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Canadian Standards
of Psychiatric and Mental Health Nursing Practice |
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Canadian Standards
of Psychiatric and Mental Health Nursing Practice |
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The purpose of the Canadian Standards of Psychiatric and Mental Health Nursing (PMHN) Practice is to provide a basis for the evaluation of professional, ethical, psychiatric and mental health nursing practice competencies. This purpose is in accordance with the Nursing profession’s obligation to the maintenance and improvement of the quality of nursing care. This document includes a statement of beliefs about psychiatric and mental health nursing, standards of practice, and a glossary.
Standards are meant to reflect the current state of knowledge and understanding of a discipline and are, therefore, conditional, dynamic and subject to change. The manner in which the individual psychiatric and mental health (PMH) nurse will achieve accepted competency levels will be determined by the conceptual model of nursing utilized; as well, the social, cultural, economic and political environments of health care will influence every nurse’s practice (Health and Welfare Canada, 1988). For example, current major changes in the delivery of mental health care include:
The context (the environment & practice setting) for the practice of PMHN today and into the new millennium is characterized by "change, challenge and competency" (CNA, 1997b, p.30). The first edition of the Standards was published in 1995 (Austin, Gallop, Harris, Spencer, 1996). It is intended that this second edition reflects more of a community mental health and community development model.
The Standards are conceptualized within a "domains of practice" framework. Competencies are classified under seven domains (Benner, 1984). These domains are, the helping role, the diagnostic and monitoring function, the administering and monitoring of therapeutic interventions, effective management of rapidly changing situations, the teaching/coaching function, monitoring and ensuring the quality of health care practices, and organizational and work role competencies. The use of these domains as an organizing framework permits an encompassing description of PMHN practice.
The level of practice described by these Standards is typified by a nurse who has two to three years experience in this specialty area and who judiciously applies knowledge, skills, attitudes and judgements required for performance in a designated role and setting. Nurses at this level differ from a beginning practitioner "by their increased clinical understanding, technical skill, organizational ability, and the ability to anticipate the likely course of events" (Benner, Tanner & Chesla, 1996, p.78).
Beliefs About Psychiatric and Mental Health Nursing
Psychiatric and mental health nursing is a specialized area of nursing that has as its focus the promotion of mental health, the prevention of mental illness and the care of clients experiencing mental health problems and mental disorders.
The psychiatric and mental health nurse works with clients in a variety of settings, including institutional, facility and community settings. Clients may be unique in their vulnerability as, in this area of nursing practice, they can be involved involuntarily and can be committed to care under the law. Further, clients may receive treatment against their will. This fact affects the nature of the nurse-client relationship and can raise complex ethical dilemmas.
The centrality of PMHN practice is the therapeutic use of self ; nurse-client interactions are purposeful and goal directed. The psychiatric and mental health nurse understands how the psychiatric disease process, the illness experience, the recuperative powers and the perceived degree of mental health are affected by contextual factors. Advances in knowledge (for instance, the current increase in understanding the biological basis of mental disorders, and the sociological determinants of behaviour) require that psychiatric and mental health nurses continually incorporate new research-based findings into their practice. PMH nurses acknowledge a responsibility to promote evidence-based, outcomes-oriented practice to enhance knowledge and skill development within the specialty. PMH nurses also acknowledge a responsibility to personal mental health promotion and maintenance.
PMHN knowledge is based on nursing theory, which is integrated with physical science theory, social science theory and human science theory. PMHN shares with other mental health disciplines a body of knowledge based on theories of human behaviour. As well, "reflection on practice" continues to develop the nurses habitual practices and skills of being truly present to the client situation at hand (Benner et al., 1996, p.325). In some settings there may be an overlapping of professional roles and/or a sharing of competencies. PMH nurses recognize their accountability to society for both the discrete and shared functions of practice.
I. Provides Competent Professional Care Through The Helping Role
II. Performs\Refines Client Assessments Through The Diagnostic and Monitoring Function
III. Administers and Monitors Therapeutic Interventions
IV. Effectively Manages Rapidly Changing Situations
V. Intervenes Through the Teaching-Coaching Function
VI. Monitors and Ensures the Quality of Health Care Practices
VII. Practices Within Organizational and Work-Role Structures
Standard I: Provides Competent Professional Care Through The Helping Role
The helping role is fundamental to all nursing practice. PMH nurses "enter into partnerships with clients, and through the use of the human sciences, and the art of caring, develop helping relationships" (CNA, 1997b, p.43) and therapeutic alliances with clients. A primary goal of psychiatric and mental health nursing is the promotion of mental health and the prevention or diminution of mental disorder.
The nurse:
1. Assesses and clarifies the influences of personal beliefs, values and life experiences on the therapeutic relationship.
2. Establishes and maintains a caring goal directed environment.
3. Uses a range of therapeutic communication skills, both verbal and nonverbal, including core communication skills (e.g. empathy, listening, observing).
4. Makes distinctions between social and professional relationships.
5. Recognizes the influence of culture and ethnicity on the therapeutic process and negotiates care that is culturally sensitive.
6. Mobilizes resources that increase clients' access to mental health services.
7. Understands and responds to human responses to distress such as: anger, anxiety, fear, grief, helplessness, hopelessness and humour.
8. Guides the client through behavioral, developmental, emotional, or spiritual change while acknowledging and supporting the client's participation, responsibility and choices in own care.
9. Supports the client’s sense of resiliency, for example self-esteem, power and hope.
10. Offers supportive and therapeutic care to the client’s significant others.
11. Reflectively critiques therapeutic effectiveness of nurse-client relationships by evaluating client responses to therapeutic processes, and by evaluating personal responses to client. Seeks clinical supervision with ongoing therapeutic skill development.
Standard II: Performs/Refines Client Assessments Through The Diagnostic and Monitoring Function
Effective diagnosis and monitoring is central to the nurse's role and is dependent upon theory, as well as upon understanding the meaning of the health or illness experience from the perspective of the client. This knowledge, integrated with the nurse’s conceptual model of nursing practice, provides a framework for processing client data and for developing client-focused plans of care. The nurse makes professional judgements regarding the relevance and importance of this data, and acknowledges the client as a valued and respected partner throughout the decision-making process.
The Nurse:
1. Collaborates with clients to gather holistic assessments through observation, examination, interview, and consultation, while being attentive to issues of confidentiality and pertinent legal statutes.
2. Documents and analyzes baseline data to identify health status, potential for wellness, health care deficits, potential for danger to self and others; alterations in thinking, perceiving, communicating and decision-making abilities; substance abuse and dependency; and history of abuse (emotional, physical, sexual or verbal).
3. Formulates and documents a plan of care in collaboration with the client and with the mental health team, recognizing variability in the client's ability to participate in the process.
4. Refines and extends client assessment information by assessing and documenting significant change in the client’s status, and by comparing new data with the baseline assessment and intermediate client goals.
5. Anticipates problems in the future course of the client’s functional status: e.g. shifts in mood indicative of change in potential for self-harm; effects of 'flashbacks'.
6. Determines most appropriate and available therapeutic modality that will potentially best meet client's needs, and assists the client to access these resources.
Standard III: Administers and Monitors Therapeutic Interventions
Due to the nature of mental health problems and mental disorders, there are unique practice issues confronting the psychiatric and mental health nurse in administering and monitoring therapeutic interventions. Safety in psychiatric and mental health nursing has unique meaning since many clients are at risk for self-harm and/or self-neglect. Clients may not be mentally competent to participate in decision-making. The PMH nurse needs to be alert to adverse reactions as clients’ ability to self-report may be impaired. The PMH nurse uses evidence-based and experiential knowledge from nursing, health sciences and related mental health disciplines to both select and tailor nursing interventions. This is accomplished in collaboration with the client to the greatest possible extent.
The nurse:
1. Assists and educates clients to select choices which will support positive changes in their affect, cognition, behavior and/or relationships (CNA, 1997b, p.68).
2. Supports clients to draw on own assets and resources for self care and mental health promotion (CNA, 1997b, p.68).
3. Makes discretionary clinical decisions, using knowledge of client’s unique responses and paradigm cases as the basis for the decision, e.g., frequency of client contact in the community.
4. Uses appropriate technology to perform safe, effective and efficient nursing intervention (CNA, 1997b, p.68).
5. Administers medications accurately and safely, monitoring therapeutic responses, reactions, untoward effects, toxicity and potential incompatibilities with other medications or substances.
6. Assesses client responses to deficits in "activities of daily living" and mobilizes resources in response to client's capabilities.
7. Provides support and assists with protection for clients experiencing difficulty with self protection.
8. Utilizes therapeutic elements of group process.
9. Incorporates knowledge of family dynamics and cultural values and beliefs about families in the provision of care.
10. Collaborates with the client, health care providers and community to access and co-ordinate resources.
11. Incorporates knowledge of community needs or responses in the provision of care.
12. Encourages and assists clients to seek out support groups for mutual aid and support.
13. Assesses the client’s response to, and perception of, nursing and other therapeutic interventions.
Standard IV: Effectively Manages Rapidly Changing Situations
The effective management of rapidly changing situations is essential in critical circumstances which may be termed psychiatric emergencies. These situations include self harm and other assaultive behaviours and rapidly changing mental health states. This domain also includes screening for risk factors and referral related to psychiatric illnesses and social problems, i.e., substance abuse, violence/abuse and suicide/homicide (SERPN, 1996, p.41).
The nurse:
1. Assesses clients for risk of substance use/abuse, victim violence/abuse, suicide or homicide.
2. Knows resources required to manage potential emergency situations and plans access to these resources.
3. Monitors client safety and utilizes continual assessment to detect early changes in client status, and intervenes in situations of acute agitation.
4. Implements crisis intervention as necessary.
5. Commences critical procedures: in an institutional setting, eg., suicide precautions, emergency restraint, elopement precautions, when necessary; in a community setting, uses appropriate community support systems, eg., police, ambulance services, crisis response resources.
6. Coordinates care to prevent errors and duplication of efforts where rapid response is imperative.
7. Considers the legal and ethical implications of responses to rapidly changing situations; invokes relevant provisions in mental health acts as necessary.
8. Evaluates the effectiveness of the rapid responses and modifies critical plans as necessary.
9. Explores with the client and/or family the precipitates of the emergency event and plans to minimize risk of recurrence.
10. Participates in 'debriefing' process with team (including client and family) and other service providers, e.g., reviews of critical event and/or emergency situation.
Standard V: Intervenes Through The Teaching-Coaching Function
All nurse-client interactions are potentially teaching/learning situations. The PMH nurse attempts to understand the life experience of the client and uses this understanding to support and promote learning related to health and personal development. The nurse provides mental health promotion information to individuals, families, groups, populations and communities.
The nurse:
1. In collaboration with the client, determines clients' learning needs.
2. Plans and implements, with the client, health education while considering the context of the client's life experiences on readiness to learn. Plans teaching times and strategies accordingly.
3. Provides anticipatory guidance regarding the client’s situational needs, eg. assists the client in identifying living, learning or working needs and ways in which to access available community or other resources.
4. Facilitates the client's search for ways to integrate mental illness, chronic illness or improved functioning into lifestyle.
5. Considers a variety of learning models and utilizes clinical judgement when creating opportunities with clients regarding their learning needs.
6. Provides relevant information, guidance and support to the client’s significant others within the bounds of any freedom of information legislation.
7. Documents the teaching/learning process (assessment, plan, implementation, client involvement and evaluation).
8. Evaluates and validates with the client the effectiveness of the educational process, and seeks clients input into developing other means of providing teaching opportunities.
9. Engages in learning/teaching opportunities as partners with consumer groups.
Standard VI: Monitors and Ensures the Quality of Health Care Practices
Clients may be particularly vulnerable as recipients of health care, because of the nature of mental health problems and mental disorders. Mental health care is conducted under the provisions of provincial/territorial Mental Health Acts and related legislation. It is essential for the PMH nurse to be informed regarding the interpretation of relevant legislation and its implications for nursing practice. The nurse has a responsibility to advocate for the client’s right to receive the least restrictive form of care and to respect and affirm the client’s right to pursue individual goals of equality and justice.
The nurse:
1. Identifies limitations in the workplace or care setting that interfere with the nurse’s ability to perform with skill, safety and compassion and takes appropriate action.
2. Identifies limitations at a community level that interfere with the entire health of the community, e.g., poverty, malnutrition, unsafe housing.
3. Expands knowledge of innovations and changes in mental health and psychiatric nursing practice to ensure safe and effective care.
4. Critically evaluates current mental health and psychiatric research findings and uses research findings in practice.
5. Ensures and documents ongoing review and evaluation of psychiatric and mental health nursing care activities.
6. Understands and questions the interdependent functions of the team within the overall plan of care.
7. Advocates for the client within the context of institutional, professional, family and community interests.
8. Follows agency/institutional procedures when dissatisfied with the safety of a treatment plan and/or management interventions of other mental health care providers.
9. Uses sound judgement in advocating for safe, competent and ethical care for clients and colleagues even when there are system barriers to enacting an advocacy function.
10. Maintains and monitors confidentiality of client information.
11. Attends to changes in the mental health services system by recognizing changes that affect practice and client care, and by developing strategies to manage these changes (CNA, 1997b, p.79).
Standard VII: Practices Within Organizational and Work-Role Structures
The PMHN role is assumed within organizational structures, both community and institutional, particular to the provision of health care. In PMHN, the ethic of care is based on thoughtful and wise practice judgements within multiple, complex situations. As mental health care in Canada evolves into community based care, the psychiatric and mental health nurse needs to be skilled in collaborative partnering and decision-making, mental health promotion and community development.
The nurse:
1. Collaborates in the formulation of mental health promotion, and in activities and overall treatment plans and decisions with the client and treatment team and, throughout the continuum of care (primary, secondary and tertiary).
2. Recognizes and addresses the impact of the dynamic of the treatment team on the therapeutic process.
3. Uses conflict resolution skills to facilitate interdisciplinary health team interactions and functioning.
4. Uses computerized and other mental health and nursing information systems in planning, documenting and evaluating client care.
5. Demonstrates knowledge of collaborative strategies in
working with consumer/advocacy groups.
(SERPN, 1996, p.50)
6. Actively participates in developing, implementing and critiquing mental health policy in the workplace.
7. Acts as a role model for nursing students and the beginning practitioner in the provision of psychiatric and mental health nursing care.
8. Practices independently within legislated scope of practice.
9. Supports professional efforts in psychiatric and mental health practice to achieve a more mentally healthy society.
These descriptions apply for the purposes of this document.
| clients: | individuals, families, groups, populations or communities. Synonymous terms may be patients, beneficiaries, partners, recipients, consumers. Clients exist in social systems that may influence the onset and duration of illness and the extent of mental health. |
| contextual
factors: |
the personal, interpersonal and environmental variables that comprise a person’s unique life experience. |
| competencies: | the integrated knowledge, skills, attitudes and judgements expected of the PMH nurse (CNA, 1998). |
| holistic assessment | a data collection process which recognizes the interrelated physical, mental, emotional, spiritual and social dimensions of the person, family or group participating with the nurse in the process. |
| mental disorder: | a recognized medically diagnosable illness that results in the significant impairment of an individual’s cognitive, affective or relational abilities. There are relationships between mental disorders and biological, developmental, and/or psychosocial factors (Health and Welfare Canada, 1988, p.8). |
| mental health: | the capacity of the individual, the group and the environment to interact with one another in ways that promote subjective well-being, the optimal development and use of mental abilities (cognitive, affective and relational), the achievement of individual and collective goals consistent with justice and the attainment and preservation of conditions of fundamental equality (Health and Welfare Canada, 1988, p.7 ). |
| mental health problem: | a disruption in the interactions between the individual, the group and the environment. Such a disruption may result from factors within the individual, including physical or mental illness, or inadequate coping skills. It may also spring from external causes, such as the existence of harsh environmental conditions, unjust social structures, or tensions within the family or community (Health and Welfare Canada, 1988, p.8). |
| mental health promotion: | the process of enhancing the capacity of individuals and communities to take control over their lives and improve their mental health. Mental health promotion uses strategies that foster supportive environments and individual resilience, while showing respect for culture, equity, social justice, interconnections and personal dignity" (Joubert & Raeburn, 1997, p.4). |
| paradigm case: | a composite case that emerges from knowledge and experience and serves as a guide for practice. (Benner, 1984) |
| rapidly changing mental health states: | severe impairments of thought and judgment, constituting a medical emergency, which can occur in association with acute psychosis (a clinical syndrome that may be caused by a variety of disorders such as mania, schizophrenia, drug abuse). |
| therapeutic alliance: | a process that emerges within a nurse-client relationship in which each party is working toward the health goal(s) of the client. The activities to be carried out to meet the goal are mutually negotiated, and the relationship itself is one of trust, support and equity (Madden, 1990). |
| therapeutic use of self: | a combination of self-awareness
with theoretical and experiential knowledge of therapeutic relationships, ie. (a)
understanding, using, and controlling affective responses to clients; (b) integrating
affective and cognitive responses with appropriate interventions; (c) continuing
clarification and maintenance of professional boundaries with clients. (SERPN, 1996, p.40) |
| significant others: | Those to whom the client attributes affection, emotional ties and a sense of belongingness (adapted from Wright & Leahey, 1994, p.39). |
Austin, W., Gallop, R., Harris, D., & Spencer, E. (1996). A ‘domains of practice' approach to the standards of psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing, 3, 111-115.
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.
Benner, P., Tanner, C., & Chesla, C. (1996). Expertise in nursing practice. Caring, clinical judgement, and ethics. New York: Springer.
Canadian Nurses Association [CNA] (1997a). Code of ethics for Registered Nurses. Ottawa, ON: Author.
Canadian Nurses Association (1997b, June). National nursing competency project. Final report. Ottawa, ON: Author.
Canadian Nurses Association (1998, April). A national framework for the development of standards for the practice of nursing: A discussion paper for Canadian Registered Nurses. (ISBN 1-55119-033-8). Ottawa, ON: Author.
Health & Welfare Canada. (1988). Mental health for Canadians: Striking a balance (Cat. H39-128/1988E). Ottawa, Ontario: Minister of Supply and Service Canada.
Joubert, N., & Raeburn, J. (1997, April). Mental health promotion: What is it? What can it become? Paper presented at the Ayrshire International Mental Health Promotion Conference.
Madden, B. (1990). The hybrid model for concept development: Its value for the study of therapeutic alliance. Advances in Nursing Science, 12 (3), 75-87.
Society for Education and Research in Psychiatric-Mental Health Nursing [SERPN] (1996). Educational preparation for psychiatric-mental health nursing practice. Pensacola, FL: Author.
Wright, M. & Leahey, M. (1994). Nurses and families (2nd ed.). Philadelphia, PA: F.A. Davis.
