses data about the client. Data may include the following dimensions –
physical, psychological, socio-cultural, spiritual, cognitive functional
abilities, developmental, economic and life style (ANA-2004)
RATIONALE
The assessment
interview, which requires linguistically and culturally
Effective
communication skills, interviewing, behavioral observation,
record review,
and comprehensive assessment of the patient and relevant systems, enables the
psychiatric–mental health nurse to make
sound clinical judgments and plan appropriate interventions with the patient.
KEY ELEMENTS:
Identify the
patient’s reason for seeking help. Assess for risk factors related to the
patient’s safety, including potential for the following:
·
Suicide
or self-harm
·
Assault
or violence
·
Substance
abuse withdrawal
·
Allergic
reaction or adverse drug reaction
·
Seizure
·
Falls
or accidents
·
Elopement
(if hospitalized)
·
Physiological
instability
·
Complete
a biopsychosocial assessment of patient needs related to this treatment
encounter, including the following:
·
Patient
and family appraisal of health and illness
·
Previous
episodes of psychiatric care in self and family
·
Current
medications
·
Physiological
coping responses
·
Mental
status coping responses
·
Coping
resources, including motivation for treatment and functional
supportive
relationships
·
Adaptive
and maladaptive coping mechanisms
·
Psychosocial
and environmental problems
·
Global
assessment of functioning
·
Knowledge,
strengths, and deficits
In the assessment phase, information is obtained from the patient in a
direct and structured manner through observations, interviews, and examinations.
The nurse also should use the most appropriate behavioral rating
scales. These
can help define current pretreatment aspects
of the patient’s problems, increase the patient’s involvement in treatment, document the patient’s
progress over time and the
efficacy of the treatment plan, and compare the patient’s responses with those of groups of
people with the same illness. This information can help formulate diagnoses and
treatment plans, as well as
document clinical outcomes of care.
Interviewing is
a goal-directed method of communication.It is required in a formal admission
procedure and should be focused but open ended, progressing from general to
specific and allowing spontaneous patient self-expression. The nurse’s
role is to maintain the flow of the interview and to listen to the verbal
and nonverbal messages conveyed by the patient. Nurses also must be aware of
their responses to the patient.
Although the patient should be
regarded as the primary source of validation, the nurse should be prepared to
talk with family members or other people knowledgeable about the patient.
This is particularly important when the patient is unable to provide reliable
information because of the symptoms of the psychiatric illness. The nurse also
might consider using a variety of other information sources, including the
patient’s healthcare record, nursing rounds, change-of-shift reports, nursing
care plan, and evaluation by other health professionals, such as psychologists,
social workers, or psychiatrists.
Standard 2:
Diagnosis
The psychiatric–mental health
registered nurse analyzes the assessment data to determine diagnoses or
problems, including level of risk.
“ Nursing Diagnosis are clinical judgments
about individual, family or community responses to actual are potential health
problems/life processes. A nursing diagnosis provides the basis for selection
of nursing intervention to achieve outcomes for which the nurse is accountable” NANDA-2005
RATIONALE:
The basis for
providing psychiatric–mental health nursing care is the recognition and
identification of patterns of response to actual or potential psychiatric
illnesses, mental health problems, and potential co morbid physical illnesses.
KEY POINTS:
Diagnoses should
reflect adaptive and maladaptive coping responses
based on nursing
frameworks such as those of NANDA International
(NANDA-I).
Diagnoses
should incorporate health problems or disease states such
as
those identified in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR) (American
Psychiatric Association [APA],2000)
and the International Classification
of Diseases and
Related Health Problems (World
Health Organization [WHO], 1992).
Diagnoses
should focus on the phenomena of concern to psychiatric–
mental
health nurses
Structural Parts
A nursing diagnosis
has 3 structural component
·
Problem
(unmet need)
·
Etiology
(Probable cause)
·
Supporting
data (signs and Symptoms)
1. Problem
Problem are unmet
needs describes the state of the patient
at present. Problems that are within the nurse’s domain to treat are termed as
Nursing Diagnoses. The nursing diagnosis title states that what should change.
For example -
Hopelessness
2.
Etiology
Etiology or probable
cause is linked to the diagnostic title with the words ‘ related to’ .Stating
the etiology/probable cause tells what needs to be addressed to effect the
change and identifies causes the nurse can treat through nursing interventions.
For example- Hopelessness related to multiple losses.
3.
Supporting Data
Supporting data or signs or symptoms,
state what the condition is like at present. It may be linked to the diagnosis
and etiology with the words ‘As evidenced by’. Supporting data (defining
characteristics) that validate the diagnosis includes:-
·
The
patients statement
E.g. it’s no use, nothing will change.
·
Lack of
involvement with family and friends.
·
Lack of
motivation to care for self or environment.
A complete nursing
diagnosis must be Hopelessness related to multiple losses, as evidenced by lack of motivation to
care for self”
Format of nursing diagnosis
Two –part statements
Risk problem
Part 1-Nursing diagnosis
·
Risk for
other directed violence
Part 2-Risk factors
·
History
of violence
·
Hyperactivity
secondary to manic stage
·
Low
impulse control
Three-part statements
Actual problem
Part 1-Nursing diagnosis
·
Post
trauma syndrome
Part 2-Etiologic factors(related to)
·
Overwhelming
anxiety secondary to:
1. Rape or assault
2. Catastrophic illness
3. Disasters
4. War
Part 3-Defining characteristics
·
Re
experience of traumatic event
·
Repetitive
dreams or nightmares
·
Excess
verbalization of traumatic event
RISK
DIAGNOSES
“ Problems at risk for becoming actual”
A risk diagnosis
refers to an individual’s vulnerable health status. It means that a person is exposed to factors
that increase chance of injury or illness. If the risk is not addressed by the preventable
efforts of the nurse the potential problems may become actual,
and an actual diagnosis will replace the risk diagnosis.
There are no defining characteristics in a risk
diagnosis as the actual problem has not been manifested. Thus a risk diagnosis has two-part statement and
an actual diagnosis has three-part statement.
Examples of a risk diagnosis
Part 1-nursing diagnosis-Risk for constipation
Part 2-Risk factors-Tricyclic antidepressant
medications
Refusal to
drink water,
juice.
GUIDELINES FOR HEALTH PROMOTION/WELLNESS DIGNOSIS
“Readiness for enhanced level of functioning”
A wellness
diagnosis is a clinical judgment about an individual, family, community in transition from one level of wellness to a higher level.
Most wellness diagnosis are one part statement
.Examples are “Readiness for enhanced
communication”.
PHENOMENA
OF CONCERN FOR PSYCHIATRIC MENTAL HEALTH NURSE:
Ø Promotion of optimal mental and physical health and
wellbeing and prevention of mental illness
Ø Impaired ability to function related to psychiatric,
emotional,and physiological distress
Ø Alterations in thinking, perceiving, and
communicating because of psychiatric disorders or mental health problems
Ø Behaviors and mental states that indicate potential
danger to self or others
Ø Emotional stress related to illness, pain,
disability, and loss
Ø Symptom management, side effects to toxicities
associated with self-administered drugs, psychopharmacological intervention,
and other treatment modalities
Ø The barriers to treatment efficacy and recovery
posed by alcohol and substance abuse and dependence
Ø Self-concept and body image changes, developmental
issues, life process changes, and end-of-life issues
Ø Physical symptoms that occur along with altered
psychological status
Ø Psychological symptoms that occur along with altered
physiological status
Ø Interpersonal, organizational, sociocultural,
spiritual, or environmental
Ø circumstances or events that have an effect on the
mental and emotional well-being of the individual and
Ø family or community
Ø Elements of recovery, including the ability to
maintain housing,employment, and social support, that help individuals reengage
in seeking meaningful lives
Ø Societal factors such as violence, poverty, and
substance abuse
BOX 11-1 PHENOMENA OF CONCERN FOR PSYCHIATRIC–MENTAL HEALTH
NURS
Standard
3: Outcomes Identification
The psychiatric–mental health registered
nurse identifies expected outcomes for a plan individualized to the patient or
to the situation
Rationale
Within
the context of providing nursing care, the ultimate goal is to influence mental
health outcomes and improve the patient’s health status.
Key Elements
·
Outcomes should be mutually identified with the patient.
·
Outcomes should be identified as clearly and objectively as
possible.
·
Well-written outcomes help nurses determine the effectiveness and
efficiency of their interventions.
·
Before defining expected outcomes, the nurse must realize that
patients often seek treatment with goals of their own.
Patient outcomes
may include relieving symptoms or improving functional ability. Sometimes a
patient cannot identify specific goals or may describe them in general
terms. Translating nonspecific concerns into specific goal statements is not
easy. The nurse must understand the patient’s coping responses and the
factors that influence them.
• The patient may view a personal problem as
someone else’s behavior. This may be the case of a father who brings his
adolescent son in for counseling. The father may view the son as the problem,
whereas the adolescent may feel his only problem is his father. One approach to
this situation is to focus help on the person who brought the problem into
treatment because he “owns” the problem at that moment. The nurse might suggest,
“Let’s talk about how I could help you deal with your son. A change in your response
might lead to a change in his behavior also.”
• The patient may express a problem as a feeling,
such as “I’m lonely” or “I’m so unhappy.” Besides trying to help the patient clarify the feeling, the
nurse might ask, “What could you do
to make yourself feel less alone and more
loved by others?” This helps patients see the connection among their actions, thoughts, and
feelings and increase their sense of
responsibility for themselves.
• The patient’s problem may be one of lacking
a goal or an idea of exactly what is desired from life. In this case it
might be helpful for the nurse to
point out that values and goals are
not magically discovered but must be created by people for themselves. The patient can then actively explore ways to construct goals or adopt the
objectives of a social, service, religious,
or political group with whom the patient identifies.
• The patient’s problem may be a choice conflict. This is especially
common if all the choices are unpleasant, unacceptable, or unrealistic. An
example is a couple who wants to divorce but does not want to see their child
hurt or suffer the financial hardship that would result. Although undesirable
choices cannot be made desirable, the nurse can help patients use the
problem-solving process to identify the full range of alternatives available to
them. The patient’s goals may be inappropriate, undesirable, or unclear.
However, the solution is not for the nurse to impose goals on the patient. Even
if the patient’s desires seem to be against self-interests, the most the nurse
can do is reflect the patient’s behavior and its consequences. If the patient
then asks for help in setting new goals, the nurse can help.
Mutually
identifying goals and expected outcomes is an essential step in the
therapeutic process.
Expected
outcomes can be documented using standardized classification systems, such as
the Nursing Outcomes Classification (NOC) (Moorhead et al,2008). Long- and short-term
goals should contribute to the expected outcomes. Following is a sample
expected outcome
and long- and
short-term goals:
Expected outcome: Patient
will be socially engaged in the community.
Long-term goal: The
patient will travel about the community independently within 2 months.
Short-term goals:
• At the end of
1 week, the patient will sit on the front steps at home.
• At the end of
2 weeks, the patient will walk to the corner and back home.
• At the end of
3 weeks, the patient, accompanied by the nurse, will walk in the neighborhood.
• At the end of
4 weeks, the patient will walk in the neighborhood alone.
• At the end of
6 weeks, the patient will drive her car in the neighborhood.
• At the end of
8 weeks, the patient will drive to the mall and meet a friend for dinner.
In writing
goals, psychiatric nurses should remember that they can be classified into the
“ABCs,” or three domains, of knowledge:
1. Affective
(feeling)
2. Behavioral
(psychomotor)
3. Cognitive
(thinking)
Correctly identifying the domain of
the expected outcome is very important in planning nursing interventions. Some
psychiatric nurses place all their emphasis on outcomes related to learning new
information (cognitive). They forget about the equally important needs of
patients to acquire new values (affective) and to master new skills (behavior).
Finally, it is important to explore
with the patient the cost/ benefit effect of all identified goals, that is,
what is being given up (cost) versus what is being gained (benefit) from
attaining the goal. This can be thought of as exploring advantages, or positive
effects, and disadvantages, or negative effects
Patients are not likely to commit themselves to a goal or to work toward
attaining a goal if the stakes are too high or the payoffs too low.
Standard 4:
Planning
The psychiatric–mental health
registered nurse develops a plan that prescribes strategies and alternatives to
attain expected patient outcomes.
Planning phase consists of the total planning of the clients overall
treatment to achieve quality outcomes in a safe, effective, timely manner.
Nursing interventions with rationales are selected in
the planning phase based on the client’s identified risk factors and defining
characteristics.
The process of planning
includes
·
Collaboration
by the nurse with clients, significant others, and treatment team members
·
Identification
of priorities of care
·
Critical
decisions regarding the use of psychotherapeutic principles and practices
·
Coordination
and delegation of responsibilities according to the treatment team’s expertise
as it relates to client needs.
Rationale:
A
plan of care is used to guide therapeutic interventions systematically,
document progress, and achieve the expected patient outcomes.
Key Elements:
The
plan of nursing care must always be individualized for the patient.
Planned
interventions should be based on current evidence in the field and contemporary
clinical psychiatric–mental health nursing practice.
Planning
is done in collaboration with the patient, the family, and the health care
team.
Documentation
of the plan of care is an essential nursing activity
One of the most
important tasks for the nurse and patient is to assign priorities to the goals.
Those goals related to protecting the patient from self-destructive
impulses always receive top priority. Because the nursing care plan
is dynamic, priorities are constantly changing. If the focus is always on the
patient’s behavioral responses, priorities can be modified as the patient
changes. If the goal answers the question of what, the plan of care
answers the questions of how and why. Once again, the patient’s
active involvement leads to a more successful care plan.
After writing a tentative care plan,
the nurse must validate this plan with the patient. This communicates to the
patient a sense of self-responsibility for getting well. The patient can tell
the nurse that a proposed plan is unrealistic based on financial status,
lifestyle, value system, culture or, perhaps, personal preference. Usually
several approaches to a patient’s problem are possible. Choosing the one most
acceptable to the patient improves the chances for success. Failure to reach a
goal through one plan can lead to the decision to adopt a new approach or
re-evaluate the goal.
The joint Commission (TJC) standards specify
that the nursing plan of care must contain the six elements. They are
ESSENTIAL ELEMENTS OF THE NURSING PLAN OF CARE
1.
Initial
assessment and reassessment.
2.
Nursing
diagnosis or patient’s care needs.
3.
Interventions
identified to meet the patients nursing care needs
4.
Nursing
care provided.
5.
Patients
response to and the outcomes of the nursing care provided.
6.
Ability
of the patient or significant others to manage continuing care needs after
discharge.
Standard 5:
Implementation
The
psychiatric–mental health registered nurse implements the identified plan.
Nursing interventions (also known as nursing orders or
nursing prescriptions) are critical action components
of the implementation phase and are the most powerful pieces of the nursing
process. They make up the management and treatment approach to an identified
health problem. Interventions are selected to achieve client outcomes and to
prevent or reduce problems.
Rationale:
In implementing the plan of care,
psychiatric–mental health nurses use a wide range of interventions designed to
prevent mental and physical illness and to promote, maintain, and restore
mental and physical health. Psychiatric–mental health nurses select
interventions according to their level of practice.
At the basic level nurses
may select counseling, milieu therapy, promotion of self-care activities,
intake screening and evaluation, psychobiological interventions, health
teaching, case management, health promotion and health maintenance, crisis
intervention, community-based care, psychiatric home health care, telehealth,
and a variety of other approaches to meet the mental health needs of patients.
In addition to the intervention
options available to the basic level psychiatric–mental health nurse, at the
advanced level the advanced practice registered nurse in psychiatric–mental
health (APRN-PMH) may provide consultation, engage in psychotherapy, and
prescribe pharmacological agents were permitted by state statutes or
regulations.
Key Elements:
Nursing
interventions should reflect a holistic, biopsychosocial approach to patient
care.
Nursing
interventions are implemented in a safe, efficient, and caring
The level at which a nurse functions and the
interventions implemented are based on the nursing practice acts in one’s
state, the nurse’s qualifications (including education, experience, and certification),
the caregiving setting, and the nurse’s initiative.
Standard 5a:
Coordination of Care
The
psychiatric–mental health registered nurse coordinates care delivery.
Measurement Criteria
The
psychiatric mental health registered nurse:
Ø Coordinates
implementation of the plan.
Ø Documents
the coordination of care.
Additional Measurement Criteria for
Psychiatric Mental Health Advanced Practice Registered Nurse
Ø Provides
leadership in the coordination of multidisciplinary health care for integrated
delivery of patient care services.
Ø Synthesizes
data and information to prescribe necessary system and community support
measures, including environmental modifications.
Ø Coordinates
system and community resources that enhance delivery of care across continuums.
Ø Assists
patients in getting financial assistance as needed to maintain appropriate
care.
Standard 5b:
Health Teaching and Health Promotion
The
psychiatric–mental health registered nurse employs strategies
to
promote health and a safe environment.
Rationale
The psychiatric mental health registered
nurse, through health teaching, promotes the
patient’s personal and social integration and
assists the patient in achieving satisfying,
productive, and health patterns of living.
Measurement Criteria
The
psychiatric mental health registered nurse:
Ø Uses
health promotion and health teaching methods appropriate to the situation, patient’s
developmental level, learning needs, readiness, ability to learn, language
preference and culture.
Ø Provides
health teaching related to the patient’s needs and situation that may include, but
is not limited to, mental health problems and psychiatric disorders, treatment regimen,
coping skills, relapse prevention, self-care activities, resources, conflict management,
problem-solving skills, stress management and relaxation techniques, and crisis
management. .
Ø Integrates
current knowledge and research regarding psychotherapeutic educational strategies and content.
Ø Engages
consumer alliances and advocacy groups, as appropriate, in health teaching and
health promotion activities.
Ø Identifies
community resources to assist consumers in using prevention and mental health
care services appropriately
Ø Seeks
opportunities for feedback and evaluation of the effectiveness of strategies utilized.
Ø Provides
anticipatory guidance to individuals and families to promote mental health and to
prevent or reduce the risk of psychiatric disorders.
Standard 5c:
Milieu Therapy
The
psychiatric–mental health registered nurse provides, structures, and maintains
a safe and therapeutic environment in collaboration with patients, families,
and other health care clinicians
Rationale
The therapeutic environment consists of the
physical environment, social structures, and the philosophy of care and
treatment that provides safety at points of crisis and supports the patient’s
ability to use new adaptive coping strategies and available resources.
Measurement
Criteria
The
psychiatric mental health registered nurse:
Ø Orients
the patient and family to the care environment including the physical environment, the roles of different health
care team providers in their care, how to be involved in the treatment and care
delivery processes, schedules of events pertinent to their care and treatment,
and expectations regarding behaviors.
Ø Orients
the patient to their rights and responsibilities particular to the treatment or
care environment.
Ø Conducts
ongoing assessments of the patient in relationship to the environment to guide
nursing interventions in maintaining a safe environment and patient safety.
Ø Selects
specific activities that meet the patient’s physical and mental health needs for
meaningful participation in the milieu and promoting personal growth.
Ø Ensures
that the patient is treated in the least restrictive environment necessary to
maintain the safety of the patient and others.
Ø Informs
the patient in a culturally competent manner about the need for the limits and
the conditions necessary to remove the restrictions.
.
Standard 5d:
Pharmacological, Biological, and Integrative
Therapies
The
psychiatric–mental health registered nurse incorporates knowledge of
pharmacological, biological, and complementary interventions with applied
clinical skills to restore the patient’s health and prevent further disability.
Measurement Criteria
The psychiatric mental health registered
nurse:
Ø Applies
current research findings to guide nursing actions related to pharmacology,
other biological therapies, and complementary therapies.
Ø Assesses
patient’s response to biological interventions based on current knowledge of
pharmacological agents’ intended actions, interactive effects, potential un
toward effects and therapeutic doses.
Ø Includes
health teaching for medication management to support patients in managing their
own medications, and adherence to prescribed regimen.
Ø Educates
on information about mechanism of action, intended effects, potential adverse
effects of the proposed prescription, ways to cope with transitional side
effects and other treatment options, including no treatment.
Ø Directs
interventions toward alleviating untoward effects of biological interventions.
Ø Communicates
observations about the patient’s response to biological interventions are to
other health clinicians
Advanced-Practice Interventions 5e to 5g
The
following interventions (5e to 5g) may be performed only by the APRN
Standard 5e: Prescriptive
Authority and Treatment
The
psychiatric–mental health advanced practice registered nurse uses prescriptive
authority, procedures, referrals, treatments, and therapies in accordance with
state and federal laws and regulations
Measurement Criteria
The APRN
Ø Conducts
a thorough assessment of past medical trials, side effects, efficacy and
patient preference.
Ø Prescribes
or recommends pharmacological agents based on research evidence and knowledge
of psychopathology, neurobiology, physiology, expected therapeutic actions,
anticipated side effects and courses of action.
Ø Prescribes
or recommends psychotropic and related medications based on clinical indicators
of patient status. Assesses a reasoned balance of risk and benefits,
including results of diagnostic and lab
tests as appropriate, to treat symptoms of psychiatric disorders and improve functional status
Ø Provides
health teaching about mechanism of action, intended effects, potential adverse
effects of the proposed prescription, ways to cope with transitional side
effects and other treatment options, including no treatment.
Ø Educates
and assists the patient in selecting the appropriate use of complementary and
alternative therapies.
Ø Evaluates
therapeutic and potential adverse effects of pharmacological and non
pharmacological treatments.
Ø Evaluates
pharmacological outcomes by utilizing standard symptom measurements and patient report to determine efficacy.
Ø Adjusts
medications based on continual monitoring in collaboration with patient.
Standard 5f:
Psychotherapy
The
psychiatric–mental health advanced practice registered nurse conducts
individual, couples, group, and family psychotherapy using evidence-based
psychotherapeutic frameworks and nurse-patient therapeutic relationships.
The
APRN
Uses knowledge of
personality theory, growth and development, psychology, neurobiology,
psychopathology, social systems small-group and family dynamics stress and
adaptation, and theories and best available research evidence to select therapeutic methods based on the
patient’s needs.
Structures the therapeutic contract to
include, but not limited to:
• Purpose, goals, and expected outcomes
• Time, place and frequency of therapy
• Participants involved in therapy
• Confidentiality and appropriate written
release of information
• Availability and means of contacting
therapist
• Responsibilities of both patient and
therapist
• Fees and payment schedule
• Cancellations/alteration in schedule policy
Ø Utilizes
interventions that promote mutual trust to build a therapeutic treatment alliance.
Ø Empowers
patients to be active participants in treatment.
Ø Applies
therapeutic communication strategies based on theories and research evidence to
reduce emotional distress, facilitate cognitive and behavioral change and
foster personal growth.
Ø Uses
self-awareness of emotional reactions and behavioral responses to others to enhance
the therapeutic alliance.
Ø Analyzes
the impact of duty to report and other advocacy actions on the therapeutic
alliance.
Ø Arranges
for the provision of care in the therapist’s absence.
Ø Applies
ethical and legal principles to the treatment of patients with mental health problems
and psychiatric disorders.
Ø Makes
referrals when it is determined that the patient will benefit from a transition
of care or consultation due to change in clinical condition.
Ø Evaluates
effectiveness of interventions is relation to outcomes using standardized
methods as appropriate.
Ø Monitors
outcomes of therapy and adjusts plan of care when indicated.
Ø Therapeutically
concludes the nurse-patient relationship and transitions the patient to other
levels of care, when appropriate.
Ø Identifies
and maintains professional boundaries to preserve the integrity of the therapeutic
process.
Standard 5g:
Consultation
The
psychiatric–mental health advanced practice registered nurse provides consultation
to influence the identified plan, enhance the abilities of other clinicians to
provide services for patients, and effect change.
The standards of practice for
implementation are detailed and explicit. The standards identify the range of
activities psychiatric nurses. Implementation is the actual delivery of nursing
care to the patient and the patient’s response to that care.
Nursing
interventions should be based on evidence of the effectiveness of the
treatment. The use of a standardized classification system of
interventions that nurses perform, such as the Nursing Interventions
Classification (NIC) (Bulechek et al, 2008), is useful for clinical
documentation, communication of care across settings, integration of
data across systems, effectiveness research, productivity measurement competency
evaluation, and reimbursement.
The
psychiatric nurse helps the psychiatric patient do two things: develop insight
and change behavior. These two areas for nursing intervention correspond with
the responsive and action dimensions of the nurse–patient relationship
Insight is
the patient’s development of new emotional and cognitive understandings.
However, knowing something on an intellectual level does not necessarily
lead to a change in behavior. Another step is needed. Patients must
decide whether they will continue to use maladaptive coping mechanisms or adopt
new, adaptive, and constructive approaches to life.
The first step in helping a patient
translate insight into action is to build incentives to abandon old,
maladaptive patterns of behavior. The nurse should help the patient see the
negative consequences of current actions and that they do more harm than good. The
patient will not learn new patterns until the motivation to change is
greater than the motivation to stay the same. This is the idea
behind motivational interviewing
The nurse should encourage the patient’s
desires for mental health, emotional growth, and freedom from suffering. The nurse
also should continue to motivate and support patients as they test new,
adaptive behaviors and coping mechanisms. Many of the patient’s maladaptive
patterns have built up over years. The nurse cannot expect the patient to
change them in a matter of days or weeks. The nurse must help the patient
evaluate these new patterns, integrate them into life experiences, and practice
problem solving to prepare for future experiences.
A
final issue for the psychiatric nurse to consider in the implementation process
is that there are four possible treatment stages
1.
Crisis
2.
Acute
3.
Maintenance
4.
Health
promotion
Standard 6:
Evaluation
The
psychiatric–mental health registered nurse evaluates progress toward attainment
of expected outcomes.
Rationale
Nursing
care is a dynamic process involving change in the patient’s health status over
time, giving rise to the need for data, different diagnoses, and modifications
in the plan of care. Therefore, evaluation is a continuous process of
appraising the effect of nursing and the treatment regimen on the patient’s
health status and expected outcomes.
Key Elements
Ø Evaluation
is an ongoing process.
Ø Patient
and family participation in evaluation is essential.
Ø Goal
achievement should be documented and revisions in the plan
of care should be implemented as appropriate.
Evaluation is a mutual
process based on the patient’s and family’s previously identified goals and
their satisfaction with the processes and outcomes of care. Patients,
families, and psychiatric nurses often have different views of treatment
and the effectiveness of care. It is therefore critical that psychiatric
nurses have a systematic and objective way to learn from patients and
families which aspects of the nursing care provided were helpful and
what additional nursing actions may have further helped them.
Often, progress with
psychiatric patients is slow and occurs in small steps rather than dramatic
leaps. Realizing that progress has been made can produce growth and inspire new
hope in both the patient and the nurse.
STANDARDS OF
PROFESSIONAL PERFORMANCE
The conditions and behaviors
related to each standard of professional Performance. The Standards of
Professional Performance apply to self-definition, self-regulation,
accountability, and autonomy for practice by psychiatric nurses, both
individually and as a group.
QUALITY OF
PRACTICE
Standard 7:
Quality of Practice
The
psychiatric–mental health registered nurse systematically enhances the quality
and effectiveness of nursing practice.
Rationale
The
dynamic nature of the mental health care environment and the growing body of
psychiatric nursing knowledge and research provide both the impetus and the
means for the psychiatric–mental health nurse to be competent in clinical
practice, to continue to develop professionally, and to improve the quality of
patient care.
Key Elements
Ø The
nurse should be open to critically analyzing the caregiving process.
Ø The
patient and family should be partners with the nurse in the evaluation of care
activities.
Ø Improving
the quality of care provided goes beyond discussion and analysis to actually
implementing actions that will improve practice.
Psychiatric nurses
participate in the organizational evaluation of overall patterns of care
through a variety of quality improvement or process
improvement activities. In these activities, the focus is not on the nurse
but on the patient, the overall program of care, and health-related outcomes of
care. Specific objectives include the following:
•
Continuous improvement of customer satisfaction
•
Continuous improvement of patient outcomes
•
Efficient use of resources
•
Adherence to professional and regulatory standards
EDUCATION
Standard 8:
Education
The
psychiatric–mental health registered nurse attains knowledge and competency
that reflect current nursing practice.
Rationale
The
rapid expansion of knowledge pertaining to basic and behavioral sciences,
technology, information systems, and research requires a commitment to learning
throughout the psychiatric–mental health nurse’s professional career. Formal
education, continuing education, independent learning activities, and
experiential and other learning activities are some of the means the
psychiatric–mental health nurse uses to enhance nursing expertise and advance
the profession.
Key Elements
Ø Professional
learning should be regarded as a lifelong process.
Ø The
nurse should pursue a variety of educational opportunities.
Ø New
knowledge should be translated into professional nursing practice.
Psychiatric
nurses are expected to engage in a continuous learning process to keep up with
emerging knowledge.
They
may do this in the following ways:
•
Formal educational programs
•
Continuing education programs
•
Independent learning activities
• Lectures,
conferences, and workshops
•
Credentialing
•
Certification
Ø Reading
journals and textbooks and collaborating with colleagues are other important
ways to remain current with expanding areas of knowledge. Journals that relate
to psychiatric nursing practice include
Ø Archives
of Psychiatric Nursing,
Ø Journal
of the American Psychiatric Nurses Association,
Ø Journal of
Psychosocial Nursing,
Ø Journal
of Child and Adolescent Psychiatric Nursing,
Ø Issues
in Mental Health Nursing,
Ø Perspectives in
Psychiatric Care.
A
major resource for psychiatric nurses is the Internet, which allows nurses
access to information around the globe.
PROFESSIONAL
PRACTICE
Standard 9:
Professional Practice Evaluation
The psychiatric–mental health
registered nurse evaluates one’s own practice in relation to the professional
practice standards and guidelines and relevant statutes, rules, and
regulations.
Rationale
The
psychiatric–mental health nurse is accountable to the public for providing
competent clinical care and has inherent responsibility as a professional to
evaluate the role and performance of psychiatric– mental health nursing
practice according to standards established by the profession.
Key Elements
Ø Supervision
should be viewed as an essential and ongoing aspect of one’s professional life.
Ø The
nurse should strive to grow and develop professional knowledge, skills, and
expertise.
Ø Professional
practice evaluation for the psychiatric nurse is generally provided in two
ways:
a.
Administrative
b. Clinical.
Administrative
performance appraisal involves the review, management, and
regulation of competent psychiatric nursing practice. It involves a supervisory
relationship in which a nurse’s work performance is compared with role
expectations in a formal way, such as in a nurse’s annual performance
evaluation. Administrative performance evaluations should identify areas of
competency and areas for improvement.
Clinical
performance appraisal is guidance provided through a mentoring
relationship and clinical supervision with a more experienced, skilled, and
educated nurse. Clinical
supervision is a support
mechanism for practicing professionals within which they can share clinical,
organizational, developmental, and emotional experiences with another
professional in a secure, confidential environment to enhance knowledge and
skills. Psychiatric nurses are aware of the need for ongoing mentorship to
improve their nursing practice. Clinical supervision reviews one’s clinical
care and also can serve as a support system for the nurse.
In many ways the process of
supervision parallels the nurse patient relationship. Both involve a learning
process that takes place in the context of a meaningful relationship that
facilitates positive change. Self-exploration is a critical element of both.
The supervisor should provide the same responsive and action dimensions present
in the nurse–patient relationship to help supervised nurses be most effective.
The
common types of supervision are as follows:
• Dyadic,
or one-on-one supervision, in which the supervisor meets individually with
the nurse being supervised
• Group
supervision, in which several supervised nurses meet for a shared session
with the supervisory nurse
• Peer
review, in which nurses meet with nurse colleagues without a supervisor to
evaluate their clinical practice
All have the same purpose of
exploring problem areas and maximizing the strengths of those being supervised.
Despite its intensity, supervision is not therapy. The essential
difference between the two is a difference of purpose. The goal of
supervision is to teach psychotherapeutic skills. The goal of
therapy is to change a person’s way of coping to help the person to function
more effectively. Supervision or consultation is necessary for the practicing
psychiatric nurse. Although it is essential for novices, it is equally
important for experienced practitioners. Finally, supervision is only as
helpful as the skill of the supervisor, the openness of the supervised nurse,
and the motivation of both to learn and grow.
COLLEGIALITY
Standard 10:
Collegiality
The
psychiatric–mental health registered nurse interacts with and contributes to
the professional development of peers and colleagues.
Rationale
The psychiatric–mental health nurse
is responsible for sharing knowledge, research, and clinical information with
colleagues, through formal and informal teaching methods, to enhance
professional growth.
Key Element
The
nurse should regard other nurses as colleagues and partners in
caregiving.
Mentorship within nursing is important both to nurses
as
individuals and to the nursing profession as a whole.
Collegiality requires that nurses view their nurse
peers as collaborators in the care giving process who are valued and respected
for their unique contributions, regardless of educational, experiential, or
specialty background. It suggests that nurses view themselves as members of an
organized professional group or unit and that nurses trust, support, and
demonstrate commitment to other nurses.
Nurses need to work together as
colleagues to blend their various skills and abilities in creating a better
health care system and enhancing the quality and quantity of psychiatric nursing
services provided. One way to do this is for psychiatric nurses to join a
professional nursing organization. The largest psychiatric nursing organization
that is open to nursing students and psychiatric nurses of all educational and
experiential backgrounds is the American Psychiatric Nurses Association (APNA).
Information about joining is available on their website: www.apna.org.
COLLABORATION
Standard 11:
Collaboration
The psychiatric–mental
health registered nurse collaborates with patients, family, and others in the
conduct of nursing practice.
Rationale
Ø Psychiatric–mental
health nursing practice requires a coordinated, ongoing interaction between
consumers and clinicians to deliver comprehensive services to the patient and
the community.
Ø Through
the collaborative process, different abilities of health care clinicians are
used to identify problems, communicate, plan and implement interventions, and
evaluate mental health services.
Key Elements
Ø Respect
for others grows out of respect for self.
Ø Nurses
should be able to clearly articulate their professional abilities and areas of
expertise to others.
Ø Collaboration
involves the ability to negotiate and formulate new solutions with others.
Collaboration is the shared planning, decision making,
problem solving, goal setting, and assumption of responsibilities by
individuals who work together cooperatively and with open communication. Three
key ingredients are needed for collaboration:
1.
Active and assertive contributions from each person
2.
Receptivity and respect for each person’s contribution
3.
Negotiations that build on the contributions of each person to form a new way
of conceptualizing the problem
Psychiatric
nurses have many potential collaborators, including patients and families,
interdisciplinary colleagues, and nursing peers
Each of these groups allows the psychiatric nurse an opportunity to
solve problems in new ways and thus better plan and implement nursing
care.
Most
organized mental health settings use an interdisciplinary or interprofessional
team approach, which requires highly coordinated and often interdependent
planning based on the separate and distinct roles of each team member.
It
is important for nurses to maintain their professional identity and integrity
when they collaborate with other professionals. Within the health care setting,
psychiatric nurses must determine whether they as a group are ready to engage
in collaborative practice. Questions that should be considered include the
following:
•
Can psychiatric nurses define, describe, and appropriately defend psychiatric
nursing roles and functions?
• Is
the psychiatric nursing leadership ready for collegial practice?
•
Are psychiatric nursing roles and functions appropriate for nurses’ education,
experience, and expertise?
• Is
nurse staffing appropriate in numbers, patterns, and ratios?
•
Are the other disciplines prepared for and supportive of collaboration?
• Is
the organizational climate conducive to collaboration?
Collaborative relationships for psychiatric nurses
|
Patients
and
families
|
|
Health
team
members
|
|
Nurse
colleagues
|
ETHICS
Standard 12:
Ethics
The
psychiatric–mental health registered nurse integrates ethical provisions in all
areas of practice.
Rationale
The public’s trust
and its right to humane psychiatric–mental health care are upheld by
professional nursing practice. Ethical standards describe a code of behaviors
to guide professional practice. People with psychiatric– mental health needs
are an especially vulnerable population. The foundation of psychiatric–mental
health nursing practice is the development of a therapeutic relationship with
the patient. Boundaries need to be established to safeguard the patient’s
well-being.
Key Elements
Ø Nurses
should be sensitive to the social, moral, and ethical environment in which they
practice.
Ø Patient
and family advocacy is a core aspect of nursing practice.
Ø Ethical
conduct is essential to the nurse–patient relationship.
Ethical considerations
combine with legal and therapeutic issues to affect all aspects of psychiatric
nursing practice. The American Nurses Association (2001) has
a code of ethics for nurses. It emphasizes that the nurse’s primary commitment
is to the patient and expands the ethical perspective of nurses to include
the health care system and duties of the nurse to oneself.
The
ANA House of Delegates approved these nine provisions of the new Code
of Ethics for Nurses at its June 30, 2001 meeting in Washington, DC.
In July, 2001, the Congress of Nursing Practice and Economics voted to accept
the new language of the interpretive statements resulting in a fully approved
revised Code of Ethics for Nurses With Interpretive Statements.
1.
The nurse, in all professional
relationships, practices with compassion and respect for the inherent dignity,
worth and uniqueness of every individual, unrestricted by considerations of
social or economic status, personal attributes, or the nature of health
problems.
2.
The nurse's primary commitment is to
the patient, whether an individual, family, group, or community.
3.
The nurse promotes, advocates for,
and strives to protect the health, safety, and rights of the patient.
4.
The nurse is responsible and
accountable for individual nursing practice and determines the appropriate
delegation of tasks consistent with the nurse's obligation to provide optimum
patient care.
5.
The nurse owes the same duties to
self as to others, including the responsibility to preserve integrity and
safety, to maintain competence, and to continue personal and professional
growth.
6.
The nurse participates in
establishing, maintaining, and improving healthcare environments and conditions
of employment conducive to the provision of quality health care and consistent
with the values of the profession through individual and collective action.
7.
The nurse participates in the
advancement of the profession through contributions to practice, education,
administration, and knowledge development.
8.
The nurse collaborates with other
health professionals and the public in promoting community, national, and
international efforts to meet health needs.
9.
The profession of nursing, as
represented by associations and their members, is responsible for articulating
nursing values, for maintaining the integrity of the profession and its practice,
and for shaping social policy.
RESEARCH
Standard 13:
Research
The
psychiatric–mental health registered nurse integrates research findings into
practice.
Rationale
Nurses
in psychiatric–mental health nursing are responsible for contributing to the further development
of the field of mental health by participating in research. At the basic level
of practice, the psychiatric–mental health nurse uses research findings to
improve clinical care and identifies clinical problems for research study. At
the advanced level, the psychiatric–mental health nurse engages and/or
collaborates with others in the research process to discover, examine, and test
knowledge, theories, and creative approaches to practice.
Key Elements
Ø Research
links nursing theory and practice and is essential to the development of a
profession.
Ø Outcome
research helps to establish the value of nursing in an era
health care reform.
The progression of observing
from practice, theorizing, testing in research, and modifying practice is an
essential part of psychiatric nursing. The clinical problems are
many, and as nurses gain the skills and experience to validate their work
scientifically, they can make a significant contribution to psychiatric
theory and practice through research. Actively involving consumers and
families in psychiatric research can improve the quality of research and
clinical outcomes. In this process the role of the nurse is one of
patient advocate and educator.
RESOURCE
UTILIZATION
Standard 14:
Resource Utilization
The
psychiatric–mental health registered nurse considers factors related to safety,
effectiveness, cost, and impact on practice in the planning and delivery of
nursing services.
Rationale
The
patient is entitled to psychiatric–mental health care that is safe, effective,
and affordable. As the cost of health care increases, treatment decisions must
be made in such a way as to maximize resources and maintain quality of care.
The psychiatric–mental health nurse seeks to provide cost-effective, quality
care by using the most appropriate resources and delegating care to the most
appropriate, qualified health care clinician.
Key Elements
Nurses
play a critical role in integrating and coordinating health care services.
Nurses
should be fiscally accountable for the care they provide.
Resources
should be allocated based on cost/benefit analyses and documented expected
outcomes.
Resource use is one of the most
important aspects of psychiatric nursing practice. Discussing the costs and
benefits of treatment options with patients, families, providers, and
reimburses is an essential part of the professional psychiatric nursing role.
To meet this performance standard, psychiatric nurses need to request and
obtain both cost and outcome information related to tests, consultations,
evaluations, therapies, and continuum of care alternatives. Nurses need to
assume an active role in questioning, advising, and advocating for
the most cost-effective use of resources.
LEADERSHIP
Standard 15:
Leadership
The
psychiatric–mental health registered nurse provides leadership in the
professional practice setting and the profession.
Rationale
Psychiatric
nurses have a responsibility to demonstrate leadership by working for greater
professional accountability and autonomy for nurses through a negotiated
process with their peers, other health care providers, administrators,
consumers, and society at large, with the ultimate goal of improving patient
care.
Key Elements
Ø An
inherent part of nurses’ role should be focused on the growth and success of
their profession, their peers, and the care provided in their practice setting.
Ø Mentorship
and team building are skills to be cultivated.
Ø Advocacy
and participation in key governance groups are the best way to effect change.
The
standard of leadership is one of the most important, since it requires
psychiatric nurses to think beyond their immediate care giving responsibilities
to the way in which they can impact the broader health care environment. Their
interactions with other nurses and providers, health care
administrators, and the public define them and reflect on their
profession.
Nurses who have a positive regard for
themselves, their knowledge, and their skills will reach out to mentor and
teach others, including new nursing students, trainees, and professional
colleagues. They will be open to new ideas and see every problem as an
opportunity for new learning. They also will understand that true change comes
about through active participation on influential committees, boards, and
decision-making bodies. They will therefore be both active and proactive in
sharing their understandings, challenging existing ways of thinking, and
demonstrating leadership on behalf of their profession and the patients whom
they serve.
BIBLIOGRAPHY
1.Elizabeth.M
.Varcarolis;Foundations Of Psychiatric Mental Health Nursing;Saunders Publications
;6th Edition
2.Mary.C.Townsend;Concepts
Of Care In Evidence Based Practise;Jaypee Publications;Fifth Edition page no;
3.Katherine
.M.Fortinash,Patricia A.Holoday Worret;Psychiatric Mental Health Nursing;Mosby
Publications;3rd Edition;Page
4.K.P
Neeraja;Essentials Of Mental Health And Psychiatric Nursing Vol-1;Jaypee
publications ;3rd edition
5.Neeraja
Ahuja;Textbook Of Postgraduate Psychiatry;Jaypee Publications;3rd
edition;
6.Gail W Staurt , PRINCIPLES AND
PRACTICE OF PSYCHIATRIC NURSING, 10th edition Mosby
Publications,
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