Implementing the Nursing Process: Standards of Practice and Professional Performance

Implementing the Nursing Process

Standards of Practice and Professional Performance

Gail W. Stuart

By establishing a therapeutic nurse–patient relationship and using the nursing process, the nurse promotes the patient’s mental health and well-being. This chapter discusses the Standards of Practice and the Standards of Professional Performance as described in Psychiatric–Mental Health Nursing: Scope and Standards of Practice (ANA, 2007).

Neither set of standards stands alone. Together they complete the picture of contemporary psychiatric nursing practice.

The Nursing Process

The nursing process is an interactive, problem-solving process and a systematic and individualized way to achieve the outcomes of nursing care. The nursing process respects the individual’s autonomy and freedom to make decisions and be involved in nursing care. The nurse and patient are partners in a relationship built on trust and directed toward maximizing the patient’s strengths, maintaining integrity, and promoting adaptive responses to stress. A nurse uses the nursing process with individuals, families, and groups at any point on the health-illness continuum. The needs of the patient will determine whether this process is directed toward primary, secondary, or tertiary prevention.

When used with psychiatric patients, the nursing process can present unique challenges. Mental health problems may be vague and elusive, not tangible or visible like many physiological illnesses. Many psychiatric patients may be unable to describe their problems. They may be withdrawn, highly anxious, or out of touch with reality. Their ability to participate in the problem-solving process also may be limited if they see themselves as powerless victims or if their illness impairs them from fully engaging in the treatment process.

It is essential that the nurse and the patient become partners in the problem-solving process. Nurses may be tempted to exclude patients, particularly if they resist becoming involved, but this should be avoided for two reasons. First, learning is most effective when patients participate in the learning experience. Second, by including patients as active participants in the nursing process, nurses help restore their sense of control over life and their responsibility for action. They reinforce the message that patients, whether they have an acute crisis or a serious and persistent mental illness, can choose either adaptive or maladaptive coping responses.

Most importantly, only if a nurse establishes a true partnership with a patient can problems fully be identified and an effective treatment plan developed. Most issues related to patient compliance are a result of a poor therapeutic alliance and a lack of mutually developed treatment goals and strategies.

Standards of Practice

The phases of the nursing process as described by the Standards of Practice in Psychiatric–Mental Health Nursing: Scope and Standards of Practice are assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Validation is part of each step, and all phases may overlap or occur simultaneously. The nursing conditions and nursing behaviors related to each of these phases are shown in Figure 11-1. Each of these phases, as it applies to psychiatric nursing practice, is now described.


Standard 1: Assessment

The psychiatric–mental health registered nurse collects comprehensive health data that are pertinent to the patient’s health or situation.

Key Elements

Identify the patient’s reason for seeking help.

Assess for risk factors related to the patient’s safety, including potential for the following:

Complete a biopsychosocial assessment of patient needs related to this treatment encounter, including the following:

Coping resources, including motivation for treatment and functional supportive relationships

In the assessment phase, information is obtained from the patient in a direct and structured manner through observations, interviews, and examinations. An assessment tool or nursing history form can provide a systematic format that becomes part of the patient’s written record. It should include the mental status examination (see Chapter 6).

The nurse also should use the most appropriate behavioral rating scales. These can help define current pretreatment aspects of the patient’s problems, increase the patient’s involvement in treatment, document the patient’s progress over time and the efficacy of the treatment plan, and compare the patient’s responses with those of groups of people with the same illness. This information can help formulate diagnoses and treatment plans, as well as document clinical outcomes of care.

The patient data identified in Standard 1 relate to all parts of the Stuart Stress Adaptation Model used in this text: predisposing factors, precipitating stressors, appraisal of stressors, coping resources, coping mechanisms, and coping responses as described in Chapter 3. The baseline data should include both content and process, and the patient is the ideal source of validation. The nurse should select a private place, free from noise and distraction, in which to interview the patient.

Interviewing is a goal-directed method of communication. It is required in a formal admission procedure and should be focused but open ended, progressing from general to specific and allowing spontaneous patient self-expression. The nurse’s role is to maintain the flow of the interview and to listen to the verbal and nonverbal messages conveyed by the patient. Nurses also must be aware of their responses to the patient.

Although the patient should be regarded as the primary source of validation, the nurse should be prepared to talk with family members or other people knowledgeable about the patient. This is particularly important when the patient is unable to provide reliable information because of the symptoms of the psychiatric illness. The nurse also might consider using a variety of other information sources, including the patient’s health care record, nursing rounds, change-of-shift reports, nursing care plan, and evaluation by other health professionals, such as psychologists, social workers, or psychiatrists.


Standard 2: Diagnosis

The psychiatric–mental health registered nurse analyzes the assessment data to determine diagnoses or problems, including level of risk.

Key Elements

Diagnoses should reflect adaptive and maladaptive coping responses based on nursing frameworks such as those of NANDA International (NANDA-I).

Diagnoses should incorporate health problems or disease states such as those identified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association [APA], 2000) and the International Classification of Diseases and Related Health Problems (World Health Organization [WHO], 1992).

Diagnoses should focus on the phenomena of concern to psychiatric–mental health nurses as described in Box 11-1.


• Promotion of optimal mental and physical health and well-being and prevention of mental illness

• Impaired ability to function related to psychiatric, emotional, and physiological distress

• Alterations in thinking, perceiving, and communicating because of psychiatric disorders or mental health problems

• Behaviors and mental states that indicate potential danger to self or others

• Emotional stress related to illness, pain, disability, and loss

• Symptom management, side effects to toxicities associated with self-administered drugs, psychopharmacological intervention, and other treatment modalities

• The barriers to treatment efficacy and recovery posed by alcohol and substance abuse and dependence

• Self-concept and body image changes, developmental issues, life process changes, and end-of-life issues

• Physical symptoms that occur along with altered psychological status

• Psychological symptoms that occur along with altered physiological status

• Interpersonal, organizational, sociocultural, spiritual, or environmental circumstances or events that have an effect on the mental and emotional well-being of the individual and family or community

• Elements of recovery, including the ability to maintain housing, employment, and social support, that help individuals reengage in seeking meaningful lives

• Societal factors such as violence, poverty, and substance abuse

Copyright © American Nurses Association. Reprinted with permission. All rights reserved.

After collecting all data, the nurse compares the information with documented norms of health and adaptation. Because standards of behavior are culturally determined, the nurse should consider both the patient’s individual characteristics and the characteristics of the larger social group to which the patient belongs. The nurse then analyzes the data and derives a nursing diagnosis. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes (NANDA, 2009).

The subject of nursing diagnoses is the patient’s behavioral response to stress. This response may lie anywhere on the coping continuum from adaptive to maladaptive. Phenomena of concern to psychiatric nurses are listed in Box 11-1.

Nursing interventions are based on the nursing assessment as well as the medical evaluation to ensure a coordinated plan of treatment. Therefore, when formulating nursing diagnoses and using the nursing process, nurses also should be familiar with medical diagnoses and treatment plans.

A medical diagnosis is the health problem or disease state of the patient. In the medical model of psychiatry the health problems are mental disorders or mental illnesses that are classified in the DSM-IV-TR, which describes the symptoms of mental disorders (APA, 2000). Specific diagnostic criteria are provided for each mental disorder but causes of the disorders are not discussed.

Outcomes Identification

Standard 3: Outcomes Identification

The psychiatric–mental health registered nurse identifies expected outcomes for a plan individualized to the patient or to the situation.

Key Elements

Patient outcomes may include relieving symptoms or improving functional ability. Sometimes a patient cannot identify specific goals or may describe them in general terms. Translating nonspecific concerns into specific goal statements is not easy. The nurse must understand the patient’s coping responses and the factors that influence them.

• The patient may view a personal problem as someone else’s behavior. This may be the case of a father who brings his adolescent son in for counseling. The father may view the son as the problem, whereas the adolescent may feel his only problem is his father. One approach to this situation is to focus help on the person who brought the problem into treatment because he “owns” the problem at that moment. The nurse might suggest, “Let’s talk about how I could help you deal with your son. A change in your response might lead to a change in his behavior also.”

• The patient may express a problem as a feeling, such as “I’m lonely” or “I’m so unhappy.” Besides trying to help the patient clarify the feeling, the nurse might ask, “What could you do to make yourself feel less alone and more loved by others?” This helps patients see the connection among their actions, thoughts, and feelings and increase their sense of responsibility for themselves.

• The patient’s problem may be one of lacking a goal or an idea of exactly what is desired from life. In this case it might be helpful for the nurse to point out that values and goals are not magically discovered but must be created by people for themselves. The patient can then actively explore ways to construct goals or adopt the objectives of a social, service, religious, or political group with whom the patient identifies.

• The patient’s problem may be a choice conflict. This is especially common if all the choices are unpleasant, unacceptable, or unrealistic. An example is a couple who wants to divorce but does not want to see their child hurt or suffer the financial hardship that would result. Although undesirable choices cannot be made desirable, the nurse can help patients use the problem-solving process to identify the full range of alternatives available to them.

The patient’s goals may be inappropriate, undesirable, or unclear. However, the solution is not for the nurse to impose goals on the patient. Even if the patient’s desires seem to be against self-interests, the most the nurse can do is reflect the patient’s behavior and its consequences. If the patient then asks for help in setting new goals, the nurse can help. Mutually identifying goals and expected outcomes is an essential step in the therapeutic process.

In this process a well-intentioned nurse sometimes overlooks the patient’s goals and develops a treatment plan leading to an outcome that the nurse thinks is better. However, this is a mistake because the experience of working cooperatively with the nurse to identify mutually acceptable goals is extremely valuable. If the patient does not share the nurse’s goals, it is best to wait until the patient agrees on its importance. If this is not done the patient is not likely to adhere to the treatment plan and will be seen as noncompliant.

Once overall goals are agreed on, the nurse must state them explicitly. Expected outcomes are derived from diagnoses, guide later nursing actions, and enhance the evaluation of care. Each goal is stated as an observable behavior and includes the period of time in which it is to be accomplished and any other conditions. Expected outcomes can be documented using standardized classification systems, such as the Nursing Outcomes Classification (NOC) (Moorhead et al, 2008). Long- and short-term goals should contribute to the expected outcomes. Following is a sample expected outcome and long- and short-term goals:

In writing goals, psychiatric nurses should remember that they can be classified into the “ABCs,” or three domains, of knowledge:

Correctly identifying the domain of the expected outcome is very important in planning nursing interventions. Some psychiatric nurses place all their emphasis on outcomes related to learning new information (cognitive). They forget about the equally important needs of patients to acquire new values (affective) and to master new skills (behavior).

For example, it would be of limited help to teach a patient about medication if the patient did not value taking medications based on a personal belief system or previous life experiences. It would be equally unsuccessful to engage in medication education if the patient did not know how to take public transportation to fill the prescription.

Finally, it is important to explore with the patient the cost/benefit effect of all identified goals, that is, what is being given up (cost) versus what is being gained (benefit) from attaining the goal. This can be thought of as exploring advantages, or positive effects, and disadvantages, or negative effects.

Patients are not likely to commit themselves to a goal or to work toward attaining a goal if the stakes are too high or the payoffs too low. Exploring advantages and disadvantages helps the patient anticipate what price will be paid to achieve the goal and then decide if the change is worth the cost to oneself or significant others. Sometimes it is helpful to write these down in the form of two columns (advantages and disadvantages) that can be added to or changed at any time.


Standard 4: Planning

The psychiatric–mental health registered nurse develops a plan that prescribes strategies and alternatives to attain expected patient outcomes.

Key Elements

One of the most important tasks for the nurse and patient is to assign priorities to the goals. Those goals related to protecting the patient from self-destructive impulses always receive top priority. Because the nursing care plan is dynamic, priorities are constantly changing. If the focus is always on the patient’s behavioral responses, priorities can be modified as the patient changes. If the goal answers the question of what, the plan of care answers the questions of how and why. Once again, the patient’s active involvement leads to a more successful care plan.

After writing a tentative care plan, the nurse must validate this plan with the patient. This communicates to the patient a sense of self-responsibility for getting well. The patient can tell the nurse that a proposed plan is unrealistic based on financial status, lifestyle, value system, culture or, perhaps, personal preference. Usually several approaches to a patient’s problem are possible. Choosing the one most acceptable to the patient improves the chances for success. Failure to reach a goal through one plan can lead to the decision to adopt a new approach or re-evaluate the goal.


Standard 5: Implementation

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


In implementing the plan of care, psychiatric–mental health nurses use a wide range of interventions designed to prevent mental and physical illness and to promote, maintain, and restore mental and physical health. Psychiatric–mental health nurses select interventions according to their level of practice.

At the basic level nurses may select counseling, milieu therapy, promotion of self-care activities, intake screening and evaluation, psychobiological interventions, health teaching, case management, health promotion and health maintenance, crisis intervention, community-based care, psychiatric home health care, telehealth, and a variety of other approaches to meet the mental health needs of patients.

In addition to the intervention options available to the basic-level psychiatric–mental health nurse, at the advanced level the advanced practice registered nurse in psychiatric–mental health (APRN-PMH) may provide consultation, engage in psychotherapy, and prescribe pharmacological agents where permitted by state statutes or regulations.

Key Elements

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Feb 25, 2017 | Posted by in NURSING | Comments Off on Implementing the Nursing Process: Standards of Practice and Professional Performance

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