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Canadian Standards for Psychiatric-Mental Health Nursing

4th Edition March 2014

Standards of Practice

Canadian Federation of Mental Health Nurses • www.cfmhn.ca

How to reach us:

Canadian Federation of Mental Health Nurses c/o First Stage Enterprises 1 Concorde Gate, Suite 109 Toronto, ON M3C 3N6

Tel: 416.426.7229 Fax: 416.426.7280

E-mail: [email protected]

www.cfmhn.ca

Canadian Standards for Psychiatric- Mental Health Nursing4th Edition (2014)

Authors

Gloria McInnis-Perry, RN, PhD, DNSc, CNS, CPMHN(C) (PEI), Chair

Ann Greene, RN, MEd, CPMHN(C) (BC), Co-chair

Elaine Santa Mina, RN, PhD (ON) Co-chair

Sue Chong, RN, MSN., BA., CPMHN(C) (BC)

Marlee Groening, RN, BSN, MN (BC)

Gwen Campbell MacArthur, RPN, RN, BScN, MN (BC)

Kathy Wong, RN, BScN, MEd, CPMHN(C) (ON)

Sylvie Buisson, RN, MEd, CPMHN(C) (QC)

Edna Carloss, RN, BScN (NS)

Robert Meadus, RN, PhD (NL)

Acknowledgements

Leigh Blaney, RN, BSN, MA, CPMHN(C) (BC)

Margaret Osborne, RN, PhD (AB)

Brittany Schutte, RN, BScN (AB)

Robb Desrocher, RN, BA (MB)

Carrie McCallum, RN, BScN, CPMHN(C) (ON)

Mari-M Gagnon, RN, MN, CPMHN(C) (QC)

Joanna Cox, RN, BScN, BA (NS)

Aboriginal Nurses Association of Canada (ANAC)

Reference: Canadian Federation of Mental Health Nurses. (2014). Canadian Standards for Psychiatric-Mental Health Nursing (4th Ed.). Toronto, ON. Author. Gloria McInnis-Perry (PhD), Ann Greene (MEd), Elaine Santa Mina (PhD), et al.

© 2014 Canadian Federation of Mental Health Nurses.

Canadian Standards of Psychiatric-Mental Health Nursing 1

Table of ContentsIntroduction .......................................................................................................................3

Standards Development ....................................................................................................4

Purpose of Standards ........................................................................................................4

Current Issues ...................................................................................................................5

Beliefs/Values ....................................................................................................................5

Standards ..........................................................................................................................7

Standard I: Provides Competent Professional Care Through the Development of a Therapeutic Relationship ...................................................................................................7

Standard II: Performs/Refines Client Assessments Through the Diagnostic and Monitoring Function ............................................................................................................................8

Standard III: Administers and Monitors Therapeutic Interventions .......................................9

Standard IV: Effectively Manages Rapidly Changing Situations .........................................10

Standard V: Intervenes Through the Teaching-Coaching Function ....................................11

Standard VI: Monitors and Ensures the Quality of Health Care Practices ..........................11

Standard VII: Practices Within Organizational and Work-Role Structure ...........................12

Glossary ..........................................................................................................................13

References ......................................................................................................................14

Appendix .........................................................................................................................16

Canadian Standards of Psychiatric-Mental Health Nursing2


IntroductionPsychiatric-mental health nurses provide mental health care to individuals, families, groups,

communities, and populations in many settings. Over time, psychiatric-mental health

nursing practice responds to changes in the needs of patients and clients, an expansion of

knowledge about health care and nursing, and a growing array of alternative care delivery

technologies (Fritzsche, 2008). Psychiatric-mental health nurses adapt to change by

expanding their knowledge and understanding of mental health and mental illness while

delivering competent, evidenced-informed, safe, and ethical care.

Changes in government legislation and policy also affect the field of mental health

tremendously since Canada’s mental health system operates under the provisions of federal,

provincial, and territorial Mental Health Acts and related legislation. Psychiatric-mental health

nurses have long advocated for improvements to Canada’s mental health system and are

pleased with the Mental Health Commission’s recent Mental Health Strategy for Canada

(2012) entitled Changing Directions, Changing Lives. This strategy document, informed

by consumers, families, and health professionals, provides a framework for change of the

mental health system through six key recommendations. In general, the report recommends

establishing diverse community-focused services that use a recovery-based approach. All

nurses, including psychiatric-mental health nurses, support Canada’s mental health strategy

and collaborate with others to facilitate implementation.

To maintain quality care in a changing professional field, the Canadian Standards of

Psychiatric-Mental Health Nursing provide direction to all nurses and to the public on

acceptable practices of a psychiatric-mental health nurse. Revision of the Standards is

necessary to ensure that psychiatric-mental health nursing remains contemporary, relevant,

and responsive to the current needs of individuals, families, communities, and the health

care system.

We begin the fourth edition of the Canadian Standards of Psychiatric-Mental Health

Nursing with a brief discussion of the Standards development process, the purpose of the

Standards, various current issues, and the beliefs and values which inform the Standards.

We then present the revised practice standards, a glossary, and an appendix. In the

appendix, we include a historical overview of psychiatric-mental health nursing since it

provides context to the evolution of our practice and standards.


Standards DevelopmentThe Canadian Federation of Mental Health Nurses (CFMHN) published the first edition

of the Canadian Standards of Psychiatric-Mental Health Nursing in 1995 (Austin, Gallop,

Harris, & Spencer, 1996). Subsequent editions reflected the evolution of practice. The

second edition focused on a community mental health and community development model

(Buchanan, Harris, Greene, Newton, & Austin, 1998). The third edition (2006) addressed

issues important at that time and included consumer input. This fourth edition builds upon

previous revisions and includes survey feedback from psychiatric-mental health nurses

across Canada.

In the spring of 2012, the Standards Committee of the Canadian Federation of Mental Health

Nurses developed a national survey for CFMHN members which requested input regarding

potential Standards revisions. A majority of the respondents reported that the Standards remain

relevant to practice, education, and teaching. Approximately 43% suggested changes to the

Standards, while 36% suggested no change. The main themes from those who requested

changes to the Standards were requests for the fourth edition to:

• reflect more of the primary health care principles;

• enhance the recovery model;

• increase the language of ethics (autonomy, empowerment, engagement);

• enhance the importance of the therapeutic relationship (language);

• support the reduction of stigma;

• reflect the work of the Mental Health Commission of Canada;

• articulate the need for future research;

• update the literature to support the Standards;

• make the Standards accessible to different groups of expert psychiatric-mental health

nurses who practice across all sectors, from academic to clinical and research settings.

The fourth edition reflects the integration of the themes stemming from the survey results,

supports the current issues that affect the practice of psychiatric-mental nurses, and

addresses the need for Standards that are supported by current relevant literature.

The Standards continue to use Benner’s (1984) “domains of practice” as the conceptual

framework (Austin, Gallop, Harris, & Spencer, 1996). The competencies are classified under

seven domains: the therapeutic relationship, systematic assessment and decision making,

the administering and monitoring of therapeutic interventions, effective management of rapidly

changing situations, the teaching/coaching function, monitoring and ensuring the quality of

health care practices, and organizational and work role competencies.

Purpose of Standards

“The primary purpose of having standards is to provide direction for professional practice in

order to promote competent, safe and ethical service for clients” (CNA, 2008a, p. 9). The

standards enable nurses to articulate and be accountable to the desired and achievable

level of performance in this specialty area. Psychiatric-Mental Health Nursing Practice


Standards provide a guide for the evaluation of psychiatric-mental health nursing practice

within a professional and ethical framework.

Current Issues

Professional standards reflect the current state of knowledge and understanding of

a discipline and are therefore contextual and dynamic. The theoretical framework for

understanding practice influences how the individual psychiatric-mental health (PMH) nurse

achieves the accepted standards of practice. Psychiatric-mental health nurses’ embrace

the social, cultural, economic, and political contexts for caregiving, which strongly influence

nursing practice (CNA, 2002b). The social justice paradigm goes further to consider the

social determinants of health, and values equity and the empowerment of the individual

in recovery as well as in health care. Various contextual forces can challenge psychiatric-

mental health nurses to provide service from a social justice paradigm. Current issues

considered in the Standards include:

• inequities in population demographics and increases in cultural diversities (e.g., age,

gender, ethnicity, race, sexual orientation, language, socio-economic status, and

spirituality);

• inequities in financial allocation of acute and chronic care resources;

• increased prevalence of concurrent disorders (addictions);

• a trend toward policy and program planning for the integration of addictions and mental

health;

• multiple morbidities that result in increased acuity and complexity;

• a focus on determinants of health in understanding psychiatric-mental health issues and

needs;

• an expanded view of the health care team to include partnership/collaborative

relationships with clients and their natural support systems and with advocacy and self-

help groups;

• stigma and discrimination;

• promotion of recovery and well-being;

• support of Canada’s mental health strategy, Changing Directions, Changing Lives;

• increased psychiatric-mental health nursing research that is evidence-informed and/or

presents best practices in psychiatric-mental health care.

Beliefs/Values

Psychiatric-mental health nursing is a specialized area of nursing practice, education,

and research. The PMH nurse uses evidence-informed and experiential knowledge from

nursing and related health sciences. This practice is grounded in the values as stated in the

Canadian Nurses Association Code of Ethics (CNA, 2008a). Practice involves the promotion

of mental health and the prevention, treatment, and management of mental disorders.

Psychiatric-Mental Health Nurses believe in:

• the centrality of therapeutic nurse-client relationships, based on trust and mutual

respect, to practice;


• the alleviation of stigma and discrimination;

• the promotion of recovery and well-being for people of all ages living with mental health

problems and illnesses;

• the conduct and utilization of research for improvement in care;

• social action to promote political and social awareness to influence health and

organizational policy;

• working in collaborative relationships with the individual, family, community, different

populations, and social agencies;

• a holistic approach that is essential to understanding the unique experience of the client;

• equitable access to culturally competent care;

• reflective ethical practice and a commitment to continuous learning;

• the protection of human rights in the context of civil commitment and relevant aspects

of jurisprudence;

• advocating for practice environments that facilitate and ensure safe and positive work

relationships;

• fostering a legacy of moral and visionary psychiatric-mental health nursing leaders.


StandardsStandard I: Provides Competent Professional Care through the Development of a Therapeutic RelationshipA primary goal of psychiatric-mental health nursing is the promotion of mental health and the

prevention or diminution of mental disorder. The development of a therapeutic relationship is

the foundation from which the psychiatric-mental health nurse can “enter into partnerships

with clients, and through the use of the human sciences, and the art of caring, develop

helping relationships” (RNAO, 2002b).

The nurse:

1. assesses and clarifies the influences of personal beliefs, values, and life experience

on the therapeutic relationships and distinguishes between social and therapeutic

relationships;

2. works in partnership with diverse and heterogeneous populations, families, and relevant

others to determine goal-directed needs and to establish an environment that is

conducive to goal achievement;

3. uses a range of therapeutic verbal and non-verbal communication skills that include

empathy, active listening, observing, genuineness, and curiosity;

4. recognizes the influence of age, culture, class, ethnicity, language, stigma, and social

exclusion on the therapeutic process and negotiates care that is sensitive to these

influences;

5. mobilizes and advocates for resources that improve community integration and increase

the ability of diverse and heterogeneous populations and their families, including those

isolated geographically, to access mental health services;

6. understands and responds to human reactions to distress and loss of control that may

be expressed as anger, anxiety, fear, grief, helplessness, hopelessness, and humour;

7. recognizes and respects the client’s expert and unique knowledge, and facilitates the

client’s behavioural, developmental, emotional, or spiritual change while acknowledging

and supporting the client’s participation, responsibility, and choices in his/her care;

8. respects the client’s and family’s lived expertise and unique knowledge in promoting

recovery;

9. fosters mutuality of the relationship by reflectively critiquing therapeutic effectiveness

through client and family responses and feedback, clinical supervision, and self-

evaluation;

10. understands the nature of chronic illness and applies the principles of health promotion

and disease prevention when working with clients and families in the promotion of

recovery.


Standard II: Performs/Refines Client Assessments through the Diagnostic and Monitoring FunctionEffective assessment, diagnosis, and monitoring is central to the nurse’s role and depends

upon theory as well as upon understanding the meaning of the health or illness experience

from the perspective of the client. The nurse explains the assessment process to the client

and provides feedback. Knowledge is integrated with the nurse’s conceptual model of

nursing practice, which provides a framework for processing client data and for developing

client-focused plans of care. The nurse makes professional judgements based upon

evidence, and recognizes and includes the client as a valued partner.

The nurse:

1. collaborates with clients and with other members of the health care team to gather

holistic, client-centered assessments through observation, engagement, examination,

interview (using respectful, recovery focussed language), and consultation while

attending to confidentiality and pertinent legal statutes;

2. assesses, documents, and analyzes data to identify health status, potential for wellness,

health care deficits, potential for risk to self and others; alterations in thought content

and/or process, affect behaviour, communication and decision-making abilities;

substance use and dependency; and history of trauma and/or abuse (emotional,

physical, neglect, sexual, or verbal);

3. formulates and documents a plan of care in collaboration with the client, family, and

mental health team that supports recovery and reintegration/social inclusion in the

community through discharge planning and provision for ongoing support, all while

recognizing variability in the client’s ability to participate in the process;

4. refines and expands client assessment information by assessing and documenting

significant change(s) in the client’s status, and by comparing new data with the baseline

assessment and client goals;

5. assesses and anticipates potential needs and risks, collaborating with the client to

examine his/her environment for risk factors such as self-care, housing, nutrition,

economic support, psychological state, and social interactions;

6. determines the most appropriate and available therapeutic modality that meets the

client’s needs, and assists the client to access necessary resources.


Standard III: Administers and Monitors Therapeutic InterventionsThe nature of mental health problems and mental disorders raises specific practice issues

for the psychiatric-mental health nurse in the assessment and the administration of

therapeutic interventions. Many clients are at risk for harm to self or others, either directly or

through neglect (including self-neglect). Every effort will be made to include the client in all

aspects of decision-making. The PMH nurse will be alert and respond to adverse reactions.

The nurse:

1. utilizes and evaluates evidence-based interventions to provide ethical, culturally

competent, safe, effective, and efficient nursing care consistent with the mental,

physical, spiritual, emotional, social, and cultural needs of the individual;

2. provides information to clients and families/significant others in accordance with relevant

legislation;

3. assists, educates, and empowers clients to select choices which support informed

decision-making and provides information about the possible consequence(s) of the

choice;

4. supports clients to draw on their own assets and resources for self-care, daily living

activities, resource mobilization, and mental health promotion;

5. determines clinical intervention, using knowledge of client’s responses;

6. uses technology appropriately to perform safe, effective, and efficient nursing

intervention;

7. uses knowledge of age-specific implications of psychotropic medications and

administers medications accurately and safely, monitoring therapeutic responses,

reactions, untoward effects, toxicity, and potential incompatibilities with other

medications or substances and provides medication education with appropriate

content;

8. utilizes therapeutic elements of group process;

9. incorporates knowledge of family dynamics, cultural values, and beliefs in the provision

of care;

10. collaborates with the client, health care providers, and community members to access

and coordinate resources such as employment, education, and volunteering, and seeks

feedback from the client and others regarding interventions;

11. encourages and assists clients to seek out mutual support groups and to strengthen

social support networks as needed;

12. seeks out the client’s response to, and perception of, nursing and other therapeutic

interventions and incorporates it into practice;

13. ensures care for individuals of different populations (e.g., incarcerated individuals,

individuals with intellectual disabilities) from therapeutic and rehabilitative perspectives.


Standard IV: Effectively Manages Rapidly Changing SituationsThe effective management of rapidly changing situations is essential in critical circumstances

that may be termed psychiatric emergencies. These situations include risk factors for

self-harm, aggressive behaviours, and rapidly changing mental and physical health states

(SERPN, 1996).

The nurse:

1. utilizes the therapeutic relationship throughout the management of rapidly changing

situations;

2. assesses the client using a comprehensive holistic approach for actual or potential

health issues, problems, risk factors, and/or crisis/emergency/catastrophic situations;

3. knows about resources required to manage actual and potential crisis/emergency/

catastrophic situations and plans access to these resources;

4. monitors client safety and utilizes continual assessment to detect early changes in client

status, and intervenes accordingly;

5. implements timely, age-appropriate, and client-specific crisis/emergency/catastrophic

interventions as necessary;

6. uses trauma-informed care when managing crisis situations with clients to minimize

further trauma and interference with recovery objectives;

7. commences critical procedures when necessary which, in an institutional setting,

includes suicide precautions, emergency restraint, elopement precautions, and

infectious disease management and, in a community setting, includes community

support systems such as police, ambulance, and crisis response resources;

8. utilizes a least restraint approach to care;

9. develops and documents the management plan of care and intervention;

10. coordinates care to prevent errors and duplication of efforts where rapid intervention is

imperative;

11. evaluates the effectiveness of the rapid responses with the client and modifies critical

plans as necessary;

12. involves, with client collaboration, the family and significant others to identify the

precipitates of the event and to plan ways to minimize risk of recurrence;

13. participates in process review with the client, family, health care team, and other service

providers as needed;

14. utilizes safety measures to protect client, self, and colleagues from potentially abusive

situations in the work environment;

15. participates in and implements activities that improve client safety in the practice setting.


Standard V: Intervenes through the Teaching-Coaching FunctionAll interactions are potentially teaching/learning situations. The PMH nurse attempts to

understand the life experience of the client and uses this understanding to support and

promote learning related to health and personal development. The nurse provides health

promotion information to individuals, families, communities, and different populations.

The nurse:

1. collaborates with the client to determine learning needs, emphasizing and supporting

the client’s potential for recovery;

2. plans and implements health promotion education with the client while considering the

context of the client’s life experiences, readiness, culture, literacy, language, preferred

learning style, and available resources;

3. explores options and resources with the client to build knowledge for making informed

choices related to health needs and for accessing the system as needed;

4. incorporates knowledge of diverse learning models and principles, including the

principles of recovery, when creating learning opportunities for clients;

5. provides guidance, support, and relevant information (with appropriate critiques) to

clients, families, and significant others;

6. documents the teaching/learning process (assessment, implementation, client

involvement, and evaluation);

7. determines with the client the effectiveness of the educational process and

collaboratively develops or adapts it to meet learning needs;

8. engages in teaching/learning opportunities as a partner with clients, families, and

community agencies.

Standard VI: Monitors and Ensures the Quality of Health Care PracticesThe nurse has a responsibility to advocate for clients’ rights to receive the lease restrictive

form of care and to respect and affirm clients’ rights to self-determination in a safe

and equitable manner. The PMH nurse must be informed about relevant legislation, its

interpretation, and its implications for nursing practice.

The nurse:

1. identifies philosophies, attitudes, values, and beliefs of the workplace culture that affect

the nurse’s performance, safety, and compassion, and responds appropriately;

2. understands how the determinates of health affect community well-being and PMH

nursing practice;

3. understands relevant legislation and its implications for nursing practice, and utilizes it

appropriately;


4. expands and incorporates knowledge of innovations and changes in mental

health psychiatric nursing practice to ensure safe, confidential, and effective care;

5. ensures and documents ongoing review and evaluation of psychiatric-mental health

nursing care activities;

6. participates in dialogue and critical reflection about the interdependent functions of the

team within the overall plan of care;

7. advocates for the client within the context of the health care environment;

8. advocates for continuous improvement to the organizational/systemic structures

consistent with the principles of safe, ethical, and competent care;

9. recognizes the dynamic changes in health care locally and globally and, with

stakeholders, supports strategies to manage these changes.

Standard VII: Practices Effectively within Organizational and Work-Role StructurePsychiatric-mental health nursing care occurs in both community and hospital settings. For the

PMH nurse, care requires a therapeutic relationship involving reflective, ethical, and evidence-

based practice within complex and dynamic situations. The PMH nurse must be able to plan

and implement collaborative care, apply recovery principles, promote mental health, consult

with community members, and advocate for the mental health of their clients and others.

The nurse:

1. collaborates with clients/families/significant others and other stakeholders to facilitate

safe, supportive, and respectful environments for all persons;

2. actively participates to sustain and promote a climate which supports ethical practice

and a moral community;

3. understands and utilizes quality outcome indicators and strives for continuous quality

improvement;

4. seeks to utilize constructive and collaborative approaches to resolve differences among

members of the health care team which may impact care;

5. participates in developing, implementing, and critiquing mental health policy which

fosters recovery and continuity of care;

6. advocates and supports a nursing leadership role;

7. supports and helps to mentor and coach newly graduated nurses;

8. utilizes knowledge of collaborative strategies for social action in working with consumer

and advocacy groups;

9. pursues opportunities to reduce stigma and to promote social inclusion and community

integration for clients.


GlossaryThese descriptions apply for the purposes of this document:

client: Individuals, families, groups, populations, or communities. Synonymous terms may be patients, beneficiaries, partners, recipients, consumers. Clients

exist in social systems that may influence the onset and duration of illness and the extent of mental health (RNAO, 2002a).

crisis: An emotional upset arising from situational, developmental, biological, psychological, socio-cultural, and/or spiritual factors. This state of emotional

distress results in a temporary inability to manage using one’s usual resources and coping mechanisms. Unless the stressors that precipitated the crisis are

alleviated and/or the coping mechanisms are bolstered, major disorganization may result. Because a crisis state is subjective, it may be defined by the client, the

family, or other members of the community (RNAO, 2002b).

contextual factors: The personal, interpersonal, and environmental variables that comprise a person’s unique life experience.

competencies: The integrated knowledge, skills, attitudes, and judgements expected of the PMH nurse (CNA, 2002b, p. 49).

cultural safety and cultural competence: Evolving and largely complementary frameworks that have been developed to address the diverse mental health needs

of people living in Canada. They encourage service providers, regardless of their cultural background, to communicate and practice in a way that considers and

respects the cultural, social, political, linguistic, and spiritual realities of the people with whom they are working. Cultural safety has its origins in the indigenous

experience of colonization, and draws attention to issues of power and discrimination as well as to structural barriers that can limit access to appropriate care for

people from diverse backgrounds. Approaches that build on cultural competence have also emphasized the necessity of addressing these dimensions (Mental

Health Commission of Canada, 2009, p. 120).

empower: To make others stronger and more confident, especially in controlling their life and claiming their rights (Empower, n.d.).

family: The significant and unique people in one’s life who are defined as family. Family members can include, but are not limited to, parents, children, siblings,

neighbours, and significant people in the community (RNAO, 2002b).

least restrictive care: The provision of safe, competent, and ethical care which respects individual rights, dignity, and autonomy with the least possible recourse

to mechanical, chemical, environmental, or physical measures to limit the activity or control the behaviour of a person or a portion of their body (Mental Health

Commission of Canada, 2009, p. 121)

marginalize: To treat (a person, group, or concept) as insignificant or peripheral (Marginalize, n.d.).

mental disorder: A health condition characterized by alterations in several factors that include mood, affect, behaviour, thinking, and cognition. The disorders are

associated with various degrees of distress and impaired functioning (Austin & Boyd, 2009, p. 23).

mental health: The capacity to feel, think, and act in ways that enhance one’s ability to enjoy life and deal with challenges. The term refers to various capacities

including the ability to understand oneself and one’s life, relate to other people, and respond to one’s environment; experience pleasure and enjoyment; handle

stress and withstand discomfort; evaluate challenges and problems; pursue goals and interests; and explore choices and make decisions (Health Canada, 2002).

mental health problem: The diminished capacities – whether cognitive, emotional, interpersonal, motivational, or behavioural – that interfere with a person’s

enjoyment of life or adversely affect interactions with society and environment (Stephens, 1999).

mental health promotion/mental illness prevention: Mental health promotion aims to foster positive mental health for all people, regardless of whether they are

living with a mental health problem or illness, while prevention focuses on measures taken to prevent mental health problems and illnesses, to the greatest extent

possible. Efforts to promote mental health and well-being can overlap with those directed at preventing mental health problems and illnesses (Mental Health

Commission of Canada, 2009, p. 122).

mental illness: A mental state characterized by alteration in thinking, mood, or behavior (or some combination thereof) and associated with significant distress

and impaired functioning over an extended period of time. The symptoms of mental illness vary from mild to severe, depending on the type of mental illness, the

individual, the family, and the socio-economic environment (Health Canada, 2002).

moral community: A community is moral when there is coherence between what a health care organization publicly professes to be (e.g., a helping, healing,

caring environment that embraces values intrinsic to the practice of health care) and what employees, patients, and others both witness and participate in

(Webster & Baylis, 2000).

rapidly changing mental health state: Severe impairments of thought and judgement constituting a medical emergency, which can occur in association with

acute psychosis (a clinical syndrome that may be caused by disorders such as mania, schizophrenia, or drug abuse).

recovery: A process in which people with mental health problems and illnesses are empowered and supported to engage actively in their own journey of well-

being. The recovery process builds on individual, family, cultural, and community strengths and enables people to enjoy a meaningful life in their community while

striving to achieve their full potential (Mental Health Commission of Canada, 2009, p. 122).

self-awareness: The ability to reflect on one’s practice, thoughts, feeling, needs, fears, strengths, and weakness and to understand how these might affect one’s

actions and the nurse-client relationship (RNAO, 2002b).

significant others: Those to whom the client attributes affection, emotional ties, and a sense of belongingness (adapted from Wright & Leahey, 1994).

therapeutic relationship: A relationship grounded in an interpersonal process that occurs between the nurse and the client(s). The therapeutic relationship is a

purposeful, goal-directed relationship intended to advance the best interest and outcome of the client (RNAO, 2002b).


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Appendix AHistory of Canada’s Psychiatric-Mental Health NursingUntil the late nineteenth century, people with mental illness were usually cared for by their families. From that time, institutional care for the person with mental illness considered “dangerous to be at large” became available as provinces passed legislation for the formal admission of this group to asylums headed by physicians titled “medical superintendents” and staffed by lay attendants. Early in the twentieth century, several asylums in Ontario, Nova Scotia, and Quebec initiated specialized mental health nurse training schools modeled closely on general hospital schools. Under the auspices of general nursing leaders, mental hospital graduate nurses eventually became eligible for general nurse registration in those provinces. Asylum training schools appeared some time later in western Canadian asylums as well, but those graduates generally were not eligible for provincial nurse registration and eventually formed a separate registration system.

Public funding for Canada’s mental hospitals remained a challenge, and problems of limited resources and overcrowding soon made the institutions difficult to manage, resulting in a poor reputation. Influenced by the mental hygiene movement of the 1920s, ideas about care of the person with mental illness gradually shifted to place more emphasis upon prevention of mental illness and promotion of mental health among the general population. Following World War Two, the health care system rapidly expanded, new psychotropic medications became available, and care of the mentally ill diversified. Large mental hospitals remained, but as general hospitals created psychiatric departments and outpatient clinics, services expanded. Beginning in the mid-1960s, the focus of mental health care slowly shifted from institutional to community-based care, with a wider range of available professional services. The number of patients cared for in the provincial hospitals decreased significantly.

Throughout the postwar years and during the transition to community care, psychiatric-mental health nursing remained central to the care of the person with mental illness; however, the role of nurses and their education changed. In all provinces, psychiatric-mental health nursing is now a component of generic nursing education programs that prepare graduates for positions in this speciality as part of the professional work of nursing. Today, psychiatric-mental health nurses are an integral part of multidisciplinary teams, providing a wide range of inpatient and community mental health care services in partnership with consumers and their families.

(Boschma, 2003 & Tipliski, 2002)


Standard Statement Reference number(s)

Current Issues

1. inequities in population demographics and increases in cultural diversities (e.g., age, gender, ethnicity, race, sexual orientation, language, socio-economic status, and spirituality)

13, 16, 34, 47

2. inequities in financial allocation of acute and chronic care resources 6, 40

3. increased prevalence of concurrent disorders (addictions) 13, 19

4. a trend toward policy and program planning of the integration of addictions and mental health

13, 19, 49

5. multiple morbidities resulting in increasing acuity and complexity 2

6. a focus on determinants of health in understanding psychiatric-mental health issues and needs

2, 4, 5, 13, 16, 17, 20, 34, 36, 37, 38, 39, 40, 49, 57

7. an expanded view of the health care team to include partnership/collaborative relationships with clients and their natural support systems and with advocacy and self-help group

3, 4, 6, 7, 13, 35, 36, 38, 46

8. stigma and discrimination 6

9. promotion of recovery and well-being 6

10. support of Canada’s mental health strategy 36

11. increased psychiatric mental health nursing research that is evidence-informed and/or presents best practices in psychiatric mental health care

6

Beliefs and Values

1.the centrality of the therapeutic nurse-client relationships, based on trust and mutual respect, to practice

5, 6, 21, 27, 32, 34, 35, 37, 42, 43, 44, 47, 49, 50, 57

2. the alleviation of stigma and discrimination 6, 7, 12, 13, 16, 17, 35, 36, 37, 49, 50, 54

3. the promotion of recovery and well-being for people of all ages living with mental health problems and illnesses

18, 20, 33, 35, 36

4. the conduct and utilization of research for improvement in care 12, 13, 16, 17, 21, 36, 49, 50

5. social action to promote political and social awareness to influence health and organizational policy

13, 16, 17, 19, 20

6. working in collaborative relationships with the individual, family, community, different populations, and social agencies

4, 6, 7, 21, 35, 13, 46, 57

7. a holistic approach that is essential to understanding the unique experience of the client 4, 5, 6, 7, 13, 17, 21, 27, 28, 30, 35, 38, 39, 44, 47, 48, 50, 54, 57

8. equitable access to culturally competent care 4, 6, 13, 16, 30, 32, 35, 38, 50, 52, 54

9. reflective ethical practice and a commitment to continuous learning 6, 21, 25, 27, 35, 42, 43, 49, 50

10. the protection of human rights in the context of civil commitment and relevant aspects of jurisprudence

27

11. advocating for practice environments that facilitate and ensure safe and positive work relationships

21, 27

12. fostering a legacy of moral and visionary psychiatric mental health nursing leaders 37

Appendix B



Standard I: Provides Competent Professional Care through the Development of a Therapeutic Relationship

1. assesses and clarifies the influences of personal beliefs, values and life experience on the therapeutic relationships and distinguishes between social and therapeutic relationships

6, 7, 27, 35, 37, 44, 49, 50, 57

2. works in partnership with diverse and heterogeneous populations, families, and relevant others to determine goal directed needs and to establish an environment that is conducive to goal achievement

3, 6, 35, 36, 42

3. uses a range of therapeutic verbal and non-verbal communication skills that include empathy, active listening, observing, genuineness, and curiosity

42, 43, 44

4. recognizes the influence of age, culture, class, ethnicity, language, stigma, and social exclusion on the therapeutic process and negotiates care that is sensitive to these influences

6, 13, 35, 36, 41, 46, 47, 49, 54, 57

5. mobilizes and advocates for resources that increase the ability of diverse and heterogeneous populations and their families to access to mental health services and that improve community integration, including those isolated geographically

1, 2, 13, 16, 18, 20, 36, 40, 39, 49

6. understands and responds to human reactions to distress and loss of control that may be expressed as anger, anxiety, fear, grief, helplessness, hopelessness, and humour

43, 50

7. recognizes and respects the client’s expert and unique knowledge, and facilitates the client’s behavioural, developmental, emotional, or spiritual change while acknowledging and supporting the client’s participation, responsibility, and choices in his/her care.

18, 42

8. respects the client’s and family’s lived expertise and unique knowledge in promoting recovery

39, 48

9. fosters mutuality of the relationship by reflectively critiquing therapeutic effectiveness through client and family responses and feedback, clinical supervision, and self-evaluation

7

10. understands the nature of chronic illness and applies the principles of health promotion and disease prevention when working with clients and families in the promotion of recovery

16, 35

Standard II: Performs/Refines Client Assessments through the Diagnostic and Monitoring Function

1. collaborates with clients and with other members of the health care team to gather holistic, client centered assessments through observation, engagement, examination, interview (using respectful, recovery focussed language), and consultation while attending to confidentiality and pertinent legal statutes

21, 27, 47

2. assesses, documents, and analyzes data to identify health status, potential for wellness, health care deficits, potential for risk to self and others, alterations in thought content and/or process, affect behaviour, communication and decision-making abilities, substance use and dependency, and history of trauma and/or abuse (emotional, physical, neglect, sexual, or verbal)

47

3. formulates and documents a plan of care in collaboration with the client, family, and mental health team that supports recovery and reintegration/social inclusion in the community through discharge planning and provision for ongoing support, all while recognizing variability in the client’s ability to participate in the process

43, 47

4. refines and expands client assessment information by assessing and documenting significant change(s) in the client’s status, and by comparing new data with the baseline assessment and client goals

49, 50

5. assesses and anticipates potential needs and risks continuously, collaborating with the client to examine his/her environment for economic, psychological, and social risk factors such as self-care, housing, and nutrition

39, 49, 50

6. determines the most appropriate and available therapeutic modality that meets the client’s needs, and assists the client to access necessary resources

41, 49



Standards III: Administers and Monitors Therapeutic Interventions

1. utilizes and evaluates evidence-based interventions to provide ethical, culturally competent, safe, effective, and efficient nursing care consistent with the mental, physical, spiritual, emotional, social, and cultural needs of the individual

1, 2, 3, 6, 27, 35, 46, 49, 50

2. provides information to clients and families/significant others in accordance with relevant legislation

1, 3, 6, 18, 35, 37, 39

3. assists, educates, and empowers clients to select choices which support informed decision-making and provides information about the possible consequence(s) of the choice

3, 6, 18, 27, 35, 49

4. supports clients to draw on their own assets and resources for self-care, daily living activities, resource mobilization, and mental health promotion

13, 39

5. determines clinical intervention, using knowledge of client’s responses 43, 47

6. uses technology appropriately to perform safe, effective, and efficient nursing intervention 2

7. uses knowledge of age-specific implications of psychotropic medications and administers medications accurately and safely, monitoring therapeutic responses, reactions, untoward effects, toxicity, and potential incompatibilities with other medications or substances and provides medication education with appropriate content

37, 49

8. utilizes therapeutic elements of group process 37, 45, 51

9. incorporates knowledge of family dynamics, cultural values, and beliefs in the provision of care

6, 13, 18, 37, 39, 46, 57

10. collaborates with the client, health care providers, and community members to access and coordinate resources such as employment, education, and volunteering, and seeks feedback from the client and others regarding interventions

1, 3, 18, 42

11. encourages and assists clients to seek out mutual support groups and to strengthen social support networks as needed

46

12. seeks out the client’s response to, and perception of, nursing and other therapeutic interventions and incorporates it into practice

3, 6, 7, 39, 42, 51

13. ensures care for individuals of different populations (e.g., incarcerated individuals, individuals with intellectual disabilities) from therapeutic and rehabilitative perspectives

6, 39

Standard IV: Effectively Manages Rapidly Changing Situations

1. utilizes the therapeutic relationship throughout the management of rapidly changing situations

5, 37, 43, 50, 57

2. assesses the client using a comprehensive holistic approach for actual or potential health issues, problems, risk factors, and/or crisis/emergency/catastrophic situations

5, 37, 50, 57

3. knows resources required to manage actual and potential crisis/emergency/catastrophic situations and plans access to these resources

37

4. monitors client safety and utilizes continual assessment to detect early changes in client status, and intervenes accordingly

5, 37, 50

5. implements timely, age appropriate, and client specific crisis/emergency/catastrophic interventions as necessary

6, 35, 37, 43

6. uses trauma-informed care when managing crisis situations with clients to minimize further trauma and interference with recovery objectives

37, 43, 44, 47, 49

7. commences critical procedures when necessary which, in an institutional setting, includes suicide precautions, emergency restraint, elopement precautions, and infectious disease management, and, in a community setting, includes community support systems such as police, ambulance services, and crisis response resources

5, 6, 12, 27, 39, 50, 57

8. utilizes a least restraint approach to care 27, 37

9. develops and documents the plan and intervention 1



10. coordinates care to prevent errors and duplication of efforts where rapid intervention is imperative

1, 3, 40

11. evaluates the effectiveness of the rapid responses with the client and modifies critical plans as necessary

37

12. in collaboration with the client, facilitates the involvement of the family and significant others to identify the precipitates of the event and to plan to minimize risk of recurrence

37, 43, 50

13. participates in process review with the client, family, health care team, and other service providers as needed

37, 39

14. utilizes safety measures to protect client, self, and colleagues, from potentially abusive situations in the work environment

27

15. participates in and implements activities that improve client safety in the practice setting 1, 3, 12, 27, 37, 50

Standard V: Intervenes through the Teaching-Coaching Function

1. determines client’s learning needs in collaboration with the client, emphasizing and supporting the client’s potential for recovery

39, 42

2. plans and implements health promotion education with the client while considering the context of the client’s life experiences, readiness, culture, literacy, language, preferred learning style, and available resources

17, 42, 57

3. engages with the client to explore available options and resources to build knowledge to make informed choices related to health needs and to access the system as needed

6, 7, 17, 18, 27, 35, 39, 42, 47

4. incorporates knowledge of a wide variety of learning models and principles, including the principles of recovery, when creating learning opportunities for clients

42

5. provides relevant information (with appropriate critiques), guidance, and support to clients, families, and significant others

39

6. documents the teaching/learning process (assessment plan, implementation, client involvement, and evaluation)

49

7. determines with the client the effectiveness of the educational process and collaboratively develops or adapts it to meet learning needs

42

8. engages in teaching/learning opportunities as a partner with consumers, families, and community agencies

3, 57

Standard VI: Monitors and Ensures the Quality of Health Care Practices

1. identifies philosophies, attitudes, values, and beliefs of the workplace culture that impact on the nurse’s ability to perform with skill, safety, and compassion and takes action as appropriate

6, 21, 27, 36, 37, 47, 54

2. understands how the determinates of health impact on the health of the community and affect PMH nursing practice

17, 21, 26, 36, 37, 38, 39, 49, 52, 54, 57

3. understands and utilizes current and relevant legislation and the implications for nursing practice

3, 6, 27, 35, 37

4. expands and incorporates knowledge of innovations and changes in mental health and psychiatric nursing practice to ensure safe, confidential, and effective care

1, 6, 35

5. ensures and documents ongoing review and evaluation of psychiatric mental health nursing care activities

1

6. participates in dialogue and critical reflection around the interdependent functions of the team within the overall plan of care

6, 21, 37

7. advocates for the client within the context of the health care environment 6, 13, 27, 35, 36, 40, 37, 38, 39, 48, 49

8. advocates for continuous improvement to the organizational/system structures in keeping with the principles of delivering safe, ethical, and competent care

1, 13, 20, 21, 27, 36, 38, 40, 49



9. recognizes the dynamic changes in health care locally and globally and, in collaboration with stakeholders, supports strategies to manage these changes

16, 39, 40

Standard VII: Practices within Organizational and Work-Role Structure

1. works in collaborative partnerships with clients/families/significant others and other stakeholders to facilitate environments that ensure the safety, support, and respect for all persons

1,2, 4, 12, 13, 16, 36, 38, 39, 42, 49

2. actively participates to sustain and promote a climate which supports ethical practice and the establishment of a moral community

6, 21, 25, 27, 35, 36, 58

3. understands and utilizes quality outcome indicators and strives for continuous quality improvement

1, 2, 16, 21, 27

4. seeks to utilize constructive and collaborative approaches to resolve differences among members of the health care team which may impact care

21, 22, 27

5. participates in developing, implementing, and critiquing mental health policy which fosters recovery and continuity of care

16, 17

6. advocates and supports a nursing leadership role 6, 35

7. supports and participates in the mentoring and coaching new graduates 38

8. utilizes knowledge of collaborative strategies for social action in working with consumer and advocacy groups

40

9. pursues opportunities to reduce stigma and to promote social inclusion and community integration for clients

6


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38. Native Mental Health Association of Canada. (2007). Charting the future of native mental health in Canada: A ten year strategic plan 2008 to 2018. Chilliwack, BC: Author. Retrieved from: http://www.nmhac.ca/documents/Final_NMHAC_STRATEGIC_PLAN_April_07[1].pdf

39. Neville. C., Fley, D., Quinn, J., Weir, J., Hegney, D., Hangan,C., & Grasby, D. (2006 ). Mental health nursing standards and practice indicators for Australia: a review of current literature. International Journal of Mental Health Nursing, 17(2), 138-146.

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CFMHN works with others to influence policy and decision making and provides expertise on community health nursing issues.

La CFMHN s’associe à d’autres organismes pour influencer les politiques et les décisions, et elle fournit des conseils sur les

questions relatives aux soins infirmiers communautaire en santé mentale.

Your FederationHelping meet your professional goals

An associate group of the Canadian Nurses’ Association (CNA),

we are a national voice for psychiatric and mental health (PMH)

nursing. Our objectives are to:

• Assure national leadership in the development and

application of nursing standards that inform and affect

psychiatric and mental health nursing practice.

• Examine and influence government policy, and address

national issues related to mental health and mental illness.

• Communicate and collaborate with national and

international groups that share our professional interests.

• Facilitate excellence in psychiatric and mental health nursing

by providing our members with educational and networking

resources.

Formed in 1988, the Federation pioneered national credentialing

in psychiatric and mental health nursing and achieved CNA

certification status seven years later.

Because of our efforts, nurses across the country can qualify

for the national psychiatric and mental health nursing credential.

Nurses with certification are eligible to use the CPMHN(C)

designation after their names and wear the official CNA

certification pin – a sign of professional achievement.

There is a National Certification Exam available to all

Mental Health Nurses through CNA. For more information

on the certification process please see www.cna-nurses.ca

Canadian Federation of Mental Health Nurses Fédération Canadienne des Infirmières et Infirmiers en Santé Mentale

c/o First Stage Enterprises 1 Concorde Gate, Suite 109 Toronto, ON M3C 3N6

Tel: 416.426.7229 Fax: 416.426.7280

E-mail: [email protected]

www.cfmhn.ca

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