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The American Psychiatric Nurses Association (APNA), the International Society of Psychiatric- Mental Health Nurses (ISPN), and the American Nurses Association (ANA) are national professional associations. This joint publication, Psychiatric Mental Health Nursing: Scope and Standards of Practice, 2nd Edition, reflects the thinking of the practice specialty of psychiatric-mental health nursing on various issues and should be reviewed in conjunction with state board of nursing policies and practices. State law, rules, and regulations govern the practice of nursing, while Psychiatric Mental Health Nursing: Scope and Standards of Practice, 2nd Edition guides psychiatric-mental health nurses in the application of their professional skills and responsibilities.

The American Psychiatric Nurses Association (APNA) is your resource for psychiatric-mental health nursing. A professional organization with more than 9,000 members, we are committed to the practice of psychiatric mental health (PMH) nursing, health and wellness promotion through identification of mental health issues, prevention of mental health problems and the care and treatment of persons with psychiatric disorders. To facilitate professional advancement, APNA provides quality psychiatric-mental health nursing continuing education; a wealth of resources for established, emerging, and prospective PMH nurses; and a community of dynamic collaboration. APNA champions psychiatric-mental health nursing and advocates for mental health care through the development of positions on key issues, the widespread dissemination of current knowledge and developments in PMH nursing, and collaboration with consumer groups, to promote evidence-based advances in recovery-focused assessment, diagnosis, treatment, and evaluation of persons with mental illness and substance use disorders. For more information: www.apna.org.

The International Society of Psychiatric-Mental Health Nurses exists to unite and strengthen the presence and the voice of specialty psychiatric-mental health nursing while influencing healthcare policy to promote equitable, evidence-based and effective treatment and care for individuals, families, and communities. http://www.ispn-psych.org

The American Nurses Association is the only full-service professional organization representing the interests of the nation’s 3.1 million registered nurses through its constituent/state nurses associations and its organizational affiliates. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on healthcare issues affecting nurses and the public.

Copyright © 2014 American Nurses Association, American Psychiatric Nurses Association and International Society of Psychiatric-Mental Health Nurses. All rights reserved. Reproduction or transmission in any form is not permitted without written permission of the American Nurses Association (ANA). This publication may not be translated without written permission of ANA. For inquiries or to report unauthorized use, email [email protected]

ISBN-13: 978-1-55810-557-7 SAN: 851-3481 06/2014

First printing: June 2014

Contents

Contributors

Preface

Scope of Practice of Psychiatric-Mental Health Nursing

Origins of the Psychiatric-Mental Health Advanced Practice Nursing Role

Current Issues and Trends

Prevalence of Mental Disorders across the Lifespan: Critical Facts

Substance Abuse Disorders: Prevalence and Comorbidities

Children and Older Adults

Disparities in Mental Health Treatment

Opportunities to Partner with Consumers for Recovery and Wellness

Structure of a Person-Centered, Recovery-Oriented Public Health Care Model: Unifying Efforts

Prevention: The Promise of Building Resiliency

Screening and Early Intervention

Integrated Care

Technology of a Public Health Model of Mental Health Care

Emerging Models of Acute Care

Workforce Requirements for a Public Health Model of Mental Health Care

Psychiatric-Mental Health Nursing Leadership in Transforming the Mental Health System

Definition of Psychiatric-Mental Health Nursing

Phenomena of Concern for Psychiatric-Mental Health Nurses

Psychiatric-Mental Health Nursing Clinical Practice Settings

Crisis Intervention and Psychiatric Emergency Services

Acute Inpatient Care

Intermediate and Long-Term Care

Partial Hospitalization and Intensive Outpatient Treatment

Residential Services

Community-Based Care

Assertive Community Treatment (ACT)

Levels of Psychiatric-Mental Health Nursing Practice

Psychiatric-Mental Health Registered Nurse (PMH-RN)

Psychiatric-Mental Health Advanced Practice Registered Nurse (PMH-APRN)

Consensus Model: LACE (Licensure, Accreditation, Certification and Education) and APRN Roles

Primary Care

Psychotherapy

Psychopharmacological Interventions

Case Management

Program, System, and Policy Development and Management

Psychiatric Consultation–Liaison Nursing (PCLN)

Clinical Supervision

Administration, Education, and Research Practice

Self-Employment

Other Specialized Areas of Practice

Integrative Programs

Telehealth

Forensic Mental Health

Disaster Psychiatric-Mental Health Nursing

Ethical Issues in Psychiatric-Mental Health Nursing

Respect for the Individual

Commitment to the Healthcare Consumer

Advocacy for the Healthcare Consumer

Responsibility and Accountability for Practice

Duties to Self and Others

Contributions to Healthcare Environments

Advancement of the Nursing Profession

Collaboration to Meet Health Needs

Promotion of the Nursing Profession

Standards of Psychiatric-Mental Health Nursing Practice

Standards of Practice for Psychiatric-Mental Health Nursing

Standard 1. Assessment

Standard 2. Diagnosis

Standard 3. Outcomes Identification

Standard 4. Planning

Standard 5. Implementation

Standard 5A. Coordination of Care

Standard 5B. Health Teaching and Health Promotion

Standard 5C. Consultation

Standard 5D. Prescriptive Authority and Treatment

Standard 5E. Pharmacological, Biological, and Integrative Therapies

Standard 5F. Milieu Therapy

Standard 5G. Therapeutic Relationship and Counseling

Standard 5H. Psychotherapy

Standard 6. Evaluation

Standards of Professional Performance for Psychiatric-Mental Health Nursing

Standard 7. Ethics

Standard 8. Education

Standard 9 Evidence-Based Practice and Research

Standard 10. Quality of Practice

Standard 11. Communication

Standard 12. Leadership

Standard 13. Collaboration

Standard 14. Professional Practice Evaluation

Standard 15. Resource Utilization

Standard 16. Environmental Health

Glossary

References

Abbreviations

Appendix A. Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2007)

Index

Contributors

APNA and ISPN Joint Task Force Members

Kris A. McLoughlin, DNP, APRN, PMHCNS-BC, CADC-II, FAAN—APNA Co-Chair

Catherine F. Kane, PhD, RN, FAAN—ISPN Co-Chair

Kathleen Delaney, PhD, PMH-NP, FAAN

Sara Horton-Deutsch, PhD, APRN, PMHCNS, RN, ANEF

Amanda Du Wick, BSN, RN-BC

Kay Foland, PhD, RN, PMHNP-BC, PMHCNS-BC, CNP

Susan L.W. Krupnick MSN, PMHCNS-BC, ANP-BC, C-PREP

Sue M. Odegarden, MA, MS, BSN

Bethany J. Phoenix, PhD, RN, CNS

Peggy Plunkett, MSN, APRN, PMHCNS-BC

Diane Snow, PhD, RN, PMHNP-BC, CARN, FAANP

Victoria Soltis-Jarrett, PhD, PMHCNS/NP-BC

Christine Tebaldi, MSN, APRN, PMHNP-BC

Edilma L. Yearwood, PhD, PMHCNS-BC, FAAN

ANA Staff

Carol J. Bickford, PhD, RN-BC, CPHIMS—Content editor

Maureen E. Cones, Esq.—Legal counsel

Yvonne Daley Humes, MSA—Project coordinator

Eric Wurzbacher, BA—Project editor

About the American Psychiatric Nurses Association

The American Psychiatric Nurses Association (APNA) is your resource for psychiatric-mental health nursing. A professional organization with more than 9,000 members, we are committed to the practice of psychiatric-mental health (PMH) nursing, health and wellness promotion through identification of mental health issues, prevention of mental health problems and the care and treatment of persons with psychiatric disorders. To facilitate professional advancement, APNA provides quality psychiatric-mental health nursing continuing education; a wealth of resources for established, emerging, and prospective PMH nurses; and a community of dynamic collaboration. APNA champions psychiatric-mental health nursing and advocates for mental health care through the development of positions on key issues, the widespread dissemination of current knowledge and developments in PMH nursing, and collaboration with consumer groups, to promote evidence-based advances in recovery-focused assessment, diagnosis, treatment, and evaluation of persons with mental illness and substance use disorders. For more information: www.apna.org.

About the International Society of Psychiatric-Mental Health Nurses

The International Society of Psychiatric-Mental Health Nurses (ISPN) exists to unite and strengthen the presence and the voice of specialty psychiatric-mental health nursing while influencing healthcare policy to promote equitable, evidence-based and effective treatment and care for individuals, families, and communities. http://www.ispn-psych.org

About the American Nurses Association

The American Nurses Association (ANA) is the only full-service professional organization representing the interests of the nation’s 3.1 million registered nurses through its constituent/state nurses associations and its organizational affiliates. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the public.

About Nursesbooks.org, The Publishing Program of ANA

Nursesbooks.org publishes books on ANA core issues and programs, including ethics, leadership, quality, specialty practice, advanced practice, and the profession’s enduring legacy. Best known for the foundational documents of the profession on nursing ethics, scope and standards of practice, and social policy, Nursesbooks.org is the publisher for the professional, career-oriented nurse, reaching and serving nurse educators, administrators, managers, and researchers as well as staff nurses in the course of their professional development.

Preface

In 2011, the American Psychiatric Nurses Association (APNA) and the International Society of Psychiatric-Mental Health Nurses (ISPN) appointed a joint task force to begin the review and revision of Psychiatric-Mental Health Nursing: Scope and Standards of Practice, published in 2007 by the American Nurses Association (ANA07). The taskforce members were comprised of psychiatric-mental health nursing clinical administrators, staff nurses, nursing faculty, and psychiatric advanced practice registered nurses working in psychiatric facilities and the community. This taskforce convened in July 2011 to conduct an analysis of the existing document and begin crafting sections incorporating the results of the analysis.

In accordance with ANA recommendations, this document reflects the template language of the most recent publication of ANA nursing standards, Nursing: Scope and Standards of Practice, Second Edition (ANA10). In addition, the introduction has been revised to highlight the leadership role of psychiatric-mental health nurses in the transformation of the mental health system as outlined in Achieving the Promise, the President’s New Freedom Commission Report on Mental Health (United States Department of Health and Human Services03) and the Institute of Medicine’s Report (IOM) The Future of Nursing (2010). The prevalence of mental health issues and psychiatric disorders across the age span, and the disparities in access to care and treatment among diverse groups attest to the critical role that psychiatric-mental health (PMH) nursing must continue to play in meeting the goals for a healthy society. Safety issues for persons with psychiatric disorders and the nurses involved in the recovery processes of persons with mental disorders are major priorities for PMH nursing in an environment of fiscal constraints and disparities in reimbursement for mental health services.

Development of this edition of Psychiatric-Mental Health Nursing: Scope and Standards of Practice included a two-stage field review process: 1) review and feedback from the boards of the American Psychiatric Nurses Association and the International Society of Psychiatric- Mental Health Nursing and 2) posting of the draft for public comment at www.ISPN-psych.org with links from the ANA website, www.nursingworld.org, and the APNA website, www.apna.org. Notice of the public comment period was distributed to nursing specialty organizations, state boards of nursing, nursing schools, faculty groups, and state nurses associations. All groups were encouraged to disseminate notice of the postings to all of their members and other stakeholders. The feedback was carefully reviewed and integrated when appropriate.

Scope of Practice of Psychiatric-Mental Health Nursing

Psychiatric-mental health nursing is the nursing practice specialty committed to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and comorbid conditions across the lifespan. Psychiatric-mental health nursing intervention is an art and a science, employing a purposeful use of self and a wide range of nursing, psychosocial, and neurobiological evidence to produce effective outcomes.

Introduction

By developing and articulating the scope and standards of professional nursing practice, the nursing profession both defines its boundaries and informs society about the parameters of nursing practice. The scope and standards also guide the development of state level nurse practice acts and the rules and regulations governing nursing practice.

Because each state develops its own regulatory language about nursing, the designated limits, functions, and titles for nurses, particularly at the advanced practice level, may differ significantly from state to state. Nurses must ensure that their practice remains within the boundaries defined by their state practice acts. Individual nurses are accountable for ensuring that they practice within the limits of their own competence, professional code of ethics, and professional practice standards.

Levels of nursing practice are differentiated according to the nurse’s educational preparation. The nurse’s role, position, job description, and work setting further define practice. The nurse’s role may be focused on clinical practice, administration, education, or research.

This document addresses the role, scope of practice, and standards of practice specific to psychiatric-mental health nursing. The scope statement defines psychiatric-mental health nursing and describes its evolution in nursing, the levels of practice based on educational preparation, current clinical practice activities and sites, and current trends and issues relevant to the practice of psychiatric-mental health nursing. The standards of psychiatric- mental health nursing practice are authoritative statements that describe the responsibilities for which its practitioners are accountable.

History and Evolution of Psychiatric-Mental Health Nursing

Psychiatric-mental health nursing began with late 19th century reform movements to change the focus of mental asylums from restrictive and custodial care to medical and social treatment for the mentally ill. The “first formally organized training school within a hospital for insane in the world” was established by Dr. Edward Cowles at McLean Asylum in Massachusetts in 1882 (Church85). The use of trained nurses, rather than “keepers,” was central to Cowles’ effort to replace the public perception of “insanity” as deviance or infirmity with a belief that mental disorders could be ameliorated or cured with proper treatment. The McLean nurse training school was the first in the United States to allow men the opportunity to become trained nurses (Boyd98). Eventually, asylum nursing programs established affiliations with general hospitals so that general nursing training could be provided to their students.

Early on, training for psychiatric nurses was provided by physicians. The first nurse-organized training course for psychiatric nursing within a general nursing education program was established by Effie Jane Taylor at Johns Hopkins Hospital in 1913 (Boyd98). This course served as a prototype for other nursing education programs. Taylor’s colleague Harriet Bailey published the first psychiatric nursing textbook, Nursing Mental Disease, in 1920 (Boling03). Under nursing leadership, psychiatric-mental health nursing developed a biopsychosocial approach with specific nursing methods for individuals with mental disorders. The PMH nurse also began to identify the didactic and clinical components of training needed to care for persons with mental disorders. In the post-WWI era, “nursing in nervous and mental diseases” was added to curriculum guides developed by the National League for Nursing Education and was eventually required in all educational programs for registered nurses (Church85).

The next wave of mental health reform and expansion in psychiatric nursing began during World War II. The public health significance of mental disorders became widely apparent when a significant proportion of potential military recruits were deemed unfit for service as a result of psychiatric disability. In addition, public attention and sympathy for the large number

of veterans with combat-related neuropsychiatric casualties led to increased support for improving mental health services. As a psychiatric nurse consultant to the American Psychiatric Association, Laura Fitzsimmons evaluated educational programs for psychiatric nurses and recommended standards of training. These recommendations were supported by professional organizations and backed with federal funding to strengthen educational preparation and standards of care for psychiatric nursing (Silverstein08).

The national focus on mental health, combined with admiration for the heroism shown by nurses during the war, led to the inclusion of psychiatric nursing as one of the core mental health disciplines named in the National Mental Health Act (NMHA) of 1946. This act greatly increased funding for psychiatric nursing education and training (Silverstein08) and led to a growth in university-level nursing education. In 1954, Hildegard Peplau established the first graduate psychiatric nursing program at Rutgers University.

The post-war era was marked by growing professionalization in psychiatric-mental health nursing (PMH). Funding provided by the NMHA led to a rapid expansion of graduate programs and the start of psychiatric-mental health nursing research. In 1963, the first journals focused on psychiatric-mental health nursing were published. In 1973, the ANA first published the Standards of Psychiatric-Mental Health Nursing Practice and began certifying generalists in psychiatric-mental health nursing (Boling03). Peplau’s Interpersonal Relations in Nursing (1992), which emphasized the importance of the therapeutic relationship in helping individuals to make positive behavior changes, articulated the predominant psychiatric-mental health nursing approach of the period.

The process of deinstitutionalization began in the late 1950s when the majority of care for persons with psychiatric illness began to shift away from hospitals and toward community settings. Contributing factors included the establishment of Medicare and Medicaid, changing rules governing involuntary confinement, and the passage of legislation supporting construction of community mental health centers (Boling03). Although psychiatric-mental health nurses prepared at the undergraduate level continued to work primarily in hospital- based and psychiatric acute care settings, many also began to practice in community-based programs such as day treatment and assertive community treatment.

Mental health care in the United States began another transformation in the 1990s, the “Decade of the Brain.” The dramatic increase in the number of psychiatric medications on the market, combined with economic pressures to reduce hospital stays, resulted in briefer psychiatric hospitalizations characterized by use of medication to stabilize acute symptoms. Shorter hospital stays and higher patient acuity began to shift psychiatric nursing practice away from the emphasis on relationship-based care advocated by Peplau and toward interventions focused on stabilization and immediate safety. Psychiatric-mental health nursing education began to include more content on psychopharmacology and the pathophysiology of psychiatric disorders.

More recent trends in psychiatric-mental health nursing include an emphasis on integrated care and treatment of those persons with co-occurring psychiatric and substance use disorders, as well as integrated care and treatment of those with co-occurring medical and psychiatric disorders. Integrated care emphasizes that both types of disorders are primary and must be treated as such.

Since the Substance Abuse and Mental Health Services Administration (SAMHSA) has declared that recovery is the single most important goal in the transformation of mental health care in America (SAMHSA06), psychiatric-mental health nursing is moving to integrate person-centered, recovery-oriented practice across the continuum of care. This continuum includes settings where psychiatric-mental health nurses have historically worked, such as hospitals, as well as emergency rooms, jails and prisons, and homeless outreach services. Psychiatric-mental health nursing is also tasked with developing and applying innovative approaches in caring for the large population of military personnel, veterans, and their families experiencing war-related mental health conditions as a result of military conflicts.

Major developments in the nursing profession have a corresponding effect within psychiatric- mental health nursing. The Institute of Medicine’s (2010) report, The Future of Nursing: Leading Change to Advance Health has strengthened the role of psychiatric-mental health nurses as mental health policy and program development leaders in both national and international arenas. Nursing’s emphasis on the use of research findings to develop and implement evidence-based practice is driving improvements in psychiatric-mental health

nursing practice.

Origins of the Psychiatric-Mental Health Advanced Practice Nursing Role

Specialty nursing at the graduate level began to evolve in the late 1950s in response to the passage of the National Mental Health Act of 1946 and the creation of the National Institute of Mental Health in 1949. The National Mental Health Act of 1946 identified psychiatric nursing as one of four core disciplines for the provision of psychiatric care and treatment, along with psychiatry, psychology, and social work. Nurses played an active role in meeting the growing demand for psychiatric services that resulted from increasing awareness of post- war mental health issues (Bigbee & Amidi-Nouri00). The prevalence of “battle fatigue” led to recognizing the need for more mental health professionals.

The first degree in psychiatric-mental health nursing, a master’s degree, was conferred at Rutgers University in 1954 under the leadership of Hildegard Peplau. In contrast to existing graduate nursing programs that focused on developing educators and consultants, graduate education in psychiatric-mental health nursing was designed to prepare nurse therapists to assess and diagnose mental health problems and psychiatric disorders and provide individual, group, and family therapy. Psychiatric nurses pioneered the development of the advanced practice nursing role and led efforts to establish national certification through the American Nurses Association.

The Community Mental Health Centers Act of 1963 facilitated the expansion of psychiatric- mental health clinical nurse specialist (PMHCNS) practice into community and ambulatory care sites. PMHCNSs with master’s and doctoral degrees fulfilled a crucial role in helping deinstitutionalized mentally ill persons adapt to community life. Traineeships to fund graduate education provided through the National Institute of Mental Health played a significant role in expanding the PMHCNS workforce. By the late 1960s, PMHCNSs provided individual, group, and family psychotherapy in a broad range of settings and obtained third-party reimbursement. PMHCNSs also functioned as educators, researchers, and managers, and worked in consultation-liaison positions or in the area of addictions. These roles continue today.

Another significant shift occurred as research renewed the emphasis on the neurobiologic basis of mental disorders, including substance use disorders. As more efficacious psychotropic medications with fewer side effects were developed, psychopharmacology assumed a more central role in psychiatric treatment. The role of the PMHCNS evolved to encompass the expanding biopsychosocial perspective, and the competencies required for practice were kept congruent with emerging science. Many psychiatric-mental health graduate nursing programs added neurobiology, advanced health assessment, pharmacology, pathophysiology, and the diagnosis and medical management of psychiatric illness to their curricula. Similarly, preparation for prescriptive privileges became an integral part of advanced practice psychiatric-mental health nursing graduate programs (Kaas & Markley98).

Other trends in mental health and the larger healthcare system also sparked significant changes in advanced practice psychiatric nursing. These trends included:

■ A shift in National Institute of Mental Health (NIMH) funds from education to research, leading to a dramatic decline in enrollment in psychiatric nursing graduate programs (Taylor99);

■ An increased awareness of physical health problems in mentally ill persons living in community settings (Chafetz et al.05);

■ A shift to primary care as a key point of entry for comprehensive health care, including psychiatric care; and

■ The growth and public recognition of the nurse practitioner role in primary care settings.

In response to these challenges, psychiatric nursing graduate programs modified their curricula to include greater emphasis on comprehensive health assessment, referral, and management of common physical health problems, and a continued focus on educational preparation to meet the state criteria and professional competencies for prescriptive authority. The tremendous expansion in the use of “nurse practitioners” in primary care settings had made nurse practitioner (NP) synonymous with “advanced practice registered

nurse” in some state nurse practice acts and for many in the general public. In response to conditions including public recognition of the role, market forces, and state regulations, psychiatric-mental health nursing began utilizing the Nurse Practitioner title and modifying graduate psychiatric nursing programs to conform to requirements for NP credentialing (Wheeler & Haber04; Delaney et al.99). The Psychiatric-Mental Health Nurse Practitioner role was clearly delineated by the publication of the Psychiatric-Mental Health Nurse Practitioner Competencies (National Panel03), the product of a panel with representation from a broad base of nursing organizations sponsored by the National Organization of Nurse Practitioner Faculty (NONPF).

Whether practicing under the title of clinical nurse specialist (CNS) or NP, Psychiatric-Mental Health Advanced Practice Registered Nurses share the same core competencies of clinical and professional practice. Although psychiatric-mental health nursing is moving toward a single national certification for new graduates of advanced practice programs, titled Psychiatric-Mental Health Nurse Practitioner, persons already credentialed as Psychiatric- Mental Health Clinical Nurse Specialists will continue to practice under this title (NCSBN Joint Dialogue Group Report08).

Current Issues and Trends

Since the publication of the landmark report Achieving the Promise: Transforming Mental Health Care in America (DHHS03), mental health professionals have been sensitized to the need for a recovery-oriented mental health system. Further, in 2010, SAMHSA approved awards to five national behavioral healthcare provider associations, including the American Psychiatric Nurses Association, to promote awareness, acceptance, and adoption of recovery- based practices in the delivery of mental health services. This theme of integrating recovery in practice has been echoed in Leading Change, SAMHSA’s (2011) most recent statement on federal priorities in mental health. Here recovery is endorsed as the essential platform for treatment, along with seven other foci: prevention, health reform, health information technology (IT), data/quality and outcomes, trauma and justice, military families, and public awareness and support. These themes are echoed in important reports from the Centers for Disease Control and Prevention (CDC) and the Institute of Medicine, and have been endorsed by consumer groups.

The current mental health treatment landscape has also been shaped by multiple legislative and economic developments. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that has and is expected to continue to favorably affect the quality of care for individuals with mental and substance use disorders. The MHPAEA prevents group health plans and health insurance issuers that provide mental health and substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations for MH/SUD benefits than on medical/surgical coverage. Thus, this vulnerable and highly stigmatized population will have equivalent MH/SUD benefits to those that are provided for general medical treatment.

Another important development is the Patient Protection and Affordable Care Act (PPACA) that brought, among other transformational changes, the promise of expanded healthcare coverage and an assessment of the current system’s capacity to address anticipated demand. In the midst of launching this landmark policy, the economic downturn reverberated through federal and state budgets, which created immediate impacts on mental health services and became a harbinger of a decade of fiscally conservative policies (National Alliance on Mental Illness11). Another major focusing event was the publication of data on the medical comorbidities and decreased life expectancy of individuals with serious mental illness (McGuire et al.02). These data hastened the movement toward integrated behavioral/primary care with the Centers for Medicare and Medicaid Services (CMS) monies rapidly shifting to fund innovations in integrated care delivery.

The mental health initiatives of the PPACA and SAMHSA are also affected by the triple aim of the broader federal policy agenda: improving the experience of care, improving the health of populations, and reducing per capita costs of health care (Berwick, Nolan, & Whittington08). This shift is accompanied by significant payment reform (most prominently the return of case based and capitation models) and a call for partnership with healthcare consumers (Onie, Farmer, & Behforouz12). This federal focus is finding its way into mental health care, particularly via initiatives to move Medicare and Medicaid into a capitated system (Manderscheid12). This shifting reimbursement structure reflects the realization that

engineering a significant impact on the mental health of individuals demands building healthy communities that increase support, reduce disparities, and promote the resiliency of members. This 21st century mental healthcare system must be equally focused on prevention, quality, an integrated approach to health, and a paradigm shift that puts mental health care into the hands of the consumer.

Prevalence of Mental Disorders across the Lifespan: Critical Facts

Despite the promise of recovery, the prevalence of mental disorders continues to impose a significant burden on individuals, families, and society. According to 2008 SAMHSA data, during the preceding year, an estimated 9.8 million adults aged 18 and older in the United States had a serious mental disorder and 2 million youth aged 12 to 17 had a major depressive episode. More recent incidence data (CDC11) indicate that 6.8% of U.S. adults had a diagnosable episode of depression during the 2 weeks before the survey was administered. In a multi-state survey spanning 2-year collection points, the reported rates of lifetime depression were similar in 2006 (15.7%) and 2008 (16.1%). The prevalence of lifetime diagnosis of anxiety disorders was 11.3% in 2006 and 12.3% in 2008. Finally in 2007, the National Health Interview Survey data on lifetime diagnosis of bipolar disorder and schizophrenia indicated that 1.7% of participants had received a diagnosis of bipolar disorder, and 0.6% had received a diagnosis of schizophrenia (CDC11).

Although the prevalence of mental disorders remains high, treatment rates are distressingly low. In 2010, fewer than 40% of the 45.9 million adults with mental disorders had received any mental health services. The figure only improved slightly for those individuals with serious mental illness (SMI). Approximately 60% of the 11.4 million adults with SMI in the prior year had received treatment (SAMHSA12).

In 2006, increased mortality was found to be coupled with high prevalence of chronic medical conditions in individuals with mental health issues (Parks, Svendsen, Singer, & Forti06). Further study indicated that, on average, people with SMI die 25 years earlier than those without these illnesses, and little of that increased mortality is attributable to direct effects of the SMI (Prince et al.07). These findings lent increased urgency to the call for integration of medical and mental health services (Manderscheid10). In addition to premature mortality, Scott et al. (2009) found that comorbidity of chronic physical and mental disorders creates a synergistic impact on disability, thus supporting the need to give both mental and physical conditions equal priority in order to adequately manage comorbidity and reduce disability. These comorbidities significantly increase healthcare costs (Melek & Norris08), with only a small fraction of those costs (16%) attributable to mental health services. Estimates show that 2.8 million citizens in the United States are dealing with problems related to substance use. This figure is expected to double in 2020, particularly in adults over 50, casting specific concerns for the older adult population (Han, Gfroerer, Colliver, & Penne09).

Substance Abuse Disorders: Prevalence and Comorbidities

High rates of substance use disorders (SUD) and co-occurring serious mental disorders are also of great concern. The National Drug Use and Health survey estimates that 25.7% of adults with SMI had co-occurring dependence or abuse of either illicit drugs or alcohol (SAMHSH09). This figure puts co-occurring substance use disorders among individuals with SMI at a rate nearly four times higher than SUD in the general population (SAMHSH12). These individuals, particularly persons dealing with co-occurring SUD and major depression or post-traumatic stress disorder (PTSD), demonstrate poorer life outcomes (Najt, Fusar-Poli, & Brambilla11) such as increased disability and higher suicide rates.

Children and Older Adults

Prevalence of psychiatric disorders in children is not as well documented as it is in the adult population. It is estimated that approximately 13% of children ages 8 to 15 had a diagnosable mental disorder within the previous year (Merikangas et al.10). The 12-month prevalence estimates for specific disorders of children range from a high of 8.6% for attention deficit/hyperactivity disorder to a low of 0.1% for eating disorders (Merikangas et al.10). Similarly, the prevalence estimate of any Diagnostic and Statistical Manual, 4th Edition (DSM-IV) disorder among adolescents is 40.3% at 12 months (79.5% of lifetime cases); the most common disorder among adolescents is anxiety, followed by behavior, mood, and substance use disorders (Kessler et al.12).

Approximately 10.8% of the older adult population had some form of mental distress in 2009, and half of nursing home residents carried a psychiatric diagnosis (SAMHSA09). This prevalence does not include cognitive impairments and dementias like Alzheimer’s disease, the most common of these impairments (New Freedom Commission on Mental Health03). Considering that in 2030% of United States residents will be 65 years or older (Vincent & Velkoff10), the need for mental health services for this population will continue to increase (SAMHSA 200912).

Disparities in Mental Health Treatment

Data from the U.S. Census Bureau (2004) demonstrate significant changes in the racial and ethnic composition of the U.S. population. Most significant is the steady increase in the Hispanic or Latino population, which rose to 12.6% in 2000 and will likely rise to 30.2% in 2050 (Shrestha & Heisler11). Although rates of mental disorders in minority populations are estimated to be similar to those in the white population, minorities are less likely to receive mental health services for many reasons, including financial, affective, cognitive, and access barriers (Leong & Kalibatseva12). Efforts to improve quality and access to mental health services for minority populations will need to include greater emphasis on expanding outreach to ethnic communities, developing cultural awareness and sensitivity among individual mental healthcare providers, and increasing cultural sensitivity in healthcare organizations.

Barriers to social inclusion, as well as barriers to accessible, effective, and coordinated treatment, contribute to health disparities within the entire population (Institute of Medicine05). Financial barriers include lack of parity in insurance coverage for psychiatric- mental health care and treatment, resulting in restrictions on the number and type of outpatient visits, limits on the number of covered inpatient days, and high co-pays for services. The payment changes anticipated by the PPACA, particularly the expansion of Medicaid to 133% of persons above the poverty level, are likely to bring more individuals into the mental health system. However, the probability of receiving actual treatment may be affected by barriers such as scarcity and maldistribution of mental health providers. Geographical barriers include lack of affordable, accessible public transportation in urban areas and lack of accessible clinical services in rural areas. Cultural issues, including lack of knowledge, fear of treatment, and stigma associated with mental disorder, also constitute barriers to seeking help for mental health problems. Though growing evidence shows the effectiveness of treatment for behavioral problems and psychiatric disorders, these disparities necessitate further efforts to improve access to mental health services.

Opportunities to Partner with Consumers for Recovery and Wellness

The growing demand for coordinated, cost-effective psychiatric-mental health nursing presents the opportunity to be creative in developing psychiatric-mental health registered nurse (PMH-RN) roles in care coordination, enhancing psychiatric-mental health advanced practice registered nurse (PMH-APRN) roles in integrated care, and developing service delivery models that align with what consumers want. The reimbursement shift away from fee for service and toward caring for populations creates incentives to develop non-traditional services that may have greater effectiveness in supporting the mental health of individuals and families and the construction of healthy communities.

The focus on recovery supports PMH traditions of relationship-based care where the focus is on the care and treatment of the person with the disorder, not the disorder itself. By using therapeutic interpersonal skills, PMH-RNs are able to assist persons with mental disorders in achieving their own individual recovery and wellness goals. Research specific to recovery- oriented PMH nursing practices is beginning to emerge. However, more of this research needs to be conducted in varied care and treatment settings and specific outcomes must be connected to recovery-oriented nursing interventions (McLoughlin & Fitzpatrick08).

At the systems level, current developments offer opportunities for psychiatric-mental health nurses to connect to the broader nursing and healthcare community to achieve a public health model of mental health care. In such a model, individuals would receive mental health and substance use interventions at multiple points of connection with the healthcare delivery system and the system would aim to match the intensity of service with the intensity of need. The vision must aspire to create a person-centered mental health system where prevention efforts are balanced with attention to individuals with serious mental disorders. Such a vision will require unifying nurses from a wide range of specialties to create the structure for

integrated care; it will also involve constructing consumer-centered outcome evaluation strategies so that all efforts are aligned with the individual goals of the person seeking care or treatment.

Structure of a Person-Centered, Recovery-Oriented Public Health Care Model: Unifying Efforts

Prevention: The Promise of Building Resiliency

In 2009, the Institute of Medicine released its report Preventing Mental, Emotional and Behavioral Disorders among Young People: Progress and Possibilities (O’Connell, Boat, & Warner09). The report contained a landmark synthesis of what was known about the onset of mental disorder, risk factors, environmental influences, and how prevention was possible through strengthening protective factors and reducing risk factors. The report also provided a systematic review of the science of the prevention of mental disorders, articulating the promise of developmental neuroscience not only to map the possible origins and courses of disorders, but also to demonstrate how prevention and early intervention might build resiliency. Clearly, the future of mental health must be grounded in prevention, on platforms of effective programs such as newborn home visiting for at-risk mothers, early childhood interventions, increasing children’s social and emotional skills, and creating social supports within communities (Beardslee, Chien, & Bell11).

This paradigm shift has profound implications for PMH nurses, particularly in regard to their work with children and adolescents and their families. Creating a prevention-oriented mental health system will demand that PMH nurses, pediatric nurses, and family nurses understand the science base that supports prevention and the scientific principles aimed at helping children achieve regulation and build resiliency (Greenberg06). Further, it is essential that nurses communicate how a shared science base will help nurses refine interventions that are applicable in both primary care and mental health care (Yearwood, Pearson, & Newland12).

Understanding the interplay of environment and risk has implications for SMI prevention throughout the lifespan. Such an approach recognizes the multiple determinants of mental health, risk, and protective factors (WHO04). In a report about global initiatives on prevention, the World Health Organization (WHO) carefully traced the relationship of SMI to social problems, particularly poverty, as well as the relationship of SMI to nutritional, housing, and occupational issues. Prevention, therefore, relies on impacting social determinants of health and reducing the impact of factors that increase risk, such as poverty and abuse/trauma (Onie, Farmer, & Behforouz12). An increasingly important emphasis is placed on strengthening the health of communities, which empowers and supports individuals, as well as builds protective connectivity.

Screening and Early Intervention

Evidence that roughly half of all lifetime mental health disorders start in the mid-teens (Kessler et al.07) increases the need for screening and early intervention in children and adolescents. The synergy of prevention and developmental neuroscience is progressing, particularly at the juncture where early intervention targets psychological processes relevant to the origins of particular mental disorders (March09). Evidence-based programs are increasingly emerging to address early signs of anxiety, depression, and conduct issues in children and teens (Delaney & Staten10). The profound impact of early adverse childhood events (ACE) such as family dysfunction and abuse on an individual’s mental and physical health throughout the lifespan is well documented (Felitti et al.98) and informs innovative programs for addressing early trauma and its impact (Brown & Barila12).

Screening and early intervention is critical throughout the lifespan, requiring shifting attention away from pathology and dysfunction and toward optimal functioning. Recent recommendations include depression screening in primary care when practices have the capacity for depression care support (USPSTF12). There is increasing interest in prevention of depression relapse and the possible mechanisms that may limit its all too frequent occurrence (Farb, Anderson, Block, & Siegel12). Embedding screening and early intervention into practice will require shifting attention away from pathology and dysfunction and toward optimal functioning. Psychiatric nursing will be pivotal in weaving together the emerging neuroscience that supports building resiliency and the evidence-based practices that support early intervention. Their efforts must extend to building communication networks with nurses in primary care specialties to create prevention efforts that span disciplinary

silos.

Integrated Care

Several promising initiatives, such as the Penn Resiliency program for teenage depression, demonstrate how to structure early intervention as signs of mental distress are emerging. In this program, using a cognitive behavioral therapy (CBT) approach, preadolescents are taught how to challenge negative thinking; i.e., by evaluating the accuracy of the thought, assessing the evidence to support it, and then devising an alternate response. This program has been implemented in a variety of settings, including schools. In program outcomes across 13 studies, data demonstrate that intervention prevents symptoms of anxiety and depression (Gillham & Reivich, n.d.). Healthcare systems, such as Intermountain Healthcare, have developed scales for systematically screening healthcare consumers; after the assessment, professionals complete a Mental Health Integration form based on the scale scores. The healthcare consumer is then assigned a level of treatment that matches her or his level of service need (Intermountain Healthcare09). Such secondary prevention efforts of school- based health centers and large primary care organizations such as Intermountain must become the norm if APRNs are to engineer systems where persons are treated holistically, and mental health and medical needs are systematically acknowledged with equal vigor. This effort will demand that nurses see themselves as one workforce while recognizing the unique skills that each specialty contributes to the team.

Problems such as high costs, fragmentation, gaps in coverage and care, and tendency to deliver care in highly specialized subsystems in the United States healthcare system have provided momentum to the movement toward an integrated care system. Integrated care involves caring for the whole person in a single place, an organization of services that is both more effective and less costly (Manderscheid12). Manderscheid (2012) believes the pace of organizational change to accommodate integrated care is accelerating “like snow in an avalanche.” Initially, models of integrated care called for variations in co-location of services where the emphasis of treatments depended on the needs of the population (National Council for Community Behavioral Healthcare09; Parks et al.05). These diverse and evolving models rely on technology and innovations such as integrated services in healthcare homes (Collins, Hewson, Munger, & Wade10). Psychiatric nurses, who always remain close to the needs of the consumer, must ensure that as systems of integrated care are constructed, there is a parallel effort to ensure that individuals can access them, are not intimidated by them, and know how to make the most of the services offered (Geis & Delaney11). Integration should also be guided by the voice of consumers who outline how to build systems on collaboration, effective communication, use of peer navigators, and the critical support of family and community members (CalMed11).

Technology of a Public Health Model of Mental Health Care

Healthcare technology will be expanded in the coming decade via the increasing use of telehealth and Internet-delivered services, the rising prevalence of Health Information Technology (HIT) to connect service sectors and build care coordination, and the integration of data systems to track outcomes and engineer rapid quality improvement. In their vision for the use of health information technology, SAMHSA (2011) plans innovation support of HIT and the electronic health record (EHR) to reach a 2014 goal of behavioral health care interoperating with primary care. Within this initiative are plans for developing the infrastructure for an interoperable EHR and addressing the accompanying privacy, confidentiality, and data standards. Such information exchange is anticipated to integrate care, contain costs, and increase consumers’ control of their personal health care and health information.

Internet-delivered behavioral health interventions, such as online cognitive-behavioral treatments for depression and anxiety, are rapidly being developed, which continues to clarify their key elements and outcomes (Bastelaar et al.11; Bennett & Glasgow09). Rapid growth in Internet behavioral health treatment is likely to continue, and must address the challenge of creating interventions with fidelity to the framework of the original intervention and the careful measurement of outcomes.

Emerging Models of Acute Care

While there is widespread agreement among mental health providers and consumers that treatment should be provided in the least restrictive environment, there is also recognition

that, when needed, inpatient services must be available for those in crisis (NAMI11). The continual shrinkage of inpatient psychiatric beds in the United States, which some estimates put at a deficit of nearly 100,000, has caused increases in homelessness and the use of emergency rooms, jails, and prisons as de-facto psychiatric inpatient treatment centers (Bloom, Krishnan, & Lockey08; Treatment Advocacy Center, n.d.). In tandem with efforts to preserve needed inpatient beds are evolving models to provide acute care services to individuals in crisis both within emergency departments and on small specialty units (Knox, Stanley, Currier, Brenner, Ghahramanlou-Holloway, & Brown12; Kowal, Swenson, Aubry, Marchand, & MacPhee11).

The integration of Mental Health Recovery components into all service systems, including into all forms of acute treatment, is now considered vital. Persons in crisis need a safe environment and, as their illness stabilizes, a culture that empowers them to re-engage with life in the community (Tierney & Kane11; Barker & Buchanan-Barker10; Sharfstein09). Consumers, the federal government, and regulators believe that to reach these goals psychiatric services must be recovery-oriented and delivered using a person-centered approach.

Since the elements of the recovery framework mirror the Institute of Medicine’s indicators for quality in health services (IOM01), PMH nurses now have a platform for assessing quality in inpatient psychiatric care. This is a welcome expansion of inpatient quality indicators that have centered on limiting restraint and seclusion use in the last decade (Joint Commission10; Stefan06). While restraint reduction is critical, this narrow focus on quality fails to recognize that in addition to a safe environment, individuals with SMI need services that are person- centered and recovery-oriented. As the single largest professional group practicing in inpatient arenas, PMH nurses must provide leadership in constructing recovery-oriented environments and measuring these efforts with tools that capture the social validity of the services provided; e.g., the extent to which the type of help provided in inpatient care is seen as acceptable and having a positive impact in ways that are important to consumers (Ryan et al.08).

Workforce Requirements for a Public Health Model of Mental Health Care

Availability of a mental health workforce with the appropriate skills to implement necessary changes in the healthcare system, as well as appropriate geographic distribution of this workforce, is crucial to improving access and quality. While the overall number of mental health professionals appears adequate, rural areas face shortages of clinicians (SAMHSA12). Independent of healthcare reform and its potential to increase access through expansion of health insurance, an estimated 56 million individuals nationally will face difficulties accessing needed health care because of shortages of providers in their communities (National Association of Community Health Centers [NACHC]12).

Nursing models for rural mental health care specifically address the interplay of poverty, mental disorders, and social issues (Hauenstein97). Such nursing models recognize that resource-poor environments require service models that move clients into self-management and bridge systems so that medical issues are addressed. The need for PMH nurses is great because their command of multiple bodies of knowledge (medical science, neurobiology of psychiatric disorders, treatment methods, and relationship science) positions them as the healthcare professionals best suited to facilitate connections between mental health, primary care, acute care, and case management systems (Hanrahan & Sullivan-Marx05).

Given that the supply of psychiatrists is showing only modest increases (Vernon, Salsberg, Erikson, & Kirch09), there is a great need, especially in rural areas, for additional clinicians who can provide psychotherapy, case management, medication management, and a range of other services. PMH-APRNs are prepared to provide a full scope of behavioral health services, including both substance use and mental health services (Funk et al05).However, restrictive reimbursement policies and regulatory barriers associated with scope of practice that limit healthcare consumer access to APRNs must be addressed to achieve access and quality goals. PMH-APRNs need to continue systematic and enhanced data collection on practice and outcomes to document their contribution to quality health care.

Several curriculum frameworks have been developed to prepare nurses with the appropriate knowledge and skills to meet future healthcare challenges. Essential PMH competencies have been presented for all practicing RNs (Psychiatric-Mental Health Substance Abuse Essential Competencies Taskforce of the American Academy of Nursing Psychiatric-Mental Health

Substance Abuse Expert Panel12). The APNA Recovery to Practice (RTP) curriculum committee is producing a curriculum to integrate recovery into PMH nursing practice, which will be disseminated by SAMHSA as part of the Recovery to Practice initiative. A key aspect of this curriculum development, and of program development in general, is having consumers of these mental health services at the table and contributing to the development of these systems of care (SAMHSA10). Curriculum models should also include the competencies promoted by the Quality and Safety Education for Nurses (QSEN) Institute, which provides “the knowledge, skills and attitudes necessary to continuously improve the quality and safety of the healthcare systems in which they work” (QSEN, n.d.).

A comprehensive blueprint for building the PMH-APRN workforce has been suggested that includes recommendations for how the PMH nursing will increase its numbers and prepare practitioners with the specific competencies needed to build a transformed mental health system (Hanrahan, Delaney, & Stuart12). This workforce plan calls on PMH-APRNs to include the role of individuals in recovery into every aspect of planning and delivery of mental health care. An additional emphasis focuses on expanding the capacity of communities to effectively identify their needs and promote behavioral health and wellness. Indeed, the coming era will demand strong alliances with individuals, families, and communities to build health, recovery, and resilience.

Psychiatric-Mental Health Nursing Leadership in Transforming the Mental Health System

In the course of their practice, it is critical that PMH nurses consider the particular vision of mental health care that informs their practice. Federal agencies, commissions, and advocacy groups have identified a future vision of a mental healthcare system as person-centered, recovery-oriented, and organized to respond to all consumers in need of services. These reports converge on several points, but most crucial is that a transformed mental health system is centered on the person. Integral in this vision are strategies for remedying the inadequacy and fragmentation of services, and for creating a workforce to carry out the transformation. There is particular emphasis on providing services to children, adolescents, older adults, and other underserved populations. In leading the transformation of the mental healthcare delivery system, PMH nurses must understand the key threads in the government/agency/consumer group plan and the factors that can affect enactment.

The transformed mental health system will require nurses who can work between and within systems, connecting services and acting as an important safety net in the event of service gaps. PMH nurses are perfectly positioned to fill this role and make significant contributions to positive clinical recovery outcomes for this vulnerable and often underserved population.

Definition of Psychiatric-Mental Health Nursing

Nursing’s Social Policy Statement (ANA10) defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.”

Psychiatric-mental health nursing is the nursing practice specialty committed to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and comorbid conditions across the lifespan. Psychiatric-mental health nursing intervention is an art and a science, employing a purposeful use of self and a wide range of nursing, psychosocial, and neurobiological evidence to produce effective outcomes.

PMH nurses work with people who are experiencing physical, psychological, mental, and spiritual distress. They provide comprehensive, person-centered behavioral and psychiatric care in a variety of settings across the continuum of care. Essential components of PMH nursing practice include health and wellness promotion through identification of mental health issues, prevention of mental health problems, care of mental health problems, and treatment of persons with psychiatric disorders, including substance use disorders. Due to the complexity of care in this population, the preferred educational preparation is at the baccalaureate level with credentialing by the American Nurses Credentialing Center (ANCC) or a recognized certification organization.

The role of the PMH nurse is to not only provide care and treatment for the healthcare consumer, but also to develop partnerships with healthcare consumers to assist them with their individual recovery goals. These goals may include: renewing hope, redefining self

beyond illness, incorporating illness, becoming involved with meaningful activities, overcoming barriers to social inclusion, assuming control, becoming empowered, exercising citizenship, managing symptoms, and being supported by others (Davidson, O’Connell, Sells, & Stacheli03). The PMH nurse has the responsibility to do more for the person when the person can do less, and to do less for the person when he or she is able to do more for him or herself. In this way PMH nurses develop and implement nursing interventions to assist the person in achieving recovery-oriented outcomes (McLoughlin11). This philosophy of directing and providing care when the person is in acute distress and eventually transferring the decision-making and self-care to the individual is rooted in Peplau’s theory of Interpersonal Relations in Nursing (Peplau91).

An important focus of PMH nursing involves substance disorders. Just as Schizophrenic Spectrum and Other Psychotic Disorders are described in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), Substance-Related and Addictive Disorders are also described in the DSM as Mental Disorders (American Psychiatric Association13). For example, a healthcare consumer may have a primary mental disorder with a secondary substance-related disorder (e.g., a person diagnosed with bipolar disorder with hypomanic symptoms who uses alcohol to slow down); or, a person may have a primary substance disorder with a secondary mental disorder, (e.g., a person who is addicted to cocaine and becomes suicidal as a result of the cocaine use), or a person may have two primary disorders such as schizophrenia and alcohol addiction. The Substance Abuse and Mental Health Services Administration (SAMHSA) has long advocated for integrated treatment of both mental and substance disorders (U.S. Health and Human Services05). Thus, in the first example, if a healthcare consumer was admitted to a hospital with symptoms of hypomania, the PMH-RN would not only need to assess and treat the symptoms related to mania, but would also need to assess the consumer for alcohol use and treatment that might include detoxification. Therefore, the PMH-RN requires competency in assessment and treatment of both disorders.

Further, PMH nurses provide basic care and treatment, general health teaching, health screening, and appropriate referral for treatment of general or complex physical health problems (Kane & Brackley11; Haber & Billings, 1995). The PMH nurse’s assessment synthesizes information obtained from interviews, behavioral observations, and other available data. From these, the PMH nurse determines diagnoses or problems that are congruent with available and accepted classification systems. This synthesis and development of a problem or area of focus differentiates the PMH nurse from others who work as nursing staff who may gather data for the PMH nurse.

Next, personal goals or outcomes are established, with the individual directing this process as much as possible. Finally, the nurse and the healthcare consumer develop a treatment plan based on assessment data and the healthcare consumers’ goals. The PMH nurse then selects and implements interventions to assist a person in achieving their recovery goals and periodically evaluates both attainment of the goals and the effectiveness of the interventions. Use of standardized classification systems enhances communication and permits the data to be used for research. However, in keeping with person-centered, recovery-oriented practice, the goal/outcome development must be individualized as much as possible, ideally with the consumer developing her or his own goals with assistance from the PMH nurse (Adams & Grieder05; McLoughlin & Geller10).

Mental health problems and psychiatric disorders are addressed across a continuum of care. A continuum of care consists of an integrated system of settings, services, healthcare clinicians, and care levels spanning health states from illness to wellness. The primary goal of a continuum of care is to provide treatment that allows the individual to achieve the highest level of functioning in the least restrictive environment.

Phenomena of Concern for Psychiatric-Mental Health Nurses

Phenomena of concern for psychiatric-mental health nurses are dynamic, exist in all populations across the lifespan and include but are not limited to:

■ Promotion of optimal mental and physical health and well-being

■ Prevention of mental and behavioral distress and illness

■ Promotion of social inclusion of mentally and behaviorally fragile individuals

■ Co-occurring mental health and substance use disorders

■ Co-occurring mental health and physical disorders

■ Alterations in thinking, perceiving, communicating, and functioning related to psychological and physiological distress

■ Psychological and physiological distress resulting from physical, interpersonal, and/or environmental trauma or neglect

■ Psychogenesis and individual vulnerability

■ Complex clinical presentations confounded by poverty and poor, inconsistent, or toxic environmental factors

■ Alterations in self-concept related to loss of physical organs and/or limbs, psychic trauma, developmental conflicts, or injury

■ Individual, family, or group isolation and difficulty with interpersonal relations

■ Self-harm and self-destructive behaviors including mutilation and suicide

■ Violent behavior including physical abuse, sexual abuse, and bullying

■ Low health literacy rates contributing to treatment non-adherence

Psychiatric-Mental Health Nursing Clinical Practice Settings

Psychiatric-mental health registered nurses practice in a variety of clinical settings across the care continuum and engage in a broad array of clinical activities including but not limited to health promotion and health maintenance; intake screening, evaluation, and triage; case management; provision of therapeutic and safe environments; promotion of self-care activities; administration of psychobiological treatment regimens and the monitoring of response and effects; crisis intervention and stabilization; and psychiatric rehabilitation, or interventions that assist in a person’s recovery. PMH nurses may be paid for their services on a salaried, contractual, or fee-for-service basis.

In the 21st century, advances in the neurosciences, genomics, and psychopharmacology, as well as evidenced-based practice and cost-effective treatment, enable the majority of individuals, families, and groups in need of mental health services to be cared for in community settings. Acute, intermediate, and long-term care settings still admit and care for healthcare consumers with behavioral and psychiatric disorders. However, lengths of stay, especially in acute and intermediate settings, have decreased in response to fiscal mandates, the availability of community-based settings, and consumer preference.

Crisis Intervention and Psychiatric Emergency Services

One of the most challenging clinical environments in psychiatric nursing is the psychiatric emergency department. Emergency departments are fast-paced, often overstimulating environments, with typically limited resources for those individuals with psychiatric and/or substance-related emergencies. Psychiatric emergency service can be based in a hospital or a community. The specific models of care continue to evolve and develop based on identified local health care needs. The current models in dealing with psychiatric emergencies include consultative services in a medical center or hospital emergency department (these psychiatric services may either be internally based or externally contracted); an enhanced, autonomous psychiatric emergency department; extended observation units; crisis stabilization units; respite services; and mobile crisis teams (Glick, Berlin, Fishkind, & Zeller08). Extended observation units, crisis stabilization units, respite service, and mobile crisis teams are alternative treatment options for individuals with a psychiatric emergency or crisis that does not require inpatient psychiatric treatment.

Acute Inpatient Care

This setting involves the most intensive care and is reserved for acutely ill healthcare consumers who are at imminent risk for harming themselves or others, or are unable to care for their basic needs because of their level of impairment. This treatment is typically short-

term, focusing on crisis stabilization. These units may be in a psychiatric hospital, a general care hospital, or a publicly funded psychiatric facility.

Intermediate and Long-Term Care

Intermediate and long-term care psychiatric facilities may admit patients directly but more often receive patients transferred from acute care settings. Intermediate and long-term care provides treatment, habilitation, and rehabilitation for patients who are at chronic risk for harming themselves or others due to mental disorders or who are unable to function with less intense supervision and support. Long-term inpatient care usually involves a minimum of 3 months. Both public and private psychiatric facilities provide this type of care. Long-term care hospitals also include state hospitals that admit patients through the criminal justice system. Often these forensic patients must remain in locked facilities for long periods of time; this is related to state statutes and legal statuses rather than clinical status.

Partial Hospitalization and Intensive Outpatient Treatment

The aim of partial hospitalization and intensive outpatient programs is acute symptom management and stabilization with safe housing options. Partial hospitalization and intensive outpatient treatment programs admit healthcare consumers who are in acute need of treatment but do not require 24-hour medical management or 24-hour nursing care. These programs function as free-standing programs and also serve as step-down programs for patients discharged from inpatient units.

Residential Services

A residential facility provides 24-hour care and housing for an extended period of time. Services in typical residential treatment facilities include psychoeducation for symptom management and medications, assistance with vocational training, and, in the case of the severely and persistently mentally ill, training for daily activities. Independent living is often a goal for occupants of residential treatment facilities.

Community-Based Care

Psychiatric-mental health registered nurses provide care within the community as an effective method of responding to the mental health needs of individuals, families, and groups. Community-based care refers to all non-hospital or facility-based care, and therefore may include care delivered in partnership with healthcare consumers in their homes, worksites, mental health clinics and programs, health maintenance organizations, shelters and clinics for the homeless, crisis centers, senior centers, group homes, and other community settings. Schools and colleges are an important site of mental health promotion, primary prevention, and early intervention programs for children and youth that involve psychiatric-mental health registered nurses. Psychiatric-mental health registered nurses are involved in educating teachers, parents, and students about mental health issues and in screening for depression, suicide risk, post-traumatic stress disorder, and alcohol, substance, and tobacco use.

Assertive Community Treatment (ACT)

ACT is a team treatment approach designed to provide comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with SMI (Assertive Community Treatment Association12). An ACT team is comprised of a group of professionals whose background and training include social work, rehabilitation, peer counseling, nursing, and psychiatry. The ACT approach provides highly individualized services directly to consumers 24 hours a day, 7 days a week, and 365 days a year. A 2003 study on ACT teams found that a full- time nurse was rated as the most important member of an ACT team (McGrew, Pescosilido, & Wright03).

Levels of Psychiatric-Mental Health Nursing Practice

There are two levels of practice. The first level of PMH practice is that of the psychiatric- mental health registered nurse (PMH-RN), with educational preparation within a bachelor’s degree, associate’s degree, or a diploma program. This level is discussed in the next section. The next level of PMH practice is that of the psychiatric-mental health advanced practice registered nurse (PMH-APRN) with educational preparation within a master’s degree or doctoral degree program. That level is discussed starting on pg. page 28.

Further, two sub-categories exist at the advanced practice register nurse level: the psychiatric-mental health mental clinical nurse specialist (PMHCNS) and the psychiatric- mental health nurse practitioner (PMHNP). The Doctor of Nursing Practice (DNP) as described by the American Association of Colleges of Nursing (AACN04) has advanced education in systems function, analysis, health policy, and advocacy. Nurses with the doctor of nursing practice degree may be at the PMH-RN level (e.g., RN administrators or educators) or at the APRN level (e.g., clinical nurse specialists or nurse practitioners).

Psychiatric-Mental Health Registered Nurse (PMH-RN)

A psychiatric-mental health registered nurse (PMH-RN) is a registered nurse who demonstrates competence—including specialized knowledge, skills, and abilities—obtained through education and experience in caring for persons with mental health issues, mental health problems, psychiatric disorders, and co-occurring psychiatric and substance use disorders.

The science of nursing is based on a critical thinking framework, known as the nursing process, composed of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. These steps serve as the foundation for clinical decision making and are used to provide an evidence base for practice (ANA10).

Psychiatric-mental health registered nursing practice is characterized by the use of the nursing process to treat people with actual or potential mental health problems, psychiatric disorders, and co-occurring psychiatric and substance use disorders. This nursing process is meant to promote and foster health and safety; assess dysfunction and areas of individual strength; assist persons to achieve their own personal recovery goals by gaining, re-gaining, or improving coping abilities, living skills, and managing symptoms; maximize strengths; and prevent further disability. Data collection at the point of contact involves observational and investigative activities, which are guided by the nurse’s knowledge of human behavior and the principles of the psychiatric interviewing process.

The data may include but are not limited to the healthcare consumer’s:

■ Central complaint, focus, or concern and symptoms of major psychiatric, substance related, and medical disorders

■ Strengths, supports, and individual goals for treatment

■ History and presentation regarding suicidal, violent, and self-mutilating behaviors

■ History of ability to seek professional assistance before engaging in behaviors dangerous to self or others

■ History of reasons why it may have been difficult in the past to follow-through with suggested or prescribed treatment

■ Pertinent family history of psychiatric disorders, substance abuse, and other mental and relevant physical health issues

■ Evidence of abuse, neglect, or trauma

■ Stressors, contributing factors, and coping strategies

■ Demographic profile and history of health patterns, illnesses, past treatments, and difficulties and successes in follow-through

■ Actual or potential barriers to adherence to recommended or prescribed treatment

■ Health beliefs and practices

■ Methods of communication

■ Religious and spiritual beliefs and practices

■ Cultural, racial, and ethnic identity and practices

■ Physical, developmental, cognitive, mental, and emotional health concerns, as well as

neurological assessment

■ Daily activities, personal hygiene, occupational functioning, functional health status, and social roles

■ Work, sleep, and sexual functioning

■ Economic, political, legal, and environmental factors affecting health

■ Significant support systems and community resources, including those that have been available and underutilized

■ Knowledge, satisfaction, and motivation to change, related to health

■ Strengths and competencies that can be used to promote health

■ Employment and military service

■ Current and past medications, both prescribed and over-the-counter, including herbs, alternative medications, vitamins, or nutritional supplements

■ Medication interactions and history of side effects and past effectiveness

■ Allergies and other adverse reactions

■ History and patterns of alcohol, substance, and tobacco use, including type, amount, most recent use, and withdrawal symptoms

■ Complementary therapies used to treat physical and mental disorders and their outcomes

The work of psychiatric-mental health registered nurses is accomplished through the interpersonal relationship, therapeutic intervention skills, and professional attributes. These attributes include but are not limited to self-awareness, empathy, and moral integrity, which enable psychiatric-mental health nurses to practice the artful use of self in therapeutic relationships. Some characteristics of artful therapeutic practice are respect for the person or family, availability, spontaneity, hope, acceptance, sensitivity, vision, accountability, advocacy, and spirituality.

Psychiatric-mental health registered nurses play a significant role in the articulation and implementation of new paradigms of care and treatment that place the healthcare consumer at the center of the care delivery system. PMH-RNs are key members of interdisciplinary teams in implementing initiatives such as fostering the development of person-centered, trauma-informed care environments in an effort to promote recovery and reduce or eliminate the use of seclusion or restraints; promoting individually-driven, person-centered treatment planning processes; and, developing skill-building programs to assist individuals to achieve their own goals.

Psychiatric-mental health registered nurses maintain current knowledge of advances in genetics and neuroscience and their impact on psychopharmacology and other treatment modalities. In partnership with healthcare consumers, communities, and other health professionals, psychiatric-mental health nurses provide leadership in identifying mental health issues and in developing strategies to ameliorate or prevent them.

Psychiatric-Mental Health Advanced Practice Registered Nurse (PMH-APRN)

The American Nurses Association (ANA) defines advanced practice registered nurses (APRNs) as professional nurses who have successfully completed a graduate program of study in a nursing specialty that provides specialized knowledge and skills that form the foundation for expanded roles in health care.

The psychiatric-mental health advanced practice registered nurse is educated at the master’s or doctoral level with the knowledge, skills, and abilities to provide continuous and comprehensive mental health care, including assessment, diagnosis, and treatment across settings. Psychiatric-mental health advanced practice nurses (PMH-APRN) include both nurse practitioners (PMH-NP) and clinical nurse specialists (PMH-CNS). Psychiatric-mental health advanced practice registered nurses are clinicians, educators, consultants, and researchers

who assess, diagnose, and treat individuals and families with behavioral and psychiatric problems and disorders or the potential for such disorders. Psychiatric-mental health nursing is necessarily holistic and considers the needs and strengths of the individual, family, group, and community.

APRNs play a pivotal role in the future of health care. Often primary care providers, they are at the forefront of providing preventive care to the public (ANA, n.d.1) ). Demand for healthcare services will continue to grow as millions of Americans gain health insurance under the Affordable Care Act and baby boomers dramatically increase Medicare enrollment. The nation will call on APRNs to meet these needs and participate as key members of healthcare teams (ANA, n.d.2).

Consensus Model: LACE (Licensure, Accreditation, Certification and Education) and APRN Roles

The Consensus Model for Advanced Practice Registered Nurse (APRN) Regulation—focusing on licensure, accreditation, certification, and education (LACE)—was completed in 2008 by the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee. Broadly, the model identifies four APRN roles for which to be certified: clinical nurse specialist (CNS), certified nurse practitioner (CNP), certified registered nurse anesthetist (CRNA), and certified nurse midwife (CNM). Each of these roles involves specialized graduate educational preparation that can be applied to a focused population. Finally, a nurse must demonstrate specific competencies as outlined by her or his practice area (NCSBN Joint Dialogue Group Report08).

Unlike other areas in nursing, the roles of a PMH-CNS and PMH-NP are virtually synonymous. In 2007, American Psychiatric Nurses Association (APNA) and the American Nurses Credentialing Center (ANCC) conducted a logical job analysis that described the purpose, essential functions, setting, and qualifications needed to perform as a PMH-CNS or a PMH- NP. This analysis confirmed that the vast commonalities in practice warranted the development of one advanced practice examination for both roles (Rice, Moller, DePascale, & Skinner07). With mental health parity and other healthcare reforms, PMH-CNSs and PMH- NPs play key roles in the integration of physical and mental health care and treatment in both hospital and community settings.

All APRNs are educationally prepared to provide a scope of services to a population across the continuum of care as defined by nationally recognized role and population-focused competencies; however, the emphasis and implementation within each APRN role varies based on care needs (NCSBN Joint Dialogue Group Report08)

The full scope and standards of practice for psychiatric-mental health advanced practice nursing is set forth in this document. While individual PMH-APRNs may actually implement portions of the full scope and practice based on their role, position description, and practice setting, the full breadth of the knowledge base informs their practice.

PMH-APRN practice focuses on the application of competencies, knowledge, and experience to individuals, families, or groups with complex psychiatric-mental health problems. Promoting mental health in society is a significant role for the PMH-APRN, as is collaboration with and referral to other health professionals, as either the individual need or the PMH- APRN’s practice focus may dictate.

The scope of advanced practice in psychiatric-mental health nursing is continually expanding, consonant with the growth in needs for service, practice settings, and the evolution of various scientific and nursing knowledge bases. PMH-APRNs are accountable for functioning within the parameters of their education and training, as well as the scope of practice as defined by their state practice acts. PMH-APRNs are responsible for making referrals for health problems that are outside their scope of practice. Although many primary care clinicians treat some symptoms of mental health problems and psychiatric disorders, the PMH-APRN provides a full range of specialized services that constitute mental health and psychiatric primary care and treatment (see below).

Specialty programs in advanced psychiatric-mental health nursing education generally have focused either on adult or child-adolescent psychiatric-mental health nursing practice. However, with the ongoing national implementation of the APRN Consensus Model and Licensure, Accreditation, Certification, and Education (LACE) recommendations, advanced

psychiatric-mental health nursing educational preparation has adopted a lifespan approach which includes preparing PMH-APRN to care for individuals, families, groups, and communities from pre-birth until death.

PMH-APRNs are accountable for their own practice and are prepared to perform services independent of other disciplines in the full range of delivery settings. Additional functions of the PMH-APRN include prescribing pharmacological agents, providing integrative therapy interventions, various forms of psychotherapy and community interventions, case management, consultation and liaison services, clinical supervision, developing policy for programs and systems, and actively engaging in advocacy activities, education, and research.

The settings and arrangements for psychiatric-mental health nursing practice vary widely in purpose, type, and location, and in the auspices under which they are operated. The PMH- APRN may be self-employed or employed by an agency, practice autonomously or collaboratively, and may or may not bill clients for services provided.

Primary Care

Currently, PMH-APRNs provide mental health services in primary care via several avenues. Examples of how PMH-APRNs practice in primary care settings include but are not limited to (a) collaboration and consultation with a primary care provider, (b) providing behavioral health care in integrated settings, and/or (c) unifying primary care and behavioral health within a mental health service site in what has been termed reverse co-location models. These roles are constantly evolving as healthcare reform, payment structures, and service delivery models continue to alter the nature of primary care and its relationship to mental health service delivery (Delaney & Kwasky13). Healthcare consumers are more likely to see a primary care provider than connect with scarce mental health care. Additionally, healthcare consumers may prefer receiving services in less stigmatizing primary care. Thus, integrated care is a strategy that is likely to expand (Manderscheid10). Evolving and diversifying models for integrated care is essential, especially with regard to the large number of people that will be seeking mental health services in primary care settings, the complexity of treating medical and wellness issues among the serious mentally-ill (SMI) population, and the varying levels of mental health need that must be addressed in primary care (Delaney, Robinson, & Chafetz13).

To build these systems will require not just innovations in integrated service delivery models, but also attention to how the various components of these systems fit together—i.e., the work flow process, financial integration, the teams to build a culture of care, and the workforce to enact it (Delaney et al.13; Reiss-Brennan, Cannon, Briesacher, & Leckman11). Effective integrated care models will necessitate that clinicians develop the knowledge and competencies to provide person-centered care and address the various levels of intensity of mental health needs, including individuals with complex comorbidities (Delaney et al.13).

An important issue related to building this workforce involves how primary care is currently conceptualized, which in turn influences how the integrated care workforce is defined and how its training is supported (APNA13). This workforce crosses traditional primary care and behavioral health care lines. The current restrictive definition of primary care (as residing in one of five specialty areas and at the point of first contact) limits the boundaries of the primary care workforce and perpetuates a mind-body split. A conceptualization of primary care that fits with the current expansion of services is found in an earlier definition of primary care forwarded by the IOM:

Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community (Donaldson, Yordy, & Vanselow94, p.1).

This definition creates more appropriate boundaries for the integrated care models that reside in both traditional primary care and expanded behavioral health care settings. As the conceptualization of primary care broadens to accommodate integrated care, it is clear that PMH advanced practice nurses are, by this definition, already delivering primary care services, which include the diagnosis and treatment of common health problems. These roles will only increase as the systems evolve and, given their unique skill set and clinical training, primary care PMH-APRN practice will only expand in the next decade.

Psychotherapy

Psychotherapy interventions include all generally accepted and evidence-based methods of brief or long-term therapy, specifically including individual therapy, group therapy, marital or couple therapy, and family therapy. These interventions use a range of therapy models including but not limited to psychodynamic, cognitive, behavioral, and supportive interpersonal therapies to promote insight, produce behavioral change, maintain function, and promote recovery.

“Psychotherapy” denotes a formally structured relationship between the therapist (PMH- APRN) and the healthcare consumer for the explicit purpose of effecting negotiated outcomes. This treatment approach to mental disorders is intended to alleviate emotional distress or symptoms, to reverse or change maladaptive behaviors, and to facilitate personal growth and development. The psychotherapeutic contract with the healthcare consumer is mutually agreeable and usually verbal, although it may be written. The contract includes well-accepted elements such as purpose of the therapy, treatment goals, time, place, fees, confidentiality and privacy provisions, and emergency after-hours contact information.

Psychopharmacological Interventions

Psychopharmacological interventions include the prescribing or recommending of pharmacologic agents and the ordering and interpretation of diagnostic and laboratory testing. Collaboration with the person seeking help is essential to promote adherence and recovery. In utilizing any psychobiological intervention, including the prescribing of psychoactive medications, the PMH-APRN intentionally seeks specific therapeutic responses, anticipates common side effects, safeguards against adverse drug interactions, and monitors for unintended or toxic responses. Current technology and research, including genomic testing, can help PMH-APRNs understand medication efficacy.

Case Management

Case management by the PMH-APRN involves population-specific nursing knowledge coupled with research, knowledge of the social and legal systems related to mental health, and expertise to engage a wide range of services for the consumer regardless of age or healthcare setting. The PMH-APRN is the point person who is responsible for the integration of all care and related decision-making. The PMH-APRN case manager designates an organized, coordinated approach to care by overseeing or directly engaging in case management activities. The PMH-APRN case manager identifies and analyzes real or potential barriers to care and intervenes to help provide access to appropriate levels and types of care and treatment to achieve optimum outcomes. Case manager interventions may be with a single client, or a designated family, group, or population.

Program, System, and Policy Development and Management

The PMH-APRN may focus on the mental health needs of the population as a whole on various levels, including community, state, national, or international. This focus involves the design, implementation, management, and evaluation of programs and systems to meet the mental health needs of a general population (e.g., persons with serious mental illnesses and co- occurring substance use disorders) or target a population at risk for developing mental health problems through prevention, health and wellness promotion, identification and amelioration of risk factors, screening, and early intervention. These activities are informed by the full range of nursing knowledge, which includes a holistic approach to individuals, families, and communities that is cognizant and respectful of cultural and spiritual norms and values. Additionally, policy, practice, program management, quality management, and data analysis knowledge and skills are essential for success in this arena. This area of practice has taken on a greater importance since the 2010 Institute of Medicine’s (IOM) consensus report on the future of nursing. One of the key messages of this report is that “nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States” (IOM10, p.3). The PMH-RN with advanced education and experience may assume these responsibilities in select instances.

Psychiatric Consultation–Liaison Nursing (PCLN)

Psychiatric consultation–liaison nursing (PCLN) practice emphasizes the assessment, diagnosis, and treatment of behavioral, cognitive, developmental, emotional, and spiritual responses of individuals, families, and significant others with co-occurring [actual or potential] physical illness(es) and/or dysfunction (ANA90). This advanced practice psychiatric-

mental health nursing role is performed in settings other than traditional psychiatric settings —most often in medical hospitals and skilled nursing facilities. Additionally, practice settings have expanded to primary care, “healthcare homes,” and community settings. As an APRN, the PCLN role requires expanded knowledge of complex psychiatric and medical disorders, the ability to complete diagnostic assessments leading to DSM diagnoses, and considerable expertise in navigating intricate health systems.

Consultation is used as a modality to provide successful psychiatric and biopsychosocial treatment for healthcare consumers/families and to enable non-psychiatric healthcare providers to provide such care. PMH-APRNs will often work as integral members of an interdisciplinary consultation-liaison team, apsychosomatic service, on independent liaison nursing teams, or as individual consultants within medical settings. PMH-APRNs provide highly specialized advanced assessments, diagnoses, and interventions with recommendations for effective behavioral health care planning and symptom management.

Psychiatric-mental health consultation may be accomplished by either direct or indirect consultation models. In the direct model, the consultee is typically the healthcare consumer or family. Specific activities may include psychopharmacologic recommendations, prescriptions, and monitoring, behavioral care plan development, and implementation of stabilization- focused therapeutic interventions for individuals and families. For example, a hospitalized child that is diagnosed with rheumatoid arthritis (RA) may present increased anxiety, depressive symptoms, and suicidal tendencies. The PCLN may be asked to consult, which may include completing a full psychiatric evaluation and recommending psychopharmacological treatments. It is the PCLN who has the expertise to differentiate between medication-induced psychiatric symptoms, primary psychiatric disorders, or a combination of both. Additionally, the PCLN would work with the nursing staff to develop a plan of how to keep the child safe and improve the child’s mental status while continuing the medical treatment needed for the RA.

In the indirect model, the consultee is the care provider or organization. In this approach, best practices are applied to general and unique clinical scenarios to improve individualized care as well as to improve overall health systems. The goals of consultation and liaison are mutually complimentary and interdependent. PCLN uses both processes in conjunction with specific theoretical knowledge, clinical expertise, and an ability to synthesize and integrate information to influence healthcare delivery systems (Gonzalez, Walker, & Krupnick95; Lewis & Levy82; Robinson87).

The PCLN role continues to develop, as does international expansion of the role (Sharrock11). Referenced earlier in this document, integrated care is a major trend in today’s healthcare landscape. The specialty skills and knowledge inherent in PCLN will continue to be invaluable as new integrated care models are implemented.

Clinical Supervision

The PMH-APRN provides clinical supervision to assist other mental health clinicians to evaluate their practice, expand their clinical practice skills, meet the standard requirement for ongoing peer consultation, and fulfill the need for peer supervision. This process, aimed at professional growth and development rather than staff performance evaluation, may be conducted in an individual or group setting. As a clinical supervisor, the PMH-APRN is expected both to be involved in direct care and to serve as a clinical role model and a clinical consultant.

Through educational preparation and clinical experience in individual, group, and family therapy, the PMH-APRN is qualified to provide clinical supervision at the request of other mental health clinicians and clinician-trainees. Although clinical supervision is not exactly the same as a therapy relationship, the PMH-APRN uses similar theories and methods to assist clinicians in examining and understanding their practices and developing new skills. PMH- APRN nurses providing clinical supervision must be aware of the potential for impaired professional objectivity or exploitation when they have dual or multiple relationships with supervisees or healthcare consumers. The nurse should avoid providing clinical supervision for people with whom they have pre-existing relationships that could hinder objectivity. Nurses who provide clinical supervision maintain confidentiality, except when disclosure is required for evaluation and necessary reporting.

Administration, Education, and Research Practice

The PMH-APRN or the PMH-RN with advanced education or experience also plays a significant role in administrative, educational, and research arenas. As health care is a clinical, consumer-centered business, a key to successful outcomes is to have people who are both clinically knowledgeable and knowledgeable about business practices making administrative decisions and holding significant leadership positions in healthcare organizations. Roles also include nursing educators, nursing school faculty, and researchers. Research practice may include a broad range of quantitative and qualitative approaches among the healthcare consumer population, nursing education, policy, and practice. Additionally, translational science in which nursing science is translated to the care and treatment of the healthcare consumer is another important piece of the PMH-RN’s role.

Self-Employment

Self-employed PMH-APRNs offer direct services in solo private practice and group practice settings, or through contracts with employee assistance programs, health maintenance organizations, managed care companies, preferred provider organizations, industry health departments, home health care agencies, or other service delivery arrangements. In these settings, the PMH-APRN provides comprehensive mental health care to clients. In the consultation and liaison role, the PMH-APRN may also provide consultative services at the organization, state, and national levels. This type of consultation includes the provision of clinical or system assessment, development, implementation, and evaluation. Further, psychiatric nurse consultants have independent practices as legal consultants or experts for both individual legal actions and systemic actions or litigations. Self-employed nurses may be sole-proprietors or form nurse-owned corporations or organizations that provide mental health service contracts to industries or other employers.

Other Specialized Areas of Practice

PMH nurses practice in a variety of specialized areas. As healthcare policies change and the needs of the healthcare consumer change so does the PMH nurses’ areas of practice. Some key areas include: programs of integrated care and treatment, telehealth, forensic mental health, and disaster psychiatric-mental health.

Integrative Programs

Integrative programs provide simultaneous care and treatment for individuals with all mental disorders, including substance use disorders and co-occurring disorders. Typically provided by a team of trained professionals, these programs exist across the care continuum and the span of all disorders included in Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association, (American Psychiatric Association13). As such, providers of mental health services, including PMH-RNs and PMH-APRNs, must be well-versed in the assessment, care, and treatment of those with co-occurring mental and substance disorders. In a 1998 SAMHSA consensus report on co-occurring disorder standards, practice, competencies, and training curricula, the following principle was emphasized: comorbidity should be expected, not considered an exception. Consequently, the whole system must be welcoming and accessible to consumers with all combinations of diagnoses; and, whenever possible, treatment of persons with complex comorbid disorders should be provided by individuals, teams, or programs with expertise in mental health and substance use disorders (SAMHSA98). Further, individuals with co-occurring disorders present complicated, chronic, interrelated conditions that often require personalized solutions for the specific set of symptoms, level of severity, and other psychosocial and environmental factors. Thus, treatment plans must be individualized to address each person’s specific needs using staged interventions and motivational enhancement to support recovery (SAMHSA02).

Telehealth

Telehealth is the use of telecommunications technology to remove time and distance barriers from the delivery of healthcare services and related healthcare activities. Electronic therapy is an expanded means of communication that promotes access to health care (Center for Substance Abuse Treatment09). The psychiatric-mental health registered nurse may use electronic means of communication such as telephone consultation, computers, electronic mail, image transmission, and interactive video sessions to establish and maintain a therapeutic relationship by creating an alternative sense of the nursing presence that may or may not occur in “real time.” In telehealth, psychiatric-mental health nursing care incorporates practice and clinical guidelines that are based on empirical evidence and

professional consensus. Telehealth encounters raise special issues related to confidentiality and regulation. Telehealth technology can cross state and even national boundaries and must be practiced in accordance with all applicable state, federal, and international laws and regulations. Particular attention must be directed to confidentiality, informed consent, documentation, maintenance of records, and the integrity of the transmitted information.

Forensic Mental Health

PMH-RN and the PMH-APRN levels of practice are found within forensic mental health settings. Roles include working with victims and offenders across the continuum of care from community (forensic ACT and conditional-release teams) settings to jails, prisons, and state psychiatric hospitals. In essence, any intersection between the criminal justice system and psychiatric nursing can be considered to be in the area of forensic mental health. Estimates indicate that one-third of persons in jails and prisons have mental disorders, and most admissions to inpatient care are court-ordered (Torrey, Kennard, Eslinger, Lamb, & Pavle, (2010). Forensic PMH-APRNs perform psychiatric assessments, prescribe and administer psychiatric medications, and educate correctional officers about mental health issues. Forensic PMH-APRNs also provide therapeutic services to witnesses and victims of crime.

Disaster Psychiatric-Mental Health Nursing

Psychiatric-mental health nurses provide psychological first aid and mental health clinical services as first responders through organizational systems in response to environmental and man-made disasters. Disaster psychiatry is a growing field of practice designed to facilitate effective coping by disaster victims and relief workers as they experience extreme stresses in the aftermath of a disaster. The mental health problems experienced by disaster survivors are typically stress-induced symptoms that are precipitated by numerous and simultaneous practical problems that they encounter after the disaster. Disaster psychiatry and mental health services encompass a wide range of activities, including public health preparations, early psychological interventions, psychiatric consultation to surgical units, relief units to facilitate appropriate triage, and psychotherapeutic interventions to alleviate stress to individuals, families, and children. Both PMH-RNs and PMH-APRNs may be actively engaged in the practical work of providing psychological first aid (Young06) and community education networking to assist in building community resilience. The APRN–PMH also engages in psychiatric triage, referral, and crisis stabilization, and addresses specific health issues with individuals who have pre-existing psychiatric-mental health and/or substance use disorders (Stoddard, Pandya, & Katz11; Ursano, Fullerton, Weisaeth, & Raphael07).

Psychiatric-mental health nurses care for persons with psychiatric, behavioral health, and comorbid conditions across the lifespan and continuum of care. Using therapeutic interpersonal and/or pharmacological interventions, PMH nurses promote recovery for countless persons afflicted with the debilitating effects of behavioral, psychiatric, and substance use disorders.

Ethical Issues in Psychiatric-Mental Health Nursing

PMH nurses adhere to all aspects of Code of Ethics for Nurses with Interpretive Statements (ANA01). Codes of ethical practice educate and inform professionals about sound ethical behavior while mandating a minimal standard of practice. While PMH nurses have the same goals as all nurses, there are unique ethical dilemmas in PMH nursing practice.

Specific examples are provided for each of the nine provisions of the Code of Ethics for Nurses. These provisions are comprised of three groupings: the first three describe the most fundamental values and commitments of each nurse; the next three address the boundaries of loyalty and duty; and the last three examine the duties beyond individual encounters with patients and healthcare consumers [ANA01, p. 10].

Respect for the Individual

Provision 1: The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

Compassion is a key value of PMH nursing. PMH nurses show compassion by recognizing the

importance of helping others through caring; instilling hope in those who feel hopeless; and empowering those who are powerless as a result of PMH disorders. Respect is another key value. PMH nurses respect the dignity and worth of every individual, based on the understanding that PMH disorders, like other chronic health problems, can be treated. Hence, PMH nurses are staunch advocates in helping to overcome negative attitudes and beliefs related to PMH to ensure appropriate, compassionate, and respectful care.

Commitment to the Healthcare Consumer

Provision 2: The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.

Personal behaviors and attitudes can conflict with ethical guidelines. PMH nurses must be open to exploring and reconciling their personal experiences. They must also have a keen awareness of boundary issues with clients, whether healthcare consumers, their families, or the community and other groups. PMH nurses are willing to participate in self, peer, and supervisory assessment of clinical skills and practice.

PMH nurses recognize that people with PMH disorders may have maladaptive coping behaviors that affect the individual, the family and other groups, and society as a whole. Grounded on the understanding that these are brain-based disorders, PMH nurses appreciate the difficulties that individuals experience in continuing to behave despite significant negative consequences. PMH nurses also understand the behavior change process and recognize that setbacks will occur during progress toward recovery and the initiation or maintenance of a behavior change goal.

The PMH nurse is always cognizant of the responsibility to balance human rights with safety and the potential need for coercive practices (e.g., restrictive measures such as restraint or seclusion) or forced treatment (e.g., court-mandated treatment or mental hygiene arrest/involuntary admission for an emergent psychiatric evaluation) when individuals lack the ability to maintain their own safety.

Advocacy for the Healthcare Consumer

Provision 3: The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

The PMH nurse monitors and carefully manages confidentiality, therapeutic self-disclosure, and professional boundaries through all forms of interaction (i.e., face-to-face, electronic record, social media). These obligations are intensified in PMH nursing due to the vulnerability of the population, the complexity of clinical care, and legal issues which are dictated by legislation and the criminal justice system.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted to help protect confidential information through specific rules that outline how confidential information is shared. Because these rules have potentially severe civil and criminal penalties for non-compliance, the PMH nurse has an obligation to be aware of the rules regarding protected confidential information.

The PMH nurse understands that the therapeutic relationship between the PMH nurse and the healthcare consumer and family is unbalanced in nature. To formulate effective nursing interventions, care and treatment often includes gaining knowledge of the healthcare consumer’s intimate thoughts, feelings, and behaviors. Therefore, any sort of sexual activity or sexual intimacies (physical, verbal, electronic, social media) with current clients, their close relatives, guardians, or significant others is unethical (American Psychiatric Association10a; American Psychological Association10b).

The PMH nurse helps resolve ethical issues by participating in such activities as consulting with and serving on ethics committees, or advocating for optimal psychiatric care through policy formation and political action.

Responsibility and Accountability for Practice

Provision 4: The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to

provide optimum patient care.

The population of PMH providers is quite diverse. The specific proficiencies, skills, levels of involvement with healthcare consumers, and scopes of practice vary widely among specializations (e.g., physicians, nurses, social workers, psychologists, counselors/therapists, case workers, mental health workers, peer counselors). These roles often become blurred with inappropriate functions subsumed by healthcare providers working outside their scope of practice (e.g., assessment or diagnosis by a non-licensed provider and/or noncertified provider), academic preparation, training, or competency. PMH nurses may work in settings where nursing administration may not be dominant or even present. Thus, PMH nurses must be able to articulate their competence as well as their scope of practice; be aware of the professional standards that guide other team members; and possess the knowledge, skills, and abilities that all PMH providers have in common.

Duties to Self and Others

Provision 5: The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.

PMH nurses must accord moral worth and dignity to all human beings. This moral respect extends to oneself and to others, including nurse colleagues whose practice may be impaired as a result of substance use, PMH disorders, or other physical disorders. PMH nurses are in key roles to change prevailing negative perceptions and attitudes toward individuals with PMH disorders.

The PMH nurse demonstrates a commitment to practicing and maintaining self-care, managing stress, nurturing self, and maintaining supportive relationships with others so that the nurse is meeting her or his own needs outside of the therapeutic relationship. Moral distress (Jameton93) should be identified, addressed, and reduced using an appropriate action plan (Epstein & Delgado10; Lachman10). PMH nurses render respectful and skilled care, understanding that lifelong learning is critical for professional growth and competence.

Contributions to Healthcare Environments

Provision 6: The nurse participates in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.

Given their knowledge, skills, and abilities, PMH nurses are often the first to recognize signs or symptoms of a psychiatric disorder in the workplace (e.g., depression, eating disorder, substance use). PMH nurses have an ethical obligation to report peer observations or concerns to their nurse leader. PMH nurses have a moral obligation to help address problems faced by colleagues with symptoms suggestive of mental distress and/or substance use that may potentially impact patient safety and violate public trust. PMH nurses may face situations of competing values, loyalties, and obligations that generate tension and conflict. Satisfying solutions to these situations preserve the integrity of nursing values while helping to maintain a safe environment for healthcare consumers.

Advancement of the Nursing Profession

Provision 7: The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.

PMH nurses have an ethical obligation to be knowledgeable of and apply evidence-based practice guidelines, which includes risk assessment and management. PMH nurses need to engage in continuous quality improvement efforts to promote the highest quality of care for individuals, families, and populations affected by PMH disorders. The PMH nurse engages in continuing education experiences to maintain and advance professional competence regardless of whether these continuing education experiences are required by the state board of nursing.

Collaboration to Meet Health Needs

Provision 8: The nurse collaborates with other health professionals and the public in

promoting community, national, and international efforts to meet health needs.

PMH nurses engage in partnerships with other specialty nurses (e.g., oncology nursing, addictions nursing, pain management nursing, emergency nursing, correctional nursing), government agencies (e.g., SAMHSA, NIH, IOM), the larger nursing community (e.g., ANA, APNA, ISPN, state nurses associations), and the public (e.g., National Alliance for the Mentally Ill, Mental Health America) to promote the societal benefits of prevention, treatment, and recovery to affected individuals, groups, and populations.

Promotion of the Nursing Profession

Provision 9: The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

PMH nurses have a central role in advocating for environments where the human rights, values, customs, and spiritual beliefs of individuals, families, and communities are respected. PMH nurses recognize the importance of direct human interactions, communication, and professional collaboration. These relationships may be with individuals, with populations, and with other healthcare professionals and health workers, both within and between nurses and public representatives. Within the larger nursing community, PMH nurses inform policy development and implementation in recognition that PMH disorders are treatable and that nursing service is delivered with respect for human needs and values and without prejudice to vulnerable populations.

Standards of Psychiatric-Mental Health Nursing Practice

The following Standards of Practice and Standards of Professional Performance specify psychiatric-mental health competencies that must be demonstrated in addition to the current edition of Nursing: Scope and Standards of Practice (ANA10). These practice and performance standards are written in such a way that each standard and competency listed for the psychiatric-mental health registered nurse (PMH-RN) also applies to the psychiatric- mental health-advanced practice registered nurse (PMH-APRN). In several instances, additional standards and competencies for the PMH-APRN are only applicable to the advanced practice registered nurse.

Standards of Practice for Psychiatric-Mental Health Nursing

Standard 1. Assessment

The psychiatric-mental health registered nurse collects and synthesizes comprehensive health data that are pertinent to the healthcare consumer’s health and/or situation.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Collects comprehensive data including but not limited to psychiatric, substance, physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments in a systematic and ongoing process while focusing on the uniqueness of the person.

■ Elicits the healthcare consumer’s values, preferences, knowledge of the healthcare situation, expressed needs, and recovery goals.

■ Involves the healthcare consumer, family, other healthcare providers, and other consumer- identified support systems (as appropriate) in holistic data collection.

■ Demonstrates effective clinical interviewing skills that facilitate development of a therapeutic relationship.

■ Prioritizes data collection activities based on the healthcare consumer’s immediate condition and the anticipated needs of the consumer or situation.

■ Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data.

■ Uses analytical models and problem-solving techniques.

■ Ensures that appropriate consents, as determined by regulations and policies, are obtained to protect confidentiality and support the healthcare consumer’s rights in the process of data gathering.

■ Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances.

■ Uses therapeutic principles to understand and make inferences about the healthcare consumer’s emotions, thoughts, behaviors, and condition.

■ Documents relevant data in a retrievable format.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Performs a comprehensive psychiatric and mental health diagnostic evaluation.

■ Initiates and interprets diagnostic tests and procedures relevant to the healthcare consumer’s current status.

■ Employs evidence-based clinical practice guidelines to guide screening and diagnostic activities as available and appropriate.

■ Conducts a multigenerational family assessment, including medical, psychiatric, and substance use history.

■ Assesses interactions among the individual, family, community, and social systems and their relationship to mental health functioning.

Standard 2. Diagnosis

The psychiatric-mental health registered nurse analyzes the assessment data to determine diagnoses, problems, and areas of focus for care and treatment, including level of risk.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Identifies actual or potential risks to the healthcare consumer’s health and safety or barriers to mental and physical health which may include but are not limited to interpersonal, systematic, or environmental circumstances.

■ Derives the diagnoses, problems, or areas in need of care and treatment from the assessment data.

■ Develops the diagnosis or problems with the healthcare consumer, significant others, and other healthcare clinicians to the greatest extent possible in concert with person-centered, recovery-oriented practice.

■ Develops diagnoses or problems that, to the greatest extent possible, are in the healthcare consumer’s words and congruent with available and accepted classification systems.

■ Documents diagnoses or problems in a manner that facilitates the determination of the expected outcomes and plan.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Develops standard psychiatric and substance use diagnoses (e.g., DSM, IDC-10).

■ Systematically compares and contrasts clinical findings with normal and abnormal variations and developmental events in formulating a differential diagnosis.

■ Utilizes complex data and information obtained during interview, examination, and diagnostic procedures in identifying diagnoses.

■ Identifies long-term effects of psychiatric disorders on mental, physical, and social health.

■ Evaluates the health impact of life stressors, traumatic events, and situational crises within the context of the family cycle.

■ Evaluates the impact of the course of psychiatric disorders and mental health problems on the path of recovery, including quality of life and functional status.

■ Assists staff in developing and maintaining competency in the diagnostic process.

Standard 3. Outcomes Identification

The psychiatric-mental health registered nurse identifies expected outcomes and the healthcare consumer’s goals for a plan individualized to the healthcare consumer or to the situation.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Involves the healthcare consumer to the greatest extent possible in formulating mutually agreed upon outcomes and individualized healthcare consumer goals.

■ Involves the healthcare consumer’s family, healthcare providers, and other significant supports in formulating expected outcomes when possible and as appropriate.

■ Derives culturally appropriate expected outcomes from the identified diagnoses and problems.

■ Considers associated risks, benefits, costs, current scientific evidence, and clinical expertise when formulating expected outcomes.

■ Identifies expected outcomes that incorporate scientific evidence and are achievable through implementation of evidence-based practices.

■ Defines expected outcomes in terms of the healthcare consumer, the healthcare consumer’s values, ethical considerations, environment or situation, with consideration of associated risks, benefits, costs, current scientific evidence, and personal recovery goals.

■ Develops expected outcomes that provide direction for continuity of care.

■ Documents expected outcomes as healthcare consumer-focused measurable goals in language either developed by the healthcare consumer or understandable to the healthcare consumer.

■ Includes a time estimate for attainment of expected outcomes.

■ In partnership with the healthcare consumer, modifies expected outcomes based on changes in the status of the healthcare consumer or evaluation of the situation.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Assists the PMH-RN in identifying expected outcomes that incorporate scientific evidence and are achievable through implementation of evidence-based practices.

■ Identifies expected outcomes that incorporate cost and clinical effectiveness, satisfaction, and continuity and consistency among providers.

■ Develops, implements, and supports and uses clinical guidelines linked to positive clinical outcomes.

Standard 4. Planning

The psychiatric-mental health registered nurse develops a plan that prescribes strategies and alternatives to assist the healthcare consumer in attainment of expected outcomes.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Develops an individualized plan in partnership with the healthcare consumer, family, and others considering the healthcare consumer’s characteristics or situation; this plan can include, but is not limited to, values, beliefs, spiritual and health practices, preferences, choices, developmental level, coping style, culture and environment, available technology, and individual recovery goals.

■ Establishes the plan priorities with the healthcare consumer, family, and others as appropriate.

■ Prioritizes elements of the plan based on the assessment of the healthcare consumer’s level of risk for potential harm to self or others and safety needs.

■ Includes strategies in the plan that address each of the identified problems or issues, including strategies for the promotion of recovery, restoration of health, and prevention of illness, injury, and disease.

■ Considers the economic impact of the plan.

■ Assists healthcare consumers in securing treatment or services in the least restrictive environment.

■ Includes an implementation pathway or timeline in the plan.

■ Provides for continuity in the plan.

■ Utilizes the plan to provide direction to other members of the healthcare team.

■ Documents the plan using person-centered, non-jargon terminology.

■ Defines the plan to reflect current statutes, rules and regulations, and standards.

■ Integrates current scientific evidence, trends, and research.

■ Modifies the plan (goals/outcomes and interventions) based on ongoing assessment of the healthcare consumer’s achievement of goals and responses to interventions.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Identifies assessment and diagnostic strategies and therapeutic interventions that reflect current evidence, including data, research, literature, and expert clinical knowledge.

■ Plans care to minimize complications and promote individualized recovery and optimal quality of life using treatment modalities including but not limited to psychodynamic, cognitive behavioral, supportive interpersonal therapies, and psychopharmacology.

■ Selects or designs strategies to meet the multifaceted needs of complex healthcare consumers.

■ Includes synthesis of healthcare consumers’ values and beliefs regarding nursing and medical therapies in the plan.

■ Actively participates in the development and continuous improvement of systems that support the planning process.

Standard 5. Implementation

The psychiatric-mental health registered nurse implements the identified plan.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Partners with the healthcare consumer, family, significant others, and caregivers as appropriate to implement the plan in a safe, realistic, and timely manner.

■ Utilizes the therapeutic relationship and employs principles of mental health recovery.

■ Utilizes evidence-based interventions and treatments specific to the problem or issue.

■ Utilizes technology to measure, record, and retrieve healthcare consumer data, implement the nursing process, and enhance nursing practice.

■ Utilizes community resources and systems to implement the plan.

■ Provides age-appropriate care in a culturally and ethnically sensitive manner.

■ Provides care and treatment related to psychiatric, substance, and medical problems.

■ Provides holistic care that focuses on the person with the disease or disorder, not just the disease or disorder itself.

■ Advocates for the healthcare consumer.

■ Addresses the needs of diverse populations across the lifespan.

■ Collaborates with nursing colleagues and others to implement the plan.

■ Supervises ancillary staff in carrying out care interventions.

■ Integrates traditional and complementary healthcare practices as appropriate.

■ Documents implementation and any modifications, including changes or omissions, of the identified plan.

■ Incorporates new knowledge and strategies to initiate change in nursing care practices if desired outcomes are not achieved.

■ Manages psychiatric emergencies by determining the level of risk and initiating and coordinating effective emergency care.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Facilitates utilization of systems and community resources to implement the plan.

■ Supports collaboration with nursing colleagues and other disciplines to implement the plan.

■ Uses principles and concepts of project management and systems management when implementing the plan.

■ Fosters organizational systems that support implementation of the plan.

■ Provides clinical supervision to the PMH-RN in the implementation of the plan.

■ Actively participates in the development and continuous improvement of systems that support the implementation of the plan.

Standard 5A. Coordination of Care

The psychiatric-mental health registered nurse coordinates care delivery.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Coordinates implementation of the plan.

■ Manages the healthcare consumer’s care in order to maximize individual recovery, independence, and quality of life.

■ Assists the healthcare consumer to identify options for alternative care.

■ Communicates with the healthcare consumer, family, and system during transitions in care.

■ Advocates for the delivery of dignified and humane care by the interprofessional team.

■ Documents the coordination of care.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Provides leadership in the coordination of interprofessional health care for integrated delivery of care and treatment services.

■ Functions as the single point of accountability for all medical and psychiatric services.

■ Synthesizes data and information to prescribe necessary system and community support measures, including environmental modifications.

■ Coordinates system and community resources that enhance delivery of care across continuums.

Standard 5B. Health Teaching and Health Promotion

The psychiatric-mental health registered nurse employs strategies to promote health and a safe environment.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Provides health teaching (in individual or group settings) related to the healthcare consumer’s needs, recovery goals, and situation that may include but is not limited to mental health problems, psychiatric and substance use disorders, treatment regimens and self- management of those regimens, coping skills, relapse prevention, self-care activities, resources, conflict management, problem-solving skills, stress management and relaxation techniques, and crisis management.

■ Uses health promotion and health teaching methods appropriate to the situation and the healthcare consumer’s values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status.

■ Integrates current knowledge, evidence-based practices, and research regarding psychotherapeutic educational strategies and content.

■ Engages healthcare consumer alliances, such as peer specialists, and advocacy groups as appropriate in health teaching and health promotion activities.

■ Identifies community resources to assist and support healthcare consumers in using prevention and mental healthcare services.

■ Seeks opportunities from the individual healthcare consumer for feedback and evaluation of the effectiveness of strategies utilized.

■ Provides anticipatory guidance to individuals and families to promote mental health and to prevent or reduce the risk of psychiatric disorders.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Synthesizes empirical evidence on risk behaviors, learning theories, behavioral change theories, motivational theories, epidemiology, and other related theories and frameworks when designing health information and healthcare consumer education.

■ Educates healthcare consumers and significant others about intended effects and potential adverse effects of treatment options and regimes.

■ Provides education to individuals, families, and groups to promote knowledge, understanding, and effective management of overall health maintenance, mental health problems, and psychiatric and substance disorders.

■ Uses knowledge of health beliefs, practices, evidence-based findings, and epidemiological principles, along with the social, cultural, and political issues that affect mental health in the community to develop health promotion strategies.

■ Designs health information and healthcare consumer education appropriate to the healthcare consumer’s developmental level, learning needs, readiness to learn, and cultural values and beliefs.

■ Evaluates health information resources, such as the Internet, in the area of practice for accuracy, readability, and comprehensibility to help healthcare consumers access quality health information.

■ Assists the PMH-RN in curriculum and program development in the areas of health teaching and health promotion.

Standard 5C. Consultation

The psychiatric-mental health advanced practice registered nurse provides consultation to influence the identified plan, enhance the abilities of other clinicians to provide services for healthcare consumers, and effect change.

Competencies

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Initiates consultation at the request of the consultee.

■ Establishes a working alliance with the healthcare consumer or consultee based on mutual respect and role responsibilities.

■ Facilitates the effectiveness of a consultation by involving the stakeholders in the decision- making process.

■ Synthesizes clinical data, theoretical frameworks, and evidence when providing consultation.

■ Communicates consultation recommendations that influence the identified plan, facilitate understanding by involved stakeholders, enhance the work of others, and effect change.

■ Clarifies that implementation of system changes or changes to the plan of care remains the responsibility of consultee.

■ Assists the PMH-RN and other members of the interprofessional team in resolving complex clinical and other situations.

Standard 5D. Prescriptive Authority and Treatment

The psychiatric-mental health advanced practice registered nurse uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Conducts a thorough assessment of past medication trials, side effects, efficacy, and healthcare consumer preference.

■ Educates and assists the healthcare consumer in selecting the appropriate use of complementary and alternative therapies.

■ Provides healthcare consumers with information about intended effects and potential adverse effects of proposed prescriptive therapies.

■ Provides information about pharmacologic agents, costs, and alternative treatments and procedures as appropriate.

■ Prescribes evidence-based treatments, therapies, and procedures considering the healthcare consumer’s comprehensive healthcare needs.

■ Prescribes pharmacologic agents based on a current knowledge of pharmacology and physiology.

■ Prescribes specific pharmacological agents and treatments in collaboration with the healthcare consumer and based on clinical indicators, the healthcare consumer’s status, needs, and preferences, and the results of diagnostic and laboratory tests.

■ Evaluates therapeutic and potential adverse effects of pharmacological and non- pharmacological treatments.

■ Evaluates pharmacological outcomes by utilizing standard symptom measurements and healthcare consumer’s reports to determine effectiveness.

Standard 5E. Pharmacological, Biological, and Integrative Therapies

The psychiatric-mental health registered nurse incorporates knowledge of pharmacological, biological, and complementary interventions with applied clinical skills to restore the healthcare consumer’s health and prevent further disability.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Applies current research findings to guide nursing actions related to pharmacology, other biological therapies, and integrative therapies.

■ Assesses the healthcare consumer’s response to biological interventions based on current knowledge of pharmacological agents’ intended actions, interactive effects, potential untoward effects, and therapeutic doses.

■ Includes health teaching for medication management to support healthcare consumers in managing their own medications and adhering to a prescribed regimen.

■ Provides health teaching about mechanism of action, intended effects, potential adverse effects of the proposed prescription, ways to cope with transitional side effects, and other treatment options, including the selection of a no-treatment option.

■ Directs interventions toward alleviating untoward effects of biological interventions.

■ Communicates observations about the healthcare consumer’s response to biological interventions to other health clinicians.

Standard 5F. Milieu Therapy

The psychiatric-mental health registered nurse provides, structures, and maintains a safe, therapeutic, recovery-oriented environment in collaboration with healthcare consumers, families, and other healthcare clinicians.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Orients the healthcare consumer and family to the care environment, including the physical environment, the roles of different healthcare providers, how to be involved in the treatment and care delivery processes, schedules of events pertinent to their care and treatment, and expectations regarding safe and therapeutic behaviors.

■ Orients healthcare consumers to their rights and responsibilities particular to the treatment or care environment.

■ Establishes a welcoming, trauma-sensitive environment using therapeutic interventions including, but not limited to, sensory or relaxation rooms.

■ Conducts ongoing assessments of the healthcare consumer in relation to the environment to guide nursing interventions in maintaining a safe environment.

■ Selects specific activities (both individual and group) that meet the healthcare consumer’s physical and mental health needs for meaningful participation in the milieu and promotion of personal growth.

■ Advocates that the healthcare consumer is treated in the least restrictive environment necessary to maintain the safety of the individual and others.

■ Informs the healthcare consumer in a culturally sensitive manner about the need for limits related to safety and the conditions necessary to remove the restrictions.

■ Provides support and validation to healthcare consumers when discussing their illness experience, and seeks to prevent complications of illness.

Standard 5G. Therapeutic Relationship and Counseling

The psychiatric-mental health registered nurse (PHM-RN) uses the therapeutic relationship and counseling interventions to assist healthcare consumers in their individual recovery journeys by improving and regaining their previous coping abilities, fostering mental health, and preventing mental disorder and disability.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Uses the therapeutic relationship and counseling techniques to promote the healthcare consumer’s stabilization of symptoms and personal recovery goals.

■ Uses the therapeutic relationship and counseling techniques, both in the individual and group setting, to reinforce healthy behaviors and interaction patterns and help the healthcare consumer discover individualized health care behaviors to replace unhealthy ones.

■ Documents counseling interventions including but not limited to communication and interviewing techniques, problem-solving activities, crisis intervention, stress management, supportive skill building and educational groups, relaxation techniques, assertiveness training, and conflict resolution.

Standard 5H. Psychotherapy

The psychiatric-mental health advanced practice registered nurse conducts individual, couples, group, and family psychotherapy using evidence-based psychotherapeutic frameworks and the nurse–client therapeutic relationship.

Competencies

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Uses knowledge of relevant biological, psychosocial, and developmental theories, as well as best available research evidence, to select therapeutic methods based on healthcare consumer needs.

■ Utilizes interventions that promote mutual trust to build a therapeutic treatment alliance.

■ Empowers healthcare consumers to be active participants in treatment.

■ Applies therapeutic communication strategies based on theories and research evidence to reduce emotional distress, facilitate cognitive and behavioral change, and foster personal growth.

■ Uses awareness of own emotional reactions and behavioral responses to others to enhance the therapeutic alliance.

■ Analyzes the impact of duty to report and execute other advocacy actions on the therapeutic alliance.

■ Arranges for the provision of care in the therapist’s absence.

■ Applies ethical and legal principles to the treatment of healthcare consumers with mental health problems and psychiatric disorders.

■ Makes referrals when it is determined that the healthcare consumer will benefit from a transition of care or consultation due to change in clinical condition.

■ Evaluates effectiveness of interventions in relation to outcomes using standardized methods as appropriate.

■ Monitors outcomes of therapy and adjusts the care plan when indicated.

■ Therapeutically concludes the nurse–client relationship and transitions the healthcare consumer to other levels of care when appropriate.

■ Manages professional boundaries in order to preserve the integrity of the therapeutic process.

Standard 6. Evaluation

The psychiatric-mental health registered nurse evaluates progress toward attainment of expected outcomes.

Competencies

The psychiatric-mental health registered nurse (RN-PMH):

■ Conducts a systematic, ongoing, and criterion-based evaluation of the outcomes and goals in relation to the prescribed interventions by the plan and indicated timeline.

■ Collaborates with the healthcare consumer, family or significant others, and other healthcare clinicians in the evaluation process.

■ Documents results of the evaluation.

■ Evaluates the effectiveness of the planned strategies in relation to healthcare consumer responses and the attainment of the expected outcomes.

■ Uses ongoing assessment data to revise the diagnoses and problems, outcomes, and interventions, as needed.

■ Adapts the plan of care for the trajectory of treatment according to evaluation of response.

■ Disseminates the results to the healthcare consumer and others involved in the care or situation, as appropriate, in accordance with state and federal laws and regulations.

■ Participates in assessing and assuring the responsible and appropriate use of interventions in order to minimize unwarranted or unwanted treatment and healthcare consumer suffering.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Evaluates the accuracy of the diagnosis and effectiveness of the interventions in relationship to the healthcare consumer’s attainment of expected outcomes.

■ Synthesizes the results of the evaluation analyses to determine the impact of the plan on the affected healthcare consumers, families, groups, communities, and institutions.

■ Uses the results of the evaluation analyses to make or recommend process or structural changes, including policy, procedure, or protocol documentation, as appropriate.

■ Assists the PMH-RN in the evaluation and re-formulation of the plan in complex situations.

Standards of Professional Performance for Psychiatric-Mental Health Nursing

Standard 7. Ethics

The psychiatric-mental health registered nurse integrates ethical provisions in all areas of practice.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Uses Code of Ethics for Nurses with Interpretive Statements (ANA01) to guide practice.

■ Delivers care in a manner that preserves and protects healthcare consumer autonomy, dignity, and rights.

■ Recognizes and avoids using the power inherent in the therapeutic relationship to influence the healthcare consumer in ways not related to the treatment goals.

■ Maintains healthcare consumer confidentiality within legal and regulatory parameters.

■ Serves as a healthcare consumer advocate protecting healthcare consumer rights and assisting healthcare consumer in developing skills for self-advocacy.

■ Maintains therapeutic and professional interpersonal relationships with appropriate professional role boundaries.

■ Demonstrates a commitment to practicing self-care, managing stress, and connecting with self and others.

■ Contributes to resolving ethical issues of healthcare consumers, colleagues, or systems as evidenced in such activities as recommending ethics clinical consultations for specific healthcare consumer situations and participating on ethics committees.

■ Reports illegal, incompetent, or impaired practices.

■ Promotes advance care planning related to behavioral health issues which may include behavioral health advance directives.

■ Assists healthcare consumers, particularly those who may be facing life threatening medical illnesses, to plan for and gain access to appropriate palliative and hospice care.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Informs the healthcare consumer of the risks, benefits, and outcomes of healthcare regimens.

■ Participates in interprofessional teams that address ethical risks, benefits, and outcomes.

■ Promotes and maintains a system and climate that is conducive to providing ethical care.

■ Utilizes ethical principles to advocate for access and parity of services for mental health problems, psychiatric disorders, and addiction services.

Standard 8. Education

The psychiatric-mental health registered nurse attains knowledge and competence that reflect current nursing practice.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Participates in ongoing educational activities related to appropriate knowledge bases and professional issues.

■ Participates in interprofessional educational opportunities to promote continuing skill- building in team collaboration.

■ Demonstrates a commitment to lifelong learning through self-reflection and inquiry to identify learning needs.

■ Seeks experiences that reflect current practice in order to maintain skills and competence in clinical practice or role performance.

■ Acquires knowledge and skills appropriate to the specialty area, practice setting, role, or situation.

■ Maintains professional records that provide evidence of competency and lifelong learning.

■ Seeks experiences and formal and independent learning activities, to maintain and develop clinical and professional skills and knowledge.

■ Seeks experiences and formal and independent learning activities to maintain and develop skills in and knowledge of electronic healthcare media.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Uses current healthcare research findings and other evidence to expand clinical knowledge, enhance role performance, and increase knowledge of professional issues.

■ Contributes to an environment that promotes interprofessional education.

■ Models expert practice to interprofessional team members and healthcare consumers.

■ Mentors registered nurses and colleagues as appropriate.

■ Participates in interprofessional teams contributing to role development and advanced nursing practice and health care.

Standard 9. Evidence-Based Practice and Research

The psychiatric-mental health registered nurse integrates evidence and research findings into practice.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Utilizes evidence-based nursing knowledge, including research findings, to guide practice decisions.

■ Actively participates in research activities at various levels appropriate to the nurse’s level of education and position. Such activities may include:

• Identifying clinical problems specific to psychiatric-mental health nursing research

• Participating in data collection (surveys, pilot projects, and formal studies)

• Assisting with informed consent process

• Participating in a formal committee or program

• Sharing research activities and findings with peers and others

• Conducting evidence-based practice projects and research

• Critically analyzing and interpreting research for application to practice

• Using research findings in the development of policies, procedures, and standards of practice in nursing care

• Incorporating research as a basis for learning

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Contributes to nursing knowledge by conducting, critically appraising, or synthesizing research that discovers, examines, and evaluates knowledge, theories, criteria, and creative approaches to improve healthcare practice.

■ Promotes a climate of research and clinical inquiry.

■ Formally disseminates research findings through activities such as presentations, publications, consultation, and journal clubs.

■ Promotes a culture that consistently integrates the best available research evidence into practice.

Standard 10. Quality of Practice

The psychiatric-mental health registered nurse systematically enhances the quality and effectiveness of nursing practice.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Demonstrates quality by documenting the application of the nursing process in a responsible, accountable, and ethical manner.

■ Uses the results of quality improvement activities to initiate changes in nursing practice and in the healthcare delivery system.

■ Uses creativity and innovation in nursing practice to improve care delivery.

■ Incorporates new knowledge to initiate changes in nursing practice if desired outcomes are not achieved.

■ Participates in quality improvement activities. Such activities may include:

• Identifying aspects of practice important for quality monitoring

• Using indicators developed to monitor quality and effectiveness of nursing practice

• Collecting data to monitor quality and effectiveness of nursing practice

• Analyzing quality data to identify opportunities for improving nursing practice

• Formulating recommendations to improve nursing practice or outcomes

• Implementing activities to enhance the quality of nursing practice

• Developing, implementing, and evaluating policies, procedures, and guidelines to improve the quality of practice

• Participating on interprofessional teams to evaluate clinical care or health services

• Participating in efforts to minimize costs and unnecessary duplication

• Analyzing factors related to safety, satisfaction, effectiveness, and cost–benefit options

• Analyzing organizational systems for barriers

• Implementing processes to remove or decrease barriers within organizational systems

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Obtains and maintains professional certification at the advanced level in psychiatric-mental health nursing.

■ Designs quality improvement initiatives to improve practice and health outcomes.

■ Identifies opportunities for the generation and use of research and evidence.

■ Evaluates the practice environment and quality of nursing care rendered in relation to existing evidence.

Standard 11. Communication

The psychiatric-mental health registered nurse communicates effectively in a variety of formats in all areas of practice.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Assesses communication format preferences of healthcare consumers, families, and colleagues.*

■ Assesses her or his own communication skills in encounters with healthcare consumers, families, and colleagues.*

■ Seeks continuous improvement of her or his own communication and conflict resolution skills.*

■ Conveys information to healthcare consumers, families, the interprofessional team, and others in communication formats that promote accuracy.

■ Questions the rationale supporting care processes and decisions when they do not appear to be in the best interest of the healthcare consumer.*

■ Discloses observations or concerns related to hazards and errors in care or the practice environment to the appropriate level.

■ Maintains communication with other members of the interprofessional team to minimize risks associated with transfers and transition in care delivery.

■ Documents referrals, including provisions for continuity of care.

■ Contributes her or his own professional perspective in discussions with the interprofessional team.

■ Documents plan of care communications, rationales for changes, and collaborative discussions to improve nursing care.

*(BHE.MONE06)

Standard 12. Leadership

The psychiatric-mental health registered nurse provides leadership in the professional practice setting and the profession.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Oversees the nursing care given by others while retaining accountability for the quality of care given to the healthcare consumer.

■ Abides by the vision, the associated goals, and the plan to implement and measure progress of an individual healthcare consumer or progress within the context of the healthcare organization.

■ Demonstrates a commitment to continuous lifelong learning and education for self and others.

■ Mentors colleagues for the advancement of nursing practice, the profession, and quality health care.

■ Treats colleagues with respect, trust, and dignity.*

■ Develops communication and conflict resolution skills.

■ Participates in professional organizations.

■ Communicates effectively with the healthcare consumer and colleagues.

■ Seeks ways to advance nursing autonomy and accountability.*

■ Participates in efforts to influence healthcare policy involving healthcare consumers and the profession.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Influences decision-making bodies to improve the professional practice environment and healthcare consumer outcomes.

■ Influences health policy to promote person-centered, recovery–oriented services for prevention and treatment of mental health problems and psychiatric disorders.

■ Provides direction to enhance the effectiveness of the interprofessional team.

■ Designs innovations to effect change in practice and improve health outcomes.

■ Promotes advanced practice nursing and role development by interpreting its role for healthcare consumers, families, and others.

■ Models expert practice to interprofessional team members and healthcare consumers.

■ Mentors colleagues in the acquisition of clinical knowledge, skills, abilities, and judgment.

(* BHE.MONE06)

Standard 13. Collaboration

The psychiatric-mental health registered nurse collaborates with the healthcare consumer, family, interprofessional health team, and others in the conduct of nursing practice.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Shares knowledge and skills with peers and colleagues as evidenced by such activities as healthcare conferences or presentations at formal or informal meetings.

■ Provides peers with feedback regarding their practice and role performance.

■ Interacts with peers and colleagues to enhance one’s own professional nursing practice and role performance.

■ Maintains compassionate and caring relationships with peers and colleagues.

■ Contributes to an environment that is conducive to the education of healthcare professionals.

■ Contributes to a supportive and healthy work environment.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Models expert practice to interprofessional team members and healthcare consumers.

■ Mentors other registered nurses and colleagues as appropriate.

■ Participates in interprofessional teams that contribute to role development and advanced nursing practice and health care.

■ Partners with other disciplines to enhance health care through interprofessional activities such as education, consultation, management, technological development, or research opportunities.

■ Facilitates an interprofessional process with other members of the healthcare team.

Standard 14. Professional Practice Evaluation

The psychiatric-mental health registered nurse evaluates one’s own practice in relation to the professional practice standards and guidelines, relevant statutes, rules, and regulations.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Applies knowledge of current practice standards, guidelines, statutes, rules, and regulations.

■ Engages in self-evaluation of practice on a regular basis, identifying areas of strength as well as areas in which professional development would be beneficial.

■ Obtains informal feedback regarding practice from healthcare consumers, peers, professional colleagues, and others.

■ Participates in systematic peer review as appropriate.

■ Takes action to achieve goals identified during the evaluation process.

■ Provides rationale for practice beliefs, decisions, and actions as part of the informal and formal evaluation processes.

■ Seeks formal and informal constructive feedback from peers and colleagues to enhance psychiatric-mental health nursing practice or role performance.

■ Provides peers with formal and informal constructive feedback to enhance psychiatric- mental health nursing practice or role performance.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Engages in a formal process seeking feedback regarding one’s own practice from healthcare consumers, peers, professional colleagues, and others.

■ Models self-improvement by reflecting on and evaluating one’s own practice and role performance, and sharing insights with peers and professional colleagues.

Standard 15. Resource Utilization

The psychiatric-mental health registered nurse considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing services.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Evaluates factors such as safety, effectiveness, availability, cost–benefit, efficiencies, and impact on practice when choosing practice options that would result in the same expected outcome.

■ Assists the healthcare consumer and family in identifying and securing appropriate and available services to address health-related needs.

■ Assists the healthcare consumer and family in factoring in costs, risks, and benefits in decisions about treatment and care.

■ Assigns or delegates elements of care to appropriate healthcare workers, based on the needs and condition of the healthcare consumer, potential for harm, stability of the healthcare consumer’s condition, complexity of the task, and predictability of the outcome.

■ Assists the healthcare consumer and family in becoming informed about the options, costs, risks, and benefits of treatment and care.

■ Advocates for resources that promote quality care, including technologies.

■ Identifies the evidence when evaluating resources.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Utilizes organizational and community resources to formulate interprofessional plans of care.

■ Formulates innovative solutions for healthcare consumer problems that address effective resource utilization and maintenance of quality.

■ Designs evaluation strategies to demonstrate quality, cost effectiveness, cost–benefit, and efficiency factors associated with nursing practice.

■ Builds constructive relationships with hospital and community providers, organizations, and systems to promote collaborative decision-making and planning to identify and meet resource needs.

Standard 16. Environmental Health

The psychiatric-mental health registered nurse practices in an environmentally safe and healthy manner.

Competencies

The psychiatric-mental health registered nurse (PMH-RN):

■ Attains knowledge of environmental health concepts, such as implementation of environmental health strategies.

■ Promotes a practice environment that reduces environmental health risks for workers and healthcare consumers.

■ Assesses the practice environment for factors such as sounds, odors, noises, and lights that threaten health.

■ Advocates for the judicious and appropriate use of products in health care.

■ Communicates environmental health risks and exposure reduction strategies to healthcare consumers, families, colleagues, and communities.

■ Utilizes scientific evidence to determine if a product or treatment is an environmental threat.

■ Participates in strategies to promote healthy communities.

Additional competencies for the psychiatric-mental health advanced practice registered nurse

The psychiatric-mental health advanced practice registered nurse (PMH-APRN):

■ Creates partnerships that promote sustainable environmental health policies and conditions.

■ Analyzes the impact of social, political, and economic influences on the environment and human health exposures. Critically evaluates the manner in which environmental health issues are presented by the popular media.

■ Advocates for implementation of environmental principles for nursing practice.

■ Supports nurses in implementing environmental principles in nursing practice.

Glossary

Assessment. A systematic, dynamic process by which the registered nurse collects and analyzes data received through interaction with the healthcare consumer, family, groups, communities, populations, and healthcare providers. Assessment may include the following dimensions: physical, psychological, socio-cultural, spiritual, cognitive, functional abilities, developmental, economic, and lifestyle.

Caregiver. A person who provides direct care for another, such as a child, dependent adult, the disabled, or the chronically ill.

Code of ethics. A list of provisions that makes explicit the primary goals, values, and obligations of the profession.

Comorbidity. The simultaneous occurrence of more than one disease or condition in the same client. One condition may cause the other or make the client more vulnerable to it; the comorbidities may be induced by common factors; or, they may be unrelated.

Continuity of care. An interprofessional process that includes healthcare consumers, families, and significant others in the development of a coordinated plan of care. This process facilitates the healthcare consumer’s transition between settings and healthcare providers, and is based on changing needs and available resources.

Criteria. Relevant, measurable indicators of the standards of practice and professional performance.

Diagnosis. A clinical judgment about a healthcare consumer’s response to actual or potential health conditions or needs. The diagnosis may be framed in terms of a problem, issue, or target behavior that provides the basis for determination of a plan to achieve expected outcomes. Registered nurses utilize nursing and/or medical diagnoses depending on educational and clinical preparation and legal authority.

Environment. The atmosphere, milieu, or conditions in which an individual lives, works, or plays and in which the registered nurse practices.

Evaluation. The process of determining the healthcare consumer’s progress toward attainment of expected outcomes and the effectiveness of the registered nurse’s care and interventions.

Evidence-based practice. Applying the best available synthesis of research results (the evidence) when making healthcare decisions. Healthcare professionals engaged in evidence- based practice use research evidence along with clinical expertise and patient preferences. Systematic reviews (summaries of healthcare research results) provide information that aids in the process of evidence-based practice. (Adapted from AHRQ, n.d.)

Expected outcomes. Behaviorally-focused, measurable, individual, family, or community states or perceptions that indicate desirable results. Outcomes are measured along a continuum and are responsive to nursing interventions.

Family. Family of origin or significant others as identified by the healthcare consumer.

Guidelines. Systematically developed statements that describe recommended actions based on available scientific evidence and expert opinion. Clinical guidelines describe a process of health care management that has the potential of improving the quality of clinical and consumer decision-making.

Health. An experience that is often expressed in terms of wellness and illness, and may occur in the presence or absence of disease or injury.

Healthcare consumer. The person, client, family, group, community, or population who is the focus of attention and to whom the registered nurse is providing services as sanctioned by the state regulatory bodies.

Healthcare providers. Individuals with special expertise who provide healthcare services or assistance to healthcare consumers. They may include nurses, physicians, psychologists,

social workers, nutritionist/dietitians, and various therapists.

Holistic. Treatment based on recognizing the interconnectedness of the physical, mental, social, and spiritual aspects of a healthcare consumer and that these factors all need to be included in an individual’s treatment plan and nursing interventions.

Illness. The subjective experience of discomfort.

Implementation. Activities such as teaching, monitoring, providing, counseling, delegating, and coordinating.

Interprofessional. Reliant on the overlapping skills and knowledge of each team member and discipline, resulting in synergistic effects where outcomes are enhanced and more comprehensive than the simple aggregation of the team members’ individual efforts.

Knowledge. Information that is synthesized so that relationships are identified and formalized.

Mental disorder. Any condition of the brain that adversely affects a person’s cognition, emotions, or behavior.

Mental health. Emotional and psychological wellness; the capacity to interact with others, deal with ordinary stress, and perceive one’s surroundings realistically.

Milieu therapy. A therapeutic milieu is a safe, welcoming, supportive, and functional physical treatment environment (McLoughlin et al10). Milieu therapy includes the nursing interventions used to assist healthcare consumers to make positive change and promote recovery by providing empathy, assisting in problem solving, acting as a role model, demonstrating leadership, confronting discrepancies when necessary, encouraging self- efficacy, decreasing stimuli when necessary, and manipulating the environment such that the above interventions can be effective (Delaney06; Yurkovich89).

Multidisciplinary. Reliant on each team member or discipline; contributing discipline-specific skills.

Nursing process. A critical thinking model used by nurses that comprises the integration of the singular, concurrent actions of these six components: assessment, diagnosis, identification of outcomes, planning, implementation, and evaluation.

Peer review. A collegial, systematic, and periodic process by which registered nurses are held accountable for practice, which fosters the refinement of one’s knowledge, skills, and decision making at all levels and in all areas of practice.

Plan. A comprehensive outline of the steps that need to be completed to attain expected outcomes.

Psychiatric disorder. Any condition of the brain that adversely affects a person’s cognition, emotions, or behavior.

Psychiatric-mental health nursing. A specialized area of nursing practice committed to promoting mental health through the assessment, diagnosis, and treatment of human responses to mental health problems and psychiatric disorders.

Psychotherapy. A general term used to describe the process of treating health care consumers with mental health issues or psychiatric disorders. Psychiatric-mental health advanced practice nurses, clinical psychologists, psychiatrists, and clinical social workers all engage in psychotherapy. There are many specific types of psychotherapy, including cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), group therapy, psychoanalytic therapy, and client-centered therapy.

Quality of care. The degree to which health services for consumers, families, groups, communities, or populations increase the likelihood of desired outcomes and are consistent with current professional knowledge.

Recovery. Refers to the process in which people are able to live, work, learn, and participate fully in their communities. For some individuals, recovery implies the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete

remission of symptoms (US DHHS, p.703).

Recovery-oriented. The care psychiatric caregivers and practitioners offer in support of the healthcare consumer’s recovery. It embeds the language, spirit, and culture of recovery with the caregivers themselves and with the healthcare consumers and their families. Recovery- oriented interventions focus on the healthcare consumer’s goals as he or she defines them and focuses on the healthcare consumer as a leader or guide of the care process to the fullest extent possible. Recovery-oriented care focuses on utilizing strengths of the healthcare consumer in identifying and addressing barriers to wellness and gaining health.

Standard. An authoritative statement defined and promoted by the profession, by which the quality of practice, service, or education can be evaluated.

Stigma. The extreme disapproval of, or discontent with, a person on the grounds of characteristics that distinguish them from other members of society. Stigma may be attached to a person who differs from social or cultural norms. Social stigma can result from the perception or attribution, rightly or wrongly, of mental disorder, physical disabilities, diseases, illegitimacy, sexual orientation, gender identity, skin tone, nationality, ethnicity, religion (or lack of religion) and criminality, thus, promoting a negative stereotype about a group of people.

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Abbreviations

AACN American Association of Colleges of Nursing

ACE Adverse childhood events

ACT Assertive community treatment

ANA American Nurses Association

ANCC American Nurses Credentialing Center

APRN Advanced practice registered nurse

APNA American Psychiatric Nurses Association

CBT Cognitive behavioral therapy

CDC Centers for Disease Control and Prevention

CMS Centers for Medicare and Medicaid Services

CNM Certified nurse midwife

CNP Certified nurse practitioner

CNS Clinical nurse specialist

CRNA Certified registered nurse anesthetist

DHHS Department of Health and Human Services

DNP Doctor of Nursing Practice

DSM-IV Diagnostic and Statistical Manual, 4th Edition

DSM-5 Diagnostic and Statistical Manual, 5th Edition

EHR Electronic health record

HIPAA Health Insurance and Accountability Act of 1996

IOM Institute of Medicine

ISPN International Society of Psychiatric-Mental Health Nurses

LACE Licensure, accreditation, certification, and education

MHPAEA Mental Health Parity and Addiction Equity Act of 2008

NACHC National Association of Community Health Centers

NAMI National Alliance for the Mentally Ill

NCSBN National Council of State Boards of Nursing

NIH National Institutes of Health

NIMH National Institute of Mental Health

NMHA National Mental Health Act of 1946

NONPF National Organization of Nurse Practitioner Faculty

NP Nurse practitioner

PCLN Psychiatric consultation liaison nurse or nursing

PMH Psychiatric-mental health

PMH-APRN Psychiatric-mental health advanced practice registered nurse

PMH-CNS Psychiatric-mental health clinical nurse specialist

PMH-NP Psychiatric-mental health nurse practitioner

PMH-RN Psychiatric-mental health registered nurse

PPACA Patient Protection and Affordable Care Act

PTSD Post-traumatic stress disorder

QSEN Quality and Safety Education for Nurses

RA Rheumatoid arthritis

RTP Recovery to Practice

SAMHSA Substance Abuse and Mental Health Services Administration

SMI Serious mental illness

SUD Substance use disorders

WHO World Health Organization

Appendix A

Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Appendix A: Psychiatric–Mental Health Nursing: Scope and Standards of Practice (2007)

This appendix is not current and is of historical significance only.

Index

Note: Entries with [2007] indicate content from Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2007), reproduced in Appendix A. That information is not current but included for historical purposes only.

A

Abilities in PMH nursing practice

See also Knowledge, skills, and abilities

Ability to answer

Accountability in PMH nursing practice

Accreditation

Achieving the Promise: Transforming Mental Health Care in America

ACT. See Assertive community treatment (ACT)

Acute care, models of

Acute inpatient care

Administration in PMH nursing practice

Adolescents, psychiatric disorders in

Adults

psychiatric disorders in

substance abuse disorders in

Advanced practice registered nurses (APRNs) in PMH nursing practice

accreditation

certification

competencies

assessment

collaboration

collegiality

consultation

coordination of care

diagnosis

education

environmental health

ethics

evaluation

evidence-based practices and research

health teaching and health promotion

implementation

leadership

outcomes identification

planning

prescriptive authority and treatment

professional practice evaluation

psychotherapy

quality of practice

research

resource utilization

Consensus Model for

education

licensure

origins of role

roles and responsibilities

administration, education and research practice

case management

clinical supervision

primary care

psychiatric consultation-liaison nursing

psychotherapy

self-employment

Advocacy in PMH nursing

Adverse childhood effects (ACE)

Age-specific issues in PMH nursing practice. See Children; Older adults.

Alzheimer’s disease

American Nurses Association (ANA)

American Nurses Credentialing Center (ANCC)

American Psychiatric Nurses Association (APNA), ix

ANA. See American Nurses Association (ANA)

Analysis. See Critical thinking

ANCC. See American Nurses Credentialing Center (ANCC)

Anxiety

APNA. See American Psychiatric Nurses Association (APNA)

Assertive community treatment (ACT)

Assessment in PMH nursing practice

assessment data

competencies involving

defined

Standard of Practice

[2007]

Attitudes in PMH nursing

B

Battle fatigue

Bipolar disorder

C

Care coordination in PMH nursing practice

See also Coordination of care

Care delivery in PMH nursing practice

See also Coordination of care

Care recipients. See Healthcare consumers

Caregiver, defined

Case management

CBT. See Cognitive behavioral therapy (CBT)

Centers for Disease Control and Prevention (CDC)

Centers for Medicare and Medicaid Services (CMS)

Certification and credentialing in PMH nursing practice

Certified nurse midwife (CNM)

Certified nurse practitioner (CNP)

Certified registered nurse anesthetist (CRNA)

Children

psychiatric disorders in

serious emotional disorder in

Clients. See Healthcare consumers

Clinical nurse specialist (CNS)

Clinical practice settings

Clinical settings in PMH nursing practice. See practice environments and settings

Clinical supervision

CMS. See Centers for Medicare and Medicaid Services (CMS)

CNM. See Certified nurse midwife (CNM)

CNP. See Certified nurse practitioner (CNP)

CNS. See Clinical nurse specialist (CNS)

Code of ethics, defined

Code of Ethics for Nurses with Interpretive Statements

Cognitive behavioral therapy (CBT)

Collaboration in PMH nursing practice

competencies involving

defined

Standard of Professional Performance

[2007]

See also Communication

Collegiality in PMH nursing practice

Commitment in PMH nursing practice

Communication in PMH nursing practice

competencies involving

defined

Standard of Professional Performance

See also Collaboration

Community Mental Health Centers Act of 1963

Community-based care

Comorbidity in PMH nursing practice

defined

substance abuse and

Competencies in PMH nursing practice

for APRNs

assessment

collaboration

collegiality

communication

coordination of care

diagnosis

education

environmental health

ethics

evaluation

evidence-based practices and research

health teaching and health promotion

implementation

leadership

milieu therapy

outcomes identification

pharmacological, biological, and integrative therapies

planning

professional practice evaluation

quality of practice

research

resource utilization

for RNs

therapeutic relationship and counseling

See also Standards of Practice; Standards of Professional Performance

Consensus Model and APRN roles

Confidentiality and privacy in PMH nursing practice

See also Ethics

Consultation in PMH nursing practice

competencies involving

defined

Standard of Practice

[2007]

See also Psychiatric consultation–liaison nursing.

Continuity of care, defined

Coordination of care in PMH nursing practice

competencies involving

defined

Standard of Practice

[2007]

Cost and economic controls in PMH nursing practice

Credentialing. See Certification and credentialing

Crisis intervention

Criteria in PMH nursing practice assessment, [2007]

collegiality

consultation

coordination of care

defined

diagnosis

education

ethics

evaluation

health teaching and health promotion

implementation

milieu therapy

outcomes

outcomes identification

pharmacological, biological, and integrative therapies

prescriptive authority and treatment

psychotherapy

quality of practice

Critical thinking in PMH nursing

See also Evidence-based practices and research; Knowledge, skills, and abilities; Nursing process

CRNA. See Certified registered nurse anesthetist (CRNA)

D

Data and information in PMH nursing practice

See also Assessment

Data systems

“Decade of the Brain”

Delegation in PMH nursing practice

Dementias

Diagnosis in PMH nursing practice

competencies involving

defined

Standard of Practice

[2007]

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Disaster PMH nursing

Documentation in PMH nursing practice

competencies involving

Duties to self and others

E

Early intervention

Education in PMH nursing practice

APRNs

competencies involving

defined

Standard of Professional Performance

[2007]

Education of healthcare consumers and others

See also Health teaching and health promotion

Environment, defined

Environmental health in PMH nursing practice

competencies involving

defined

Standard of Professional Performance

Ethics in PMH nursing practice

competencies involving

provisions

advancement of nursing profession

advocacy for

collaboration to meet health needs

commitment to healthcare consumers

contributions to healthcare environments

duties to self and others

promotion of nursing profession

respect for individuals

responsibility and accountability for practice

Standard of Professional Performance

[2007]

Evaluation in PMH nursing practice

competencies involving

defined

Standard of Practice

[2007]

See also Professional practice evaluation

Evidence-based practices and research in PMH nursing practice

competencies involving

current issues and trends

defined

Standards of Professional Performance

Expected outcomes, defined

F

Families in PMH nursing practice

acute care and

alliance with

collaboration with

communication with

community-based care and

current issues and trends

environmental health and

health teaching and health promotion

history

integrative programs and

milieu therapy and

prevalence of mental disorders and

psychotherapy

public health care model and

recovery/wellness and

See also Healthcare consumers

Family, defined

Forensic mental health

The Future of Nursing: Leading Change to Advance Health

H

Health, defined

Health information technology (HIT)

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Health teaching and health promotion in PMH nursing practice

competencies involving

defined

Standard of Practice

[2007]

Healthcare consumers

acute inpatient care

advocacy for

clinical supervision

commitment to

communication with

community-based care for

consultation

counseling for

defined

education of

early intervention

ethical issues and

integrated care for

milieu therapy for

partial hospitalization and intensive outpatient care

partnership with

pharmacological, biological, and integrative therapies for

primary care

psychotherapy

recovery and wellness of

responsibility and accountability to

safety for

screening

See also Families

Healthcare providers, defined

HIPAA. See Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Hispanic population

psychiatric disorders in

HIT. See Health information technology (HIT)

Holistic, defined

I

Illness, defined

Implementation in PMH nursing practice

competencies involving

defined

Standard of Practice

[2007]

Institute of Medicine (IOM)

Integrative programs and therapies

interventions

Intensive outpatient treatment

Interdisciplinary processes and teams in PMH nursing

See also Collaboration; Interprofessional

International Society of Psychiatric-Mental Health Nursing, ix

Intermediate and long-term care

Interpersonal Relations in Nursing

Interprofessional, defined

Interprofessional processes and teams in PMH nursing

Interventions in PMH nursing practice

competencies involving

crisis interventions

defined

psychopharmaceutical interventions

psychotherapy interventions

J

Judgment in PMH nursing

See also Knowledge, skills, and abilities

K

Knowledge, defined

Knowledge, skills, and abilities in PMH nursing practice

See also Critical thinking; Education; Evidence-based practices and research

L

LACE (Licensure, Accreditation, Certification and Education), Consensus Model, and APRN roles

Latino population

Laws and regulations in PMH nursing practice

Leadership in PMH nursing practice

competencies involving

defined

Standard of Professional Performance

[2007]

Leading Change

Liaison

Licensing and licensure in PMH nursing practice

Long-term care

M

Measurement criteria. See Criteria

Medicaid

Medicare

Mental disorders

in adolescents

in children

defined

disparities among diverse populations

disparities in treatment of

mortality rate

in older adults

prevalence of

across lifespan

Mental health care

disparities in treatment

physical health and

public health model

technology of

workforce requirements

rural

Mental health, defined

Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)

MHPAEA. See Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)

Milieu therapy in PMH nursing practice

competencies involving

defined

Standard of Practice

[2007]

Minority populations

psychiatric disorders in

Multidisciplinary, defined

See also Interprofessional

N

National Alliance for the Mentally Ill

National Council on Disabilities

National Institute of Mental Health (NIMH)

National Mental Health Act (NMHA)

National Mental Health Act of 1946 (NMHA)

National Organization of Nurse Practitioner Faculty (NONPF)

NIMH. See National Institute of Mental Health (NIMH)

NMHA. See National Mental Health Act of 1946 (NMHA)

NONPF. See National Organization of Nurse Practitioner Faculty (NONPF)

Nurse practitioners

Nursing competence. See Competencies

Nursing education. See Education

Nursing Mental Disease

Nursing process

defined

competencies involving

See also Standards of Practice

Nursing’s Social Policy Statement

O

Older adults, psychiatric disorders in

Outcomes identification in PMH nursing

competencies involving

defined

Standard of Practice

[2007]

See also Planning

Outpatient treatment

P

Partial hospitalization

Patient Protection and Affordable Care Act (PPACA)

Patients. See Healthcare consumers

PCLN. See Psychiatric consultation-liaison nursing (PCLN)

Peer review in PMH nursing practice

Pharmacological, biological, and integrative therapies in PMH nursing practice

competencies involving

defined

intergrative therapies

psychopharmacological therapies

Standard of Practice

[2007]

See also Prescriptive authority and treatment

Pharmacological, biological, and integrative therapies, Standard of Practice [2007]

Phenomena of concern

Plan, defined

Planning in PMH nursing practice

competencies involving

plan defined

Standard of Practice

[2007]

See also Implementation; Outcomes identification

Post-traumatic stress order (PTSD)

PPACA. See Patient Protection and Affordable Care Act (PPACA)

Practice environments and settings for PMH nursing practice

acute inpatient care

assertive community treatment

community-based care

crisis intervention

intensive outpatient treatment

intermediate and long-term care

partial hospitalization

psychiatric emergency services

residential services

Prescriptive authority and treatment in PMH nursing

competencies involving

Standard of Practice

[2007]

See also Pharacological, biological, and integrative therapies

President’s New Freedom Commission

Preventing Mental, Emotional and Behavioral Disorders among Young People

Prevention and treatment in PMH nursing practice

collaboration

health teaching and health promotion

integrative programs

planning

primary prevention

secondary prevention

Primary care

Professional practice evaluation in PMH nursing practice

competencies involving

defined

Standard of Professional Performance

[2007]

See also Peer review

Program development and management

PSTD

Psychiatric clinical nurse specialists

Psychiatric consultation-liaison nursing (PCLN)

Psychiatric disorder, defined

Psychiatric emergency services

Psychiatric-mental health advanced practice registered nurse (PMH-APRN)

accreditation

certification

competencies

assessment

collaboration

collegiality

consultation

coordination of care

diagnosis

education

environmental health

ethics

evaluation

evidence-based practices and research

health teaching and health promotion

implementation

leadership

outcomes identification

planning

prescriptive authority and treatment

professional practice evaluation

psychotherapy

quality of practice

research

resource utilization

Consensus Model for

education

licensure

origins of role

roles and responsibilities

administration, education and research practice

case management

clinical supervision

primary care

psychiatric consultation-liaison nursing

psychotherapy

self-employment

Psychiatric-mental health clinical nurse specialist (PMHCHNS)

Psychiatric-Mental Health Nurse Practitioner Competencies

Psychiatric-mental health (PMH) nurses

phenomena of concern for

roles and responsibilities of

safety for

specialized areas of practice

disaster PMH nursing

forensic mental health

integrative programs

telehealth

Psychiatric-mental health (PMH) nursing

current issues and trends

defined

ethical issues in

advancement of nursing profession

advocacy for

collaboration to meet health needs

commitment to healthcare consumers

contributions to healthcare environments

duties to self and others

promotion of nursing profession

respect for individuals

responsibility and accountability for practice

history and evolution of

in mental health system transformation

opportunities in

origins of

scope of practice

specialized areas of practice

acute inpatient care

assertive community treatment

clinical practice settings

community-based care

crisis intervention and psychiatric emergency services

disaster mental health

forensic mental health

integrative programs

intermediate and long-term care

partial hospitalization and intensive outpatient care

primary care

residential services

self-employment

telehealth

Psychiatric-mental health (PMH) nursing practice

clinical settings

acute inpatient care

assertive community treatment

community-based care

crisis intervention

intensive outpatient treatment

intermediate and long-term care

partial hospitalization

psychiatric emergency services

residential services

current issues and trends

disparities among diverse populations

evidence-based practice and lifelong learning

leadership in transforming mental health system

prevalence of mental disorders across lifespan

prevention

role of national data systems to improve quality

safety for patients and for PMH nurses

history and evolution of

levels of

case management

clinical supervision

consultation and liaison

PMH advanced practice registered nurse

PMH registered nurse

program development and management

psychopharmacological interventions

psychotherapy

scope of

Psychiatric-mental health registered nurse (PMH-RN)

competencies

assessment

collaboration

collegiality

communication

coordination of care

diagnosis

education

environmental health

ethics

evaluation

evidence-based practices and research

health teaching and health promotion

implementation

leadership

milieu therapy

outcomes identification

pharmacological, biological, and integrative therapies

planning

professional practice evaluation

quality of practice

research

resource utilization

therapeutic relationship and counseling

roles and responsibilities

Psychopharmacology in PMH nursing practice interventions

Psychotherapy in PMH nursing practice

competencies involving

defined

PHM nursing practice and

Standard of Practice [2007]

Public health care model

early intervention

emerging models of acute care

integrated care

person-centered, recovery-oriented

screening

Public health model

technology

workforce requirements

Q

Quality and Safety Education for Nurses (QSEN) Institute

Quality of care in PMH nursing practice

Quality of practice in PMH nursing practice

competencies involving

defined

Standard of Professional Performance [2007]

R

Recipient of care. See Healthcare consumers

Recovery

defined

Recovery to practice (RTP)

Recovery-oriented, defined

Registered nurses, (RNs) in PMH nursing practice

competencies

assessment

collaboration

collegiality

communication

coordination of care

diagnosis

education

environmental health

ethics

evaluation

evidence-based practices and research

health teaching and health promotion

implementation

leadership

milieu therapy

outcomes identification

pharmacological, biological, and integrative therapies

planning

professional practice evaluation

quality of practice

research

resource utilization

therapeutic relationship and counseling

roles and responsibilities

Regulations. See Laws and regulations

Research in PMH nursing practice

competencies involving

current issues and trends

Standard of Professional Performance

[2007]

See also Evidence-based practices and research

Residential services

Resource utilization in PMH nursing practice

competencies involving

defined

Standard of Professional Performance

[2007]

Respect for individuals

Responsibility in PMH nursing practice

Rheumatoid arthritis

Rural mental health care

S

Safety

Quality and Safety Education for Nurses (QSEN)

SAMHSA. See Substance Abuse and Mental Health Services Administration (SAMHSA)

Schizophrenia

Schizophrenic spectrum disorders

Scope of PMH nursing practice

Screening

Self-employment

Serious emotional disorder (SED)

Serious mental illness (SMI)

Settings for PMH practice. See Practice environments and settings

SMI. See Serious mental illness (SMI)

Standard, defined

Standards of Practice for PMH Nursing

assessment

consultation

coordination of care

diagnosis

evaluation

health teaching and health promotion

implementation

milieu therapy

outcomes identification

pharmacological, biological, and integrative therapies

planning

prescriptive authority and treatment

psychotherapy

therapeutic relationship and counseling

Standards of Professional Performance for PMH Nursing

collaboration

collegiality

communication

education

environmental health

ethics

evidence-based practice and research

leadership

professional practice evaluation

quality of practice

resource utilization

Standards of Psychiatric-Mental Health Nursing Practice

Stigma, defined

Substance Abuse and Mental Health Services Administration (SAMHSA)

Substance use disorders (SUD)

assessment and treatment of

comorbidities

co-occurring disorders

interventions

prevalence of

Substance-related and addictive disorders

SUD. See Substance use disorders (SUD)

T

Teams and teamwork. See Interdisciplinary; Interprofessional

Telehealth

Therapeutic relationship and counseling in PMH nursing practice

competencies involving

defined

Standard of Practice

W

Wellness

WHO. See World Health Organization (WHO)

Work and practice environments for PMH nursing practice. See Clinical Settings; Practice environments and settings

Workforce requirements

World Health Organization (WHO)