CASN & CFMN Entry-to-Practice Mental Health and Addiction Competencies for Undergraduate Nursing Education
Professional Responsibility & Accountability:
o Applies mental health and substance knowledge
o Therapeutically engages with people with dignity and respect
o Upholds rights and autonomy of people w/ mental health condition or addiction
Knowledge-based practice
o Uses relational practice to conduct a person focused mental health/substance use assessment (MSE, assessment)
o Develops plan of care in collaboration w/ person, family, and health team to promote recovery
Ethical Practice
o Acts in accordance w/ CAN code of ethics w/ ppl with mental health condition or addiction
Service to the Public
o Works collaboratively w/ partners to promote mental health and advocate in health services
Self-Regulation
o Develops competencies through self-reflection and new opportunities working w/ persons experiencing mental health condition or addiction
Therapeutic Communication
Therapeutic Communication Skills
* Effective interpersonal communication skills are the building blocks of all successful therapeutic relationships
* Mental health and substance use nurses need to learn a wide range of communication skills and be able to apply these appropriately in interactions with their clients
What are some Important Principles of Therapeutic Communication?
- Client is primary focus
- Professional attitude sets the tone of relationship
- Use self-disclosure cautiously & only when it serves a therapeutic purpose
o Means giving personal info
o If client asks, you should find underlying reason why, it should always be purposeful to care - Avoid social relationships with clients
- Maintain client confidentiality
- Assess competence of client to determine level of understanding
- Non-judgemental attitude
- Guide client to reinterpret their experiences rationally
- Use clarifying statements.
Therapeutic Communication Skills: Non-verbal
- Silence
- Facial expressions
- Active listening
- Gestures
- Body language
- Leaning forward
Potential Blocks to Therapeutic Communication
- Giving Advice
- Asking personal questions/probing
- Automatic Responses/Cliches
- Giving approval/disapproval
- Agreeing/Disagreeing
- Asking for explanations/”why questions
- Inappropriate Self-disclosure
- Defensive Responses
- Changing the Subject
- Arguing
Essential Conditions for Establishing, Maintaining & Terminating Therapeutic Relationships in Nursing
- Unconditional Positive Regard (acceptance and caring)
- Congruence (genuineness and realness)
- Empathy (being listened to and being understood)
Therapeutic Nurse-Client Relationships
Power
o There is power imbalance in favor of the nurse
Trust
o Clients assume nurse has the knowledge, skills, and abilities to provide care
Personal Closeness
o Relationship involves personal closeness w/ clear boundaries
Respect
o Nurse has responsibility to respect client regardless of their race, religion, ethnic origin, social or health status
What are Peplau’s Therapeutic Nurse Client Relationship Stages & Tasks
Orientation Phase (where nurse and client get to know each other)
* First meeting
* Build trust & rapport
* Confidentiality in the relationship
o Discuss and be clear w/ who info is shared with
o Do not share information online
* Setting parameters
* Testing the relationship
o Client will test relationship to see if nurse will really accept them
o Must understand behaviour as testing and be available to client, be patient
E.g., client has paranoia so will have difficulty building trust and take longer
E.g., depressed client may have difficulty expressing needs at first until comfortable
Working Phase
* Problems and issues are identified
* Plans are made to address problems and act on them
* Ongoing assessment
Termination Phase (resolution phase)
* Begins when actual problems are resolved and ends w/ termination of relationship
* Last meeting
* Celebrate goals that have been met
* Acknowledge loss that may accompany ending of the therapeutic relationship
* Validate plans for the future
What’s Therapeutic about Therapeutic Nurse-Client Relationships (Shattell, Starr & Thomas, 2007)
Knowing the Whole Person
* Therapeutic relationships require in-depth personal knowledge of service recipients which is acquired only with time, understanding and skill
* Knowing the whole person is key to enhancing the therapeutic potential of relationships
What Service Recipients Find therapeutic About Therapeutic Relationships
* Relate to me
o Show acceptance
o Understanding
o Validation
* Get to know me
* Listen attentively
* Get to the solution
* Confidence
* Emotional support and care
* Appropriate education and referrals
What is transference?
TRANSFERENCE – when client redirects their feelings unconsciously about past person they know onto nurse
* E.g., client being hostile to nurse b/c of underlying resentment of authority figures
* A client’s expectations, feelings, and desires for a person in their past unconsciously transferring and being redirected to a nurse counsellor
* When transference occurs, the client may start to interact with the nurse as though they are the individual in their past
* Common types of transference include maternal transference (treating the person like a mother), paternal transference, sibling transference and non-familial transference
What is countertransference?
COUNTERTRANSFERENCE – the provider’s emotional reaction to the client based on personal unconscious needs and conflicts
* E.g., telling pt. they should have good relationship w/ dad when they are arguing (nurse saying this b/c nurse’s dad just passed away and is grieving so it affected her response)
* A nurse’s expectations, feelings, and desires for a person in their past unconsciously transferring and being redirected to a client
* When countertransference occurs, the nurse may start to interact with the client as though they are the individual in their past
o E.g., excessive self-disclosure or inappropriate interest in irrelevant details from them
* Common types of countertransference include maternal countertransference, paternal countertransference, sibling countertransference and non-familial countertransference
Managing Transference & Countertransference in Therapeutic Relationships
- Mindfulness
- Clear boundaries
- Continual self-reflection
- Peer support
- Empathy
Bio/psycho/social/spiritual Assessment
BIOLOGICAL FACTORS
* Physical, physiological, chemical, neurological or genetic conditions/factors
PSYCHOLOGICAL FACTORS
* Factors related to psychological processing of thoughts, feelings, and behaviour sense of self and well-being
SOCIAL FACTORS
* Factors that account for the influence of social forces encompassing the patient, family, and community within cultural settings.
SPIRITUAL
* Relates to the core of whom we are; the essence of our being
The Assessment Process
- A purposeful, systematic, and dynamic process that is ongoing throughout the nurse’s relationship with individuals in her or his care
- Involves the collection, validation, analysis, synthesis, organization, and documentation of client health illness information
Is this statement true or false?
* A comprehensive assessment includes a complete health history, recognized symptoms, risk factors, or emotional difficulties.
- True
- Rationale: A comprehensive assessment includes a complete health history and physical examination; considers the psychological, emotional, social, spiritual, ethnic, and cultural dimensions of health; attends to the meaning of the client’s health–illness experience; and evaluates how all of this affects the individual’s daily living.
Comprehensive assessment
- Includes a complete health history, physical, and diagnostic testing
- Screening: recognize symptoms, risk factors, or emotional difficulties
- Develops a holistic understanding of the individual’s problems
Focused assessment
- A collection of specific information about a particular need
- Briefer, narrower in scope, and more present oriented
- Two key factors: the immediate needs of the client and the practice setting
Components of a Psychiatric Interview
- Chief Complaint
- History of Present Illness
- Psychiatric Review of Symptoms
- Psychiatric History
- Suicide and Homicide Risk Assessment
- Medical History
- Family History
- Social history
- Substance use
- Mental Status Examination
Mental health Assessment: Biologic Domain
Health history
o Health history and significance to psychiatric and mental health problems
Physical examination
o Process by which a clinician collects objective information about the client’s health
o Includes height and weight, vital signs, examination of all body systems, and diagnostic testing appropriate to the individual’s age, level of risk, and sex
o Selected hematologic measures and their relevance to psychiatric disorders
Mental health Assessment: Psychological Domain
Includes manifestations of PMH problems/disorders; mental status; stress and coping; and risk assessment.
o An important part of assessing the psychological domain is to explore the individual’s experience of illness.
The mental status examination is a systematic assessment of an individual’s appearance, affect (emotion), behaviour, and cognitive processes.
o Reflects “a snapshot” of the examiner’s observations and impressions at the time of the interview
o Evaluates developmental, neurologic, and psychiatric disorders.
Mental Status Examination
- The Mental status examination (MSE) is a set of standardized observations and questions designed to evaluate sensorium, perception, thinking, feeling and behavior
- The MSE records observed behavior, cognitive abilities and inner experiences expressed during a psychiatric interview
- The MSE yields information that is critical for making a diagnostic assessment and initiating or modifying a course of treatment
Mental Status Examination (MSE)
- General observations (examiner’s observations and impressions of individual at time of interview)
o Physical appearance, psychomotor behaviour/activity, attitude toward interviewer - Mood and affect
o Euthymic (normal), euphoric (really happy), dysphoric (depressed, restless) - Speech
o Provides clues on thoughts, emotions, and cognitive processes - Perception
o Hallucinations – can be through all 5 senses
o Illusions – misperception of real sensory stimuli (e.g., thinking wind is a voice) - Thought
o See if they have disturbed thoughts or delusions - Sensorium (assesses brain function and cognitive abilities)
o Level of consciousness, orientation, memory, attention and concentration - Insight and judgment
o Insight: Person’s understanding of circumstances
o Judgement: ability to reach a logical decision about a situation and to choose reasonable course of action.
o Stress and coping pattern
What are the components of the mental status examination (mnemonic)?
A.B.C. S.T.A.M.P. L.I.C.K.E.R.
* Appearance
* Behavior
* Cooperation with Interview
* Speech
* Thought process and thought content
* Affect
* Mood
* Perception
* Level of Consciousness
* Insight
* Cognition
* Knowledge
* Endings
* Reliability
Assessing Risk and Protective Factors:
Risk factors (threats to safety or well-being)
o Protective factors – conditions that reduces risk
o Promotive factors – conditions that enhance well-being
Suicide Assessment
* Involves garnering specific details regarding:
o Suicidal ideation – thoughts of self-harm or self-killing
o Threats of suicide
o Suicide attempt
o Self-harm
