Standard of Care in Psychiatric Nursing Process

The nurse-patient relationship is the vehicle for applying the nursing process. The goal of nursing care is to maximize the patient’s positive interaction with the environment, promote a level of wellness, and enhance self-actualization. By establishing a therapeutic nurse-patient relationship and using the nursing process, the nurse strives to promote and maintain patient behavior that contributes to integrated functioning.

The nursing process is an interactive, problem solving process. It is a systematic and individualized way to achieve the outcomes of nursing care. Since it is a deliberate and organized approach, it requires knowledge, judgment, and experience. The nursing process respect the individual’s autonomy and freedom to make decisions and be involved in nursing care. Thus the nurse and patient emerge as partners in a relationship built on trust and directed toward maximizing the patient’s strengths, maintaining integrity, and promoting adaptive response to stress.

In dealing with psychiatric patients, the nursing process can present unique challenges. Emotional problems may be vague and elusive, not tangible or visible like many physiological disruptions. Emotional problems also can show different symptoms and arise from a number of causes. Similar past events may lead to very different forms of present behavior. Many psychiatric patient are initially unable to describe their problems. They may be withdrawn, highly anxious, or out of touch with reality. Their ability to participate in the problem-solving process may also be limited if they see themselves as powerless victims or if their illness impairs them from fully engaging in the treatment process.

Geach has identified three aspects of problem solving with psychiatric patients:
1.The nurse involves the patient in the process
2.The problem that nurse and patient address has immediate relevance to what is happening between them, at least initially
3.The nurse and patient form some sort of relationship so that they can solve problems within a relationship rather than in isolation

It is essential that the nurse and patient become partners in the problem-solving process. Nurses may be tempted to exclude patients, particularly if they avoid or resist becoming involved, but this should be avoided for two reasons. First, learning is more effective when patients participate in the learning experience. Second, by including patients as active participants in the nursing process, the nurse helps restore their sense of control over life and their responsibility for action. It reinforces the message that patients, whether they have an acute crisis or a serious and persistent mental illness, can choose either adaptive or maladaptive coping responses.

The phases of the nursing process as described by Standards of Psychiatric-Mental Health Clinical Nursing Practice are assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Validation is part of each step, and all phases may overlap or occur simultaneously.

Standard I. Assessment
The psychiatric-mental health nurse collects client health data

Standard II. Diagnosis
The psychiatric-mental health nurse analyzes the assessment data in determining diagnosis

Standard III. Outcome Identification
The psychiatric-mental health nurse expected outcomes individualized to the client

Standard IV. Planning
The psychiatric-mental health nurse develops a plan of care that prescribes intervention to attain expected outcomes

Standard V. Implementation
The psychiatric-mental health nurse implements the interventions identified in the plan of care

Standard V-A. Counseling
The psychiatric-mental health nurse uses counseling intervention to assist clients in improving or regaining their previous coping abilities, fostering mental health, and preventing mental illness and disability

Standard V-B. Milieu Therapy
The psychiatric-mental health nurse provides, structures, and maintains a therapeutic environment in collaboration with the client and other health care providers

Standard V-C. Self Care Activities
The psychiatric-mental health nurse structures intervention around the client’s activities of daily living to foster self-care and mental and physical well-being
Standard V-D. Psychobiological Intervention
The psychiatric-mental health nurse uses knowlegde of psychobiological intervention and applies clinical skills to restore the client health and prevent further disability

Standard V-E. Health Teaching
The psychiatric-mental health nurse, through health teaching, assist clients in achieving satisfying, productive, and healthy patterns of living

Standard V-F. Case Management
The psychiatric-mental health nurse provides case management to coordinate comprehensive health service and ensure continuity of care

Standard V-G. Health Promotion and Health Maintenance
The psychiatric-mental health nurse employs strategies and interventions to promote and maintain mental health and prevent mental illness

Standard V-H. Psychotherapy
The certified specialist in psychiatric-mental health nursing uses individual, group, and family psychotherapy, child psychotherapy, and other therapeutic treatments to assist clients in fostering mental health, preventing mental illness and disability, and improving or regaining previous health status and functional abilities

Standard V-I. Prescription of Pharmacologic Agent
The certified specialist uses prescription of pharmacologic agent in accordance with the state nursing practice act, to treat symptoms of psychiatric illness and improve functional health status

Standard V-J. Consultation
The certified specialist provides consultation to health care providers and others to influence the plans of care for clients, and to enhance the abilities of others to provide psychiatric and mental health care and effect change in systems

Standard VI. Evaluation
The psychiatric-mental health nurse evaluates the client’s progress in attaining expected outcomes

Standard I : Quality of Care
Standard II : Performance Appraisal
Standard III : Education
Standard IV : Collegiality
Standard V : Ethics
Standard VI : Collaboration
Standard VII : Research
Standard VII : Resource Utilization


Collects data through pertinent clinical observations based on a knowledge of nursing and the behavioral and physical sciences
Organized clinical observation is a prerequisite for realistic assessment of an individual's* needs and for formulation of appropriate nursing intervention. Knowledge acquired in the study of the nursing, behavioral and physical sciences fosters acuity of perception and alerts the Registered Psychiatric Nurse to physical, psychological, cultural, social, spiritual and other relevant data.
Assessment Factors:
1. Collects data and identifies areas of need
2. Observes, records, analyzes and presents data based upon principles derived from nursing as well as from the behavioral and physical sciences in so far as these are relevant to psychiatric nursing practice
3. Analyzes and interprets behavioral and physical patterns of behavior
4. Uses knowledge gained from the individual and other appropriate sources to develop a comprehensive understanding of the individual's experience
5. Discusses and validates observations with the individual and other appropriate persons
6. Makes inferences from collected data to formulate psychiatric nursing interventions

* Individual(s) refers to patient, client, consumer, resident or any person entering
the health care system at any point for the purpose of receiving services

Involves the individual, family and appropriate others in the assessment, planning, implementation and evaluation of the individual's nursing care program.
Since the problem-solving process is a learning experience, the individual should be encouraged to participate as actively as possible in his program. The ability to participate in such a process will vary from person to person and even within the same person. The family unit is one of the most influential groups in society. Therefore, the most effective and individualized program may be developed when the family and other relevant persons are included.
Assessment Factors:
1. Assesses the individual's and family's capabilities for program participation
2. Respects the individual's right to participate in decisions affecting his care
3. Identifies priority of needs in collaboration with the individual and other relevant persons
4. Provides the individual, and his family, with information about the individual's health problem
5. Discusses with the individual alternatives which may be selected by the individual to deal with his health problem
6. Determines with the individual the goals and method of achieving, evaluating and revising them
7. Discusses with the individual his progress in attaining stated goals

Uses problem-solving in developing a psychiatric nursing care plan
Problem-solving is a systematic, step-by-step approach to the resolution of an identified problem. Based on pertinent theories of human behavior the psychiatric nursing care plan is systematized by the problem-solving method, individualized by the characteristics and capacities of the individual and his environment, and used to maximize program effectiveness.
Assessment Factors:
1. Discusses the psychiatric nursing care plan with other professional and non-professional persons giving care
2. Incorporates observations and reports of others in developing and modifying the psychiatric nursing care plan
3. Initiates the psychiatric nursing care plan using established data base
4. Involves the individual and when appropriate, family and other relevant persons, in developing the psychiatric nursing care plan
5. Uses the psychiatric nursing care plan to guide nursing intervention
6. Records and assesses the effects of the psychiatric nursing care plan
7. Modifies the psychiatric nursing care plan as indicated

Promotes the realization of optimal health in individuals through health teaching
Health teaching is an essential part of a psychiatric nurse's role. Every interaction can be utilized as a teaching-learning situation. Formal and informal teaching methods can be used in working with individuals. Emphasis is on understanding mental health problems as well as on developing ways of coping with them, thus promoting optimum health.
Assessment Factors:
1. Identifies the individual's needs for health teaching
2. Uses appropriate teaching techniques to meet the individual's learning needs
3. Seeks assistance, when needed, to deal with the individual's learning needs
4. Provides the individual with opportunities for learning new behaviors
5. Teaches basic principles of mental and physical health as well as interpersonal and social skills
6. Records and assesses the individual's attainment of learning objectives

Uses activities of daily living in a goal-directed way when interacting with individuals.
Activities of daily living include the individual's personal and social living patterns. An individual's development and intellectual level, emotional state and physical status are reflected in and influenced by these activities. Therefore, the Registered Psychiatric Nurse is in a unique position to assess and intervene in these processes in order to encourage constructive changes in the individual's behavior so that each may realize his full potential.
Assessment Factors:
1. Assesses the individual's capability in activities of daily living based on needs, strengths, and levels of functioning
2. Demonstrates a consistent approach when assisting the individual with his activities of daily living
3. Uses appropriate skills to encourage the individual toward independence and self-direction
4. Records and assesses the effects of this goal-directed approach

Uses knowledge of somatic therapies and related clinical skills while working with individuals
Various treatment methods may be needed by individuals. Clinical observations and judgments are made concerning the effects of all treatments used in the therapeutic program.
Assessment Factors:
1. Observes and interprets pertinent reactions to somatic therapies in terms of underlying principles of each therapy
2. Provides information to the individual about therapies before, during and after treatment
3. Performs safely, nursing skills related to somatic therapies
4. Provides emotional support to the individual receiving somatic therapies
5. Provides emotional support to the family of the individual receiving somatic therapies
6. Encourages the individual and family to discuss, question and explore their feelings and concerns about past, current or projected use of somatic therapies
7. Records and assesses the effects of somatic therapies and, when appropriate, recommends changes in the treatment plan

Modifies the environment to establish and maintain a therapeutic Milieu
Any environment is composed of both human and non-human resources which may work for or against the individual's well-being. The Registered Psychiatric Nurse works with people in a variety of settings. The milieu is structured and/or altered so that it serves the individual's best interests as an inherent part of the overall therapeutic plan.
Assessment Factors:
1. Identifies environmental factors affecting the individual's health and wellbeing
2. Identifies the effect of the individual's behavior on the environment
3. Incorporates behavioral, cultural, economic and physiological concepts in developing and maintaining a therapeutic milieu
4. Establishes and maintains, within the environment, communications which are congruent with identified goals
5. Uses resources in the environment to meet identified goals
6. Evaluates nursing participation and its effectiveness in establishing and maintaining a therapeutic milieu

Participates with members of the multi-disciplinary team in assessing, planning, implementing and evaluating selected programs for the individual
Services to the individual are provided by a variety of professional personnel in addition to the Registered Psychiatric Nurse. It is essential, therefore, that all contributions become part of an integrated total program.
Assessment Factor:
1. Identifies specific psychiatric nursing knowledge, skills and activities and articulates information so that it may be co-ordinated with the contribution of others working with an individual or program
2. Recognizes and respects the contributions of other team members
3. Seeks consultation with other team members
4. Provides psychiatric nursing consultation to other team members
5. Participates in the formulation of overall team goals and plans
6. Uses the small group decision-making process to facilitate team activities

Uses psychotherapeutic interventions to assist the individual in achieving optimal health.
In order to help the individual achieve better adaptation and improved health, the Registered Psychiatric Nurse assists the individual to explore and identify his mode of living and relating, and to accept possible alternatives.
Assessment Factors:
1. Establishes and maintains psychotherapeutic relationships with individuals
2. Applies knowledge of behavioral sciences in planning and implementing programs of care
3. Assists the individual to identify, test out and evaluate constructive patterns of living
4. Reinforces positive behavioral patterns in the individual's interactions with others
5. Employs principles of communication, problem solving, interviewing and crisis intervention in carrying through psychotherapeutic intervention
6. Sets limits on behavior with the ultimate goal of assisting the individual to develop internal controls and constructive ways of dealing with feelings
7. Uses input from the individual, family and other team members in evaluating the individual's behavioral changes
8. Modifies nursing interventions based on the individual's needs

Practices as an accountable health professional in providing psychiatric nursing care
The Registered Psychiatric Nurse in accepting responsibility for his professional behavior enters into agreement with the individual. This agreement defines the expectations of the individual and the Registered Psychiatric Nurse.
Assessment Factors:
1. Evaluates his ability to function therapeutically
2. Accepts accountability for his psychiatric nursing practice
3. States clearly the expectations between the individual and the Registered Psychiatric Nurse
4. Seeks supervision and consultation whenever necessary
5. Seeks learning opportunities to further develop skills and knowledge
6. Assesses routinely the effectiveness of his psychiatric nursing care
7. Assesses routinely the effectiveness of care planned by other team members
8. Seeks peer review of care plan effectiveness

Participates with members of the multi-disciplinary team in community mental health planning
There is a need for the Registered Psychiatric Nurse to participate in programs that strengthen the existing health potential of all members of society. Concepts such as prevention, early intervention, continuity of care and health promotion are essential in planning to meet the community's mental health needs. The Registered Psychiatric Nurse uses his psychiatric nursing expertise as well as his organizational, educational and consultative skills and works in co-operation and collaboration with other community agencies to facilitate the development and implementation of mental health services.
Assessment Factors:
1. Identifies the basic structure and function of the local community in which the Registered Psychiatric Nurse practices
2. Identifies basic ethnic, racial and socio-economic factors and their effect on mental health problems
3. Recognizes current social issues that influence the nature of mental health problems.
4. Assists in identifying high-risk population groups
5. Participates with other members of the mental health team in assessing community mental health needs and identifying gaps in community services
6. Participates with other members of the mental health team and members of the community in planning, implementing and evaluating selected programs to meet the community's mental health needs
7. Participates in assessing the strengths and capabilities of individuals, families and selected groups in the community and uses these assessments to promote and increase their health potential
8. Evaluates the contribution of psychiatric nursing in meeting community mental health needs
9. Refers individuals, families and selected groups in need to appropriate community resources.
10. Describes the mental health services of the agency to others in the community
11. Participates with agencies and other appropriate sources to ensure continuity of mental health service for individuals, families and selected groups

Contributes to the leadership of personnel in the provision of psychiatric nursing care.
As a member of the nursing team, the Registered Psychiatric Nurse shares the responsibility for a leadership role including the supervision and teaching of ancillary and other personnel in meeting the psychiatric nursing care needs of the individual. The focus is on the continued development of each member of the team.
Assessment Factors:
1. Accepts basic leadership roles and responsibilities
2. Builds on areas of strength to actively compensate for weaknesses in his own performance and that of others
3. Uses judgment in accepting and delegating responsibilities
4. Encourages continuing self-development of team members
5. Actively co-operates with the individual and team members in determining and implementing priorities for psychiatric nursing care
6. Participates in teaching of ancillary and other personnel to meet the nursing needs of individuals
7. Participates in predicting and evaluating outcomes of own and nursing team members' actions
8. Acts as role model when participating in direct nursing care
9. Participates in evaluation of own performance and that other nursing team members

Assumes responsibility for personal and professional development and contributes to the professional growth of others
In order to function effectively and to enhance professional competence in a world of rapid cultural, social and technological changes, the Registered Psychiatric Nurse must assume responsibility of his own continuing development. Multi-disciplinary team functioning necessitates that the Registered Psychiatric Nurse support others in their development.
Assessment Factors:
1. Identifies and plans ways to meet personal and professional educational needs
2. Shares in identifying the educational needs of other members of the nursing team
3. Shows evidence of participation in professionally and/or academically oriented educational activities
4. Shows evidence of participation in professional meetings and activities, e.g. attendance at conventions, seminars, workshops
5. Applies and shares knowledge and skills, acquired through continuing education endeavours, to improve psychiatric nursing practice
6. Uses knowledge of developments in nursing and relevant fields to improve psychiatric nursing care
7. Reads nursing and other relevant professional journals and shares appropriate clinical content from those readings with team members to improve individual care
8. Demonstrates willingness to modify role in relation to changes within the health care delivery system

Contributes to the development of psychiatric nursing
Psychiatric nursing uses a pragmatic and eclectic approach to the resolution of nursing problems. The Registered Psychiatric Nurse has responsibility for the continuing development and refinement of knowledge in the psychiatric nursing field.
Assessment Factors:
1. Approaches nursing with an inquiring and open mind
2. Co-operates actively with other health disciplines by participating in and supporting research projects/studies
3. Demonstrates awareness of innovations pertinent to psychiatric nursing practice
4. Seeks appropriate consultation and/or supervision as required to implement and evaluate nursing innovations
5. Shares innovations in psychiatric nursing practice with others
6. Documents findings about psychiatric nursing practice

Understands the provincially and federally sponsored legal limitations, statutes and acts covering his actions as a registered psychiatric nurse functioning in current health systems in Canada
The Registered Psychiatric Nurse must be thoroughly aware of the legal ramifications affecting self and others in order to make sound, independent judgments concerning the individual's needs and rights.
Assessment Factors:
1. Maintains an understanding of current legal implications in relation to the Registered Psychiatric Nurse's functioning in the health care delivery system
2. Maintains membership in good standing in the professional organization
3. Recognizes his own professional limitations and refers the individual to appropriate resources whenever necessary
4. Uses professional judgment in carrying out prescribed orders
5. Uses information about relevant federal and provincial statutes to regulate psychiatric nursing activities
6. Anticipates the legal implications of his own actions and those of other team members

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Stuart, Gail Wiscarz and Sandra J. Sundeen. 1995. Principles and Practice of Psychiatric Nursing, Fifth Edition. St Louis: Mosby Year Book Inc.

Registered Psychiatric Nurses of Canada. 2008. Guidelines for RPN in Independent Practice. Alberta: Board of Director RPN of Canada. [11 Desember]

Vaecolis, Elizabeth M., Verna B.C. and Nancy C.S. 2006. Foundation of Psychiatric Mental Health Nursing: A Clinical Approach, Fifth Edition. Missouri: Saunders Elsevier

Zauszniewski, Jaclene A. and Jane Suresky. 2004. Evidence for Psychiatric Nursing Practice: An Analysis of Three Years of Published Research. The Online Juournal Issues in Nursing Vol. 9 No. 1. [11 Desember 2009]

_________. 2006. Psychiatric Mental Health Nursing Scope and Standard, Draft Revision.
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