Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D., & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122–131.

QSEN has underscored the need to increase knowledge about patient safety practices and the value of redesigning student learning experiences to improve the integration of this content (Sherwood & Hicks, 2011). Clinical simulations using sophisticated mannequins, combined with instructors who can provide realistic case scenarios and provide debriefing through videotaped patient care sessions are useful in safely identifying and reinforcing quality care concepts. Self-directed computer-based simulation programs are also popular and effective. These programs portray virtual clinical settings and may use avatars to offer students a chance to implement their knowledge, skills, and attitudes without the potential for patient harm (Durham & Sherwood, 2008).

Suggestions for the use of QSEN competencies in the discussion of Standards of Practice can be found in “Competency Knowledge, Skills, Attitudes (KSAs) (Pre-Licensure)” at the website www.qsen.org/competencies/pre-licensure-ksas/.

The following sections describe the Standards of Practice, which “describe a competent level of psychiatric-mental health nursing care as demonstrated by the critical thinking model known as the nursing process (ANA et al., 2007).” The Standards of Practice and Professional Performance are listed on the inside back cover of this book.

Standard 1: Assessment

A view of the individual as a complex blend of many parts is consistent with nurses’ holistic approach to care. Nurses who care for people with physical illnesses ideally maintain a holistic view that involves an awareness of psychological, social, cultural, and spiritual issues. Likewise, nurses who work in the psychiatric mental health field need to assess or have access to past and present medical history, a recent physical examination, and any physical complaints, as well as document any observable physical conditions or behaviors (e.g., unsteady gait, abnormal breathing patterns, wincing as if in pain, doubling over to relieve discomfort).

The assessment process begins with the initial patient encounter and continues throughout the care of the patient. To develop a basis for the plan of care and in preparation for discharge, every patient should have a thorough, formal nursing assessment on entering treatment. Subsequent to the formal assessment, data is collected continually and systematically as the patient’s condition changes and—hopefully—improves. Perhaps the patient came into treatment actively suicidal, and the initial focus of care was on protection from injury; through regular assessment, it may be determined that although suicidal ideation has diminished, negative self-evaluation is still certainly a problem.

Assessments are conducted by a variety of professionals, including nurses, psychiatrists, social workers, dietitians, and other therapists. Virtually all facilities have standardized nursing assessment forms to aid in organization and consistency among reviewers. These forms may be paper or electronic versions, according to the resources and preferences of the institution. The time required for the nursing interview—a standard aspect of the formal nursing assessment—varies, depending on the assessment form and the patient’s response pattern (e.g., a patient who is lengthy or rambling, is prone to tangential thought, has memory disturbances, or gives markedly slowed responses). Refer to Chapter 9 for sound guidelines for setting up and conducting a clinical interview.

In emergency situations, immediate intervention is often based on a minimal amount of data. In all situations, however, the patient, who must also receive a copy of the Health Insurance Portability and Accountability Act (HIPAA) guidelines, gives legal consent. Essentially, the purpose of the HIPAA privacy rule is to ensure that an individual’s health information is properly protected, while at the same time allowing health care providers to obtain personal health information for the purpose of providing and promoting high-quality health care (USDHHS, 2003). HIPAA was first enacted in 1996, but compliance was not mandated until April 14, 2003. Chapter 7 has a more detailed discussion of HIPAA. Visit www.hhs.gov/ocr/privacy/hipaa/understanding/index.html for a full overview.

In patient-centered care, the nurse’s primary source for data collection is the patient; however, there may be times when it is necessary to supplement or rely completely on another for the assessment information. These secondary sources can be invaluable when caring for a patient experiencing psychosis, muteness, agitation, or catatonia. Such secondary sources include members of the family, friends, neighbors, police, health care workers, and medical records.

The best atmosphere in which to conduct an assessment is one of minimal anxiety; therefore, if an individual becomes upset, defensive, or embarrassed regarding any topic, the topic should be abandoned. The nurse can acknowledge that the subject makes the patient uncomfortable and suggest within the medical record that the topic be discussed when the patient feels more comfortable. It is important that nurses not probe, pry, or push for information that is difficult for the patient to discuss; however, it should be recognized that increased anxiety about any subject is data in itself. The nurse can note this in the assessment without obtaining any further information.

Age considerations

Assessment of children

An effective interviewer working with children should have familiarity with basic cognitive and social/emotional developmental theory and have some exposure to applied child development (Sommers-Flanagan & Sommers-Flanagan, 2009).

The role of the caretaker is central in the interview; however, when assessing children, it is important to gather data from a variety of sources. Although the child is the best source in determining inner feelings and emotions, the caregivers (parents or guardians) often can best describe the behavior, performance, and conduct of the child. Caregivers also are helpful in interpreting the child’s words and responses, but a separate interview is advisable when an older child is reluctant to share information, especially in cases of suspected abuse (Arnold & Boggs, 2011).

Developmental levels should be considered in the evaluation of children. One of the hallmarks of psychiatric disorders in children is the tendency to regress (i.e., return to a previous level of development). Although it is developmentally appropriate for toddlers to suck their thumbs, such a gesture is unusual in an older child.

One study found that children felt more comfortable if their health care provider was the same gender (Bernzweig et al., 1997). Another study indicated that although 60% of parents preferred that a man care for their children, 79% of the children, regardless of gender, requested that a female physician care for them (Waseem & Ryan, 2005). Age-appropriate communication strategies are perhaps the most important factor in establishing successful communication (Arnold & Boggs, 2011).

Assessment of children should be accomplished by a combination of interview and observation. Watching children at play provides important clues to their functioning. From a psychodynamic view, play is a safe area for the child to act out thoughts and emotions and can serve as a safe way in which children can release pent-up emotions—for example, having a child act out their story with the use of anatomically correct dolls or tell a story of their family using a family of dolls. Asking the child to tell a story, draw a picture, or engage in specific therapeutic games can be a useful assessment tool when determining critical concerns and painful issues a child may have difficulty expressing. Usually, a clinician with special training in child and adolescent psychiatry works with young children.

Assessment of adolescents

Adolescents are especially concerned with confidentiality and may fear that anything they say to the nurse will be repeated to their parents. Lack of confidentiality can become a barrier of care with this population. Adolescents need to know that their records are private; they should receive an explanation as to how information will be shared among the treatment team. Questions related to such topics as substance abuse and sexual abuse demand confidentiality (Arnold & Boggs, 2011); however, threats of suicide, homicide, sexual abuse, or behaviors that put the patient or others at risk for harm must be shared with other professionals, as well as with the parents. Because identifying risk factors is one of the key objectives when assessing adolescents, it is helpful to use a brief, structured interview technique such as the HEADSSS interview (Box 7-2).

BOX 7-2 THE HEADSSS PSYCHOSOCIAL INTERVIEW TECHNIQUE

H Home environment (e.g., relations with parents and siblings)

E Education and employment (e.g., school performance)

A Activities (e.g., sports participation, after-school activities, peer relations)

D Drug, alcohol, or tobacco use

S Sexuality (e.g., whether the patient is sexually active, practices safe sex, or uses contraception)

S Suicide risk or symptoms of depression or other mental disorder

S “Savagery” (e.g., violence or abuse in home environment or in neighborhood)

Assessment of older adults

As we get older, our five senses (taste, touch, sight, hearing, and smell) and brain function begin to diminish, but the extent to which this affects each person varies. Your patient may be a spry and alert 80-year-old or a frail and confused 60-year-old; therefore, it is important not to stereotype older adults and expect them to be physically and/or mentally deficient. For example, the tendency may be to jump to the conclusion that someone who is hard of hearing is cognitively impaired. By the same token, many older adults often need special attention. The nurse needs to be aware of any physical limitations—any sensory condition (difficulty seeing or hearing), motor condition (difficulty walking or maintaining balance), or medical condition (back pain, cardiac or pulmonary deficits)—that could cause increased anxiety, stress, or physical discomfort for the patient during assessment of mental and emotional needs.

It is wise to identify any physical deficits at the onset of the assessment and make accommodations for them. If the patient is hard of hearing, speak a little more slowly in clear, louder tones (but not too loud), and seat the patient close to you without invading his or her personal space. Often, a voice that is lower in pitch is easier for older adults to hear, although a higher-pitched voice may convey anxiety to some. Refer to Chapter 30 for more on assessing and communicating with the older adult.

Language barriers

It is becoming more and more apparent that psychiatric mental health nurses can best serve their patients if they have a thorough understanding of the complex cultural and social factors that influence health and illness. Awareness of individual cultural beliefs and health care practices can help nurses minimize stereotyped assumptions that can lead to ineffective care and interfere with the ability to evaluate care. There are many opportunities for misunderstandings when assessing a patient from a different cultural or social background from your own, particularly if the interview is conducted in English and the patient speaks a different language or a different form of English (Fontes, 2008).

Often health care professionals require a translator to understand the patient’s history and health care needs. There is a difference between an interpreter and a translator. An interpreter is more likely to unconsciously try to make sense of (interpret) what the patient is saying and therefore inserts his or her own understanding of the situation into the database. A professional translator, on the other hand, tries to avoid interpreting. DeAngelis (2010) strongly advises against the use of untrained interpreters such as family members, friends, and neighbors. These individuals might censor or omit certain content (e.g. profanity, psychotic thoughts, and sexual topics) due to fear or a desire to protect the patient. They can also make subjective interpretations based on their own feelings, share confidential details with outsiders, or leave out traumatic topics because they hit too close to home for them.

For patients who do not speak English or have language difficulties, federal law mandates the use of a trained translator (Arnold & Boggs, 2011). In fact, Poole and Higgo state that the “use of a trained translator is essential wherever the patient’s first language is not spoken English (even where the person has some English)” (2006, p. 135). A professionally trained translator is proficient in both English and the patient’s spoken language, maintains confidentiality, and follows specific guidelines. Unfortunately, professional translators are not always readily available in many health care facilities.

Psychiatric mental health nursing assessment

The purpose of the psychiatric mental health nursing assessment is to:

• Establish rapport

• Obtain an understanding of the current problem or chief complaint

• Review physical status and obtain baseline vital signs

• Assess for risk factors affecting the safety of the patient or others

• Perform a mental status examination

• Assess psychosocial status

• Identify mutual goals for treatment

• Formulate a plan of care

Gathering data

Review of systems.

The mind-body connection is significant in the understanding and treatment of psychiatric disorders. A primary care provider also gives many patients who are admitted for treatment of psychiatric conditions a thorough physical examination. Likewise, most nursing assessments include a baseline set of vital statistics, a historical and current review of body systems, and a documentation of allergic responses.

Poole and Higgo (2006) point out that several medical conditions and physical illnesses may mimic psychiatric illnesses (Box 7-3); therefore, physical causes of symptoms must be ruled out. Conversely, psychiatric disorders can result in physical or somatic symptoms such as stomachaches, headaches, lethargy, insomnia, intense fatigue, and even pain. When depression is secondary to a known medical condition, it often goes unrecognized and thus untreated. All patients who come into the health care system need to have both a medical and mental health evaluation to ensure a correct diagnosis and appropriate care.

BOX 7-3 SOME MEDICAL CONDITIONS THAT MAY MIMIC PSYCHIATRIC ILLNESS

Depression

Neurological disorders: