A Statement on

Psychiatric-Mental
Health Clinical
Nursing Practice
and
Standards of
Psychiatric-Mental
Health Clinical
Nursing Practice
 s»!S*ass&sS

Donated To
W.F. Maag Library
of
Youngstown State
University

Gift of
The St. Elizabeth
School of Nursing |
 bi. ELIZABETH HOSPITAL MEDICAL CENTER
SCHOOL OF NURSING LIBRARY. . V7 P
1044 BELMONT AVE. /
.YOUNGSTOWN, OHIO 44501-1790

STATEMENT
on
Psychiatric-Mental Health
Clinical Nursing Practice
and
STANDARDS

Psychiatric-
Clinical
,, -A

'\ \V V American Nurses Association

<fdunCil on Psychiatric and Mental Health Nursing
American Psychiatric Nurses Association

Association of Child and Adolescent Psychiatric Nurses

Society for Education and Research in Psychiatric-Mental
Health Nursing

WILLIAM F. MAAG LIBRARY

YOUNGSTOWN STATE UNIVERSITY
This document is a collaborative effort of the members of the Coalition of
Psychiatric Nursing Organizations, under the leadership of the Executive
Committee of the American Nurses Association's (ANA) Council on Psychi¬
atric and Mental Health Nursing. The Council gratefully acknowledges all
the valuable assistance given by various individuals and groups across the
country who have contributed comments and recommendations through¬
out the revision process.
Task Force to Revise Statement on Psychiatric-Mental Health Nursing Prac¬
tice and Standards of Psychiatric-Mental Health Clinical Nursing Practice
Carolyn V. Billings, M.S.N., R.N.,C.S., Chairperson
ANA Council on Psychiatric and Mental Health Nursing
Jean Blackburn, M.S.N., R.N., C.S.
ANA Council on Psychiatric and Mental Health Nursing
Mickie Crimone, M.S., R.N., C.S. *
Society for Education and Research in Psychiatric-Mental Health Nursing
Carol Dashiff, Ph.D., R.N., C.S.
Association for Child and Adolescent Psychiatric Nurses
Anita O'Toole, Ph.D., R.N., C.S., F.A.A.N.
ANA Council on Psychiatric and Mental Health Nursing
Kathleen Scharer, M.S., R.N., C.S., F.A.A.N.
ANA Committee on Nursing Practice Standards and Guidelines
Carole A. Shea, Ph.D., R.N., C.S.
American Psychiatric Nurses Association

Contributors
Margery Chisholm, Ed.D., R.N., C.S.
Sandra J. Fitzgerald, B.S.N., R.N., C.
Executive Committee, ANA Council on Psychiatric and Mental Health
Nursing
Carolyn V. Billings, M.S.N., R.N., C.S., Chairperson
Christina Sieloff, M.S.N., R.N., C.N.A. Chair-elect
Jean Blackburn, M.S.N., R.N., C.S.
Beverly Farnsworth, Ph.D., R.N., C.S.
Judith Haber, Ph.D., R.N., C.S., F.A.A.N.
H. Marie McGrath, Ph.D., R.N.

Staff: ANA Department of Practice, Economics, and Policy

Sarah Stanley, M.S., R.N., C.N.A., C.S., Senior Policy Analyst
Valarie Carty, Administrative Assistant
ISBN 1-55810-098-9
Published by
American Nurses Publishing
600 Maryland Avenue, SW
Suite 100 West
Washington, DC 20024-2571
Copyright © 1994 by the American Nurses Association. All rights reserved.
PMH-12 7.5M 1/94
1X3-
lMo
CONTENTS
^ Preface . iii
Introduction. v
Statement on Psychiatric-Mental Health
Clinical Nursing Practice
Contemporary Issues and Trends. 3
Rapid Expansion of Biological Sciences and Technology. 3
Demographic Shifts in the Population. 4
Changes in Delivery of Mental Health Services. 5
Description of Psychiatric-Mental Health Nursing . 7
Psychiatric-Mental Health Nursing Practice Ethics. 9
Scope of Psychiatric-Mental Health Clinical Nursing Practice . 10
Levels of Psychiatric-Mental Health Clinical Nursing Practice. 10
Basic Level. 10
Advanced Level . 11
Subspecialization. 11
Psychiatric-Mental Health Nursing Clinical Practice Functions . 12
Basic Level Functions. 12
Health Promotion and Health Maintenance. 13
Intake Screening and Evaluation. 13
Case Management. 13
Milieu Therapy. 13
Self-Care Activities. 14
Psychobiological Interventions . 14
Health Teaching . 14
Crisis Intervention. 15
Counseling. 15
Home Visit. 15
Community Action . 15
Advocacy. 16
Advanced Level Functions. 16
Psychotherapy . 17
Psychobiological Interventions . 18
Clinical Supervision/Consultation . 18
Consultation-Liaison. 19
Psychiatric-Mental Health Nursing Clinical Practice Settings. 19
Conclusion. 20
Standards of Psychiatric-Mental Health
Clinical Nursing Practice
Introduction. 23
Standards of Care. 25
I. Assessment. 25
II. Diagnosis. 26

* WILLIAM F. MAAS ' '‘ i’ '' '

^£7M0UNGST0WN state UN.VFRSH
 III. Outcome Identification. 27
IV. Planning. 28
V. Implementation . 28
Va. Counseling. 29
Vb. Milieu Therapy . 29
Vc. Self-Care Activities. 30
Vd. Psychobiological Interventions . 30
Ve. Health Teaching. 31
Vf. Case Management. 31
Vg'. Health Promotion and Health Maintenance. 31
Vh.-Vj. Advanced Practice Interventions. 32
Vh. Psychotherapy . 32
Vi. Prescription of Pharmacological Agents .. 33
Vj. Consultation. 33
VI. Evaluation. 33
Standards of Professional Performance. 34
I. Quality of Care . 34
II. Performance Appraisal .•. 35
III. Education. 36
IV. Collegiality. 37
V. Ethics. 37
VI. Collaboration. 38
VII. Research . 38
VIII. Resource Utilization. 39
References . 41
Glossary. 42
 PREFACE
The Executive Committee of the American Nurses Association's (ANA)
Council on Psychiatric and Mental Health Nursing convened the 1992 Task
Force to Revise the Statement and Standards of Psychiatric-Mental Health
Nursing Practice. This revision, coordinated by the ANA council, is the joint
effort of the members of the Coalition of Psychiatric Nursing Organizations
(COPNO). COPNO includes the ANA Council on Psychiatric and Mental
Health Nursing, the American Psychiatric Nurses Association, the Associa¬
tion of Child and Adolescent Psychiatric Nurses, and the Society for Educa¬
tion and Research in Psychiatric-Mental Health Nursing. Each of these
organizations focuses on different aspects of the specialty and many nurses
are members of more than one.
 INTRODUCTION
In 1967, ANA's Division of Psychiatric and Mental Health Nursing Practice
published the Statement on Psychiatric Nursing Practice (ANA 1967). ANA
published a revision of this statement in 1976 (ANA 1976). Current trends
and developments in the practice of nursing, in concert with issues and
advances in the broader field of mental health care delivery, have high¬
lighted the need to review and interpret the responsibilities of nurses within
the specialty, particularly in regard to clinical practice. As a result, this
revision focuses entirely on the clinical aspects of psychiatric-mental health
nursing practice.
In the belief that scope of practice is inextricably linked to practice
standards, this book also incorporates a substantive revision of the 1982
ANA publication. Standards of Psychiatric and Mental Health Nursing Practice
(ANA 1982). The specialty standards contained in this publication provide
specific measurement criteria for the clinical practice of psychiatric-mental
health nursing and are built on the broader general standards of nursing
practice as delineated in the ANA Standards of Clinical Nursing Practice (ANA
1991b).
This book provides definitions and descriptions of basic and advanced
psychiatric-mental health clinical nursing practice. It delineates the scope,
functions, and roles of the clinical practice of psychiatric-mental health
nurses as well as the diverse settings in which they practice. In addition, it
establishes the clinical practice standards for the specialty. This publication
is intended for those who deliver, benefit from, and pay for psychiatric-
mental health services. It is useful for nurse colleagues and other profes¬
sionals with an interest in the specialty practice of psychiatric-mental health
nursing. Finally, it provides policy makers, insurers, and the public with
information about the roles and responsibilities of psychiatric-mental health
nurses across the continuum of care.
*•,
 STATEMENT
on
PSYCHIATRIC-MENTAL
HEALTH
CLINICAL NURSING
PRACTICE
 CONTEMPORARY ISSUES AND TRENDS
Psychiatric-mental health nursing is both a product of society and a force for
social change. As such, the discipline has been evolving from a highly
specialized field to a broader, more expansive area of practice that seeks to
integrate the biological and the psychosocial domains of the human condi¬
tion. This evolution is the result of major developments in science, society,
health care, and the nursing profession.

Rapid Expansion of Biological Sciences and

Technology
The National Institute of Mental Health (NIMH) has proclaimed the 1990s
the “Decade of the Brain." This was a response to the phenomenal discov¬
eries in medicine, neuroscience, endocrinology, immunology, and genetics
which are providing an understanding of the direct links among brain bio¬
chemistry, human functioning, and conditions of health and illness. Also,
the creation of sophisticated technology is illuminating the structure and
function of the brain. One hundred years after Dr. Sigmund Freud hypothe¬
sized about the wonders of the mind, modern scientists have rediscovered
the importance of the brain itself as a powerful influence on and complex
determinant of human behavior.
With research providing evidence that the most serious mental disor¬
ders should be regarded as diseases of the brain, there is a major shift
toward the “medicalization" of mental illness (Lowery 1992). The positive
side of this shift is that, much as biomedical advances helped conquer many
physical illnesses, advances such as magnetic resonance imaging, neuro¬
surgical techniques, psychopharmacology, and genetic therapy hold prom¬
ise for more effective treatment for those with depression, schizophrenia,
anxiety, and other serious mental disorders. These advances foster new
hope among mental health providers and consumers that dramatic scientific
breakthroughs will produce the means to treat and ultimately prevent many
mental illnesses.
Some fear that the pendulum may swing too far in the direction of
relying on medical treatments for all psychiatric and mental health prob¬
lems, to the exclusion of psychotherapeutic interventions. This is unlikely
since research to date substantiates the superiority of the combined treat¬
ment of psychopharmacology and psychotherapy in severe mental illness to
any one treatment by itself.
It is predicted that there will still be a need for psychotherapeutic tech¬
niques to help people cope with the psychosocial aspect of acute and
chronic mental illness, the effects of stressful lifestyles, dysfunctional inter¬
active patterns, societal problems, aging, serious illness, and their

3
responses to treatment. Also, various approaches such as behavioral, cogni¬
tive, dynamic, insight, solution-focused, and system-directed therapies will
become more targeted toward specific conditions, and, consequently, will
produce even more beneficial and measurable outcomes.
Nurses in psychiatric-mental health practice are in an advantageous
position to address the re-integration of physical and psychosocial care for
individuals with mental illness (McBride 1990). The emphasis on the con¬
nections among brain, spirit, mind, and body is revitalizing psychiatric
nursing practice. Psychiatric-mental health nurses are skilled in the spe¬
cialized use of communication, counseling, and psychotherapeutic tech¬
niques. In addition, they incorporate a general practice knowledge stressing
the relationship between biological, psychological, social, cultural, spiritual,
and environmental factors and health and illness. With continuing educa¬
tion in neuroscience as well as behavioral science, psychiatric-mental health
nurses will continue to fine-tune their abilities to assess, diagnose, and treat
human responses to a wide spectrum of illnesses.

Demographic Shifts in the Population

A major change in the demographic composition of the population is taking
place in America. There is an unprecedented increase in the number of
elderly, ethnic minorities, and the economically and educationally disadvan¬
taged. The shift in population fuels tension among different racial, cultural,
economic, political, social, educational, and religious groups, profoundly
affecting all aspects of society.
There is a concomitant crisis in the mental health of the nation. Not
only are more people at risk for and experiencing mental illness related to
the pressures of these social conditions, but our understanding of mental
illness itself is changing. Some known disorders are evolving into long-term
chronic illnesses that drain the energy and resources of families, commu¬
nities, and the mental health care system. Relatively newly recognized dis¬
orders such as Acquired Immune Deficiency Syndrome (AIDS) dementia,
post-traumatic stress disorder (PTSD), and chemical dependence in new¬
borns and children, present a challenge to the use of well-established
models of treatment and the increasing scarcity of psychiatric care resources
(Pothier, Stuart, Puskar, and Babich 1990).
The difficulty in working to solve mental health problems—which fre¬
quently are compounded by other problems such as the culture of violence,
joblessness, homelessness, teenage pregnancy, illiteracy, and failing physi¬
cal health—is magnified by the myriad different life experiences, value sys¬
tems, languages, cultural beliefs, and generational perspectives of those
who need mental health services. A further complication is that professional
providers often differ significantly from the recipients of their care in terms
of these background and experience variables, and hence must be educated
more broadly to provide culturally sensitive care.

4
 Increasing numbers of psychiatric nurses are working in community-
based settings with individuals, families, and communities that are experi¬
encing both the opportunities and challenges which accompany societal
shifts and pandemic health care problems. Educational programs are seek¬
ing non-traditional clinical placements for psychiatric nursing students and
including courses which focus on assessment of strengths and competen¬
cies, cultural diversity, healthy aging, short-term therapies, nutrition, and
language study to prepare psychiatric nurses for practice with diverse
populations.
There is more focus on the developmental issues and mental health
needs of men and women, children and adolescents, and the elderly. While
women customarily have been a disproportionate part of the patient popu¬
lation in psychiatry, research on female physiology and psychological devel¬
opment suggests that diagnostic and treatment formulations will change to
reflect new knowledge.
There is also emphasis on the special needs of rural, homeless, and
other underserved populations. This has been encouraged by governmental
initiatives and private-sector funding for demonstration projects providing
mental health services for these hard-to-reach groups. By focusing on the
care of particular age groups (e.g., child, adolescent, and elderly) or popula¬
tions (e.g., survivors of violence, cocaine-addicted mothers, homeless fami¬
lies, and immigrants), psychiatric nurses are continuing to develop the in-
depth knowledge, cultural sensitivity, and therapeutic skills necessary to
build new models for care and to design relevant interventions. They are
working to establish common ground with those whose needs for psychi¬
atric and mental health care are not being met in the present system. How¬
ever, there still must be a concerted effort to attract more racial minorities
and ethnically diverse individuals to the psychiatric-mental health nursing
profession.

Changes in the Delivery of Mental Health Services

Prior to the end of World War II, psychiatric care was delivered in separate
facilities, on a long-term basis, and with most of the financing coming from
either non-insured private payers or very limited tax-supported programs.
This “system” limited individuals' access to care and placed an inordinate
emotional and financial burden on their families and communities. Efforts
to improve access and develop new models of care in the '60s and '70s
eventually failed because of changes in governmental spending priorities,
failure of the system to convert to new approaches, and pervasive public
attitudes about the stigma surrounding mental illness (Billings 1993).
Since then, a complex sequence of events has changed the nature and
delivery of mental health services. These events include the de¬
institutionalization of tens of thousands of patients from mental hospitals.

5
the subsequent breakdown of the public sector, the skyrocketing inflation of
health care costs, the ascendancy of privatization and managed care, and
the movement for reform of general health care. The result of these events is
a pattern of service delivery which is payer-driven rather than practice-
driven in an effort to contain costs.
With a major focus on cost containment, there is evidence that many
individuals with serious psychiatric illness remain under-diagnosed and
under-treated. Those who are most severely ill are hospitalized in psychi¬
atric intensive-care units where they are treated with psychopharmacologic
agents and discharged after a very limited stay. A premium is put on the use
of medical intervention. For nurses who provide expert care in these units,
the work is complicated by the management of complex behavioral prob¬
lems of the patients and the pressure to strive for cost containment. Because
there is pressure to decrease the patient's length of stay in the hospital,
most patients are barely stabilized before they are discharged. Early dis¬
charge leads to more acutely ill patients in the community who continue to
need expert professional care and intensive case management.
In the future, given the downsizing of specialized psychiatric units and
the privatization of outpatient psychiatric care, using a managed-care
model, it is predicted that very acutely ill psychiatric patients will be admit¬
ted to general hospital units for highly technological diagnostic procedures
and aggressive medical treatment, much as patients with serious physical
illnesses are admitted to critical-care units now (Lowery~ 1992). The spe¬
cialized psychiatric facilities that remain may also become more dependent
on this high-tech approach to diagnosis and treatment of mental illness.
Furthermore, the total spectrum of mental health care needs will
expand to include health promotion and disease prevention. For example,
programs that address healthy parenting, stress management, and learning
adaptive coping skills, enhance mental health and may prevent the psycho¬
logical trauma associated with family violence. Education of young children
about the effects of addictive substances may interrupt the cycle of addic¬
tion, saving the next generation of children from the effects of psychosocial
problems and learning disabilities. There will be an emphasis on the con¬
sumer's responsibility and involvement in self-care related to mental health.
Nurses will share information so that consumers and families can make
informed choices and give input about their care.
Therefore, delivery of mental health care will take place more fre¬
quently on an outpatient basis or in community-based settings such as
homes, schools, halfway houses—even the streets (Koldjeski 1984). Also, as
the brain-mind-body connection becomes better understood,there will be a
continuing effort to provide psychosocial care for the physically ill in the
community. These trends will reactivate the community mental health
movement because its goals dovetail with the federal government's goal to
focus on health promotion and disease prevention through the Healthy Peo¬
ple 2000 (HHS 1990) objectives.

6
 These service delivery trends have resulted in the need for psychiatric-
mental health nurses to provide primary mental health care. Nurses are
alert to opportunities to promote mental health, to detect and intervene in
situations with increased stress, developmental crises, and family violence
and abuse which often predispose the people involved to mental disorders.
Nurses must be able to make rapid comprehensive assessments; use effec¬
tive problem-solving skills in making complex clinical decisions; act autono¬
mously as well as collaboratively with other professionals; be sensitive to
issues such as ethical dilemmas, cultural diversity, and access to mental
health care for underserved populations; be comfortable working in decen¬
tralized settings; and be sophisticated about the costs and benefits of pro¬
viding care within fiscal constraints. Psychiatric-mental health nurses have
the knowledge, skills, and creativity to adapt their practice to meet
the demands of new delivery systems while improving quality mental
health care.
There is also a need for psychiatric care to be mainstreamed into the
overall health care system. Sweeping changes are forecast for the delivery of
all health services in the near future, and reform of the system must include
parity for mental health services. It is imperative that those needing mental
health services have access and benefits equal to those individuals needing
general health care services. In any national health reform legislation there
must be equitable coverage based on clinical needs for all mental and physi¬
cal health care services delivered in managed care systems. Access to care
must be enhanced, especially for those who are uninsured and unem¬
ployed. (ANA 1991a, Krauss 1993)
Psychiatric-mental health nurses are active as informed individuals and
through their professional nursing organizations in the advocacy of
increased access, equal treatment and insurance coverage for persons with
mental illness and their families. In seeking parity for mental health ser¬
vices, psychiatric nursing organizations have formed partnerships with con¬
sumer groups and other professional organizations to educate the public
about the similar and unique needs of those with mental health problems.

DESCRIPTION OF PSYCHIATRIC-MENTAL
HEALTH NURSING
Psychiatric-mental health nursing is the diagnosis and treatment of human
responses to actual or potential mental health problems. Psychiatric-mental
health nursing is a specialized area of nursing practice, employing theories
of human behavior as its science and purposeful use of self as its art.
Psychiatric-mental health nurses deliver primary mental health care.
Primary mental health care is initiated at the first point of contact with the
mental health care system. Primary mental health care is defined as the
continuous and comprehensive services necessary for promotion of optimal

maag library
F■

Youngstown state univeikit

PSYCHIATRIC-MENTAL HEALTH NURSING'S
PHENOMENA OF CONCERN

Actual or potential mental health problems of clients pertaining to:

*the maintenance of optimal health and well-being and the prevention

of psychobiologic illness.

*self-care limitations or impaired functioning related to mental and

emotional distress.

‘deficits in the functioning of significant biological, emotional, and

cognitive systems.
%
■v

‘emotional stress or crisis components of illness, pain, and disability.

‘self-concept changes, developmental issues, and life process changes.

‘problems related to emotions such as anxiety, anger, sadness,

loneliness, and grief.

‘physical symptoms that occur along with altered psychological

functioning.

‘alterations in thinking, perceiving, symbolizing, communicating, and

decision making.

‘difficulties in relating to others.

‘behaviors and mental states that indicate the client is a danger to self
or others or has a severe disability.

‘interpersonal, systemic, sociocultural, spiritual, or environmental

circumstances or events which affect the mental and emotional well¬
being of the individual, family, or community.

‘symptom management, side effects/toxicities associated with

psychopharmacologic intervention and other aspects of the treatment
regimen.

Figure 1. Psychiatric-Mental Health Nursing's Phenomena of Concern.

8
mental health, the prevention of mental illness, health maintenance, man¬
agement of, and/or referral of mental and physical health problems, the
diagnosis and treatment of mental disorders and their sequelae, and reha¬
bilitation (Haber and Billings 1993). Because of its scope, psychiatric-mental
health nursing is necessarily holistic and considers the needs and strengths
of the whole person, the family and the community.
Diagnosis of human responses to actual or potential mental health
problems involves the application of theory to human phenomena, through
the processes of assessment, diagnosis, planning, intervention or treat¬
ment, and evaluation. Theories relevant to psychiatric-mental health nurs¬
ing are derived from various sources, including those from nursing as well
as the biological, cultural, environmental, psychological and sociological
sciences. These theories provide a basis for psychiatric-mental health nurs¬
ing practice.
An assessment, derived from data collection, interview and behavioral
observations, provides information upon which a diagnosis is based and,
when appropriate, validated with the client. The psychiatric-mental health
nurse uses nursing diagnoses and standard classifications of mental disor¬
ders such as The Diagnostic and Statistical Manual of Mental Disorders of the
American Psychiatric Association (American Psychiatric Association 1987)
or the International Classification of Diseases (World Health Organization 1993)
to develop a treatment plan based on assessment data and theoretical prem¬
ises. The nurse then selects and implements interventions directed toward a
client's response to an actual or potential health problem. The nurse peri¬
odically evaluates the client outcome and revises the plan of care to achieve
optimal results.

PSYCHIATRIC-MENTAL HEALTH NURSING

PRACTICE ETHICS
Nursing's respect for the client's dignity, autonomy, cultural beliefs, and
privacy is of particular concern in psychiatric-mental health nursing prac¬
tice. The nurse serves as an advocate for the client and is obliged to demon¬
strate nonjudgemental and nondiscriminatory attitudes and behaviors that
are sensitive to client diversity. Unethical behavior—e.g., violations of
informed consent, breaches of confidentiality, undue coercion, and illegal
acts—can increase the client's vulnerability demanding special vigilance on
the part of the nurse who is responsible to protect the client and to report
practices which compromise the public's right to humane and appropriate
care. Nurses working with psychiatric-mental health clients are prepared to
recognize the special nature of the provider-patient relationship and take
steps to assure therapeutic relationships are conducted in a manner that
adheres to the mandates stipulated in the Code for Nurses (ANA 1980).

9
 SCOPE OF PSYCHIATRIC-MENTAL HEALTH
CLINICAL NURSING PRACTICE
The scope of psychiatric-mental health nursing practice is differentiated
according to the nurse's level of practice and further delineated by the role
of the nurse and the work setting. It is the responsibility of individual
nurses to identify their practice parameters within their state nurse practice
act, professional code, and professional practice standards, and, according
to their own personal competency, to perform particular activities or func¬
tions. The nurse's competence is circumscribed by the individual nurse's
education, knowledge, experience, and abilities. While psychiatric-mental
health nurses are accountable for their own nursing practice, as profes¬
sionals they have a responsibility to collaborate and to coordinate care with
others who may be working with the client and with those whose expertise
can enhance the quality of service.

LEVELS OF PSYCHIATRIC-MENTAL HEALTH

CLINICAL NURSING PRACTICE
Psychiatric-mental health nurses are registered nurses (RNs) who are educa¬
tionally prepared in nursing and licensed to practice in'their individual
states. Registered nurses are qualified for specialty practice at two levels—
basic and advanced. These levels are differentiated by educational prepara¬
tion, professional experience, type of practice, and certification. In addition,
these levels can differ based on the nurse's focus on clinical, administrative,
educative, and research roles. This book is confined to a statement which
addresses the clinical role, scope and standards of practice in the specialty
area of psychiatric-mental health nursing.

Basic Level
Psychiatric-Mental Health Registered Nurse. The Psychiatric-Mental Health
Nurse is a licensed RN who has a baccalaureate degree in nursing and
demonstrated clinical skills, within the specialty, exceeding those of a begin¬
ning RN or a novice in the specialty. The designation, Psychiatric-Mental
Health Nurse, applies to those nurses who are certified within the specialty
and who meet the profession's standards of knowledge and experience.
Certification is the formal process that validates the nurse's clinical compe¬
tence. The letter "C," placed after the R.N. (i.e., R.N., C.), is the initial that
designates basic-level certification status.
Many professional nurses who contribute to the practice of psychiatric-
mental health nursing and care for mental health clients are either entry-

10
level RNs or are novices in the specialty. These nurses practice in conjunc¬
tion with psychiatric-mental health nurses and are responsible for adhering
to the specialty practice standards as designated by the profession.

Advanced Level
Psychiatric-Mental Health Advanced Practice Registered Nurse. The Psychiatric-
Mental Health Advanced Practice Registered Nurse (APRN) is a licensed RN
who is educationally prepared at the master's level, at a minimum, and is
nationally certified as a clinical specialist in psychiatric and mental health
nursing. This preparation is distinguished by a depth of knowledge of the¬
ory and practice, supervised clinical practice, and competence in advanced
clinical nursing skills. The psychiatric-mental health APRN has the ability to
apply knowledge, skills, and experience autonomously to complex mental
health problems.
The doctorally prepared psychiatric-mental health nurse in advanced
practice has both a master's degree in nursing and a doctorate in nursing or
a related field. Academic programs in nursing leading to a doctorate follow
one of two traditions: 1) advanced development of the clinical nursing role
with a research component directed toward the investigation of specific
clinical problems (Doctor of Nursing Science-D.N.Sc.); or 2) research and
theory development in the science of psychiatric-mental health nursing
(Doctor of Philosophy-Ph.D.).
The scope of practice in psychiatric-mental health nursing is expanding
as the context of practice, the need for client access to holistic care, and the
various scientific and nursing knowledge bases evolve. Many state legisla¬
tures and Congress have acknowledged the unique role of advanced prac¬
tice psychiatric nurses in the delivery of mental health services by passing
legislation which makes them eligible for prescriptive authority, admission
privileges, and third-party reimbursement.
Historically, the psychiatric-mental health nurse in advanced practice
has been called a clinical nurse specialist (CNS). The term advanced practice
registered nurse (inclusive of the terms clinical nurse specialist, nurse anes¬
thetist, nurse midwife, nurse practitioner) has emerged in response to the
need for uniform titling within the nursing profession. The appropriate
credential for advanced clinical practice in this specialty is that of the Certi¬
fied Specialist in Psychiatric and Mental Health Nursing (R.N., C.S.). In this
book, the psychiatric-mental health advanced practice nurse is referred to as
a certified specialist.

SUBSPECIALIZATION
Subspecialization in a specific area of practice occurs during master's and
doctorate preparation in nursing and/or through continuing professional

11
education. Subspecialization is focused on the development of additional
knowledge and skills for providing services to a population. Subspecializa¬
tions within psychiatric-mental health nursing emerge based on current and
anticipated societal needs for specific specialty nursing services. This sub¬
specialization may be categorized according to a developmental period (e.g.
child and adolescent, adult, geriatric) (ANA 1985), a specific mental/
emotional disorder (e.g. addiction, depression, chronic mental illness), a
particular practice focus (e.g. community, group, couple, family, individ¬
uals), and/or a specific role or function (e.g. psychiatric consultation-
liaison). These categories are not mutually exclusive but provide a matrix
within which the parameters of subspecialization are defined.
Some psychiatric-mental health nurses in advanced practice seek certi¬
fication in subspecialty areas as a means of obtaining recognition in a par¬
ticular practice focus. At this time, not all subspecialties are coupled with a
certification process, nor is subspecialty certification essential for practice. It
is graduate preparation, additional training and experience, and the individ¬
ual nurse's judgment about readiness to work with a particular situation or
client population that constitute appropriate practice.
Given this additional preparation, as long as the nurse is certified as a
specialist in an area of psychiatric/mental health nursing, that nurse can
appropriately practice in a subspecialty area with or without certification in
that area. In other words, subspecialty certification in a particular category
of psychiatric-mental health nursing does not confine the certified specialist
only to the area of subspecialization. For example, nurses certified as spe¬
cialists in adult psychiatric and mental health nursing appropriately work
with children as part of a family approach either in family therapy or
adjunctively in the treatment of adult parents. Similarly, certified specialists
in child and adolescent psychiatric and mental health nursing see adults (for
example, parents) in therapy.

PSYCHIATRIC-MENTAL HEALTH NURSING

CLINICAL PRACTICE FUNCTIONS

Basic Level Functions

The psychiatric-mental health nurse works with individuals, families,
groups, and communities to assess mental health needs, develop diag¬
noses, and plan, implement, and evaluate nursing care. Basic level
psychiatric-mental health nursing practice is characterized by interventions
that promote and foster health, assess dysfunction, assist clients to regain or
improve their coping abilities, and prevent further disability. These inter¬
ventions focus on psychiatric-mental health clients and include health pro¬
motion and health maintenance; intake screening and evaluation; case man-

12
agement; provision of a therapeutic environment (i.e., milieu therapy);
tracking clients and assisting them with self-care activities; administering
and monitoring psychobiological treatment regimens (including prescribed
psychopharmacologic agents and their effects); health teaching; crisis inter¬
vention and counseling; and outreach activities such as home visits and
community action.
Health Promotion and Health Maintenance. As a primary mental health care
provider, the psychiatric-mental health nurse emphasizes health promotion
and health maintenance reflecting nursing's long-standing concern for indi¬
vidual, family, group, and community well-being. The psychiatric-mental
health nurse conducts health assessments, targets at-risk situations, and initi¬
ates interventions such as assertiveness training, stress management, parent¬
ing classes, and health teaching, in addition to targeting potential complica¬
tions related to symptoms of mental illness and adverse treatment effects.
Intake Screening and Evaluation. Psychiatric-mental health nurses func¬
tion at the point of an individual client's entry into the mental health sys¬
tem, performing intake screening and evaluation including physical and
psychosocial assessments, rendering diagnostic and dispositional judg¬
ments, and facilitating the client's movement into appropriate services.
Data collection at the point of contact involves observational and investiga¬
tive activities which are guided by the nurse's knowledge of human behav¬
ior and the principles of the psychiatric interviewing process. The nurse
considers biophysical, psychological, social, cultural, economic, and envi¬
ronmental aspects of the client's life situation to gain an understanding of
the problem as it has been experienced and to plan the kind of assistance
that is indicated. The nurse is responsible for recognizing areas where addi¬
tional clinical data are needed and referring the client for more specialized
testing and evaluation.
Case Management. Case management is a clinical component of a nurse's
role in both inpatient and outpatient settings. Nurses who are case man¬
agers support the client's highest level of functioning through culturally
relevant interventions designed to enhance self-sufficiency and progress
toward optimal health. These can include supportive counseling, problem¬
solving, teaching, medication and status monitoring, comprehensive care
planning, and linkage to and identification and coordination of various
other health and human services.
Milieu Therapy. In the practice of milieu therapy, the nurse utilizes the
human and other resources of institutional and supervised community-
based residential or day treatment settings to foster the restoration of indi¬
vidual clients' previous adaptive abilities and their acquisition of new ones.
A key idea in milieu therapy is that virtually all aspects of the therapeutic
community, comprised of staff and clients, can exert a major influence on
behavior, facilitating or impeding the individual's potential for growth and
change. On behalf of individual clients, the psychiatric-mental health nurse
assesses and develops the therapeutic potential of a given setting by attend-

13
ing to a wide range of factors such as the physical environment, the social
structure and interaction processes, and the culture of the setting.
Similarly, the nurse may practice the use of self as a therapeutic
resource through interactions at a one-to-one or group level, in structured or
informal sessions, and in the physical as well as the psychosocial aspects of
care. Formulation and implementation of the nursing care program proceed
from individualized assessments of client needs and involve the client and
the client's family and significant others to the fullest extent possible.
Self-Care Activities. A major dimension of direct nursing care functions
within the therapeutic milieu involves self-care activities of daily living.
Examples of nursing care which takes advantage of the learning potential
inherent in the daily life cycle are personal hygiene, feeding, recreational
activities, and socialization in practical skills of community life such as shop¬
ping and using public transportation. By comforting, guiding, and setting
limits, the nurse can make use of clients' experiences of daily living to help
them move from dependent to more independent modes of behavior.
Psychobiological Interventions. Another dimension of psychiatric-mental
health nursing derives from the understanding and application of psycho-
biological knowledge bases for psychiatric-mental health nursing care. The
nurse's distinctive contribution rests in the ability to evaluate holistically
and treat client responses to actual and potential health problems. The
psychiatric-mental health nurse employs psychobiological interventions
which include various emergency procedures and standard nursing mea¬
sures such as relaxation techniques, nutrition/diet regulation, exercise and
rest schedules, and other somatic treatments, including monitoring of the
client's responses to psychobiological interventions and the overall treat¬
ment program. Psychobiological interventions also include such activities as
the interpretation and implementation of prescriptions related to medica¬
tion, electroconvulsive therapy, and other treatment regimens.
Nurses in a variety of mental health settings plan and implement ser¬
vices to meet clients' needs for a stable emotional and social support system.
A frequent component of these support services is the nurse's support and
surveillance of the client's pharmacotherapeutic treatment. These services
may be provided on an individual or group basis. The aim is to teach clients
about their medications and assist them in dealing with practical problems
related to side effects and other difficulties encountered in continuing a
prescribed medication regimen while maintaining residence in the commu¬
nity setting.
An essential aspect of the client's response is the right to exercise per¬
sonal choice about participation in proposed treatments. The nurse's
responsible use of authority respects the client's freedom to choose among
existing alternatives and facilitates awareness of resources available to assist
with decision making.
Health Teaching. Another aspect of the psychiatric-mental health nurse's
work with individuals, families, and community groups is health teaching.

14
In performing this function, the nurse integrates knowledge of the princi¬
ples of teaching and learning with knowledge of health and illness. The
need for health teaching may relate to biological, pharmacologic, physical,
sociocultural, or psychological aspects of the learner's care. Selection of
particular formal and informal learning methods depends on identified
needs and learning outcomes. Nurses recognize that experiential learning
opportunities are particularly important in developing understanding of
mental health problems and skills to cope with them. Constructive role
modeling by the nurse is an inherent part of the teaching function.
Crisis Intervention. Psychiatric-mental health nurses provide direct crisis
intervention services to persons in crisis and serve as members of crisis
teams. Crisis intervention is a short-term therapeutic process that focuses
on the resolution of an immediate crisis or emergency through the use of
available professional personnel, family, and/or environmental resources.
Counseling. In nursing, the aim of counseling is to focus specifically—
and for a limited period of time—with a client, family, or group, on a prob¬
lem representing an immediate difficulty related to health or well-being.
The difficulty is investigated using a problem-solving approach, so that the
experience may be understood more fully and integrated with other life
experiences.
Home Visit. Psychiatric-mental health nurses utilize the home visit as an
effective method of responding to the mental health needs of an individual
or family. In this context, the term home refers to private residences or
substitute dwellings—e.g. prisons, halfway houses, homes for the disabled,
nursing homes, foster care residences, or shelters for the homeless. In some
instances, the nurse's insight into a mental health problem and the
resources available to cope with it depend on the assessment data available
in the home setting. The nurse also may select the home visit as the most
efficacious means of intervention by helping to stimulate the potential help¬
ing responses of family members or other significant persons. Efforts to help
the family adapt to the re-entry of the discharged psychiatric patient into the
home environment is another example of the nurse's function within the
home setting.
Community Action. Psychiatric-mental health nursing involvement
includes community action—i.e., concern for sociocultural factors that
adversely affect the mental health of population groups and the design of
activities that can ameliorate these problems. The psychiatric-mental health
nurse who functions in the life of the community itself often may deal with
problems that occur at a wide variety of different points on the health/illness
continuum. The practices of these community-oriented nurses vary in the
emphasis given to consultation and education aimed at enhancing others'
mental health capabilities, on the one hand, and direct therapeutic involve¬
ment with clients, on the other hand. Involvement with community plan¬
ning boards, advisory groups, paraprofessionals and other key people is an
important means by which nurses can mobilize the community's resources

15
and bring about changes that address the mental health needs of particular
population groups.
Advocacy. A particularly important dimension of the clinical role of
psychiatric-mental health nurses is that of the advocate and policy
influencer/maker. These nurses have a long history of supporting the cause
of one of the most neglected constituencies—those with mental illness.
However, there is a need for new energy and political activism. Some nurses
are influencing policy by assuming leadership positions in government
agencies at the local, state, and federal level, and by running for legislative
office.
Others are joining in consumer and professional groups' campaigns to
demystify mental illness, abolish the stigma so often attached to it, and
achieve parity between mental and physical illness health care coverage. To
accomplish this, nurses are engaging in public speaking, writing articles for
the popular press, and lobbying their congressional representatives on
behalf of better mental health and psychiatric care for all Americans. In
clinical practice, the nurse-advocate vigilantly protects the rights of clients
and speaks for those who, for whatever reason, cannot speak for them¬
selves. Because of nursing's strong commitment to the health, welfare, and
safety of the client, the nurse must be aware of any activity which places the
rights or well-being of the client in jeopardy and take appropriate action in
the client's behalf.

Advanced Level Functions

While all aspects of the role functions of the psychiatric-mental health nurse
at the basic level of practice can be performed by the certified specialist,
psychiatric-mental health nursing at the advanced level demands expertise
in psychotherapy modalities associated with various client systems (individ¬
ual, couple, group, family, and community). Along with the nursing focus
on the full range of activity from mental health promotion to illness reha¬
bilitation, the advanced practice role also involves additional psychobiologic
interventions involved in the diagnosis and treatment of mental disorders.
These include the prescription of psychoactive medications and the order¬
ing of appropriate diagnostic and laboratory tests, according to state nursing
regulations.
The certified specialist is a primary mental health care provider who is
prepared to carry out health promotion activities at the macro-system level.
In community mental health and primary care settings, the Certified Spe¬
cialist in Psychiatric-Mental Health Nursing analyzes the health needs of
both individuals and populations and designs programs which target at-risk
groups and cultural and environmental factors which foster health and pre¬
vent mental illness. Typical activities include the development of and par¬
ticipation in programs such as mobile services for the homeless; suicide

16
prevention projects targeted at school children; substance abuse and vio¬
lence prevention strategies; rural mental health clinics; and other creative
programming which is flexibly oriented to community needs.
The certified specialist combines case management functions with
population-specific nursing knowledge coupled with research competen¬
cies, expertise in supportive psychotherapy, and the ability to work with
complex and severe mental health problems. The result is the mobilization
of therapeutic resources and the maximization of positive outcomes.
Certified specialists frequently provide clinical supervision to assist
others in further developing their clinical practice skills. The certified spe¬
cialist may also practice consultation-liaison nursing to provide consultation
and direct care services in non-psychiatric settings such as general health
care centers.
Psychotherapy. Certified specialists who have demonstrated a high level
of competence in psychotherapy by acquiring certification credentials are
qualified to assume autonomous responsibility for the primary therapist
role. Such nurses are accountable for their own practices and are prepared
to perform psychotherapy services independent of any other discipline in
the full range of delivery settings. The nurse-therapist's educational prepa¬
ration in both the biological and social sciences gives that therapist a unique
ability to differentiate various aspects of the client's functioning and to make
appropriate judgments about the need for interventions, referral, or consul¬
tation with other specialists.
Psychotherapy refers to all generally accepted methods of therapy, spe¬
cifically including individual therapy (e.g., play therapy and other expres¬
sive therapies, insight therapy, behavioral therapy; brief and long-term ther¬
apy, goal or solution-oriented therapy, and cognitive therapy), group
therapy, couple/marital therapy, and family therapy. Psychotherapy
denotes a formally structured, contractual relationship between the thera¬
pist and client(s) for the explicit purpose of effecting change in the client
system. This approach attempts to treat mental disorders, alleviate emo¬
tional distress, reverse or change maladaptive behavior, and facilitate per¬
sonal growth and development.
The therapeutic contract with the client is structured in the beginning
phase of the therapy relationship. Included in the terms of the contract are
such elements as purpose, time, place, fees, the individuals participating,
confidentiality, and access to emergency after-hours assistance. To assure
quality, the nurse must continually scrutinize the therapy sessions in relation
to the content, process, and rationales for therapeutic judgments and actions.
Proficiency in the art and science of psychotherapy is an outgrowth of
advanced, specialized educational experience and of efforts to refine psy¬
chotherapy skills through practice, continuing education, and the use of
competent consultation with other psychotherapists. This consultation min¬
imizes personal inferences on the part of the therapist, and enhances the
therapist's competence in the conduct and evaluation of therapy.

17
 The various psychotherapies (individual, family, and group) are distin¬
guished by who receives the care. Even though individual psychotherapy is
variable in the theories and techniques employed by different therapists, it
does possess some stable, common elements. It is a relationship between
two persons who engage in a confidential, and primarily (for adults) verbal,
series of interactions, over an identified period of time, with the agreed
upon purpose of change on the part of the client. Experienced certified
specialists who have developed skills in individual psychotherapy are quali¬
fied to teach and provide clinical consultation to other professionals or psy¬
chotherapy training programs.
Family and marital (couple) therapy has as its primary focus and goal
the improvement of the couple or family system of interaction. The certified
specialist acting as a family therapist can use a variety of approaches to
enhance the function of the family's patterns of communication and rela¬
tionship. Family diagnosis, interventions, and outcome evaluations empha¬
size the observable, interrelated behaviors that characterize the family sys¬
tem. Nurses who acquire specialized preparation in family therapy have the
advantage of building on prior nursing education and experience in which
family-centered orientations are developed. These nurse family therapists
are qualified to offer clinical supervision to other therapists who work with
families and to teach family therapy content and methods.
In group psychotherapy, the dynamics of behavior in small groups is
purposefully used to foster exploration of adjustment patterns and to dis¬
cover more effective and realistic behavioral alternatives. In the role of
group therapist, the certified specialist utilizes knowledge of behavior at the
intrapersonal, interpersonal, and group levels. Experienced certified spe¬
cialists who have developed skills in group work are qualified to function as
teachers and clinical supervisors in group therapy training programs.
Psychobiological Interventions. Psychobiological interventions include a
range of therapies from diet/nutrition regulation, hypnosis, and relaxation
techniques to the use of pharmacologic agents. The focus of these interven¬
tions is to integrate physiological and psychological dimensions of care and
to improve the client's psychological well-being and ability to function.
The clinical role of the certified specialist may incorporate the prescrib¬
ing of pharmacologic agents to promote the client's optimum functioning.
In this role, the nurse applies biological, immunological, neurobiological,
pharmacological, and physiological knowledge in assessment and planning
strategies. The certified specialist who has prescriptive authority functions
in accordance with the state practice act and state and federal regulations.
Clinical Supervision/Consultation. Clinical supervision/consultation is an
educative and consultative function of the advanced practice clinical role.
Through professional preparation and clinical experience the certified spe¬
cialist is qualified to provide clinical supervision at the request of other
mental health providers and provider-trainees. Clinical supervision/
consultation is based on many factors, including knowledge of human

18
behavior and symptomatology and an understanding of the variations of
human behavior through which pathology is expressed, familiarity with
advanced therapeutic techniques, competency in clinical case management
through all phases of the therapeutic process, and expertise in the dynamics
of the supervisory process itself. Certified specialists who function as clini¬
cal supervisors maintain and improve their own competencies by giving
direct care to selected clients, thus serving as clinical role models as well as
clinical consultants.
Consultation-Liaison. Consultation-liaison nursing is another primary
mental-health advanced nursing practice role in psychiatric and non¬
psychiatric settings. The clinical aspect of this role ranges from mental
health promotion to illness rehabilitation. In consultation-liaison activities,
the certified specialist focuses on the emotional, spiritual, developmental,
cognitive, and behavioral responses of clients who enter the health care
system with actual or potential physical dysfunction. The psychiatric
consultation-liaison nurse makes psychiatric and psychosocial diagnoses
and implements a wide variety of interventions with physically ill or dis¬
abled clients and families. These certified specialists also function in the
indirect care roles of consultant and educator with nurses and other health
care providers who are consultees in a variety of physical care delivery
systems. (ANA 1990)

PSYCHIATRIC-MENTAL HEALTH NURSING

CLINICAL PRACTICE SETTINGS
There are two principle arrangements for the clinical practice of psychiatric-
mental health nursing: organized health care settings and self-employment.
Nurses who work within organized settings are paid for their services on a
salaried, contractual, or fee-for-service basis. The settings and arrangements
for psychiatric-mental health nursing practice vary widely in purpose, type,
location, and the auspices under which they are operated.
Consistent with the concepts of the community mental health move¬
ment, nurses seek to position themselves on the basis of the client's right of
access to needed services and to the fullest possible use of nursing knowl¬
edge and skills. As nurses have increased their contributions to a full range
of mental health services, they have become more flexibly deployed in a
variety of settings with responsibility for providing mental health care to
individuals, families, and communities.
Some nurses enter the social environments which are integral parts of
people's daily lives—homes, schools, and work sites—to provide mental
health services. Community-based psychiatric-mental health nurses are piv¬
otal in providing primary mental health care and preserving the supports
which facilitate family and social network functioning. The community-
based settings where these nurses practice include, but are not limited to,

19
educational and judicial system programs, home-health agencies, employee
assistance programs, mental health clinics, health maintenance organiza¬
tions, primary care centers, clinics for the homeless, senior centers, emer¬
gency and crisis centers, day care shelters for battered women and children,
and soup kitchens and shelters for individuals with chronic mental illness.
The versatility of the psychiatric-mental health nurse promotes the develop¬
ment of a wide variety of linkages for access to mental health services.
Psychiatric-mental health nurses practice effectively in a range of inter¬
mediate- and long-term care settings which exist for treatment and support
of those with severe and persistent mental disorders. These include day-
and night-care services, residential care facilities, rehabilitation settings, and
therapeutic foster care as well as other innovative service delivery pro¬
grams. Nurses continue to practice in more traditional psychiatric treatment
settings such as general hospitals, psychiatric units of community hospitals,
centers for detoxification and the treatment of chemical dependence, psy¬
chiatric rehabilitation facilities, private inpatient settings, and the publicly
funded hospital system. An important focus for the nurse is to assist in the
client's transition from the institutional to the community setting.
Self-employed certified specialists offer direct services in solo private
practice and group practice settings, or through contracts with employee
assistance programs, health maintenance organizations, managed care com¬
panies, preferred provider organizations, industry health departments,
home-health agencies, or other service delivery arrangements. In these set¬
tings, the certified specialist provides primary mental health care to clients
in the nurse's caseload. These nurses also may form nurse-owned corpora¬
tions or organizations which can compete with other provider groups for
mental health service contracts with industries or employers.

CONCLUSION
By defining, clarifying, and reviewing the clinical practice of psychiatric-
mental health nursing, this statement contributes to the further develop¬
ment of nursing practice and education. It emphasizes the strong influence
nurses have on health promotion, illness prevention, and the provision of
comprehensive care. By attesting to the significant nursing contributions to
mental health care delivery, this document reflects psychiatric-mental
health nursing's responsiveness to the needs of the consumer of mental
health services.

20
 Standards of
Psychiatric-Mental
Health
Clinical Nursing
Practice
 INTRODUCTION
This section of the book sets forth standards of professional clinical practice
for the specialty of psychiatric-mental health nursing. Standards are author¬
itative statements in which the nursing profession describes the responsi¬
bilities for which nurses are accountable. Consequently, standards reflect
the values and priorities of the profession. Standards provide direction for
professional nursing practice and a framework for the evaluation of practice.
Written in terms of measurable criteria, standards also define the nursing
profession's accountability to the public and the client outcomes for which
nurses are responsible. Standards are relatively enduring, while the criteria
by which they are measured may change to reflect new knowledge and
technology in current practice.
Standards of Psychiatric-Mental Health Clinical Nursing Practice describes a
competent level of professional nursing care and professional performance
common to nurses engaged in psychiatric-mental health nursing practice in
any setting. These standards apply to nurses who are qualified by education
and experience to practice at either the basic level or the advanced level of
psychiatric-mental health nursing. Since some nursing activities are highly
dependent on variables such as client situation, clinical setting, and
instances of individual judgment, language such as "as appropriate,"
"when possible," and "as applicable" is used to recognize circumstances
where exceptions may occur.
Standards of Psychiatric-Mental Health Clinical Nursing Practice applies to
the care that is provided to all clients. Clients can include an individual,
family, group, or community for whom the nurse is providing formally
specified psychiatric-mental health services as sanctioned by state nursing
practice acts. This care may be provided in the context of health promotion,
disease or injury prevention, health maintenance, or health restoration. The
cultural, racial, spiritual/religious, and ethnic heritage of the client must
always be respected and taken into account in providing psychiatric-mental
health nursing services.
The professional practice of psychiatric-mental health nursing is charac¬
terized by the application of relevant theories to explain human behavior
and related phenomena and to provide a basis for nursing intervention and
evaluation of client-oriented health outcomes. The psychiatric-mental
health nurse's critical thinking and selective use of theoretical knowledge
and research provides for the comprehensive biopsychosocial assessment
and accurate diagnosis of the client's response to actual or potential mental
health problems and for analysis of the reciprocal interaction between client
and environment.
Theory and research also guide the nurse's analysis «^f data, choice of
interventions, methods of implementation, and evaluation of client out¬
comes, as well as the application of theory to practice. To sustain and build
on theory-based practice, psychiatric-mental health nurses, in their practice

23
settings, must have resource materials in that setting, support for and access
to continuing education programs, and a philosophy that is congruent with
theory-based nursing actions.
Standards of Clinical Practice in Psychiatric-Mental Health Nursing has two
sections. The first includes those standards related to the direct clinical care
the patient receives, as demonstrated through the nursing process. ANA
calls these "Standards of Care." The second is "Standards of Professional
Performance," which describes a competent level of behavior in the profes¬
sional role.
 STANDARDS OF CARE
"Standards of Care" pertain to professional nursing activities that are dem¬
onstrated by the nurse through the nursing process. These involve assess¬
ment, diagnosis, outcome identification, planning, implementation, and
evaluation. The nursing process is the foundation of clinical decision mak¬
ing and encompasses all significant action taken by nurses in providing
psychiatric-mental health care to all clients.

Standard I. Assessment
THE PSYCHIATRIC-MENTAL HEALTH NURSE COLLECTS CLIENT HEALTH
DATA.
Rationale
The assessment interview—which requires linguistically and culturally
effective communication skills, interviewing, behavioral observation,
database record review, and comprehensive assessment of the client and
relevant systems—enables the psychiatric-mental health nurse to make
sound clinical judgments and plan appropriate interventions with the client.
Measurement Criteria
1. The priority of data collection is determined by the client's immedi¬
ate condition or need.
2. The data may include but are not limited to:
a. ability to remain safe and not be a danger to oneself and others.
b. client's central complaint, symptoms, or focus of concern.
c. physical, developmental, cognitive, mental, and emotional
health status.
d. history of health patterns and illness.
e. family, social, cultural, and community systems.
f. daily activities, functional health status, substance use, health
habits, and social roles, including work and sexual functioning.
g. interpersonal relationships, communication skills, and coping
patterns.
h. spiritual or philosophical beliefs and values.
i. economic, political, legal, and environmental factors affecting
health.
j. significant support systems, both available and underutilized.
k. health beliefs and practices.
l. knowledge, satisfaction, and motivation to change, related to
health.
m. strengths and competencies that can be used to promote health.
n. other contributing factors that influence health.
3. Pertinent data are collected from multiple sources using various
assessment techniques and standardized instruments as appropri-
ST. ELIZABETH HOSPITAL MEDICAL CE
SCHOOL OF NURSING LIBRARY
25 1(M4 BELMONT AVE.
YOUNGSTOWN, OHIO 44501-1790
 ate. Multiple sources of assessment data can include not only the
client, but also family, social network, other health care providers,
past and current medical records, and community agencies and sys¬
tems (with consideration of the client's confidentiality).
4. The client, significant others, and interdisciplinary team members
are involved in the assessment process to the extent possible.
5. The client and significant others are informed of their respective
roles and responsibilities in the assessment process and data
analysis.
6. The assessment process is systematic and ongoing.
7. The data collection is based on clinical judgment to ensure that rele¬
vant and necessary data are collected.
8. The database is synthesized, prioritized, and documented in a
retrievable form.

Standard II. Diagnosis

THE PSYCHIATRIC-MENTAL HEALTH NURSE ANALYZES THE ASSESS¬
MENT DATA IN DETERMINING DIAGNOSES.
Rationale
The basis for providing psychiatric-mental health nursing care is the recog¬
nition and identification of patterns of response to actual of potential psy¬
chiatric illnesses and mental health problems.
Measurement Criteria
1. Diagnoses and potential problem statements are derived from
assessment data.
2. Interpersonal, systemic, or environmental circumstances—that affect
the mental well-being of the individual, family, or community—are
identified.
3. The diagnosis is based on an accepted framework which supports
the psychiatric-mental health nursing knowledge and judgment
used in analyzing the data.
4. Diagnoses conform to accepted classifications systems—such as
North American Nursing Diagnosis Association (NANDA) Nursing
Diagnosis Classification, International Classification of Diseases (WHO
1993), and The Diagnostic and Statistical Manual of Mental Disorders
(APA 1987) used in the practice setting.
5. Diagnoses and risk factors are validated with the client, significant
others, and other heath care providers when appropriate and
possible.
6. Diagnoses identify actual or potential psychiatric illness and mental
health problems of clients pertaining to:
a. the maintenance of optimal health and well-being and the pre¬
vention of psychobiologic illness.

26
 b. self-care limitations or impaired functioning related to mental
and emotional distress.
c. deficits in the functioning of significant biological, emotional,
and cognitive systems.
d. emotional stress or crisis components of illness, pain, and
disability.
e. self-concept changes, developmental issues, and life process
changes.
f. problems related to emotions such as anxiety, aggression, sad¬
ness, loneliness, and grief.
g. physical symptoms that occur along with altered psychological
functioning.
h. alterations in thinking, perceiving, symbolizing, communicat¬
ing, and decision making.
i. difficulties in relating to others.
j. behaviors and mental states that indicate the client is a danger to
self or others or has a severe disability.
k. interpersonal, systemic, sociocultural, spiritual, or environmen¬
tal circumstances or events which have an affect on the mental
and emotional well-being of the individual, family, or
community.
l. symptom management, side effects/toxicities associated with
psychopharmacologic intervention and other aspects of the
treatment regimen.
7. Diagnoses and clinical impressions are documented in a manner that
facilitates the identification of client outcomes and their use in the
plan of care and research.

Standard III. Outcome Identification

THE PSYCHIATRIC-MENTAL HEALTH NURSE IDENTIFIES EXPECTED OUT¬
COMES INDIVIDUALIZED TO THE CLIENT.
Rationale
Within the context of providing nursing care, the ultimate goal is to influ¬
ence health outcomes and improve the client's health status.
Measurement Criteria
1. Expected outcomes are derived from the diagnoses.
2. Expected outcomes are client-oriented, therapeutically sound, realis¬
tic, attainable, and cost-effective.
3. Expected outcomes are documented as measurable goals.
4. Expected outcomes are formulated by the nurse and the client, sig¬
nificant others, and interdisciplinary team members, when possible.
5. Expected outcomes are realistic in relation to the client's present and
potential capabilities.

27
 6. Expected outcomes are identified with consideration of the associ¬
ated benefits and costs.
7. Expected outcomes estimate a time for attainment.
8. Expected outcomes provide direction for continuity of care.
9. Expected outcomes reflect current scientific knowledge in mental
health care.
10. Expected outcomes serve as a record of change in the client's health
status.

Standard IV. Planning

THE PSYCHIATRIC-MENTAL HEALTH NURSE DEVELOPS A PLAN OF
CARE THAT PRESCRIBES INTERVENTIONS TO ATTAIN EXPECTED
OUTCOMES.
Rationale
A plan of care is used to guide therapeutic intervention systematically and
achieve the expected client outcomes.
Measurement Criteria
1. The plan is individualized, tailored to the client's mental health
problems, condition, or needs and it:
a. identifies priorities of care in relation to expected outcomes.
b. identifies effective interventions to achieve the outcomes.
c. specifies interventions that reflect current psychiatric-mental
health nursing practice and research.
d. includes an education program related to the client's health
problems, treatment, and self-care activities.
e. indicates responsibilities of the psychiatric-mental health nurse
and the client, and may include responsibilities for inter¬
disciplinary team members to carry out the plan of care.
f. gives direction for client-care activities delegated by the
psychiatric-mental health nurse to other care providers.
g. provides for appropriate referral and case management to insure
continuity of care.
2. The plan is developed in collaboration with the client, significant
others, and interdisciplinary team members, when appropriate.
3. The plan is documented in a manner that allows access to it by team
members and modification of the plan as necessary.

Standard V. Implementation
THE PSYCHIATRIC-MENTAL HEALTH NURSE IMPLEMENTS THE INTER¬
VENTIONS IDENTIFIED IN THE PLAN OF CARE.
Rationale
In implementing the plan of care, psychiatric-mental health nurses use a
wide range of interventions designed to prevent mental and physical ill-

28
ness, and promote, maintain, and restore mental and physical health.
Psychiatric-mental health nurses select interventions according to their level
of practice. At the basic level, the nurse may select counseling, milieu ther¬
apy, self-care activities, psychobiological interventions, health teaching,
case management, health promotion and health maintenance, and a variety
of other approaches to meet the mental health needs of clients. In addition
to the intervention options available to the basic-level psychiatric-mental
health nurse, at the advanced level the certified specialist may provide
consultation, engage in psychotherapy, and prescribe pharmacologic agents
where permitted by state statutes or regulations.
Measurement Criteria
1. Interventions are selected based on the needs of the client and
accepted nursing practice.
2. Interventions are selected according to the psychiatric-mental health
nurse's level of practice, education, and certification.
3. Interventions are implemented within the established plan of care.
4. Interventions are performed in a safe, ethical, and appropriate
manner.
5. Interventions are documented.

Standard Va. Counseling

THE PSYCHIATRIC-MENTAL HEALTH NURSE USES COUNSELING INTER¬
VENTIONS TO ASSIST CLIENTS IN IMPROVING OR REGAINING THEIR
PREVIOUS COPING ABILITIES, FOSTERING MENTAL HEALTH, AND PRE¬
VENTING MENTAL ILLNESS AND DISABILITY.
Measurement Criteria
1. Counseling interventions—including communication and interview¬
ing techniques, problem-solving skills, crisis intervention, stress
management, relaxation techniques, assertiveness training, conflict
resolution, and behavior modification—are documented.
2. Counseling reinforces healthy behaviors and interaction patterns
and helps the client modify or discontinue unhealthy ones.
3. Counseling promotes the client's personal and social integration.

Standard Vb. Milieu Therapy

THE PSYCHIATRIC-MENTAL HEALTH NURSE PROVIDES, STRUCTURES,
AND MAINTAINS A THERAPEUTIC ENVIRONMENT IN COLLABORATION
WITH THE CLIENT AND OTHER HEALTH CARE PROVIDERS.
Measurement Criteria
1. The client is familiarized with the physical environment, the sched¬
ule of activities, and the norms and rules that govern behavior and
activities of daily living, as applicable.
2. Current knowledge of the effects of the client's environment is used
to guide nursing actions.

29
 3. The therapeutic environment is designed utilizing the physical envi¬
ronment, social structures, culture, and other available resources.
4. Communication among clients and staff supports an effective milieu.
5. Specific activities are selected that meet the client's physical and
mental health needs.
6. Limits of any kind (e.g , restriction of privileges, restraint, seclusion,
timeout) are used in a humane manner, are the least restrictive nec¬
essary, and are employed only as long as needed to assure the safety
of the qlient and of others.
7. The client is given information about the need for limits and the
conditions necessary for removal of the restriction, as appropriate.
8. The client and significant others are given the opportunity to ask
questions and discuss their feelings and concerns' about past, cur¬
rent, and projected use of various environments.

Standard Vc. Self-Care Activities

THE PSYCHIATRIC-MENTAL HEALTH NURSE STRUCTURES INTERVEN¬
TIONS AROUND THE CLIENT'S ACTTVITIES OF DAILY LIVING TO FOSTER
SELF-CARE AND MENTAL AND PHYSICAL WELL-BEING.
Measurement Criteria
1. The self-care interventions assist the client in assuming personal
responsibility for activities of daily living.
2. The self-care activities of daily living are appropriate for the client's
age, developmental level, gender, sexual orientation, ethnic/social
background, and education.
3. Self-care interventions are aimed at maintaining and improving the
client's functional status.

Standard Vd. Psychobiological Interventions

THE PSYCHIATRIC-MENTAL HEALTH NURSE USES KNOWLEDGE OF PSY¬
CHOBIOLOGICAL INTERVENTIONS AND APPLIES CLINICAL SKILLS TO
RESTORE THE CLIENT'S HEALTH AND PREVENT FURTHER DISABILITY.
Measurement Criteria
1. Current knowledge of psychopharmacology and other psycho-
biological therapies are used to guide nursing action.
2. Psychopharmacological agents' intended actions, untoward effects, and
therapeutic doses are monitored, as are blood levels where appropriate.
3. The client's responses to therapies serve as clinical indications of
treatment effectiveness.
4. Nursing interventions are directed toward alleviating untoward
effects of psychobiological interventions, when possible.
5. Opportunities are provided for the client and significant others to
question, discuss, and explore their feelings about past, current, and
projected use of therapies.

r
30
 6. Nursing observations about the client's response to psychobiological
interventions are communicated to other health providers.

Standard Ve. Health Teaching

THE PSYCHIATRIC-MENTAL HEALTH NURSE, THROUGH HEALTH
TEACHING, ASSISTS CLIENTS IN ACHIEVING SATISFYING, PRODUC¬
TIVE, AND HEALTHY PATTERNS OF LIVING.
Measurement Criteria
1. Health teaching is based on principles of learning.
2. Health teaching includes information about coping, interpersonal
relations, mental health problems, mental disorders, and treatments
and their effects on daily living, as well as information pertinent to
physical status or developmental needs.
3. The nurse uses health teaching methods appropriate to the client's
age, developmental level, gender, ethnic/social background, and
education.
4. Constructive feedback and positive rewards reinforce the client's
learning.
5. Practice sessions and experiential learning are used as needed.

Standard Vf. Case Management

THE PSYCHIATRIC-MENTAL HEALTH NURSE PROVIDES CASE MANAGE¬
MENT TO COORDINATE COMPREHENSIVE HEALTH SERVICES AND
ENSURE CONTINUITY OF CARE.
Measurement Criteria
1. Case management services are based on a comprehensive approach to
the client's physical, mental, emotional, and social health problems.
2. Case management services are provided in terms of the client's
needs and the accessibility, availability, quality, and cost-
effectiveness of care.
3. Health-related services and more specialized care are negotiated as
needed—on behalf of the client—with the appropriate agencies and
providers.
4. Relationships with agencies and providers are maintained through¬
out the client's use of the health care services to ensure continuity of
care.
5. The client's decisions related to the plan of care and treatment
choices are supported, as appropriate.

Standard Vg. Health Promotion and Health Maintenance

THE PSYCHIATRIC-MENTAL HEALTH NURSE EMPLOYS STRATEGIES AND
INTERVENTIONS TO PROMOTE AND MAINTAIN MENTAL HEALTH AND
PREVENT MENTAL ILLNESS.

31
Measurement Criteria
1. Health promotion and disease prevention strategies are based on
knowledge of health beliefs, practices, and epidemiological princi¬
ples, along with the social, cultural, and political issues that affect
mental health in an identified community.
2. Health promotion and disease prevention interventions are de¬
signed for clients identified as at-risk for mental health problems.
3. Consumer participation is encouraged in identifying mental health
problems in the community and planning, implementing, and eval¬
uating programs to address those problems.
4. Community resources are identified to assist consumers in using
prevention and mental health care services appropriately.

Advanced Practice Interventions Vh-Vj

The following interventions (Vh-Vj) may be performed only by the certified
specialist in psychiatric-mental health nursing.

Standard Vh. Psychotherapy

THE CERTIFIED SPECIALIST IN PSYCHIATRIC-MENTAL HEALTH NURS¬
ING USES INDIVIDUAL, GROUP, AND FAMILY PSYCHOTHERAPY, CHILD
PSYCHOTHERAPY, AND OTHER THERAPEUTIC TREATMENTS TO ASSIST
CLIENTS IN FOSTERING MENTAL HEALTH, PREVENTING MENTAL ILL¬
NESS AND DISABILITY, AND IMPROVING OR REGAINING PREVIOUS
HEALTH STATUS AND FUNCTIONAL ABILITIES.
Measurement Criteria
1. The therapeutic contract with the client is structured to include:
a. purpose, goals, and expected outcomes.
b. time, place, and frequency of therapy.
c. fees and payment schedule.
d. participants involved in therapy.
e. confidentiality.
f. availability and means of contacting therapist.
g. responsibilities of both client and therapist.
2. Knowledge of personality theory, growth and development, psy¬
chology, psychopathology, social systems, small-group and family
dynamics, stress and adaptation, and theories related to selected
therapeutic methods is used, based on the client's needs.
3. Therapeutic principles are used to understand and interpret the cli¬
ent's emotions, thoughts, and behaviors.
4. The client is helped to deal constructively with thoughts, emotions,
and behaviors.
5. Increasing responsibility and independence are fostered in the client
to reinforce healthy behaviors and interactions.

32
 6. Continuity of care is provided in therapist's absence.
7. Nursing care for the client's physical needs is referred to another
provider when it is determined that such care provided by the thera¬
pist would impair the client/therapist relationship.

Standard Vi. Prescription of Pharmacologic Agents

THE CERTIFIED SPECIALIST USES PRESCRIPTION OF PHARMACOLOGIC
AGENTS IN ACCORDANCE WITH THE STATE NURSING PRACTICE ACT,
TO TREAT SYMPTOMS OF PSYCHIATRIC ILLNESS AND IMPROVE FUNC¬
TIONAL HEALTH STATUS.
Measurement Criteria
1. Prescriptive authority for pharmacologic agents is used only by
those nurses who are qualified by education and experience and in
accordance with the state nursing practice act or state and federal
regulations.
2. Psychoactive pharmacologic agents are prescribed based on a knowl¬
edge of psychopathology, neurobiology, physiology, immunology,
expected therapeutic actions, anticipated side effects, and courses of
action for unintended or toxic effects.
3. Specific pharmacological agents are prescribed based on clinical indi¬
cators of the client's status, including the results of diagnostic and
laboratory tests, as appropriate.
4. Information about intended effects, potential side effects of the pro¬
posed prescription, and alternative treatments is provided to the
client.

Standard Vj. 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 PRO¬
VIDE PSYCHIATRIC AND MENTAL HEALTH CARE AND EFFECT CHANGE
IN SYSTEMS.
Measurement Criteria
1. Consultation activities are based on models of consultation, systems
principles, communication and interviewing techniques, problem¬
solving skills, change theories, and other theories as indicated.
2. A working alliance, based on mutual respect and role responsi¬
bilities, is established with the consultee.
3. The decision to implement the system change or plan of care
remains the responsibility of the consultee.

Standard VI. Evaluation

THE PSYCHIATRIC-MENTAL HEALTH NURSE EVALUATES THE CLIENT'S
PROGRESS IN ATTAINING EXPECTED OUTCOMES.

33
Rationale
Nursing care is a dynamic process involving change in the client's health
status over time, giving rise to the need for new data, different diagnoses,
and modifications in the plan of care. Therefore, evaluation is a continuous
process of appraising the effect of nursing interventions and the treatment
regimen on the client's health status and expected health outcomes.
Measurement Criteria
1. Evaluation is systematic and ongoing.
2. The client, significant others, and team members are involved in the
evaluation process, as possible, to ascertain the client's level of satis¬
faction with care and evaluate the cost and benefits associated with
the treatment process.
3. The client's responses to interventions are documented.
4. The effectiveness of interventions in relation to outcomes is
evaluated.
5. Ongoing assessment data are used to revise diagnoses, outcomes,
and the plan of care as needed.
6. Revisions in the diagnoses, outcomes, and the plan of care are
documented.
7. The revised plan provides for continuity of care.

STANDARDS OF PROFESSIONAL
PERFORMANCE
"Standards of Professional Performance" describe a competent level of
behavior in the professional role, including activities related to quality of
care, performance appraisal, education, collegiality, ethics, collaboration,
research, and resource utilization. All psychiatric-mental health nurses are
expected to engage in professional role activities appropriate to their educa¬
tion, position, and practice setting. Therefore, some standards or measure¬
ment criteria identify these activities.
While "Standards of Professional Performance" describe the roles of all
professional nurses, there are many other responsibilities that are hallmarks
of psychiatric-mental health nursing. These nurses should be self-directed
and purposeful in seeking necessary knowledge and skills to enhance career
goals. Other activities—such as membership in professional organizations,
certification in specialty or advanced practice, continuing education, and
further academic education—are desirable methods of enhancing the
psychiatric-mental health nurse's professionalism.

Standard I. Quality of Care

THE PSYCHIATRIC-MENTAL HEALTH NURSE SYSTEMATICALLY EVALU¬
ATES THE QUALITY OF CARE AND EFFECTIVENESS OF PSYCHIATRIC-
MENTAL HEALTH NURSING PRACTICE.

34
Rationale

The dynamic nature of the mental health care environment and the growing
body of psychiatric nursing knowledge and research provide both the impe¬
tus 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 client care.

Measurement Criteria

1. The psychiatric-mental health nurse participates in quality-of-care

activities as appropriate to the nurse's position, education, and prac¬
tice environment. Such activities can include:
a. identification of aspects of care important for quality monitoring—
e.g., functional status, symptom management and control, health
behaviors and practices, safety, client satisfaction, and quality
of life.
b. identification of indicators used to monitor the effectiveness of
psychiatric-mental health nursing care.
c. collection of data to monitor quality and effectiveness of
psychiatric-mental health nursing care.
d. analysis of quality data to identify opportunities for improving
psychiatric-mental health nursing care.
e. formulation of recommendations to improve psychiatric-mental
health nursing practice or client outcomes.
f. implementation of activities to enhance the quality of
psychiatric-mental health nursing practice.
g. participation on interdisciplinary teams which evaluate clinical
practice or mental health services.
h. development of policies and procedures to improve quality
psychiatric-mental health care.
2. The psychiatric-mental health nurse seeks feedback from the client
and significant others about their satisfaction with care.
3. The psychiatric-mental health nurse uses the results of quality-of-
care activities to initiate changes in psychiatric-mental nursing
practice.
4. The psychiatric-mental health nurse uses the results of quality-of-
care activities to initiate changes throughout the mental health care
delivery system, as appropriate.

Standard II. Performance Appraisal

THE PSYCHIATRIC-MENTAL HEALTH NURSE EVALUATES OWN

PSYCHIATRIC-MENTAL HEALTH NURSING PRACTICE IN RELATION TO
PROFESSIONAL PRACTICE STANDARDS AND RELEVANT STATUTES AND
REGULATIONS.

35
Rationale
The psychiatric-mental health nurse is accountable to the public for provid¬
ing competent clinical care and has an inherent responsibility as a profes¬
sional to evaluate the role and performance of psychiatric-mental health
nursing practice according to standards established by the profession and
regulatory bodies.
Measurement Criteria
1. The psychiatric-mental health nurse engages in performance
appraisal of own clinical practice and role performance with peers or
supervisors on a regular basis, identifying areas of strength as well
as areas for professional/practice development.
2. The psychiatric-mental health nurse seeks constructive feedback
regarding own practice and role performance from peers, profes¬
sional colleagues, clients, and others.
3. The psychiatric-mental health nurse takes action to achieve goals
identified during performance appraisal and peer review, resulting
in changes in practice and role performance.
4. The psychiatric-mental health nurse participates in peer review
activities when possible.

Standard III. Education

THE PSYCHIATRIC-MENTAL HEALTH NURSE ACQUIRES AND MAIN¬
TAINS CURRENT KNOWLEDGE IN NURSING PRACTICE.
Rationale
The rapid expansion of knowledge pertaining to basic and behavioral sci¬
ences, technology, information systems, and research requires a commit¬
ment to learning throughout the psychiatric-mental health nurse's profes¬
sional career. Formal education, continuing education, certification, and
experiential learning are some of the means the psychiatric-mental health
nurse uses to enhance nursing expertise and advance the profession.
Measurement Criteria
1. The psychiatric-mental health nurse participates in educational
activities to improve clinical knowledge, enhance role performance,
and increase knowledge of professional issues.
2. The psychiatric-mental health nurse seeks experiences and indepen¬
dent learning activities to maintain and develop clinical skills.
3. The psychiatric-mental health nurse seeks additional knowledge and
skills appropriate to the practice setting by participating in educa¬
tional programs and activities, conferences, workshops, and inter¬
disciplinary professional meetings.
4. The psychiatric-mental health nurse documents own educational
activities.
5. The psychiatric-mental health nurse seeks certification when
eligible.

36
Standard IV. Collegiality
THE PSYCHIATRIC-MENTAL HEALTH NURSE CONTRIBUTES TO THE PRO¬
FESSIONAL DEVELOPMENT OF PEERS, COLLEAGUES, AND OTHERS.
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.
Measurement Criteria
1. The psychiatric-mental health nurse uses opportunities in practice to
exchange knowledge, skills, and clinical observations with col¬
leagues and others.
2. The psychiatric-mental health nurse assists others in identifying
teaching/learning needs related to clinical care, role performance,
and professional development.
3. The psychiatric-mental health nurse provides peers with construc¬
tive feedback regarding their practices.
4. The psychiatric-mental health nurse contributes to an environment
that is conducive to clinical education of nursing students, as
appropriate.

Standard V. Ethics
THE PSYCHIATRIC-MENTAL HEALTH NURSE'S DECISIONS AND
ACTIONS ON BEHALF OF CLIENTS ARE DETERMINED IN AN ETHICAL
MANNER.
Rationale
The public's trust and its right to humane psychiatric-mental health care are
upheld by professional nursing practice. The foundation of psychiatric-
mental health nursing practice is the development of a therapeutic relation¬
ship with the client. The psychiatric-mental health nurse engages in thera¬
peutic interactions and relationships which promote and support the heal¬
ing process. Boundaries need to be established to safeguard the client's
well-being and to prevent the development of intimate or sexual
relationships.
Measurement Criteria
1. The psychiatric-mental health nurse's practice is guided by the Code
for Nurses.
2. The psychiatric-mental health nurse maintains a therapeutic and
professional relationship with clients at all times.
3. The psychiatric-mental health nurse maintains client confidentiality
and appropriate professional boundaries.
4. The psychiatric-mental health nurse functions as a client advocate.
5. The psychiatric-mental health nurse delivers care in a nonjudgmen-
tal and nondiscriminatory manner sensitive to client diversity.

37
 6. The psychiatric-mental health nurse identifies ethical dilemmas
that occur within the practice environment and seeks available
resources to help formulate ethical decisions.
7. The psychiatric-mental health nurse reports abuse of clients' rights,
and incompetent, unethical, and illegal practices.
8. The psychiatric-mental health nurse participates in obtaining the
client's informed consent for procedures, treatments, and research,
as appropriate.
9. The psychiatric-mental health nurse discusses with the client the
delineation of roles and the parameters of the relationship.
10. The psychiatric-mental health nurse carefully manages self¬
disclosure.
11. The psychiatric-mental health nurse does not promote or engage in
initimate or sexual relationships with current clients.
12. The psychiatric-mental health nurse avoids sexual relationships
with clients or former clients and recognizes that to engage in such
a relationship is unusual and an exception to accepted practice.

Standard VI. Collaboration

THE PSYCHIATRIC-MENTAL HEALTH NURSE COLLABORATES WITH THE
CLIENT, SIGNIFICANT OTHERS, AND HEALTH CARE PROVIDERS IN PRO¬
VIDING CARE.
Rationale
Psychiatric-mental health nursing practice requires a coordinated, ongoing
interaction between consumers and providers to deliver comprehensive ser¬
vices to the client and the community. Through the collaborative process,
different abilities of health care providers are used to solve problems, com¬
municate, and plan, implement, and evaluate mental health services.
Measurement Criteria
1. The psychiatric-mental health nurse collaborates with the client, sig¬
nificant others, and health care providers in the formulation of over¬
all goals, plans, and decisions related to client care and the delivery
of mental health services.
2. The psychiatric-mental health nurse consults with other health care
providers on client care, as appropriate.
3. The psychiatric-mental health nurse makes referrals—including pro¬
visions for continuity of care—as needed.
4. The psychiatric-mental health nurse collaborates with other disci¬
plines in teaching, consultation, management, and research activ¬
ities as opportunities arise.

Standard VII. Research

THE PSYCHIATRIC-MENTAL HEALTH NURSE CONTRIBUTES TO NURSING
AND MENTAL HEALTH THROUGH THE USE OF RESEARCH.

38
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 prob¬
lems 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.

Measurement Criteria

1. The psychiatric-mental health nurse uses interventions substanti¬

ated by research as appropriate to the nurse's position, education,
and practice environment.
2. The psychiatric-mental health nurse participates in research as
appropriate to the nurse's position, education, and practice environ¬
ment. Such activities can include:
a. identification of clinical problems suitable for psychiatric-mental
health nursing research.
b. participation in data collection.
c. participation in unit, organization, or community research com¬
mittees or programs.
d. sharing research activities with others.
e. conducting research and disseminating findings.
f. critiquing research for application to practice.
g. using research findings in the development of policies, pro¬
cedures, and guidelines for client care.
h. consulting with research experts and colleagues as necessary.
3. The psychiatric-mental health nurse participates in human-subject
protection activities as appropriate and is particularly cognizant of
the needs of the vulnerable group served.

Standard VIII. Resource Utilization

THE PSYCHIATRIC-MENTAL HEALTH NURSE CONSIDERS FACTORS
RELATED TO SAFETY, EFFECTIVENESS, AND COST IN PLANNING AND
DELIVERING CLIENT CARE.
Rationale
The client is entitled to psychiatric-mental health care which is safe, effec¬
tive, 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 provider.

39
Measurement Criteria
1. The psychiatric-mental health nurse analyzes factors related to
safety, effectiveness, and cost when two or more practice options
would result in the same expected client outcome.
2. The psychiatric-mental health nurse discusses benefits and cost of
treatment options with the client, significant others, and other pro¬
viders, as appropriate.
3. The psychiatric-mental health nurse assists the client and significant
others in identifying and securing appropriate services available to
address health-related needs.
4. The psychiatric-mental health nurse assigns tasks or delegates care
based on the needs of the client and the knowledge and skills of the
selected provider.
5. The psychiatric-mental health nurse participates in ongoing resource
utilization review.

40
 REFERENCES
American Nurses Association. 1967. Statement on psychiatric and mental health nursing
practice. Kansas City, MO: the Author.
-. 1976. Statement on psychiatric and mental health nursing practice. Kansas City,
MO: the Author.
-. 1980. Code for nurses. Kansas City, MO: the Author.
-. 1982. Standards of psychiatric and mental health nursing practice. Kansas City,
MO: the Author.
-. 1985. Standards of child and adolescent psychiatric and mental-health nursing prac¬
tice. Kansas City, MO: the Author.
-. 1990. Standards of psychiatric consultation-liaison nursing practice. Kansas City,
MO: the Author.
-. 1991a. Nursing's agenda for health care reform. Kansas City, MO: the Author.
-. 1991b. Standards of clinical nursing practice. Kansas City, MO: the Author.
American Psychiatric Association. 1987. Diagnostic and statistical manual of mental disor¬
ders (third edition, revised). Washington, DC: the Author.
Billings, C. V. 1993, February. The possible dream of mental health reform. The
American Nurse 25 (2), 5.
Haber, and Billings, C. 1993. Primary mental health care: A vision for the future of
psychiatric-mental health nursing. ANA Council Perspectives 2 (2), 1.
Koldjeski, D. 1984. Community mental health nursing: Directions in theory & prac¬
tice. New York: John Wiley & Sons.
Krauss, J. 1993. Health care reform: Essential mental health services. Washington,
DC: American Nurses Publishing.
Lowery, B.J. 1992. Psychiatric nursing in the 1990s and beyond. Journal of Psychosocial
Nursing 30, 7-13.
McBride, A.B. 1990. Psychiatric nursing in the 1990s. Archives of Psychiatric Nursing IV
(1), 21-28.
Pothier, P.C., Stuart, G.W., Puskar, K., and Babich, K. 1990. Dilemmas and directions
for psychiatric nursing in the 1990s. Archives of Psychiatric Nursing IV (5), 284-91.
U.S. Department of Health and Human Services, U.S. Public Health Service. 1990.
Healthy people 2000: National health promotion and disease prevention. Washington,
DC: U.S. Government Printing Office.
World Health Organization. 1993. International classification of diseases (10th edition).
Geneva: the Author.
Worley, N.K., Drago, L., and Hadley, T. 1990. Improving the physical health-mental
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41
 GLOSSARY

Activities of daily living Self-care actrvrties—such as eating, [personal

hygiene, dressing, recreational activities, and
socialization—that are performed daily by
healthy individuals as part of independent liv¬
ing. During periods of illness, individuals
may not be able to perform some or all of
these self-care activities.
Allied I ancillary personnel Non-nurse health care workers, such as nurs¬
ing assistants and licensed practical nurses
(LPNs).
Assessment The systematic [process of'collecting relevant
client data for the purpose of determining
actual or potential health problems and func¬
tional status. Methods used to obtain data
include interviews, observations, physical
examinations, review of records, and collab¬
oration with colleagues.
Brief therapy Treatment that focuses on the resolution of a
specific problem or behavior in a limited num¬
ber of sessions.
Case management An intervention in which health care is inte¬
grated, coordinated, and advocated for indi¬
viduals, families, and groups who require ser¬
vices. The aim of case management is to
decrease fragmentation and insure access to
appropriate, individualized, and cost-effective
care. As a case manager, the nurse has the
authority and accountability required to nego¬
tiate with multiple providers and obtain
diverse services.
Certification The formal process by which clinical compe¬
tence is validated in a specialty area of prac¬
tice.
Certified Specialist in A psychiatric-mental health clinical nurse spe¬
psychiatric-mental health cialist who is nationally certified and qualified
nursing (RN, CS) for autonomous advanced practice.
Client/client system The individual, family, group, or community
for whom the nurse is providing formally spe¬
cified services.
Clinical supervision/consultation The process in which one mental health pro¬
fessional seeks assistance from another to dis¬
cuss therapeutic issues or to identify or clarify
a concern or problem and to consider alterna¬
tives available for problem resolution.

42
Counseling A specific, time-limited interaction of a nurse
with a client, family, or group experiencing
immediate or ongoing difficulties related to
their health or well-being. The difficulty is
investigated using a problem-solving ap¬
proach for the purpose of understanding the
experience and integrating it with other life
experiences.
Crisis intervention A short-term therapeutic process that focuses
on the rapid resolution of an immediate crisis
or emergency using available personnel, fam¬
ily, and/or environmental resources.
Critical Path A standard written plan and timetable for care
that identifies routine treatments, activities,
medications, expected length of stay, and dis¬
charge planning.
Diagnostic and Statistical Published by the American Psychiatric Asso¬
Manual of Mental Disorders ciation, the manual provides a listing of offi¬
cial diagnostic classifications for mental disor¬
ders. Each disorder is classified on one of five
Axes—I and II include all clinical syndromes
and personality disorders. III contains physi¬
cal disorders, and IV and V provide informa¬
tion about psychosocial stressors and adaptive
functioning.
Family and marital therapy Approaches used to enhance the family's or
couple's relationship and patterns of commu¬
nication. Diagnoses, interventions, and out¬
comes emphasize the observable, interrelated
behaviors that characterize the family or cou¬
ple system.
Functional status Level of the client's ability to perform inde¬
pendently activities related to self-care, social
relations, occupational functioning, and use
of leisure time.
Holistic treatment Provision of comprehensive care that identi¬
fies physical, emotional, social, economic, and
spiritual needs as they relate to the individ¬
ual's response to illness and to the ability to
perform activities of daily living.
Illness trajectory The course of the illness or chronic condition,
which depends on the individual, the inter¬
ventions utilized, and unpredictable events
that occur during the illness' course.
Interventions Nursing activities that promote and foster
health, assess dysfunction, assist clients to
regain or improve their coping abilities, and

43
 prevent further disabilities—e.g., conducting
intake screening and evaluation; delivering
case management services; maintaining a
therapeutic environment (i.e., milieu ther¬
apy); tracking and assisting with self-care
activities; administering and monitoring treat¬
ment regimens and their effects, including
prescribed psychopharmacologic agents; pro¬
viding health education; intervening and
counseling during a crisis; and providing out¬
reach activities.
Managed care Spans a broad continuum of entities, from the
simple requirement of prior authorization for
a service in an indemnity health insurance
plan, to the assumption of all legal, financial,
and organizational risks for the provision of a
set of comprehensive benefits to a defined
population. Also, the management of health
care clinical services supplied by groups of
providers with the aims of cost-effectiveness,
quality, and accessibility.
Mental disorder/illness A disturbance in thoughts or mood that
causes maladaptive behavior, inability to cope
with normal stresses, and/or impaired func¬
tioning. Etiology may include genetic, physi¬
cal, chemical, biological, psychological, or
sociocultural factors.
Mental health State of well-being in which individuals func¬
tion well in society and are generally satisfied
with their lives.
Milieu therapy/therapeutic A type of psychotherapy using the total envi¬
environment ronment to provide a therapeutic community.
The emphasis is on developing the therapeu¬
tic potential of the setting by developing the
physical surroundings, structured activities, a
stable social structure, and cultural setting to
promote interactions and personal growth.
Non-deferrable care Treatment that cannot be postponed.
Nurse practice act State statutes that define the legal limits of
practice for registered nurses.
Nursing diagnosis classification A name, taxonomy label, or summarizing
group of words that conveys a nursing assess¬
ment conclusion regarding actual or potential
health problems of the client. Identifying a
nursing diagnosis involves a clinical judgment
that the problem being addressed is one that
nurses have the legal authority to treat.

44
Nursing practice standards Authoritative statements that describe a level of
care or performance, common to the profession
of nursing, by which the quality of nursing
practice can be judged. They include activities
related to assessment, diagnosis, outcome
identification, planning, implementation, eval¬
uation, quality of care, performance appraisal,
education, collegiality, ethics, collaboration,
research, and resource utilization.
Nursing process A systematic and interactive problem-solving
approach that includes individualized patient/
client assessment, planning, implementation/
intervention, and evaluation.
Outcome The client's goal, or the result of interven¬
tions, that includes the degree of wellness and
the continued need for care, medication, sup¬
port, counseling, education.
Pathophysiology The body's biological and physical processes
which result in observable signs and symp¬
toms.
Phenomena of concern Actual or potential mental problems that are of
concern to psychiatric-mental health nurses.
Prescriptive authority The statutory/regulatory authority to pre¬
scribe drugs and devices as a component of a
profession's scope of practice.
Primary mental health care A mode of service delivery that is initiated at
the first point of contact with the mental
health care system. It involves the continuous
and comprehensive mental health services
necessary for promotion of optimal mental
health, prevention of mental illness, and
intervention, health maintenance, and reha¬
bilitation.
Professional code Statement of ethical guidelines for nursing
behavior that serves as a framework for deci¬
sion making.
Psychiatric-mental health A specialized area of nursing practice that em¬
nursing ploys theories of human behavior as its sci¬
ence and the purposeful use of "self" as its
art. It is the diagnosis and treatment of human
responses to actual or potential mental disor¬
ders and their long-term effects. Interventions
include the continuous and comprehensive
primary mental health care services necessary
for the promotion of optimal mental health,
the prevention of mental illness, rehabilitation
from mental disorders, and health mainte¬
nance.

45
 Psychiatric-mental health A baccalaureate-prepared registered nurse who
registered nurse demonstrates clinical skills exceeding those of a
beginning registered nurse or novice in the spe¬
cialty and who is employed in the specialized
practice of psychiatric-mental health nursing
(see "Psychiatric-mental health nursing"). This
designation is for those who are nationally cer¬
tified within the specialty. In this basic practice
level, the nurse can function in clinical, admin¬
istrative, consultative, educative, research, and
advocacy roles.
Psychopathology The mind's biological and physical processes
which result in observable signs and symp¬
toms of mental disorder. „
Psychopharmacologic agents Medications used to treat mental disorders.
Psychosocial domain The range of diagnoses and treatments that
are related to mental health, social status, and
functional ability.
Psychotherapy A formally structured, contractual relation¬
ship between the therapist and client(s) for
the purpose of effecting change in the client
system. Approaches include all generally
accepted and respected methods of therapy,
including individual therapy (play and other
expressive therapies, insight therapy, behav¬
ioral therapy, cognitive therapy, and brief
goal- or solution-oriented therapy), group
therapy, couple/marital therapy, and family
therapy.
Registered nurse (RN) An individual educationally prepared in nurs¬
ing and licensed by the state board of nursing
to practice nursing in that state. Registered
nurses may qualify for specialty practice at
two levels—basic and advanced. These levels
are differentiated by educational preparation,
professional experience, type of practice, and
certification.
Scope of practice A range of nursing functions that are differen¬
tiated according to level of practice, role of the
nurse, and work setting. The parameters are
determined by each state's nursing practice
act, professional code of ethics, and nursing
practice standards, as well as each individ¬
ual's personal competency to perform particu¬
lar activities or functions.
Psychobiological interventions Interventions—e.g., relaxation techniques,
hypnosis, nutrition and dietary regulations,
exercise, rest schedules, and pharmacologic

46

V
 agents—used to improve well-being and func¬
tioning.
Therapeutic community The physical environment, clients, staff, and
policies of the therapeutic facility, which have
an influence on individual functioning in the
activities of daily living.
Therapeutic process Use of the nurse/client relationship and the
nursing process to promote and maintain a
client's adaptive coping responses.
Therapeutic use of self Individualized interventions in which the
nurse uses theory and experiential knowledge
along with self-awareness in assisting clients
to explore their impact on others. The goal of
therapeutic use of self is the facilitation of
behavior change in the client.

47
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