1. Introduction
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 (Heal tang welfare Canada, 1988). For example, current major changes in the delivery of mental health care include :
• Increasing access to mental health service, and an emphasis on community –based care incorporating mental health promotion , prevention and/or early detection of mental illness.
• Expanding views of the health care “team” to include partnership/ collaborative relationship with clients and their natural support systems and with community professional and advocacy/ self-help groups. Such changes are creating new opportunities and increased vision for PMH nurses.
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 standard ins typed by a nurse who has 2 to 3 years experience in this specially area and who judiciously applies knowledge, skills, attitudes and judgments 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)
2. The Standards of Care for Psychiatric Nursing
STANDARD I (ASSESSMENT)
The Registered Psychiatric Nurse systematically collects, analyses, and synthesizes
data about a client’s health status. Systematic collection of data is the first part of the nursing process and is a prerequisite for realistic assessment of a client’s, family’s, or community’s needs for the formulation of the entire care plan.
Criteria:
1. Systematically collects data about the client from all available sources.
2. Organizes and analyses the data using a nursing model.
3. Formulates and organizes by prioritizing actual and potential nursing diagnoses.
4. Identifies health strengths.
Assessment Tools
• We use a nursing history format to learn more about the client and his needs.
• Assessment includes general information, psychiatric and medical history, family history, cultural and social history, stage of development, support systems, coping styles, stressors, losses/changes, education, strengths, prrecipitasting event, anxiety level, defense mecvhanisms, medications, physical assessment,mental statues assessment.
• Mental Status Exam
• Spiritual Assesment
• Substance Abuse Assessment Assessment- The Cage
• Domestic Violence Assessment
• Suicidal Risk Assessment
• Lethality Risk Scale
STANDARD II (DIAGNOSIS)
After collecting all data, the nurse compares the information and then analyses the data and derives a nursing diagnosis.
A nursing diagnosis is a statement of the patient’s nursing problem that includes both the adaptive and maladaptive health responses and contributing stressors. These nursing problems concern patient’s health aspects that may need to be promoted or with which the patient needs help.
A nursing diagnostic statement consists of three parts:
• Health problem
• Contributing factors
• Defining characteristics
The defining characteristics are helpful because they reflect the behaviour that are the target of nursing intervention .They also provide specific indicators for evaluating the outcome of psychiatric nursing interventions and for determining whether the expected goals of the nursing care were met.
Example:
• If a patient is making statements about dying, he is isolative, anorexic, cannot sleep and wants to die. Then the nursing diagnosis can be-
• Helplessness, related to physical complaints, as evidenced by decreased appetite and verbal cues indicating despondency.
• Fatigue related to insomnia, as evidenced by an increases in physical complaints and disinterest in surroundings.
• Social isolation , related to anxiety, as evidenced by withdrawal and uncommunicative behaviour.
According to KONAS V (National Conference) about mental-health nursing in Indonesia, there are 7 competence Nursing process for the client in psychiatric nursing :
1. Low self esteem chronic
2. Social isolation
3. Self care deficit
4. Disturbed sensory perception : hallucinations
5. Disturbed thought processes
6. Violent Behaviour
7. Risk for suicide
STANDARD III (OUTCOME)
The psychiatric mental health nurse identifies expected outcomes individualized to the client. the main goal is to affect health outcomes and improve the health status of client.
Before defining expected outcomes, the nurse must realize that patient often seek treatment with goals of their own. These goals may be expressed as relieving symptoms or improving functional ability. The nurse must understand the patient’s coping response and the factors that influence them. Some of these difficulties in defining goals are as follows-
• The patient may view a personal problem as someone else’s behaviour.
• The patient may express a problem as feeling, such as “I am lonely” or “I am so unhappy”.
Clarifying goals is an essential step in the therapeutic process. Therefore the patient nurse relationship should be based upon mutually agreed goals. Once the goals are a greed on they must be stated in writing .Goals should be written in behavioural terms, and should be realistically described what the nurse wishes to accomplish within a specific time span. Expected outcomes and short term goals should be developed with short tem objectives contributing to the long term expected outcomes.
STANDARD IV (PLANNING)
Sets realistic goals in collaboration with clients, which are client-centered, target-specific expected outcomes with specific time frames for achievement, and which are derived from prioritized nursing diagnoses.
Nursing Interventions Classification (NIC) -
A comprehensive, standardized language describing treatments that nurses perform in all settings and in all specialties. NIC interventions based on research and reflect current clinical practice.
STANDARD V (IMPLEMENTATION)
Psychiatric/mental health nurses use a wide variety of interventions to prevent mental and physical illness and to promote, maintain and retain health. The Psychiatric Nurse selects interventions according to their level of practice. The basic level nurse may select counseling, case management, self-care activities, group therapy, health teachings, and a variety of other approaches to meet the mental health needs of clients. The advanced level nurse may engage in psychotherapy, and act as a consultant in addition to the basic level interventions. Specific interventions:
- Standard Va (Counseling)
To assist clients in improving coping skills and preventing mental illness and disability One to one listening.
- Standard Vb (Milieu therapy)
To provide and maintain a therapeutic environment for client. RN designs unit activities based on client needs
- Standard Vc (Self care activities)
To foster independence and mental and physical well being bathing, eating, working, paying bills.
- Standard Vd (Psychobiological interventions)
To restore the client s client’s health and prevent further disability medications disability-medications.
- Standard Ve (Health teaching)
To assist clients in achieving satisfying, productive, and healthy patterns of living Stress management, anger management.
- Standard Vf (Case management)
To Coordinate comprehensive health services and ensure continuity of care refer to programs,community support groups.
- Standard Vg (Health promotion and health maintenance)
Implements strategies with clients to promote and maintain mental health and prevent mental illness.
Advanced Practice Interventions
also include:
- Standard Vh (Psychotherapy)
Provides therapy for individuals, groups, families, and children to foster mental health and prevent disability advanced practice role.
- Standard Vi (Prescriptive authority and treatment)
Authority to make recipes, procedures and therapies in accordance with the laws and regulations to deal with mental symptoms and improve functional health status.
- Standard Vj (Consultation)
Provides consultation to enhance the abilities of other clinicians to provide services for clients and effect change in the system effect system--Usually advanced practice Master practice Master’s Prepared nurses.
STANDARD VI (EVALUATION)
The psychiatric/mental health nurse evaluates the client s progress in attaining expected outcomes. client’s Collaborate with others on the team including patient and family.
3. Applying Nursing Process
Role of the nurse in psychiatry
• The nurse assists the client’s successful adaptation to stressors within the environment. Goals are directed toward change in thoughts, feelings, and behaviors that are age appropriate and congruent with local and cultural norms.
• The nurse is a valuable member of the interdisciplinary team, providing a service that is unique and based on sound knowledge of psychopathology, scope of practice, and legal implications of the role.
4. Documentation of the Nursing Process
• Documentation of the steps of the nursing process is often considered as evidence indetermining certain cases of negligence by nurses.
• It is also required by some agencies that accredit healthcare organizations.
Examples of documentation that reflect use of the nursing process
Bibliography :
- American Nurses Association. 2000. Scope and Standards of Psychiatric-mental Health Clinical Nursing Practice. Washington, DC: The Association.
- Frisch, Noreen Cavan.2006.Psychiatric Mental Health Nursing. Thomson Delmar Learning:Canada.
- College of Registered Psychiatric Nurses of British Columbia. 1995. Standards of Psychiatric Nurses in British Columbia. Available at http://free-new-ebook.com. Accessed on 12 december 2009.
- Jyoti Beck, RN, RM,DPN. The Nursing Process :Context Of Psychiatric Nursing. Available at http://www.nursingplanet.com/pn/nursing_process_psychiatric_nursing.htm#Outcome%20Identification. Accessed on 12 December 2009.
- NANDA List. Complete Listing of All NANDA Nursing Diagnoses Through The 12th Conference (1996). Available at http://www.efn.org/~nurses/nanda.html. accessed on 12 December 2009.
- Stuart, Gail W. 2006. Pocket Guide to Psychiatric Nursing 5 ed. Mosby.
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 (Heal tang welfare Canada, 1988). For example, current major changes in the delivery of mental health care include :
• Increasing access to mental health service, and an emphasis on community –based care incorporating mental health promotion , prevention and/or early detection of mental illness.
• Expanding views of the health care “team” to include partnership/ collaborative relationship with clients and their natural support systems and with community professional and advocacy/ self-help groups. Such changes are creating new opportunities and increased vision for PMH nurses.
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 standard ins typed by a nurse who has 2 to 3 years experience in this specially area and who judiciously applies knowledge, skills, attitudes and judgments 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)
2. The Standards of Care for Psychiatric Nursing
STANDARD I (ASSESSMENT)
The Registered Psychiatric Nurse systematically collects, analyses, and synthesizes
data about a client’s health status. Systematic collection of data is the first part of the nursing process and is a prerequisite for realistic assessment of a client’s, family’s, or community’s needs for the formulation of the entire care plan.
Criteria:
1. Systematically collects data about the client from all available sources.
2. Organizes and analyses the data using a nursing model.
3. Formulates and organizes by prioritizing actual and potential nursing diagnoses.
4. Identifies health strengths.
Assessment Tools
• We use a nursing history format to learn more about the client and his needs.
• Assessment includes general information, psychiatric and medical history, family history, cultural and social history, stage of development, support systems, coping styles, stressors, losses/changes, education, strengths, prrecipitasting event, anxiety level, defense mecvhanisms, medications, physical assessment,mental statues assessment.
• Mental Status Exam
• Spiritual Assesment
• Substance Abuse Assessment Assessment- The Cage
• Domestic Violence Assessment
• Suicidal Risk Assessment
• Lethality Risk Scale
STANDARD II (DIAGNOSIS)
After collecting all data, the nurse compares the information and then analyses the data and derives a nursing diagnosis.
A nursing diagnosis is a statement of the patient’s nursing problem that includes both the adaptive and maladaptive health responses and contributing stressors. These nursing problems concern patient’s health aspects that may need to be promoted or with which the patient needs help.
A nursing diagnostic statement consists of three parts:
• Health problem
• Contributing factors
• Defining characteristics
The defining characteristics are helpful because they reflect the behaviour that are the target of nursing intervention .They also provide specific indicators for evaluating the outcome of psychiatric nursing interventions and for determining whether the expected goals of the nursing care were met.
Example:
• If a patient is making statements about dying, he is isolative, anorexic, cannot sleep and wants to die. Then the nursing diagnosis can be-
• Helplessness, related to physical complaints, as evidenced by decreased appetite and verbal cues indicating despondency.
• Fatigue related to insomnia, as evidenced by an increases in physical complaints and disinterest in surroundings.
• Social isolation , related to anxiety, as evidenced by withdrawal and uncommunicative behaviour.
According to KONAS V (National Conference) about mental-health nursing in Indonesia, there are 7 competence Nursing process for the client in psychiatric nursing :
1. Low self esteem chronic
2. Social isolation
3. Self care deficit
4. Disturbed sensory perception : hallucinations
5. Disturbed thought processes
6. Violent Behaviour
7. Risk for suicide
STANDARD III (OUTCOME)
The psychiatric mental health nurse identifies expected outcomes individualized to the client. the main goal is to affect health outcomes and improve the health status of client.
Before defining expected outcomes, the nurse must realize that patient often seek treatment with goals of their own. These goals may be expressed as relieving symptoms or improving functional ability. The nurse must understand the patient’s coping response and the factors that influence them. Some of these difficulties in defining goals are as follows-
• The patient may view a personal problem as someone else’s behaviour.
• The patient may express a problem as feeling, such as “I am lonely” or “I am so unhappy”.
Clarifying goals is an essential step in the therapeutic process. Therefore the patient nurse relationship should be based upon mutually agreed goals. Once the goals are a greed on they must be stated in writing .Goals should be written in behavioural terms, and should be realistically described what the nurse wishes to accomplish within a specific time span. Expected outcomes and short term goals should be developed with short tem objectives contributing to the long term expected outcomes.
STANDARD IV (PLANNING)
Sets realistic goals in collaboration with clients, which are client-centered, target-specific expected outcomes with specific time frames for achievement, and which are derived from prioritized nursing diagnoses.
Nursing Interventions Classification (NIC) -
A comprehensive, standardized language describing treatments that nurses perform in all settings and in all specialties. NIC interventions based on research and reflect current clinical practice.
STANDARD V (IMPLEMENTATION)
Psychiatric/mental health nurses use a wide variety of interventions to prevent mental and physical illness and to promote, maintain and retain health. The Psychiatric Nurse selects interventions according to their level of practice. The basic level nurse may select counseling, case management, self-care activities, group therapy, health teachings, and a variety of other approaches to meet the mental health needs of clients. The advanced level nurse may engage in psychotherapy, and act as a consultant in addition to the basic level interventions. Specific interventions:
- Standard Va (Counseling)
To assist clients in improving coping skills and preventing mental illness and disability One to one listening.
- Standard Vb (Milieu therapy)
To provide and maintain a therapeutic environment for client. RN designs unit activities based on client needs
- Standard Vc (Self care activities)
To foster independence and mental and physical well being bathing, eating, working, paying bills.
- Standard Vd (Psychobiological interventions)
To restore the client s client’s health and prevent further disability medications disability-medications.
- Standard Ve (Health teaching)
To assist clients in achieving satisfying, productive, and healthy patterns of living Stress management, anger management.
- Standard Vf (Case management)
To Coordinate comprehensive health services and ensure continuity of care refer to programs,community support groups.
- Standard Vg (Health promotion and health maintenance)
Implements strategies with clients to promote and maintain mental health and prevent mental illness.
Advanced Practice Interventions
also include:
- Standard Vh (Psychotherapy)
Provides therapy for individuals, groups, families, and children to foster mental health and prevent disability advanced practice role.
- Standard Vi (Prescriptive authority and treatment)
Authority to make recipes, procedures and therapies in accordance with the laws and regulations to deal with mental symptoms and improve functional health status.
- Standard Vj (Consultation)
Provides consultation to enhance the abilities of other clinicians to provide services for clients and effect change in the system effect system--Usually advanced practice Master practice Master’s Prepared nurses.
STANDARD VI (EVALUATION)
The psychiatric/mental health nurse evaluates the client s progress in attaining expected outcomes. client’s Collaborate with others on the team including patient and family.
3. Applying Nursing Process
Role of the nurse in psychiatry
• The nurse assists the client’s successful adaptation to stressors within the environment. Goals are directed toward change in thoughts, feelings, and behaviors that are age appropriate and congruent with local and cultural norms.
• The nurse is a valuable member of the interdisciplinary team, providing a service that is unique and based on sound knowledge of psychopathology, scope of practice, and legal implications of the role.
4. Documentation of the Nursing Process
• Documentation of the steps of the nursing process is often considered as evidence indetermining certain cases of negligence by nurses.
• It is also required by some agencies that accredit healthcare organizations.
Examples of documentation that reflect use of the nursing process
- Problem Oriented Recording (POR)
- Focus Charting ®
- APIE method
Bibliography :
- American Nurses Association. 2000. Scope and Standards of Psychiatric-mental Health Clinical Nursing Practice. Washington, DC: The Association.
- Frisch, Noreen Cavan.2006.Psychiatric Mental Health Nursing. Thomson Delmar Learning:Canada.
- College of Registered Psychiatric Nurses of British Columbia. 1995. Standards of Psychiatric Nurses in British Columbia. Available at http://free-new-ebook.com. Accessed on 12 december 2009.
- Jyoti Beck, RN, RM,DPN. The Nursing Process :Context Of Psychiatric Nursing. Available at http://www.nursingplanet.com/pn/nursing_process_psychiatric_nursing.htm#Outcome%20Identification. Accessed on 12 December 2009.
- NANDA List. Complete Listing of All NANDA Nursing Diagnoses Through The 12th Conference (1996). Available at http://www.efn.org/~nurses/nanda.html. accessed on 12 December 2009.
- Stuart, Gail W. 2006. Pocket Guide to Psychiatric Nursing 5 ed. Mosby.
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