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UNIT 1 ESSENTIAL THEORETICAL 15 Mood Disorders: Depression, 247

16 Bipolar Spectrum Disorders, 279
CONCEPTS FOR 17 Schizophrenia Spectrum
PRACTICE Disorders and Other Psychotic
Disorders, 303
1 Practicing the Science and the Art of Psychiatric 18 Neurocognitive Disorders, 336
Nursing, 2 19 Substance–Related and Addictive
2 Mental Health and Mental Illness, 11 Disorders, 362
3 Theories and Therapies, 24
4 Biological Basis for Understanding
Psychopharmacology, 45 UNIT 4 CARING FOR PATIENTS
5 Settings for Psychiatric Care, 67 EXPERIENCING
6 Legal and Ethical Basis for Practice, 79 PSYCHIATRIC
20 Crisis and Mass Disaster, 397
21 Child, Partner, and Elder
7 Nursing Process and QSEN: The Foundation Violence, 412
for Safe and Effective Care, 96 22 Sexual Violence, 431
8 Communication Skills: Medium for All Nursing 23 Suicidal Thoughts and Behaviors, 446
Practice, 116 24 Anger, Aggression, and Violence, 461
9 Therapeutic Relationships and the Clinical 25 Care for the Dying and Those Who
Interview, 135 Grieve, 479


PSYCHOBIOLOGI­CAL 26 Children and Adolescents, 500
DISORDERS 27 Adults, 515
28 Older Adults, 537
10 Stress and Stress-Related
Disorders, 155
11 Anxiety, Anxiety Disorders, and Obsessive- APPENDIXES
Compulsive Disorders, 165
12 Somatic Symptom Disorders and Related A DSM–5 Classification, 556
Disorders, 192 B NANDA-I Nursing Diagnoses 2012-2014, 572
13 Personality Disorders, 213 C DSM–5 Criteria Boxex, 576
14 Eating Disorders, 231
of Psychiatric
Mental Health

Evolve ® Student Learning Resources for Varcarolis: Essentials of
Psychiatric Mental Health Nursing Revised Reprint, offers the following
• C
 hapter Review Answers
Answers for the review questions at the end of each chapter
• C
 ase Studies and Nursing Care Plans
Detailed case studies and care plans for specific psychiatric disorders
• N
 urse, Patient, and Family Resources
Include website addresses, association information, and additional
resources for patient teaching material, medication information, and
support groups

of Psychiatric
Mental Health

A Communication Approach to
Evidence-Based Care

Elizabeth M. Varcarolis, RN, MA

Professor Emeritus
Formerly Deputy Chairperson, Department of Nursing
Borough of Manhattan Community College;
Associate Fellow
Albert Ellis Institute for Rational Emotional Behavioral Therapy (REBT);
Former Major Army Nurse Corps Reserve
New York, New York
3251 Riverport Drive
St. Louis, Missouri 63043


CARE REVISED REPRINT ISBN: 978-0-323-28788-3
Copyright © 2013, 2009 by Saunders, an imprint of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by
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Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment, and drug therapy may become neces-
sary or appropriate. Readers are advised to check the most current information provided (i) on
procedures featured or (ii) by the manufacturer of each product to be administered, to verify the
recommended dose or formula, the method and duration of administration, and contraindica-
tions. It is the responsibility of the practitioner, relying on their own experience and knowledge of
the patient, to make diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the
Publisher nor the Authors assume any liability for any injury and/or damage to persons or prop-
erty arising out of or related to any use of the material contained in this book.
The Publisher


Senior Content Strategist: Yvonne Alexopoulos

Senior Content Developmental Specialist: Lisa P. Newton
Publishing Services Manager: Jeff Patterson
Project Manager: Jeanne Genz
Designer: Ashley Eberts

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To the memory of Josiah and Ruth Merrill, who
gave me life and opportunity and who I miss every day.

And especially to my husband Paul, whose love

and devotion become more and more evident as time
passes. Thanks for the wonderful years.
I love you dearly.

To the memory of Ruth Matheney

and Suzanne Lego, who as mentors made such
a difference in my professional career.

To the memory of three deeply loved friends, Nancy

and John Berry, and Betty Rosenbluth.

Betsy Varcarolis
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As is always the case, I owe a huge debt of gratitude to many for their contributions and support.
I thank Dr. Margaret (Peggy) Jordan Halter for her generous and outstanding contributions to the first
edition of Essentials. Peggy brings multiple talents and expertise to any project she undertakes. Thank you
Peggy for your hard work on the first edition. She has since taken over as the sole editor/author of the popu-
lar Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, a huge undertaking. She was
the sole editor/author of the sixth edition and will continue through future editions. She is launching this
well-regarded text into the 21st century.
The two unique and creative features that are the “gems” of this text continue in this edition. They are
enticing, interesting, and great learning tools for our students. The first of these features is “Examining the
Evidence” boxes. I am grateful to Lois Angelo, MSN, APRN, for her contributions to all but three of the
“Examining the Evidence” boxes and for her diligence in introducing pressing issues within the practice
of psychiatric nursing as well as the latest evidence to help guide nurses in their care and understanding of
current issues. I thank Dr. Margaret Halter for her “Examining the Evidence” box in Chapter 1, which was
used in the first edition of this text.
I have been fortunate enough to have Dr. Dolly C. Sadow and Marie Ryder, CPRP, CNS-BC, submit
“Examining the Evidence” boxes on “stigma” and “peer supervision in consumer providers” in Chapters 2
and 3, respectively.
The second gem is the “Applying the Art” boxes, all contributed by Dawn Scheick; they are found in all of
the clinical chapters (Chapters 10-19). Dawn offers excellent examples of how a nurse can incorporate effec-
tive and insightful communication while working with patients possessing a variety of needs and displaying
a wide range of behaviors.
Communication is one of the arts taught to all nursing students, and effective communication strategies
are the cornerstone of psychiatric mental health nursing. The text offers many pedagogical features that will
benefit both the cognitive as well as the visual learner. It is hoped that the reader will gain fresh insights,
attain a broader understanding, and learn effective tools in their interactions with vulnerable individuals
during their treatment toward a more mentally healthy quality of life.
I want to offer special thanks to the amazing authors who have contributed to this edition of Essentials of
Psychiatric Mental Health Nursing and for their expertise and hard work. Sincere and profound thanks go to
Peggy Halter, Dorothy Varchol, Penny Brooke, Kathleen Ibrahim, Kathy Kramer-Howe, and Ed Herzog in
order of the appearance of their chapters.
A very special thanks to Teresa Burckhalter and Mary Gilkey for their creative work on the instructor and
student ancillaries to accompany this book.
I have been fortunate to be part of a patient and hard-working team. The people working behind the
scenes are always pivotal to the production of any successful text. These are the people who have provided
support, kept the project on track, and solved a myriad of problems that are inherent in any production:
• Yvonne Alexopoulos, Senior Content Strategist, always supported and provided everything needed to
make the revised second edition of Essentials a success.
• Lisa P. Newton, Senior Content Developmental Specialist, pulled together resources, provided support,
and untangled dilemmas during the publication process.
• Kit Blanke, Editorial Assistant, handled multiple details for the book.
• Jeanne Genz and Johnny Gabbert, Project Managers, managed consistency to the minutest detail and
have made me look good through the process. Thanks, you two.
• Ashley Eberts, Book Designer, created a vivid, exciting, and reader-friendly design.

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Lois Angelo, MSN, APRN, BC Dolly C. Sadow, PhD, ABPP Shirley A. Smoyak, RN, PhD, FAAN
Assistant Professor of Nursing Med Options of Massachusetts Professor II (distinguished)
University of New Hampshire Bedford, Massachusetts Rutgers University
Durham, New Hampshire New Brunswick, New Jersey
Dawn M. Scheick, EdD RN,
Ann Wolbert Burgess, DNSc, APRN, ­PMHCNS, BC Dorothy A. Varchol, RNBC, MA, MSN
BC, FAAN Chair and Professor of Nursing Nursing Faculty in Health and Public
Professor of Psychiatric Nursing Alderson-Broaddus College; Safety
William F. Connell School of Nursing Therapist Cincinnati State Technical and
Boston College Barbour County Health Department ­Community College
Chestnut Hill, Massachusetts Philippi, West Virginia Cincinnati, Ohio

Margaret Jordan Halter, PhD, APRN Sheila Rouslin Welt, MS, APN Teresa S. Burckhalter, MSN, RN, BC
Associate Dean Private Practice, Psychotherapy Nursing Faculty
Ashland University College of Nursing Morristown, New Jersey; Technical College of the Lowcountry
Ashland, Ohio Educational Consultation Beaufort, South Carolina
The Pingry School Test Bank
Edward A. Herzog, MSN, APRN Short Hills, New Jersey
Faculty Mary Blessing Gilkey, APRN, BC, MS
Kent State University Marie K. Ryder, CPRP, CNS-BC Assistant Professor
Kent, Ohio Professor of Nursing Hampton University
Middlesex Community College Hampton, Virginia
Kathleen Ibrahim, MA, APRN, BC Bedford, Massachusetts Student Resources
Assistant to the Director of Nursing
New York State Psychiatric Institute Penny Simpson Brooke, APRN, Marie Messier, MSN, RN
New York, New York MS, JD Associate Professor of Nursing
University of Utah Germanna Community College
Kathy Kramer-Howe, MSW, LCSW College of Nursing Locust Grove, Virginia
Hospice of the Valley Salt Lake City, Utah Student Resources
Phoenix, Arizona


Janet Flynn, RN, MSN Cindy Parsons, DNP, PMHNP-BC, Kathleen Slyh, RN, MSN
Associate Professor of Nursing FAANP Nursing Instructor
Elgin Community College Assistant Professor of Nursing Technical College of the Lowcountry
Elgin, Illinois University of Tampa Beaufort, South Carolina
Tampa, Florida
Phyllis Jacobs, BSN, MSN Donna Webb, RN, BSN, MSN
Assistant Professor/Director Marie K. Ryder, CPRP, CNS-BC Nursing Instructor
Undergraduate Nursing Program Professor of Nursing Texas State Technical College
Wichita State University Middlesex Community College Brownwood, Texas
Wichita, Kansas Bedford, Massachusetts

Loyce A. Kennedy, MSN, RN

Assistant Professor of Nursing
Arkansas Tech University—Fort Smith
Sparks Hospital
Fort Smith, Arkansas


The DSM-5 has finally published, and this revised edition of the science employed by nurses caring for patients with mental
Essentials of Psychiatric Mental Health Nursing: A Communi- health problems and psychiatric disorders:
cation Approach to Evidence-Based Care, ed 2, Revised Reprint, “Psychiatric–mental health nursing, a core mental health
presents updated DSM-5 criteria and recently approved medi- profession, employs a purposeful use of self as its art and a wide
cations, along with a totally revamped chapter on Substance range of nursing, psychosocial, and neurobiological theories
Use. Appendix C provides actual DSM-5 criteria, especially for and research evidence as its science.”
those disorders that are most commonly seen in clinical prac- In Essentials of Psychiatric Mental Health Nursing: A Com-
tice. This revision continues to provide the essential content for munication Approach to Evidence-Based Care, ed 2, Revised
a shorter course without sacrificing either the current research Reprint, there is an effort to integrate and balance these two
or the nursing and psychotherapeutic interventions necessary aspects of nursing care and present all of the essential informa-
to sound practice. In fact, all efforts have been taken to ensure tion on each so that students will be prepared to offer the best
research and psychotherapeutic interventions reflect current possible care when they enter practice.
This Essentials, ed 2, continues to provide a comprehensive The Science
but concise review of the prominent theorists and all therapeu- Over the past couple decades we have seen remarkable scien-
tic modalities in use today, including milieu, group, and family tific progress in our understanding of the workings of the brain
therapies, in Chapter 3, “Theories and Therapies.” Within each and how abnormalities in the function of the brain are related
of the clinical chapters (Chapters 10 through 19), chapters that to mental illness. As confidence in this research grew, the focus
examine various psychiatric emergencies (Chapters 20-25), on scientific research expanded and led to more scientifically
and chapters that address discrete patient populations across based treatment approaches, and the concept of evidence-based
the life span (Chapters 26 through 28), specific therapeutic practice became a dominant focus of mental health treatment.
modalities that have proven effective for each topic are thor- While writing this text a great effort was made to provide
oughly covered. the most current evidence-based information in the field while
In addition to the overview of medication groups in at the same time keeping the material comprehensible and
Chapter 4, “Biological Basis for Understanding Psychopharma- reader-friendly. Relevant information drawn from science is
cology,” specific medications are covered in full for each of the woven throughout the book.
discrete clinical disorders, including patient and family teaching Chapter 1, “Practicing the Science and Art of Psychiatric
guidelines. Integrative therapies are also included in each of the Nursing,” introduces the student to the evolution of evidence-
clinical chapters where they have proven effective. based practice (EBP) and the mechanics of the practice and
In order to present the most essential base of knowledge for gives the reader guidelines for where and how to gather infor-
a shorter course, the pertinent information on some topics has mation for applying EBP in psychiatric nursing practice.
been incorporated into the clinical chapters where applicable, Perhaps one of the two most unique features of this book
rather than included in a separate chapter. For example, rather is the Examining the Evidence feature, which is introduced
than include a general chapter on culture, each of the clinical in Chapter 1 and runs throughout the clinical chapters. Each
chapters incorporates relevant information on cultural aspects box poses a question, walks the readers through the process of
of the various clinical disorders, which can also help give the gathering evidence-based data from a variety of sources, and
reader a broader cultural perspective. presents the evidence from different points of view.
Forensic issues related to the nursing care of patients are
included in specific chapters, especially “Child, Partner, and The Art
Elder Violence” (Chapter 21) and “Sexual Violence” (Chapter In comparison with the medical model, the recovery model is a
22). This is in addition to Chapter 6, “Legal and Ethical Basis more social, relationship-based model of care. The focus of the
for Practice.” recovery model is more of a nurse/physician partner relation-
ship. The recovery model began in the addiction field, in which
THE SCIENCE AND ART OF PSYCHIATRIC the goal was for individuals to recover from substance abuse
and addictions. Today the recovery model is gaining momen-
MENTAL HEALTH NURSING tum in the larger mental health community. Its focus is on
The American Nurses Association’s Psychiatric Mental Health empowering patients by supporting hope, strengthening social
Nursing: Scope and Standards of Practice begins with the follow- ties, developing more effective coping skills, and fostering the
ing statement that stresses the importance of both the art and use of spiritual strength, and more.


By definition, nurses are primed to incorporate the bio- clinical disorders are chosen based on which of them most
psychosocial and cultural/spiritual approaches to care. Some fit specific patient needs, including communication guide-
nursing leaders express concern that the “art” of nursing is lines, health teaching and health promotion, milieu ther-
becoming marginalized by the emphasis on evidence-based apy, psychotherapy, and pharmacological, biological, and
practice. Chapter 1 covers some of these often minimized and integrative therapies.
uncharted interventions such as the art of caring, the skill of • Evaluation
attending, and patient advocacy. However, what also might
be minimized and deemphasized are the tools that make
nurses unique. Some of these tools include possessing effec-
tive communication skills, forming therapeutic relationships, In addition to boxes Examining the Evidence boxes and
and understanding ways of interviewing and assessing our Applying the Art tables described above, the following features
patients’ needs. These areas are stressed in Chapter 8, “Com- are included in the book to inform, heighten understanding,
munication Skills: Medium for All Nursing Practice,” and and engage the reader:
Chapter 9, “Therapeutic Relationships and the Clinical Inter- • Chapters open with Objectives and Key Terms and Con-
view.” There is also a section in each of the clinical chapters cepts to orient the reader.
on useful communications techniques for a specific disorder • Numerous Vignettes describing psychiatric patients and
or situation. their disorders attract and hold the readers’ interest.
The second of the unique features that are also included • Assessment Guidelines are included in clinical chapters to
in the clinical chapters are the Applying the Art boxes, which familiarize readers with methods of assessing patients; also
depict a clinical scenario demonstrating the interactions for use in the clinical setting.
between a student and a patient (both therapeutic and non- • Potential Nursing Diagnoses tables list several possible
therapeutic), the student’s perception of the interaction, and nursing diagnoses for a particular disorder along with the
the identification of the mental health nursing concepts in play. associated signs and symptoms.
• Nursing Interventions tables list interventions for a given
ORGANIZATION disorder or clinical situation, along with rationales for each
Organized into five units, the chapters in the book have been • Key Points to Remember present the main concepts of each
grouped to emphasize the clinical perspective and to facilitate chapter in an easy to comprehend and concise bulleted list.
locating information. All clinical chapters are organized in a • Critical Thinking questions at the end of all chapters intro-
clear, logical, and consistent format with the nursing process duce clinical situations in psychiatric nursing and encour-
as the strong, visible framework. The basic outline for clinical age critical thinking processes essential for nursing practice.
chapters is: • Chapter Review questions at the end of each chapter rein-
• Prevalence and Comorbidity force key concepts. Answers are listed on the Evolve website.
Knowing the comorbid disorders that are often part of the clin- • Appendixes provide the DSM-5 Classification list, NANDA-I
ical picture of specific disorders helps students as well as clini- Diagnoses, and select DSM-5 Criteria boxes.
cians understand how to better assess and treat their patients.
• Cultural Considerations
• Clinical Picture For Students
• Application of the Nursing Process The Evolve Student Resources for this book include the
• Assessment following:
Presents appropriate assessment for a specific disorder, • Chapter Review Answers, included for every chapter
including assessment tools and rating scales. The rat- • Case Studies and Nursing Care Plans for clinical disorders
ing scales included help highlight important areas in the • Concept Supplements for additional help
assessment of a variety of behaviors or mental conditions. • Nurse, Patient, and Family Resources, which include web
Because many of the answers are subjective, experienced addresses, association information, and additional resources
clinicians use these tools as a guide when planning care, in for patient teaching material, medication information, and
addition to their knowledge of their patients. support groups
• Diagnosis
Includes the latest NANDA-I (2012-2014) terminology. For Instructors
• Outcomes Identification The Evolve Instructor Resources for this book include the
• Planning following:
• Implementation • TEACH for Nurses Lesson Plans, based on textbook chap-
Interventions follow the categories set by the ANA ter Learning Objectives, serve as ready-made, modifiable
­Psychiatric–Mental Health Nursing: Scope and Standards lesson plans and a complete roadmap to link all parts of
of Practice (2007). Various interventions for each of the the educational package. These concise and straightforward

lesson plans can be modified or combined to meet your par- • Audience Response Questions for i>clicker and other sys-
ticular scheduling and teaching needs. tems with 2 to 5 multiple-answer questions per chapter to
• Test Bank in ExamView formats, featuring approximately stimulate class discussion and assess student understanding
800 test items, complete with correct answer, rationale, of key concepts.
cognitive level, nursing process step, appropriate NCLEX© I hope you all find that Essentials of Psychiatric Mental
label, and corresponding textbook page references. The Health Nursing: A Communication Approach to Evidence-Based
ExamView program allows instructors to create new tests; Care, ed 2, Revised Reprint, provides you with the information
edit, add, and delete test questions; sort questions by you need to be successful in your practice of nursing… Good
NCLEX category, cognitive level, and nursing process step; luck to you all.
and administer and grade tests online. Betsy Merrill Varcarolis
• PowerPoint Presentations with more than 600 customiz-
able lecture slides.
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Other Major Theories, 33

UNIT 1 ESSENTIAL Cognitive Development, 33
THEORETICAL CONCEPTS Theory of Psychosocial Development, 34
FOR PRACTICE Theory of Object Relations, 34
Theories of Moral Development, 34
1 Practicing the Science and the Art of Ethics of Care Theory, 35
Psychiatric Nursing, 2 Models, Theories, and Therapies in Current
Elizabeth M. Varcarolis Practice, 35
The Science of Nursing: Finding the Evidence Biological Model, 35
for the Practice, 3 Nursing Models, 36
The Research-Practice Gap, 6 Interpersonal Relations in Nursing, 37
The Art of Nursing: Developing the Skills for Influence of Theories and Therapies on
the Practice, 6 Nursing Care, 37
Caring, 6 Therapies for Specific Populations, 38
Attending, 8 4 Biological Basis for Understanding
Patient Advocacy, 8 Psychopharmacology, 45
2 Mental Health and Mental Illness, 11 Dorothy A. Varchol
Elizabeth M. Varcarolis Brain Structures and Functions, 46
The Diagnostic and Statistical Manual of Cerebrum, 46
Mental Disorders, DSM-5, 13 Subcortical Structures, 47
Concepts of Mental Health and Illness, 14 Brainstem, 48
Epidemiology and Prevalence of Mental Cerebellum, 49
Disorders, 15 Thalamus, 49
Mental Illness and Policy Issues, 15 Hypothalamus, 49
Medical Diagnosis and Nursing Diagnosis of Visualizing the Brain, 49
Mental Illness, 17 Cellular Composition of the Brain, 49
Medical Diagnoses and the DSM-5, 17 Neurons, 49
Psychiatry and Spirituality, 18 Synaptic Transmission, 50
Nursing Diagnoses and NANDA Neurotransmitters, 50
International, 19 Interaction of Neurons, Neurotransmitters,
Introduction to Culture and Mental Illness, 19 and Receptors, 51
3 Theories and Therapies, 24 Psychotropic Drugs and Interactions, 56
Margaret Jordan Halter Antidepressant Drugs, 57
Prominent Theories and Therapeutic Monoamine Oxidase Inhibitors (MAOIs), 57
Models, 25 Tricyclic Antidepressants (TCAs), 58
Psychoanalytic Theory, 25 Selective Serotonin Reuptake Inhibitors
Interpersonal Theory, 26 (SSRIs), 58
Behavioral Theories, 26 Serotonin-Norepinephrine Reuptake
Humanistic Theory, 30 Inhibitors (SNRIs), 59
Rogers’ Person-Centered Theory, 30 Serotonin-Norepinephrine Disinhibitors
Cognitive Theory, 31 (SNDIs), 59
A Note on How Psychotherapy Changes the Other Antidepressants, 59
Brain, 32 Norepinephrine-Dopamine Reuptake
Mental Health Recovery Model, 33 Inhibitors (NDRIs), 59
The Recovery Model in Psychiatric Treating Anxiety Disorders With
Nursing, 33 Antidepressants, 59


Antianxiety or Anxiolytic Drugs, 59 Rights Surrounding Involuntary

Benzodiazepines, 59 Commitment and Psychiatric Advance
Non-Benzodiazepines, 60 Directives, 84
Mood Stabilizers, 60 Rights Regarding Restraint and
Lithium, 60 Seclusion, 84
Anticonvulsant Mood Stabilizers, 60 Maintenance of Patient Confidentiality, 85
Other Agents, 60 Ethical Considerations, 85
Antipsychotic Drugs, 61 Legal Considerations, 85
The First-Generation Agents (FGA)/ Tort Law Applied to Psychiatric Settings, 87
Conventional Antipsychotic Common Liability Issues, 87
Agents, 61 Violence, 87
The Second-Generation (SGA) or Atypical Negligence/Malpractice, 89
Antipsychotic Agents, 62 Determination of a Standard of Care, 89
Psychoneuroimmunology (PNI), 63 Guidelines for Nurses Who Suspect
Considering Culture, 64 Negligence, 90
5 Settings for Psychiatric Care, 67 Duty to Intervene and Duty to Report, 90
Margaret Jordan Halter Unethical or Illegal Practices, 90
Background, 68 Documentation of Care, 91
Outpatient Care Settings, 69 Purpose of Medical Records, 91
Role of Nurses in Outpatient Care Facility Use of Medical Records, 91
Settings, 70 Medical Records as Evidence, 91
Inpatient Care Settings, 71 Nursing Guidelines for Computerized
State Acute Care System, 73 Charting, 91
General Hospital Psychiatric Units and Forensic Nursing, 92
Private Psychiatric Hospital Acute
Care, 74
Role of Psychiatric Nurses in Inpatient UNIT 2 TOOLS FOR PRACTICE
Care Settings, 74 OF THE ART
Special Treatment Settings, 74
Pediatric Psychiatric Care, 74 7 Nursing Process and QSEN: The Foundation
Geriatric Psychiatric Care, 74 for Safe and Effective Care, 96
Veterans Administration Centers, 74 Elizabeth M. Varcarolis
Forensic Psychiatric Care, 75 Standard 1: Assessment, 97
Alcohol and Drug Abuse Treatment, 75 Age Considerations, 99
Self-Help Options, 75 Language Barriers, 100
Paying for Mental Health Care, 75 Psychiatric Nursing Assessment, 100
A Vision for Mental Health Care in Using Rating Scales, 104
America, 76 Standard 2: Diagnosis, 104
6 Legal and Ethical Basis for Practice, 79 Formulating a Nursing Diagnosis, 104
Penny Simpson Brooke Standard 3: Outcomes Identification, 106
Legal and Ethical Concepts, 80 Determining Outcomes, 106
Mental Health Laws, 80 Standard 4: Planning, 106
Civil Rights, 81 Interventions Planning, 108
Admission and Discharge Procedures, 81 Standard 5: Implementation, 109
Due Process in Civil Commitment, 81 Basic Level and Advanced Practice
Admission to the Hospital, 81 Interventions, 109
Discharge from the Hospital, 82 Advanced Practice Interventions Only, 109
Patients’ Rights Under the Law, 82 Standard 6: Evaluation, 110
Right to Treatment, 82 Documentation, 110
Right to Refuse Treatment, 83 Documentation of “Noncompliance”, 110
Right to Informed Consent, 83 Systems of Charting, 110

8 Communication Skills: Medium for All UNIT 3 CARING FOR

Nursing Practice, 116
Elizabeth M. Varcarolis
Communication, 117 PSYCHOBIOLOGICAL
The Communication Process, 117 DISORDERS
Factors That Affect Communication, 119
Verbal Communication, 119 10 Stress and Stress-Related Disorders, 155
Nonverbal Communication, 119 Elizabeth M. Varcarolis
Interaction of Verbal and Nonverbal Physiological and Psychological Responses to
Communication, 119 Stress, 156
Effective Communication Skills for The Autonomic Nervous System―
Nurses, 121 Fight-or-Flight Response, 156
Use of Silence, 121 Stress Reduction Techniques, 157
Active Listening, 121 Stress-Related Disorders, 157
Clarifying Techniques, 122 Posttraumatic Stress Disorder, 157
Nontherapeutic Techniques, 123 Goals of Treatment, 160
Asking Excessive Questions, 123 Psychotherapeutic Treatment Strategies, 160
Giving Approval or Disapproval, 123 Psychopharmacology, 160
Advising, 127 Acute Stress Disorder, 160
Asking “Why” Questions, 127 Critical Incident Debriefing, 162
Cultural Considerations: Negotiating Self-Care for Nurses, 162
Barriers, 127 11 Anxiety, Anxiety Disorders, and
Communication Styles, 128
Obsessive-Compulsive Disorders, 165
Eye Contact, 128
Elizabeth M. Varcarolis
Touch, 129
Anxiety, 166
Cultural Filters, 129
Levels of Anxiety, 166
Telehealth Through Information
Mild Anxiety, 167
Communication Technologies (ICTs), 129
Moderate Anxiety, 167
Evaluation of Clinical Skills, 131
Severe Anxiety, 168
9 Therapeutic Relationships and the Clinical Panic Level of Anxiety, 168
Interview, 135 Interventions, 168
Elizabeth M. Varcarolis Mild to Moderate Levels of Anxiety, 168
Nurse-Patient Relationships, 136 Severe to Panic Levels of Anxiety, 168
Therapeutic Versus Other Types of Defense Mechanisms, 168
Relationships, 136 Healthy Defenses, 170
Establishing Relationship Boundaries, 138 Intermediate Defenses, 171
Values, Beliefs, and Self-Awareners, 139 Immature Defenses, 171
Phases of the Nurse-Patient Anxiety Disorders, 172
Relationship, 140 Prevalence and Comorbidity, 174
What Hinders and What Helps, 145 Theory, 174
Factors That Enhance Growth, 146 Neurobiology, 174
The Clinical Interview, 147 Cognitive Behavioral Therapy, 175
Preparing for the Interview, 147 Cultural Considerations, 175
Introductions, 148 Clinical Picture, 175
Initiating the Interview, 148 Panic Disorders, 175
Tactics to Avoid, 148 Phobias, 176
Helpful Guidelines, 149 Generalized Anxiety Disorder, 177
Attending Behaviors: The Foundation of Anxiety Due to other Medical Conditions, 177
Interviewing, 149 Obsessive-Compulsive Disorder (OCD), 178
Clinical Supervision and Process Body Dysmorphic Disorder, 179
Recordings, 150 Hoarding, 179


PROCESS, 179 Ability to Communicate Feelings and
Assessment, 179 Emotional Needs, 197
Symptoms of Anxiety, 179 Dependence on Medication, 198
Defenses Used in Anxiety Disorders, 180 Diagnosis, 198
Diagnosis, 180 Outcomes Identification, 199
Outcomes Identification, 180 Planning, 199
Planning, 180 Implementation, 199
Self-Care for Nurses, 180 Communication Guidelines, 199
Implementation, 181 Health Teaching and Health Promotion, 199
Communication Guidelines, 181 Case Management, 199
Health Teaching and Health Promotion, 183 Pharmacological Therapies, 200
Milieu Therapy, 183 Evaluation, 200
Psychotherapy, 183 DISSOCIATIVE DISORDERS, 200
Pharmacological, Biological, and Prevalence and Comorbidity, 201
Complementary and Alternative Theory, 202
Therapies, 185 Biological Factors, 202
Other Classes of Medication, 187 Genetic Factors, 202
Complementary and Alternative Medicine Psychosocial Factors, 202
(CAM), 187 Cultural Considerations, 202
Evaluation, 189 Clinical Picture, 202
12 Somatic Symptom Disorders and Related Depersonalization/Derealization
Disorders, 192 Disorder, 202
Elizabeth M. Varcarolis Dissociative Amnesia, 203
Somatic Symptom Disorder and Related Dissociative Amnesia with Fugue, 203
Disorders, 193 Dissociative Identity Disorder, 203
Prevalence and Comorbidity, 193 PROCESS, 204
Theory, 194 Assessment, 204
Genetic and Familial Factors, 194 Medical Workup, 204
Learning and Sociocultural Factors, 194 Identity and Memory, 204
Psychological Theory, 194 Patient History, 204
Interpersonal Model, 194 Mood, 204
Cultural Considerations, 194 Use of Alcohol and Other Drugs, 204
Making a Diagnosis, 194 Effect on Patient and Family, 204
Factitious Disorder, 195 Suicide Risk, 205
Malingering, 195 Diagnosis, 205
Clinical Picture, 195 Outcomes Identification, 206
Somatic Symptom Disorders, 195 Planning, 206
Conversion Disorders, 196 Implementation, 206
Body Dysmorphic Disorder, 196 Communication Guidelines, 206
Pseudocyesis, 197 Health Teaching and Health Promotion, 206
Nursing Process: Somatic Symptoms and Milieu Therapy, 206
Related Disorders, 197 Pharmacological, Biological, and
APPLICATION OF THE NURSING Integrative Therapies, 211
PROCESS, 197 Evaluation, 211
Assessment, 197 13 Personality Disorders, 213
Symptoms and Unmet Needs, 197 Elizabeth M. Varcarolis
Voluntary Control of Symptoms, 197 Prevalence and Comorbidity, 214
Secondary Gains, 197 Comorbid/Co-occurring Disorders, 215


Genetic Factors, 215 PROCESS: ANOREXIA NERVOSA, 235
Neurobiological Factors, 215 Assessment, 235
Psychological Influences, 215 Diagnosis, 236
Cultural Considerations, 215 Outcomes Identification, 236
Clinical Picture, 215 Planning, 236
Cluster A Disorders, 216 Implementation, 236
Schizotypal Personality Disorder, 216 Acute Care, 236
Paranoid Personality Disorder, 216 Communication Guidelines, 236
Schizoid Personality, 216 Health Teaching and Health Promotion, 237
Cluster B Personality Disorders, 217 Milieu Therapy, 237
Antisocial Personality Disorder, 217 Psychotherapy, 239
Borderline Personality Disorder Pharmacological, Biological, and
(BPD), 217 Integrative Therapies, 240
Narcissistic Personality Disorder, 219 Long-Term Treatment, 240
Histrionic Personality Disorder Traits, 219 Evaluation, 240
Cluster C Personality Disorders, 220 APPLICATION OF THE NURSING
Avoidant Personality Disorder, 220 PROCESS: BULIMIA NERVOSA, 240
Obsessive-Compulsive Personality Assessment, 240
Disorder, 220 Diagnosis, 241
Dependent Personality Disorder, 220 Outcomes Identification, 241
A Potential Future Personality Disorder, 221 Planning, 241
Passive-Aggressive Traits, 221 Implementation, 241
PROCESS, 221 Communication Guidelines, 242
Assessment, 221 Milieu Therapy, 242
Primitive Defenses, 221 Health Teaching and Health
Assessment Tools, 222 Promotion, 242
Self-Care for Nurses, 222 Psychotherapy, 242
Diagnosis, 223 Pharmacological, Biological, and
Outcomes Identification, 223 Integrative Therapies, 242
Planning, 224 Evaluation, 242
Implementation, 224 BINGE EATING DISORDER, 242
Communication Guidelines, 224
15 Mood Disorders: Depression, 247
Milieu Therapy, 224
Elizabeth M. Varcarolis
Psychotherapy, 224
Prevalence and Comorbidity, 248
Pharmacological, Biological, and
Children and Adolescents, 248
Integrative Therapies, 228
Older Adults, 249
Evaluation, 228
Theory, 249
14 Eating Disorders, 231 Biological Theories, 250
Kathleen Ibrahim Psychosocial Theories, 252
Prevalence and Comorbidity, 232 The Stress-Diathesis Model of
Theory, 232 Depression, 252
Neurobiological and Neuroendocrine Cognitive Theory, 252
Models, 232 Learned Helplessness, 252
Genetic Models, 232 Cultural Considerations, 252
Psychological Models, 233 Clinical Picture, 252
Cultural Considerations, 233 Major Depressive Disorder (Single Episode
Self-Care for Nurses, 233 or Recurrent), 253
Clinical Picture, 233 Persistent Depressive Disorder, 254


PROCESS, 255 Self-Care for Nurses, 289
Assessment, 255 Acute Phase, 290
Assessment Tools, 255 Pharmacological, Biological, and
Assessment of Suicide Potential, 255 Integrative Therapies, 293
Areas to Assess, 255 Continuation Phase, 298
Self-Care for Nurses, 258 Maintenance Phase, 298
Diagnosis, 259 Evaluation, 299
Outcomes Identification, 260 17 Schizophrenia Spectrum
Planning, 260 Disorders and Other Psychotic
Implementation, 260 Disorders, 303
Communication Guidelines, 260 Elizabeth M. Varcarolis
Health Teaching and Health Prevalence and Comorbidity, 304
Promotion, 261 Theory, 306
Milieu Therapy, 261 Neurobiological Factors, 306
Psychotherapy, 261 Genetic Factors, 307
Mindfulness-Based Cognitive Therapy Neuroanatomical Factors, 307
(MBCT), 262 Nongenetic Risk Factors, 307
Group Therapy, 264 Cultural Considerations, 307
Pharmacological, Biological, and Clinical Picture, 308
Integrative Therapies, 264 APPLICATION OF THE NURSING
Brain Stimulation Therapies, 271
Evaluation, 275
Assessment, 308
16 Bipolar and Related Disorders, 279 Course of the Disease, 308
Elizabeth M. Varcarolis Treatment-Relevant Dimensions of
Prevalence and Comorbidity, 281 Schizophrenia, 308
Theory, 281 Specifier: Catatonia, 314
Biological Theories, 281 Diagnosis, 316
Neurobiological Factors, 282 Outcomes Identification, 316
Psychological Influences, 282 Phase I (Acute), 316
Cultural Considerations, 282 Phase II (Stabilization) and Phase III
Clinical Picture, 282 (Maintenance), 316
PROCESS, 282 Phase I (Acute), 316
Assessment, 282 Phase II (Stabilization) and Phase III
Level of Mood, 282 (Maintenance), 316
Behavior, 284 Implementation, 318
Thought Processes, 286 Self-Care for Nurses, 318
Cognitive Function, 286 Phase I (Acute), 318
Diagnosis, 288 Phase II (Stabilization) and Phase III
Outcomes Identification, 288 (Maintenance), 318
Phase I (Acute Mania), 288 Communication Guidelines, 318
Phase II (Continuation of Health Teaching and Health
Treatment), 289 Promotion, 321
Phase III (Maintenance Milieu Therapy, 323
Treatment), 289 Psychotherapy, 323
Planning, 289 Pharmacological, Biological, and
Acute Phase, 289 Integrative Therapies, 324
Continuation Phase, 289 Evaluation, 333
Maintenance Phase, 289

18 Neurocognitive Disorders, 336 Contributing Factors in the Development of

Elizabeth M. Varcarolis Substance Use Disorder/Addictions and
Prevalence and Comorbidity, 337 Dependencies, 368
DELIRIUM (A POTENTIALLY REVERSIBLE The Neurobiology of Addictions, 368
NEUROCOGNITIVE DISORDER), 338 Genetic Contributions, 368
Psychological Observations, 368
Societal and Cultural Considerations, 368
PROCESS: DELIRIUM, 339 Effects of Substance Use in Pregnancy, 369
Assessment, 339
Pregnant Women, 369
Cognitive and Perceptual Disturbances, 340
Chemically Impaired Health Care Workers,
Physical Needs, 340
Moods and Physical Behaviors, 341
Phenomena Observed in Substances Use
Diagnosis, 342
Disorders, 370
Outcomes Identification, 342
Clinical Picture Including Pharmacological
Implementation, 342
Treatments, 371
Evaluation, 342
Central Nervous System Depressants, 371
(DEMENTIA), 342 Alcohol Withdrawal, 372
Cultural Considerations, 343 Alcohol Withdrawal Delirium, 373
Risk Factors for Alzheimer’s Disease, 345 Psychopharmacology Used to Maintain
Theory, 345 Sobriety, 373
Genetic Theories, 345 Opiates, 375
Anatomical Pathology of Alzheimer’s Psychopharmacology in the Treatment of
Disease, 345 Opiate Addiction, 375
APPLICATION OF THE NURSING Pharmacotherapy for Long-Term
PROCESS: DEMENTIA, 346 Management of Opioid Use Disorder, 375
Assessment, 346 Buprenorphine Maintenance, 375
Overall Assessment, 346 Anabolic-Androgenic Steroids, 375
Assessing Stages of AD, 346 Central Nervous System Stimulants, 376
Diagnostic Tests for Dementia, 349 Cocaine and Crack, 376
Diagnosis, 349 Methamphetamine, 377
Outcomes Identification, 350 Nicotine, 377
Planning, 350 Substance Use in Early Adolescence and
Implementation, 351 Young Adulthood, 378
Communication Guidelines, 352 Marijuana, 378
Health Teaching and Health Rave/“Club Drugs”, 378
Promotion, 354 Date Rape Drugs, 379
Milieu Therapy, 356 Hallucinogens, 379
Pharmacological, Biological, and Lysergic Acid Diethylamide and Similar
Integrative Therapies, 356 Drugs, 379
Evaluation, 359 Dissociative Drugs, 380
19 Substance–Related and Addictive Phencyclidine and Ketamine, 380
Disorders, 362 Inhalants, 381
Elizabeth M. Varcarolis Application of the Nursing Process, 381
Prevalence and Comorbidity, 364 Assessment, 381
Prevalence of Substance Use, 364 Initial Interview Guidelines, 383
Psychiatric Comorbidity, 365 Further Initial Assessment, 384
Medical Comorbidity, 365 Psychological Changes, 384
Central Nervous System Stimulants, 366 Diagnosis, 385
Nicotine, 366 Outcomes Identification, 385
Anabolic-Androgenic Steroids, 367 Planning, 385

Implementation, 385 21 Child, Partner, and Elder Violence, 412

Communication Guidelines, 385 Elizabeth M. Varcarolis
Health Teaching and Health Promotion, 387 Theory, 413
Principles and Awareness of Co-Occurring/ Social Learning Theory, 414
Dual Disorders, 390 Societal and Cultural Factors, 414
Psychotherapy and Therapeutic Psychological Factors, 414
Modalities, 390 CHILD ABUSE, 414
Self-Help Groups for Patient APPLICATION OF THE NURSING
and Family, 391
Twelve-Step Programs, 391
Assessment, 416
Residential Programs, 391
Child, 416
Intensive Outpatient Programs, 391
Parent or Caregiver, 416
Outpatient Drug-Free Programs and
Diagnoses and Outcomes Identification, 417
Employee Assistance Programs, 391
Implementation, 417
Evaluation, 391
Follow-Up Care, 417
Primary Prevention, 418
Characteristics of Intimate Partner
EXPERIENCING Violence, 419
PSYCHIATRIC The Battered Partner, 419
EMERGENCIES The Batterer, 420
Cycle of Violence, 420
20 Crisis and Mass Disaster, 397 Why Abused Partners Stay, 421
Prevalence and Comorbidity, 398 PROCESS, 424
Theory, 398 Assessment, 424
Clinical Picture, 399 Diagnosis and Outcomes Identification, 424
Types of Crises, 399 Implementation, 424
Disaster Response, 401 A Note on Programs for Batterers, 424
Self-Care for Nurses, 401 ELDER ABUSE, 426
Phases of Crisis, 402 Characteristics of Elder Abuse, 427
PROCESS, 402 The Abuser, 427
Assessing the Patient’s Perception of the PROCESS, 427
Precipitating Event, 402 Assessment, 427
Assessing the Patient’s Situational Diagnosis and Outcomes Identification, 427
Supports, 402 Implementation, 428
Assessing the Patient’s Personal Coping Evaluation, 428
Skills, 403 22 Sexual Violence, 431
Diagnosis, 403 Elizabeth M. Varcarolis
Outcomes Identification, 403 Prevalence and Comorbidity, 433
Planning, 404 Children: Child Sexual Abuse/
Implementation, 404 Incest, 433
Levels of Nursing Care, 405 High School, 433
Evaluation, 406 Young Adults, 433
Male Victims of Sexual Assault, 433
Cultural Considerations, 435


Vulnerable Individuals, 436 PROCESS, 465
The Perpetrator of Sexual Assault, 436 Assessment, 465
PROCESS, 437 Objective Data, 465
Assessment, 437 Diagnosis, 466
Calling Hotlines or Other Sources, 437 Outcomes Identification, 466
Emergency Departments, 437 Planning, 466
Diagnosis, 438 Implementation, 467
Rape-Trauma Syndrome, 438 Ensuring Safety, 467
Outcomes Identification, 439 Stages of the Violence Cycle, 468
Short-Term Goals, 439 Critical Incident Debriefing, 472
Long-Term Goals, 439 Documentation of a Violent Episode, 473
Implementation, 439 Anticipating Increased Anxiety and Anger
Pharmacological, Biological, and in Other Hospital Settings, 473
Integrative Therapies, 439 Anxiety Reduction Techniques, 474
Psychotherapy, 442 Interventions for Patients With
Evaluation, 442 Neurocognitive Deficits, 474
23 Suicidal Thoughts and Behaviors, 446 Psychotherapy, 475
Elizabeth M. Varcarolis Pharmacological, Biological, and
Prevalence and Comorbidity, 447 Integrative Therapies, 476
Theory, 448 Evaluation, 476
Contributing Risk Factors for 25 Care for the Dying and Those Who
Suicide, 448 Grieve, 479
Cultural Considerations, 451 Kathy Kramer-Howe
APPLICATION OF THE NURSING Nursing Goals in End-of-Life Care, 481
PROCESS, 451 Helping Bereaved Caregivers Make Sense
Assessment, 451 of Their Feelings, 481
Verbal Clues, 451 Helping People Say Goodbye, 482
Behavioral Clues, 451 Helping Families Maintain Hope, 482
Lethality of Plan, 451 The Intervention of Presence, 483
Diagnosis, 452 Facilitating End-of-Life Conversations, 483
Outcomes Identification and Planning, 452 Assessing for Spiritual Issues, 484
Implementation, 453 Self-Care for Nurses, 484
Communication Guidelines, 453 Self-Care for Nurses and Staff, 485
Psychotherapy, 453 Grief and Loss, 485
Postvention, 453 Disenfranchised Grief, 486
Self-Care for Nurses, 457 Theory, 486
Shock and Disbelief, 487
24 Anger, Aggression, and Violence, 461
Development of Awareness, 487
Elizabeth M. Varcarolis
Bullying in the Nursing Profession, 462 APPLICATION OF THE NURSING
Prevalence and Comorbidity, 463 PROCESS, 488
Theory, 463 Assessment, 488
Environmental and Demographic Diagnosis, 490
Correlates of Violence, 463 Complicated Grieving or Risk for
Neurobiological Factors, 463 Complicated Grieving, 490
Genetic Factors, 465 Outcomes Identification, 491
Cultural Considerations, 465 Planning, 491
Implementation, 491
Psychotherapy, 491
Evaluation, 493

Issues Affecting Society and the

26 Children and Adolescents, 500 Assessment, 518
Elizabeth M. Varcarolis Diagnosis, 519
Prevalence and Comorbidity, 501 Outcomes Identification, 519
Theory, 501 Implementation, 519
Genetic Factors, 502 Pharmacological, Biological, and
Biochemical Factors, 502 Integrative Therapies, 519
Environmental Factors, 502
Resiliency, 502
Theory, 522
Mental Health Assessment, 502
Biological Factors, 522
DISORDERS, 503 Psychological Factors, 522
Intellectual Developmental Disoder Clinical Picture, 522
(Intellectual Disability), 503 Effect on Individuals, Families, and
Nursing Diagnosis, 504 Society, 522
Autism Spectrum Disorder, 504
Assessment, 505
Diagnosis, 505
Assessment, 524
Implementation, 505
Diagnosis, 524
Attention Deficit/Hyperactivity
Outcomes Identification, 524
Disorder, 506
Implementation, 524
Diagnosis, 506
Pharmacological, Biological, and
Implementation, 507
Integrative Therapies, 524
Tourette’s Disorder, 507
Gender Dysphoria/Gender Identity
Assessment, 507
Disorder, 525
Diagnosis, 507
Paraphilias, 526
Implementation, 508
Theory, 526
DISRUPTIVE BEHAVIORAL Biological Factors, 526
DISORDERS, 508 Psychological Factors, 526
Oppositional Defiant Disorder, 508 Clinical Picture, 526
Conduct Disorder, 508 Effect on Individuals, Families, and
Diagnosis, 509 Society, 527
Implementation, 509
Separation Anxiety Disorder, 510 Self-Care for Nurses, 528
Diagnosis, 510 Assessment, 528
Implementation, 510 Diagnosis, 528
AND ADOLESCENT DISORDERS, 511 Implementation, 528
27 Adults, 515 Pharmacological and Therapeutic
Edward A. Herzog Interventions, 528
Understanding Severe and Persistent Mental ADULT ATTENTION DEFICIT/
Extent of the Problem, 516 Prevalence and Comorbidity, 530
Issues Facing Those With Severe and Theory, 531
Persistent Mental Illness, 517 Genetic Factors, 531

Biological Factors, 531 Suicide, 545

Psychological Factors, 531 Assessment of Suicide Risk, 546
Clinical Picture, 531 Right to Die, 546
Effect on Individuals, Families, and Alcoholism and Substance Abuse, 547
Society, 531 Alcoholism, 547
PROCESS, 531 Acquired Immunodeficiency Syndrome and
Assessment, 531 Aids-Related Dementia, 550
Outcomes Identification, 532 AFFECT THE MENTAL HEALTH OF
Implementation, 532 OLDER ADULTS, 550
Pharmacological, Biological, and Use of Restraints, 550
Integrative Therapies, 532 Physical Restraints, 550
28 Older Adults, 537 Chemical Restraints, 551
Elizabeth M. Varcarolis Control of the Decision-Making Process, 551
A Note on Pharmacology and the Aging Patient Self-Determination Act, 551
Adult, 538 Nursing Role in the Decision-Making
Ageism, 539 Process, 552
Ageism Among Health Care Workers, 539 Appendixes
Assessment and Communication A DSM-5 Classification, 556
Strategies, 540 B NANDA-I Nursing Diagnoses 2012-2014, 572
Depression, 543
Antidepressant Therapy, 544
Psychotherapy, 545
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U N I T  1
Essential Theoretical
Concepts for Practice
Hildegard E. Peplau (1909-1999)
“Mother of Psychiatric Nursing”

Hildegard Peplau has had the most profound effect on the

practice of nursing since Florence Nightingale. Peplau’s
interpersonal theory of nursing was strongly influenced by
Harry Stack Sullivan’s Interpersonal Relationship Theory,
as well as Maslow, Freud and others. Peplau was the first
nursing theorist to bring in theory from other scientific
fields and integrate them into a nursing theory. Her inter-
personal theories lead to a paradigm shift in the nature of
the nurse-patient relationship (now often referred to in
medicine as the patient-centered relationship). Peplau was
the first to theorize that the nurse’s therapeutic use of self
during the nurse-patient interactions had a direct bearing
on the outcome of the patient’s well-being.
Hildegard Peplau received a master’s and doctorate
degree from Teachers College, Columbia University and it
was there that she developed the first graduate program specific to psychiatric nursing. At Rutgers
University, New Jersey (1954 to 1974) she created a Master’s program for the preparation of clinical
specialists in psychiatric nursing, the first of its kind for any nursing discipline.
As you read through this text you will learn about the different levels of anxiety, the phases of the
nurse-patient relationship, and the importance of observing your own thoughts and feelings within
the context of the nurse-patient interaction. These are all indispensible tools used by competent
nurses today, all contributions from Hildegard Peplau. Peplau’s model and contributions have served
as a springboard for later nurse theorists and clinicians in developing more sophisticated and thera-
peutic nursing interventions.
Peplau’s contribution goes way beyond psychiatric nursing. She promoted the idea of advanced
practice nursing which lead to professional standards and regulation through credentialing. Even
nurses who never heard of Hildegard Peplau are profoundly affected by the art and the science she
brought to nursing, and are fundamental to nursing as well as the practice of psychiatric nursing.


Practicing the Science and the Art
of Psychiatric Nursing
Elizabeth M. Varcarolis

  For additional DSM-5 criteria content, see Appendix C


5 A’s, p. 4 evidence-based practice (EBP), p. 3
attending, p. 8 nurse-patient partnership, p. 3
caring, p. 6 patient advocate, p. 8
Three fundamental elements of patient
clinical algorithms, p. 5 psychiatric mental health
advocacy include:
clinical/critical pathways, p. 6 nursing, p. 3
• To ensure that patients are informed
clinical practice guidelines, p. 5 recovery model, p. 3
of their rights in a particular situation,
including the right to refuse treatment.
• To support patients and decisions
they make.
• To protect patients, which includes
reporting threats to their well-being.
Inherent in the responsibilities of advo-
cating for patients include the following
• Privacy
• Confidentiality
• Protection in participation in research
• Standards and review mechanisms
• Acting on questionable practices
• Addressing impaired practice
(Marcus, 2011; ANA, 2001)

CHAPTER 1  Practicing the Science and the Art of Psychiatric Nursing 3

1. Contrast and compare the focus and approach of the men- 4. Identify four resources that nurses can use as guidelines for
tal health recovery model to the evidence-based practice best-evidence interventions.
(EBP) model. 5. Defend why the concept of “caring” should be a basic
2. Identify the “5 A’s” in the simple multistep process of ingredient to the practice of nursing and how it is
evidence-based practice and describe what is inherent in expressed by nurses in the clinical setting.
each step of this process. 6. Discuss what is meant by being a patient advocate.
3. Discuss at least three current dilemmas nurses face when   
they seek the best evidence for their interventions.

Psychiatric nursing is a specialized area of nursing practice. Its self-determination, meaning, and satisfaction; and to the high-
focus is the treatment of human responses to mental health est quality of life within the limitations of the illness. The prin-
problems and psychiatric disorders. “Psychiatric–mental ciples of the recovery model have been adopted by a number of
health nursing, a core mental health profession, employs a countries and states. The focus of the recovery model has the
purposeful use of self as its art and a wide range of nursing, psy- following mandates (Caldwell et al., 2010, p. 43):
chosocial, and neurobiological theories and research evidence • Mental health care is to be consumer and family driven.
as its science” (ANA, 2007, p. 1). • Care must focus on increasing consumer’s ability to be
Starting around the 1990s (the “Decade of the Brain”) successful in coping with life’s challenges, facilitating
more funding for brain research became available and remark- recovery, and building resilience—not just managing
able progress was made in our understanding of how to treat symptoms.
illnesses caused by brain dysfunction. The method for using • An individualized plan of care is to be at the core of con-
treatment approaches to medical illness and mental health ill- sumer-centered recovery—recovery-oriented services
ness that are scientifically grounded or evidence based became that allow consumers to realize improved mental health
known as evidence-based practice (EBP). In psychiatry the and quality of life.
evidence-based focus extends to treatment approaches in which • Consumers must be partners in decision making in all
there is scientific evidence for psychological and sociological aspects of care.
treatment methodologies, as well as evidence related to the Therefore the concept of the nurse-patient relationship,
neurobiology of psychiatric disorders and psychopharmacol- or physician-patient relationship originating from the medical
ogy. Therefore evidence-based practice strives to decrease the model, suggests an unequal status with the nurse/health care
gap between research and practice (Dorn, 2005). This model is worker as the person in authority. The emphasis today is much
consistent with the familiar traditional medical model. more on the nurse-patient partnership, which is more in line
The mental health recovery model, on the other hand, is with the emphasis on “relationships” in the recovery model
more of a social model of disability than a medical model of (Stuart, 2011).
disability. Therefore the focus shifts from one of illness and dis- Forchuk (2001), Benner (2004), and other psychiatric nurs-
ease to an emphasis on rehabilitation and recovery (Caldwell ing leaders stress the importance of psychiatric nursing taking
et al., 2010). The recovery model originated from the 12-step a leadership role in creating patient-centered care that demon-
program of Alcoholics Anonymous and was advanced by a strates how to establish a relationship within a recovery-based
grassroots advocacy initiative called the Consumer/Survivor/ model and at the same time understand and incorporate the
Ex-patient Movement during the 1980s and early 1990s. The evidence related to the neurobiology of psychiatric disorders
concept of recovery refers primarily to managing symptoms, and psychotropic medications.
reducing psychosocial disability, and improving role perfor-
mance (Pratt et al., 2006). Holistic interventions are designed THE SCIENCE OF NURSING: FINDING
to increase recovery as evidenced by engagement in work and
engagement in community/social life, as well as a reduction of
symptoms (Beebe, 2010). Recovering from a mental illness is Basing nursing and medical practice on a systematic approach
viewed as a personal journey of healing. to care is not new. In the past century, nursing began with a
The goal of recovery is to empower those with mental ill- strong emphasis on practice. McDonald (2001) states that
ness to find meaning and satisfaction in their lives, realize ­Florence Nightingale (1820 to 1910), the founder of modern
personal potential, and function at their optimal level of inde- nursing, had a philosophy reflecting an evidence-based frame-
pendence. It has been found that supportive relationships, work. Nightingale advocated for the “best possible research,
social inclusion, acquisition of needed coping skills, recovery- access the best available governmental statistics and exper-
oriented services, and sense of hope for the future can lead to tise…” (p. 2). During the 1860 International Statistical ­Congress
a sustainable belief in oneself; to a sense of empowerment and held in London, Nightingale made a proposal that was to result
4 UNIT 1  Essential Theoretical Concepts for Practice

in “the first model for systemic collection of hospital data using 3.  Appraise the literature. Evaluate and synthesize the
a uniform classification of diseases and operations and was to research evidence regarding its validity, relevance, and
form the basis of the International Statistical Classification of applicability using criteria of scientific merit.
Diseases and Related Health Problems (ICD) used today world- 4.  Apply the evidence. Choose interventions that are based
wide” (Keith, 1988). Mental health professionals in the United on the best available evidence with the understanding of
States substitute the Diagnostic and Statistical Manual of Mental the patient’s preference and needs.
Disorders (DSM) for the mental health section of the ICD. The 5.  Assess the performance. Evaluate the outcomes, using
DSM is discussed in more detail in Chapter 2. clearly defined criteria and reports, and document results.
Hildegard Peplau (1909 to 1999), considered the mother Evaluating the evidence is done through a hierarchical rating
of psychiatric nursing, had a passion for clarifying and devel- system. Randomized controlled studies and evidence-based clini-
oping the art and science of professional nursing practice and cal practice guidelines provide the strongest evidence on which
believed that a scientific approach was essential to the practice to base clinical practice. In a randomized controlled trial (RCT)
of psychiatric nursing (Haber, 2000). Her contributions went patients are chosen at random (by chance) to receive one of several
far beyond what she brought to the field of psychiatric nursing. clinical interventions. One intervention would be the interven-
She introduced the concept of advanced nursing practice and tion under study and another might be the standard intervention
promoted professional standards and regulation through cre- or a placebo. The weakest level is from expert committee reports,
dentialing among a multitude of other contributions to nurs- opinions, clinical experience, or descriptive studies. Table 1-1
ing (Tomey, 2006). presents a hierarchy of evidence and grading for each level.
It should be noted that psychiatry was one of the first medi- The first Surgeon General’s report published on the topic
cal specialties to extensively use randomized controlled trials. of mental health was in 1999 (U.S. Department of Health and
One of the founding principles of clinical psychology in the Human Services [USDHHS], 1999). This landmark document
1950s was that practice should be based on the results of exper- was based on an extensive review of the scientific literature and
imental comparisons of treatment methods (Geddes et al., in consultation with mental health providers and consumers
2004). However, without scientific evidence for practice, much (Zauszniewski & Suresky, 2003). The document concluded
of nursing care has been based on tradition, personal experi- that there are numerous effective psychopharmacological and
ence, unsystematic trial and error, and the earlier experiences psychosocial treatments for most mental disorders. However,
of nurses and others in the health care profession (Wilson, it raised some questions for psychiatric nurses, including the
2004; Zauszniewski & Suresky, 2003). following (Stuart, 2001):
The emergence of evidence-based nursing practice in the • Are psychiatric nurses aware of the efficacy of the treatment
United States originated from the evidence-based practice and interventions they provide?
movement in the medical community in England and Canada • Are they truly practicing evidence-based care?
during the 1980s and 1990s (Mick, 2005). During that time • Is there documentation of the nature and outcomes of the
there was an increase in research-related journals, the most rel- care they provide?
evant of which for nurses was the development of the Evidence- There is no question that emphasis on evidence-based prac-
Based Nursing journal in 1998. tice in medicine and mental health is expanding. Interventions
The University of Minnesota defines EBP as “the process based on the best research evidence combined with clinical
by which the best available research evidence (from well- expertise seem an ideal approach. However, this approach will
designed studies), clinical expertise, and patient preferences not provide easy answers, and much discussion and questions
are used for making clinical decisions.” Melnyk (2004) states are raised regarding the practice of evidence-based mental
there is no magic bullet that provides a formula describing health nursing. First, who interprets “best evidence”?
the weight of evidence that patient values and preferences and Second, not all nursing problems are able to be reduced to
clinical expertise should take in making clinical decisions. a clear issue solvable by scientific experiments (White, 1997).
­Mantzoukas (2007) warns that although EBP is equated with White continues to stress that many problems are addressed by
effective decision making, avoidance of habitual practice, and using “artistry” to find solutions.
enhanced clinical performance, there is a tendency to over- Third, relatively few studies backed by rigorous quantitative
look certain types of knowledge that through reflection can research are available from which to select nursing interven-
provide useful information for individualized and effective tions and to guide psychiatric nursing care practices. Of 227
practice. data-based studies published between 2000 and 2003, only 52
Numerous definitions delineate the multistep process of (23%) included nurses, student nurses, or other mental health
integrating EBP into clinical practice. One that is simply stated care professionals. Of these 52 studies, only 11 (21%) involved
and apt is used at the Children’s Mercy Hospital in Kansas City, examining psychiatric nursing interventions. Promoting EBP
Missouri (Mick, 2005), referred to as the 5 A’s: in psychiatric nursing will require increasing the number of
1.  Ask a question. Identify a problem or need for change studies by researchers who possess clinical knowledge and
for a specific patient or situation. research expertise (Zauszniewski & Suresky, 2003).
2.  Acquire literature. Search the literature for scientific Fourth, there is the question: How do nurses who are
studies and articles that address the issue(s) of concern. practicing in an environment of reduced staffing, increased
CHAPTER 1  Practicing the Science and the Art of Psychiatric Nursing 5


Each recommendation has been allocated a grading that directly reflects the hierarchy of evidence on which it has been
based. Please note that the hierarchy of evidence and the recommendation gradings relate to the strength of the litera-
ture, not to clinical importance.
Level Type of Evidence Level Type of Evidence
Ia Evidence from systematic reviews or meta-analyses A Based on hierarchy I evidence
of randomized controlled trials
Ib Evidence from at least one randomized controlled
IIa Evidence from at least one controlled study B Based on hierarchy II evidence or extrapolated
without randomization from hierarchy I evidence
IIb Evidence from at least one other type of
­quasi-experimental study
III Evidence from nonexperimental descriptive C Based on hierarchy III evidence or extrapolated
studies, such as comparative studies, correlation from hierarchy I or II evidence
studies, and case control studies
IV Evidence from expert committee reports or D Directly based on hierarchy IV evidence or
opinions and/or clinical experience of respected extrapolated from hierarchy I, II, or III evidence
From Hierarchy of evidence and grading of recommendations. (2004). Thorax, 59(3), 181-272.

complexity, and stress on issues of cost-effectiveness find time

to research the literature, evaluate numerous studies (if indeed
they are available), and make decisions on “best evidence?”
This question still needs a definitive answer; however, some of • American Association of Pastoral Counselors:
the following provide valuable guidelines for current practice:
1. Internet mental health resources. A number of sites provide • American Psychiatric Association:
mental health resources online for information, treatment • American Psychological Association:
provisions, and the results of recent clinical studies. There • American Psychiatric Nurses Association: www.apna.
are self-tests for people to see if they may be experiencing, at org
least in part, a specific syndrome or disorder (e.g., depression, • Brain Technologies:
elation, attention deficit/hyperactivity disorder [ADHD]). • Centre for Addiction and Mental Health:
There are also resources for acquiring support and treat- • National Institute of Mental Health:
ment. Box 1-1 provides a short list of popular mental health • National Institute of Nursing Research:
sites. It is best to focus on sites that are maintained by pro- • U.S. Department of Health and Human Services, National
fessional societies, professional librarians, or other organiza- Guideline Clearinghouse:
tions whose quality is evidence based in order to reduce the
amount of uncensored information of low quality.
2. Clinical practice guidelines. Clinical practice guidelines are at which this “best evidence” needs to be integrated with
systematically developed statements that identify, appraise, individual clinical experience and patients’ needs and goals
and summarize the best evidence about prevention, diag- in deciding on a course of action. The American Psychiat-
nosis, prognosis, therapy, and other knowledge necessary ric Association’s (APA) Clinical Practice Guidelines and the
to make informed decisions about specific health problems. National Quality Measures Clearinghouse offer such guide-
They are based on literature review (scientific research in lines. The U.S. Department of Health and Human Services
the form of randomized controlled clinical trials; reports sponsors a National Guidelines Clearinghouse of evidence-
of series, or case studies; or “expert clinical experience” based guidelines pertaining to a wide range of medical and
[AAPMR, 2006]). The development and use of practice mental health conditions (
guidelines can increase quality and consistency of care and 3. Clinical algorithms. Clinical algorithms are step-by-step
facilitate outcome research. Essentially, they (1) identify guidelines prepared in a flowchart format. Alternative
practice questions and explicitly identify all the decision diagnostic and treatment approaches are described based
options and outcomes; (2) identify the “best evidence” on decisional points using a large database relevant for
about prevention, diagnosis, prognosis, therapy, harm, the symptoms, diagnosis, or treatment modalities. Algo-
and cost-effectiveness; and (3) identify the decision points rithms are especially helpful in deciding what medication
6 UNIT 1  Essential Theoretical Concepts for Practice

to use considering a wide variety of variables related to the Clinical suspicion

patient’s personal situation (e.g., age, gender, current medi- of suicide risk
cations, ethnic origin, allergies). Figure 1-1 depicts a clinical
algorithm for the suspicion of suicide risk.
4. Clinical/critical pathways. Clinical/critical pathways are Risk factors:
usually specific to the institution using them. They are Social isolation
Spiritual isolation
most often used in relation to hospitalized patients and Male gender
target a specific population (e.g., suicidal patient, bipo- Chronic medical illness
lar patient–manic, a depressed patient, an individual with Chronic psychiatric illness
Substance abuse
schizophrenia). These clinical pathways serve as a “map” Plans
for specified treatments and interventions to occur within
a specific time frame, often days. For example, the clinical
guide may state for the day of admission certain goals are
to be reached and specific interventions are to be carried One or fewer positive Two or more positive
out by different members of the health team (e.g., physi-
cians, nurses, social workers, dietitians). The interventions
include preadmission workup, tests, diet and health teach- Attempt to reduce suffering Immediate psychiatric
ing, medication, and observation of effectiveness or adverse Initiate medical consultation
management with close
effects, through discharge plans and follow-up care. Each observation
pathway lists the expected outcomes using a measurable,
time-limited format, and documentation is ongoing. Some FIGURE 1-1  Clinical algorithm for the suspicion of suicide
institutions computerize these clinical pathways within the risk. (Modified from Goldman, L., & Ausiello, D. [2008]. Cecil
patient’s chart. Clinical/critical pathways and maps offer a medicine [23rd ed.]. Philadelphia: Saunders.)
great opportunity for the integration of research into clini-
cal practice when the interventions are evidence based. THE ART OF NURSING: DEVELOPING
Unfortunately, there is a wide gap between the best evidence Contemporary nursing relies on a high level of scientific thought
treatments and their effective delivery into practice. The need in its theories, research, and knowledge base. However, there is
for continued research on how best to apply the findings of clin- an “art” to nursing as well. Even the best evidence-based guide-
ically relevant issues and their delivery into clinical practice has lines may not be sufficient for the patient who stands in front
been the emphasis of the Institute of Medicine (IOM) (2006): of you with a very individualized set of problems and capacities.
Such individuality is complex, demanding that nurses use intu-
“…research that has identified the efficacy of specific treat-
ition, interpersonal skills, and the therapeutic use of self. These
ments under rigorously controlled conditions has been
“arts” complement nursing’s scientific base and are indispens-
accompanied by almost no research identifying how to make
able for treating any patient effectively. As Williams and Garner
these same treatments effective when delivered in usual set-
(2002, p. 8) conclude, “Too great an emphasis on evidence-
tings of care…when administered by service providers with-
based medicine oversimplifies the complex and interpersonal
out specialized education in the therapy” (p. 350).
nature of clinical care.”
Effective research is reported in language that is understand- What components are integral to nursing as an art as well as
able and free of statistical and research jargon (Zauszniewski & a science? Benner (2004) suggests that many of the attributes of
Suresky, 2003), and appropriate dissemination of findings needs nursing that fall under the “art of nursing” are invisible, intan-
to reach nursing practitioners. Despite the complexities and gible, rarely charted, and almost never suggested in a nursing
concerns that demand to be addressed, evidence-based nurs- care plan. Consequently, these attributes are often marginal-
ing is becoming a foundation for nursing practice. Eventually ized, undervalued, and demeaned. Three areas inherent in the
the use of scientific evidence-based practice will reduce the use “art” of nursing addressed here are (1) caring, (2) attending,
of unwarranted nursing practices and alleviate the severity of and (3) patient advocacy.
nursing errors. Furthermore, the use of evidence-based practice
optimizes the process of evaluation and facilitates the nurse’s Caring
development and professional advancement (Jasmine, 2009). Kari Martinsen (born 1943), a psychiatric nurse and philoso-
To help the reader understand how best evidence is identi- pher from Norway, believed that “caring involves how we
fied and applied to nursing interventions, this textbook con- relate to each other, how we show concern for each other in our
tains a feature titled Examining the Evidence. It is hoped that daily life. Caring is the most natural and the most fundamental
this feature, presented in each of the clinical chapters, will aspect of human existence” (Alvsvåg, 2006, p. 173). A survey
underscore the importance of sound scientific inquiry and by Schoenhofer and colleagues (1998) used a group process
ignite the reader’s interest in research. method (13 groups of 3 to 5 people each) to synthesize what
CHAPTER 1  Practicing the Science and the Art of Psychiatric Nursing 7


The Importance of Evidence-Based Research in Practice
Nursing Mental Diseases is a textbook that was century, it is certain that some currently accepted treatments
written in 1934 by a registered nurse, Harriet Bailey and nursing interventions will one day be abandoned and
(Bailey, 1934). It is fascinating, informative, and well replaced with interventions that are more effective.
written, yet clearly dated. Let us try to answer a Formal decisions to adopt practice protocols or guide-
hypothetical question based on information presented lines (innovation) or abandon old ones (exnovation) are not
in this textbook of common nursing measures used typically based on a single study, but are made after a com-
during this period. prehensive review of information. Evidence-based practice
Nursing measures to improve a patient’s mood include all includes not only evaluating research but also integrating it
of the following except: with input from experts and patients (Polit & Beck, 2006).
1. Hosing them down alternately with hot and cold water Although the vast majority of nurses—professionals
2. Providing a diet that consists exclusively of milk for charged with decisions about lives and even life and death
several days issues—do not conduct extensive literature reviews, it is
3. Encouraging social support and family involvement essential to consider your education a continual endeavor.
4. Putting the patient to bed for 4 to 10 weeks Reading professional journals and keeping abreast of cur-
Incorrect answers: 1. Hydrotherapy was commonly used rent research play an essential role in this education.
as a “nerve stimulant” to improve mood. 2. A milk diet In each of this text’s clinical chapters, an interesting ques-
was followed by a sudden introduction of a full diet (no tion (which is how any research project initially starts—
rationale given; your guess is as good as mine). 4. Bed with a question) about mental health, psychiatric disorders,
rest was seen as a treatment for mental illness. and treatment that you might actually ask yourself is pre-
Correct answer: 3. The patient was removed from family sented. Literature and expert opinions are provided that
and friends who may have sympathized or criticized too explore possible responses and opposing positions to the
much; after 4 to 10 weeks patients were permitted to question. You are encouraged to read these boxes and
receive a letter from home on a test basis. evaluate the evidence. What is your opinion? What other
Psychiatric nurses today do not hose down patients, provide information would you need to draw a conclusion? How
milk diets, or enforce prolonged bed rest. They do encourage can researchers best approach this question?
patients to interact with others and promote family involve- We hope that these boxes will not only make you think
ment when possible. Although sophistication in psychiatric but also increase your appreciation for research and
nursing interventions has improved drastically in the past explain why it is necessary.

Bailey, H. (1934). Mental health nursing (2nd ed.). New York: Macmillan.
Polit, D. F., & Beck, C. T. (2006). Essentials of nursing research: method, appraisal, and utilization (6th ed.). Philadelphia: Lippincott.
Margaret J. Halter (Taken from first edition of Essentials of Psychiatric Mental Health Nursing).

was meant by caring to the participants. The following three However, a nurse may be at a level of competence but
themes emerged from the shared narratives: unable to demonstrate caring. The absence of caring can leave
1. Caring is evidenced by empathic understanding, actions, memorable scars and make patients feel distrustful, discon-
and patience on another’s behalf. nected, uneasy, and discouraged (Halldorsdottir & Hamrin,
2. Caring for one another by actions, words, and being 1997). Using communications that are destructive or devalue
there leads to happiness and touches the heart. a patient’s worth can have lasting negative effects. Examples of
3. Caring is giving of self while preserving the importance uncaring behaviors include denying patients’ feelings, respond-
of self. ing with indifference to patients’ concerns, and failing to check
Dr. Jean Watson’s caring theory incorporates humanistic- to see if medications given to relieve discomfort or distress are
altruistic values, creative problem solving, faith-hope, existen- working. These are examples of behaviors that violate a patient’s
tial and spiritual forces, and more. integrity and dignity and are never justified (Cooper, 2001).
The caring nurse is first and foremost a competent nurse Comforting can also be assumed under the mantle of car-
(Cooper & Powell, 1998). Indeed, Locsin (1995) expanded the ing. Benner (2004) states that comforting includes providing
concept of caring in the theory of technological competence as social, emotional, physical, and spiritual support for a patient
caring in critical care nursing. Without knowledge and compe- that is consistent with the holistic approach to nursing care.
tence, the demonstration of compassion and caring alone is pow- The provision of comfort measures can even be lifesaving in
erless to help those under our care. Without a base of knowledge fragile patients, and is a basic component to good care. Car-
and skills, care alone cannot eliminate another person’s confu- ing as practiced from a caring perspective/theory applies to all
sion, grief, or pain, but a response of care can transform fear, pain, settings, all populations (including cultural/ethnic/minority
and suffering into a tolerable, shared experience (Cooper, 2001). groups), and all age groups (Jasmine, 2009). Unfortunately,
8 UNIT 1  Essential Theoretical Concepts for Practice

there are many impediments to practicing “caring” in our being a patient advocate is not a legal role but rather an ethi-
present health care system that are driven by economic con- cal one. Ethics is an integral part of the foundation of nursing.
siderations. We continue to be in a period of nursing shortage You, no doubt, have had a class that includes the ethical code
in institutions (e.g., hospitals, community centers, emergency for nurses. However, the role of patient advocate bears men-
departments) with many graduating nurses not being hired at tioning here. The term patient advocate was first placed in the
this time because of budgetary factors. This low staffing puts a 1976 American Nurses Association (ANA) Code of Ethics for
greater burden on nurses while working with greater workloads Nurses, revision, and remains essentially unchanged up to the
and sicker patients. However, as Cooper aptly points out, car- present. It reads:
ing is both an attitude that one communicates, a way of being
The nurse must be alert to and take appropriate action
with a patient, as well as a set of skills that can be learned and
regarding any instances of incompetent, unethical, illegal,
developed. Both require nurturing and practice. Cooper goes
or impaired practices(s) by any member of the health team
on to say that while it does take time to listen to patients, “in
or the health care system itself, or any action on the part of
time you will be able to do the tasks of nursing while attending
others that places the rights or best interest of the patient in
to the patient, and get to know the patient as you are doing an
jeopardy (ANA, 2001, 3.5).
assessment or intervention” (p. 95).
And, yes, sometimes it takes a great deal of courage to
Attending advocate for our patients when we witness behaviors or actions
Attending refers to an intensity of presence, being there for and of other health care professionals that could have serious
in tune with the patient. The experience of emotional or physi- consequences for the patient.
cal suffering can be isolating. When patients perceive that the Advocacy in nursing includes a commitment to patients’
nurse is there for them, a human connection is made and the health, well-being, and safety across the life span, and the alle-
patient’s sense of isolation is minimized or eliminated (Cooper, viation of suffering and promoting a peaceful, comfortable,
2001). Being present requires entering the patient’s experience. and dignified death (ANA, 2001). Nurses advocate for patients
Attending behaviors may include listening, touching, or giving when they advise patients of their rights (including the right
attentive physical care (Cooper, 2001). It is through active lis- to refuse treatment), provide accurate and current information
tening skills and the use of effective communication skills that so patients can make informed decisions, and support those
we can fully understand another person’s immediate experi- decisions (Mallik, 1997). Advocating for the patient demon-
ence and distressing fears, perceptions, and concerns. Attend- strates respect for human life (the patient’s as well as our own)
ing behaviors are learned and are inherent in a true therapeutic and validates the belief in the value of human life, whether it is
relationship. Chapter 9 discusses attending behaviors in more to save a life or to bring comfort to those who are dying. Psy-
detail within the context of the nurse-patient relationship. chiatric mental health nurses function as advocates when they
engage in public speaking, write articles for the popular press,
Patient Advocacy and lobby congressional representatives to help improve and
Essentially, a patient advocate is one who speaks up for anoth- expand mental health care for everyone (ANA, 2007).
er’s cause, who helps others by defending and comforting Throughout the text a special feature titled Applying the Art
them, especially when the other person lacks the knowledge, gives the reader a glimpse of a nurse-patient interaction and
skills, ability, or status to speak for himself/herself. Lawyers are the nurse’s thought processes while attending to the patient’s
often viewed as advocates for their clients; however, in nursing, immediate concern.


• E vidence-based practice (EBP) is a process by which the • A sound body of knowledge of effective psychiatric nurs-
best available research evidence, clinical expertise, and ing interventions is available and in use today. However, a
patient preferences are used for making clinical decisions. great deal more observations and studies need to be done to
• The “5 A’s” process to delineate the multistep process of ascertain whether we are using best-evidence interventions
integrating best evidence into clinical practice includes in our clinical practice.
(1) asking, (2) acquiring, (3) appraising, (4) applying, and • Best evidence for appropriate medication and therapies for
(5) assessing. use in patients with specific mental health conditions has
• The mental health recovery model is one of helping people been more readily studied and documented.
with psychiatric disabilities effectively manage their symp- • Three specific areas are inherent within the art of nursing:
toms, reduce psychosocial disability, and find a meaningful (1) caring, (2) attending, and (3) patient advocacy.
life in a community of their choosing.
• Some sources for obtaining research findings are (1) Inter-
net mental health resources, (2) clinical practice guidelines,
(3) clinical algorithms, and (4) clinical/critical pathways.
CHAPTER 1  Practicing the Science and the Art of Psychiatric Nursing 9

 A P P L Y I N G C R I T I C A L J U D G M E N T
1. A friend of yours has recently returned from the war in has lots of stories and affidavits from people who are alco-
Afghanistan. You are startled when you see him on the street holics whom he has treated with success to drink in a con-
in a disheveled state. He appears frightened, seems to be trolled manner.” You tell him that that is not good evidence
talking to himself, and jumps a mile when a car backfires for such a claim.
nearby. You are astounded because he was always so smart A. How would you, as a nurse, evaluate this claim? Explain
and well liked, thought of as kind and personable, and had a the five steps you would take to find the strength of this
good career ahead of him as a computer programmer. When claim.
you approach him he backs away in a protective manner. B. Using Table 1-1, what would you say about the quality
A. How would the contribution of evidence-based practice of the evidence given above?
(EBP) be helpful to his recovery? Give examples. C. If your friend were in recovery and thinking of trying
B. What might be some specific needs that could be met this treatment, what would you say to him that would
under the recovery model? make a strong argument against such a decision?
C. Discuss how nurses can incorporate both EBP and the 3. You are a new nursing student and a friend of yours says,
recovery model in their practice. “What the devil is the ‘art of nursing’? Isn’t that from the
D. Explain which model might be the most useful during the middle ages?”
acute phase of his recovery, and which model might be A. Discuss three components that might be considered

more effective in the continuation period of his recovery. under the art of nursing.
2. A friend of yours says that he heard about a new practi- B. Give your friend an example of how nurses demonstrate
tioner in the area that is going to teach alcoholics how to “caring” in the clinical area.
safely drink in moderation. You are thinking of two of your C. Explain why patients need to have nurses act as their
friends who are now in recovery, one of whom nearly died advocate. Can you think of an example from your clini-
from an alcoholic event. You state that from all you have cal experience?
read, and from your friends’ experience, that “controlled 4. Go to the Centre for Evidence-Based Mental Health at
drinking isn’t thought to be an acceptable practice.” Your and check out at least one available clini-
friend says, sure there is good evidence, “This professional cal trial.

 C H A P T E R R E V I E W Q U E S T I O N S
Choose the most appropriate answer(s). 4. Patient advocacy:
1. The “art” of psychiatric mental health nursing, according to 1. is a legal role.
Benner, includes: (select all that apply) 2. requires courage.
1. caring. 3. is an optional aspect of nursing.
2. attending. 4. was developed in 2007.
3. patient advocacy. 5. When an experienced psychiatric nurse listens carefully to
4. ethics. a patient’s detailed recounting of a traumatic emotional
2. The “science” of psychiatric mental health nursing includes: experience, the nurse is:
(select all that apply) 1. acting as a patient advocate.
1. a sense of tradition. 2. using an attending behavior.
2. nursing theory. 3. interpreting “best evidence.”
3. psychosocial theory. 4. using a systematic approach to care.
4. neurobiological theory.
3. Caring is: (select all that apply)
1. an attitude that one communicate.
2. a way of being with the patient.
3. intensity of presence.
4. giving of self.
10 UNIT 1  Essential Theoretical Concepts for Practice

REFERENCES Locsin, R. C. (1995). Machine technologies and caring in nursing.

Image: Journal of Nursing Scholarship, 27(3), 201–203.
Alvsvåg, H. (2006). Philosophy of caring. In A. M. Tomey, & M. R. Mallik, M. (1997). Advocacy in nursing: a review of the literature.
Alligood (Eds.), Nursing theorists and their work. St Louis: Mosby. Journal of Advanced Nursing, 23, 130–138.
American Academy of Physical Medicine and Rehabilitation Mantzoukas, S. (2007). A review of evidence-based practice, nursing
(AAPMR). (2006). Practice guidelines committee develops definitions research and reflection: leveling the hierarchy. Journal of Clinical
of term. Retrieved August 24, 2006, from Nursing, 17(2), 214–223.
pracguide/terms.htm. Marcus, K. (2011). The nurse as patient advocate: is there a conflict of
American Nurses Association (ANA). (2007). Psychiatric–mental interest? In P. S. Cowen, & S. Moorehead (Eds.), Current issues in
health nursing: scope and standards of practice. Silver Spring, MD: nursing (8th ed., pp. 609–674). St Louis: Mosby/Elsevier.
The Association. McDonald, L. (2001). Florence Nightingale and the early origins of
American Nurses Association (ANA). (2001). Code of ethics with inter- evidence-based nursing. Evidence-Based Nursing, 4, 68–69.
pretive statements. Silver Spring, MD: The Association. Melnyk, B. M. (2004). Integrating levels of evidence into clinical deci-
Beebe, L. H. (2010). Adjunctive psychiatric treatments and recovery- sion making. Pediatric Nursing, 30(4), 323–324.
focused care. Journal of Psychosocial Nursing Mental Health Mick, K. (2005). Evidence-based nursing practice: putting the pieces
Services, 48(11), 4–5. together. Retrieved July 18, 2006,
Benner, P. (2004). Relational ethics of comfort, touch, and solace Pratt, C., Gill, K., Barrett, N., & Roberts, M. (2006). Psychiatric reha-
endangered arts? American Journal of Critical Care, 13, 346–349. bilitation (2nd ed.). San Diego: Academic Press.
Caldwell, B. A., Sclasani, M., Swarbrick, M., & Piren, K. (2010). Schoenhofer, S., Bingham, V., & Hutchins, G. (1998). Giving of one-
Psychiatric nursing practice & the recovery model of care. Journal self on another’s behalf: the phenomenology of everyday caring.
of PSN, 48(7), 42–48. International Journal of Human Caring, 2(2). 32–29.
Cooper, C. (2001). The art of nursing: a practical introduction. Stuart, G. W. (2001). Evidence-based psychiatric nursing practice:
­Philadelphia: Saunders. rhetoric or reality? Journal of the American Psychiatric Nurses
Cooper, C., & Powell, E. (1998). Technology and care in a bone mar- Association, 7(4), 103–114.
row transplant unit: creating and assuaging vulnerability. Holistic Stuart, G. W. (2011). Psychiatric mental health nursing: recent
Nursing Practice, 12, 57–68. changes in current issues. In P. S. Cowen, & S. Moorehead (Eds.),
Dorn, K. (2005). Topics in advanced practice nursing. E Journal, 4(4). Current issues in nursing. St Louis: Mosby/Elsevier.
Medscape. Tomey, A. M. (2006). Nursing theorists of historical significance. In
Forchuk, C. (2001). Evidence-based psychiatric/mental health nurs- A. M. Tomey, & M. R. Alligood (Eds.), Nursing theorists and their
ing. Evidence-Based Mental Health, 4(2), 39–40. work (6th ed.). St Louis: Mosby.
Geddes, J., Reynolds, S., Streiner, D., & Szatmari, P. (2004). Evidence U.S. Department of Health and Human Services (USDHHS). (1999).
based practice in mental health. Centre for Evidence-Based Medi- Mental health: a report from the surgeon general. Rockville, MD:
cine. Retrieved from National Institute of Mental Health.
htm. White, S. I. (1997). Evidence-based practice and nursing: the new
Haber, J. (2000). Hildegard Peplau: the psychiatric nursing legacy of panacea? British Journal of Nursing, 6(3), 175–178.
a legend. Journal of the American Psychiatric Nurses Association, Williams, D. D. R., & Garner, J. (2002). The case against “the
6(2), 56–62. evidence”: a different perspective on evidence-based medicine.
Halldorsdottir, S., & Hamrin, E. (1997). Caring and uncaring encoun- British Journal of Psychiatry, 180, 8–12.
ters in nursing and health care from the cancer patient’s perspec- Wilson, H. S. (2004). Evidence-based practice in psychiatric-mental
tive. Cancer Nursing, 20, 120–128. health nursing. In C. R. Kneisl, H. S. Wilson, & E. Trigoboff
Institute of Medicine (IOM). (2006). Improving the quality of health (Eds.), Contemporary psychiatric-mental health nursing. Upper
care for mental and substance-use conditions. Institute of Medicine Saddle River, NJ: Pearson Prentice-Hall.
of the National Academies. Washington, DC: National Academies Zauszniewski, J. A., & Suresky, J. (2003). Evidence for psychiatric
Press. nursing practice: an analysis of three years of published research.
Jasmine, T. (2009). Art, science, or both? Keeping the care in nursing. Online Journal of Issues in Nursing, 9(1). Retrieved July 18, 2006,
Nursing Clinics of North America, 44, 415–421. from
Keith, J. M. (1988). Florence Nightingale: statistician and consultant
epidemiologist. International Nursing Review, 35, 147–150.

Mental Health and Mental Illness
Elizabeth M. Varcarolis

  For additional DSM-5 criteria content, see Appendix C


biologically based mental mental illness, p. 13 SELECTED CONCEPT: Stigma and
illness, p. 15 myths and misconceptions, p. 14
Mental Health
culture-related syndromes, p. 19 prevalence rate, p. 15
False beliefs, myths, and lack of under-
Diagnostic and Statistical psychiatry’s definition of normal
standing of mental illness can cause tre-
Manual of Mental Disorders mental health, p. 14
mendous pain and negative consequences
(DSM-5), p. 13 psychobiological disorder, p. 15
for individuals or groups who develop men-
epidemiology, p. 15 resiliency, p. 15
tal health problems. Stigma may be obvi-
mental disorders, p. 13 stigma/stigmatizing, p. 18
ous and direct, or expressed in more subtle
mental health, p. 13
Some of the harmful effects of stigma
toward those with mental health issues
• Discrimination at work or school
• Difficulty finding housing
• Bullying, physical violence or
•  Health insurance that doesn’t ade-
quately cover a person’s mental
health dysfunction/disorder
•  Instilling self-doubt regarding ability
to succeed in certain challenges and
perceiving that there is nothing that
can help
• Further isolation from friends, family,
and colleagues.
(Mayo Clinic, 2011)

12 UNIT 1  Essential Theoretical Concepts for Practice

1. Assess mental health using the seven signs of mental health 4. Identify the processes leading up to stigmatizing, and some
identified in this chapter (Table 2-1 and Figure 2-1). of the effects stigma can have on the medical and psycho-
2. Summarize factors that can affect the mental health of an logical well-being of an individual, group, and/or culture.
individual and the ways that these factors influence con- 5. Compare and contrast a DSM-5 diagnosis with a nursing
ducting a holistic nursing assessment. diagnosis.
3. Discuss some dynamic factors (including social climate, 6. Give examples of how consideration of norms and other
politics, cultural beliefs, myths, and biases) that contribute cultural influences can affect making an accurate DSM-5
to making a clear-cut definition of mental health elusive. diagnosis.


Happiness Major Depressive Episode
Finds life enjoyable Loses interest or pleasure in all or almost all usual
Can see in objects, people, and activities activities and pastimes
the possibilities for meeting his or her Describes mood as depressed, sad, hopeless,
needs discouraged, “down in the dumps”
Control Over Behavior Control Disorder: Undersocialized, Aggressive
Can recognize and act on cues to existing limits Shows repetitive and persistent pattern of
Can respond to rules, routines, and customs of any group aggressive conduct in which basic rights of others
to which he or she belongs are violated
Appraisal of Reality Schizophrenic and Other Disorders
Accurate picture of what is happening around the individual Shows bizarre delusions, such as delusions of being
Good sense of consequences, both good and bad, controlled
that will follow his or her acts Has auditory hallucinations
Can see difference between “as if” and “for real” in situations Manifests delusions with persecutory or jealous content
Effectiveness in Work Adjustment Disorder With Work (or Academic)
Within limits set by abilities, can do well in tasks attempted Inhibition
When meeting mild failure, persists until determines Shows inhibition in work or academic functioning
whether he or she can do the job in which previously there was adequate performance
Healthy Self-Concept Dependent Personality Disorder
Sees self as approaching individual ideals, as capable Passively allows others to assume responsibility for
of meeting demands major areas of life because of inability to function
Has reasonable degree of self-confidence that helps independently
in being resourceful under stress Lacks self-confidence (i.e., sees self as helpless, stupid)
Satisfying Relationships Borderline Personality Disorder
Experiences satisfaction and stability in Shows pattern of unstable and intense interpersonal
relationships relationships
Socially integrated and can rely on social supports Has chronic feelings of emptiness
Effective Coping Strategies Substance Dependencies
Uses stress reduction strategies that address the problem, Repeatedly self-administers substances despite signifi-
issue, threat (e.g., problem solving, cant substance-related problems (e.g., threat to job,
cognitive restructuring) family, social relationships)
Uses coping strategies in a healthy way that does
not cause harm to self or others
Modified from Redl, F., & Wattenberg, W. (1959). Mental hygiene in teaching (pp. 198-201). New York: Harcourt, Brace & World;
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC:
Author; Farber, E.W., & Kaslow, F.W. (2003). Social psychology: theory, research, and mental health implications. In A. Tasman, J. Kay, &
J.A. Lieberman (Eds.), Psychiatry (2nd ed.). West Sussex, England: Wiley.
CHAPTER 2  Mental Health and Mental Illness 13

Mental health and mental illness are not specific entities but result of a chain of events that include flawed biological, psycho-
rather they exist on a continuum. The mental health contin- logical, social, and cultural processes. However, mental illnesses
uum is dynamic and ever-shifting, ranging from mild to mod- are treatable, and individuals can experience relief from their
erate to severe to psychosis (see Figure 2-1). symptoms with treatment and support. Although there may not
The groundbreaking Report of the Surgeon General (USD- be a cure, recovery is always a possibility (NAMI, 2011).
HHS, 1999) defines mental health as successful performance of This chapter discusses concepts of mental health and
mental functions, resulting in the ability to engage in produc- mental illness. The reader will be introduced to the concept
tive activities, enjoy fulfilling relationships, and adapt to change of mental disorders as medical diseases. You will come to
and cope with adversity. Mental health is from early childhood understand both how mental disorders are categorized using
until death “the springboard of thinking and communication the Diagnostic and Statistical Manual of Mental Disorders
skills, learning, emotional growth, resilience, and self-esteem” (DSM-5) and also the considerations that go into making a
(USDHHS, 1999). It is a state of well-being in which individu- proper a patient assessment.
als are able to realize their abilities within the normal stresses of
life and function productively within their personal lives as well THE DIAGNOSTIC AND STATISTICAL
as contribute to their community (WHO, 2010).
According to the National Alliance on Mental Illness (NAMI,
2011) mental illnesses are medical conditions that affect a per- The Diagnostic and Statistical Entities Manual of Mental Dis-
son’s thinking, feeling, mood, ability to relate to others, and orders, DSM-5 is the current official guidebook for categorizing
daily functioning. Basically, mental illness can be seen as the and diagnosing psychiatric mental health disorders in the United

of reality
Ability to (Table 1-1) Ability to love
play and laugh and experience joy

Maintain a healthy Capacity to deal with

self-concept and self-value conflicting emotions

Ability to work Ability to live without (undue)

and be productive fear, guilt, or anxiety

Negotiate each Ability to take responsibility

developmental task for one's own actions

Attain self-defined Ability to control one's

spirituality own behavior

Relate to others Think clearly

• Form relationships • Problem solve
• Have close, • Use good judgment
loving, adaptive • Reason logically
relationships • Reach insightful
• Experience empathy conclusions
toward others • Be creative
• Manage interpersonal
conflict constructively

FIGURE 2-1  Some attributes of mental health.

14 UNIT 1  Essential Theoretical Concepts for Practice

States. The primary objective of the DSM-5 is to provide clinicians, the preceding year, rated on a scale of 1 to 100 (1 indicates
researchers, psychiatric drug regulation agencies, health insurance persistent danger of severely hurting oneself or others, and
companies, pharmacological companies, and policy makers with 100 indicates superior functioning in a variety of activities at
a common language and standard criteria for the classification of the time of the evaluation, as well as the highest level of func-
mental disorders. The DSM-5 is used by clinicians as a guide for tioning for at least a few months during the past year).
planning care and evaluating patients’ treatments (e.g., psychia- The DSM-5 no longer uses an axial system. A DSM-5 diag-
trists, psychiatric nurses, psychologists, and others who plan care noses. AXIS 1-11 and 111 are now combined to align with the
for people experiencing mental distress/dysfunction). The DSM- International Classification of Disease (ICD) codes. Global
5 focuses on research and clinical observation when constructing functioning is now measured by The World Health Organiza-
diagnostic categories for a discrete mental disorder. This chapter tions Disability Assessment Schedule (WHODAS).
describes how nursing diagnoses can be used to ensure appropri-
ate care. This chapter also addresses the importance of assess-
ing a person’s ethnic background, culture, and minority group
before making a valid diagnosis and executing an effective treat- The World Health Organization declared that 4 of the 10 lead-
ment plan. ing causes of disability in the United States and other developed
Previously, the DSM-IV-TR organized each psychiatric countries are mental health disorders (NAMI, 2011). Unfortu-
diagnosis into five levels (axes) relating to different aspects of nately our understanding of mental illness is plagued by a host
disorder or disability: of myths and misconceptions. One myth is that to be mentally
Axis I referred to the collection of signs and symptoms that ill is to be different and odd. Another misconception is that to be
together constitute a particular disorder (for example, schizo- mentally healthy, a person must be logical and rational. All of us
phrenia) or a condition that may be a focus of treatment. (Refer dream “irrational” dreams at night, and “irrational” emotions
to Appendix A for a list of all the mental disorders catalogued not only are universal human experiences but also are essential
in the current DSM-5.) to a fulfilling life. There are people who show extremely abnor-
Axis II referred to personality disorders and mental retar- mal behavior and are characterized as mentally ill and yet they
dation. Thus, Axes I and II constitute the classification of are far more like the rest of us than different from us. There is
abnormal behaviors. Later, Axes I and II were separated to no obvious and consistent line between mental illness and men-
ensure that the possible presence of long-term disturbance is tal health. In fact, all human behavior lies somewhere along a
considered when attention is directed to the current disorder. continuum of mental health and mental illness.
For example, a heroin addict would be diagnosed on Axis I Psychiatry’s definition of normal mental health changes
as having a substance-related disorder (DSM-5: Opioid Use over time and reflects changes in cultural norms, society’s
Disorder). Such a patient might also have a long-standing expectations and values, professional biases, individual
antisocial personality disorder, which would be noted on differences, and even the political climate of the time. For
Axis II. This is another example of a person having more than example, criticisms have arisen from various groups who
one mental disorder at the same time. This phenomenon of believe that they were or are stereotyped in the psychiatric
coexisting disorders is often termed co-occurring or dual community. Their concerns include the way in which the
diagnosis. psychiatric community places an emphasis on the group’s
Although it was understood that the remaining three axes psychopathology rather than on health attributes. The psy-
were not needed to make the actual diagnosis, their inclusion in chology of women and the issues surrounding homosexual-
the DSM-IV-TR indicated the recognition that factors other than ity are two very important examples but are by no means
a person’s symptoms should be considered in an assessment. the only ones.
On Axis III, the clinician indicated any general medical con- We are taught to assess the strengths in our patients with
ditions believed to be relevant to the mental disorder in question. mental health issues and their areas of high functioning, as
In some individuals, a physical disorder (e.g., a neurological dys- well as their symptoms and disabilities. You will find many
function) may be the cause of the abnormal behavior, whereas in attributes of mental health in some of your patients with
others it may be an important factor in the individual’s overall mental health issues. It is these strengths that we develop and
condition (e.g., diabetes in a child with a conduct disorder). encourage. By the same token, those who are “normal” or
Axis IV was for reporting psychosocial and environmental “mentally healthy” may have several areas of dysfunction at
problems that may affect the diagnosis, treatment, and progno- different times in their lives. We are all different, have differ-
sis of a mental disorder. These may include occupational prob- ent backgrounds, and reflect different cultural influences, even
lems, educational problems, economic problems, interpersonal within the same subculture. We grow at different rates intel-
difficulties with family members, and a variety of problems in lectually and emotionally, make various decisions at different
other life areas. Often a psychosocial assessment will uncover times in our lives, choose or refuse to evaluate our behaviors
these (see Chapter 7). and grow within ourselves, may choose to have deep-seated
Finally, Axis V was called Global Assessment of Function- spiritual beliefs, and so on. Understandably, then, there can
ing (GAF), which gave an indication of the person’s best level be no one definition of mental health that fits all. However,
of psychological, social, and occupational functioning during there are some traits that mentally healthy people share and
CHAPTER 2  Mental Health and Mental Illness 15

that contribute to a better quality of life. Some of these traits at a time. For example, some people diagnosed with a depressive
are depicted in Figure 2-1. disorder may also have a coexisting anxiety disorder. Therefore
A characteristic of mental health that is increasingly being some people have dual diagnoses (coexisting disorders).
promoted is the concept of resiliency. Resiliency is the abil- Table 2-2 shows the prevalence rates and includes the epi-
ity to recover from or adjust easily to misfortune and change. demiology of some psychiatric disorders in the United States.
Resiliency is closely associated with the process of adapting
and helps people facing tragedy, loss, trauma, and severe stress
(American Psychological Association, 2004). Research has
demonstrated that this ability to recover from painful expe- Many factors can affect the severity and progress of a mental
riences and difficult events is not an unusual quality, but is a illness, biologically based or otherwise, and these same factors
trait possessed by many people and can be developed in almost can affect a “normal” person’s mental health as well. Some of
everyone. Disasters occur all too frequently, such as terrorist these factors include available support systems, family influ-
attacks (World Trade Center), the devastation of hurricanes ences, developmental events, cultural or subcultural beliefs
(Sandy, Katrina), senseless shootings (Sandy Hook, Colum- and values, health practices, and negative influences imping-
bine) and crippling floods (Japan, Haiti). These are just a few of ing on an individual’s life. If possible, these influences need
the many disasters in which people united to help one another to be evaluated and factored into an individual’s plan of care.
and continue their lives despite horrendous loss, illustrating Figure 2-2 identifies some influences that can have an effect on
resilience. Being resilient does not mean that people are unaf- a person’s mental health. In 1996 the Mental Health Parity Act
fected by stressors. It means that rather than falling victim to the was passed by Congress. This legislation required insurers that
negative emotions, resilient people recognize the feelings, read- provide mental health coverage to offer benefits at the same level
ily deal with them, and learn from the experience given time. provided for medical and surgical coverage. In 2000 the Govern-
Table 2-1 compares some important aspects of mental health ment Accounting Office found that although 86% of health plans
with those of specific mental disorders. These aspects include complied with the 1996 law, 87% of health plans that complied
degree of (1) happiness, (2) control over behavior, (3) appraisal with the law imposed new limits on mental health coverage.
of reality, (4) effectiveness in work, (5) healthy self-concept, The 1999 USDHHS report entitled Mental Health: A Report
(6) satisfying relationships, and (7) effective coping strategies. of the Surgeon General stated the following:
• Mental health is fundamental to health.
EPIDEMIOLOGY AND PREVALENCE • Mental disorders are real health conditions that have an
immense impact on individuals and families.
OF MENTAL DISORDERS • The efficacy of mental health treatment is well documented.
Epidemiology is the quantitative study of the distribution • A range of treatments exists for most mental disorders.
of disorders in human populations. Once the distribution of On April 29, 2002, President George W. Bush endorsed parity
mental disorders has been determined quantitatively, epide- and established a new mental health commission. In February
miologists can identify high-risk groups and high-risk factors. 2003, the Senator Paul Wellstone Mental Health Equitable
Study of these high-risk factors may lead to important clues Treatment Act was introduced into the Senate and the House
about the etiology of various mental disorders. of Representatives. In July 2003, the President’s New Freedom
Clinical epidemiology is a broad field that addresses the Commission on Mental Health also endorsed parity.
outcomes of people with illnesses who are seen by providers of Since 1996 the limited federal law has been kept in place
clinical care. Studies use traditional epidemiological methods through a series of 1-year extensions, and stronger bills have
and are conducted in groups that are usually defined by illness repeatedly been introduced and vetoed (National Mental Health
or symptoms, or by diagnostic procedures or treatments given Association [NMHA], 2004). State bills were proposed to close
for the illness or symptoms. the federal loopholes, and as of 2006, 34 states had adopted laws.
Results of epidemiological studies are now routinely included However, many require full insurance parity for only a limited
in the DSM to describe the frequency of mental disorders. Anal- number of psychiatric diagnoses. One method many states use
ysis of epidemiological studies can assess the frequency with to determine coverage is by making a distinction of whether the
which symptoms appear concurrently. For example, epidemio- problem is a biologically based mental illness, that is, a mental
logical studies demonstrate the significance of depression as a disorder caused by neurotransmitter dysfunction, abnormal brain
risk factor for death in people with cardiovascular disease and structure, inherited genetic factors, or other biological causes.
for premature death in people with breast cancer. Another term for such an illness is psychobiological disorder.
The prevalence rate is the proportion of a population with These biologically influenced illnesses include the following:
a mental disorder at a given time. Kessler and colleagues (2005) • Schizophrenia
(the latest study of the lifetime prevalence of mental disorders) • Bipolar disorder
and concluded in their survey that about half of Americans will • Major depression
meet the criteria for a DSM disorder sometime in their life, with • Obsessive-compulsive and panic disorders
the first onset in childhood or adolescence. It is important to • Posttraumatic stress disorder
note that many individuals have more than one mental disorder • Autism
16 UNIT 1  Essential Theoretical Concepts for Practice


Schizophrenia 1.1 2.2 million Affects men and women equally; may
appear earlier in men than in women
Any affective (mood) disorder; 9.5 18.8 million Women affected twice as much as
includes major depression, men (12.4 million women; 6.4 million
dysthymic disorder, and bipolar men); depressive disorders may appear
disorder earlier in life in those born in recent
decades compared with past; often
co-occurs with anxiety and substance
Major depressive disorder 5 9.9 million Leading cause of disability in the United
States and established economies
worldwide; nearly twice as many
women (6.5%) as men (3.3%) suffer
from a major depressive disorder every
Bipolar affective disorder 1.2 2.3 million Affects men and women equally
Anxiety disorders; includes panic 13.3 19.1 million Anxiety disorders frequently co-occur with
disorder, obsessive-compulsive depressive disorders, eating disorders,
disorder, posttraumatic stress and/or substance abuse
disorder (PTSD), generalized
anxiety disorder, and phobias
Panic disorder 1.7 2.4 million Typically develops in adolescence or
early adulthood; about one in three
people with panic disorder develops
Obsessive-compulsive 2.3 3.3 million First symptoms begin in childhood or
disorder adolescence
PTSD 3.6 5.2 million Can develop at any time; approximately
30% of Vietnam veterans experienced
PTSD after the war; percentage high
among first responders to 9/11/01
terrorist attacks
Generalized anxiety disorder 2.8 4 million Can begin across life cycle; risk is
highest between childhood and middle
Social phobia 3.7 5.3 million Typically begins in childhood or
Agoraphobia 2.2 3.2 million
Specific phobia 4.4 6.3 million
Any substance abuse 11.3
Alcohol dependence 7.2
Data from National Institute of Mental Health. (2004). The numbers count: mental disorders in America (NIH Pub. No. 01-4584).
Retrieved August 1, 2004, from
CHAPTER 2  Mental Health and Mental Illness 17

• Friends
Environmental • Family Spirituality,
experiences • Community religious influences

Inherited factors
Family influences

Biological influences
Developmental events

Hormonal influences Personality traits

and states

Health practices Demographic and

and beliefs geographic locations

Cultural/subcultural Negative influences

beliefs and • Psychosocial
values stressors
• Poverty
• Impaired/

FIGURE 2-2  Influences that can have an effect on an individual’s mental health.

Other severe and disabling mental disorders include the plan and evaluate treatment for their patients. A necessary ele-
following: ment for categorization includes agreement regarding which
• Anorexia nervosa behaviors constitute a mental illness.
• Attention deficit/hyperactivity disorder
• Many of the most prevalent and disabling mental disor- Medical Diagnoses and the DSM-5
ders have been found to have strong biological influences; In the DSM-5 the mental disorders are conceptualized as clinically
therefore we can look at these disorders as “diseases.” significant behavioral or psychological syndromes or patterns
The DSM-5 cautions that the emphasis on the term mental that occur in an individual and that are associated with distress
disorder implies a distinction between “mental” disorder and (e.g., a painful symptom) or disability (i.e., impairment in one
“physical” disorder, which is an outdated concept, and stresses or more important areas of functioning) or with a significantly
mind-body dualism: “There is much ‘physical’ in ‘mental’ dis- increased risk of suffering death, pain, disability, or an important
orders and much ‘mental’ in ‘physical’ disorders” (American loss of freedom. This syndrome or pattern must not be merely an
Psychiatric Association, 2013). expected and culturally sanctioned response to a particular event,
such as the death of a loved one. Whatever the original cause,
MEDICAL DIAGNOSIS AND NURSING it must currently be considered a manifestation of a behavioral,
psychological, or biological dysfunction in the individual within
DIAGNOSIS OF MENTAL ILLNESS the individual’s cultural boundaries. Deviant behavior (e.g.,
To perform their professional responsibilities, clinicians and political, religious, or sexual) and conflicts between the individual
researchers need clear and accurate guidelines for identifying and society are not considered mental disorders unless the devi-
and categorizing mental illness. Such guidelines help clinicians ance or conflict is a symptom of a dysfunction in the individual.
18 UNIT 1  Essential Theoretical Concepts for Practice

It is important to stress that the DSM classifies disorders and brings peace and serenity into people’s lives. Mysticism,
that people have, and not the person. For this reason, the text meditation (e.g., Dhyana, a form of concentrated meditation
of the DSM avoids the use of expressions such as “a schizo- taught by Buddha; Zen Buddhism, a Japanese practice in
phrenic” or “an alcoholic” and instead uses the more accurate which a spiritual master instructs students in meditation, used
terms “an individual with schizophrenia” or “an individual throughout the United States; and transcendental medita-
with alcohol dependence.” Since the third edition of the DSM tion, a Hindu meditative process), and mindfulness medita-
appeared in 1980 through to the DSM-5 in 2013, the criteria tion (derived from Buddhist practice) are just a few examples.
for classification of mental disorders have been sufficiently Mindfulness meditation is used today and has many health
detailed for clinical, teaching, and research purposes. benefits; it is a valuable tool for dealing with chronic pain and
stress. It is actively employed with dialectic behavioral therapy
The DSM in Culturally Diverse Populations (DBT), stress reduction programs, and some forms of cogni-
Special efforts have been made in the DSM to incorporate an tive therapy (Favazza, 2009). Prayer is most widely used in
awareness that the manual is used in culturally diverse popu- the United States; it is used for many reasons and is also tied
lations in the United States and internationally. It is true that to many different cultures. For example, some people pray
culture is an inclusive term and there are many definitions for by singing; others pray by dancing, spinning, or reciting the
culture; most anthropologists agree that “culture includes tra- rosary; some people pray at certain times of the day and/or
ditions of thought and behavior, such as language and history facing a specific direction; and still other people only pray in
that can be socially acquired, shared, and passed on to new gen- private or only in public. In all cases prayer represents a way to
erations” (Hays, 2008). However, evaluations of an individu- connect with a supreme spiritual being and to activate spiritual
al’s cultural background should also include minority groups. energy, which can reveal itself in everyday life (Favazza, 2009).
Minorities need to include not only different ethnicities but also Caution must be exercised to avoid labeling or stereotyping
older adults; people who have disabilities; lesbian, gay, bisexual, when a medical diagnosis or a nursing diagnosis is being formu-
and transgender (LGBT) individuals; and women, for example lated. Anthropologists, historians, and students of cross-cultural
(Hays, 2008). Therefore clinicians are urged to evaluate indi- society have long observed that every society has its own view of
viduals from numerous ethnic groups/cultural backgrounds and health and illness and its own classification of diseases.
minority backgrounds. Assessment can be especially challenging Over the last 13 to 14 years, stigma has been acknowledged
when a clinician from one ethnic/cultural or minority group uses to be a major barrier to mental health treatment and recovery to
the DSM classification to evaluate an individual from a different people with mental health disorders (Pinto-Foltz et al., 2009).
ethnic/cultural or minority group. Stigma is a “collection of negative attitudes, beliefs, thoughts,
and behaviors that influence the individual, or the general
public, fear, reject, or avoid, be prejudiced, and discriminate
PSYCHIATRY AND SPIRITUALITY people” (Gary, 2005, p. 980). Goffman’s classic definition of
An important part of a culture is spirituality, which for a long stigma is “an attribute that is deeply discrediting where a person
time played a secondary role in the medical holistic assessment is reduced from a whole unusual person to a tainted, discounted
of people with mental health distress and/or disorders. How- one” (Goffman, 1963). Stereotyping, labeling, separating, status,
ever, be aware there have been many leaders in nursing who loss, and discrimination in a context of power imbalance are
have advanced the importance of the concept of spirit­uality in many of the psychosocial processes that lead to stigmatization.
health care and healing, and have made significant contribu- Stigmatizing attitudes toward the mentally ill can have harmful
tions in research and writings to the nursing literature. Finally, effects on an individual and family, especially if the diagnosis
psychiatry is beginning to comprehend the importance of is made on the basis of insufficient evidence and proves faulty.
spiritual belief. Spirituality is a much broader concept than just These attitudes result in social isolation and reduced oppor-
religion alone; spirituality “provides an essential core, enrich- tunities. For example, stigmatizing interferes with the person
ing experience, and a reason to live for many people” (Favazza, establishing and maintaining friendships, employment, and
2009, p. 2633). There are many ways to achieve a spiritual housing. It also impacts the person’s ability to obtain psy-
moment and lead a spiritual life. For example, among certain chological treatment and general medical treatment (Sadow &
cultural groups, particular religious practices or beliefs (e.g., Ryder, 2008). Stigmatizing a group or an individual results in
hearing or seeing a deceased relative during bereavement) may painful feelings of shame, and a negative sense of self, which can
be misdiagnosed as manifestations of a psychotic disorder; directly impact recovery. Stigmatization erodes an individual’s
furthermore, a syndrome often manifests in different superfi- or a group’s confidence in the fact that mental illnesses “are
cial forms in different cultures. Also, people from minority or treatable health conditions” (NAMI, 2011).
migrant populations may have good reason to be distrustful, An example of the influence of cultural and social stigmatiz-
and it should not be assumed that these patients are suffer- ing when making a bias on psychiatric diagnosis is the inclu-
ing from paranoia or paranoid schizophrenia. There are many sion of homosexuality as a psychiatric disease in both the first
ways that people can induce or enhance spirituality. Favazza and second editions of the DSM. All research consistently failed
(2009) cites the following examples of how people obtain an to demonstrate that people with a homosexual orientation
altered state of consciousness, which is spiritually enriching were any more maladjusted than heterosexuals, but despite the
CHAPTER 2  Mental Health and Mental Illness 19

research data, change occurred in the medical community only illness was popular, physicians interpreted bizarre behavior as
when gay rights’ activists advocated an end to discrimination stemming from attacks by biological agents.
against lesbians and gay men. No longer is homosexuality clas- Cultures differ not only in the way they view mental illness
sified as a mental disorder. but also in the types of behavior categorized as mental illness.
Instances of stigma and prejudicial bias toward minor- For example, the content of a person’s delusions, hallucina-
ity groups encompass a wide range of circumstances, such tions, obsessional thoughts, and phobias often reflects what is
as people with different sexual orientations, African Ameri- important in the person’s culture.
cans, the mentally ill, the disabled, and cognitively impaired A number of culture-related syndromes appear to be
older adults, children, and women. Biases are often reflected more influenced by culture alone and are not seen in all areas
in our power structures and political systems. Awareness of of the world. For example, one form of mental illness recog-
the cultural bias and dangers in stereotyping and holding nized in parts of Southeast Asia is running amok, in which
stigmatizing attitudes has enormous implications for nurs- someone (usually a male) runs around engaging in furi-
ing practice, especially in the field of mental health, because ous, almost indiscriminate violent behavior. Pibloktoq is an
nurses often take their cues from the medical structure. uncontrollable desire to tear off one’s clothing and expose
“Increasing awareness about the pervasive nature of stigma as oneself to severe winter weather; it is a recognized form of
well as special educational interventions can help nurses and psychological disorder in parts of Greenland, Alaska, and the
other health professionals in training to avoid this pitfall” Arctic regions of Canada. In our own society, we recognize
(Sadow, 2011). anorexia nervosa as a psychobiological disorder that entails
voluntary starvation. This disorder is well-known in Europe,
Nursing Diagnoses and NANDA International North America, and Australia, but unheard of in many other
Psychiatric mental health nursing includes the diagnosis and parts of the world.
treatment of human responses to actual or potential mental What is to be made of the fact that certain disorders occur
health problems. NANDA International (NANDA-I) describes in some cultures but are absent in others? One interpreta-
a nursing diagnosis as a clinical judgment about individual, fam- tion is that the conditions necessary for causing a particular
ily, or community responses to actual or potential health prob- disorder occur in some places but are absent in other places.
lems and life processes. Therefore the DSM is used to diagnose Another interpretation is that people learn certain kinds
a psychiatric disorder, whereas a well-defined nursing diagno- of abnormal behavior by imitation. However, the fact that
sis provides the framework for identifying appropriate nursing some disorders may be culturally determined does not prove
interventions for dealing with the phenomena a patient with a that all mental illnesses are so determined. The best evidence
mental health disorder is experiencing (e.g., hallucinations, self- suggests that schizophrenia and bipolar affective disorders
esteem issues, impaired ability to function). See Chapter 7 for are found throughout the world. The symptom patterns of
more on the formulation of nursing diagnoses in psychiatric schizophrenia have been observed among indigenous Green-
nursing. landers and West African villagers, as well as in our own
Appendix B lists NANDA-I–(2012-2014) approved nursing Western culture.
diagnoses. The individual clinical chapters offer suggestions for Many believe that the helpers of choice for many people
potential nursing diagnoses for the behaviors and phenomena from minority cultures are their traditional helpers/therapists.
often encountered in association with specific disorders. This is particularly true for problems that have psychological
or psychosocial aspects. One example would be people of Cen-
INTRODUCTION TO CULTURE tral and Latin American cultures. Many people from this area
of the world may prefer curanderos (male healers) or curanderas
AND MENTAL ILLNESS (female healers), who would be sought for healing a number of
The DSM includes information specifically related to culture symptoms that are perceived to originate from psychological
in three areas: components, such as susto (fright) and mal de ojo (evil eye) (Fali-
1. A discussion of cultural variations for each of the clinical cop, 1998, p. 173; Hays, 2008). Another example is that of the
disorders Mexican and Mexican Americans who primarily prefer female
2. A description of culture-bound syndromes healers. The practices employed by these healers are a mixture of
3. An outline designed to assist the clinician in evaluating and Catholicism, ancient Mayan and Aztec cultures, and herbology
reporting the impact of the individual’s cultural context (Hays, 2008; Novas, 1994).
Health care providers must consider the norms and influ- A traditional helping strategy that we use in American
ence of culture in determining the mental health or mental mainstream therapies, especially with children, is that of story-
illness of the individual. Throughout history, people have telling. It is also one that is common to many indigenous cul-
interpreted health or sickness according to their own cultural tures. The “therapist” uses a metaphor in the form of a “story”
views. People in the Middle Ages, for example, regarded bizarre that offers a social message, but does not directly give advice or
behavior as a sign that the disturbed person was possessed by a tell the person what to do. The listeners are then left to draw
demon. To exorcise the demon, priests resorted to prescribed their own conclusions and make changes if they are ready to do
religious rituals. During the 1880s, when the “germ theory” of so (Swinomish Tribal Community, 1991).
20 UNIT 1  Essential Theoretical Concepts for Practice

Indeed, psychotherapy would be considered the treat- et al., 2006). The most effective therapists will be those who
ment of last resort in many cultures because (1) it is are eclectic in their knowledge, come from a background
unavailable, (2) shame is attached to using therapies in the of working with different cultures, have a broad knowl-
dominant culture, or (3) there are more effective or pre- edge of coping strategies, and are flexible in their approach
ferred treatments in their own culture (Hays, 2008; Yeh (Hays, 2008).


What is stigma? This all sounds complicated. Is there a cost-effective,
The American Heritage Dictionary (1991) defines stigma as simple intervention that can be used in a classroom
“a mark of infamy, disgrace or reproach.” People often feel and that will make some difference?
that stigma disqualifies one from full social acceptance. Many Yes. Sadow and Ryder (2008) found that exposure to a
groups are stigmatized in our society, but we will focus on person living with mental illness, but being in recovery,
the stigma of mental illness to illustrate the effects of stigma. significantly reduces stigmatizing attitudes held by nursing
students. It is important to have a person in recovery speak
What are the effects of stigma? to the class and be available to answer questions. This per-
Stigma and discrimination against people with mental illness sonal exposure was found to be more effective than using
are often major barriers to success in relationships, employ- books or movies to change the perception of mental illness.
ment, and treatment programs (Gill, 2008). Even worse, Health professionals are often exposed to people whose
efforts to achieve rehabilitation and recovery from mental mental illness is in its most acute phase, when they do not
illness can be sabotaged by prejudice and negative assump- function well. Professional do not often have an opportunity
tions (Hinshaw & Stier, 2008). The availability of health care in to see patients when they are well and are leading normal
general is also affected by the stigma of mental illness. Peo- lives. Thus professionals erroneously conclude that no recov-
ple with mental illness receive fewer medical services than ery is possible. Cohen and Cohen (1984), in a classic paper,
those not labeled in this manner (Thornicroft et al., 2007). call this “the clinician’s illusion.” This illusion is not factual.
A seminal long-term (3 decades) study in Maine and Ver-
Well, do they at least receive the best psychiatric mont (DeSisto et al., 1995) found that many people cop-
treatment? ing with serious mental illness improved over time, even if
Not always. There are several mechanisms by which they did not receive treatment.
stigma affects mental health care including avoiding treat-
ment, abandoning treatment, and harming one’s sense of Where can someone find an “appropriate” person
self (Corrigan et al., 2010). in recovery to speak to a class?
Contact (National Alliance on Mental Illness) or
Well, stigma sounds not only unpleasant, but is also call 1-800-950-NAMI (6269) and ask for ‘In Our Own Voice’
dangerous to one’s health. The mentally ill, though, (IOOV). This program (IOOV) will connect you with people
work with health and mental health professionals, who are trained speakers who generously share personal
and they are not like that. testimonies about living with and overcoming the chal-
Health care providers are not immune. A proportion of pro- lenges posed by mental illness. You and your class will be
viders hold negative and unfounded views of people with assisted in arranging a free presentation in your area.
mental illness today (Rao et al., 2009). Negative attitudes
and discrimination towards mental illness within the nursing Why bother?
profession have also been studied (Ross & Goldner, 2009). There are two very important reasons. First, preliminary
research indicates that people who attend an IOOV presen-
Is there anything we can do to reduce stigma? tation experience a promising reduction in stigmatizing atti-
There are multiple methods that can be employed to reduce tudes (Corrigan & O’Shaughnessy, 2007). Second, research
stigma; unfortunately, they are efficacious only some of the (Sadow & Ryder, 2008) indicates that student nurses,
time with some populations (Lyons et al., 2009). Some cam- after completing their psychiatric clinical experience, have
paigns in the media have focused on changing the presenta- an increase in stigmatizing attitudes. Consequently, it is
tion of people with mental illness. Others have educated the imperative that student nurses experience programs such
general public or targeted populations about the treatability as IOOV in order to be exposed to people who had pre-
of mental illness. Other efforts have focused on exposing the viously been hospitalized with mental illness and are now
public to real people with mental illness in an effort to reduce recovered and focused on living/building full lives. This may
stigma (Lyons et al., 2009). Stigma then might be reduced encourage us, as healers, to embrace the concepts of hope
by education, by contact or personal acquaintance, and by and recovery, and begin to eliminate the stigma of mental
offering different ways of perceiving people and situations. illness.
CHAPTER 2  Mental Health and Mental Illness 21


References c’est la même chose (the more things change, the more they
Cohen, P., & Cohen, J. (1984). The clinician’s illusion. Archives stay the same). Journal of Psychiatric and Mental Health Nurs-
of General Psychiatry, 41(12), 1178–1182. Retrieved from ing, 16(6), 501–507. doi:10.1111/j.1365-2850.2009.01390.x.
EBSCOhost. NAMI: In our own voice. (n.d.). Retrieved March 17, 2011, from
Corrigan, P. W., Morris, S., Larson, J., Rafacz, J., Wassel, A., National Alliance on Mental Illness website:
et al. (2010). Self-stigma and coming out about one’s mental template.cfm?section=In_Our_Own_Voice.
illness. Journal of Community Psychology, 38(3), 259–275. Rao, H. H., Mahadevappa, H. H., Pillay, P. P., Sessay, M. M.,
Retrieved from EBSCOhost. Abraham, A. A., et al. (2009). A study of stigmatized attitudes
Corrigan, P. W., & O’Shaughnessy, J. R. (2007). Changing men- towards people with mental health problems among health
tal illness stigma as it exists in the real world. Australian Psy- professionals. Journal of Psychiatric and Mental Health Nurs-
chologist, 42(2), 90–97. doi:10.1080/00050060701280573. ing, 16(3), 279–284. doi:10.1111/j.1365-2850.2008.01369.x.
DeSisto, M., Harding, C., McCormick, R., Ashikaga, T., & Brooks, Ross, C. A., & Goldner, E. M. (2009). Stigma, negative atti-
G. (1995). The Maine and Vermont three decade studies of tudes and discrimination towards mental illness within
serious mental illness. I. Matched comparison of cross-sec- the nursing profession: a review of the literature. Journal
tional outcome. British Journal of Psychiatry: Journal of Men- of Psychiatric and Mental Health Nursing, 16(6), 558–567.
tal Science, 167(3), 331–338. Retrieved from EBSCOhost. doi:10.1111/j.1365-2850.2009.01399.x.
Gill, K. J. (2008, Winter). The persistence of stigma and dis- Sadow, D., & Ryder, M. (2008, November). Reducing stigma-
crimination. Psychiatric Rehabilitation Journal, 183–184. tizing attitudes held by future health professionals: the per-
doi:10.2975/31.3.2008.183.184. son is the message. Psychological Services, 5(4), 362–372.
Hinshaw, S. P., & Stier, A. (2008, April). Stigma as related to doi:10.1037/‌.5.4.362.
mental disorders. Annual Review of Clinical Psychology, 4, Thornicroft, G., Rose, D., & Kassam, A. (2007). Discrimina-
367–393. Retrieved from tion in health care against people with mental illness.
/.clinpsy.4.022007.141245. International Review of Psychiatry, 19(2), 113–122.
Lyons, C. C., Hopley, P. P., & Horrocks, J. J. (2009). A decade of doi:10.1080/09540260701278937.
stigma and discrimination in mental health: plus ça change, plus

Contributed by Dolly Sadow and Marie Ryder.

 K E Y P O I N T S T O R E M E M B E R
• M ental illness is difficult to define, and people have many • C linicians use the five axes of the DSM and the GAF scale
myths regarding mental illness. as a guide for diagnosing and categorizing mental disor-
• Mental health can be conceptualized along a continuum, ders, allowing for a more holistic approach to the assess-
from mild to moderate to severe to psychosis. ment. Medical condition, psychosocial and environmental
• There are many important aspects of mental health (e.g., influences, and present and past levels of functioning are
happiness, control over behavior, appraisal of reality, effec- considered.
tiveness in work, a healthy self-concept, presence of satis- • Factors that may influence the intensity or cause of a mental
fying relationships, and effective coping strategies). Some illness are illustrated in Figure 2-2.
components of mental health are identified in Figure 2-1. • Using well-conceived nursing diagnoses helps target the symp-
• The processes that lead to stigmatization (labeling, ste- toms and needs of patients so that ideally they may achieve a
reotyping, status, loss, and discrimination in a context of higher level of functioning and a better quality of life.
power imbalance) can lead to an increase in social isolation, • The influence of culture on behavior and the way in which
an enhanced struggle to recover, poor social functioning, symptoms present may reflect a person’s cultural patterns.
significant barriers to obtaining psychiatric and medical Symptoms need to be understood in terms of a person’s cul-
services, and more. The mental anguish and excruciating tural background.
pain caused by stigmatization effect tremendous damage to • Caution is recommended for all health care professionals
individuals and their families, groups, and/or cultures. concerning the damage and disservice that stigmatizing/ste-
• The study of epidemiology can help identify high-risk reotyping can cause for medical and mental health patients.
groups and behaviors. In turn, this can lead to a better Stigmatizing is acknowledged to be a barrier to proper or
understanding of the causes of some disorders. Prevalence appropriate mental health/recovery and medical services as
rates help us identify the proportion of a population with a well. Indeed, it may even prevent a person from accessing
mental disorder at a given time. or receiving help. Stigmatizing/stereotyping causes shame
• With the current recognition that many common mental disor- and pain for the individual and their families, or the groups
ders are biologically based, it is easier to see how these biologi- being stigmatized, and greatly impacts the quality of life or
cally based disorders can be classified as medical diseases as well. ability to lead a healthy life.
22 UNIT 1  Essential Theoretical Concepts for Practice

 A P P L Y I N G C R I T I C A L J U D G M E N T
1. T
 imothy Harris is a college sophomore with a grade point (2) If an antidepressant medication could help him with
average of 3.4. He was brought to the emergency depart- his depression, explain why this alone would not
ment after a suicide attempt. He has been extremely meet his multiple needs. What issues do you think
depressed since the death of his girlfriend 5 months previ- have to be addressed if Timothy is to receive a holis-
ously when the car he was driving careened out of control tic approach to care?
and crashed. Timothy’s parents have been very distraught (3) Formulate at least two potential nursing diagnoses
since the accident. To compound things, the parents’ reli- for Timothy.
gious beliefs include the conviction that taking one’s own (4) Would the religious beliefs of Timothy’s parents

life will prevent a person from going to heaven. Timothy affect your plan of care? If so, how?
has epilepsy and has developed increased seizures since the 2. Using Table 2-1, evaluate yourself and one of your patients
accident; he refuses help because he says he should be pun- in terms of mental health.
ished for his carelessness and does not care what happens to 3. In a small study group, share experiences you have had
him. He has not been to school and has not shown up for with others from unfamiliar cultural, ethnic, or racial back-
his part-time job of tutoring younger children in reading. grounds and identify two positive learning experiences
A. Questions regarding Timothy: from these encounters.
(1) What might be a possible DSM-5 diagnosis? 4. Before your first day of clinical experience write what you
(2) What factors should be included in the diagnoses honestly think about people who have for one reason or
regarding Timothy’s physical health? another developed a mental health disorder.
(3) What factors should be included in Timothy’s recent A. After your clinical rotation, write what you now hon-
psychological and situational factors? estly think about individuals who have developed a
(4) How does Timothy’s previous level of functioning in mental health disorder.
comparison to his present level of functioning factor B. If your impressions are different after your experience,
into a plan of care? clarify what is different.
B. Questions regarding mental health and mental illness: C. Explore with your classmates how the clinical rotation
(1) What are some factors that you would like to assess and what you have learned from your readings and your
regarding aspects of Timothy’s overall mental health instructors influenced the changes in your thinking, if
and other influences that can affect mental health there are changes.
before you plan your nursing care?

 C H A P T E R R E V I E W Q U E S T I O N S
Choose the most appropriate answer(s). 4. The nurse must contribute these data for epidemiological
1. Which statement about mental illness is true? research.
1. Mental illness is a matter of individual nonconformity 4. Factors that affect a person’s mental health are: (select all
with societal norms. that apply)
2. Mental illness is present when individual irrational and 1. support systems.
illogical behavior occurs. 2. developmental events.
3. Mental illness is defined in relation to the culture, time 3. socioeconomic status.
in history, political system, and group in which it occurs. 4. cultural beliefs.
4. Mental illness is evaluated solely by considering indi- 5. Which statement best describes a major difference between
vidual control over behavior and appraisal of reality. a DSM-IV-TR diagnosis and a nursing diagnosis?
2. Axis V of the DSM multiaxial system: 1. There is no functional difference between the two. Both
1. refers to medical illnesses. serve to identify a human deviance.
2. reports psychosocial and environmental problems. 2. The DSM-IV-TR diagnosis disregards culture, whereas
3. indicates a need for substance abuse treatment. the nursing diagnosis takes culture into account.
4. describes a person’s level of functioning. 3. The DSM-IV-TR is associated with present distress
3. Why is it important for a nurse to be aware of the multiple or disability, whereas a nursing diagnosis considers
factors that can influence an individual’s mental health? past and present responses to actual mental health
1. Rates of illness differ among various groups. problems.
2. The DSM cannot be used without information on mul- 4. The DSM-IV-TR diagnosis distinguishes a person’s spe-
tiple factors. cific psychiatric disorder, whereas a nursing diagnosis
3. The nurse diagnoses and treats human responses, which offers a framework for identifying interventions for phe-
are influenced by many factors. nomena a patient is experiencing.
CHAPTER 2  Mental Health and Mental Illness 23

REFERENCES National Alliance on Mental Illness (NAMI). (2011). What is mental

illness: mental illness facts. Retrieved July 9, 2011, from www.nami.
Altrocchi, J. (1980). Abnormal behavior. New York: Harcourt Brace org/PrinterTemplate.cfm?section= about_mental_illness.
Jovanovich. National Institute of Mental Health. (2004). The numbers count:
American Psychiatric Association. (2013). Diagnostic and statistical mental disorders in America (NIH Pub. No. 01–4584). Retrieved
manual of mental disorders (DSM-5) (5th ed.). Washington, DC: August 1, 2004, from
Author. National Mental Health Association. (2004). Congress must pass men-
American Psychiatric Association. (2000). Diagnostic and statistical tal health parity now. Retrieved July 31, 2004, from www.nmha.
manual of mental disorders (DSM-IV-TR) (4th ed., text rev.). org/federal/parity/parityfactsheet.cfm.
Washington, DC: Author. Novas, H. (1994). Everything you need to know about Latino history.
American Psychological Association. (2004). The road to resilience. New York: Plume/Penguin.
Washington, DC: Author. Pinto-Foltz, M., Space, D., & Logsdon, M. C. (2009). Reducing stigma
Endicott, J., Spitzer, R. L., Fleiss, J. L., et al. (1976). The global assess- related to mental disorders: initiatives, interventions, and recom-
ment scale: a procedure for measuring overall severity of psychiat- mendations for nursing. Archives of Psychiatric Nursing, 23(1), 32–40.
ric disturbance. Archives of General Psychiatry, 33, 766–771. Sadock, B. J., & Sadock, V. A. (2007). Kaplan and Sadock’s synopsis of
Falicop, C. J. (1998). Latino families in therapy. New York: Guilford psychiatry (10th ed.). Philadelphia: Lippincott Williams & Wilkins.
Press. Sadow, D. (personal communication). January 30, 2011.
Favazza, A. (2009). Psychiatry and spirituality. In B. J. Sadock, V. A. Sadow, D., & Ryder, M. (2008). Reducing stigmatizing attitudes held
Sadock, & P. Ruiz (Eds.), Kaplan and Sadock’s comprehensive text- by future health professionals: the person is the message.
book of psychiatry (9th ed., Vol. 11, pp. 2033–2049). Philadelphia: Psychological Services, 5(4), 362–372.
Williams & Wilkins. Swinomish Tribal Community. (1991). A gathering of wisdom: tribal
Gary, F. A. (2005). Stigma: barrier to mental health care among ethnic mental health: a cultural perspective. LaConnor, WA: Author.
minorities. Issues in Mental Health Nursing, 26, 979–999. U.S. Department of Health and Human Services (USDHHS). (1999).
Goffman, E. (1963). Stigma: notes on the management of spoiled iden- Mental health: a report of the Surgeon General. Rockville, MD:
tity. Upper Saddle River, NJ: Prentice Hall. USDHHS, Center for Mental Health Services, National Institutes
Hays, P. A. (2008). Addressing cultural complexities in practice: assess- of Health.
ment, diagnosis, and therapy (2nd ed.). Washington, DC: Ameri- World Health Organization (WHO). (2010). Mental health: strength-
can Psychological Association. ening our response. Retrieved July 9, 2011, from
Kessler, R. C., Berglund, P., Demler, O. L., et al. (2005). Lifetime mediacenter.
prevalence and age-of-onset distribution of DSM-IV disorders in Yeh, C. J., Innan, A. G., Kim, A. B., & Okubo, Y. (2006). Asian
the national comorbidity survey replication. Archives of General American families collective coping strategies in response to 9/11.
Psychiatry, 62, 593–602. Cultural Diversity and Ethnic Minority Psychology, 12, 134–148.
Luborsky, L. (1962). Clinician’s judgments of mental health. Archives
of General Psychiatry, 7, 407–417.
Mayo Clinic Staff. (2011). Mental health: overcoming the stigma of
mental health. Retrieved July 10, 2011, from www.mayoclinic.
com/health/mental-health/MH00076/Method= print.

Theories and Therapies
Margaret Jordan Halter

  For additional DSM-5 criteria content, see Appendix C


automatic thoughts, p. 32 id, p. 25
boundaries, p. 41 object permanence, p. 34
of Care
cognitive distortions, p. 32 operations, p. 34
The Mental Health Recovery Model is not
conscious, p. 25 preconscious, p. 25
a focus on a cure, but instead emphasizes
conservation, p. 34 recovery model, p. 33
living adaptively with chronic mental ill-
countertransference, p. 26 schemata, p. 33
ness. It is viewed as both an overarching
curative factors, p. 39 self-actualization, p. 30
philosophy of life for people with mental
ego, p. 25 superego, p. 25
illness and as an approach to care for use
group content, p. 38 transference, p. 26
by those who treat, finance, and support
group process, p. 38 unconscious, p. 25
mental health care.
The recovery model switches the focus
from nurse-patient relationship to nurse-
partner relationship and had its initial
success with those struggling with sub-
stances of abuse.
(Halter, the Text)

1. Discuss the contributions of theories and therapies from 5. Demonstrate comprehensive understanding of Peplau’s
a variety of disciplines and areas of expertise. theoretical base for practice that is beneficial to all settings.
2. Choose two of the major theories that you believe are 6. Identify three different theoretical models of mental health
among the most relevant to psychiatric and mental health care and demonstrate how each could be used in specific
nursing care and defend your choice, giving examples. circumstances.
3. Identify the origins and progression of dominant theories 7. Distinguish models of care used in clinical settings,
and treatment modalities. and cite benefits and limitations of these models.
4. Discuss the relevance of these theories and treatments
to the provision of psychiatric and mental health care.

CHAPTER 3  Theories and Therapies 25

We expect ourselves and others to behave in certain ways, PROMINENT THEORIES

and we seek explanations for behavior that deviates from AND THERAPEUTIC MODELS
what we believe to be normal. What causes excessive sadness
or extreme happiness? How do we explain mistrust, anxiety, Psychoanalytic Theory
confusion, or apathy—degrees of which may range from Sigmund Freud (1856 to 1939), an Austrian neurologist, is
mildly disturbing to incapacitating? It is by understanding considered the “father of psychiatry.” His work was based on
a problem that we can begin to devise solutions to treat or psychoanalytic theory, in which Freud claims that most psycho-
eradicate it. Mental illness has long defied explanation, even logical disturbances are the result of early trauma or incidents
as other so-called physical illnesses were being quantified and that are often not remembered or recognized.
often controlled. Freud (1961) identified three layers of mental activity: the
It was not until the late 1800s that psychological models conscious, the preconscious, and the unconscious mind.
and theories were conceived, developed, and disseminated The conscious mind is your current awareness—thoughts,
into mainstream thinking. They provided structure for con- beliefs, and feelings. However, most of the mind’s activity
sidering developmental processes and possible explanations occurs outside of this conscious awareness, like an iceberg
about how we think, feel, and behave. The theorists believed with its bulk hidden underwater. The preconscious mind
if complex workings of the mind could be understood they contains what is lying immediately below the surface, not cur-
also could be treated, and from these models and theories rently the subject of our attention, but accessible. The biggest
therapies evolved. chunk of the iceberg is the unconscious mind; it is here where
Early practitioners used various forms of talk therapy, or our primitive feelings, drives, and memories reside, especially
psychotherapy, focusing on the complexity and inner workings those that are unbearable and traumatic. The conscious mind
of the mind and emphasizing environmental influences on its is then influenced by the preconscious and unconscious mind
development and its stability. Beginning in the early twentieth (Figure 3-1).
century, biological explanations for mental alterations began to One of Freud’s later and widely known constructs concerns
gain acceptance. Currently the dominant and common belief is the intrapsychic struggle that occurs within the brain among
that mental health and mental illness are on a continuum and the id, the ego, and the superego. The id is the primitive, plea-
comprised of both psychological and biological factors and that sure-seeking part (particularly sexual pleasure) of our person-
there is a dynamic interplay between the two. alities that lurks in the unconscious mind.
Mental health professionals continue to rely on theoreti- The ego is our sense of self and acts as an intermediary
cal models as a basis for understanding and treating psychi- between the id and the world by using ego defense mecha-
atric alterations and mental health issues. No single model nisms, such as repression, denial, and rationalization (see
fully explains psychiatric illness and pathology. This chapter Chapter 11).
provides an overview of developmental theories, psycho- The superego is our conscience and is greatly influenced by
therapeutic models, and related treatments and discusses the our parents’ or caregivers’ moral and ethical stances. In healthy
potential connection between them and the provision of psy- individuals, the ego is able to realistically evaluate situations,
chiatric nursing care. Table 3-1 provides a brief overview of limit the id’s primitive impulses, and keep the superego from
the major theories. becoming too rigid and obsessive.


Psychoanalytic Freud Unconscious thoughts; Psychoanalysis to learn unconscious thoughts;
­psychosexual development therapist is nondirective and interprets
Interpersonal Sullivan Relationships as basis for mental Therapy focuses on here and now and
health or illness ­emphasizes relationships; therapist is an
active participant
Behavioral Pavlov, Watson- Behavior is learned through Behavioral modification addresses maladaptive
Skinner conditioning behaviors by rewarding adaptive behavior
Cognitive Beck Negative and self-critical thinking Cognitive behavioral therapists assist in
causes depression identifying negative thoughts patterns and
replacing them with rational ones
Biological Many Psychiatric disorders are the Neurochemical imbalances are corrected
result of physical (brain) through medication and talk therapy
26 UNIT 1  Essential Theoretical Concepts for Practice

Freud’s theory of development focused on sexual urges and were caused primarily by social forces and interpersonal situ-
has been criticized for being sexist; perhaps his harshest criti- ations. Human beings are driven by the need for interaction;
cism stems from the notion of “penis envy”—in which girls indeed, Sullivan (1953) viewed loneliness as the most painful
suffer from feelings of inferiority for not having male genitalia. human experience. He emphasized the early relationship with
Freud describes each developmental stage in terms of the id’s the significant other (primary parenting figure) as crucial for
focus on an erogenous zone of the body. Fixation, typically as personality development, and believed that healthy relation-
the result of childhood sexual abuse, at any given point results ships were necessary for a healthy personality. Anxiety is an
in pathologic conditions and personality disorders. Table 3-2 interpersonal phenomenon that is transmitted empathically
provides a comparison of Freud’s, Sullivan’s, and Erikson’s from the significant other to the child, and also by perceived
developmental stages. degrees of approval or disapproval felt by the child. Accord-
ing to Sullivan, all behavior is aimed at avoiding anxiety and
Therapeutic Model threats to self-esteem.
Psychoanalytic therapy was Freud’s answer for a scientific One of the ways that we avoid anxiety is by focusing on our
method to relieve emotional disturbances by knowing the positive attributes, or the good me (“I’m a good skier”), and by
unconscious mind. An often time-consuming (sometimes hiding the negative aspects, or the bad me (“I failed an exam”),
daily), expensive, and emotionally painful process, the goal of of ourselves from others and maybe even from ourselves. The
this therapy is to know and understand what is happening at not me is used to separate us from parts of ourselves that we
the unconscious level in order to uncover the truth. The ana- cannot imagine being part of us and is pushed deeply into the
lyst uses free association to search for forgotten and repressed unconscious. An example is an adolescent in a strict and con-
memories by encouraging the patient to say anything that servative family who begins to have stirrings of attraction, yet
comes to mind. For example, “What do you think of when I firmly maintains (and believes) that she does not have feelings
say ‘water’?” A patient may respond, “Warm…June…darkness for boys.
…can’t breathe,” revealing a long-forgotten, but traumatic Sullivan’s theory of development echoes that of Freud’s in
near-drowning incident. that personalities are influenced by the social environment as
The analyst is nondirective, but does make interpretations children, particularly as adolescents. He believed that personal-
of symbols, thoughts, and dreams. Psychodynamic therapy is ity is most influenced by the mother, but that personality could
theoretically related to psychoanalytic therapy and views the be molded even as adults. Stages occur in a stepwise fashion
mind in essentially the same way. It tends to be shorter, about that is environmentally influenced (see Table 3-2).
10 to 12 sessions (Sadock & Sadock, 2008), and the therapist
takes a more active role because the therapeutic relationship is Therapeutic Model
part of the healing process. Transference occurs as the patient Interpersonal therapy (IPT) is a hands-on system in which
projects intense feelings onto the therapist related to unfin- therapists actively guide and challenge maladaptive behav-
ished work from previous relationships; safe expression of iors and distorted views. The focus is on the “here and now”
these feelings is crucial to successful therapy. Psychodynamic with an emphasis on the patient’s life and relationships
therapists recognize that they, too, have unconscious emo- at home, at work, and in the social realm. The therapist
tional responses to the patient, or countertransference, which becomes a “participant observer” and reflects the patient’s
must be scrutinized in order to prevent damage to the thera- interpersonal behavior, including responses to the therapist.
peutic relationship. The premise for this work is that if people are aware of their
dysfunctional patterns and unrealistic expectations, they can
Interpersonal Theory modify them.
Interpersonal theory focuses on what occurs between people, as
opposed to psychoanalytic theory that is rooted in what occurs Behavioral Theories
in the mind. Harry Stack Sullivan (1892 to 1949), an American As the psychoanalytic movement was developing in the
psychiatrist, believed that personality dynamics and disorders twentieth century, so too was the behaviorist school of
thought. Ivan Pavlov (1927) is famous for investigating clas-
sical conditioning, in which involuntary behavior or reflexes
could be conditioned to respond to neutral stimuli. Pavlov’s
experimental dogs became accustomed to receiving food
Ego after a bell was rung; later these dogs salivated in response
SURFACE OF to the ring alone. For human beings, classical conditioning
CONSCIOUS WATER can occur under such circumstances as when a baby’s cry-
UNCONSCIOUS ing induces a milk let-down reflex or when a rape victim
begins to hyperventilate and sweat when she hears footsteps
Id behind her.
John B. Watson (1930) rejected psychoanalysis and
FIGURE 3-1  Mind as an iceberg. was seeking an objective therapy that did not focus on
Oral—birth to 1½ years Infancy—birth to 1½ years Infancy—birth to 1½ years
Pleasure-pain principle ­Mothering object relieves tension Trust vs. mistrust
Id, the instinctive and primitive through empathic intervention and Egocentric
mind, is dominant ­tenderness, leading to decreased Danger—during second half of first year, an abrupt and prolonged separation may
Demanding, impulsive, ­irrational, anxiety and increased satisfaction intensify the natural sense of loss and may lead to a sense of mistrust that may
asocial, selfish, trustful, and ­security; mother becomes last throughout life
­omnipotent, and dependent ­symbolized “good mother” Task—develop a basic sense of trust that leads to hope
Primary thought processes Goal is biological satisfaction Trust requires a feeling of physical comfort and a minimal experience of fear or
Unconscious instincts— and psychological security uncertainty; if this occurs, the child will extend trust to the world and self
source-energy-aim-object Denial of tension relief creates
Mouth—primary source of anxiety, and mother becomes
pleasure symbolized as “bad mother”
Immediate release of tension/ Anxiety in mother yields anxiety and
anxiety and immediate fear in child via empathy
­gratification through oral These states are experienced by
gratification the child in diffuse-undifferentiated
Task—develop a sense of trust manner
that needs will be met Task—learn to count on others for

CHAPTER 3  Theories and Therapies

satisfaction and security to trust
Anal—1½ to 3 years Childhood—1½ to 6 years Early childhood—1½ to 3 years
Reality principle—postpone Muscular maturation and learning to Autonomy vs. shame/doubt
immediate discharge of energy ­communicate verbally Develop confidence in physical and mental abilities that leads to the
and seek actual object to satisfy Learning social skills through ­development of an autonomous will
needs ­consensual validation Danger—development of a deep sense of shame/doubt if child is deprived of
Learning to defer pleasure Beginning to develop self-esteem via the opportunity to rebel; learns to expect defeat in any battle of wills with
Gaining satisfaction from toler- reflected appraisals: those who are bigger and stronger
ating some tension-mastering Good me Task—gain self-control of and independence within the environment
impulses Bad me
Focus on toilet training—retaining/ Not me
letting go; power struggle Levels of awareness
Ego development—functions of Awareness
the ego include problem-solving Selective inattention
skills, perception, ability to Dissociation
mediate id impulses Task—learn to delay satisfaction
Task—delay immediate of wishes with relative comfort

UNIT 1  Essential Theoretical Concepts for Practice
Phallic—3 to 7 years Play—3 to 6 years
Superego develops via Initiative vs. guilt
­incorporating moral values, Interest in socially appropriate goals leads to a sense of purpose
ideals, and judgments of right Imagination is greatly expanded because of increased ability to move around
and wrong that are held by freely and increased ability to communicate
parents; superego is primarily Intrusive activity and curiosity and consuming fantasies, which lead to feelings
unconscious and functions on of guilt and anxiety
the reward and punishment Establishment of conscience
­principle (sexual identity attained Danger—may develop a deep-seated conviction that he or she is essentially
via resolving oedipal conflict) bad, with a resultant stifling of initiative or a conversion of moralism to
Conflict differs for boy and girl vindictiveness
masturbatory activity Task—achieve a sense of purpose and develop a sense of mastery over tasks
Task—develop sexual identity
through identification with
­same-sex parent
Latency—7 to 12 years Juvenile—6 to 9 years School age—6 to 12 years
De-sexualization; libido diffused Absorbed in learning to deal with Industry vs. inferiority
Involved in learning social skills, ­ever-widening outside world, peers, Develops a healthy competitive drive that leads to confidence
exploring, building, collecting, and other adults In learning to accept instruction and to win recognition by producing “things,”
accomplishing, and hero worship Reflections and revisions of self-image the child opens the way for the capacity of work enjoyment
Peer group loyalty begins and parental images Danger—the development of a sense of inadequacy and inferiority in a child
Gang and scout behavior Task—develop satisfying interpersonal who does not receive recognition
Growing independence from family relationships with peers that involve Task—gain a sense of self-confidence and recognition through learning,
Task—sexuality is repressed during competition and compromise competing, and performing successfully
this time; learn to form close Preadolescence—9 to 12 years
relationship(s) with same-sex peers Develops intimate interpersonal
relationship with person of same sex
who is perceived to be much like
oneself in interests, feelings, and
mutual collaboration
Task—learn to care for others of same
sex who are outside the family;
Sullivan called this the “normal
­homosexual phase”
Genital phase (adolescence)— Adolescence—12 to 20 years Adolescence—12 to 20 years
13 to 20 years Early adolescence—12 to 14 years Identity vs. role confusion
Fluctuation regarding emotion Establishing satisfying relationships Diffusion
stability and physical maturation with opposite sex Differentiation from parents leads to fidelity (sense of self)
Very ambivalent and labile, seeking Late adolescence—14 to 20 years Physiological revolution that accompanies puberty (rapid body growth
life goals and emancipation from Interdependent and establishing and sexual maturity) forces the young person to question beliefs and to
parents durable sexual relations with a select refight many of the earlier battles
Dependence vs. independence member of the opposite sex Danger—temporary identity diffusion (instability) may result in a permanent
Reappraisal of parents and self; Task—form intimate and long-lasting inability to integrate a personal identity
intense peer loyalty relationships with the opposite sex Task—integrate all the tasks previously mastered into a secure sense of self
Task—form close relationships and develop a sense of identity Young adulthood—20 to 30 years
with members of the opposite Intimacy and solidarity vs. isolation
sex based on genuine caring and Maturity and social responsibility results in the ability to love and be loved
pleasure in the interaction As people feel more secure in their identity, they are able to establish
­intimacy with themselves (their inner life) and with others, eventually in a
love-based satisfying sexual relationship with a member of the opposite sex
Danger—fear of losing identity may prevent intimate relationship and result
in a deep sense of isolation
Task—form intense long-term relationships and commit to another person,
cause, institution, or creative effort
Adulthood—30 to 65 years

CHAPTER 3  Theories and Therapies

Generativity vs. self-absorption
Interest in nurturing subsequent generations creates a sense of caring,
contributing, and generativity
Danger—lack of generativity results in self-absorption and stagnation
Task—achieve life goals and obtain concern and awareness of future
Senescence—65 years to death
Integrity vs. despair
Acceptance of mortality and satisfaction with life leads to wisdom
Satisfying intimacy with other human beings and adaptive response
to triumphs and disappointments
Marked by a sense of what life is, was, and its place in the flow of history
Danger—without this “accrued ego integration,” there is despair, usually
marked by a display of displeasure and distrust
Task—derive meaning from one’s whole life and obtain/maintain a sense
of self-worth
*Developed from original sources by Freud, Sullivan, and Erikson.

30 UNIT 1  Essential Theoretical Concepts for Practice

unconscious motivations. He contended that personality traits for development, knowledge attainment, motivation, and
and responses, adaptive and maladaptive, were learned. In a understanding.
famous (but terrible) experiment, Watson conditioned Little Maslow’s hierarchy of needs theory was developed in 1954
Albert, a 9-month-old child, to be terrified at the sight of white by Abraham Maslow (1970). Needs are placed conceptually on
fur or hair. He concluded that through behavioral techniques a pyramid, with the most basic and important needs on the
anyone could be trained to be anything, from a beggar to a lower level (Figure 3-2). The higher levels, the more distinctly
merchant. human needs, occupy the top sections of the pyramid. Accord-
B.F. Skinner (1938) conducted research on operant condi- ing to Maslow, when lower level needs are met, higher level
tioning in which voluntary behaviors are learned through con- needs are able to emerge.
sequences of positive reinforcement (a consequence that causes • P  hysiological needs. The most basic needs are the physi-
the behavior to occur more frequently) or negative reinforce- ological drives, including the need for food, oxygen,
ment or punishment (a consequence that causes the behavior water, sleep, sex, and a constant body temperature.
to occur less frequently). Studying hard results in good grades If all the needs were deprived, this level would take
and increases the chances that studying will continue to occur; priority.
driving too fast may result in a speeding ticket and in mature • S afety needs. Once physiological needs are met, the
and healthy individuals can decrease the chances that speeding safety needs emerge. They include security, protection,
will recur. freedom from fear/anxiety/chaos, and the need for law,
order, and limits.
Therapeutic Models • B  elongingness and love needs. People have a need for
Behavioral therapy, or behavior modification, uses basic an intimate relationship, love, affection, and belong-
tenets from each of the behaviorists described previously. It ing and will seek to overcome feelings of loneliness
attempts to correct or eliminate maladaptive behaviors or and alienation. Maslow stresses the importance of hav-
responses by rewarding and reinforcing adaptive behavior. ing a family and a home and being part of identifiable
Systematic desensitization is based on classical con- groups.
ditioning. The premise is that learned responses can be • E  steem needs. People need to have a high self-regard
reversed by first promoting relaxation and then gradually and have it reflected to them from others. If self-esteem
facing a particular anxiety-provoking stimulus. This method needs are met, we feel confident, valued, and valuable.
has been particularly successful in extinguishing phobias. When self-esteem is compromised, we feel inferior,
Agoraphobia, the fear of open places, can be treated initially worthless, and helpless.
by visualizing trips outdoors while using relaxation tech- • S  elf-actualization. We are preset to strive to be every-
niques. Later, the individual can practice more challenging thing that we are capable of becoming. Maslow said,
excursions, which should result in eliminating or reducing “What a man can be, he must be.” What we are capable
agoraphobia. of becoming is highly individual—an artist must paint,
Aversion therapy is based on both classical and operant a writer must write, and a healer must heal. The drive
conditioning and is used to eradicate unwanted habits by to satisfy this need is felt as a sort of restlessness, a
associating unpleasant consequences with them. A pharma- sense that something is missing. It is up to each per-
cologically based aversion therapy is a regimen of disulfi- son to choose a path that will result in inner peace and
ram (Antabuse); people who take this medication and then fulfillment.
ingest alcohol become extremely ill. Aversion therapy also Although Maslow’s early work included only five levels
has been used with sex offenders who may, for example, of needs, he later took into account two additional factors:
receive electric shocks in response to arousal from child (1) cognitive needs (the desire to know and understand) and
pornography. (2) aesthetic needs (Maslow, 1970). He describes the acquisi-
Biofeedback is a technique in which individuals learn tion of knowledge (first) and the need to understand (second)
to control physiological responses such as breathing rates, as being hard-wired and essential. Furthermore, he identi-
heart rates, blood pressure, brain waves, and skin tempera- fied aesthetic needs as a craving for beauty and symmetry, a
ture. This control is achieved by providing visual or audi- ­universal need.
tory biofeedback of the physiological response and then
using relaxation techniques such as slow, deep breathing or Rogers’ Person-Centered Theory
meditation. Carl Rogers, an American psychologist, popularized person-
centered theory in the 1940s. Rogers, unlike Freud, saw people
Humanistic Theory as basically healthy and good. He identified people and all living
Humanistic psychologists rejected the psychoanalysts’ focus organisms as having innate self-actualizing tendencies to grow,
on unconscious conflicts, which they considered overpes- to develop, and to realize their full potential (Rogers, 1986).
simistic. They also rejected the behaviorists’ focus on learn- He believed that clients (he did not call them patients) were in
ing, which they considered overscientific. They sought a the best position to explore, understand, and identify solutions
psychological science concerned with the human potential to their own problems. He uses the analogy of teaching a child
CHAPTER 3  Theories and Therapies 31


Self-Actualization Needs
Becoming everything
one is capable of

Esteem Needs
Self-esteem related to competency, achievement,
and esteem from others

Love and Belonging Needs

Affiliation, affectionate relationships, and love

Safety Needs
Security, protection, stability, structure, order, and limits

Physiological Needs
Food, water, oxygen, elimination, rest, and sex

FIGURE 3-2  Maslow’s hierarchy of needs. (Adapted from Maslow, A. H. [1972]. The farther reaches of
human nature. New York: Viking.)

to ride a bicycle. It is not enough to tell the child how to ride, be a woman whose sister had been depressed since their tumul-
but is imperative that the child tries to ride the bike. (Refer to tuous and unsteady childhoods. In response to a question
Chapter 9 for further discussion on Rogers’ use of therapeutic about how she and her sibling handled their parents’ divorce
relationships.) and subsequent move to a small apartment, one of the siblings
observed: “My sister fell apart. She retreated, barely talked.
Therapeutic Models Mom asked me how I was doing. I told her I was excited to
Patient-centered therapy is an existentially based therapy; get a new bedroom and make new friends. And I was telling
the emphasis is on self-awareness and on the present, because the truth.”
the past has already occurred and the future has not yet
occurred (Boeree, 2006). The role of the therapist is that of a Therapeutic Model
nondirective facilitator who seeks clarification and provides Cognitive behavioral therapy (CBT) is a popular and com-
encouragement in this process. Three essential qualities in monly used effective and well-researched therapeutic tool. It
the therapist are congruence (genuineness), empathy, and is based on both cognitive and behavioral theory and seeks to
respect. If these three qualities are present, the patient will modify negative thoughts that lead to dysfunctional emotions
improve; without them, there is little chance that the therapy and actions. Several concepts underlie this therapy. One is that
will be successful. we all have schemata, or unique assumptions about ourselves,
others, and the world around us. For example, if someone has
Cognitive Theory a schema that no one can be trusted but themself, this person
Aaron T. Beck was convinced that depressed people generally will question everyone else’s motives and expect deception and
had standard patterns of negative and self-critical thinking eventual pain from relationships with others. Other negative
(Beck, 1963). Cognitive appraisals of events therefore lead to schemata include incompetence, abandonment, evilness, and
emotional responses—it is not the stimulus itself that causes vulnerability.
the response, but instead one’s evaluation of the stimulus. An Typically, people are unaware of their basic assumptions;
example of the stimulus-appraisal-response relationship would however, their beliefs and attitudes will make them apparent.
32 UNIT 1  Essential Theoretical Concepts for Practice


All-or-nothing thinking Thinking in black and white, reducing complex Cheryl got second-highest score in the
outcomes into absolutes cheerleading competition. She considers
herself a loser.
Overgeneralization Using a bad outcome (or a few bad outcomes) as Marty had a traffic accident. She refuses to
evidence that nothing will ever go right again drive and says, “I shouldn’t be allowed on
the road.”
Labeling A form of generalization where a characteristic “Because I failed the advanced statistics
or event becomes definitive and results in an exam, I am a failure. I might as well give up.”
overly harsh label for self or others
Mental filter Focusing on a negative detail or bad event Anne’s boss evaluated her work as
and allowing it to taint everything else ­exemplary and gave her a few suggestions
for improvement. She obsessed about the
suggestions and ignored the rest.
Disqualifying the Maintaining a negative view by rejecting “I’ve just been offered the job I’ve always
positive ­information that supports a positive view as wanted. No one else must have applied.”
being irrelevant, inaccurate, or accidental
Jumping to “My fiancé, Mike, didn’t call me for 3 hours;
Making a negative interpretation despite the fact
conclusions that there is little or no supporting evidence therefore, he doesn’t love me.”
a. Mind reading Inferring negative thoughts, responses, and The grocery store clerk was grouchy and
motives of others barely made eye contact. “I must have
done something wrong.”
b. Fortune-telling Anticipating that things will turn out badly as an “I’ll ask her out, but I know she won’t have a
error established fact good time.”
Magnification or Exaggerating the importance of something (such “I’m alone on a Saturday night because no
minimization as a personal failure or the success of others) or one likes me. When other people are alone,
reducing the importance of something (such as it’s because they want to be.”
a personal success or the failure of others)
a. Catastrophizing An extreme form of magnification in which the “If I don’t make a good impression on the boss
very worst is assumed to be a probable outcome at the company picnic, she will fire me.”
Emotional reasoning Drawing a conclusion based on an emotional “I’m nervous about the exam. I must not be
state prepared. If I were, I wouldn’t be afraid.”
“Should” and “must” Rigid self-directives that presume an unrealistic “My patient is worse today. I should give
statements amount of control over external events better care so that she will get better.”
Personalization Assuming responsibility for an external event or “I’m sorry that your party wasn’t more fun.
situation that was likely out of personal control It’s probably because I was there.”
Adapted from Burns, D. D. (1980). Feeling good: the new mood therapy. New York: William Morrow.

Rapid, unthinking responses based on these schemata are thoughts based on rational evidence and thoughts. This is
known as automatic thoughts. These responses are particu- sometimes referred to as the ABCs of irrational beliefs and
larly intense and frequent in psychiatric disorders such as is a good exercise for nursing students to try for themselves
depression and anxiety. Often these automatic thoughts, or (Box 3-1).
cognitive distortions, are irrational because people make false
assumptions and misinterpretations. Common cognitive dis- A Note on How Psychotherapy Changes the Brain
tortions are listed in Table 3-3. Numerous studies have indicated that all mental processes
The goal of CBT is to identify the negative patterns of are derived from the brain. Therefore psychotherapeutic
thought that lead to negative emotions. Once the maladap- outcomes such as changes in symptoms, psychological abili-
tive patterns are identified, they can be replaced with rational ties, personality, or social functioning, are generally accepted
thoughts. A particularly useful technique in CBT is to use a to be attributed to brain changes brought about either by
four-column format to record the precipitating event or situ- medication or psychotherapy (Karisson, 2011). Numerous
ation, the resulting automatic thought, the ensuing feeling(s) studies compiled by Karisson (2011) substantiate positive
and behavior(s), and, finally, a challenge to the negative treatment responses with various psychotherapies resulting
CHAPTER 3  Theories and Therapies 33

concepts to guide federal and state initiatives, particularly

as they relate to empowering mental health consumers
OF IRRATIONAL BELIEFS (people with mental illness) and in campaigns to reduce
Activating Event mental illness stigma.
Edward has been in counseling for depression. His
therapist’s secretary called and canceled this week’s The Recovery Model in Psychiatric Nursing
appointment. The use of the recovery model in psychiatric nursing is a
Belief natural extension of what we have traditionally done. Pep-
My therapist is disgusted with me and wants to avoid lau (1952) set the standard by urging nurses to develop
me. therapeutic interpersonal relationships; the recovery model
Consequence moves this relationship from nurse-patient to nurse-partner.
Sadness, rejection, and hopelessness. Decides to call According to Hanrahan and colleagues (2011), it is crucial to
off work and return to bed. increase individual and family roles in recovery. Caldwell and
Reframing colleagues (2010) assert that psychiatric nurses should edu-
There is no evidence to believe that I disgust my thera- cate other health care professionals about recovery concepts
pist. Why would he have rescheduled if he really didn’t and suggest methods to empower consumers and promote
want to see me? recovery:
• Advocate for self-administration of medications when
possible, with appropriate supports in the community.
• Encourage the development of medication records to
in brain changes for the following disorders: major depres- schedule dosing and to share with other health care
sive disorder (MDD), anxiety disorders (panic disorder, providers.
social anxiety disorder, specific phobias), posttraumatic • Develop a personal relapse prevention program by
stress disorder (PTSD), borderline personality disorder, and knowing the symptoms of relapse, by realizing the
obsessive-compulsive disorder (OCD). These studies sug- effects of environmental and internal triggers on emo-
gest that at present the most effective therapies that result tional well-being, and by enlisting others for support.
in brain changes are cognitive behavioral therapy (CBT), • Recommend supported employment in regular commu-
dialectic behavior therapy (DBT), psychodynamic psycho- nity settings to reduce isolation and improve confidence.
therapy, and interpersonal psychotherapy (IP) are effective • Utilize psychiatric advance directives to enable consum-
for treating the aforementioned disorders (Karisson, 2011). ers to plan for mental health treatment in the event of a
crisis should they become incompetent.
Mental Health Recovery Model
Although we tend think of recovery as regaining health or OTHER MAJOR THEORIES
being cured from an episode of illness, the term recovery in
this model has a different meaning. The mental health recovery Cognitive Development
model is not a focus on a cure, but instead emphasizes living Jean Piaget (1896 to 1980) was a Swiss psychologist and
adaptively with chronic mental illness. It is viewed both as an researcher (Smith, 1997). While working at a boys’ school
overarching philosophy of life for people with mental illness run by Alfred Binet, developer of the Binet Intelligence Test,
and as an approach to care for use by those who treat, finance, Piaget helped to score these tests. He became fascinated by
and support mental health care. It is also an effective approach the fact that young children consistently gave wrong answers
to dealing with substance abuse. on intelligence tests, wrong answers that revealed a discern-
A diagnosis of mental illness once meant that you lis- ible pattern of cognitive processing that was different from
tened to health care professionals and relied upon them to that of older children and adults. He concluded that cogni-
chart your course in life. This medical model approach often tive development was a dynamic progression from primi-
results in apathy and discouragement: “They want me to tive awareness and simple reflexes to complex thought and
take medication for the rest of my life; I don’t like it and responses (Piaget & Inhelder, 1969). Our mental represen-
won’t take it.” The recovery model shifts the responsibility tations of the world, or schemata, depend on the cognitive
for care from the provider to the individual: “I will discuss stage we have reached.
the medication side effects with my friends who have similar An understanding of cognitive development can assist
problems and then talk to my nurse practitioner about my nurses to tailor their care to suit the cognitive level of the
options and preferences.” patient. For example, the concept of dying is difficult to grasp
This model emphasizes hope, social connection, empow- for the 5-year-old child who has lost a parent; support for
erment, coping strategies, and meaning in life. A recovery this child will require different skills than those required for
approach to care has been embraced by the American Psy- a 10-year-old child, who can understand the permanence of
chiatric Association from a service perspective. The U.S. death. Whereas each of the cognitive stages describes a child,
Department of Health and Human Services uses recovery Piaget’s theory can be useful in understanding cognitive
34 UNIT 1  Essential Theoretical Concepts for Practice

ability in people with problems such as developmental delay junctures. For example, a child had inconsistent and abusive
and ­mental retardation: parenting; he may grow into a mistrustful adult. However, by
• S ensorimotor stage (birth to 2 years). Begins with basic experiencing corrective, dependable, and positive relationships
reflexes and culminates with purposeful movement, spa- later in life, he could become an appropriately trusting adult.
tial abilities, and hand-eye coordination. Physical interac-
tion with the environment provides the child with a basic Theory of Object Relations
understanding of the world. By about 9 months, object The theory of object relations was developed by interper-
permanence is achieved and the child can conceptualize sonal theorists, who emphasize past relationships in influenc-
objects that are no longer visible. The delight of the game ing a person’s sense of self as well as the nature and quality of
of ­peek-a-boo can be explained by this emerging skill as the relationships in the present. The term object refers to another
child begins to anticipate the face hidden behind the hands. ­person, particularly a significant person.
• P  reoperational stage (2 to 7 years). Operations is a term Margaret Mahler (1895 to 1985) was a Hungarian-born
used to describe thinking about objects. Children are not child psychologist who worked with emotionally disturbed
yet able to think abstractly or generalize qualities in the children. She developed a framework for studying how an
absence of specific objects, but rather think in a concrete infant transitions from complete self-absorption, with an
fashion. Egocentric thinking is demonstrated through a inability to separate from its mother, to a physically and psy-
tendency to expect others to view the world as they do. chologically differentiated toddler. Mahler believed that psy-
They are also unable to conserve mass, volume, or num- chological problems were largely the result of a disruption of
ber. An example of this is thinking that a tall, thin glass this separation (Mahler et al., 1975).
holds more liquid than a short, wide glass. During the first 3 years, the significant other (e.g., the
• C  oncrete operational stage (7 to 11 years). Logical thought mother) provides a secure base of support that promotes
appears and abstract problem solving is possible. The enough confidence for the child to separate. This is achieved
child is able to see a situation from another’s point of view by a balance of holding (emotionally and physically) a child
and can take into account a variety of solutions to a prob- enough for the child to feel safe, while encouraging indepen-
lem. Conservation is possible; for example, 2 small cups dence and natural exploration.
of liquid can be seen to equal a tall glass. They are able to Problems may arise in this process. If a toddler leaves his or
classify based on discrete characteristics, order objects in her mother on the park bench and wanders off to the sandbox, the
a pattern, and understand the concept of reversibility. child should be encouraged with smiles and reassurance, “Go on
• F  ormal operational stage (11 years to adulthood). Concep- honey; it’s safe to go away a little.” Then the mother needs to be
tual reasoning commences at approximately the same time reliably present when the toddler returns, thereby rewarding his
as does puberty. At this stage the child’s basic abilities to or her efforts. Mahler notes that raising healthy children does not
think abstractly and problem solve mirror those of an adult. require that parents never make mistakes, and that “good enough
parenting” will promote successful separation-individuation.
Theory of Psychosocial Development
The German-born American Erik Erikson (1902 to 1994) was a Theories of Moral Development
child psychoanalyst. Erikson (1963) described development as Stages of Moral Development
occurring in eight predetermined life stages, stages whose levels Lawrence Kohlberg (1927 to 1987) was an American psycholo-
of success are related to the preceding stage (see Table 3-2). These gist whose work reflected and expanded on Piaget’s by applying
stages are characterized by developmental tasks that ideally his theory to moral development, a development that coincided
result in a successful resolution. One of the stages, for example, with cognitive development (Crain, 1985). While visiting Israel,
occurs from the ages of 7 to 12. During that time, the child’s Kohlberg became convinced that children living in a kibbutz had
task is to gain a sense of his or her own abilities and compe- advanced moral development, and he believed that the atmosphere
tence, and expand relationships beyond the immediate family of trust, respect, and self-governance nurtured this development.
to include peers. The attainment of this task (industry) brings In the United States, he created schools or “just communities” that
with it the virtue of confidence. If children are unable to gain a were based on these concepts. Based on interviews with youths,
mastery of age-appropriate tasks, and cannot make a connec- Kohlberg developed a theory of how people progressively develop
tion with their peers, they will feel like failures (inferiority). a sense of morality (Kohlberg & Turiel, 1971).
It is important to note that the resolution of each stage does His theory provides a framework for understanding the
not depend completely on integrating the positive characteris- progression from black-and-white thinking about right and
tic and completing eschewing the negative. Ideally, harmony is wrong to a complex, variable, and context-dependent decision-
achieved between the two characteristics. For example, we would making process regarding the rightness or wrongness of action.
not want a child to be 100% trusting—a child who trusted every- Pre-conventional level
one would be totally vulnerable; a degree of mistrust is essential Stage 1: Obedience and punishment. The hallmarks of
to survival. Additionally, E­ rikson did not states that developmen- this stage are a focus on rules and on listening to authority.
tal tasks had to be mastered within the prescribed time period, People at this stage believe that obedience is the method to
but he did believe that some tasks are naturally easier at certain avoid punishment.
CHAPTER 3  Theories and Therapies 35

Stage 2: Individualism and exchange. Individuals become TABLE 3-4 GILLIGAN’S STAGES

aware that not everyone thinks the way that they do, and that
rules are seen differently by different people. If they or others
decide to break the rules, they are risking punishment. STAGE GOAL ACTION
Conventional level Pre-conventional Goal is individual Caring for self
Stage 3: Good interpersonal relationships. Children survival—­
begin to view rightness or wrongness as related to motivations, selfishness
personality, or the goodness or badness of the person. Gener- Conventional Self-sacrifice is Caring for
ally speaking, people should get along and have similar values. goodness— others
Stage 4: Maintaining the social order. A “rules are rules” responsibility
mindset returns. However, the reasoning behind it is not sim- to others
ply to avoid punishment; it is because the person has begun to Post-conventional Principle of Balancing
adopt a broader view of society. Listening to authority main- nonviolence— caring for self
tains the social order; bureaucracies and big government agen- do not hurt with caring
cies often seem to operate with this tenet. others or self for others
Post-conventional level
Stage 5: Social contract and individual rights. People in
stage 5 still believe that the social order is important, but the mental disorders will respond to physical treatment. Sigmund
social order must be good. For example, if the social order is Freud himself researched neurological causes for mental illness
corrupt, then rules should be changed and it is a duty to protect and considered cocaine a possible treatment.
the rights of others. In the 1950s a surgeon noticed that surgical patients were
Stage 6: Universal ethical principles. Actions should create calmed by the administration of chlorpromazine (Thorazine);
justice for everyone involved. We are obliged to break unjust laws. it soon became widely used for the treatment of schizophrenia
and dramatically reduced the use of restraint and seclusion.
Ethics of Care Theory This discovery spurred the development of other drug-based
Carol Gilligan (born 1936) is an American psychologist, ethi- treatments and the adoption of a chemical imbalance theory of
cist, and feminist who inspired the normative ethics of care mental disorders.
theory. She worked with Kohlberg as he developed his theory of If chemical imbalances exist, how do they develop? Twin
moral development and later criticized his work for being based studies have been useful to support the genetic transmission
on a sample of boys and men. Additionally, she believed that he of certain disorders. Whereas only 1% of the population has
used a scoring method that favored males’ methods of reason- schizophrenia, among identical twins the concordance rate
ing, resulting in lower moral development scores for girls as (the percent of the time that both twins will be affected) is
compared to boys. Based on Gilligan’s critique, Kohlberg later about 50% (Sadock & Sadock, 2008). Although this indicates
revised his scoring methods, which resulted in greater similar- genetic involvement, it cannot be the whole story. If it were,
ity between girls’ and boys’ scores. the concordance rate of schizophrenia in identical twins would
Gilligan’s 1982 book, In a Different Voice: Psychological The- be 100%. It is likely that the environment exerts an influence
ory and Women’s Development, suggests that a morality of care on the developing embryo or child. Research has shown that
should replace Kohlberg’s “justice view” of morality, which toxins, viruses, hostile environments, and brain traumas have
maintains that we should do what is right no matter the per- been proposed as catalysts for the development of psychiatric
sonal cost or the cost to those we love. Gilligan’s “care view” disorders (see Chapter 4).
emphasizes the importance of forming relationships, banding
together, and putting the needs of those for whom we care above Biological Therapy
the needs of strangers. Gilligan asserts that a female approach Psychopharmacology is the primary biological treatment for
to ethics has always been in existence but has been trivial- mental disorders. (Refer to Chapter 4 for a full discussion
ized. Like Kohlberg, Gilligan asserts that moral development of the biological basis for understanding psychopharmacol-
progresses through three major divisions: pre-­conventional, ogy.) Major classifications of medications are antidepres-
conventional, and post-conventional. These transitions are not sants, antipsychotics, antianxiety agents, mood stabilizers,
dictated by cognitive ability, but rather through personal devel- and psychostimulants. Clinicians recognize the importance
opment and changes in a sense of self (Table 3-4). of optimizing other biological variables, such as correcting
hormone levels (as in hypothyroidism), regulating nutri-
MODELS, THEORIES, AND THERAPIES tionally deficient diets, and balancing inadequate sleep pat-
IN CURRENT PRACTICE terns. (Refer to Chapters 10 through 19 for relevant uses of
Biological Model Electroconvulsive therapy (ECT) has proven to be an
Psychiatric care is dominated by the biological model, in which effective treatment for severe depression and other psychiat-
mental disorders are believed to have physical causes; therefore ric conditions. ECT is a procedure that uses electrical current
36 UNIT 1  Essential Theoretical Concepts for Practice


Dorothy Johnson Behavioral system Helping a patient return to a state Providing prn antianxiety medication
of equilibrium when exposed to and encouraging slow, deep
stressors by reducing or removing breathing for a patient who is
them and by supporting adaptive experiencing panic attacks
processes (Johnson, 1980)
Imogene King Goal attainment Developing an interpersonal relationship Sitting with a new mother who is
and helping the patient to achieve his/ experiencing depression and devel-
her goals based on the patient’s roles oping a discharge plan in the context
and social contexts (King, 1981) of childcare and financial deficits
Madeleine Culture care Promoting health and helping people Including the family in the plan of
Leininger* to cope with illness while ­recognizing care for an Amish man who has
cultural issues and their importance recently attempted suicide
to health (Leininger, 1995)
Betty Neuman* System model Developing a nurse-patient relation- Considering the impact of shingles
ship; assessing and intervening with and graduate school stressors
the person’s response to stress on a person diagnosed with
(Neuman, 1982) generalized anxiety disorder
Dorothea Orem Self-care deficit Addressing self-care deficits and encour- Temporarily helping a person with
aging patients to be actively involved an exacerbation of paranoia to
in their own care (Orem, 2001) meet his/her hygiene needs
Ida Orlando* Dynamic Addressing the patient’s immediate Asking, “Would you like to talk?” to
nurse-patient need for help; the longer the unmet a man who has begun pacing in
relationship need, the more stress will be the hallway and shaking his head
­experienced (Orlando, 1990)
Hildegard Interpersonal Using the interpersonal environment Sitting quietly beside a new father
Peplau* relations as a therapeutic tool for healing and who has recently lost his job and
in reduction of anxiety (Peplau, 1992) attempted suicide and does not
want to talk
Jean Watson* Transpersonal Caring is as important as procedures Taking time from a busy assignment
caring and tasks; developing a nurse- to meet a patient’s husband
patient relationship that results in a
­therapeutic outcome (Watson, 2007)
*Psychiatric nursing background.

to induce a seizure, and is thought to work by affecting neu- & Tomey, 2010). The drive to create these theories began as a
rotransmitters and neuroreceptors (see Chapter 15 for more result of nursing education being moved from hospital-based
discussion regarding ECT). programs to college- and university-based programs where
Most mental health professionals combine biological ap­­ nurses became involved in research. This research became the
proaches with talk therapy. Research indicates that using medi- impetus for nurses to develop theories and a strong scientific
cation and cognitive behavioral therapy is an extremely effective body of knowledge.
treatment for many psychiatric disorders, especially major de- Hildegard Peplau’s work in the early 1950s is most often
pression (Black & Andreasen, 2011; Sadock & Sadock, 2008). associated with psychiatric nursing, and her work will be
If a hostile environment can trigger negative brain chemistry presented in the following section. However, most nursing
or transmission, then a positive environment may reverse and theories are applicable and of value to psychiatric nursing
improve the process. because interpersonal relations, caring, and communication
are keys to the foundation of nursing. A summary of selected
Nursing Models nursing theorists, the focus of their theoretical works, and
We have been examining theories and therapies developed by examples of how their contributions could be utilized in
professionals from a variety of disciplines that date back to psychiatric nursing is provided in Table 3-5. It is worth
the late 1800s. It was not until the 1950s that the profession of noting that among nurse theorists, psychiatric nurses are
nursing began to develop, record, and test theories (Alligood well-represented.
CHAPTER 3  Theories and Therapies 37

Interpersonal Relations in Nursing Influence of Theories and Therapies on Nursing

Hildegard Peplau’s (1909 to 1999) seminal work, Interpersonal Care
Relations in Nursing, was first published in 1952 and has served Other theories and therapies presented earlier in this chapter
as a foundation for understanding and conducting therapeu- also are relevant to nursing care. Nurses constantly borrow con-
tic nursing relationships ever since. Peplau based her work cepts and carry out interventions that are supported by these
on Sullivan’s interpersonal theory and emphasized that the models. Some examples of how they may be used are as follows:
nature of the nurse-patient relationship strongly influenced • B  ehavioral: Promoting adaptive behaviors through
the outcome for the patient. reinforcement can be valuable and important in work-
Peplau made an extremely useful contribution to under- ing with patients, especially when working with a pedi-
standing anxiety by conceptualizing the four levels still in use atric population. These patients look forward to positive
today: reinforcement for good behavior and will work hard for
1. Mild anxiety is day-to-day, “I’m awake and taking care of gold stars or other privileges.
business” alertness. Stimuli in the environment are per- • C  ognitive: Helping patients identify negative thought
ceived and understood, and learning can easily take place. patterns is a worthwhile intervention in promoting
2. Moderate anxiety is felt as a heightened sense of aware- healthy functioning and improving neurochemistry.
ness, such as when you are about to take an exam. The Workbooks are available to aid in the process of identi-
perceptual field is narrowed and an individual hears, fying these cognitive distortions.
sees, and understands less. Learning can still take place, • P  sychosocial development: Erikson’s theory provides
although it may require more direction. structure for understanding critical junctures in devel-
3. Severe anxiety interferes with clear thinking and the per- opment. The older adult gentleman who has suffered
ceptual field is greatly diminished. Nearly all behavior is a stroke may be depressed and despairing because he
directed at reducing the anxiety. An example of this is can no longer take care of his house. In this case the
your response to skidding your car on wet pavement. nurse and patient could explore ways of optimizing the
4.  Panic anxiety is overwhelming and results in either patient’s remaining strengths and talents, such as by
paralysis or dangerous hyperactivity. An individual can- nurturing and tutoring young people or by developing
not communicate, function, or follow direction. This is attainable and progressive goals such as getting the mail,
the sort of anxiety that is associated with the terror of taking out the trash, and so forth.
panic attacks. • H  ierarchy of needs: Maslow’s work is useful in prioritiz-
Refer to Chapter 11 for application of these levels to the ing nursing care. When working with an actively suicidal
nursing process. patient, students sometimes think it is rude to ask if the pa-
One of the most useful constructs of Peplau’s theory is in tients are thinking about killing themselves. However, safety
providing structure for how we view the therapeutic relation- supersedes this potential threat to self-esteem. Although
ship, which she divided into four phases. Each of these overlap- the “must do’s” in nursing begin with physical care (such
ping and interlocking phases includes tasks, the expression of as providing medication and hydration through IV fluids),
needs by the patient, and the interventions facilitated by the the goal should also include higher level needs, which can be
nurse. Refer to Chapter 9 for more information on the phases obtained by listening, observing, and collaborating with the
of the nurse-patient relationship. patient in the development of the plan of care.


Let’s give a warm welcome to the Consumer Providers if they successfully pass, they become Certified Peer
(CPs) who are now joining the Mental Health Team!!! ­ pecialists. In order to maintain their certification, they
OK…But who are consumer providers? must be involved in continuing education programs and,
The Rand Corporation, a nonprofit research organization, like all mental health professionals, need supervision in
has identified the following important information about the ­clinical setting (Chinman et al., 2008).
Consumer Providers: So, what is the role of CPs in the clinical setting?
“Consumer Providers (CPs) are individuals with serious CPs serve as role models to encourage people who are
mental illness who are trained to use their experiences struggling with mental health issues. When appropriate,
to provide recovery–oriented services and to support they share their personal recovery story to show that
­others with mental illness in a mental health delivery set- recovery from mental illness is possible.
ting” (Chinman et al., 2008, p. v). The CP receives spe- CPs teach goal setting, problem solving, symptom man-
cialized training in mental health concepts with a focus agement skills, and a variety of recovery tools.
on hope and recovery. After completing this intensive CPs facilitate or lead groups to provide peer support for
training, some CPs take a rigorous national exam, and clients (Chinman et al., 2008).

38 UNIT 1  Essential Theoretical Concepts for Practice


What are the advantages of having CPs on the mental So, having CPs on the mental health team sounds
health team? like a sweeping movement that is transforming the
It must be noted that, although reasonable evidence mental health system!
supports the efficacy of structured self-management Yes! Now that the idea of “recovery” is the focus of
programs for physical conditions such as diabetes, there mental health treatment, CPs provide an important strat-
is far less research to evaluate outcomes for mental dis- egy for making mental health care more oriented to the
orders (Cook et al., 2009). That point being noted, Cook goal of leading people to paths of resiliency and recovery
and colleagues examined changes in measures of recov- (Chinman et al., 2008).
ery and psychosocial outcomes of participants involved in
a peer-led intervention called Wellness Recovery Action EXCELLENT!!! So, as nurses, we will be sure to give
Planning (WRAP). The results of this research concluded a resounding welcome to consumer providers, who
that “the efficacy and effectiveness of peer-led self- bring the essential elements of hope and recovery to
management has the potential to enhance self-determi- the Mental Health Team!
nation and promote recovery for people with psychiatric
disabilities” (Cook et al., 2009, p. 1). Additionally, many References
Chinman, M., Hamilton, A., Butler, B., Knight, E., Murray, S.,
investigators are presently engaged in research that will
et al. (2008). Mental health consumer providers: a guide for
definitively answer the questions regarding the efficacy clinical staff. Retrieved from Rand Health website: www.
of having CPs provide peer-led services. Still, “overall
the results suggest that peer support services have a Cook, J., Copeland, M. E., Hamilton, M., et al. (2009). Initial
positive impact in the lives of those that receive this outcomes of mental illness self-management program
care, and help foster recovery and promote resiliency” based on Wellness Recovery Action Planning. Psychiatric
(Daniels et al., 2009, p. 10). Services, 60, 246–249.
Daniels, A. S., Grant, E. A., Filson, B., Powell, I. G., Fricks, L.,
Since “money makes the world go round,” how are et al. (2009, November 17). Pillars of peer support: transform-
the services of CPs billed? ing mental health systems of care through peer support ser-
More frequently, state mental health systems are allow- vices. In Pillars of peer support services summit. Atlanta, GA:
ing CP services to be reimbursed under Medicaid (Salzer Symposium conducted at The Carter Center. Retrieved from
et al., 2010.) Additionally, it is noteworthy that the Veterans
Salzer, M., Schwenk, E., & Brusilovskity, E. (2010). Certified
Administration has created job codes for CPs and allows peer specialists roles and activities: results from a national
billing of their services (Chinman et al., 2008). survey. Psychiatric Services, 61(5), 520–523.

Submitted by Marie Ryder & Dolly Sadow.

Therapies for Specific Populations traditional “classroom seating” with everyone facing a central
Group Therapy speaker, thereby limiting free interaction among participants.
This therapeutic method is commonly derived from interper- Groups possess both content and process dimensions.
sonal theory and operates under the assumption that interac- Group content refers to the actual dialogue between members
tion among participants can provide support or bring about or the type of information that can be transcribed (written or
desired change among individual participants. recorded) in minutes of meetings. Group process includes all
A group is defined as (a) “a gathering of two or more the other elements of human interaction, such as nonverbal
individuals (b) who share a common purpose and (c) meet communication, adaptive and maladaptive roles, energy flow,
over a substantial time period (d) in face-to-face interac- power plays, conflict, hidden agendas, and silences. Although
tion (e) to achieve an identifiable goal” (Arnold & Boggs, the content is essential to the group’s work, it is the process that
2011, p. 525). Experts disagree on the ideal size of the group, becomes the real challenge for leaders as well as participants.
but it is usually somewhere from 6 to 10 members. A group Group development tends to follow a sequential pattern of
that is too small will limit diversity of opinion and put pres- growth and requires less leadership with time. Understanding
sure on members to participate. Overly large groups reduce this pattern is especially helpful to the leader in order to anticipate
the members’ ability to share, especially if some members distinct phases and provide guidance and interventions that are
dominate the group. most effective. Tuckman’s (1965) model of group development
Setting. Settings for groups are important. The room should has four stages: forming, storming, norming, and performing.
be private, and the seating should be comfortable and arranged A fifth stage, adjourning (mourning), was later added (Tuckman
so that people can see one another. Using tables is discour- & Jensen, 1977). These stages are comparable to human develop-
aged because they can be psychological barriers between group ment from infancy into old age, accompanied by varying levels
members. One of the worst arrangements for discussion is the of maturity, confidence, and need for direction (Table 3-6).
CHAPTER 3  Theories and Therapies 39


Forming Infancy The task and/or purpose of the group is defined. Connecting with others, desiring
acceptance, and avoiding conflict define early groups. Members gather common-
alities and differences as they attempt to know one another. The leader is the
main connection and necessary for direction.
Storming Adolescence Important issues are being addressed, and conflict begins to surface. Personal
relations may interfere with the task at hand. Some members will dominate, and
some will be silent. Rules and structure are helpful. Members may challenge the
role of the leader, who has the opportunity to model adaptive behavior.
Norming Early adulthood Members know one another, and rules of engagement (norms) are evident. There is
a sense of group identity and cohesion. Members resist change, which could lead
to a group breakup or a return to the discomfort of storming. Leadership is shared.
Performing Mature adulthood Groups who reach this stage are characterized by loyalty, flexibility, interdepen-
dence, and productivity. There is a balance between focus on work and focus on
the welfare of group members.
Adjourning Older adult years Groups in this stage are ready to disband, tasks are terminated, and relationships
(mourning) are disengaged. Accomplishments are recognized and members are pleased to
have been part of the group. A sense of loss is an inevitable consequence.
From Tuckman, B. W., & Jensen, M. A. (1977). Stages of small-group development revisited. Group & Organization Management, 2,

Roles of group members. Studies of group dynamics have their experiences. In a creative group such as an art or horticul-
identified informal roles of members that are necessary to develop ture group, the leader may choose a laissez-faire style, giving
a successful group. The most common descriptive categories for minimal direction to allow for a variety of responses.
these roles are task, maintenance, and individual roles (Benne Types of groups. Education groups form for the purpose of
& Sheats, 1948). Task roles serve to keep the group focused and imparting information and require active expert leadership and
attend to the business at hand. Maintenance roles function to keep careful planning. Task groups are typically time limited and
the group together and provide interpersonal support. There are have a common goal, and the role of the leader is to facilitate
also individual roles that can interfere with the group’s function- team building and cooperation. Support groups bring together
ing because they are not related to the group goals, but rather to people with common concerns and may be facilitated by a sup-
specific personalities. Table 3-7 describes roles of group members. portive leader or by group members. Therapy groups are led
Roles of the group leader. The group leader has multiple by professional group therapists whose styles may range from a
responsibilities in starting, maintaining, and terminating a directive and confrontational approach to a more hands-off, let
group. In the initial forming phase, the leader defines the struc- the group members learn from each other, approach.
ture, size, composition, purpose, and timing for the group. The
leader facilitates communication and ensures that meetings start Benefits of Group Therapy
and end on time. In the adjourning phase, the leader ensures that One of the commonly cited benefits of group therapy is that it
each member summarizes individual accomplishments and gives is more efficient, both pragmatically and financially, because
positive and negative feedback regarding the group experience. many people can engage in therapy at once. However, it is the
Leadership style depends on group type (Jacobs et al., nature of the interaction between people with common con-
2012). A leader selects the style that is best suited to the thera- cerns and frames of references that seems to provide the great-
peutic needs of a particular group. The autocratic leader exerts est benefit. Yalom (1985) identified 11 benefits, or curative
control over the group and does not encourage much inter- factors, of group membership (Table 3-8).
action among members. In contrast, the democratic leader
supports extensive group interaction in the process of prob- Roles of Nurses
lem solving. A laissez-faire leader allows the group members Psychiatric–mental health nurses are involved in a variety of
to behave in any way that they choose and does not attempt to therapeutic groups in acute care and long-term treatment
control the direction of the group. For example, staff leading settings. For all group leaders, a clear theoretical framework
a community meeting with a fixed, time-limited agenda may is necessary to provide a structure to understand the group
tend to be more autocratic. In a psychoeducational group, the interaction. Co-­leadership of groups is a common practice and
leader may be more democratic to encourage members to share has several benefits: it provides training for less experienced
40 UNIT 1  Essential Theoretical Concepts for Practice


Task Roles
Coordinator Connects various ideas and suggestions
Initiator-contributor Offers new ideas or a new outlook on an issue
Elaborator Gives examples and follows up meaning of ideas
Energizer Encourages group to make decisions or take action
Evaluator Measures group’s work against a standard
Information/opinion giver Shares opinions, especially to influence group values
Orienter Notes progress of the group toward goals

Maintenance Roles
Compromiser In a conflict, yields to preserve group harmony
Encourager Praises and seeks input from others; warm and accepting
Follower Attentive listener and integral to the group
Gatekeeper Ensures participation, encourages participation, points out commonality of thought
Harmonizer Mediates conflicts constructively among members
Standard setter Assesses explicit and implicit standards for group

Individual Roles
Aggressor Criticizes and attacks others’ ideas and feelings
Blocker Disagrees with group issues, opposes others, stalls the process
Help seeker Asks for sympathy of group excessively, self-deprecating
Playboy/playgirl Distracts others from the task; jokes, introduces irrelevant topics
Recognition seeker Seeks attention by boasting and discussing achievements
Monopolizer Dominates conversation, thereby preventing equal input
Special interest pleader Advocates for a special group, usually with own prejudice or bias
Data from Benne, K. D., & Sheats, F. (1948). Functional roles of group members. Journal of Social Issues, 4(2), 41.


Altruism Giving appropriate help “We’ve spent all this time talking about me. Lou needs to talk about
to other members his visit with his dad. Let’s focus on him.”
Cohesiveness Feeling connected to “People in our group always listen to each other. We’ve been polite
other members and since the first day.”
belonging to the group
Interpersonal Learning from other “Sammi said it takes 2 weeks for Prozac to really work. I should give
learning members it more time.”
Guidance Receiving help and “I’ve also had that feeling where I just had to have a drink, Don. Just
advice pick up the phone and call me next time it happens.”
Catharsis Releasing feelings and A new mother of twins begins to cry and says, “It sounds terrible,
emotions but sometimes I wish I’d never had children.”
Identification Modeling after member David notices that the leader projects confidence by speaking clearly,
or leader making good eye contact, and sitting up straight. David does the same.
Family reenactment Testing new behaviors “I learned to always smile and agree so Dad wouldn’t go off on me.
in a safe environment I don’t have to be cheery and I can speak my mind here.”
Self-understanding Gaining personal Dale realizes that his negativity has kept him from getting the friends
insights he wants.
Instillation of hope Feeling hopeful about “Sue has managed to stay sober for 2 years. I think I can do this.”
one’s life
Universality Feeling that one is not Aaron, a quiet group member finally comments, “My son has schizo-
alone phrenia, too, and it helps to hear that other people have the same
worries I do.”
Existential factors Coming to understand “I guess I’ve been obsessing about being a perfect housekeeper and
what life is about haven’t noticed that my children are growing up without me.”
From Yalom, I. D. (1985). The theory and practice of group psychotherapy. New York: Basic Books.
CHAPTER 3  Theories and Therapies 41

staff; it allows for immediate feedback between the leaders techniques that allow for deep disclosure, sharing, confronta-
after each session; and it gives two role models for teaching tion, and healing among participants.
communication skills to members.
Basic level registered nurses have biopsychosocial educa- Therapeutic Milieu
tional backgrounds and are ideally suited to teach a variety of A therapeutic milieu, or healthy environment, combined with
health subjects. Psychoeducational groups are established to teach a healthy social structure within an inpatient setting or struc-
about subjects. These groups may be time limited or may be sup- tured outpatient clinic is essential to supporting and treating
portive for long-term treatment. Generally, written handouts or those with mental illness. Within these small versions of soci-
audiovisual aids are used to focus on specific teaching points. The ety, people are safe to test new behaviors and increase their
following psychoeducational groups are commonly led by nurses: ability to interact adaptively within the outside community.
• M  edication education groups allow patients to hear the Community meetings usually include all patients and the
experiences of others who have taken medication and have treatment team. Functions include orienting new members
an opportunity to ask questions without the fear of being to the unit, encouraging patients to engage in treatment, and
judged and learning to take the medications correctly. evaluating the treatment program. Nursing staff are the larg-
• D  ual-diagnosis groups focus on co-occurring psychi- est group of providers and give valuable feedback to the team
atric illness and substance abuse. The registered nurse about group interactions. Goal-setting meetings may be con-
(RN) may co-lead this group with a dual-diagnosis spe- ducted in inpatient settings and partial hospitalization pro-
cialist (master’s level clinician). grams to plan daily goals for each patient.
• M  ultifamily groups have evidence-based support as an Other therapeutic milieu groups aim to help increase
effective method within the severely mentally ill popula- patients’ self-esteem, decrease social isolation, encourage appro-
tion (Lemmens et al., 2009). The focus is on education priate social behaviors, and educate patients in basic living
about the mental illness and strategies for the family to skills. These groups are often led by occupational or recreational
cope with long-term disability. therapists, although nurses frequently co-lead them. Examples
• S ymptom management groups are designed for patients of therapeutic milieu groups are recreational groups, physical
to share coping skills regarding a common problem, such activity groups, creative arts groups, and storytelling groups.
as anger or psychosis. Self-control is improved and relapse
is reduced by helping patients to develop a plan for action. Family Therapy
• S tress management groups teach members about vari- Family therapy developed around the mid-twentieth century as
ous relaxation techniques, including deep breathing, an adjunct to individual treatment and refers to the treatment
exercise, music, and spirituality. of the family as a whole. Family therapists use a variety of theo-
• S elf-care groups focus on basic hygiene issues such as retical philosophies to effect change in dysfunctional patterns
bathing and grooming. of behavior and interaction. Some therapists may focus on the
Advanced practice registered nurses (APRNs) may lead present, whereas others may rely more heavily on the family’s
any of the groups described earlier as well as psychotherapy history and reports of interactions between sessions. Terms
groups. Psychotherapy groups require specialized training in related to family therapy are listed in Box 3-2.


Boundaries: Clear boundaries maintain distinctions • 
Double bind: A double bind is a no-win situation in
between individuals within the family and between the which you are “darned if you do, darned if you don’t.”
family and the outside world. Clear boundaries allow for • 
Hierarchy: The function of power and its structures in
balanced flow of energy between members. Diffuse families, differentiating parental and sibling roles and
or enmeshed boundaries are those in which there is generational boundaries.
a blending of the roles, thoughts, and feelings of the • 
Differentiation: The ability to develop a strong identity
individuals so that clear distinctions among family mem- and sense of self while maintaining an emotional con-
bers fail to emerge. Rigid or disengaged boundaries nectedness with one’s family of origin.
are those in which the rules and roles are followed in • 
Sociocultural context: The framework for viewing the
spite of the consequences. family in terms of the influence of gender, race, ethnic-
Triangulation: The tendency, when two-person relation- ity, religion, economic class, and sexual orientation.
ships are stressful and unstable, to engage a third person • 
Multigenerational issues: The continuation and per-
to stabilize the system through formation of a coalition in sistence from generation to generation of certain emo-
which two members are pitted against the third. tional interactive family patterns (e.g., reenactment of
Scapegoating: A form of displacement in which a family fairly predictable patterns; repetition of themes or toxic
member (usually the least powerful) is blamed for another issues; and repetition of reciprocal patterns such as
family member’s distress. The purpose is to keep the focus those of overfunctioner and underfunctioner).
off the painful issues and the problems of the blamers.
42 UNIT 1  Essential Theoretical Concepts for Practice

Although different therapists may adhere to different theo- • T o heighten awareness and sensitivity to other family
ries and use a wide variety of methods, the goals of family ther- members’ emotional needs and help family members
apy are basically the same. These goals include the following meet their needs
(Nichols, 2009): • To strengthen the family’s ability to cope with major life
• To reduce dysfunctional behavior of individual family stressors and traumatic events, including chronic physi-
members cal or psychiatric illness
• To resolve or reduce intrafamily relationship conflicts • To improve integration of the family system into the
• To mobilize family resources and encourage adaptive societal system (e.g., school, medical facilities, workplace,
family problem-solving behaviors and especially the extended family)
• To improve family communication skills


• T heoretical models and therapeutic strategies provide a use- • T he biological model is currently the dominant model and
ful framework for the delivery of psychiatric nursing care. focuses on physical causation for personality problems and
• The psychoanalytic model is based on unconscious motiva- psychiatric disorders. Medication is the primary biological
tions and the dynamic interplay between the primitive brain therapy.
(id), the sense of self (ego), and the conscience (superego). • Developmental theories provide general guidelines for
The focus of psychoanalytic theory is on understanding the expected progression throughout the life span. Theories
unconscious mind. focus on stage-specific tasks, the attainment of a separate
• The interpersonal model maintains that the personality and sense of self, cognitive maturation, and moral maturity.
disorders are created by social forces and interpersonal expe- • A variety of nursing theories are useful to psychiatric nurs-
riences. Interpersonal therapy aims to provide positive and ing. Hildegard Peplau developed an important interper-
repairing interpersonal experiences. sonal theory for the provision of psychiatric nursing care.
• The behavioral model suggests that because behavior is • Group therapy offers the patient significant interpersonal
learned, behavioral therapy should improve behavior feedback from multiple people.
through rewards and reinforcement of adaptive behavior. • Groups transition through predictable stages, benefit from
• The humanist model is based on human potential, and ther- therapeutic factors, and are characterized by members fill-
apy is aimed at maximizing this potential. Maslow devel- ing specific roles.
oped a theory of personality that is based on the hierarchical • Family therapy is based on various theoretical models and
satisfaction of needs. Rogers’ person-centered theory uses aims to decrease emotional reactivity among family mem-
self-actualizing tendencies to promote growth and healing. bers and encourage differentiation among individual family
• The cognitive model posits that disorders, especially depres- members.
sion, are the result of faulty thinking. Cognitive behavioral
therapy is empirically supported and focuses on the recog-
nition of distorted thinking and the replacement with more
accurate and positive thoughts.

 A P P L Y I N G C R I T I C A L J U D G M E N T
1. H
 ow could the theorists discussed in this chapter impact D. Can you think of anyone who seems to be self-­actualized?
your nursing care? Specifically: What is your reason for this conclusion?
A. How do Freud’s concepts of the conscious, precon- E. How do you utilize Maslow’s hierarchy of needs in your
scious, and unconscious affect your understanding of nursing practice?
patients’ behaviors? F. What do you think about the behaviorist point of view
B. Can you remember a young patient whose development that to change behaviors is to change personality?
was impacted by illness? How can Erikson’s psychosocial 2. Which of the therapies described here do you think can be
stages be applied to this patient? the most helpful to you in your nursing practice? What are
C. What are the implications of Sullivan’s focus on the your reasons for this choice?
importance of interpersonal relationships for your
interactions with patients?
CHAPTER 3  Theories and Therapies 43


Choose the most appropriate answer(s). 3. A ccording to Maslow’s Hierarchy of Needs, the most basic
1. Which of the following contributions to modern psychiat- needs for psychiatric mental health nursing are:
ric nursing practice was made by Freud? 1. physiological.
1. The theory of personality structure and levels of
 2. safety.
awareness 3. love and belonging.
2. The concept of a “self-actualized personality” 4. self-actualization.
3. The thesis that culture and society exert significant
 4. The premise that an individual’s behavior and affect are
influence on personality largely determined by the attitudes and assumptions the
4. Provision of a developmental model that includes the person has developed about the world underlies:
entire life span 1. modeling.
2. The theory of interpersonal relationships developed by 2. milieu therapy.
Hildegard Peplau is based on the foundation provided by 3. cognitive behavioral therapy.
which of the following early theorists? 4. psychoanalytic psychotherapy.
1. Freud 5. Providing a safe environment for patients with impaired
2. Piaget cognition, referring an abused spouse to a “safe house,” and
3. Sullivan conducting a community meeting are nursing interventions
4. Maslow that address aspects of:
1. milieu therapy.
2. cognitive therapy.
3. behavioral therapy.
4. interpersonal psychotherapy.

REFERENCES Karisson, H. (2011). How psychotherapy changes the brain. Retrieved

January 6, 2012 from
Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and their article/10168/192-6705?printable= true.
work. Maryland Heights, MO: Mosby/Elsevier. King, I. M. (1981). A theory for nursing: systems, concepts, process. New
Arnold, E., & Boggs, K. U. (2011). Interpersonal relationships: profes- York: Wiley.
sional communication skills for nurses (6th ed.). St Louis: Saunders. Kohlberg, L., & Turiel, E. (1971). Moral development and moral edu-
Beck, A. T. (1963). Thinking and depression. Archives of General cation. In G. S. Lesser (Ed.), Psychology and educational practice.
Psychiatry, 9, 324–333. Glenview, IL: Scott Foresman.
Benne, K. D., & Sheats, F. (1948). Functional roles of group members. Leininger, M. (1995). Culture care theory, research, and practice.
Journal of Social Issues, 4(2), 41–49. Nursing Science Quarterly, 9(2), 71–78.
Black, D. W., & Andreasen, N. C. (2011). Introductory textbook of psychia- Lemmens, G., Eisler, E., Lietaer, G., & Demyttenaere, K. (2009).
try (5th ed.). Washington, DC: American Psychiatric Publishing, Inc. Therapeutic factors in a systemic multi-family group treatment for
Boeree, C. G. (2006). Personality theories: Carl Rogers. Retrieved April major depression: patients’ and partners’ perspectives. Journal of
11, 2011 from Family Therapy, 31(3), 250–269.
Caldwell, B. A., Sclafani, M., Swarbrick, M., & Piren, K. (2010). Psy- Mahler, M. S., Pine, F., & Bergman, A. (1975). The psychological birth
chiatric nursing practice and the recovery model of care. Journal of of the human infant. New York: Basic Books.
Psychosocial Nursing, 48(7), 42–48. Maslow, A. H. (1970). Motivation and personality (2nd ed.). New
Crain, W. C. (1985). Theories of development (2nd ed.). Englewood York: Harper and Row.
Cliffs, NJ: Prentice Hall. Nichols, M. P. (2009). Family therapy: concepts and methods (9th ed.).
Erikson, E. (1963). Childhood and society. New York: Norton. Upper Saddle River, NJ: Prentice Hall.
Freud, S. (1961). The ego and id. In J. Strachey (Ed. and Trans.), The Orem, D. E. (2001). Nursing: concepts of practice (6th ed.). St Louis:
standard edition of the complete psychological works of Sigmund Mosby.
Freud (vol. 19, pp. 3–66). London: Hogarth Press. (Original work Orlando, I. J. (1990). The dynamic nurse-patient relationship: function,
published 1923.). process, and principles. (Pub. No. 15–2341), New York: National
Gilligan, C. (1982). In a different voice: psychological theory and League for Nursing.
women’s development. Cambridge: Harvard University Press. Pavlov, I. P. (1927). Conditioned reflexes. London: Routledge and
Hanrahan, N. P., Delaney, K. R., & Stuart, G. W. (2011). Blueprint Kegan Paul.
for the development of the psychiatric nurse workforce. Nursing Peplau, H. E. (1992). Interpersonal relations in nursing. New York:
Outlook. doi:10.1016/j.outlook.2011.04.007. Putnam.
Jacobs, E. E., Masson, R. L., Harvill, R. L., & Schimmel, C. J. (2012). Peplau, H. E. (1952). Interpersonal relations in nursing: a conceptual
Group counseling: strategies and skills (7th ed.). Pacific Grove, CA: frame of reference for psychodynamic nursing. New York: Putnam.
Brooks/Cole. Piaget, J., & Inhelder, B. (1969). The psychology of a child. New York:
Johnson, D. E. (1980). The behavioral system model for nursing. In Basic Books.
J. P. Riehl, & C. Roy (Eds.), Conceptual models for nursing practice Rogers, C. R. (1986). Carl Rogers on the development of the person-
(2nd ed). New York: Appleton-Century-Crofts. centered approach. Person-Centered Review, 1(3), 257–259.
44 UNIT 1  Essential Theoretical Concepts for Practice

Sadock, B. J., & Sadock, V. A. (2008). Concise textbook of clinical Tuckman, B. W., & Jensen, M. A. (1977). Stages of small-group
psychiatry (3rd ed.). Philadelphia: Lippincott. development revisited. Group & Organization Management, 2,
Skinner, B. F. (1938). The behavior of organisms. New York: 419–427.
Appleton-Century-Crofts. Watson, J. (2007). Watson Caring Science Institute. Retrieved April 13,
Smith, L. (1997). Jean Piaget. In N. Sheehy, A. Chapman, & W. Conroy 2011, from
(Eds.), Biographical dictionary of psychology. London: Routledge. index.html.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: Watson, J. B. (1930). Behaviorism (rev. ed.). Chicago: University of
Norton. Chicago Press.
Tuckman, B. W. (1965). Developmental sequence in small groups. Yalom, I. D. (1985). The theory and practice of group psychotherapy.
Psychological Bulletin, 63, 384–399. New York: Basic Books.

Biological Basis for Understanding
Dorothy A. Varchol

  For additional DSM-5 criteria content, see Appendix C


acetylcholine, p. 50 neurons, p. 46
agonist, p. 51 neurotransmission, p. 49
agranulocytosis, p. 62 neurotransmitter, p. 50
Pharmacology and genetics have merged
antagonist, p. 51 pharmacodynamic
into a new field called pharmacogenetics.
antianxiety or anxiolytic drugs, p. 47 interactions, p. 57
Genetic factors play a role in how indi-
basal ganglia, p. 47 pharmacokinetic
viduals respond to drugs (if it works on
circadian rhythms, p. 49 interactions, p. 56
them or not) and the side effects experi-
extrapyramidal symptoms plasticity, p. 46
enced (toxicity or tolerates well). How a
(EPS), p. 48 psychoneuroimmunology
drug is used in the body is determined by
first-generation agents (FGA)/con- (PNI), p. 63
genetically mediated patterns of protein
ventional antipsychotic agents, psychotropic, p. 46
structures, receptor sensitivities, enzyme
p. 61 receptors, p. 50
activity, and drug metabolism. These dif-
γ-aminobutyric acid (GABA), p. 50 reticular activating system
ferences are present not just through
hypnotic, p. 60 (RAS), p. 48
individual genetic factors, but are greatly
limbic system, p. 47 reuptake, p. 50
determined by ethnic associations as well.
lithium, p. 60 second-generation antipsychotic
Psychogenetics may one day lead to per-
monoamines, p. 57 agents (SGA)/atypical antipsy-
sonalized medications, safer drugs, and
monoamine oxidase (MAO), p. 57 chotic agents, p. 62
targeted pharmacological therapies deter-
monoamine oxidase inhibitors selective serotonin reuptake
mined by genetically inherited factors.
(MAOIs), p. 57 ­inhibitors (SSRIs), p. 57 (Preston et al., 2010)
mood stabilizing drugs, p. 61 synapse, p. 50
neuroimaging, p. 49 therapeutic index, p. 60

46 UNIT 1  Essential Theoretical Concepts for Practice

1. Identify at least three major brain structures and eight 5. Explain the relevance of psychodynamic and psychokinetic
major brain functions that can be altered by mental illness drug interactions in the delivery of safe, effective nursing
and psychotropic medications. care.
2. Describe how neuroimaging techniques can be helpful in 6. Discuss the rationale for special dietary and drug restric-
understanding mental illness. tions with monoamine oxidase inhibitors (MAOIs).
3. Explain the basic process of neurotransmission and synap- 7. Compare and contrast the side effect profiles of conven-
tic transmission using Figures 4-5, 4-6, and 4-7. tional antipsychotic drugs with the side effect profiles of
4. Identify the main neurotransmitters affected by the follow- atypical antipsychotic drugs.
ing psychotropic drugs and their subgroups: 8. Discuss the relationship between the immune system and
a. Antidepressants the nervous system in mental health and mental illness.
b. Antianxiety agents 9. Describe how genes and culture affect an individual’s
c. Sedative-hypnotics response to psychotropic medication.
d. Mood stabilizers
e. Antipsychotic agents
f. Anticholinesterase drugs

Whether conscious or unconscious, all mental activ- Cerebrum

ity has its locus in the brain. A primary goal of psychiatric The cerebrum consists of surface and deep areas of integrat-
mental health nursing is to understand the biological basis ing gray matter (the cerebral cortex and basal ganglia) as well
of both normal and abnormal brain function and apply as connecting tracts of white matter that link these areas with
this understanding to the care of individuals treated with each other and the rest of the nervous system. The gray matter
drugs referred to as psychotropic. Because all brain func- consists predominantly of neuronal cell bodies, dendrites, and
tions are carried out by similar mechanisms (interactions of glial cells whereas the white matter is composed of myelinated
neurons), often in similar locations, it is not surprising that nerve fibers (axons).
mental disturbances are frequently associated with altera- Progressive loss of both gray and white matter has been asso-
tions in other brain functions and that the drugs used to ciated with schizophrenia as well as use of antipsychotic medi-
treat mental disturbances can also interfere with other activ- cation (Ho et al., 2011), but it is not known whether volume
ities of the brain. Box 4-1 summarizes some of the major loss is necessarily harmful because eliminating dysfunctional or
brain functions. transformed cells may actually contribute to preserving brain
function. Plasticity is evident throughout life as gray matter
shrinks or thickens and synaptic connections are pruned or
BRAIN STRUCTURES AND FUNCTIONS forged, especially in areas where learning and memory occur.
For the brain to perform its many and varied activities, each Each hemisphere of the cerebral cortex is divided into four
part must act both independently and in concert with other lobes (Figure 4-1) that control sensory and motor function as
regions. well as higher mental activities (e.g., language, decision making,
problem solving, and a conscious sense of being). Sensory areas
are responsible for specific sensations: the parietal for touch,
BOX 4-1 FUNCTIONS OF THE BRAIN temporal for sound, and occipital for vision. Motor areas in
• Monitor changes in the external world. the frontal lobes control voluntary movement. The prefron-
• Monitor the composition of body fluids. tal cortex (PFC) coordinates complex cognitive functions and
• Regulate the contractions of the skeletal muscles. enables us to plan and execute goals (Fuster, 2008). When cir-
• Regulate the internal organs. cuitry in the PFC is impaired by a mental disorder (e.g., schizo-
• Initiate and regulate the basic drives: hunger, thirst, phrenia, major depression, or alcohol intoxication), there is
sex, aggressive self-protection. a decrease in executive function, attention, impulse control,
• Mediate conscious sensation. socialization, regulation of drives (such as libido), and emo-
• Store and retrieve memories. tions. Drugs targeting specific molecules within PFC circuits
• Regulate mood (affect) and emotions. are being developed to normalize disrupted PFC activity.
• Think and perform intellectual functions. In addition to the gray matter forming the cortex, there
• Regulate the sleep cycle. are pockets of integrating gray matter lying deep within the
• Produce and interpret language. cerebrum: the hippocampus, the amygdala, and the basal gan-
• Process visual and auditory data. glia. The hippocampus interacts with the PFC in making new
memories. The amygdala plays a major role in processing fear
CHAPTER 4  Biological Basis for Understanding Psychopharmacology 47

Cerebral cortex Sensory and Motor
(gray matter) Receive and identify
White matter sensory information
Concept formation
and abstraction
Proprioception and
body awareness
Reading, mathematics
Right and left orientation





Thought Processes
Formulate or select goals
Initiate, plan, terminate
Insight Auditory Vision
Social judgment Language comprehension Interprets visual images
Voluntary motor ability Stores sounds into memory Visual association
starts in frontal lobe (language, speech) Visual memories
Connects with limbic Involved with
system, “the emotional language formation
brain,” to allow expression
of emotions (sexual,
aggressive, fear, etc.)
FIGURE 4-1  Functions of the cerebral lobes: frontal, parietal, temporal, and occipital.

and anxiety. The hippocampus and amygdala, along with the Subcortical Structures
hypothalamus and thalamus, are part of a circle of structures Basal Ganglia
called the limbic system or “emotional brain.” Linking the The four subcortical basal ganglia that lie deep within the cere-
frontal cortex, basal ganglia, and upper brainstem, the limbic brum are the striatum, the pallidum, the substantia nigra, and
system mediates thought and feeling through complex, bidi- the subthalamic nucleus. This group of gray matter nuclei plays
rectional connections. Antianxiety drugs (anxiolytics) slow a major role in motor responses via the extrapyramidal motor
the limbic system. system, which relies on the neurotransmitter dopamine to
48 UNIT 1  Essential Theoretical Concepts for Practice


Pupillary reflex and
eye movement

Major processing station in
auditory pathways Regulates skeletal muscle
coordination and
MEDULLA OBLONGATA Maintains equilibrium
Reflex centers control:
Heart rate
Rate and depth of respirations
Coughing, swallowing, sneezing
Maintenance of blood pressure
FIGURE 4-2  Functions of the brainstem and cerebellum.

maintain proper muscle tone and motor stability. Neuroimag- breathing—and the muscles of the throat, tongue, and mouth—
ing has recently shown that the antipsychotic agent haloperidol essential for speech. Thus drugs that affect brain function can
can reduce striatal volume within hours, temporarily changing stimulate or depress respiration or affect speech patterns (e.g.,
brain structure and predicting abnormal involuntary motor slurred speech).
symptoms (extrapyramidal symptoms [EPS]) with high pre-
cision (Tost et al., 2010). In the basal ganglia, two types of Brainstem
movement disturbances may occur: (1) acute extrapyramid­al Basic vital life functions occur through the brainstem, com-
symptoms, which develop early in treatment; and (2) tardive posed of the midbrain, pons, and medulla (Figure 4-2).
dyskinesia, which usually occurs much later. Conventional Through projections called the reticular activating sys-
antipsychotics (the first generation of antipsychotic medica- tem (RAS), the brainstem sets the level of consciousness and
tions) and high doses of the atypical agent (second generation regulates the cycle of sleep and wakefulness. Unfortunately,
of antipsychotic medications) risperidone (Risperdal) are most drugs used to treat psychiatric problems may interfere with
likely to cause extrapyramidal side effects. the regulation of sleep and alertness, thus the warning to
It is important to remember that movement is regulated take sedating drugs at bedtime and to use caution while
by the basal ganglia, including the diaphragm—essential for driving.
CHAPTER 4  Biological Basis for Understanding Psychopharmacology 49

(milk flow), gynecomastia (development of breast tissue), or

Cerebellum sexual dysfunction. Among antipsychotics, conventional agents
Located behind the brainstem, the cerebellum (see Figure 4-2) and the atypical drug risperidone are the most frequent and seri-
is mainly a coordinator of motor function. However, it also ous offenders whereas most atypical antipsychotics are prolactin
interacts with the cerebrum in higher cognitive functions such sparing (Madhusoodanan et al., 2010).
as speech memory, facial recognition, visual attention, and In addition to working with the endocrine system, the hypo-
awareness (Andreasen & Pierson, 2008; Baier et al., 2010). Cer- thalamus sends instructions to the autonomic nervous system,
ebellar hypoactivation affecting posture and equilibrium is well-­ divided into the sympathetic and parasympathetic systems
documented as occurring in some people with schizophrenia, but (Figure 4-3). The sympathetic system usually increases heart rate,
the role of the cerebellum in cognition is still under investigation respirations, and blood pressure to prepare for fight or flight,
(Picard et al., 2008). whereas the parasympathetic system slows the heart rate and
begins the process of digestion. The sympathetic system is highly
Thalamus activated by sympathomimetic drugs, such as amphetamine and
Located above the brainstem, the thalamus serves as a major cocaine, as well as by withdrawal from sedating drugs, such as
relay station for sensory impulses on their way to the cerebral alcohol, benzodiazepines, and opioids (Sadock & Sadock, 2007).
cortex. Dopamine reduces the thalamic sensory filter, allowing
more sensory input to escape from the thalamus to the cortex Visualizing the Brain
(Stahl & Muntner, 2008). Corticostriatal-thalamic pathways Neuroimaging visualizes a brain that is structurally and function-
are disrupted in schizophrenia, obsessive-compulsive disorder ally interconnected. Some common brain imaging techniques
(OCD), and attention deficit/hyperactivity disorder (ADHD). measuring structure and function are identified in Table 4-1.
The thalamus also plays a role in complex reflex movements, Structural imaging techniques are computed tomography (CT)
body-alerting mechanisms, and even emotions by associating and magnetic resonance imaging (MRI). CT scans use a series of
sensory impulses with various feelings (Patton et al., 2012). x-rays to view brain structure and have been largely supplanted
Current researchers are studying the role of the thalamus in by MRI scans, which use a strong magnetic field and radio waves,
bipolar I disorder and changes in thalamic volume that occur distinguishing gray and white matter better than CT scans.
with lithium treatment (Radenbach et al., 2010). Functional neuroimaging with positron emission tomog-
raphy (PET) and single photon emission computed tomogra-
Hypothalamus phy (SPECT) use ionizing radiation to localize brain regions
The hypothalamus maintains homeostasis. It regulates tem- associated with perceptual, cognitive, emotional, and behav-
perature, blood pressure, perspiration, libido, hunger, thirst, ioral functions. Based on the increase in blood flow to the local
and circadian rhythms, such as sleep and wakefulness. Hypo- vasculature that accompanies neural activity, PET scans have
thalamic neurohormones, often called releasing hormones, provided evidence of decreased metabolism in unmedicated
direct the secretion of hormones from the anterior pituitary individuals with depression or schizophrenia and increased
gland. For example, corticotropin-releasing hormone (CRH) metabolism in obsessive-compulsive disorder (Figure 4-4).
is involved in the stress response. It stimulates the pituitary to PET and SPECT have also shown dopamine system dysregula-
release corticotropin, which in turn stimulates the cortex of tion in schizophrenia and loss of monoamines in depression.
each adrenal gland to secrete cortisol. This system is disrupted Functional magnetic resonance imaging (fMRI) demon-
in mood disorders, posttraumatic stress disorder (PTSD), and strates cognitive function without contrast injections or invasive
Alzheimer’s dementia, but abnormalities in the system may tests. It is the major method used by cognitive neuroscientists
someday be reversed by CRH antagonists (Beyer & Stahl, 2010). to observe changes that occur in various parts of the brain
The hypothalamic-pituitary-thyroid axis is involved in the while subjects perform tasks involving higher intellectual pro-
regulation of nearly every organ system because all major hor- cesses such as memory or attention. In addition, fMRI maps
mones and catecholamines (e.g., cortisol, gonadal hormones, the modulatory effects of psychotropic medication, illustrating
insulin) depend on thyroid status. Release of thyrotropin- how a therapeutic response can be achieved at minimal doses.
releasing hormone (TRH) results in pituitary secretion of Antipsychotic medications are now prescribed at a fraction of
thyrotropin (thyroid-stimulating hormone or TSH), which in the dosages that were once considered standard, in large part
turn stimulates the thyroid gland to release the thyroid hor- because of imaging studies.
mones—thyroxine (T4) and triiodothyronine (T3). Thyroid
hormones are used to treat people with depression or rapid- CELLULAR COMPOSITION OF THE BRAIN
cycling bipolar I disorder. They are also used as replacement
therapy for people who develop a hypothyroid state from lith- Neurons
ium treatment (Sadock & Sadock, 2007). The brain is composed of a vast network of more than 100 billion
The hypothalamic neurohormone dopamine inhibits the interconnected nerve cells (neurons) and the supporting cells
release of prolactin. When excess dopamine is blocked by con- that surround these neurons. An essential feature of neurons is
ventional antipsychotic drugs, blood prolactin levels increase their ability to initiate signals and conduct an electrical impulse
(hyperprolactinemia) with subsequent amenorrhea, galactorrhea from one end of the cell to the other called neurotransmission
50 UNIT 1  Essential Theoretical Concepts for Practice


Pupil Pupil
Lacrimal gland Lacrimal gland

Salivary flow Salivary flow

Heart Heart
Arterioles T-1 T-1 Arterioles
2 2
3 3
Bronchi 4 4 Bronchi
5 5
6 6
7 7
Stomach motility 8 8 Stomach motility
and secretion 9 9 and secretion
10 10
Pancreas 11 11 Pancreas
12 12
L-1 L-1
2 2 Epinephrine
3 3
4 4
Intestinal motility 5 5 Intestinal motility
S-1 S-1
2 2
3 3
4 4

Bladder contraction Bladder wall

FIGURE 4-3 Autonomic nervous system has two divisions: sympathetic and parasympa-
thetic. The sympathetic division is dominant in stress situations, such as fear and anger—
known as the fight-or-flight response.

(Figure 4-5). Electrical signals within neurons are then con- and is destroyed. Some transmitters (e.g., acetylcholine) are
verted at synapses into chemical signals through the release of destroyed by specific enzymes (e.g., acetylcholinesterase) at the
molecules called neurotransmitters, which then elicit electri- postsynaptic cell. In the case of monoamine transmitters (e.g.,
cal signals on the other side of the synapse. Together, these two norepinephrine, dopamine, serotonin), the destructive enzyme
signaling mechanisms (action potentials and synaptic signals) is monoamine oxidase (MAO).
enable information processing in the brain. Other transmitters (e.g., norepinephrine) are taken back into
the cell from which they were originally released by a process
Synaptic Transmission called cellular reuptake. On return to these cells, the transmit-
Once an electrical impulse reaches the end of a neuron, the ters are either reused or destroyed by intracellular enzymes. The
neurotransmitter is released from the axon terminal at the pre- two basic mechanisms of destruction are described in Box 4-2.
synaptic neuron. This transmitter then diffuses across a narrow
space, or synapse, to an adjacent postsynaptic neuron, where it Neurotransmitters
attaches to specialized receptors on the cell surface and either A neurotransmitter is a chemical messenger between neurons
inhibits or excites the postsynaptic neuron. It is the interaction by which one neuron triggers another. Four major groups of
between neurotransmitter and receptor that is a major target neurotransmitters in the brain are monoamines (biogenic
of psychotropic drugs. Figure 4-6 shows how an insufficient amines), amino acids, peptides, and cholinergics (e.g., acetyl-
degree of transmission may be caused by a deficient release of choline). Monoamine neurotransmitters (dopamine, norepi-
neurotransmitters from the presynaptic cell or by a decrease nephrine, serotonin) and acetylcholine are implicated in a
in receptors. Figure 4-7 illustrates how excessive transmission variety of neuropsychiatric disorders.
may be due to excessive release of a transmitter or to increased Amino acid neurotransmitters, such as the inhibitory
receptor responsiveness, as occurs in schizophrenia. γ-aminobutyric acid (GABA) and the excitatory glutamate, bal-
After attaching to a receptor and exerting its influence on the ance brain activity. Peptide neurotransmitters such as hypotha-
postsynaptic cell, the transmitter separates from the receptor lamic CRH can be thought of as modulating or adjusting general
CHAPTER 4  Biological Basis for Understanding Psychopharmacology 51


Structural: Show Gross Anatomical Details of Brain Structures
Computed Series of x-ray images are taken Can detect lesions, abrasions, Schizophrenia
tomography of brain, and computer analysis areas of infarct, aneurysm Gray matter reduction
(CT) produces “slices,” providing a Ventricle abnormalities
3D-like reconstruction of each
Magnetic Uses a magnetic field and radio Used to exclude neurological Schizophrenia
resonance waves to produce cross- disorders in those presenting Same as CT (but higher
imaging (MRI) sectional images with mental illness resolution)
Functional Relies on magnetic properties Can detect edema, ischemia,
magnetic to see images of blood flow infection, neoplasm, trauma
­resonance in brain as it occurs; avoids Detects blood flow to
imaging (fMRI) ­exposure to radioactive isotypes ­functionally active brain regions

Functional: Show Some Activity of the Brain

Positron Radioactive substance is injected, Can detect oxygen utilization, Schizophrenia
emission travels to brain, and appears glucose metabolism, blood Decreased metabolic
tomography as bright spots on scan; data flow, neurotransmitter receptor activity in frontal lobes
(PET) collected by detectors are interaction Dopamine system dys­
relayed to a computer, which regulation
produces images of activity and Blockade of dopamine
3D visualization of CNS ­receptors with antipsy-
chotic medications
Blockade of serotonin
­transporter receptors with
antidepressant medications
Alzheimer’s disease
Reduction in nicotinic recep-
tor subtype
Single photon Similar to PET but uses γ-radiation Similar to PET See PET
emission (photons)
computed SPECT is less costly, but
tomography resolution is poorer

brain function. Table 4-2 lists important neurotransmitters, Dopamine

types of receptors to which they attach, and mental disorders that The monoamine dopamine is an important neurotransmitter
are associated with an increase or decrease in neurotransmitters. that is involved in cognition, motivation, and movement. It
controls emotional responses and the brain’s reward and plea-
Interaction of Neurons, Neurotransmitters, sure centers, stimulates the heart, and increases blood flow to
and Receptors vital organs.
Most psychotropic drugs produce effects through alteration of Drugs such as cocaine interfere with the reuptake of dopa-
synaptic concentrations of dopamine, acetylcholine, norepi- mine, thereby allowing more of the neurotransmitter to stay
nephrine, serotonin, histamine, GABA, or glutamate. These active in the synapse for a longer time. The dopamine hypoth-
changes are thought to result from activation of receptor antag- esis of schizophrenia originated from the observation that
onists (blocking activity of a neurotransmitter) or agonists drugs (e.g., amphetamines) that stimulate dopamine activ-
(promoting activity of a neurotransmitter), interference with ity can induce psychotic symptoms whereas drugs that block
neurotransmitter reuptake, enhancement of neurotransmitter dopamine receptors (e.g., haloperidol) have antipsychotic
release, or inhibition of enzymes. activity.
52 UNIT 1  Essential Theoretical Concepts for Practice

Obsessive-Compulsive Disorder

High Orbital Glucose Metabolism

Normal Obsessive-
Control Compulsive

UCLA School of Medicine

FIGURE 4-4  Positron emission tomographic scans show increased brain metabolism (brighter
colors), particularly in the frontal cortex, in a patient with obsessive-compulsive disorder
(OCD), compared with a normal control. This suggests altered brain function in OCD. (From
Lewis Baxter, MD, University of Alabama, courtesy National Institute of Mental Health.)

Presynaptic cell Synapse Postsynaptic cell


K+ K+ K+ K+

Na+ Na+ Na+ Na+

Depolarization Transmitter

FIGURE 4-5  Activities of neurons. Conduction along a neuron involves the inward movement
of sodium ions (Na+) followed by the outward movement of potassium ions (K+). When the
current reaches the end of the cell, a neurotransmitter is released. The transmitter crosses
the synapse and attaches to a receptor on the postsynaptic cell. The attachment of transmit-
ter to receptor either stimulates or inhibits the postsynaptic cell.

Acetylcholine of neurons that secrete acetylcholine by use of drugs that

Dopamine is balanced by the neurotransmitter acetylcholine. inhibit the enzyme that degrades acetylcholine (i.e., acetylcho-
Neurons that release acetylcholine are said to be cholinergic linesterase). Therefore acetylcholinesterase (AChE) inhibitors
and are thought to be involved in cognitive functions, espe- such as donepezil (Aricept), galantamine (Razadyne), and riv-
cially memory. Because acetylcholine is deficient in Alzheim- astigmine (Exelon) are prescribed to delay cognitive decline in
er’s disease, attempts have been made to enhance the function Alzheimer’s disease.
CHAPTER 4  Biological Basis for Understanding Psychopharmacology 53

Norepinephrine Receptor

A Normal

B Deficient neurotransmitter

C Deficient receptor
FIGURE 4-6  Normal transmission of neurotransmitters (A). Deficiency in transmission may
be caused by a deficient release of transmitter, as shown in B, or by a reduction in receptors,
as shown in C.

Although all acetylcholine receptors respond to acetyl- pressure, or orthostatic hypotension. The α1 receptors are also
choline, they also respond to other molecules. For example, found on the vas deferens and are responsible for the pro-
nicotinic acetylcholine receptors are particularly responsive pulsive contractions leading to ejaculation. Blockage of these
to nicotine, a cholinergic receptor agonist. It is well-known receptors can lead to a failure to ejaculate.
that people with schizophrenia and attention problems are
more likely to smoke, perhaps as a way of unconsciously self-­ Serotonin
medicating. Because these individuals are also more likely to The monoamine serotonin, found in the brain and spinal cord,
suffer adverse effects, scientists are trying to develop drugs that helps regulate mood, arousal, attention, behavior, and body
target the nicotine receptors without the carcinogenic, cardio- temperature. When some antidepressants are combined with
vascular, and addictive effects. other drugs or supplements that increase serotonin production
(e.g., St. John’s wort or over-the-counter cough and cold medi-
Norepinephrine cations containing dextromethorphan), the serotonin syn-
Neurons that release the monoamine norepinephrine (NE) are drome may occur. Symptoms of high levels of serotonin range
called noradrenergic. NE and serotonin play a major role in from mild (restlessness, shivering, and diarrhea) to severe
regulating mood. A deficiency of one or both of these mono- (muscle rigidity, fever, and seizures). These symptoms can be
amines within the limbic system is thought to underlie depres- alleviated by muscle relaxants and drugs that block serotonin
sion, whereas an excess has been associated with mania. Many production. Current research focuses on serotonin dysfunction
of the standard first-generation antipsychotic drugs act as in impulsive aggression and suicide (Cardish, 2007).
antagonists at the α1 receptors for NE. Blockage of these recep- Serotonin release by platelets plays an important role in
tors can cause vasodilation and a consequent drop in blood hemostasis. Drugs with the highest degree of serotonin reuptake
54 UNIT 1  Essential Theoretical Concepts for Practice

Dopamine Dopamine receptor

A Normal

B Excess neurotransmitter

C Excess receptors
FIGURE 4-7  Causes of excess transmission of neurotransmitters. Excess transmission may
be caused by excess release of transmitter, as shown in B, or excess responsiveness of
receptors, as shown in C.


A full explanation of the various ways in which psycho- receptor, the transmitter is released and taken back into
tropic drugs alter neuronal activity requires a brief review the presynaptic cell, the cell from which it was released.
of the manner in which neurotransmitters are destroyed This process, referred to as the reuptake of neurotrans-
after attaching to the receptors. To avoid continuous and mitter, is a common target for drug action. Once inside
prolonged action on the postsynaptic cell, the neurotrans- the presynaptic cell, the transmitter is either recycled
mitter is released shortly after attaching to the postsynap- or inactivated by an enzyme within the cell. The mono-
tic receptor. Once released, the transmitter is destroyed in amine neurotransmitters norepinephrine, dopamine, and
one of two ways. serotonin are all inactivated in this manner by the enzyme
One way is the immediate inactivation of the transmitter monoamine oxidase.
at the postsynaptic membrane. An example of this method In looking at this second method, one might naturally
of destruction is the action of the enzyme acetylcholines- ask what prevents the enzyme from destroying the
terase on the neurotransmitter acetylcholine. Acetylcho- transmitter before its release. The answer is that before
linesterase is present at the postsynaptic membrane and release the transmitter is stored within a membrane
destroys acetylcholine shortly after it attaches to nicotinic and is thus protected from the degradative enzyme.
or muscarinic receptors on the postsynaptic cell. After release and reuptake, the transmitter is either
A second method of neurotransmitter inactivation is a lit- destroyed by the enzyme or reenters the membrane to
tle more complex. After interacting with the postsynaptic be reused.
CHAPTER 4  Biological Basis for Understanding Psychopharmacology 55


Dopamine (DA) D1, D2, D3, D4, D5 Fine muscle movement Increase:
Integration of emotions and thoughts Schizophrenia
Decision making Mania
Stimulates hypothalamus to release Decrease:
hormones (sex, thyroid, adrenal) Parkinson’s disease
Norepinephrine (NE) α1, α2, β1, β2 Mood Increase:
(noradrenaline) Attention and arousal Mania
Stimulates sympathetic branch of autonomic Anxiety
nervous system for “fight or flight” in Schizophrenia
response to stress Decrease:
Serotonin (5-HT) 5-HT, 5-HT2, 5-HT3, Mood Increase:
5-HT4 Sleep regulation Anxiety states
Hunger Decrease:
Pain perception Depression
Aggression and libido
Hormonal activity
Histamine H1, H2 Alertness Decrease:
Inflammatory response Sedation
Stimulates gastric secretion Weight gain

Amino Acids
γ-Aminobutyric acid GABAA, GABAB Inhibitory neurotransmitter: Increase:
(GABA) Reduces anxiety, excitation, aggression Reduction of anxiety
May play a role in pain perception Decrease:
Anticonvulsant and muscle-relaxing Mania
properties Anxiety
May impair cognition and psychomotor Schizophrenia
Glutamate NMDA, AMPA Excitatory neurotransmitter: Increase NMDA:
AMPA plays a role in learning Prolonged increase can kill
and memory neurons (neurotoxicity)
Neurodegeneration in
­Alzheimer’s disease
Decrease NMDA:
Increase AMPA:
Improvement of ­cognitive
performance in
­behavioral tasks

Acetylcholine (ACh) Nicotinic, muscarinic Plays a role in learning, memory Decrease:
(M1, M2, M3) Regulates mood: mania, sexual aggression Alzheimer’s disease
Affects sexual and aggressive behavior Huntington’s chorea
Stimulates parasympathetic nervous Parkinson’s disease
system Increase:
56 UNIT 1  Essential Theoretical Concepts for Practice


Peptides (Neuromodulators)
Substance P (SP) SP Centrally active SP antagonist has Involved in regulation
­antidepressant and antianxiety effects of mood and anxiety
in depression Role in pain management
Promotes and reinforces memory
Enhances sensitivity to pain receptors to
Somatostatin (SRIF) SRIF Altered levels associated with ­cognitive Decrease:
disease Alzheimer’s disease
Decreased levels of
SRIF in spinal fluid
of some depressed
Huntington’s chorea
Neurotensin (NT) NT Endogenous antipsychotic-like properties Decreased levels in spinal
fluid of schizophrenic
AMPA, α-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid; NMDA, N-methyl-d-aspartate; SRIF, somatotropin release-inhibiting factor.

inhibition—fluoxetine, paroxetine, and sertraline—are more Glutamate

frequently associated with altered anticoagulant effects; thus Glutamate is a potent excitability neurotransmitter that acti-
concomitant use of nonsteroidal anti-inflammatory drugs vates N-methyl-d-aspartate (NMDA) receptors. High con-
(NSAIDs), aspirin, warfarin, or other drugs that affect coagula- centrations of glutamate or overly sensitive receptors can lead
tion potentiates the risk of bleeding. to overstimulation and cell death, as occurs in neurodegen-
erative conditions such as Alzheimer’s disease. As a corollary,
Histamine NMDA receptor antagonists, such as the drug memantine,
Many standard antipsychotic agents, as well as a variety of decrease excitability and neurotoxicity. In schizophrenia it is
other psychiatric drugs, block the H1 receptors for hista- theorized that glutamate excitotoxicity may occur early in the
mine. Two significant side effects of blocking these receptors illness and NMDA receptor hypoactivation later, resulting in
are sedation and substantial weight gain. Sedation may be psychotic symptoms comparable to those seen with NMDA
beneficial in severely agitated patients, but weight gain can antagonists, phencyclidine (PCP), and ketamine. Both NMDA
lead to disturbances in glucose and lipid metabolism and and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid
insulin resistance. (AMPA) receptors are binding sites for glutamate, and the
interplay of the two receptors is being explored in developing
γ-Aminobutyric Acid (GABA) ketamine-like drugs to rapidly reverse depressive symptoms
The major inhibitory neurotransmitter γ-aminobutyric acid (Li et al., 2010).
(GABA) modulates neuronal excitability and is associated
with the regulation of anxiety. Most antianxiety (anxiolytic)
drugs act by increasing the effectiveness of this transmitter,
primarily by increasing receptor responsiveness. Combining Psychotropic drugs work by mechanisms not yet fully under-
selective serotonin reuptake inhibitors (SSRIs) and antipsy- stood, and understanding their action has become more chal-
chotics produces changes in GABAA receptors and related lenging when drug interactions alter or modify their effects.
signaling systems that differ from the effects of either drug Pharmacokinetic interactions are the effects of drugs on the
administered alone. This synergism significantly improves plasma concentrations of each other. These interactions involve
negative symptoms in patients unresponsive to antipsychotic four basic processes: absorption, distribution, metabolism, or
treatment (Danovich et al., 2011). Researchers are examin- elimination. Most pharmacokinetic interactions are a result of
ing an antipsychotic drug to simultaneously target dopamine inhibition or induction of cytochrome P450 (CYP450) enzymes.
hyperactivity and GABA hypoactivity, thereby reducing When a potent CYP450 enzyme inhibitor or inducer is added to
anxiety and improving cognitive function in schizophrenic drugs metabolized by one or more CYP450 enzymes, the patient
individuals (Davidson, 2007). experiences an adverse drug effect or therapeutic failure.
CHAPTER 4  Biological Basis for Understanding Psychopharmacology 57

Pharmacodynamic interactions are the combined effects Monoamine Oxidase Inhibitors (MAOIs)
of drugs. For example, when two agents that produce the same To understand the action of these drugs, keep in mind the
or similar end result are coadministered, there is an additive or ­following definitions:
synergistic effect. This is most evident in the enhanced sedation • M  onoamines: a type of organic compound, including
(central nervous system [CNS] depression) that occurs when the neurotransmitters that are further divided into sub-
alcohol is taken with psychotropic medications. Drugs with groups called catecholamines (e.g., norepinephrine, epi-
opposing effects would reduce the response to one or both drugs. nephrine, dopamine) and indolamines (e.g., serotonin)
An example would be the antagonistic effect of a benzodiazepine and many different drugs and food substances
with concurrent use of theophylline. Older adults with chronic • M  onoamine oxidase (MAO): an enzyme that destroys
illnesses, such as major depressive disorder, are likely to experi- monoamines
ence more pharmacodynamic interactions because of multiple • M  onoamine oxidase inhibitors (MAOIs): drugs that
comorbidities requiring other medications (Ereshefsky, 2009). increase concentrations of monoamines by inhibiting
the action of MAO (Figure 4-8)
Because MAOIs block the enzyme that metabolizes mono-
ANTIDEPRESSANT DRUGS amines, they may occasionally be used to increase the levels of
Several hypotheses of depression have been proposed for the serotonin and norepinephrine in intractable depression. However,
action of antidepressants: selective serotonin reuptake inhibitors (SSRIs) and serotonin-
1. The monoamine hypothesis suggests a lack of three mono- norepinephrine reuptake inhibitors (SNRIs) are more com-
amines (dopamine, norepinephrine, or serotonin) in monly used antidepressants because of the vasopressor effects that
various brain regions. However, there is no clear evidence occur when MAOIs are combined with other sympathomimetics
that monoamine deficiency accounts for depression. (amines that stimulate the sympathetic nervous system). The most
2. The monoamine receptor hypothesis suggests that low feared vasopressor effect is the hypertensive crisis that can result
levels of neurotransmitters cause increased receptor sen- if a patient takes over-the-counter medications with pseudoephed-
sitivity (up-regulation) over time; thus it may take sev- rine or consumes the adrenergic monoamine tyramine, commonly
eral weeks for patients to feel better when they are taking found in aged foods and beverages. Dietary restriction of tyramine
antidepressants. must be maintained for 2 weeks after stopping MAOIs to allow
3. More recent hypotheses focus on “downstream molecu- the body to resynthesize the MAO enzyme. The EMSAM patch
lar events” that the receptors trigger, including the regu- delivers the MAOI selegiline through the skin, and has diminished
lation of genes. For example, one hypothesis is that the hypertensive effects compared to the oral preparations phenelzine
gene for brain-derived neurotrophic factor (BDNF) is (Nardil) and tranylcypromine (Parnate). However, dietary precau-
repressed in depression and may be activated by anti- tions are still required. Chapter 15 contains a list of foods and bev-
depressants. Neurotrophic factors such as BDNF are erages to avoid while taking MAOIs, and gives nursing measures
critical for the survival of neurons and enhance the and instructions for teaching patients who are taking MAOIs. For
sprouting of axons to form new synaptic connections a more detailed description of how MAOIs work, visit the Evolve
(Stahl & Muntner, 2008). website at

Presynaptic cell Postsynaptic cell

MAO inhibitor



MA Monoamine

MAO Monoamine oxidase

FIGURE 4-8 Blocking of monoamine oxidase (MAO) by inhibiting agents (MAOIs), which
prevents the breakdown of ­monoamine by MAO.
58 UNIT 1  Essential Theoretical Concepts for Practice

before the patient can reach a hospital, especially if the patient is

Tricyclic Antidepressants (TCAs) an older adult with a slower rate of drug elimination. For a more
Originally termed tricyclic antidepressants (TCAs), these agents detailed description of how TCAs work, visit the Evolve website
are more accurately called cyclic antidepressants (CAs) because at
newer members of this class have a four-ring structure. TCAs,
such as amitriptyline (Elavil) and nortriptyline (Pamelor), Selective Serotonin Reuptake Inhibitors (SSRIs)
act primarily by blocking the presynaptic transporter protein As the name implies, SSRIs such as fluoxetine (Prozac), ser-
receptors for norepinephrine and, to a lesser degree, serotonin traline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and
(Figure 4-9). This blocking prevents norepinephrine from escitalopram (Lexapro), preferentially block the reuptake and
coming into contact with its degrading enzyme, MAO, and thus the destruction of serotonin. Vilazodone (Viibryd) (see
thus increases the level of norepinephrine at the synapse. Viibryd Medication Guide, 2011) is a new dual-action antide-
Multiple pharmacological mechanisms of TCAs have proven pressant that shows a significant effect as early as the first week
beneficial in treating difficult cases of depression and chronic of administration. It is an SSRI and partial agonist at serotonin
pain. However, multiple actions on several receptors also earned 5-hydroxytryptamine 1A (5-HT1A) receptors. The idea behind
TCAs the name “dirty drugs” because of their many side effects. a partial agonist is that it will effectively block the negative
For example, to varying degrees TCAs block muscarinic recep- feedback caused by higher levels of serotonin and increase sero-
tors that normally bind acetylcholine, leading to anticholiner- tonin release even more. Refer to Figure 4-10 for an explana-
gic effects. Again to varying degrees, TCAs block H1 receptors, tion of the mechanism of action of SSRIs. For a more detailed
causing sedation and weight gain. Strong binding at adrenergic description of how SSRIs work, visit the Evolve website at http:
receptors causes dizziness and hypotension, thereby increasing //
the risk for falls. Pharmacokinetics must be considered in TCA Selectivity results in fewer side effects because SSRIs do
overdose fatalities because TCAs are highly lipid soluble and not inhibit receptors for other neurotransmitters (e.g., ace-
rapidly absorbed. This may result in cardiotoxicity and death tylcholine, histamine, norepinephrine). However, too much

Presynaptic cell Postsynaptic cell



antidepressant drug NE Norepinephrine
MAO Monoamine oxidase
FIGURE 4-9  Mechanism by which tricyclic antidepressant drugs block the reuptake of norepinephrine.

Presynaptic cell Postsynaptic cell



S Serotonin
MAO Monoamine oxidase
FIGURE 4-10  Mechanism of action of selective serotonin reuptake inhibitors (SSRIs).
CHAPTER 4  Biological Basis for Understanding Psychopharmacology 59

serotonergic activity can result in anxiety, insomnia, sexual dys- OTHER ANTIDEPRESSANTS
function, and gastrointestinal disturbances. Serotonin toxicity
may occur with coadministration of other serotonergic drugs Norepinephrine-Dopamine Reuptake Inhibitors
(e.g., MAOIs, SSRIs, SNRIs, lithium, triptan, buspirone, tram- (NDRIs)
adol, over-the-counter cough and cold medications containing Unlike other currently used antidepressants, bupropion (Well-
dextromethorphan) or antidopaminergic drugs. Similarly, the butrin) does not act on the serotonin system. It inhibits dopa-
risk of serotonin toxicity may be increased by pharmacokinetic mine-norepinephrine reuptake, and it also inhibits nicotinic
interactions because serotonergic antidepressants are metabo- acetylcholine receptors to reduce the addictive action of nico-
lized by cytochrome P450 (CYP450) enzymes, and any drug tine. Thus the bupropion preparation Zyban is also prescribed
that inhibits a CYP450 enzyme increases serotonin levels. For for smoking cessation.
example, metabolism by CYP3A4 is a major elimination path- Trazodone (Desyrel) is not a first choice for antidepres-
way for SSRIs, so doses should be reduced with coadministered sant treatment, but it is often given along with another agent
CYP3A4 inhibitors (e.g., ketoconazole). On the other hand, because sedation, one of its side effects, helps with insomnia.
CYP34A inducers (e.g., rifampin) can result in inadequate Trazodone’s sedative effect is from potent histamine-1 block-
plasma concentrations and diminished effectiveness. ade. The trazodone extended-release formulation claims to
Adverse events can occur upon discontinuation of seroto- maintain blood levels within a therapeutic range for 24 hours,
nergic antidepressants, particularly when discontinuation is potentially reducing side effects while maintaining efficacy.
abrupt. The discontinuation syndrome is most likely to occur Potent α-adrenergic blocking properties can cause priapism
with SSRIs or SNRIs having a short half-life. Thus it is more (painful prolonged penile erections). Refer to Chapter 15 for
common with paroxetine (Paxil) than with fluoxetine (Prozac). more information on the antidepressant medications, nursing
considerations, and patient and family teaching.
Serotonin-Norepinephrine Reuptake Inhibitors
SNRIs increase the levels of both serotonin and norepineph-
rine. Venlafaxine (Effexor) is more of a serotonergic agent
at lower doses, but norepinephrine reuptake blockade occurs Antidepressants have been found effective in treating anxiety
at higher doses, leading to the dual SNRI action. Duloxetine disorders because of many shared symptoms, neurotransmit-
(Cymbalta) is used for depression and pain associated with dia- ters, and circuits. SSRIs are commonly used to treat panic dis-
betic neuropathy. Like the TCAs that activate descending nor- order, generalized anxiety disorder (GAD), OCD, PTSD, and
epinephrine and serotonin pathways to the spinal cord, many social phobia. The SNRIs venlafaxine (Effexor) and duloxetine
SNRIs have therapeutic effects on neuropathic pain. (Cymbalta) are also used to treat GAD.

Serotonin-Norepinephrine Disinhibitors (SNDIs) ANTIANXIETY OR ANXIOLYTIC DRUGS

SNDIs, represented by only mirtazapine (Remeron), increase
norepinephrine and serotonin transmission by blocking pre- Benzodiazepines
synaptic α2-noradrenergic receptors. Mirtazapine offers both GABA is the major inhibitory (calming) neurotransmitter in the
antianxiety and antidepressant effects, with minimal sexual CNS. The most commonly used antianxiety agents are benzodi-
dysfunction secondary to serotonin blockade. This antidepres- azepines, which promote activity of GABA by binding to a spe-
sant is particularly suited for patients with nausea because it is cific receptor on the GABAA receptor complex. Figure 4-11 shows
an antiemetic via serotonin blockade. that benzodiazepines such as diazepam (Valium), clonazepam
Benzodiazepine receptor


GABA receptor
FIGURE 4-11  Action of the benzodiazepines. Drugs in this group attach to receptors adjacent
to the receptors for the neurotransmitter γ-aminobutyric acid (GABA). Drug attachment to
these receptors results in a strengthening of the inhibitory effects of GABA. In the absence
of GABA, there is no inhibitory effect of benzodiazepines.
60 UNIT 1  Essential Theoretical Concepts for Practice

(Klonopin), and alprazolam (Xanax) bind to GABAA receptors of action is not well understood. Theories include interaction
with different α subunits. α2 subunits may be the most impor- with sodium and potassium at the cell membrane to stabilize
tant for decreasing anxiety. electric activity, reduction in the levels of the excitatory neu-
The fact that benzodiazepines do not inhibit neurons in the rotransmitter glutamate, and inhibition of the second messen-
absence of GABA limits the potential toxicity of these drugs. How- ger enzyme inositol monophosphatase. As a positively charged
ever, patients taking benzodiazepines have the potential to develop ion, similar to sodium, it may act by stabilizing electrical activity
tolerance and withdrawal reactions. Some of the various benzodi- in neurons. If the alteration of electrical currents is not respon-
azepines, such as flurazepam (Dalmane) and triazolam (Halcion), sible for its beneficial effects, it certainly explains some adverse
have a predominantly hypnotic (sleep-inducing) effect, whereas effects such as cardiac dysrhythmias, seizures, or tremors.
others, such as lorazepam (Ativan) and alprazolam (Xanax), Primarily because of its effects on electrical conductivity,
reduce anxiety without being as soporific (sleep producing). lithium has a low therapeutic index (the ratio of the lethal
The ability of benzodiazepines to potentiate GABA could dose to the effective dose); therefore it is important to monitor
account for their ability to reduce neuronal excitement in seizures blood lithium levels, which are dependent on kidney function.
and alcohol withdrawal. When used alone, even at high dosages, Lithium is particularly sensitive to interactions during excre-
benzodiazepines rarely inhibit the brain to the degree that respi- tion, and even minor changes in serum sodium or hydration
ratory depression, coma, and death result. However, when com- levels can cause lithium to accumulate. Lithium doses are dif-
bined with other central nervous system (CNS) depressants, such ficult to titrate if interacting medications (e.g., thiazide diuret-
as alcohol, opiates, or TCAs, the inhibitory actions of the ben- ics or sodium-containing antacids) are taken intermittently.
zodiazepines can lead to life-threatening respiratory depression. Long-term use of lithium increases the risk of both kidney and
Any drug that inhibits electrical activity in the brain can thyroid disease. Chapter 16 considers lithium treatment in
interfere with motor ability and judgment. Therefore, patients more detail.
must be cautioned about engaging in activities that could be
dangerous if reflexes and attention are impaired (e.g., driving). Anticonvulsant Mood Stabilizers
Ataxia is a common side effect secondary to the abundance of Valproate, available as divalproex sodium (Depakote) and
GABA receptors in the cerebellum. valproic acid (Depakene), is recommended in bipolar disor-
der for mixed episodes and rapid cycling. It is very effective in
Non-Benzodiazepines managing impulsive aggression. When lithium is not tolerated,
Buspirone divalproex may be used for long-term maintenance therapy.
Buspirone (BuSpar) is a drug that reduces anxiety without Its action in bipolar illness is unknown, but it may be related
having strong sedative-hypnotic properties. Its mechanism to increased bioavailability of the inhibitory neurotransmitter
of action is unknown, but it has a high affinity for serotonin GABA. Baseline lab work includes liver function tests and com-
receptors, acting as a serotonin 1A partial agonist. It is not a plete blood count (CBC). Once the patient is stable, valproate
CNS depressant and thus does not have as great a danger of levels are measured every 6 months and generally range from
interaction with other CNS depressants, such as alcohol. Also, 50 to 100 mcg/mL.
the potential for addiction that exists with benzodiazepines Carbamazepine (Tegretol), in a controlled-release formula,
does not exist for buspirone. is used to treat acute mania. A CBC must be done periodically
because of rare but serious blood dyscrasias (e.g., aplastic ane-
Short-Acting Sedative-Hypnotic Sleep Agents mia and agranulocytosis).
Non-benzodiazepine hypnotic agents, such as zolpidem Lamotrigine (Lamictal), approved for maintenance treat-
(Ambien), zaleplon (Sonata), and eszopiclone (Lunesta), dem- ment of bipolar disorder, modulates the release of glutamate
onstrate selectivity for GABAA receptors containing α1 sub- and aspartate and is effective in decreasing the time between
units. Termed the “Z-hypnotics,” they have sedative effects episodes of bipolar depression. The most common adverse
without the antianxiety, anticonvulsant, or muscle relaxant effects are usually mild, but about 8% of patients who begin
effects of benzodiazepines. lamotrigine will develop a rash during the first 4 months of
treatment. If this occurs, the drug should be discontinued.
Melatonin Receptor Agonists Although the rash is usually benign, there is a concern that
Ramelteon (Rozerem), a hypnotic, acts much the same way as it is an early manifestation of a toxic epidermal necrolysis
endogenous melatonin. It has a high selectivity at the ­melatonin-1 called Stevens-Johnson syndrome (Sadock & Sadock, 2007).
receptor site—thought to regulate sleepiness—and at the Another rare but serious side effect of lamotrigine is aseptic
melatonin­-2 receptor site—thought to regulate circadian rhythms. meningitis.


Off-label mood stabilizers include oxcarbazepine (Trileptal),
Lithium gabapentin (Neurontin), and topiramate (Topamax). Benzo-
Although the efficacy of lithium (Eskalith, Lithobid) as a mood diazepines may be used for their calming effects during mania,
stabilizer in bipolar disorder is well established, its mechanism and sometimes antipsychotics and antidepressants are used
CHAPTER 4  Biological Basis for Understanding Psychopharmacology 61

along with a mood stabilizer. Refer to Chapter 16 for nursing D2 blockade achieves the therapeutic effect of decreas-
considerations and patient and family teaching for the mood ing positive symptoms in schizophrenia, but it also can lead to
stabilizing drugs. extrapyramidal side effects such as dystonia (muscle stiffness),
akathisia (restlessness), tardive dyskinesia (TD), and drug-
ANTIPSYCHOTIC DRUGS induced parkinsonism. D2 blockade also may lead to a rare
but life-­threatening complication called neuroleptic malignant
The First-Generation Agents (FGA)/Conventional syndrome (NMS) involving autonomic, motor, and behavioral
Antipsychotic Agents symptoms. The antipsychotic agent should be stopped immedi-
The first-generation agents (FGA)/conventional antipsy- ately if the patient develops signs of NMS such as severe muscle
chotics were once called neuroleptics because they caused rigidity, confusion, agitation, and increased temperature, pulse,
significant neurological effects. They are also referred to as and blood pressure.
dopamine receptor agonists (DRAs) because they bind to In addition to adverse effects occurring with D2 blockade,
dopamine type 2 (D2) receptors and reduce dopamine transmis- unpleasant effects also result from antipsychotics blocking
sion as illustrated in Figure 4-12. other receptors, such as those identified in Figure 4-13. For

Presynaptic cell Postsynaptic cell





DA Dopamine
FIGURE 4-12  Mechanism by which antipsychotics block dopamine receptors.

D2 = Dopaminergic
EPS = Extrapyramidal side effects
• Dry mouth GABA = -Aminobutyric acid
• Antipsychotic effect • Blurred vision H1 = Histamine
• EPS • Urinary retention 5-HT2 = Serotonin
• Increased prolactin • Constipation
— Gynecomastia (men) • Tachycardia
— Galactorrhea
• Amenorrhea (women) • Sedation
• Substantial
Muscarinic weight gain
cholinergic • Orthostasis
D2 block
block H1
• Orthostatic hypotension block
• Dizziness 1
• Antipsychotic effect block ANTIPSYCHOTIC
• Reflux tachycardia • Antipsychotic
• Failure to ejaculate effects
5-HT2 • Weight gain
GABA • Hypotension
• Ejaculatory
• Sexual dysfunction
• Priapism

• Lowers seizure threshold

FIGURE 4-13  Adverse effects of receptor blockage of antipsychotic agents. (From Varcarolis,
E. [2011]. Manual of psychiatric nursing care plans [4th ed.]. St Louis: Saunders Elsevier.)
62 UNIT 1  Essential Theoretical Concepts for Practice

example, blocking muscarinic cholinergic receptors can result Clozapine

in blurred vision, dry mouth, constipation, and urinary hesi- Clozapine (Clozaril), the first of the atypicals, is several times
tancy. Antagonism of the histamine1 receptors causes sedation more potent in blocking serotonin 5-HT2 receptors than dopa-
and weight gain. Blockage at the α1 receptors for norepineph- mine D2 receptors. Preferential blocking of dopamine recep-
rine can affect vasodilation and a consequent drop in blood tors in the limbic system, rather than those in striatal areas, is
pressure, or orthostatic hypotension. Antagonism of either α1 thought to account for a low prevalence of movement disor-
receptors or 5-HT2 receptors may result in ejaculatory dysfunc- ders (Rothschild, 2009).
tion. For a more detailed description of how the antipsychotic Clozapine also has binding activity at a variety of other
drugs block specific receptors, visit the Evolve website at http:// receptors, which may account for its advantages in treating
evolve.elsevier.comVarcarolis/essentials. patients who respond poorly to other antipsychotics, both typi-
Conventional antipsychotics have been divided into two cal and atypical (Joober & Boksa, 2010). Clozapine is not used
groups: high potency and low potency. Low-potency neuro- as a first-line treatment because it may suppress bone marrow,
leptics such as chlorpromazine (Thorazine) are used less fre- resulting in a rare but serious decrease in the level of granu-
quently than high-potency neuroleptic medications because of lated white blood cells (WBCs) called agranulocytosis. The
problems with orthostatic hypotension. Their sedative effect risk of neutropenia and agranulocytosis is highest in the first
was seen as advantageous in controlling aggression in violent few months of treatment.
patients, but this calming effect can also be obtained by com- Clozapine has the potential for inducing seizures, a dose-
bining lorazepam (Ativan) with a high-potency drug such as related side effect, in 3.5% of patients. Caution should be used
haloperidol (Haldol). with coadministration of SSRIs because these drugs increase
Although high-potency haloperidol and fluphenazine the risk of seizures by elevating clozapine concentrations.
(Prolixin) have less sedation and fewer anticholinergic effects, When clozapine-treated patients are partial responders, topi-
they cause more extrapyramidal symptoms (EPS) than low- ramate may be used for augmentation. This drug combination
potency agents. An acute dystonic reaction (ADR) is more has been associated with weight loss and metabolic benefit
likely to occur early in treatment with a high-potency neuro- (Hahn et al., 2010).
leptic, especially if the patient uses cocaine.
In a large government-sponsored trial called “The CATIE Olanzapine
Project,” the moderate-potency conventional antipsychotic Olanzapine (Zyprexa), a derivative of clozapine, has compa-
perphenazine (Trilafon) was found to be comparable in effi- rable receptor occupancies and similar metabolic side effects,
cacy to newer atypical agents. This finding, as well as the cost- such as weight gain. Metabolic monitoring for all patients
effectiveness of conventional antipsychotics, has renewed being administered atypical antipsychotics is recommended,
interest in their use. although risperidone (Risperdal) and quetiapine (Seroquel)
have a lower weight gain and ziprasidone (Geodon) and aripip-
The Second-Generation (SGA) or Atypical razole (Abilify) are considered weight neutral.
Antipsychotic Agents Metabolic monitoring usually includes measurements of
The Second-generation antipsychotic agents (SGAs)/atypical body weight, body mass index (BMI), waist circumference,
antipsychotics are prescribed more frequently because their fasting plasma glucose level, and fasting lipid profile.
different receptor-binding profile accounts for fewer EPS, and In addition, metformin—a medication used to regulate blood
they have a greater ability to target negative symptoms of schizo- glucose level—has been shown to halt weight gain, decrease
phrenia. All antipsychotics, regardless of class, have the ability measures of insulin resistance, and possibly increase medica-
to improve cognitive function (Goff et al., 2010), but there is tion adherence. Although weight gain and metabolic effects are
controversy regarding whether the atypicals are superior in this unhealthy, these adverse effects are often more tolerable than the
function. Their tolerability may facilitate treatment adherence, neurological adverse effects of conventional antipsychotics.
which in turn may result in greater cognitive improvement Olanzapine is sedating because of its antagonism of H1
(Selva-Vera et al., 2010). Also, the higher incidence of EPS with receptors, so it is common practice to administer the medica-
conventional antipsychotics may necessitate treatment with tion at bedtime. Olanzapine was the first antipsychotic avail-
anticholinergic medication, such as benztropine (Cogentin). able as orally disintegrating tablets for patients who are unable
Anticholinergics themselves can produce sedation, inattention, or unwilling to swallow.
and memory disturbance, illustrating how both mental illness
and pharmacotherapy disrupt cognition. Risperidone
Atypicals are known as serotonin-dopamine antagonists Risperidone (Risperdal) exhibits high levels of D2-receptor
(SDAs) because they have a higher ratio of serotonin (5-HT2) blockade and a very high affinity for 5-HT2 receptors. EPS
to dopamine D2-receptor blockade than conventional dopa- may occur if the dosage is only slightly higher than the effec-
mine receptor antagonists (DRAs) (Sadock & Sadock, 2007). In tive dose. The patient should be carefully monitored for motor
addition to being potent serotonin type 2A (5-HT2a) receptor difficulties if the dosage exceeds 4 to 6 mg/day. Because ris-
antagonists, some SDAs have significant anticholinergic and peridone blocks α1 and H1 receptors, it can cause orthostatic
antihistaminic activity. hypotension and sedation, which can lead to falls—a serious
CHAPTER 4  Biological Basis for Understanding Psychopharmacology 63

problem for older adults. Weight gain, sedation, and sexual however, in regions with low dopamine concentration, it
dysfunction also are adverse effects that may affect adherence stimulates receptors to raise the dopamine level, acting as a
with the medication regimen. dopamine agonist. It is also an antagonist at serotonin 5-HT2
Risperidone (Risperdal Consta), the first atypical antipsy- receptors and a partial agonist at 5-HT1 receptors. It has little
chotic available as a long-acting injectable, was hypothesized sedation and weight gain. Although it is not common, aripip-
to result in greater improvement, increased stability, and lower razole does cause akathisia, described as restlessness or agita-
rates of relapse in unstable patients with schizophrenia because tion. Headache, insomnia, and nausea are other adverse effects
of its ability to achieve “steady state” concentrations ­(Schatzberg reported. Aripiprazole is available in a ready-to-use vial for
& Nemeroff, 2009). However, recent evidence shows that long- intramuscular injection and control of agitation in schizophre-
acting risperidone is not superior to oral risperidone, and has nia or bipolar disorder.
the added burden of adverse effects at the injection site and
more EPS (Rosenheck et al., 2011). Long-acting injectables still Iloperidone
have their place with nonadherent patients when it is necessary Iloperidone (Fanapt) functions as an antagonist at the dopa-
to keep the dosage regimen constant, particularly in patients mine D2 and D3, serotonin 5-HT1A, and norepinephrine α1/α2c
with schizophrenia incarcerated for violent acts (Nasrallah, receptors. The dose might be reduced in patients coadmin-
2011). Further research is needed to compare the atypical istered a strong CYP2D6 inhibitor (fluoxetine) or CYP34A
injectable Risperdal Consta with the conventional long-acting inhibitor or in those who are poor metabolizers. Approximately
injectables haloperidol and fluphenazine decanoate. 7% to 10% of Caucasians and 3% to 8% of Black/African
Paliperidone is the principal active metabolite of risperi- ­Americans lack the capacity to metabolize CYP2D6 substrates.
done in INVEGA extended-release tablets. Unlike risperi- Iloperidone can be administered without regard to meals.
done, paliperidone is eliminated almost independently of the
CYP2D6 pathway and is cleared through the kidneys. The Lurasidone Hydrochloride
Osmotic Release Oral System (OROS) provides consistent Lurasidone HCl (Latuda) is similar to other atypicals in having
24-hour release of medication, leading to minimal peaks and high binding affinity for dopamine D2 and serotonin 5-HT2A
troughs in plasma concentration. receptors, and its efficacy for treatment of acute schizophre-
nia is established. Available in a once-daily dose, it also tar-
Quetiapine gets selected other serotonin receptors that may play a role in
Quetiapine (Seroquel) has a broad receptor-binding pro- cognition (Terry et al., 2008). Lurasidone should not be used
file. Its strong blockage of histamine-1 receptors accounts for with strong inhibitors or inducers of the enzyme CYP3A4. It
high sedation. The combination of histamine-1 and serotonin is absorbed in the gastrointestinal tract, and reaches maximum
receptor blockage leads to weight gain and moderate risk for concentration (Cmax) in 1 to 3 hours. The Cmax doubles when
metabolic syndrome. Orthostatic hypotension is explained by lurasidone is administered with food (Lincoln & Tripathi,
antagonism of adrenergic α1 receptors. Quetiapine has a low 2011). Refer to Chapter 17 for more information on adverse
risk for EPS or prolactin level elevation from low D2 dopamine and toxic effects, nursing considerations, and patient and
binding because of rapid dissociation at these receptors. Once- ­family teaching of the antipsychotics.
daily Seroquel XR tablets is expected to increase adherence by
simplifying the dosing routine. Psychoneuroimmunology (PNI)
Psychoneuroimmunology (PNI) is a research field that focuses
Ziprasidone on the relationship between the immune system and the ner-
Ziprasidone (Geodon) is a serotonin-norepinephrine reuptake vous system. Studies investigate molecular, cellular, and neuro-
inhibitor. The main side effects are dizziness and sedation. One nal events to determine their role in psychiatric disorders. For
major safety concern with ziprasidone, as well as the atypicals example, scientists are identifying the neural circuits involved
listed earlier, is prolongation of the QTc interval, which can be in cytokine-induced depression (Loftis et al., 2010) and in
fatal if the patient has a history of cardiac dysrhythmias. Thus stress-related disorders. Neuroinflammatory processes related
a baseline electrocardiogram is recommended before treat- to cytokines, the signaling molecules of the immune system, are
ment. Food increases its absorption up to twofold; therefore also being studied as biological mechanisms underlying cogni-
ziprasidone is always taken with food. It is unlikely to cause tive deficits in Alzheimer’s disease and in tetrahydrocannabi-
significant interactions with drugs metabolized by cytochrome nol (THC) use. Activation of innate immune inflammatory
P450. Ziprasidone may be given intramuscularly for acute agi- responses and their regulation by neuroendocrine pathways
tation, but it is important to note that it is not a long-acting in patients with cancer are known to result in changes in neu-
preparation. rotransmitter metabolism, neuropeptide function, sleep-wake
cycles, regional brain activity, and ultimately behavior (Miller
Aripiprazole et al., 2008). Neuroimmunopharmacology focuses on drugs
Aripiprazole (Abilify) is a unique atypical known as a dopamine modulating neuroimmune processes, and is beginning to
system stabilizer. In areas of the brain with excess dopamine, it explore highly advanced technologies such as nanotechnology
lowers the dopamine level by acting as a receptor antagonist; to develop approved nano-drugs.
64 UNIT 1  Essential Theoretical Concepts for Practice

CONSIDERING CULTURE focusing on drug metabolism via the CYP450 enzyme systems.
Cultural and ethnic beliefs surrounding mental illness and Variation in drug response is particularly important in nonre-
pharmacotherapy affect a person’s perception of the need for sponders and adverse responders who require adjusted doses or
treatment, adherence, reporting of adverse events, and the alternate medications. Although the genetic underpinnings of
preference for alternative or complementary therapies. mental illness have yet to be determined, genetic profiles may
Cross-cultural psychopharmacology explores different someday explain why some patients respond to certain drugs and
effects or responses that exist among ethnic groups and the which patients are poor or ultrarapid metabolizers. At present,
reasons for these effects. To predict patients’ responses, scien- medications treat “target symptoms” of mental disorders so that
tists search for variants in genes that code for drug metaboliz- people can function. In the future, genetic research might per-
ing enzymes in the liver. Pharmacogenetics studies how genes sonalize treatment by targeting genetic flaws or underlying causes
influence drug metabolism and response, with much attention of these disorders, thereby leading to a cure for mental illness.

 K E Y P O I N T S T O R E M E M B E R
• A ll actions of the brain—sensory, motor, intellectual—are serotonin, and antianxiety drugs increase the effectiveness
carried out physiologically through the interactions of nerve of GABA or increase 5-HT and/or norepinephrine levels.
cells. These interactions involve impulse conduction, trans- • Because the immediate target activity of a drug can result
mitter release, and receptor response. Alterations in these in many downstream alterations in neuronal activity, drugs
basic processes can lead to mental disturbances and physical with a variety of chemical actions may show efficacy in
manifestations. treating the same clinical condition. Thus, newer drugs with
• In particular, it seems that excess activity of dopamine, novel mechanisms of action are being used in the treatment
among other factors, is involved in the thought disturbances of schizophrenia, depression, and anxiety.
of schizophrenia, and deficiencies of norepinephrine, sero- • Unfortunately, agents used to treat mental disease can cause
tonin, or both underlie depression and anxiety. Insufficient various undesired effects. Prominent among these can be
activity of GABA also plays a role in anxiety. sedation or excitement, motor disturbances, muscarinic
• Pharmacological treatment of mental disturbances is blockage, α-adrenergic antagonism, sexual dysfunction,
directed at the suspected transmitter-receptor problem. and weight gain. There is a continuing effort to develop new
Antipsychotic drugs decrease dopamine levels, antidepres- drugs that are effective, safe, and well tolerated.
sant drugs increase synaptic levels of norepinephrine and/or

 A P P L Y I N G C R I T I C A L J U D G M E N T
1. N o matter where you practice nursing, individuals under specific information would you include in medication
your care will be taking psychotropic drugs. Consider the teaching?
importance of understanding normal brain structure and A. Dopamine D2 (as with use of antipsychotic drugs)
function as they relate to mental disturbances and psycho- B. Blockage of muscarinic receptors (as with use of pheno-
tropic drugs by addressing the following questions: thiazines and other drugs)
A. How can you use your knowledge of normal brain func- C. α1 receptors (as with use of phenothiazines and other
tion (control of peripheral nerves, skeletal muscles, the drugs)
autonomic nervous system, hormones, and circadian D. Histamine (as with use of phenothiazines and other
rhythms) to better understand how a patient can be drugs)
affected by psychotropic drugs or psychiatric illness? E. Monoamine oxidase (MAO) (as with use of a mono-
B. What information from the various brain imaging tech- amine oxidase inhibitor [MAOI])
niques can you use to understand and treat patients with F. γ-Aminobutyric acid (GABA) (as with the use of
mental disorders and provide support to their families? benzodiazepines)
How might you use that information for patient and G. Serotonin (as with the use of selective serotonin reup-
family teaching? take inhibitors [SSRIs] and other drugs)
2. Based on your understanding of symptoms that may occur H. Norepinephrine (as with the use of serotonin-­

when the following neurotransmitters are altered, what norepinephrine reuptake inhibitors [SNRIs])
CHAPTER 4  Biological Basis for Understanding Psychopharmacology 65

 C H A P T E R R E V I E W Q U E S T I O N S
Choose the most appropriate answer(s). 3. diazepam.
1. All mental activity has its locus in the: 4. sertraline.
1. environmental stimuli of the patient. 4. Clozaril: (select all that apply)
2. brain. 1. is an atypical anti-psychotic drug.
3. personality structure. 2. may cause agranulocytosis.
4. emotions. 3. is indicated for severely ill schizophrenics.
2. Standard anti-psychotic drugs: (select all that apply) 4. is used for first-line treatment of psychosis.
1. lower the seizure threshold. 5. Pharmacological agents:
2. increase blood pressure. 1. are equally effective with all cultural groups.
3. can cause extrapyramidal symptoms (EPS). 2. rarely cause side effects.
4. may lead to neuroleptic malignant syndrome. 3. may have undesired effects in some cultural groups.
3. A psychiatric nurse routinely administers the following 4. Are best if they are naturally processed.
drugs to patients in the community mental health center.
The patients who should be most carefully assessed for
untoward cardiac side effects are those receiving:
1. lithium.
2. clozapine.

REFERENCES Ho, B. -C., Andreasen, N. C., Ziebell, S., Pierson, R., & Magnotta, V.
(2011). Long-term antipsychotic treatment and brain volumes:
Andreasen, N. C., & Pierson, R. (2008). The role of the cerebellum in a longitudinal study of first-episode schizophrenia. Archives of
schizophrenia. Biological Psychiatry, 64(2), 81–88. EpubApr8. General Psychiatry, 68(2), 128–137.
Baier, B., Dieterich, M., Stoeter, P., Birklein, F., & Muller, N. G. Joober, R., & Boksa, P. (2010). Clozapine: a distinct, poorly under-
(2010). Anatomical correlate of impaired covert visual attentional stood and under-used molecule. Journal of Psychiatry and Neuro-
processes in patients with cerebellar lesions. Journal of Neurosci- science, 35(3), 147–149.
ence, 30(10), 3770–3776. Li, N., Boyoung, L., Liu, R., Banasr, M., Dwyer, J. M., et al. (2010).
Beyer, C. E., & Stahl, S. M. (2010). Next generation antidepressants: mTOR-dependent synapse formation underlies the rapid antide-
moving beyond monoamines to discover novel treatment strategies pressant effects of NMDA antagonists. Science, 329(5994), 959–964.
for mood disorders. London: Cambridge University Press. Lincoln, J., & Tripathi, A. (2011). Lurasidone for schizophrenia. Cur-
Brunton, L., Chabner, B., & Knollman, B. (2011). Goodman & rent Psychiatry Online, 10(1). Accessed April 14, 2011.
­Gilman’s the pharmacological basis of therapeutics (12th ed.). Loftis, J. M., Huckans, M., & Morasco, B. J. (2010). Neuroimmune
New York: McGraw Hill Medical. mechanisms of cytokine-induced depression: current theories
Cardish, R. J. (2007). Psychopharmacologic management of suicidal- and novel treatment strategies. Neurobiological Disorders, 37(3),
ity in personality disorders. Canadian Journal of Psychiatry, 52 519–533.
(6 Suppl. 1), S115–S127. Madhusoodanan, S., Parida, S., & Jimenez, C. (2010). Hyperprolac-
Danovich, L., Weinreb, O., Youdim, M. B. H., & Silver, H. (2011). The tinemia associated with psychotropics: a review. Human Psycho-
involvement of GABAA receptor in the molecular mechanisms of pharmacology: Clinical and Experimental, 25(4), 281–297.
combined selective serotonin reuptake inhibitor-antipsychotic treat- Miller, A. H., Ancoli-Israel, S., Bower, J. E., Capuron, L., & Irwin,
ment. International Journal of Neuropsychopharmacology, 14, 143–155. M. R. (2008). Neuroendocrine-immune mechanisms of behav-
Davidson, M. (2007). First antipsychotic targeting GABA to enter phase ioral comorbidities in patients with cancer. Journal of Clinical
II trials. Retrieved February 14, 2007, from Oncology, 971–982. Nasrallah, H. A. (February 2011). Two vastly underutilized interven-
Ereshefsky, L. (2009). Drug-drug interactions with the use of psycho- tions can improve schizophrenia outcomes. Current Psychiatry
tropic medications. CNS Spectrums Supplement, 14(8). Online, 10(2).
Fuster, J. M. (2008). The prefrontal cortex (4th ed.). St Louis: Elsevier. Patton, K. T., Thibodeau, G. A., & Douglas, M. M. (2012). Essentials of
Goff, D. C., Hill, M., & Barch, D. (2010). The treatment of cogni- anatomy & physiology. St Louis: Elsevier Mosby.
tive impairment in schizophrenia. Pharmacology Biochemistry & Picard, H., Amado, I., Mouchet-Mages, I., et al. (2008). The role of
Behavior. Accessed online April 14, 2011. the cerebellum in schizophrenia: an update of clinical, cognitive,
Hahn, M. K., Remington, G., Bois, D., & Cohn, T. (2010). Topiramate and functional evidence. Schizophrenia Bulletin, 34(1), 155–172.
augmentation in clozapine-treated patients with schizophrenia: Preston, J. D., O’Neal, J. H., & Talaga, M. C. (2010). Handbook of
clinical and metabolic effects. Journal of Clinical Psychopharmacol- clinical psychopharmacology for therapists (6th ed.). Oakland, CA:
ogy, 30(6), 706–710. New Harbinger.
Halperin, D., & Reber, G. (2007). Influence of antidepressants on Radenbach, K., Flaig, V., Schneider-Axmann, T., Usher, J., Reith, W.,
hemostasis. Dialogues Clinical Neuroscience, 9(1), 47–59. et al. (2010). Thalamic volumes in patients with bipolar disorder.
European Archives of Psychiatry, 260(8), 601–607.
66 UNIT 1  Essential Theoretical Concepts for Practice

Rosenheck, R. R., Krystal, J. H., Lew, R., Barnett, P. G., Fiore, L., Stahl, S. M., & Muntner, N. (2008). Stahl’s essential pharmacology
et al. (2011). Long-acting risperidone and oral antipsychotics in (3rd ed.). New York: Cambridge University Press.
unstable schizophrenia. New England Journal of Medicine, 364, Terry, A. V., Buccafusco, J. J., & Wilson, C. (2008). Cognitive dys-
842–851. function in neuropsychiatric disorders: selected serotonin receptor
Rothschild, A. J. (Ed.). (2009). The evidence-based guide to anti- subtypes as therapeutic targets. Behavioral Brain Research, 195(1),
psychotic medications. Arlington, VA: American Psychiatric 30–38.
Publishing. Tost, H., Braus, D. F., Hakimi, S., Ruf, M., Vollmert, C., et al. (2010).
Sadock, B. J., & Sadock, V. A. (2007). Kaplan & Sadock’s synopsis Acute D(2) receptor blockade induces rapid, reversible remodel-
of psychiatry: behavioral sciences/clinical psychiatry (10th ed.). ing in human cortical-striatal circuits. Nature Neuroscience. Jun 6.
Philadelphia: Lippincott Williams & Wilkins. Viibryd Medication Guide. Accessed April 14, 2011, at
Schatzberg, A. F., & Nemeroff, C. B. (2009). The American Psychiatric downloads/Drugs/DrugSafety/UCM241524.pdf.
Association Publishing textbook of psychopharmacology (4th ed.).
Arlington, VA: American Psychiatric Publishing.
Selva-Vera, G., Balanza-Martinez, V., Salazar-Fraile, J., Sanchez-
Moreno, J., Martinez-Aran, A., et al. (2010). The switch from
conventional to atypical antipsychotic treatment should not be
based exclusively on the presence of cognitive deficits. A pilot
study in individuals with schizophrenia. BMC Psychiatry. Posted
8/04/2010. Accessed April 14, 2011, on Medscape.

Settings for Psychiatric Care
Margaret Jordan Halter

  For additional DSM-5 criteria content, see Appendix C


comorbid conditions mental health parity, p. 75 SELECTED CONCEPT 
(co-occurring), p. 73 primary care providers (PCPs), p. 69 Patient-­Centered Medical Homes (PCMH)
elopement, p. 71 stigma, p. 68 received strong support from the
least restrictive environment, p. 68 therapeutic milieu, p. 71 ­Affordable Care Act of 2010. These health
homes were developed in response to
fragmented care that resulted in some
services never being delivered while oth-
ers were duplicated. The focus of care
is patient-centered and provides access
to physical health, behavioral health, and
supportive community and social services.
Electronic communication (e.g., follow-up
emails and reminders) and record keeping
are viewed as essential to this process.
(Halter, text)

1. Describe the evolution of treatment settings 3. Discuss the role of mental health professionals in
for psychiatric care. ­assisting people with mental illness symptoms
2. Compare and contrast inpatient and outpatient treatment or mental illnesses.
environments in which psychiatric care is provided. 4. Explain methods for financing psychiatric care.

68 UNIT 1  Essential Theoretical Concepts for Practice

Obtaining traditional health care is fairly straightforward. For greatest personal freedom. This chapter also explores how
example, if you wake up with a sore throat, you know what to mental health care is funded and the challenges in securing
do and basically what will happen. It is likely that if you feel adequate funding.
bad enough, you will see your primary care provider (PCP), be
examined, and maybe get a throat culture to diagnose the prob-
lem. If the cause is bacterial, you will probably be prescribed an
antibiotic. If you do not improve in a certain length of time, Although people with financial resources have a variety of
your PCP may order more tests or recommend that you see an ­psychiatric treatment options, state or county governments
ear, nose, and throat specialist. coordinate a separate care system for uninsured individu-
Compared to obtaining treatment for physical disorders, als, often for those with the most serious and persistent ill-
entry into the health care system for the treatment of psychi- nesses. This separate system of care has its roots in asylums
atric problems can be a mystery. In fact, although 46% of the that were created in most existing states before the Civil
population will have a diagnosable mental disorder over the War. These asylums were created with good intentions in
course of a lifetime, and 80% of that population will eventually an environment of optimism about recovery and belief that
seek treatment, the delay in treatment is often years or decades states had a special responsibility to care for the “insane.”
(Kessler et al., 2005). Effective treatments were not yet developed and community
Challenges in accessing and navigating this care system care was virtually nonexistent. By the early 1950s, there were
exist for several reasons. One reason is that we just do not only two real options for psychiatric care—a private psychi-
have much of a frame of reference. We are unlikely to ben- atrist’s office or a mental hospital. At that time, there were
efit from the experience of others because having a psychi- 550,000 patients in state hospitals. A majority were individu-
atric illness is often hidden as a result of embarrassment or als with disabling conditions who had become “stuck” in the
concern over the stigma, or a sense of responsibility, shame, asylums.
and being flawed associated with these disorders (refer to The number of people in state-managed psychiatric h ­ ospitals
Chapter 2 for more on stigma). You may know that when began to decrease with the creation of Medicare and Medicaid
your grandmother had heart disease, she saw a cardiac during the 1960s Great Society reform period. M ­ edicaid had
specialist and had a coronary artery bypass, but you may an especially potent effect because it paid for short-term hos-
be unaware that she was also treated for depression by a pitalization in general hospitals and medical centers, and for
psychiatrist. long-term care in nursing homes; however, it did not cover
Seeking treatment for mental health problems is also care for most patients in psychiatric hospitals. These incentives
complicated by the very nature of mental illness. At the most stimulated development of general hospital psychiatric units,
extreme, disorders with a psychotic component may disorga- and also led states to transfer geriatric patients from 100%
nize thoughts and impede a person’s ability to recognize the state-paid psychiatric hospitals to ­Medi­caid-reimbursed nurs-
need for care. Even major depression, a common psychiatric ing facilities.
disorder, may interfere with motivation to seek care because In the 1999 Olmstead decision, the Supreme Court decreed
the illness often causes feelings of apathy, hopelessness, and that keeping people in psychiatric hospitals was “unjustified
anergia (lack of energy). isolation.” The opinion of the court was that mental illness
Mental health symptoms are also confused with other is a disability and institutionalization is in violation of the
problems. For example, anxiety disorders often manifest in ­Americans With Disabilities Act, and that all people with dis-
somatic symptoms such as racing heartbeat, sweaty palms, abilities have a right to live in the community.
and dizziness, which could be symptoms of cardiac prob- These forces combined to lead to the gradual and incom-
lems. Prudence would dictate ruling out other causes, such plete creation of state- and county-financed community care
as physical illness, particularly because diagnosing psychi- systems to complement, and largely replace, functions of
atric illness is largely based on symptoms and not on objec- the state hospitals. The number of state psychiatric hospitals
tive measurements such as electrocardiograms (ECGs) and ­continues to be cut and has been reduced to about 220 facilities
blood counts. This necessary process of ruling out other (National Association of State Mental Health Program Direc-
illnesses often results in an often-troublesome treatment tors, 2011). Figure 5-1 illustrates the current structure of one
delay. state mental health and substance abuse system. In Ohio, two
Further complicating treatment for mental illness is the state agencies—the Ohio Department of Mental Health and the
unique nature of the system of care, which is rooted in the Ohio Department of Alcohol and Drug Addiction Services—
public as well as private sectors. The purpose of this chapter certify, monitor, and fund agencies that provide services. These
is to provide an overview of this system, briefly examine the agencies may be for profit or nonprofit. County board(s)
evolution of mental health care, and explore different venues (depending on whether the alcohol or substance abuse and
by which people receive treatment for mental health prob- mental health boards are combined) provide(s) more local
lems. Treatment options are presented in order of acuteness, oversight and management of these agencies.
beginning with those in the least restrictive environment— Related to the shift from hospital to community care were
the setting that provides the necessary care while allowing the the pharmacological breakthroughs in the latter half of the
CHAPTER 5  Settings for Psychiatric Care 69


Department of
Department of alcohol and
mental health drug addiction

Combined mental
County alcohol
County mental health and
and drug
health boards alcohol and drug
addiction boards
addiction boards

Not-for-profit For-profit
provider provider
agencies agencies

FIGURE 5-1  An example of a state system of mental health and substance abuse care.

twentieth century that led to dramatic changes in the provi- This is not an unusual choice. Seeking help for mental health
sion of psychiatric care. The introduction of chlorpromazine problems from PCPs rather than from mental health specialists
(Thorazine), the first antipsychotic medication, in the early is common and similar to seeking help for other medical disor-
1950s contributed to hospital discharges. Gradually, more ders. This is especially true because most psychiatric disorders
psychopharmacological agents were added to treat psychosis, are accompanied by unexplained physical symptoms. Most
depression, anxiety, and other disorders, and treatment could people treated for psychiatric disorders will not go beyond this
be provided not only from specialists in psychiatry but also level of care and may feel more comfortable being treated in
from general practitioners. a familiar setting. Furthermore, being treated in primary care
Our current system of psychiatric care includes inpatient rather than in the mental health system may lessen the degree
and outpatient settings. Decisions for level of care tend to be of stigma, self-perceived or societally, attached to getting psy-
based on the condition being treated and the acuteness of the chiatric care.
problem. However, these are not the only criteria. Levels of care Disadvantages to being treated by PCPs include time con-
may be influenced by such factors as a concurrent psychiatric straints, because a 15-minute appointment is usually inad-
or substance abuse problem, medical problems, acceptance of equate for a mental and physical assessment. Because PCPs
treatment, social supports, and disease chronicity or potential typically have limited training in psychiatry, they may lack
for relapse. the expertise in the diagnosis and treatment of psychiatric
disorders (Boscarino et al., 2010). Whereas this may be the
only source many people use for receiving mental health
OUTPATIENT CARE SETTINGS services, sometimes PCPs refer people into specialty mental
Primary care providers (PCPs) are the first choice for most health care.
people when they are ill, but what about mental disorders? Patient-centered medical homes (PCMHs) or primary
Imagine that you are feeling depressed, so depressed, in fact, care medical homes received strong support from the Afford-
that you are miserable and cannot carry out your normal activ- able Care Act of 2010 under President Obama. These health
ities. You recall that a friend who was depressed saw a psychia- homes were developed in response to fragmented care that
trist (or was that a psychologist?), but that seems too drastic. resulted in some services never being delivered while oth-
You do not feel that bad. Perhaps you are coming down with ers were duplicated. The focus of care is patient centered and
something. After all, you have been tired and you are not eating provides access to physical health, behavioral health, and sup-
very well. You decide to visit your PCP, a general health care portive community and social services. Services range from
provider who may be a physician, advanced practice nurse, or preventive care and acute medical problems to chronic con-
physician’s assistant in an office, hospital, or clinic. ditions and end-of-life issues. According to the Agency for
70 UNIT 1  Essential Theoretical Concepts for Practice

Healthcare Research and Quality (2011), these homes have five acquisition of optimal social, working, living, and learning
key characteristics: environments (United States Psychiatric Rehabilitation
1. Patient centered—Care is relationship based with the Services, 2011).
patient (family) and takes into account the unique needs of Psychiatric home care can be provided by any mental
the whole person. The patient is a core member of the team health professional, but it is typically nurses with inpatient
who manages and organizes the care. experience who are able to provide biologically based and
2. Comprehensive care—All levels (preventive, acute, and psychotherapeutic care while working through agencies
chronic) of mental and physical care are addressed. such as visiting nurses. Home care may reduce the need for
Physicians or advanced practice nurses lead teams costly and disruptive hospitalizations and may provide a
that include nurses, physician assistants, pharma- more comfortable and safe alternative to clinical settings. To
cists, nutritionists, social workers, educators, and care qualify for reimbursement, patients must have a psychiatric
coordinators. diagnosis, be under the care of a PCP, and be homebound.
3. Coordination of care—Care is coordinated with the broader The designation of homebound generally is given when
health system such as hospitals, specialty care, and home patients cannot safely leave home, if leaving home causes
health. undue stress, if the nature of the illness results in a refusal to
4. Improved access—Patients do not wait until Monday leave home, or if they cannot leave home unaided. However,
through Friday from 9 am to 5 pm to get the care they need. Medicare reimbursement does allow for the person to leave
In addition to extended hours of service, these homes pro- home once a week for religious services and once a week for
vide e-mail and phone support. hair care.
5. Systems approach—Evidence-based care is provided with Intensive outpatient programs (IOPs) provide structured
a continuous feedback loop of evaluation and quality programs to bridge the gap between inpatient and outpatient
improvement. treatment for people who require more than outpatient care
The treatment of psychiatric disorders and mental health or who may need a transition from an intensive setting. Treat-
alterations can be addressed as part of a comprehensive ment includes individual and group therapy and psychosocial
approach to care. Electronic communication (e.g., follow- education for at least 4 hours per week.
up e-mails and reminders) and record keeping are viewed as Partial hospitalization programs (PHPs) have been
essential to this process. around since the 1960s, and like IOPs, function as an inter-
Community mental health centers (CMHCs) developed mediate step between outpatient and inpatient care. They
from President Kennedy’s Community Mental Health Cen- are the most intensive of outpatient options and tend to be
ters Act of 1963, signaling a new policy preference for com- 4 to 8 hours per day for up to 5 days a week. Structured pro-
munity care as opposed to institutionalization. Although grams are provided with nursing and medical supervision,
only about 700 of the anticipated 2800 CMHCs were intervention, and treatment. They are located within general
funded, the legislation marked a change in direction and led hospitals, in psychiatric hospitals, and as part of community
to state laws and budgets favoring community care. CMHCs mental health programs. Patients whose symptoms are under
are regulated through state mental health departments and control spend a certain number of hours at the facility each
funded by the state. Some areas may provide local fund- day and at night return to their homes, where family and
ing. Because of this limited government funding, financial friends can support them. Additionally, coping strategies that
support services may be restricted to those whose income are learned during the program can be applied and practiced
and medical expenses make them eligible. Typically, fees are in the outside world, and then later explored and discussed.
determined using a sliding scale based on income and ­ability A multidisciplinary team facilitates group therapy, individ-
to pay. ual therapy, other therapies (e.g., art and occupational), and
Community-based facilities provide comprehensive ser- pharmacological management. Patients who are admitted to
vices to prevent and treat mental illness. These services include PHPs are closely monitored in case of need for readmission
assessment, diagnosis, individual and group counseling, case to inpatient care.
management, medication management, education, rehabili-
tation, and vocational or employment services. Some centers Role of Nurses in Outpatient Care Settings
may provide an array of services across the life span, whereas Registered nurses who work in outpatient settings provide
others may be population specific, such as adult, geriatric, or nursing care for individuals with mental illness, alcoholism,
children. substance abuse problems, mental retardation, or develop-
People with serious mental illness may benefit from mental disabilities, as well as their families or caretakers. Com-
psychiatric rehabilitation in the community. This is a munity mental health nurses work to develop and implement
social model that emphasizes and supports recovery and a plan of care along with the multidisciplinary treatment team.
integration into society rather than a medical model of They may choose to be certified in psychiatric mental health
dysfunction. Serious disorders can result in isolation, pov- nursing or hold advanced practice degrees.
erty, and regression. These services focus on the develop- Community mental health nurses need to be very knowl-
ment of social skills, the ability to access resources, and the edgeable about community resources such as shelters for
CHAPTER 5  Settings for Psychiatric Care 71


TYPE OF ORGANIZATION 1980 1990 2000 2004
Number of 24-Hour Hospital and Residential Treatment Beds
All organizations 274,713 325,529 214,186 212,231
State and county mental hospitals 156,482 102,307 61,833 57,034
Private psychiatric hospitals 17,157 45,952 26,402 28,422
Nonfederal general hospitals with 29,384 53,576 40,410 41,403
separate psychiatric services
Veterans Administration (VA) 33,796 24,799 8,989 —
medical centers*
Residential treatment centers for 20,197 35,170 33,508 33,835
emotionally disturbed children
All other organizations† 1,433 63,745 43,044 53,536

24-Hour Hospital and Residential Treatment Beds per 100,000 Civilian Population
All organizations 124.3 128.5 74.8 71.2
State and county mental hospitals 70.2 40.4 21.6 19.1
Private psychiatric hospitals 7.7 18.1 9.2 9.5
Nonfederal general hospitals with 13.7 21.2 14.1 13.9
separate psychiatric services
VA medical centers 15.7 9.9 3.1 —
Residential treatment centers for 9.1 13.9 11.7 11.4
emotionally disturbed children
All other organizations† 0.6 25.2 15.0 17.3
*Department of Veterans Affairs medical centers (VA general hospital psychiatric services and VA psychiatric outpatient clinics) were
dropped from the survey as of 2004.
†Includes free-standing psychiatric outpatient clinics, partial care organizations, and multiservice mental health organizations.

Data from Center for Mental Health Services. (2006). In R. W. Manderscheid & J. T. Berry (Eds.), Mental health, United States, 2004.
USDHHS Pub. No. (SMA)-06-4195, Rockville, MD: Substance Abuse and Mental Health Services Administration.

abused women, food banks for people with severe financial Inpatient facilities provide 24-hour nursing care in a safe
limitations, and agencies that provide employment options and structured setting for people who are in need of this most
for people with mental illness. Nurses may also assess the restrictive environment. Such a setting is essential to caring
patient and living arrangements in the home, provide teach- for those who are in need of protection from suicidal ideation,
ing, refer to community supports, and supervise unlicensed aggressive impulses, medication adjustment and monitor-
care staff. An important concept for community mental ing, crisis stabilization, substance abuse detoxification, and
health nurses is viewing the entire community as a patient. behavior modification. Referrals for inpatient treatment may
This perspective promotes community interventions such as come from a PCP or mental health provider, agencies, another
conducting stress reduction classes and facilitating grief sup- hospital unit, emergency facilities, or nursing homes. Hospi-
port groups. tal admissions are made under the services of a psychiatrist,
although a PCP also may have admitting privileges.
Patients may be admitted voluntarily or involuntarily (see
INPATIENT CARE SETTINGS Chapter 6). Units may be unlocked or locked. Locked units
Inpatient care has undergone significant change over the past provide privacy and prevent elopement—leaving before being
25 years. During the 1980s, inpatient stays were at their peak discharged (also referred to as being “away without leave” or
as private and nonfederal general hospital psychiatric units AWOL). There may also be psychiatric intensive care units
proliferated. During the mid-1990s, the number of patient (PICUs) within the general psychiatric units to provide better
days, psychiatric beds, and psychiatric facilities dipped monitoring of those who display an increased risk for danger
sharply (Table 5-1). This decline was caused by improve- to self or others.
ments instigated by managed care, tougher limitations of The therapeutic milieu is essential to successful inpatient
covered days by insurance plans, and alternatives to inpatient treatment. Milieu refers to the environment in which holis-
hospitalization such as partial hospitalization programs and tic treatment occurs and includes all members of the treat-
residential facilities. ment team (Box 5-1), a positive physical setting, interactions
72 UNIT 1  Essential Theoretical Concepts for Practice


Psychiatric nurse generalists are licensed registered living skills, activities of daily living, and role performance
nurses whose focus is on mental health and illness. that have been affected by mental disorders.
They may or may not have certification in psychiatric • 
Physical therapists possess master’s or doctoral
mental health nursing. degrees and are accredited by the state. Their role is to
Advanced practice psychiatric nurses have post– rehabilitate individuals with physical disabilities that may
baccalaureate degrees and work as either clinical nurse be present concurrent with psychiatric disabilities.
specialists (CNSs) or nurse practitioners (NPs) and have • 
Art therapists are prepared at the master’s level in art
state certification. Both assess health and psychiatric therapy and registered through a professional associa-
disorders, provide psychotherapy, and prescribe medica- tion. They use art to help people understand their prob-
tions. CNSs tend to focus more on leadership, program lems, enhance healthy development, and reduce the
development, education, and psychotherapy, whereas effects of their illnesses.
NPs focus on differential diagnoses, treatment, medica- • 
Recreation therapists are typically bachelor’s prepared
tion management, and psychotherapy. and may be licensed by the state or be nationally certi-
Psychiatrists are medical doctors who have additional fied. Recreational activities are used to improve emo-
specialized training in diagnosing and treating psychi- tional, physical, cognitive, and social well-being.
atric disorders. Medication is the dominant treatment • 
Pharmacists are state licensed and are prepared
used by psychiatrists, although psychotherapy and through 6 years of secondary education for a Doctor of
other psychosocial interventions continue to be used. Pharmacy (PharmD) degree. They provide distribution
Psychologists practice under state regulations and and centralized monitoring of drug regimens.
hold doctor of philosophy in psychology degrees (which • 
Medical personnel are physicians whose focus is the
differ from doctor of medicine). Their expertise lies in provision of nonpsychiatric care for comorbid conditions.
evaluation, psychological testing, psychotherapy, and • 
Mental health workers or psychiatric aides are nonpro-
counseling. Some states may allow prescriptive author- fessional staff who may be state certified. They have
ity for psychologists. extensive contact with patients while assisting with
Social workers are licensed by the state and enter hygiene and meals and participating in unit activities. Men-
general practice with a bachelor’s degree in social work, tal health workers communicate important information
or pursue advanced practice with a master’s degree in concerning the patient’s condition to professional staff.
social work. They may provide counseling and plan for • 
Pastoral counselors are clergy who have clinical pas-
supportive services such as housing, health care, and toral education and are certified through the American
treatment after the patient is returned to the community. Association of Pastoral Counselors. They provide indi-
Counselors possess a master’s degree in psychology, vidual and group counseling.
counseling, or a related field and are licensed by the • 
Consumer providers. “Consumer Providers (CPs) are
state. They are trained to diagnose and provide individ- individuals with serious mental illness who are trained to
ual and group counseling. use their experiences to provide recovery–oriented ser-
Occupational therapists are usually state regulated and vices and to support others with mental illness in a men-
are prepared at the bachelor’s, master’s, or doctoral level. tal health delivery setting” (Chinman et al., 2008, p. v).
They assist individuals to develop or regain independent

Chinman, M., Hamilton, A., Butler, B., Knight, E., Murray, S., et al. (2008). Mental health consumer providers: a guide for clinical staff.
Retrieved from Rand Health website:

between those who are hospitalized, and activities that promote Inpatient rooms are usually less institutional looking
recovery. Inpatient care provides structure in which patients than other hospital rooms and tend to resemble hotel rooms.
eat meals, receive medication (if necessary), attend activities, Showers may be in the individual rooms or dorm-style, with
and participate in individual and group therapies on a sched- one or two per hallway. Rooms are private, semiprivate, or,
ule. For those younger than the age of 18, school attendance is occasionally, wards. Units may be made up solely of males or
required. Patients are active participants in their plans of care of females, or may be coed. Rooms are designed with safety
and have the right to refuse treatments as long as they have not in mind. Hanging is the most common method of inpa-
been declared incompetent. Advocates are usually available to tient suicide; therefore strict measures are taken to prevent
provide advice and counsel for people who have doubts, and it. Closet rods and hooks, towel bars, and shower rods are
most facilities distribute a patient’s bill of rights on admis- constructed to break if subjected to more than a minimal
sion or have it clearly posted. Box 5-2 provides a sample list of amount of weight. Sprinkler and shower heads tend to be
patient’s rights. flush mounted, and utility pipes are enclosed. Other safety
CHAPTER 5  Settings for Psychiatric Care 73


• Right to be treated with dignity • Right to informed consent
• Right to be involved in treatment planning and decisions • Right to confidentiality regarding one’s disorder and
• Right to refuse treatment, including medications treatment
• Right to request to leave the hospital, even against • Right to choose or refuse visitors
medical advice • Right to be informed of research and to refuse to
• Right to be protected against the possible impulse to participate
harm oneself or others that might occur as a result of a • Right to the least restrictive means of treatment
mental disorder • Right to send and receive mail and to be present during
• Right to the benefit of the legally prescribed process of an any inspection of packages received
evaluation occurring within a limited period (in most states, • Right to keep personal belongings unless they are
72 hours) in the event of a request for discharge against dangerous
medical advice that may lead to harm to self or others • Right to lodge a complaint through a plainly publicized
• Right to legal counsel procedure
• Right to vote • Right to participate in religious worship
• Right to communicate privately by telephone and in person

measures include locked windows, platform beds rather than collaboration with the patient’s outpatient clinician, PCP, family,
mechanical hospital beds to prevent possible crushing, and and community agencies such as the visiting nurse agency facili-
furniture with rounded corners to reduce intentional injury. tate an integrated approach and establish comprehensive transi-
Furniture for inpatient rooms tends to be heavy and dura- tion plans from inpatient to the community setting. This allows
ble so that it cannot be thrown or dismantled and used as a the patient to live effectively and safely in the community. Effec-
weapon. tive case management and collaboration also reduce recidivism.
Inpatient care begins with a medical assessment to rule out At discharge, patients should be stabilized. Discharge
or consider co-occurring/comorbid conditions. Comprehen- instructions include follow-up appointments, medication
sive assessments are conducted by a multidisciplinary team, and directions, education and prescriptions, and, if necessary, assis-
a plan of care is developed, monitored, evaluated, and refined. tance with living arrangements that may include a private resi-
Crisis intervention and stabilization and patient safety are goals dence, shelter, halfway house, or group home.
of inpatient care. Psychotropic medication evaluation, pre- Crisis care is provided in emergency departments of gen-
scription, and management are usually part of the plan of care, eral hospitals or in community-based crisis intervention centers.
as is individual therapy. Electroconvulsive therapy (ECT) may Crisis care may be initiated by the individual, friends, family,
be ordered for certain conditions, particularly for patients with health care provider, or law enforcement personnel. Some
depression who have been unresponsive to antidepressants. patients are involuntarily committed. Psychiatric emergencies
Group therapy is an important facet of inpatient care. Cop- may include suicidal (or homicidal) ideation, acute psychosis,
ing skills are taught and enhanced through cognitive behavioral or behavioral responses to drugs. The stay in such facilities
groups that focus on symptom management. Occupational tends to be short, usually less than 24 hours. At that point the
therapy provides an opportunity to practice life skills that have patient may be discharged to home, referred for inpatient care,
been delayed, hampered, or eroded. Psychoeducational groups or transferred to another community facility such as a shelter.
focus on specific psychiatric disorders, medication, goal set- Residential treatment programs are structured short- or
ting, life planning, and recovery. long-term living environments in which individuals are provided
Length of stay varies depending on the severity of the illness with varying levels of supervision and support. The residents also
and symptoms. Nationwide, the mental health average length of learn to access community support as an alternative to hospital-
stay is 8 days, and for substance abuse the average length of stay ization and are encouraged to achieve maximal independence.
is 4.8 days (Piper Report, 2011). At the state level these aver-
ages may vary significantly. Therapeutic passes may be helpful State Acute Care System
so that the patient may go home for limited periods. In some Today’s state-operated psychiatric hospitals are an extension
cases, especially with children and people with severe mental ill- of what remains of the old system, although the quality of care
ness, privileges and rewards, such as recreational outings, walks in state hospitals has improved dramatically. The clinical role
on the hospital grounds, and tokens to buy items from a unit of state hospitals is to serve the most seriously ill patients, but
“store,” may be earned in order to reinforce adaptive behaviors. this role varies widely, depending on available levels of com-
Discharge planning begins on the first day of admission munity care and on payments by state Medicaid programs.
based on the patient’s unique needs. Case management and In some states, state hospitals primarily provide intermediate
74 UNIT 1  Essential Theoretical Concepts for Practice

treatment for patients unable to be stabilized in short-term • Coordinating care by the treatment team
general hospital units, and long-term care for individuals Medication management is an essential skill for psychiatric
judged too ill for community care. In other states the emphasis nurses. In this specialty area nurses often exert a strong influ-
is on acute care that is reflective of gaps in the private sector, ence on medication decisions because continual observation of
especially for the uninsured or for those who have exhausted the expected, interactive effects and adverse effects of medica-
limited insurance benefits. tions provides the data necessary for medication adjustment.
In most states the state hospitals provide forensic (court- For example, feedback about a patient’s excessive sedation
related) care and monitoring as part of their function for those or increased agitation will lead to a decision to decrease or
found not guilty by reason of insanity (NGRI). The state or county increase the dosage of an antipsychotic medication.
system also advises the courts as to defendants’ sanity who may A common misperception regarding psychiatric nurses in
be judged to have been so ill when they committed the criminal acute care settings is that because they “just talk” they lose their
act that they cannot be held responsible, but require treatment skills, including physical tasks such as starting and maintaining
instead. One tragic example is that of Andrea Yates, the Texas intravenous (IV) lines and changing dressings. First, therapeu-
woman who in 2001 drowned her five young children under the tic communication itself is a skill that people are not born with
delusional belief she was saving them from their sinfulness. She and must learn. Second, patients on the psychiatric unit are
was found NGRI and was committed to a Texas state psychiatric not limited to DSM-IV-TR diagnoses and often have complex
facility. health care needs. For example, an older adult male with brittle
diabetes and a recent foot amputation may become actively
General Hospital Psychiatric Units and Private suicidal. In this case, it is likely he will be transferred to the psy-
Psychiatric Hospital Acute Care chiatric unit, where his blood glucose level will be monitored
Acute care general hospital psychiatric units tend to be housed and wound care completed.
on a floor or floors of a general hospital. Private psychiatric
hospitals are free-standing facilities. As noted, the dramatic
growth of acute care psychiatric hospitals and hospital units
is the result of a shift away from institutionalization in state- Treatment options are available that provide specialized care
managed hospitals. Since that time, reduced reimbursement, for specific groups of people. These options include inpatient,
increased managed care, enhanced outpatient options, and outpatient, and residential care.
expanded availability of outpatient and partial hospitalization
programs have resulted in the steady decline of these facili- Pediatric Psychiatric Care
ties. Average length of stay was declining, but has stabilized at Children with mental illnesses have the same range of treat-
about 9 days among the general population, 12 days for chil- ment options as do adults but receive them apart from adults in
dren’s programs, and approximately 15 days for older adults pediatric settings. Inpatient care may be necessary if the child’s
(National Association of Psychiatric Health Systems, 2009). symptoms become severe. Parental or guardian—including
Department of Children and Families—involvement in the
Role of Psychiatric Nurses plan of care is integral so that they understand the illness, treat-
in Inpatient Care Settings ment, and the family’s role in supporting the child. Addition-
As professional care providers available around the clock every ally, hospitalized children, if able, attend school several hours
day of the week, nurses are at the center of any acute care inpa- a day.
tient facility. Management of these units, ideally, is by nurses
with backgrounds in psychiatric mental health nursing, pref- Geriatric Psychiatric Care
erably with advanced practice degrees. Staff nurses tend to be The older adult population may be treated in specialized men-
nurse generalists, that is, nurses who have basic training as reg- tal health settings that take into account the effects of aging
istered nurses. Some registered nurses obtain national certifica- on psychiatric symptoms. Physical illness and loss of indepen-
tion in psychiatric mental health nursing through the American dence can be strong precipitants in the development of depres-
Nurses Credentialing Center. The staff psychiatric registered sion and anxiety. Dementia is a particularly common problem
nurse carries out the following nursing responsibilities: encountered in geriatric psychiatry. Treatment is aimed at
• Completing comprehensive data collection that includes careful evaluation of the interaction of mind and body and
the patient, family, and other health care workers provision of care that optimizes strengths, promotes indepen-
• Developing, implementing, and evaluating plans of care dence, and focuses on safety.
• Assisting or supervising mental health care workers
(e.g., nursing assistants with or without additional train- Veterans Administration Centers
ing in working with people who have mental illnesses) Active military personnel and veterans who were not dishonor-
• Maintaining a safe and therapeutic environment ably discharged may receive federally funded inpatient or outpa-
• Facilitating health promotion through teaching tient care and medication for psychiatric and alcohol or substance
• Monitoring behavior, affect, and mood abuse. One of the greatest challenges veterans face is dealing with
• Maintaining oversight of restraint and seclusion the aftereffects of the traumas of active combat. During Civil
CHAPTER 5  Settings for Psychiatric Care 75

War times these late effects were termed “soldiers heart.” After and support of psychiatric problems. Groups specific to anxi-
World War I, soldiers had “shell shock” and after World War II it ety, depression, loss, caretakers’ issues, bipolar disorder, post-
was termed “battle fatigue.” Currently mental health services are traumatic stress disorder, and almost every other psychiatric
inundated by people suffering from posttraumatic stress disorder issue are widely available in most communities.
(PTSD). There is a prevalence of PTSD in the general population Consumers, people who use mental health services, and
of about 7% and nearly 14% for veterans of the wars in Iraq and their family members have successfully united to shape the
Afghanistan. This creates a tremendous need for strong psychiat- delivery of mental health care. Nonprofit organizations such
ric services for this population (Gradus, 2010). as the National Alliance on Mental Illness (NAMI) encourage
self-help and promote the concept of recovery, or the self-
Forensic Psychiatric Care management of mental illness. Introduced in Chapter 1 and
Incarcerated populations, both adult and juvenile, have higher discussed further in Chapters 3 and 19, these grassroots’ groups
than average incidences of mental disorders or substance abuse. also confront social stigma, influence policies, and support the
Researchers estimate that there are more people with mental rights of people experiencing mental illness.
illness in prisons than in hospitals (Torrey et al., 2010). Treat-
ment may be provided within the prison system, where inmates
are often separated from the general prison population. State
hospitals also treat forensic patients. Most facilities provide Most Americans are covered by private insurance that pays
psychotherapy, group counseling, medication management, varying amounts for mental health care. Standard policies not
and assistance with transition to the community. only allow people to choose their providers and seek treatment
but also provide some portion of reimbursement. Managed care
Alcohol and Drug Abuse Treatment plans stipulate the providers members may visit and then may
All the mental health settings that were previously described cover the entire costs or require copays from the members. Low-
may provide treatment for alcohol and substance abuse, income Medicaid and Medicare recipients may also be enrolled
although specialized treatment centers exist apart from the in managed care plans. Both standard policies and managed
mental health care system. More than 4 million people aged 12 care plans provide coverage for mental health care, although it
or older (nearly 2% of the population) received treatment for is often not at the same rate as is coverage for physical care.
alcohol or illicit drug use in 2009 (Substance Abuse and Mental Limits in health insurance are problematic in terms of cov-
Health Services Administration [SAMHSA], 2010). This treat- erage for mental illnesses. Because most health insurance is
ment is typically outpatient and includes counseling, educa- employer based and because serious mental illness can lead to job
tion, medication management, and 12-step programs. Because loss, many individuals with serious mental illness have no cover-
alcohol detoxification can be life-threatening, inpatient care age. State systems exist, in part, as a “safety net” for the limits
may be required for medical management. Drug rehabilita- in health insurance. Furthermore, most private insurance plans
tion facilities provide inpatient care for detoxification of drugs, (along with Medicare) have enacted coverage limits that are more
including opiates and chemicals, and offer all levels of outpa- restrictive for treatment of mental illness than other illnesses with
tient care. annual or lifetime caps on days of care or on total expenses.
In 1996 the federal government enacted a mental health
Self-Help Options parity law that made it illegal for companies with more than
Obtaining sufficient sleep, meditating, eating right, exercis- 50 employees to limit annual or lifetime mental health benefits
ing, abstaining from smoking, and limiting the use of alcohol unless they also limited benefits for physical illnesses. Although
are healthy responses to a variety of illnesses such as diabetes this federal legislation was a good start, problems remained. One
and hypertension. As with other medical conditions, lifestyle problem is that reimbursement does not include substance abuse
choices and self-help responses can have a profound influence or chemical dependency treatment. The Paul Wellstone and Pete
on the quality of life and the course, progression, and outcome Domenici Mental Health Parity and Addiction Equity Act of
of psychiatric disorders. If we accept the notion that psychiat- 2008 expanded the 1996 legislation by adding addictions to the
ric disorders are usually a combination of biochemical interac- mental health benefits list; this act became effective in early 2010
tions, genetics, and environment, then it stands to reason that (SAMHSA, 2010). It is important to note that both legislators had
by providing a healthy living situation, we are likely to fare bet- relatives with severe mental illness—Wellstone’s brother had a
ter. If, for example, a person has a family history of anxiety and severe mental illness and Domenici’s daughter has schizophrenia.
has demonstrated symptoms of anxiety, then a good first step This latest federal legislation protects state parity laws that
(or an adjunct to psychiatric treatment) could be to learn yoga may actually be stronger, but preempts (takes the place of)
and balance the amounts of life’s obligations with relaxation. weaker state parity laws. Coverage varies by state. For example,
A voluntary network of self-help groups operates outside Arkansas provides coverage for all mental illness. Other states
the formal mental health care system to provide education, limit the coverage to a specific list of biologically based—a term
contacts, and support. Since the introduction of Alcoholics with several definitions—mental illnesses. In Ohio this list
Anonymous in the early twentieth century, self-help groups includes schizophrenia, schizoaffective disorder, major depres-
have multiplied and have proven to be effective in the treatment sive disorder, bipolar disorder, paranoia and other psychotic
76 UNIT 1  Essential Theoretical Concepts for Practice

disorders, obsessive-compulsive disorder, and panic disorder Psychiatric registered nurses are uniquely qualified to
(Ohio Laws, 2007). As of February 2010, 30 states were desig- address each of the aforementioned goals by virtue of an
nated as offering full parity for mental illness insurance cover- integrated educational background that includes biology,
age (National Conference of State Legislatures, 2010). psychology, and the social sciences. Nurses specializing in
In addition to the state systems of care, public assistance is this area will increasingly be in demand. As the population
available for mental health care and costs of living. Four assis- ages, more geropsychiatric nurses will be needed to work with
tance programs are Medicare, Medicaid, Social Security, and older adult psychiatric patients with complex health prob-
the Veterans Administration (VA). Medicare is a national pro- lems. Advanced practice psychiatric nurses may collaborate
gram that provides benefits to those who are 65 years of age or more with primary health care practitioners or in indepen-
older and to those who have become totally disabled. In the dent practice to fill the gap in existing community services.
case of mental illness, benefits are limited and coverage may be Psychiatric nurses can help make the vision statement from
50% for outpatient care compared with 80% for non–mental the President’s New Freedom Commission on Mental Health
health outpatient care. Medicaid operates under federal guide- (2003) a reality:
lines and state regulations and pays mental health care costs for
We envision a future when everyone with a mental illness
people who have extreme financial need.
will recover, a future when mental illnesses can be pre-
States vary widely in how they fund mental health care, but all
vented or cured, a future when mental illnesses are detected
states must provide benefits for inpatient care, PCP services, and
early, and a future when everyone with a mental illness at
treatment for those younger than age 21. Social Security has two
any stage of life has access to effective treatment supports—
federal programs designed to help people with disabilities. Social
essentials for living, working, learning, and participating
Security Disability Insurance (SSDI) may be awarded to individuals
fully in the community.
who have worked a required length of time, have paid into Social
Security, and are disabled for 12 months or more. Supplemental On March 23, 2010, President Obama, signed into law
Security Income (SSI) provides benefits based on economic need the Affordable Care Act. This groundbreaking piece of leg-
(Social Security Administration, 2011). Among people receiving islation will help insure millions of people who could not
Social Security disability income, psychiatric disorders are the larg- previously afford healthcare insurance. This will include
est and fastest growing subgroup (Drake et al., 2009). millions of children and adults with mental health condi-
tions who will no longer be denied healthcare because of
A VISION FOR MENTAL HEALTH CARE pre-existing conditions. Some other provisions under this
law include:
IN AMERICA • Insurance companies can no longer deny a person
Despite the availability and variety of community psychiatric because of pre-existing conditions or for resending or
treatments in the United States, many patients in this coun- taking away insurance for health/mental health related
try in need of services are not receiving them. In addition to reasons
stigma, there are geographic, financial, and systems factors that • Expansion of coverage for young adults up to the age of
impede access to psychiatric care. For example, mental health 26 under the parents’ family policy
services are scarce in some rural areas, and many American • A provision for people over 65 on Medicare — a 50%
families cannot afford health insurance even if they are work- discount for name brand drugs who reach the Medicare
ing. The President’s New Freedom Commission on Mental “doughnut-hole”
Health was charged with studying the mental health system and • Provides small business tax credits
issuing recommendations for its transformation (2003). It is • Provides affordable coverage to millions of Americans
likely that their recommendations will influence the direction who aren’t able to afford care
of mental health care for the next 2 decades. Their final report • People with existing healthcare coverage are able to keep
identifies that in a transformed mental health care system: or choose their doctors.
• Americans understand that mental health is essential to Parts of this law have already gone into effect, and the
overall health. complete Affordable Care Act is due to go into effect in 2014.
• Mental health care is consumer and family driven. We envision a future when everyone with a mental illness
• Disparities in mental health services are eliminated. will recover, a future when mental illnesses can be prevented
• Early mental health screening, assessment, and referral to or cured, a future when mental illnesses are detected early,
services are common practice. and a future when everyone with a mental illness at any stage
• Excellent mental health care is delivered and research is of life has access to effective treatment supports—essentials
accelerated. for living, working, learning, and participating fully in the
• Technology is used to access mental health care and community.
CHAPTER 5  Settings for Psychiatric Care 77


• C ompared to seeking care for physical disorders, finding care • I npatient care is used when less restrictive outpatient
for psychiatric disorders can be complicated by a two-tiered options are insufficient in dealing with symptoms. It can
system of care provided in the private and public sectors. be provided in general medical centers, private psychiatric
• Nonspecialist primary care providers treat a significant por- centers, crisis units, and state hospitals.
tion of psychiatric disorders. • Nurses provide the basis for inpatient care and are part of
• Psychiatric care providers are specialists who are licensed the overall unit milieu that emphasizes the role of the total
to prescribe medication and conduct therapy. They include environment in providing support and treatment.
psychiatrists, advanced practice psychiatric nurses, physi- • Specific populations such as children, veterans, geriatrics,
cians’ assistants, and, in some states, psychologists. and forensics benefit from treatment geared to their unique
• Community mental health centers are state-regulated and needs.
state-funded facilities that are staffed by a variety of mental • Financing psychiatric care has been complicated by lack
health care professionals. of parity, or equal payment for physical as compared to
• Other outpatient settings include psychiatric home care, psychiatric disorders. Legislation has been proposed and
intensive outpatient programs, and partial hospitalization passed to improve mental health parity.


1. Y
 ou are a community psychiatric mental health nurse problems, he says that he has tested positive for human
working at a local mental health center. You are conducting immunodeficiency virus and takes multiple medications
an assessment interview with a single male patient who is that he cannot name.
45 years old. He reports that he has not been sleeping and A. What are your biopsychosocial and spiritual concerns
that his thoughts seem to be “all tangled up.” He informs about this patient?
you that he hopes you can help him today because he does B. What is the highest priority problem to address before
not know how much longer he can go on. He does not make he leaves the clinic today?
any direct reference to suicidal intent. He is disheveled and C. Do you feel that you need to consult with any other mem-
has been sleeping at shelters. He has little contact with his bers of the multidisciplinary team today about this patient?
family and starts to become agitated when you suggest that D. In your role as case manager, what systems of care will
it might be helpful for you to contact them. He refuses to you need to coordinate to provide quality care for this
sign any release of information forms. He admits to recent patient?
hospitalization at the local veterans’ hospital and reports E. How will you start to develop trust with the patient to
previous treatment at a dual-diagnosis facility even though gain his cooperation with the treatment plan?
he denies substance abuse. In addition to his mental health


Choose the most appropriate answer(s). 3. W hich of the following is a benefit for patients being treated
1. A 24-year-old female is diagnosed with alcohol dependence and for mental health problems by a primary care physician
requires acute detoxification. The most appropriate setting is: rather than a psychiatrist?
1. partial hospitalization. 1. A high level of expertise in the diagnosis of psychiatric
2. residential setting. disorders
3. rehab unit. 2. Extended time in the physician’s office for a thorough
4. acute inpatient care. psychiatric assessment
2. A significant influence allowing psychiatric treatment to 3. Feeling that there is less stigma attached to treatment
move from the hospital to the community was: 4. A high level of expertise in the management of psycho-
1. television. pharmacological medications for psychiatric illnesses
2. the development of psychotropic medications. 4. A 45-year-old patient experiencing increased symptoms of
3. identification of external causes of mental illness. anxiety lives in a rural community over 100 miles from the
4. the use of a collaborative approach by patients and staff nearest psychiatrist. Other health team members are located
focusing on rehabilitation. closer to his residence. Which of the following health care
78 UNIT 1  Essential Theoretical Concepts for Practice

  C H A P T E R R E V I E W Q U E S T I O N S—cont’d
professionals could provide an initial screening and treat- The supervisor explains to the student why this assignment is
ment plan for this patient? (Select all that apply.) appropriate for her role. Which is the most suitable rationale
1. Social worker that the supervisor can provide to the student nurse?
2. Psychologist 1. Stress reduction is important to a patient’s mental health.
3. Primary care provider 2. Funding sources will support the class only if it is devel-
4. Advanced practice psychiatric nurse oped by a nurse.
5. A community mental health student nurse is asked by her 3. An important concept for community health nursing is
supervisor to develop a stress reduction class for the residents to view the entire community as a patient.
in the surrounding community. The student nurse resists, 4. Research has demonstrated that stress reduction reduces
saying that her responsibilities are to her patient caseload. hypertension in mental health patients.

REFERENCES Ohio Laws. (2007). Health coverage plans—biologically based mental

illness. Ohio Revised Code. Retrieved April 20, 2011, from http://
Agency for Healthcare Research and Quality. (2011). What is PCMH?
Retrieved 12/29/2011 from Piper Report. (2011). Hospitalizations for mental health and substance
community/pcmh__home/1483/what_is_pcmh. abuse disorders: costs, length of stay, patient mix, and payor mix.
Boscarino, J. A., Larson, S., Ladd, I., Hill, E., & Paolucci, S. J. (2010). Retrieved June 1, 2012, from
Mental health experiences and needs among primary care pro- 2011/06/25/hospitalizations-for-mental-health-and-substance-
viders treating OEF/OIF veterans: preliminary findings from abuse-disorders.
the Geisinger Veterans Initiative. International Journal of Emer- President’s New Freedom Commission on Mental Health. (2003).
gency Mental Health, 12(3), 161–170. Achieving the promise: transforming mental health care in America.
Drake, R. E., Skinner, J. S., Bond, G. R., & Goldman, H. H. (2009). Retrieved February 18, 2008, from www.mentalhealthcommission.
Social security and mental illness: reducing disability with sup- gov/reports/FinalReport/toc.html.
ported employment. Health Affairs, 28(3), 761–770. Social Security Administration. (2011). Understanding supple-
Gradus, J. L. (2010). Epidemiology of PTSD. In United States mental security income. Retrieved April 20, 2011, from
­Department of Veterans Affairs. Retrieved April 16, 2011, from Substance Abuse and Mental Health Services Administration. (2010).
asp. Results from the 2009 national survey on drug use and health.
Kessler, R. C., Berglund, P., Demler, O., et al. (2005). Lifetime Retrieved April 16, 2011, from
prevalence and age-of-onset distributions of DSM-IV disorders in NSDUH/2k9Results.htm#Ch3.
the national comorbidity survey replication. Archives of General Torrey, E. F., Kennard, A. D., Eslinger, D., Lamb, R., & Pavle, J.
Psychiatry, 62, 593–602. (2010). More mentally ill persons are in jails and prisons than hospi-
National Association of Psychiatric Health Systems. (2009). 2008 tals: a survey of the states. Retrieved April 16, 2011, from http://74.
NAPHS Annual Survey. Washington, DC: Author. 125.155.132/scholar?
National Association of State Mental Health Program Directors. percent+of+prison+population+with+a+mental+disorder&hl=en&
(2011). State psychiatric hospitals. Retrieved April 14, 2011, from as_sdt=0,36&as_ylo=2009. United States Psychiatric Rehabilitation Services. (2011). About the
National Conference of State Legislatures. (2010). State laws mandat- US Psychiatric Rehabilitation Association. Retrieved April 19, 2011,
ing or regulating mental health benefits. Retrieved April 20, 2011, from
from =USPRA&WebCode=about.

Legal and Ethical Basis for Practice
Penny Simpson Brooke

  For additional DSM-5 criteria content, see Appendix C


assault, p. 87 Health Insurance Portability SELECTED CONCEPT: Right
autonomy, p. 80 and Accountability Act to Treatment
battery, p. 87 (HIPAA), p. 85 With the enactment of the Hospitalization
beneficence, p. 80 implied consent, p. 84 of the Mentally Ill Act in 1964, the federal
bioethics, p. 80 informed consent, p. 83 statutory right to psychiatric treatment in
child abuse reporting intentional torts, p. 87 public hospitals was created. The statute
statutes, p. 87 involuntary admission, p. 81 requires that medical and psychiatric care
civil rights, p. 81 involuntary outpatient and treatment be provided to everyone
commitment, p. 82 ­commitment, p. 82 admitted to a public hospital.
conditional release, p. 82 justice, p. 80 Based on the decisions of a number of
confidentiality, p. 85 least restrictive alternative early court cases, treatment must meet
defamation of character, p. 88 ­doctrine, p. 81 the following criteria:
discharge, p. 82 negligence, p. 89 • The environment must be humane.
duty to warn, p. 86 punitive damages, p. 88 • Staff must be qualified and sufficient
elder abuse reporting right to privacy, p. 85 to provide adequate treatment.
statutes, p. 87 right to refuse treatment, p. 83 • The plan of care must be individualized.
ethical dilemma, p. 80 right to treatment, p. 82
ethics, p. 80 tort, p. 87
false imprisonment, p. 87 veracity, p. 80
fidelity, p. 80 voluntary admission, p. 81
foreseeability of harm, p. 89 writ of habeas corpus, p. 81

80 UNIT 1  Essential Theoretical Concepts for Practice

1. Compare and contrast the different admissions procedures 5. Summarize situations in which health care professionals
including admission criteria. have a duty to break patient confidentiality.
2. Summarize patients’ rights as they pertain to the patient’s 6. Discuss a patient’s civil rights and describe how they per-
(a) right to treatment, (b) right to refuse treatment, and tain to restraint and seclusion.
(c) right to informed consent. 7. Discuss in detail the balance between the patient’s rights
3. Delineate the steps nurses are advised to take if they and the rights of society with respect to the following legal
suspect negligence or illegal activity on the part of a profes- concepts relevant in nursing and psychiatric nursing: (a)
sional colleague or peer. duty to intervene, (b) documentation and charting, and
4. Discuss the legal considerations of patient privilege (a) (c) confidentiality.
after a patient has died, (b) if the patient tests positive for
human immunodeficiency virus, or (c) if the patient’s
employer states a “need to know.”

This chapter introduces you to current legal and ethical issues 2. Autonomy: Respecting the rights of others to make their
that may be encountered in the practice of psychiatric nursing. own decisions. Acknowledging the patient’s right to refuse
A fundamental goal of psychiatric care is to strike a balance medication is an example of promoting autonomy.
between the rights of the individual patient and the rights of 3. Justice: The duty to distribute resources or care equally,
society at large. This chapter is designed to assist you in under- regardless of personal attributes. An example of justice
standing the implications of ethical or legal issues on the provi- is when an intensive care unit (ICU) nurse devotes equal
sion of care in a psychiatric setting. attention both to a patient who has attempted suicide and
An ethical dilemma results when there is a conflict between to another patient who suffered a brain aneurysm.
two or more courses of action, each carrying with them favor- 4. Fidelity (nonmaleficence): Maintaining loyalty and com-
able and unfavorable consequences. How we respond to these mitment to the patient and doing no wrong to the patient.
dilemmas is based partly on our own morals (beliefs of right Maintaining expertise in nursing skill through nursing edu-
or wrong) and values. Suppose you are caring for a pregnant cation demonstrates fidelity to patient care.
woman with schizophrenia who wants to carry the baby to 5. Veracity: One’s duty to communicate truthfully. Describing
term, but whose family insists she get an abortion. In order to the purpose and side effects of psychotropic medications in
promote fetal safety, her antipsychotic medication will need a truthful and nonmisleading way is an example of veracity.
to be reduced, putting her at risk of exacerbation of the ill- Law and ethics are closely related because law tends to reflect
ness. Furthermore, there is a question as to whether she can the ethical values of society. It should be noted that although
safely care for the child. If you relied on the ethical principle of you may feel obligated to follow ethical guidelines, these guide-
autonomy, you may conclude that she has the right to decide. lines should not override laws. For example, if you are aware
Would other ethical principles be in conflict with autonomy of a statute or a specific rule or regulation created by the state
in this case? board of nursing that prohibits a certain action (e.g., restrain-
At times your values may be in conflict with the value ing patients against their will) and you feel you have an ethical
system of the institution. This situation further complicates obligation to protect the patient by engaging in such an action
the decision-making process and necessitates careful consid- (e.g., using restraints), you would be wise to follow the law.
eration of the patient’s desires. For example, you may expe-
rience a conflict in a setting where older adult patients are
routinely tranquilized to a degree that you find excessive.
Whenever one’s value system is challenged, increased stress Laws have been enacted to regulate the care and treatment
results. of the mentally ill. Mental health laws, or statutes, vary from
state to state; in order to understand the legal climate of your
specific state, you are encouraged to review its code. This can
LEGAL AND ETHICAL CONCEPTS be accomplished by visiting the webpage of your state mental
Ethics is the study of philosophical beliefs about what is con- health department or by doing an Internet search using the fol-
sidered right or wrong in a society. Bioethics is a more specific lowing key words: ‘mental +  health +  statutes + (your state).’
term that refers to the ethical questions that arise in health care. Many of these laws have undergone major revision since
The five basic principles of bioethics are as follows: 1963, which reflects a shift in emphasis from state or institu-
1. Beneficence: The duty to act so as to benefit or promote tional care of the mentally ill to community-based care. This
the good of others. Spending extra time to help calm an was heralded by the enactment of the Community Mental
extremely anxious patient is a beneficent act. Health Center Act of 1963 under President John F. Kennedy.
CHAPTER 6  Legal and Ethical Basis for Practice 81

Along with this shift in emphasis has come the more wide- to “free the person.” The writ of habeas corpus is the proce-
spread use of psychotropic drugs in the treatment of mental dural mechanism used to challenge unlawful detention by the
illness—which has enabled many people to integrate more government.
readily into the larger community—and an increasing aware- The writ of habeas corpus and the least restrictive alterna-
ness of the need to provide the mentally ill with humane care tive doctrine are two of the most important concepts applica-
that respects their civil rights. Parity in health insurance cover- ble to civic commitment cases. The least restrictive alternative
age for mental health treatment was addressed in 2010 by two doctrine mandates that the least drastic means be taken to
separate laws. The Paul Wellstone and Pete Domenici Mental achieve a specific purpose. For example, if someone can safely
Health Parity and Addiction Equity Act states that if mental be treated for depression on an outspatient basis, hospitaliza-
health or substance abuse care is covered by a private insurance tion would be too restrictive and unnecessarily disruptive.
plan, then these conditions must receive coverage equitable
to other physical medical conditions. The 2010 Health Insur- Admission to the Hospital
ance Exchanges program requires that each state offers mental All students are encouraged to become familiar with the impor-
health care and substance abuse services equal to other medical tant provisions of the laws in their own states regarding admis-
services (Bazelon, 2010). sions, discharges, patient’s rights, and informed consent.
A medical standard or justification for admission should
Civil Rights exist. A well-defined psychiatric problem must be established,
People with mental illness are guaranteed the same rights under based on current illness classifications in the current Diagnos-
federal and state laws as any other citizen. Most states specifi- tic and Statistical Manual of Mental Disorders (DSM) authored
cally prohibit any person from depriving an individual receiv- by the American Psychiatric Association. The presenting ill-
ing mental health services of his or her civil rights, including ness should also be of such a nature that it causes an immedi-
the right to vote; the right to civil service ranking; the rights ate crisis situation or that other less restrictive alternatives are
related to granting, forfeit, or denial of a driver’s license; the inadequate or unavailable. There should also be a reasonable
right to make purchases and to enter contractual relationships expectation that the hospitalization and treatment will improve
(unless the patient has lost legal capacity by being incompe- the presenting problems.
tent); and the right to press charges against another person. In the case of Olmstead v. L.C. (1999) the Supreme Court of
The psychiatric patient’s rights include the right to humane the United States ruled that states are required to place patients
care and treatment. The medical, dental, and psychiatric needs with mental health illness in less restrictive community set-
of the patient must be met in accordance with the prevailing tings, rather than institutions, when the treatment profession
standards accepted in these professions. The mentally ill in has determined that a community setting is appropriate and
prisons and jails are afforded the same protections. The right to the patient is not opposed to the decision to transfer from an
religious freedom and practice, the right to social interaction, institution to a community facility.
and the right to exercise and recreational opportunities are also
protected. Voluntary Admission
In recent years many states have established Mental Health Generally, voluntary admission is sought by the patient or the
Courts to process criminal cases involving defendants with patient’s guardian through a written application to the facil-
mental illnesses. These courts attempt to direct the offender to ity. Voluntarily admitted patients have the right to demand and
treatment and services in the community (Bazelon, 2011). obtain release. However, few states require voluntarily admitted
patients to be notified of the rights associated with their status.
ADMISSION AND DISCHARGE PROCEDURES In addition, many states require that a patient submit a written
release notice to the facility staff, who reevaluate the patient’s
Due Process in Civil Commitment condition for possible conversion to involuntary status accord-
The courts have recognized that involuntary civil commit- ing to criteria established by state law.
ment to a mental hospital is a “massive curtailment of liberty”
(Humphrey v. Cady, 1972) requiring due process protections Involuntary Admission (Commitment)
in the civil commitment procedure. This right derives from Involuntary admission is made without the patient’s consent.
the Fifth Amendment of the U.S. Constitution, which states Generally, involuntary admission is necessary when a person
that “no person shall…be deprived of life, liberty, or prop- is in need of psychiatric treatment, presents a danger to self or
erty without due process of law.” The Fourteenth Amend- others, or is unable to meet his or her own basic needs. Involun-
ment explicitly prohibits states from depriving citizens of life, tary commitment requires that the patient retain freedom from
liberty, and property without due process of law. State civil unreasonable bodily restraints as well as the right to informed
commitment statutes, if challenged in the courts on constitu- consent and the right to refuse medications, including psycho-
tional grounds, must afford minimal due process protections tropic or antipsychotic medications.
to pass the court’s scrutiny (Zinermon v. Burch, 1990). In Three different commitment procedures are commonly
most states, a patient can challenge commitments through a available: judicial determination, administrative determi-
writ of habeas corpus, which means a “formal written order” nation, and agency determination. In addition, a specified
82 UNIT 1  Essential Theoretical Concepts for Practice

number of physicians must certify that a person’s mental of voluntary patients, which enables the treating physician or
health status justifies detention and treatment. Involuntary administrator to order continued treatment on an outpatient
hospitalization can be further categorized by the nature and basis if the clinical needs of the patient warrant further care.
purpose of the involuntary admission: emergency hospitaliza-
tion; observational or temporary hospitalization; long-term or Conditional Release
formal commitment; or outpatient commitment. Conditional release usually requires outpatient treatment for a
Emergency involuntary hospitalization. Most states provide specified period to determine the patient’s adherence with medica-
for emergency involuntary hospitalization or civil commit- tion protocols, ability to meet basic needs, and ability to reintegrate
ment for a specified period (1 to 10 days on average) to prevent into the community. Generally a voluntarily hospitalized patient
dangerous behavior that is likely to cause harm to self or others. who is conditionally released can only be committed through the
Police officers, physicians, and mental health professionals may usual methods for involuntary hospitalization. However, an invol-
be designated by law to authorize the detention of mentally ill untarily hospitalized patient who is conditionally released may be
individuals who are a danger to themselves or others. reinstitutionalized while the commitment is still in effect without
Observational or temporary involuntary hospitalization. recommencement of formal admission procedures.
Civil commitment for observational or temporary involuntary
hospitalization is of longer duration than emergency hospital- Unconditional Release
ization. The primary purpose of this type of hospitalization is Unconditional release, or discharge, is the termination of a
observation, diagnosis, and treatment for those who have men- patient-institution relationship. This release may be court
tal illness or pose a danger to themselves or others. The length ordered or administratively ordered by the institution’s offi-
of time and procedures vary markedly from state to state. A cials. Generally, the administrative officer of an institution has
guardian, family member, physician, or other public health the discretion to discharge patients.
officer may apply for this type of admission. Certification by
two or more physicians, a judicial review, or administrative Release Against Medical Advice (AMA)
review and order is often required for involuntary admission. In some cases there is a disagreement between mental health
Long-term or formal commitment. Long-term commitment care providers and patients as to whether continued hospital-
for involuntary hospitalization has as its primary purpose ization is necessary. When treatment seems beneficial, but there
extended care and treatment of the mentally ill. Those who is no compelling reason (e.g., danger to self or others) to seek
undergo extended involuntary hospitalization are commit- an involuntary continuance of stay, patients may be released
ted through medical certification, judicial, or administrative against medical advice.
action. Some states do not require a judicial hearing before
commitment, but often provide the patient with an oppor-
tunity for a judicial review after commitment procedures.
This type of involuntary hospitalization generally lasts 60 to Psychiatric facilities usually provide patients with a written list
180 days, but may be for an indeterminate period. of basic patient rights. These rights are derived from a variety of
Involuntary outpatient commitment. Beginning in the sources, especially legislation that developed during the 1960s.
1990s, states began to pass legislation that permitted outpatient Since then, they have been modified to some degree, but most
commitment as an alternative to forced inpatient treatment. lists share commonalities in the following text.
Recently states are using involuntary outpatient commitment
as a preventive measure, allowing a court order before the onset Right to Treatment
of a psychiatric crisis that would result in an inpatient com- With the enactment of the Hospitalization of the Mentally Ill
mitment. The order for involuntary outpatient commitment is Act in 1964, the federal statutory right to psychiatric treatment
usually tied to receipt of goods and services provided by social in public hospitals was created. The statute requires that medi-
welfare agencies, including disability benefits and housing. cal and psychiatric care and treatment be provided to everyone
To access these goods and services the patient is mandated to admitted to a public hospital.
participate in treatment and may face inpatient admission if Although state courts and lower federal courts have decided
he or she fails to participate in treatment (Chan, 2003; Mona- that there may be a federal constitutional right to treatment, the
han et al., 2003; Rainey, 2001). Forced treatment raises ethi- U.S. Supreme Court has never firmly defined the right to treat-
cal dilemmas regarding autonomy versus paternalism, privacy ment in a constitutional principle. The evolution of these cases
rights, duty to protect, and right to treatment; and has been in the courts provides an interesting history of the development
challenged on constitutional grounds. and shortcomings of our mental health delivery system. Based
on the decisions of a number of early court cases, treatment
Discharge from the Hospital must meet the following criteria:
Release from hospitalization depends on the patient’s admission • The environment must be humane.
status. Patients who sought informal or voluntary admission, • Staff must be qualified and sufficient to provide adequate
as previously discussed, have the right to request and receive treatment.
release. Some states, however, do provide for conditional release • The plan of care must be individualized.
CHAPTER 6  Legal and Ethical Basis for Practice 83

The initial cases presenting the psychiatric patient’s right Cases involving the right to refuse psychotropic drug
to treatment arose in the criminal justice system. An interest- treatment are still evolving. Without clear direction from the
ing case regarding a person’s right to treatment is O’Connor v. Supreme Court, there will be different case outcomes in differ-
Donaldson (1975). The Court held that a “state cannot consti- ent jurisdictions.
tutionally confine a nondangerous individual who is capable The numerous cases involving the right to refuse medica-
of surviving safely in freedom by himself or with the help of tion have illustrated the complex and difficult task of translating
willing and responsible family members or friends.” social policy concerns into a clearly articulated legal standard.

Right to Refuse Treatment Right to Informed Consent

A companion to the right to consent to treatment is the right to The principle of informed consent is based on a person’s right
withhold consent. A patient may also withdraw consent at any to self-determination, as enunciated in the landmark case of
time. Retraction of consent previously given must be honored, Canterbury v. Spence (1972):
whether it is verbal or written. However, the mentally ill patient’s
right to refuse treatment with psychotropic drugs has been The root premise is the concept, fundamental in American
debated in the courts, based partly on the issue of mental patients’ jurisprudence, that every human being of adult years and
sound mind has a right to determine what shall be done with
competency to give or withhold consent to treatment and their
his own body…. True consent to what happens to one’s self is
status under the civil commitment statutes. These early cases,
the informed exercise of choice, and that entails an opportunity
initiated by state hospital patients, considered medical, legal, and to evaluate knowledgeably the options available and the risks
ethical considerations, such as basic treatment problems, the doc- attendant on each.
trine of informed consent, and the bioethical principle of auton-
omy. For a summary of the evolution of one landmark set of cases Proper orders for specific therapies and treatments are
regarding the patient’s right to refuse treatment, see Table 6-1. required and must be documented in the patient’s chart. Con-
The notion of refusing treatment becomes especially impor- sent for surgery, electroconvulsive treatment, or the use of
tant if we consider medication to be a “chemical restraint.” If it experimental drugs or procedures must be obtained. In some
is, then the infringement on a person’s liberty is at least equal to state institutions, consent is required for every medication
that with involuntary commitment. In this circumstance, the addition or change. Patients have the right to refuse participa-
noninstitutionalized, competent, mentally ill patient has the tion in experimental treatments or research and the right to
right, through substituted judgment, to determine whether to voice grievances and recommend changes in policies or services
be involuntarily committed or to be medicated. offered by the facility, without fear of punishment or reprisal.


Rogers v. Okin, 478 F. Federal district court Ruled that involuntarily hospitalized patients with mental
Supp. 1342 illness are competent and have the right to make treatment
(D. Mass. 1979) decisions.
Forcible administration of medication is justified in an emer­
gency if needed to prevent violence and if other alternatives
have been ruled out.
A guardian may make treatment decisions for an incompetent
Rogers v. Okin, 634 F. 2nd Federal court of appeals Affirmed that involuntarily hospitalized patients with mental
650 (1st Cir. 1980) illness are competent and have the right to make treatment
The staff has substantial discretion in an emergency.
Forcible medication is also justified to prevent the patient’s
A patient’s rights must be protected by judicial determination
of competency or incompetency.
Mills v. Rogers, 457 U.S. U.S. Supreme Court Set aside the judgment of the court of appeals with instruc­
291 (1982) tions to consider the effect of an intervening state court case.
Rogers v. Commissioner of Massachusetts Supreme Ruled that involuntarily hospitalized patients are competent
the Department of Mental Judicial Court answering and have the right to make treatment decisions unless they
Health, 458 N.E.2d 308 questions certified by are judicially determined to be incompetent.
(Mass. 1983) federal court of appeals
84 UNIT 1  Essential Theoretical Concepts for Practice

For consent to be effective legally, it must be informed. Gen- of individuals who are to be notified of the patient’s hospital-
erally, the informed consent of the patient must be obtained ization and who may have visitation rights is especially helpful
by the physician or other health professional who will perform given the privacy demands of the Health Insurance Portability
the treatment or procedure. Patients must be informed of the and Accountability Act (HIPAA) (Bazelon, 2003).
nature of their problem or condition, the nature and purpose of
a proposed treatment, the risks and benefits of that treatment, Rights Regarding Restraint and Seclusion
the alternative treatment options available, the probability that As mentioned, the use of the least restrictive means of restraint
the proposed treatment will be successful, and the risks of not for the shortest duration is always the general rule. Ver-
consenting to treatment. It is important for psychiatric nurses bal interventions or enlisting the cooperation of patients are
to know that the presence of psychotic thinking does not mean examples of first-line interventions. Typically, medication is
that the patient is incompetent or incapable of understanding. considered if verbal interventions fail. Chemical interventions
Neither voluntary nor involuntary admission to a men- are usually considered less restrictive than mechanical, but
tal facility determines whether patients are capable of mak- can have a greater effect on the patient’s ability to relate to the
ing informed decisions about the health care they may need. environment. When used judiciously, psychopharmacology is
Patients must be considered legally competent until they extremely effective and helpful as an alternative to other physi-
have been declared incompetent through a legal proceeding. cal methods of restraint.
Competency is related to the capacity to understand the con- The history of mechanical restraint and seclusion is one
sequences of one’s decisions. The determination of legal com- that is marked by abuses and overuse, and even a tendency to
petency is made by the courts. If found incompetent, the court use restraint as punishment. This was especially true before
may appoint a legal guardian or representative who is legally the 1950s, when there were no effective chemical treat-
responsible for giving or refusing consent for a person the court ments. Legislation has dramatically reduced this problem by
has found to be incompetent. A court-appointed guardian mandating strict guidelines. Behavioral restraint and seclu-
must always consider the patient’s wishes. Guardians are usu- sion are authorized as an intervention under the following
ally selected from among family members. The order of selec- circumstances:
tion is usually (1) spouse, (2) adult children or grandchildren, • When the particular behavior is physically harmful to
(3) parents, (4) adult brothers and sisters, and (5) nieces and the patient or a third party
nephews. In the event that a family member is either unavail- • When alternative or less restrictive measures are insuf-
able or unwilling to serve as guardian, the court may also ficient in protecting the patient or others from harm
appoint a court-trained and court-approved social worker rep- • When a decrease in sensory overstimulation (seclusion
resenting the county or state or a member of the community. only) is needed
Many procedures that nurses perform have an element of • When the patient anticipates that a controlled environ-
implied consent attached. For example, if you approach the ment would be helpful and requests seclusion
patient with a medication in hand and the patient indicates As indicated, most state laws prohibit the use of unneces-
a willingness to receive the medication, implied consent has sary physical restraint or isolation. The use of seclusion and
occurred. It should be noted that many institutions, particu- restraint is permitted only under the following circumstances
larly state psychiatric hospitals, have a requirement to obtain (Simon, 1999):
informed consent for every medication given. A general rule • On the written order of a physician
for you to follow is that the more intrusive or risky the proce- • When orders are confined to specific time-limited peri-
dure, the higher the likelihood that informed consent must be ods (e.g., 2 to 4 hours)
obtained. The fact that you may not have a legal duty to be the • When the patient’s condition is reviewed and docu-
person to inform patients of the associated risks and benefits of mented regularly (e.g., every 15 minutes)
a particular medical procedure does not excuse you from clari- • When the original order is extended after review and
fying the procedure to patients and ensuring their expressed or reauthorization (e.g., every 24 hours) and specifies the
implied consent. type of restraint
In an emergency, the nurse may place a patient in seclu-
Rights Surrounding Involuntary Commitment sion or restraint and obtain a written or verbal order as soon
and Psychiatric Advance Directives as possible thereafter. With the exception of a patient-initiated
Patients concerned that they may be subject to involuntary psy- request to be placed in seclusion, federal laws require an emer-
chiatric commitment can prepare an advance psychiatric direc- gency situation to exist in which an immediate risk of harm to
tive document that will express their treatment choices. The the patient or others can be documented. While in restraints
advance directive for mental health decision making should be the patient must be protected from all sources of harm. The
followed by health care providers when patients are not com- behavior leading to restraint or seclusion and the time the
petent to make informed decisions for themselves. This docu- patient is placed in and released from the restraint must be
ment can clarify the patient’s choice of a surrogate decision documented; the patient in restraint must be assessed at regular
maker and instructions about hospital choices, medications, and frequent intervals (e.g., every 15 to 30 minutes) for physi-
treatment options, and emergency interventions. Identification cal needs (e.g., food, hydration, toileting), safety, and comfort,
CHAPTER 6  Legal and Ethical Basis for Practice 85

and these observations also must be documented (every 15 MAINTENANCE OF PATIENT

to 30 minutes). The patient must be removed from restraints CONFIDENTIALITY
when safer and quieter behavior is observed.
Recent changes in the law regarding the use of restraints Ethical Considerations
and seclusion have prompted agencies to revise their policies Confidentiality of care and treatment is also an important
and procedures, further limiting these practices. Despite deeply right for all patients, particularly psychiatric patients. Any
held beliefs among practitioners who have used restraints, discussion or consultation involving a patient should be con-
most agencies have found no negative effect associated with the ducted discreetly and only with individuals who have a need
reduced use of restraints and seclusion. Alternative methods of and a right to know this privileged information. The Ameri-
therapy and cooperation with the patient have been successful. can Nurses Association (ANA) Code of Ethics for Nurses with
Nurses also need to know under which circumstances the use Interpretive Statements (2001) asserts the duty of the nurse to
of seclusion and restraints is contraindicated (Box 6-1). protect confidential patient information (Box 6-2). Failure to
provide this protection may harm the nurse-patient relation-
ship, as well as the patient’s well-being. However, the code clari-
BOX 6-1 CONTRAINDICATIONS fies that this duty is not absolute. In some situations disclosure
TO SECLUSION AND may be mandated to protect the patient, other people, or the
RESTRAINT public health.

• Extremely unstable medical and psychiatric con­ Legal Considerations

ditions* Health Insurance Portability and Accountability Act
• Delirium or dementia leading to inability to tolerate The psychiatric patient’s right to receive treatment and to have
decreased stimulation* confidential medical records is legally protected. The funda-
• Severe suicidal tendencies* mental principle underlying the ANA Code of Ethics for Nurses
• Severe drug reactions or overdoses or need for close on confidentiality is a person’s constitutional right to privacy.
monitoring of drug dosages* Generally, your legal duty to maintain confidentiality is to
• Desire for punishment of patient or convenience of protect the patient’s right to privacy. The Health ­Insurance
staff ­Portability and Accountability Act (HIPAA) became effec-
*Unless close supervision and direct observation are provided. tive on April 14, 2003. Therefore, you may not, without the
From Simon, R.I. (2001). Concise guide to psychiatry and law patient’s consent, disclose information obtained from the
for clinicians (3rd ed., p. 117). Washington, DC: American patient or information in the medical record to anyone except
Psychiatric Press. those individuals for whom it is necessary for implementation


The House of Delegates of the American Nurses Associa­ 5. The nurse owes the same duties to self as to others,
tion approved these nine provisions at its June 30, 2001, including the responsibility to preserve integrity and
meeting in Washington, D.C. In July 2001, the Congress safety, to maintain competence, and to continue per­
of Nursing Practice and Economics voted to accept the sonal and professional growth.
new language of the interpretive statements, resulting in 6. The nurse participates in establishing, maintaining, and
a fully approved revised Code of Ethics for Nurses with improving health care environments and conditions of
Interpretive Statements. employment conducive to the provision of quality health
The nurse, in all professional relationships, practices care and consistent with the values of the profession
with compassion and respect for the inherent dignity, through individual and collective action.
worth, and uniqueness of every individual, unrestricted 7. The nurse participates in the advancement of the pro­
by considerations of social or economic status, personal fession through contributions to practice, education,
attributes, or the nature of health problems. administration, and knowledge development.
The nurse’s primary commitment is to the patient, 8. The nurse collaborates with other health professionals
whether an individual, family, group, or community. and the public in promoting community, national, and
3. The nurse promotes, advocates for, and strives to pro­ international efforts to meet health needs.
tect the health, safety, and rights of the patient. 9. The profession of nursing, as represented by associa­
4. The nurse is responsible and accountable for individual tions and their members, is responsible for articulating
nursing practice and determines the appropriate delega­ nursing values, for maintaining the integrity of the pro­
tion of tasks consistent with the nurse’s obligation to fession and its practice, and for shaping social policy.
provide optimum patient care.

From American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC:
86 UNIT 1  Essential Theoretical Concepts for Practice

of the patient’s treatment plan. Special protection of notes Exceptions to the Rule
used in psychotherapy that are kept separate from the patient’s Duty to warn and protect third parties. The California
health information was created by this HIPAA rule (2003). Dis- Supreme Court, in its 1974 landmark decision Tarasoff v.
cussions about a patient in public places such as elevators and Regents of University of California, ruled that a psychothera-
the cafeteria, even when the patient’s name is not mentioned, pist has a duty to warn a patient’s potential victim of poten-
can lead to disclosures of confidential information and liabili- tial harm. A university student who was in counseling at a
ties for you and the hospital. California university was despondent over being rejected by
Tatiana Tarasoff. The psychologist notified police verbally and
Patients’ Employers in writing that the young man may be dangerous to Tarasoff.
Your release of information to the patient’s employer about the The police questioned the student, found him to be rational,
patient’s condition, without the patient’s consent, is a breach and secured his promise to stay away from his love interest.
of confidentiality that subjects you to liability for the tort of The student killed Tarasoff 2 months later. This case created
invasion of privacy as well as a HIPAA violation. On the other much controversy and confusion in the psychiatric and medi-
hand, discussion of a patient’s history with other staff members cal communities over breach of patient confidentiality and its
to determine a consistent treatment approach is not a breach effect on the therapeutic relationship in psychiatric care and
of confidentiality. over the ability of the psychotherapist to predict when a patient
Generally, for a situation to be created in which informa- is truly dangerous. This trend continues as other jurisdictions
tion is privileged, a patient–health professional relationship have adopted or modified the California rule despite the objec-
must exist and the information must concern the care and tions of the psychiatric community. These jurisdictions view
treatment of the patient. The health professional may refuse public safety to be more important than privacy in narrowly
to disclose information to protect the patient’s privacy. How- defined circumstances.
ever, the right to privacy is the patient’s right, and health pro- The Tarasoff case acknowledged that generally there is no
fessionals cannot invoke confidentiality for their own defense common law duty to aid third parties. An exception is when
or benefit. special relationships exist, and the court found the patient-
therapist relationship sufficient to create a duty of the therapist
Rights After Death to aid Ms. Tarasoff, the victim. The duty to protect the intended
A person’s reputation can be damaged even after death. It is victim from danger arises when the therapist determines—or,
therefore important not to divulge information after a per- pursuant to professional standards, should have determined—
son’s death that could not have been legally shared before the that the patient presents a serious danger to another. Any action
death. The Dead Man’s Statute protects confidential infor- reasonably necessary under the circumstances, including noti-
mation about people when they are not alive to speak for fication of the potential victim, the victim’s family, and the
themselves. police, discharges the therapist’s duty to the potential victim.
A legal privilege of confidentiality is enacted legislatively In 1976, the California Supreme Court issued a second rul-
and in some states exists to protect the confidentiality of ing in the case of Tarasoff v. Regents of University of California
professional communications (e.g., nurse-patient, physician- (now known as Tarasoff II). This ruling broadened the earlier
patient, attorney-patient). The theory behind such privileged ruling, the duty to warn, to include the duty to protect.
communications is that patients will not be comfortable Most states have similar laws regarding the duty to warn
or willing to disclose personal information about them- third parties of potential life threats. The duty to warn usually
selves if they fear that nurses will repeat their confidential includes the following:
conversations. • Assessing and predicting the patient’s danger of violence
In some states in which the legal privilege of confidential- toward another
ity has not been legislated for nurses, you must respond to a • Identifying the specific individual(s) being threatened
court’s inquiries regarding the patient’s disclosures even if this • Taking appropriate action to protect the identified
information implicates the patient in a crime. In these states victims
the confidentiality of communications cannot be guaranteed. If Nursing implications. As this trend toward making it the
a duty to report exists, you may be required to divulge private therapist’s duty to warn third parties of potential harm con-
information shared by the patient. tinues to gain wider acceptance, it is important for students
and nurses to understand its implications for nursing practice.
Patient Privilege and Human Immunodeficiency Although none of these cases has dealt with nurses, it is fair
Virus Status to assume that in jurisdictions that have adopted the Tarasoff
Some states have enacted mandatory or permissive statutes that doctrine, the duty to warn third parties will be applied to
direct health care providers to warn a spouse if a partner tests advanced practice psychiatric mental health nurses in private
positive for human immunodeficiency virus (HIV). Nurses practice who engage in individual therapy.
must understand the laws in their jurisdiction of practice If, however, a staff nurse who is a member of a team of psy-
regarding privileged communications and warnings of infec- chiatrists, psychologists, psychiatric social workers, and other
tious disease exposure. psychiatric nurses does not report patient threats of harm
CHAPTER 6  Legal and Ethical Basis for Practice 87

against specified victims or classes of victims to the team of You may also report knowledge of, or reasonable suspi-
the patient’s management psychotherapist for assessment and cion of, mental abuse or suffering. Dependent adults as well as
evaluation, this failure is likely to be considered substandard older adults are protected by the law from purposeful physical
nursing care. or fiduciary neglect or abandonment. Because state laws vary,
So, too, the failure to communicate and record relevant students are encouraged to become familiar with the require-
information from police, relatives, or the patient’s old records ments of their states.
might also be deemed negligent. Breach of patient-nurse confi-
dentiality should not pose ethical or legal dilemmas for nurses TORT LAW APPLIED TO PSYCHIATRIC
in these situations, because a team approach to the delivery of
psychiatric care presumes communication of pertinent infor-
mation to other staff members to develop a treatment plan in Torts are a category of civil law that commonly applies to health
the patient’s best interest. care practice. A tort is a civil wrong for which money damages
may be collected by the injured party (the plaintiff) from the
Child and Elder Abuse Reporting Statutes wrongdoer (the defendant). The injury can be to person, prop-
Because of their interest in protecting children, all 50 states and erty, or reputation. Because tort law has general applicability to
the District of Columbia have enacted child abuse reporting nursing practice, this section may contain a review of material
statutes. Although these statutes differ from state to state, they previously covered elsewhere in your nursing curriculum.
generally include a definition of child abuse, a list of individuals Bullying has become a recognized form of violence in our
required or encouraged to report abuse, and the governmental society. Nurses may encounter bullying behaviors from nurs-
agency designated to receive and investigate the reports. Most ing supervisors, peers, patients, and even family members
statutes include civil penalties for failure to report. Many states of patients. The root of this controlling type of behavior can
specifically require nurses to report cases of suspected abuse. be anxiety, stress, fear, or possibly even guilt felt by the bully
There is a conflict between federal and state laws with respect (­Boudreaux, 2010).
to child abuse reporting when the health care professional dis- When nurses in psychiatric settings encounter provoca-
covers child abuse or neglect during the suspected abuser’s tive, threatening, or violent behavior from patients, the use of
alcohol or drug treatment. Federal laws and regulations gov- restraint or seclusion might be required until a patient dem-
erning confidentiality of patient records, which apply to almost onstrates quieter and safer behavior. Accordingly, the nurse in
all drug abuse and alcohol treatment providers, prohibit any the psychiatric setting should understand the intentional torts
disclosure without a court order. In this case, federal law super- of battery, assault, and false imprisonment (described in Box
sedes state reporting laws, although compliance with the state 6-3). More on the use of restraints and seclusion is found in
law may be maintained under the following circumstances: Chapters 16 and 24.
• If a court order is obtained, pursuant to the regulations
• If a report can be made without identifying the abuser as Common Liability Issues
a patient in an alcohol or drug treatment program Protection of Patients
• If the report is made anonymously (some states, to pro- Legal issues common in psychiatric nursing relate to the fail-
tect the rights of the accused, do not allow anonymous ure to protect the safety of patients. If a suicidal patient is left
reporting) alone with the means to harm himself or herself, the nurse
As reported incidents of abuse to other persons in society who has a duty to protect the patient will be held responsible
surface, states may require health professionals to report other for the resultant injuries. Leaving a suicidal patient alone in a
kinds of abuse. A growing number of states are enacting elder room on the sixth floor with an open window is an example of
abuse reporting statutes, which require registered nurses unreasonable judgment on the part of the nurse. Precautions to
(RNs) and others to report cases of abuse of older adults. Agen- prevent harm must be taken whenever a patient is restrained.
cies who receive federal funding (i.e., Medicare or Medicaid) Miscommunications and medication errors are common in all
must follow strict guidelines for reporting and preventing areas of nursing, including psychiatric care. A common area
elder abuse. Older adults are defined as adults 65 years of age of liability in psychiatry is abuse of the therapist-patient rela-
and older. These laws also apply to dependent adults—that is, tionship. Issues of sexual misconduct during the therapeutic
adults between 18 and 64 years of age whose physical or mental relationship have become a source of concern in the psychiat-
limitations restrict their ability to carry out normal activities or ric community. Misdiagnosis is also frequently charged in legal
to protect themselves—when the RN has actual knowledge that suits. See Table 6-2 for common liability issues.
the person has been the victim of physical abuse.
Under most state laws, a person who is required to report Violence
suspected abuse, neglect, or exploitation of a disabled adult and Violent behavior is not acceptable in our society. The incidence
who willfully does not do so is guilty of a misdemeanor crime. of violence and violent acts appears to be escalating in our soci-
Most state statutes declare that anyone who makes a report in ety. Therefore we see nurses confronting increasing amounts
good faith is immune from civil liability in connection with the of violence in the workplace. Nurses must protect themselves
report. in both institutional and community settings. Employers are
88 UNIT 1  Essential Theoretical Concepts for Practice


Mrs. Plumadore was admitted to Saranac Lake General employee and was transported to the state hospital. On
Hospital for a gallbladder condition. Her medical workup arrival, the admitting psychiatrist recognized that the refer­
revealed emotional problems stemming from marital dif­ ring psychiatrist lacked the requisite authority to order her
ficulties, which had resulted in suicide attempts several involuntary commitment. He therefore requested that she
years before her admission. After a series of consultations sign a voluntary admission form, which she refused to do.
and tests, she was advised by the attending surgeon that Despite Mrs. Plumadore’s protests regarding her admis­
she was scheduled to have gallbladder surgery later that sion to the state hospital, the psychiatrist assigned her
day. After the surgeon’s visit, a consulting psychiatrist to a ward without physical or psychiatric examination and
who examined Mrs. Plumadore directed her to dress and without the opportunity to contact her family or her medi­
pack her belongings because he had arranged to have her cal physician. The record of her admission to the state
admitted to a state hospital at Ogdensburg. hospital noted an “informed admission,” which is patient-
Subsequently, two uniformed state troopers handcuffed initiated voluntary admission in New York.
Mrs. Plumadore and strapped her into the backseat of a The court awarded $40,000 to Mrs. Plumadore for false
patrol car. She was also accompanied by a female hospital imprisonment, negligence, and malpractice.


Patient safety Suicide risks
Medication errors
Boundary violations (e.g., sexual misconduct)
Defamation of character Harms patient’s reputation
• Slander (spoken) Confidential information divulged
• Libel (written) Truth is a defense
Supervisory liability (vicarious liability) Inappropriate delegation of duties
Lack of supervision of those supervising
Intentional torts Voluntary acts intended to bring a physical or mental consequence
• May carry criminal penalties Purposeful acts
• Punitive damages may be awarded Carelessness or recklessness
• Not covered by malpractice insurance No patient consent
Self-defense or protection of others may serve as a defense to charges of
an intentional tort
Negligence or malpractice Carelessness
Foreseeability of harm
Assault and battery Person apprehensive (assault) of harmful or offensive touching (battery)
Threat to use force (words not enough) with opportunity and ability
Treatment without patient’s consent
False imprisonment Intent to confine to a specific area
Indefensible use of seclusion or restraints
Detain voluntarily admitted patient with no agency or legal policies to
support detaining

not typically held responsible for employee injuries caused by potentially violent situation. Nurses, as citizens, have the same
violent patient behavior. Nurses have placed themselves know- rights as patients—that is, to be free from being threatened or
ingly in the range of danger by agreeing to care for unpredict- harmed. Appropriate security support should be readily avail-
able patients. It is therefore important for nurses to protect able to the nurse practicing in an institution. When you work
themselves by participating in setting policies that create a safe in community settings, you must avoid placing yourself unnec-
environment. Good judgment means not placing oneself in a essarily in dangerous environments, especially when alone at
CHAPTER 6  Legal and Ethical Basis for Practice 89

night. You should use common sense and enlist the support of
local law enforcement officers when needed. A violent patient
is not being abandoned if placed safely in the hands of the Professional standards of practice determined by profes-
authorities. sional associations differ from the standards embodied in
The psychiatric mental health nurse must also be aware of the minimal qualifications established by state licensure for
the potential for violence in the community when a patient is entry into the profession of nursing. The ANA has established
discharged following a short-term stay. The duty of the nurse standards for psychiatric mental health nursing practice and
to protect the patient as well as others who may be threatened credentialing for the psychiatric mental health RN and the
by the violent patient is discussed in the preceding section in advanced practice RN in psychiatric mental health nursing
this chapter titled Duty to Warn and Protect Third Parties. (ANA, 2007).
The nurse’s assessment of the patient’s potential for violence Standards for psychiatric mental health nursing practice
must be documented and monitored if there is legitimate differ markedly from minimal state requirements because the
concern regarding discharge of a patient who is discussing primary purposes for setting these two types of standards are
or exhibiting potentially violent behavior. The psychiatric different. The state’s qualifications for practice provide con-
mental health nurse must communicate his or her observa- sumer protection by ensuring that all practicing nurses have
tions to the medical staff when discharge decisions are being successfully completed an approved nursing program and
considered. passed the national licensing examination. The professional
association’s primary focus is to elevate the practice of its mem-
Negligence/Malpractice bers by setting standards of excellence.
Negligence or malpractice is an act or an omission to act that Nurses are held to the standard of care provided by other
breaches the duty of due care and results in or is responsible nurses possessing the same degree of skill or knowledge in the
for a person’s injuries. The five elements required to prove same or similar circumstances. In the past, community stan-
negligence are (1) duty, (2) breach of duty, (3) cause in fact, dards existed for urban and rural agencies. However, with
(4) proximate cause, and (5) damages. Foreseeability or likeli- greater mobility and expanded means of communication,
hood of harm is also evaluated. national standards have evolved. Psychiatric patients have the
Duty is measured by a standard of care. When nurses right to the standard of care recognized by professional bodies
represent themselves as being capable of caring for psychiat- governing nursing, whether they are in a rural or an urban facil-
ric patients and accept employment, a duty of care has been ity. Nurses must participate in continuing education courses to
assumed. The duty is owed to psychiatric patients to under- stay current with existing standards of care.
stand the theory and medications used in the specialty care of Hospital policies and procedures establish institutional
these patients. People who represent themselves as possessing criteria for care, and these criteria, such as the frequency of
superior knowledge and skill, such as psychiatric nurse special- rounds for patients in seclusion, may be introduced to prove
ists, are held to a higher standard of care in the practice of their a standard that the nurse met or failed to meet. The short-
profession. The staff nurse who is assigned to a psychiatric unit coming of this method is that the hospital’s policy may be
must be knowledgeable enough to assume a reasonable or safe substandard. For example, the state licensing laws for insti-
duty of care for the patients. tutions might set a minimal requirement for staffing or fre-
If you are not capable of providing the standard of care quency of rounds for certain patients, and the hospital policy
that other nurses would be expected to provide under similar might fall below that minimum. Substandard institutional
circumstances, you have breached the duty of care. Breach of policies do not absolve the individual nurse of responsi-
duty is the conduct that exposes the patient to an unreason- bility to practice on the basis of professional standards of
able risk of harm, through either commission or omission of nursing care.
acts by the nurse. If you do not have the required education Like hospital policy and procedures, customs can be used
and experience to provide certain interventions, you have as evidence of a standard of care. For example, in the absence
breached the duty by neglecting or omitting to provide nec- of a written policy on the use of restraint, testimony might
essary care. You can also act in such a way that the patient is be offered regarding the customary use of restraint in emer-
harmed and can thus be guilty of negligence through acts of gency situations in which the combative, violent, or confused
commission. patient poses a threat of harm to self or others. Using tradi-
Cause in fact may be evaluated by asking the ques- tions to establish a standard of care may result in the same
tion, “Except for what the nurse did, would this injury have defect as in using hospital policies and procedures: customs
occurred?” Proximate cause, or legal cause, may be evaluated may not comply with the laws, recommendations of the
by determining whether there were any intervening actions or accrediting body, or other recognized standards of care. Cus-
individuals that were, in fact, the causes of harm to the patient. toms must be carefully and regularly evaluated to ensure that
Damages include actual damages (e.g., loss of earnings, medi- substandard routines have not developed. Substandard cus-
cal expenses, and property damage) as well as pain and suf- toms do not protect you when a psychiatric patient charges
fering. Foreseeability of harm evaluates the likelihood of the that a right has been violated or that harm has been caused by
outcome under the circumstances. the staff’s common practices.
90 UNIT 1  Essential Theoretical Concepts for Practice

Guidelines for Nurses Who Suspect Negligence intervene and the patient is injured, you may be partly liable
It is not unusual for a student or practicing nurse to suspect neg- for the injuries that result because of failure to use safe nursing
ligence on the part of a peer. In most states, as a nurse you have practice and good professional judgment.
a legal duty to report such risks of harm to the patient. It is also The legal concept of abandonment may also arise when
important that you document the evidence clearly and accurately a nurse does not leave a patient safely reassigned to another
before making serious accusations against a peer. If you question health professional before discontinuing treatment. When the
a physician’s orders or actions, or those of a fellow nurse, it is wise nurse is given an assignment to care for a patient, the nurse
to communicate these concerns directly to the person involved. If must provide the care or ensure that the patient is safely reas-
the risky behavior continues, you have an obligation to commu- signed to another nurse. Abandonment issues arise when accu-
nicate these concerns to a supervisor, who should then intervene rate, timely, and thorough reporting has not occurred or when
to ensure that the patient’s rights and well-being are protected. follow-through of patient care, on which the patient is relying,
If you suspect a peer of being chemically impaired or of has not occurred. The same principles apply for the psychiatric
practicing irresponsibly, you have an obligation to protect not mental health nurse who is working in a community setting.
only the rights of the peer but also the rights of all patients For example, if a suicidal patient refuses to come to the hospital
who could be harmed by this impaired peer. If, after you have for treatment, you cannot abandon the patient but must take
reported suspected behavior of concern to a supervisor, the the necessary steps to ensure the patient’s safety. These actions
danger persists, you have a duty to report the concern to some- may include enlisting the assistance of the legal system in tem-
one at the next level of authority. It is important to follow the porarily involuntarily committing the patient.
channels of communication in an organization, but it is also The duty to intervene on the patient’s behalf poses many legal
important to protect the safety of the patients. If the supervi- and ethical dilemmas for nurses in the workplace. Institutions
sor’s actions or inactions do not rectify the dangerous situation, that have a chain-of-command policy or other reporting mecha-
you have a continuing duty to report the behavior of concern nisms offer some assurance that the proper authorities in the
to the appropriate authority, such as the state board of nursing. administration are notified. Most patient care issues regarding
A useful reference for nurses is the ANA’s Guidelines on physicians’ orders or treatments can be settled fairly early in the
Reporting Incompetent, Unethical, or Illegal Practices (1994), process by the nurse’s discussion of the concerns with the physi-
and the ANA’s Code of Ethics for Nurses with Interpretive State- cian. If further intervention by the nurse is required to protect the
ments (2001, p. 154, 2010 reissue). patient, the next step in the chain of command can be followed.
Generally, the nurse then notifies the immediate nursing super-
Reporting unethical, illegal, and in incompetent, or
visor; the supervisor thereupon discusses the problem with the
impaired nurse practices, even when done appropriately,
physician, and then with the chief of staff of a particular service,
may present substantial risk to the nurse; nevertheless such
until a resolution is reached. If there is no time to resolve the issue
risks do not eliminate the obligation to address serious
through the normal process because of the life-threatening nature
threats to patient safety.
of the situation, the nurse must act to protect the patient’s life.

Duty to Intervene and Duty to Report Unethical or Illegal Practices

The psychiatric mental health nurse has a duty to intervene The issues become more complex when a professional col-
when the safety or well-being of the patient or another per- league’s conduct, including that of a student nurse, is criminally
son is obviously at risk. A nurse who follows an order that is unlawful. Specific examples include the diversion of drugs from
known to be incorrect or that the nurse believes will harm the the hospital and sexual misconduct with patients. Increasing
patient is responsible for the harm that results to the patient. If media attention and the recognition of substance abuse as an
you have information that leads you to believe that the physi- occupational hazard for health professionals have led to the
cian’s orders need to be clarified or changed, it is your duty establishment of substance abuse programs for health care
to intervene and protect the patient. It is important that you workers in many states. These programs provide appropriate
communicate with the physician who has ordered the treat- treatment for impaired professionals to protect the public from
ment to explain the concern. If the treating physician does not harm and to rehabilitate the professional.
appear willing to consider your concerns, you should carry out The problem previously discussed—of reporting impaired
the duty to intervene through other appropriate channels. colleagues—becomes a difficult one, particularly when no
It is important for you to express your concerns to the direct harm has occurred to the patient. Concern for profes-
supervisor to allow the supervisor to communicate with the sional reputations, damaged careers, and personal privacy
appropriate medical staff for intervention in the physician’s rather than public protection has generated a code of silence
treatment plan. As the patient’s advocate, you have a duty regarding substance abuse among health professionals.
to intervene to protect the patient; at the same time, you Several states now require reporting of impaired or incom-
do not have the right to interfere with the physician-patient petent colleagues to the professional licensing boards. In the
relationship. absence of such a legal mandate, the questions of whether to
It is also important to follow agency policies and proce- report and to whom to report become ethical ones. You are again
dures for communicating differences of opinion. If you fail to urged to use the ANA’s Guidelines on Reporting Incompetent,
CHAPTER 6  Legal and Ethical Basis for Practice 91

Unethical, or Illegal Practices (1994). Chapter 19 deals more fully the medical record finds its way into legal cases for a variety of
with issues related to the chemically impaired nurse. reasons. Some examples of its use include determining (1) the
The duty to intervene includes the duty to report known extent of the patient’s damages and pain and suffering in per-
abusive behavior. Most states have enacted statutes to protect sonal injury cases, such as when a psychiatric patient attempts
children and older adults from abuse and neglect. Psychiat- suicide while under the protective care of a hospital; (2) the
ric mental health nurses working in the community may be nature and extent of injuries in child abuse or elder abuse cases;
required by law to report unsafe relationships they discover. (3) the nature and extent of physical or mental disability in dis-
ability cases; and (4) the nature and extent of injury and reha-
DOCUMENTATION OF CARE bilitative potential in workers’ compensation cases.
Medical records may also be used in police investigations,
Purpose of Medical Records civil conservatorship proceedings, competency hearings, and
The purpose of the medical record is to provide accurate and commitment procedures. In states that mandate mental health
complete information about the care and treatment of patients legal services or a patients’ rights advocacy program, audits may
and to give health care personnel responsible for that care a be performed to determine the facility’s compliance with state
means of communicating with each other. The medical record laws or violation of patients’ rights. Finally, medical records
allows for continuity of care. A record’s usefulness is deter- may be used in professional and hospital negligence cases.
mined by evaluating, when the record is read later, how accu- During the discovery phase of litigation, the medical record
rately and completely it portrays the patient’s behavioral status is a pivotal source of information for attorneys in determining
at the time it was written. The patient has the right to see the whether a cause of action exists in a professional negligence or
chart, but the chart belongs to the institution. The patient must hospital negligence case. Evidence of the nursing care rendered
follow appropriate protocol to view his or her records. will be found in the notes charted by the nurse.
For example, if a psychiatric patient describes to a nurse
a plan to harm himself or herself or another person and that Nursing Guidelines for Computerized Charting
nurse fails to document the information, including the need Accurate, descriptive, and legible nursing notes serve the best
to protect the patient or the identified victim, the information interests of the patient, the nurse, and the institution. As com-
will be lost when the nurse leaves work, and the patient’s plan puterized charting becomes more widely available, it will also
may be executed. The harm caused could be linked directly to be important for psychiatric mental health nurses to under-
the nurse’s failure to communicate this important information. stand how to protect the confidentiality of these records. Insti-
Even though documentation takes time away from the patient, tutions must also protect against intrusions into the privacy of
the importance of communicating and preserving the nurse’s the patient record systems.
memory through the medical record cannot be overemphasized. Concerns for the privacy of the legitimate patient’s records
have been addressed legally by federal laws that provide guide-
Facility Use of Medical Records lines for agencies that use computerized charting. These guide-
The medical record has many other uses aside from provid- lines include the recommendation that staff be assigned a
ing information on the course of the patient’s care and treat- password for entering patients’ records in order to identify staff
ment to health care professionals. A retrospective chart review who have accessed patients’ confidential information. There
can provide valuable information to the facility on the quality are penalties, including grounds for firing the staff, if staff
of care provided and on ways to improve that care. A facility enter a record for which they are not authorized to have access.
may conduct reviews for risk management purposes to deter- Only those staff who have a legitimate need to know about the
mine areas of potential liability for the facility and to evaluate patient are authorized to access a patient’s computerized chart.
methods used to reduce the facility’s exposure to liability. For It is important for you to keep your password private and
example, documentation of the use of restraints and seclusion never to allow someone else to access a record under your pass-
for psychiatric patients may be reviewed by risk managers. word. You are responsible for all entries into records using your
Accordingly, the chart may be used to evaluate care for qual- password. The various systems used allow specific timeframes
ity assurance or peer review. Utilization review analysts review within which the nurse must make any necessary corrections if
the chart to determine appropriate use of hospital and staff a charting error is made.
resources consistent with reimbursement schedules. Insur- Any charting method that improves communication
ance companies and other reimbursement agencies rely on the between care providers should be encouraged. Courts assume
medical record in determining what payments they will make that nurses and physicians read each other’s notes on patient
on the patient’s behalf. progress. Many courts take the attitude that if care is not docu-
mented, it did not occur. Your charting also serves as a valu-
Medical Records as Evidence able memory refresher if the patient sues years after the care
From a legal perspective, the chart is a recording of data and is rendered. In providing complete and timely information on
opinions made in the normal course of the patient’s hospital the care and treatment of patients, the medical record enhances
care. It is deemed to be good evidence because it is presumed to communication among health professionals. Internal insti-
be true, honest, and untainted by memory lapses. Accordingly, tutional audits of the record can improve the quality of care
92 UNIT 1  Essential Theoretical Concepts for Practice

rendered. Nurses’ charting is improved by following the guide- a decision on a contested issue. The nurse acts as an advocate,
lines in Box 5-6. Chapter 7 describes common charting forms educating the court about the science of nursing in this court-
and gives examples as well as the pros and cons of each. room-based practice of forensic nursing. Examples of psy-
chiatric forensic nursing may include cases related to patient
competency, fitness to stand trial, and commitment or respon-
FORENSIC NURSING sibility for a crime. The relevance of nursing facts is presented
Forensic nursing is the application of psychiatric nursing or and applied to the legal facts. Forensic cases also pertain to per-
any medical specialty principles of practice when used in a sonal injury and murder proceedings. A dentist may serve as a
court of law to assist the court to utilize this knowledge to reach forensic dentist in identifying a tooth as it relates to a corpse.


• S tates’ power to enact laws for public health and safety and • K
 nowledge of the law, the ANA’s Code of Ethics for Nurses
for the care of those unable to care for themselves often pits with Interpretive Statements, and the ANA’s standards of
the rights of society against the rights of the individual. care from Psychiatric–Mental Health Nursing: Scope and
• Psychiatric nurses frequently encounter problems requiring Standards of Practice is essential to provide safe, effective
ethical choices. psychiatric nursing care and will serve as a framework for
• The nurse’s privilege to practice nursing carries with it the decision making when the nurse is presented with complex
responsibility to practice safely, competently, and in a man- problems involving competing interests.
ner consistent with state and federal laws.


1. T
 wo nurses, Joe and Beth, have worked on the psychiatric orders. While unattended, the patient suffocates, apparently
unit for 2 years. During the past 6 months, Beth has con- by inhaling the nasal packing, which had become dislodged
fided to Joe that she has been experiencing a particularly from the nares. On the next 1-hour check, the nurse finds the
difficult marital situation. Joe has observed that over the patient without pulse or respiration. A state statute requires
6 months Beth has become increasingly irritable and dif- that a restrained patient on a psychiatric unit be assessed by
ficult to work with. He notices that minor tranquilizers are a nurse every hour for safety, comfort, and physical needs.
frequently missing from the unit dose cart on the evening A. If standards are not otherwise specified, do statutory
shift. He complains to the pharmacy and is informed that requirements set forth minimal or maximal standards?
the drugs were stocked as ordered. Several patients state B. Does the nurse’s compliance with the state statute relieve
that they have not been receiving their usual drugs. Joe finds him or her of liability in the patient’s death?
that Beth has recorded that the drugs have been given as C. Does the nurse’s compliance with the physician’s orders
ordered. He also notices that Beth is diverting the drugs. relieve him or her of liability in the patient’s death?
A. What action, if any, should Joe take? D. Was the order for the restraint appropriate for this type
B. Should Joe confront Beth with his suspicions? of patient?
C. If Beth admits that she has been diverting the drugs, E. What factors did you consider in making your

should Joe’s next step be to report Beth to the supervisor determination?
or to the board of nursing? F. Was the frequency of rounds for assessment of patient
D. Should Joe make his concern known to the nursing needs appropriate in this situation?
supervisor directly by identifying Beth, or should he G. Did the nurse’s conduct meet the standard of care for
state his concerns in general terms? psychiatric nurses? Why or why not?
E. Legally, must Joe report his suspicions to the board of H. What nursing action should the nurse have taken to pro-
nursing? tect the patient from harm?
F. Does the fact that harm to the patients is limited to 3. Assume that there are no mandatory reporting laws for
increased agitation affect your responses? impaired or incompetent colleagues in the following clini-
A 40-year-old man who is admitted to the emergency cal situation. In a private psychiatric unit in California, a
department for a severe nosebleed has both nares packed. 15-year-old boy is admitted voluntarily at the request of his
Because of his history of alcoholism and the probability of parents because of violent, explosive behavior that seems
ensuing delirium tremens, the patient is transferred to the to stem from his father’s recent remarriage after his par-
psychiatric unit. He is admitted to a private room, placed in ents’ divorce. A few days after admission, while in group
restraints, and checked by a nurse every hour per physician’s therapy, he has an explosive reaction to a discussion about
CHAPTER 6  Legal and Ethical Basis for Practice 93


weekend passes for Mother’s Day. He screams that he has C.
Is the duty owed to the patient’s father and stepmother?
been abandoned and that nobody cares about him. Several D. Would a change in the admission status from voluntary
weeks later, on the day before his discharge, he elicits from to involuntary protect the patient’s mother without vio-
the nurse a promise to keep his plan to kill his mother con- lating the patient’s confidentiality?
fidential. Consider the ANA’s Code of Ethics for Nurses on E. Would your response be different depending on the
patient confidentiality, the principles of psychiatric nursing, state in which the incident occurred? Why or why not?
the statutes on privileged communications, and the duty to F. What nursing action, if any, should the nurse take after
warn third parties in answering the following questions: the disclosure by the patient?
A. Did the nurse use appropriate judgment in promising
B. Does the nurse have a legal duty to warn the patient’s
mother of her son’s threat?


Choose the most appropriate answer(s). 4. have a consultation with other mental health profession-
1. A researcher tells the nurse that she would like to include als at the hospital’s expense.
one of her patients in a medication study. The nurse is 4. A client, covered in mud and grime, has refused to wash
responsible for: himself upon admission to the inpatient unit. Despite his
1. instructing the patient in the details of the study. protests, 2 male staff force him into the shower and wash
2. encouraging the patient to participate. him down with soap and water. What statement is correct
3. directing the client in appropriate study behaviors. regarding patient rights?
4. assessment of the client’s ability to give informed
 1. No violation as his was a threat to self
consent. 2. Violation due to forcing him against his will
2. The single most important action nurses can take to protect 3. No violation due to need for appropriate hygiene
the rights of a psychiatric patient is to: 4. Violation due to mandate for least restrictive alternative
1. be aware of that state’s laws regarding care and treat- 5. Observing the patient’s right to privacy permits the psychi-
ment of the mentally ill. atric mental health nurse to:
2. refuse to participate in imposing restraint or seclusion. 1. freely disclose information in the medical record to the
3. document concerns about unit short staffing. patient’s employer.
4. practice the five principles of bioethics. 2. use information about the patient when preparing a
3. To provide appropriate care for a patient who has been journal article.
admitted involuntarily to a psychiatric unit, the nurse must 3. discuss observations about the patient with the treat-
be aware of the fact that the patient has the right to: ment team.
1. refuse psychotropic medications. 4. disclose confidential information after the patient’s

2. be treated by unit staff of his or her choice. death.
3. be released within 24 hours of making a written request.

American Nurses Association (ANA). (2001, 2010 reissue). Code of Bazelon, D. L. (2011). Diversion from incarceration. Retrieved March
ethics for nurses with interpretive statements. Washington, DC: 4, 2011, from services/-diversion-from incarceration.
American Nurses Association (ANA). (1994). Guidelines on report- Bazelon, D. L. (2010). Mental health parity. Washington, DC: Bazelon
ing incompetent, unethical, or illegal practices. Kansas City, MO: Center for Mental Health Law. Retrieved March 4, 2011, from
American Nurses Association (ANA), American Psychiatric Nursing health parity.aspx.
Association, and International Society of Psychiatric Mental Bazelon, D. L. (2003). Advance psychiatric directives. Washington, DC:
Health Nurses. (2007). Psychiatric–mental health nursing: scope Bazelon Center for Mental Health Law.
and standards of practice. Silver Springs, MD: Boudreaux, A. (2010). Keeping your cool with difficult family mem-
American Psychiatric Association (APA). (2000). Diagnostic and bers. Nursing, 40(12), 50.
statistical manual of mental disorders (DSM-IV-TR) (4th ed., text Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972), quoting Schloen-
rev.). Washington, DC: Author. dorff v. Society of N.Y. Hosp., 211 N.Y. 125, 105 N.E. 92, 93 (1914).
94 UNIT 1  Essential Theoretical Concepts for Practice

Chan, C. (2003). Mandatory outpatient treatment: issues to consider. Rainey, C. J. (2001). Mandated outpatient treatment resources and
Chicago: Paper presented at the 153rd Annual Meeting of the data. Orlando, FL: Presented at the American Psychiatric Associa-
American Psychiatric Association. tion 53rd Institute on Psychiatric Services.
Health Insurance Portability and Accountability Act (HIPAA). U.S.C. Simon, R. I. (1999). The law and psychiatry. In R. E. Hales, S. C.
45 C.F.R § 164.501 (2003). Yudofsky, & J. A. Talbott (Eds.), The American Psychiatric Press
Humphrey v. Cady, 405 U.S. 504 (1972). textbook of psychiatry (3rd ed.). Washington, DC: American
Monahan, J., Swartz, M., & Bonnie, R. J. (2003). Mandated treat- Psychiatric Press.
ment in the community for people with mental disorders. Health Tarasoff v. Regents of University of California, 551 P.2d 334, 131 Cal
Affairs, 22(5), 28–38. Rptr 14 (1976).
O’Connor v. Donaldson, 422 U.S. 563 (1975). Tarasoff v. Regents of University of California, 529 P.2d 553, 118 Cal
Olmstead v. L.C. (98–536), 527 U.S. 581 (1999). Rptr 129 (1974).
Plumadore v. State of New York, 427 N.Y.S.2d 90 (1980). Zinermon v. Burch, 494 U.S. 113, 108 L.Ed.2d 100, 110 S. Ct. 975
U N I T  2
Tools for Practice
of the Art
Madeleine Leininger, PhD, RN, LhD, FAAN (1925-Present)
Founder of Transcultural Nursing

Madeleine Leininger is a nurse pioneer, scientist, anthropologist,

researcher, theorist, leader, certified transcultural nurse specialist, and
author/editor of more than 27 books. Leininger developed her Theory
of Cultural Care and Universality based on her observations in the
1950s and 1960s of the people of New Guinea, where she lived for 2
years. She recognized the need for nurses to deliver care that combined
both humanism and scientific knowledge that would be meaningful to
people from culturally diverse backgrounds.
She was the first graduate-prepared nurse to earn a PhD in cultural
and social anthropology. In 1954 Leininger later obtained a master’s
degree in psychiatric nursing from The Catholic University of America
in Washington, DC. Soon afterwards, she developed the first master’s
level clinical specialist program in child psychiatric nursing at the University of Cincinnati. She subse-
quently developed the first graduate transcultural nursing program in psychiatric nursing also at the
University of Cincinnati.
Simply stated, transcultural nursing is the practice of nursing that provides culturally congru-
ent, competent, and equitable care practices in a world that has become increasingly multicultural in
Leininger (1998) states that when nurses do not take into account a patient’s spiritual/religious
beliefs, family ties, and economic and educational factors, the nurse is at risk for demonstrating a
noncaring attitude that may result in nonbeneficial outcomes. Human care/caring is defined within
the context of culture. Leininger’s transcultural nursing theory has at its focus “caring.” She stated
that “…a caring focus must become the dominant focus of all areas of nursing. It is the holistic and most
complete and creative way to help people” (Leininger, 1981).

Leininger, M.M. (1998). What is transcultural nursing? Livonia, MI: Transcultural Nursing Society.
Leininger, M.M. (1981). Caring: an essential human need. Thorofare, NJ: Charles B. Slack.


Nursing Process and QSEN: The Foundation
for Safe and Effective Care
Elizabeth M. Varcarolis

  For additional DSM-5 criteria content, see Appendix C


evidence-based practice (EBP), p. 108 outcomes criteria, p. 106
health teaching, p. 109 Psychiatric Mental Health Nursing
Safety Education for Nurses (QSEN)
mental status examination Standards of Practice, p. 97
Pre-Licensure ­Competencies
(MSE), p. 100 psychosocial assessment, p. 101
The primary goal of QSEN is to prepare
milieu therapy, p. 109 Quality and Safety Education for
future nurses with the knowledge, skills,
Nursing Interventions Classifica- Nurses (QSEN), p. 97
and attitudes (KSAs) to increase the qual-
tion (NIC), p. 108 self-care activities, p. 109
ity, care, and safety in the healthcare
Nursing Outcomes Classification
(NOC), p. 106
1. Patient-centered care
2. Teamwork and collaboration
3. Quality improvement (QI)
4. Evidence-based practice
5. Safety
6. Informatics

1. Conduct a mental status examination. 6. Demonstrate basic nursing interventions and evaluation of
2. Perform a psychosocial assessment including cultural and care using the Standards of Practice (ANA, 2007).
spiritual components. 7. Compare and contrast the Nursing Interventions Clas-
3. Explain three principles a nurse follows in planning actions sification, Nursing Outcomes Classification, and evidence-
to reach approved outcome criteria. based nursing practice.
4. Construct a plan of care for a patient with a mental or 8. Access and read the prelicensure quality and
emotional health problem. safety competencies for knowledge, skills, and attitudes
5. Identify three advanced practice psychiatric nursing (KSAs) needed to prepare nurses for employment in the
interventions. health care system.

CHAPTER 7  Nursing Process and QSEN: The Foundation for Safe and Effective Care 97

The nursing process is a six-step problem-solving approach example, simulation programs are popular and effective. These
intended to facilitate and identify appropriate, safe, culturally programs portray virtual clinical settings, such as the use of
competent, developmentally relevant, and quality care for indi- avatars, and offer students a chance to implement their knowl-
viduals, families, groups, or communities. Psychiatric mental edge, skills, and attitudes without the potential for patient
health nursing practice bases nursing judgments and behaviors harm ­(Durham & Sherwood, 2008). Nurse educators have
on this accepted theoretical framework (Figure 7-1). Theoreti- described how to incorporate QSEN’s six competencies into
cal paradigms such as developmental theory, psychodynamic curricula and proposed guidelines explaining how educators
theory, systems theory, holistic theory, cognitive theory, and can incorporate these six competencies into their own curri-
biological theory are some examples. Whenever possible, inter- cula (Valiga & Champagne, 2011). This new trend in education
ventions are also supported by scientific theories when we is often referred to as performance-based learning.
apply evidence-based research to our nursing plans and actions Performance-based learning is a trend that is fundamentally
of care (see Chapter 1). changing nursing education. Performance skills are learned
The nursing process is also the foundation of the Standards more effectively through interactive strategies, which require
of Practice as presented in Psychiatric-Mental Health Nursing: changes in the traditional roles of teachers and students. There
Scope and Standards of Practice (ANA et al., 2007), which in is less emphasis on lecturing and more on participation with
turn provide the basis for the following: the student in collaborative and simulated hands-on strategies
• Criteria for certification to achieve actual practice competencies (Lasater & Nielsen,
• Legal definition of nursing, as reflected in many states’ 2009; Lenburg, 2011). The influence of concept-based learning
nurse practice acts activities and students’ clinical judgment development is part
• National Council of State Boards of Nursing Licensure of a new revolution (Lasater & Nielson, 2009).
Examination (NCLEX-RN®) Suggestions for the use of QSEN competencies in the dis-
• The Six Standards of Practice defining the critical think- cussion of Standards of Practice can be found in ‘Competency
ing model known as the nursing process Knowledge, Skills, Attitudes (Pre-Licensure)’ at the website
Safety and quality care for patients has become the new www.qsen/ksas_pre-licensure.php.
standard for nursing education. As of the late 1990s, the
Institute of Medicine (IOM; based on their Quality Chasm
reports) and other organizations found a need to improve
the quality and safety outcomes of health care delivery. As A view of the individual as a complex blend of many parts is
nursing practice focused more on quality and safety issues, it consistent with nurses’ holistic approach to care. Nurses who
became evident that graduating nursing students were miss- care for people with physical illnesses ideally maintain a holistic
ing critical competencies for safety and quality of care. The view that involves an awareness of psychological, social, cul-
context and approach of nursing education is changing, and tural, and spiritual issues as well as ethnicity, sexual orientation,
new models of education are needed (Valiga & Champagne, and age (e.g., child, teenager, older woman). Likewise, nurses
2011). The competencies mandated by the IOM require who work in the mental health field need to assess, or have
changes throughout health professionals’ education to better access to, past and present medical history, a recent physical
prepare students with the responsibilities and realities in the examination, and any physical complaints the patient is experi-
health care setting. There is now “a major national initiative encing, as well as document any observable physical conditions
centered on patient safety and quality” known as Quality and or behaviors (e.g., unsteady gait, abnormal breathing pattern,
Safety Education for Nurses (QSEN) (Sullivan, 2010). The facial grimacing, or changing position to relieve discomfort).
primary goal of QSEN is to prepare future nurses with the Assessments are conducted by a variety of professionals
knowledge, skills, and attitudes (KSAs) required to enhance including nurses, psychiatrists, social workers, dietitians, and
quality, care, and safety in the health care settings in which other therapists. Every patient should have a thorough and for-
they are employed (Cronenwett et al., 2007). QSEN bases mal nursing assessment on entering treatment to develop a basis
their work on six competencies (Box 7-1). for the plan of care in preparation for discharge. Subsequent to
The Pilot Schools Collaborative, supported by a QSEN the formal assessment, data are collected continually and sys-
grant, chose 15 schools to partner with clinical experts to tematically as the patient’s condition changes and hopefully
develop teaching strategies that included the 6 QSEN compe- improves. Perhaps the patient entered treatment actively sui-
tencies in their nursing programs. The Collaborative included cidal, and the initial focus of care was on protection from injury.
schools in which the following degrees were offered: BSN, In emergency situations, immediate intervention is often based
APN, and diploma programs. Findings reflected the need to on a minimal amount of data. In all situations, however, legal
increase knowledge about patient safety practices, the benefits consent must be given by the patient, who must also receive
of faculty development, and the value of redesigning student a copy of the Health Insurance Portability and Accountability
learning experiences (Sherwood & Hicks, 2011). There is a Act (HIPAA) guidelines. Essentially, the purpose of the HIPAA
definite need to offer students more experience in interactive privacy rule is to ensure that an individual’s health informa-
learning that would incorporate both knowledge and skills tion is properly protected, while at the same time allowing
with real-world examples (Durham & Sherwood, 2008). For health care providers to obtain personal health information for
98 UNIT 2  Tools for Practice of the Art

The assessment interview requires culturally
effective communication skills and encompasses
a large database (e.g., significant support system;
family; cultural and community system; spiritual and
philosophical values, strengths, and health beliefs and
practices; as well as many other factors).


• Construct database • Identify problem and etiology

— Mental status examination • Construct nursing diagnoses
(MSE) and problem list
— Psychosocial assessment • Prioritize nursing diagnoses
— Physical examination
— History taking
— Interviews STANDARDS OF
— Standardized rating scales PROFESSIONAL
• Verify the data
• Identify attainable and
6. EVALUATION culturally expected outcomes
• Document expected outcomes
as measurable goals
• Document results of evaluation COLLABORATION
• Include time estimate for
• If outcomes have not been 7. RESEARCH
expected outcomes
achieved at desired level: 8. RESOURCE UTILIZATION
— Additional data gathering
— Reassessment
— Revision of plan
• Identify safe, pertinent,
evidence-based actions
Basic Level and Advanced • Strive to use interventions that
Practice Interventions: are culturally relevant and
• Coordination of care compatible with health beliefs
• Health teaching and health and practices
promotion • Document plan using
• Milieu therapy recognized terminology
• Pharmacological, biological,
and integrative therapies
Advanced Practice Interventions:
• Prescriptive authority and
• Psychotherapy
• Consultation

FIGURE 7-1  The nursing process in psychiatric mental health nursing.

the purpose of providing and promoting high-quality health These forms may be hardcopy or computerized, according to the
care (USDHHS, 2003). HIPAA was first enacted in 1996, resources and preferences of the institution. The time required
but compliance was not mandated until April 14, 2003. Visit for the nursing interview varies, depending on the assessment form and on the patient’s response pattern (e.g., a lengthy or ram-
for a full overview. bling historian, a patient prone to tangential thought, or a patient
Virtually all facilities have standardized nursing assessment having memory disturbances or markedly slowed responses). In
forms to aid in organization and consistency among reviewers. emergency situations, immediate intervention is often based on a
CHAPTER 7  Nursing Process and QSEN: The Foundation for Safe and Effective Care 99


1. Patient-centered care: Recognize the patient or H Home environment (e.g., relations with parents and
designee as the source of control and full partner in siblings)
providing compassionate and coordinated care based E Education and employment (e.g., school performance)
on respect for the patient’s preferences, values, and A Activities (e.g., sports participation, afterschool activi-
needs. ties, peer relations)
2. Quality improvement: Use data to monitor the D Drug, alcohol, or tobacco use
outcomes of care processes and use improvement S Sexuality (e.g., whether the patient is sexually active,
methods to design and test changes to continuously practices safe sex, uses contraception, or practices
improve the quality and safety of health care systems. alternative sexual lifestyles)
3. Safety: Minimize risk of harm to patients and provide S Suicide risk or symptoms of depression or other men-
optimal health care through both system effective- tal disorder
ness and individual performance. S  “Savagery” (e.g., violence or abuse in home environ-
4. Informatics: Use information and technology to com- ment or in neighborhood)
municate, manage knowledge, mitigate error, and sup-
port decision making.
5. Teamwork and collaboration: Function effectively As mentioned, developmental levels should be considered
within nursing and interprofessional teams, foster- in the evaluation of children. One of the hallmarks of psychiat-
ing open communication, mutual respect, and shared ric disorders in children is the tendency to regress—that is, to
decision making to achieve quality patient care. return to a previous level of development. Although it is devel-
6. Evidence-based practice (EBP): Integrate best cur- opmentally appropriate for toddlers to suck their thumbs, such
rent evidence with clinical expertise and patient/family a gesture is unusual in an older child.
preferences and values for delivery of optimal health Assessment of children should be accomplished by a combi-
care. nation of interview and observation. Watching children at play
provides important clues to their functioning. Using storytell-
ing, playing with dolls, drawing, or playing games can be use-
minimal amount of data. Refer to Chapter 9 for sound guidelines ful as assessment tools when determining critical concerns and
for setting up and conducting a clinical interview. painful issues a child may have difficulty expressing. Usually, a
The nurse’s primary source for data collection is the patient; clinician with special training in child and adolescent psychia-
however, there may be times when it is necessary to supple- try works with young children. Refer to Chapter 26 for further
ment or rely completely on another source for the assessment discussion on the assessment of children.
information. These secondary sources can be invaluable when
caring for a patient experiencing psychosis, muteness, agita- Assessment of Adolescents
tion, or catatonia. Such secondary sources include family, All patients are concerned with confidentiality. This is espe-
friends, neighbors, police, health care workers, and medical cially true for adolescents. Adolescents may fear that anything
records. they say to the nurse will be repeated to their parents. Adoles-
cents need to know that their records are private and should
Age Considerations receive an explanation as to how information will be shared
Assessment of Children among the treatment team. Questions related to sensitive
An effective interviewer working with children should have issues such as substance abuse or sexual abuse demand con-
familiarity with basic cognitive and social/emotional develop- fidentiality (Arnold & Boggs, 2011). However, threats of sui-
mental theory and have some exposure to applied child devel- cide or homicide, use of illegal drugs, or issues of abuse must
opment (Sommers-Flanagan & Sommers-Flanagan, 2009). be shared with other professionals as well as with the parents.
The role of the caretaker is central in the interview. Because identifying risk factors is one of the key objectives
When assessing children it is important to gather data from when assessing adolescents, it is helpful to use a brief struc-
a variety of sources. Although the child is the best source in tured interview technique called the HEADSSS interview (Box
determining inner feelings and emotions, the caregivers (par- 7-2). Refer to Chapter 26 for more information on the assess-
ents or guardians) can often best describe the behavior, per- ment of adolescents.
formance, and conduct of the child. Caregivers also are often Please note that the American Academy of Child & Ado-
helpful in interpreting the child’s words and responses. How- lescent Psychiatry is urging all clinicians to become more cul-
ever, a separate interview is advisable when an older child is turally sensitive and develop greater cultural competency, and
reluctant to share information, especially in cases of suspected they have developed a model curriculum to address this need
abuse (Arnold & Boggs, 2011). (Mian et al., 2010).
100 UNIT 2  Tools for Practice of the Art

Assessment of the Older Adult • A ssess for risk factors affecting the safety of the patient
Older adults often need special attention. The nurse needs to or others.
be aware of any physical limitations—any sensory condition • Perform a mental status examination (MSE).
(vision or hearing deficits), motor condition (difficulty walking • Assess psychosocial status.
or maintaining balance), or medical condition (cardiac condi- • Identify mutual goals for treatment.
tion)—that could cause increased anxiety, stress, or physical • Formulate a plan of care.
discomfort for the patient while attempting to assess mental
and emotional needs. Gathering Data
It is wise to identify any physical deficits the patient may Review of systems. The mind-body connection is significant
have at the onset of the assessment and make accommodations in the understanding and treatment of psychiatric disorders.
for them. For example, if the patient is hard of hearing, speak a Many patients who are admitted for treatment of psychiatric
little more slowly and in clear, louder tones (but not too loud) conditions also are given a thorough physical examination by
and seat the patient close to you without invading his or her a primary care provider. Likewise, most nursing assessments
personal space. Refer to Chapter 28 for more on communicat- include a physical component, such as obtaining a baseline set
ing with the older adult. of vital statistics, a historical and current review of body sys-
tems, and a documentation of allergic responses.
Language Barriers People with certain physical conditions may be more prone to
It is becoming more and more apparent that psychiatric mental psychiatric disorders such as depression. It is generally believed that
health nurses can best serve their patients if they have a thor- the disease process of multiple sclerosis itself may actually cause
ough understanding of the complex cultural and social factors depression. Other medical diseases that are typically associated
that influence health and illness. Awareness of individual cul- with depression are coronary artery disease, diabetes, and stroke.
tural beliefs and health care practices can help nurses to mini- In fact, a recent study demonstrated that women with both depres-
mize stereotyped assumptions that can lead to ineffective care sion and diabetes have a significantly higher risk for mortality and
and interfere with the ability to evaluate care. There are many cardiovascular disease than do women with either depression or
opportunities for misunderstandings when assessing a patient diabetes alone (Brauser & Barclay, 2011). Individuals need to be
from a different cultural or social background from your own, evaluated for any medical origins of their depression or anxiety.
particularly if the interview is conducted in English and the There are many medical conditions that can mimic psychi-
patient speaks a different language or a different form of Eng- atric illnesses (Box 7-3). By the same token, when depression
lish (Fontes, 2008). is secondary to a known medical condition, it may go unrec-
Often health care professionals require a translator to under- ognized and thus untreated. Conversely, psychiatric disorders
stand the patient’s history and health care needs. There is a dif- can result in physical or somatic symptoms such as abdomi-
ference between an interpreter and a translator. An interpreter nal pain, headaches, lethargy, insomnia, and intense fatigue.
is more likely to unconsciously try to make sense of (interpret) Therefore all patients presenting to the health care system need
what the patient is saying and therefore inserts his or her own to have both a medical and a psychological health evaluation to
understanding of the situation into the database. A professional ensure a correct diagnosis and appropriate care.
translator, on the other hand, tries to avoid interpreting. Fontes Laboratory data. Disorders such as hypothyroidism may
(2008) strongly advises against the use of untrained interpret- have the clinical appearance of depression, and hyperthyroid-
ers (e.g., family members, friends, neighbors). ism may appear to be a manic phase of bipolar disorder; a sim-
For patients who do not speak English or have language ple blood test can usually differentiate between depression and
difficulties, federal law mandates the use of a trained transla- thyroid disorders. Abnormal liver enzyme levels can explain
tor (Arnold & Boggs, 2011). In fact, Poole and Higgo (2006, irritability, depression, and lethargy. People who have chronic
p. 135) state that the “use of a trained translator is essential renal disease often suffer from the same symptoms when their
wherever the patient’s first language is not spoken English blood urea nitrogen and electrolyte levels are abnormal. Results
(even where the person has some English).” A professionally of a toxicology screen for the presence of either prescription or
trained translator is proficient in both English and the patient’s illegal drugs also may provide useful information.
spoken language, maintains confidentiality, and follows spe- Mental status examination. Fundamental to the assess-
cific guidelines. Unfortunately, professional translators are not ment is a mental status examination (MSE). In fact, an MSE
always readily available in many health care facilities. is part of the assessment in all areas of medicine. The MSE in
psychiatry is analogous to the physical examination in general
Psychiatric Nursing Assessment medicine. The purpose of the MSE is to evaluate an individual’s
The psychiatric nursing assessment has many goals, including current cognitive processes. For acutely disturbed patients it is
the following: typical for the mental health clinician to administer MSEs every
• Establish rapport. day. Sommers-Flanagan and Sommers-Flanagan (2009) advise
• Obtain an understanding of the current problem or anyone seeking employment in the medical–mental health field
chief complaint. to be competent in communicating with other professionals
• Review physical status and obtain baseline vital signs. via MSE reports. Box 7-4 lists the elements of a basic MSE. An
CHAPTER 7  Nursing Process and QSEN: The Foundation for Safe and Effective Care 101


Depression Infections:
Neurological disorders: • Encephalitis
• Cerebrovascular accident (stroke) • Meningitis
• Alzheimer’s disease • Neurosyphilis
• Brain tumor • Septicemia
• Huntington’s disease Endocrine disorders:
• Epilepsy (seizure disorder) • Hypothyroidism and hyperthyroidism
• Multiple sclerosis • Hypoparathyroidism
• Parkinson’s disease • Hypoglycemia
• Cancer • Pheochromocytoma
Infections: • Carcinoid
• Mononucleosis Metabolic disorders:
• Encephalitis • Low calcium level
• Hepatitis • Low potassium level
• Tertiary syphilis • Acute intermittent porphyria
• Human immunodeficiency virus (HIV) infection • Liver failure
Endocrine disorders: Cardiovascular disorders:
• Hypothyroidism and hyperthyroidism • Angina
• Cushing’s syndrome • Congestive heart failure
• Addison’s disease • Pulmonary embolus
• Parathyroid disease Respiratory disorders:
Gastrointestinal disorders: • Pneumothorax
• Liver cirrhosis • Acute asthma
• Pancreatitis • Emphysema
Cardiovascular disorders: Drug effects:
• Hypoxia • Stimulants
• Congestive heart failure • Sedatives (withdrawal)
Respiratory disorders: Lead, mercury poisoning
• Sleep apnea
Nutritional disorders: Psychosis
• Thiamine deficiency Medical conditions:
• Protein deficiency • Temporal lobe epilepsy
• B12 deficiency • Migraine headaches
• B6 deficiency • Temporal arteritis
• Folate deficiency • Occipital tumors
Collagen vascular diseases: • Narcolepsy
• Lupus erythematosus • Encephalitis
• Rheumatoid arthritis • Hypothyroidism
• Addison’s disease
Anxiety • HIV infection
Neurological disorders: Drug effects:
• Alzheimer’s disease • Hallucinogens (e.g., LSD)
• Brain tumor • Phencyclidine
• Stroke • Alcohol withdrawal
• Huntington’s disease • Stimulants
• Cocaine
• Corticosteroids

example of a mental status examination is printed on the inside ability, and insight and judgment. Box 7-4 is an example of a
back cover of this text. standardized MSE.
Generally the mental status exam aids in collecting and orga- Psychosocial assessment. A psychosocial assessment pro-
nizing objective data. The nurse observes the patient’s physical vides additional information from which to develop a plan of
behavior, nonverbal communication, appearance, speech pat- care beyond the MSE. It includes obtaining the following infor-
terns, mood and affect, thought content, perceptions, cognitive mation about the patient:
102 UNIT 2  Tools for Practice of the Art


Personal Information • Disturbances (e.g., articulation problems, slurring,
• Age stuttering, mumbling)
• Gender • Cluttering (e.g., rapid, disorganized, tongue-tied speech)
• Marital status
• Religious preference Affect and Mood
• Race • Affect: flat, bland, animated, angry, withdrawn, appro-
• Ethnic background priate to context
• Employment • Mood: sad, labile, euphoric
• Living arrangements
Appearance • Thought process (e.g., disorganized, coherent, flight of
• Grooming and dress ideas, neologisms, thought blocking, circumstantiality)
• Level of hygiene • Thought content (e.g., delusions, obsessions, suicidal
• Pupil dilation or constriction thought)
• Facial expression
• Height, weight, nutritional status Perceptual Disturbances
• Presence of body piercing or tattoos, scars, other • Hallucinations (e.g., auditory, visual)
• Relationship between appearance and age • Illusions

Behavior Cognition*
• Excessive or reduced body movements • Orientation: time, place, person
• Peculiar body movements (e.g., scanning of the envi- • Level of consciousness (e.g., alert, confused,
ronment, odd or repetitive gestures, level of con- clouded, stuporous, unconscious, comatose)
sciousness, balance and gait) • Memory: remote, recent, immediate
• Abnormal movements (e.g., tardive dyskinesia, tremors) • Fund of knowledge
• Level of eye contact (keep cultural differences in mind) • Attention: performance on serial sevens, digit span tests
• Abstraction: performance on tests involving similari-
Speech ties, proverbs
• Rate: slow, rapid, normal • Insight
• Volume: loud, soft, normal • Judgment

*Refer to the inside back cover for the Saint Louis University Mental Status (SLUMS) exam.

•  entral or chief complaint (in the patient’s own words)

C suggested that being part of a spiritual community is helpful to
• History of violent, suicidal, or self-mutilating behaviors people coping with illness and recovering from surgery (Kling,
• Alcohol and/or substance abuse 2011). Spirituality and religious beliefs have the potential to
• Family psychiatric history exert an influence on how people understand meaning and
• Personal psychiatric treatment including medications purpose in their lives and how they use critical judgment to
and complementary therapies solve problems (e.g., crises of illness).
• Stressors and coping methods The terms spirituality and religion are different although
• Quality of activities of daily living not mutually exclusive. Spirituality refers to how we find
• Personal background meaning, hope, purpose, and a sense of peace in our lives.
• Social background including support system Spirituality is more of an internal phenomenon centering on
• Weaknesses, strengths, and goals for treatment universal personal questions and needs. It is the part of us that
• Racial, ethnic, and cultural beliefs and practices seeks to understand life. The term spirituality is more about the
• Spiritual beliefs or religious practices believer’s faith being more personal, less dogmatic, and more
The patient’s psychosocial history is most often the sub- inclusive considering that there are many spiritual paths and
jective part of the assessment. The focus of the history is the no one “real path.” A person’s spiritual beliefs may or may not
patient’s perceptions and recollections of current lifestyle, and be connected with the community or with religious rituals.
life in general (e.g., family, friends, education, work experience, Religion is an external system that includes beliefs, patterns
coping styles, and spiritual and cultural beliefs). of worship, and symbols. Religious affiliation is a choice to
Spiritual and/or religious assessment. The importance of connect personal spiritual beliefs with a larger organized group
spirituality and religious beliefs is an often overlooked element or institution and typically involves rituals. Belonging to a reli-
of patient care, although numerous empirical studies have gious community can provide support during difficult times.
CHAPTER 7  Nursing Process and QSEN: The Foundation for Safe and Effective Care 103


A. Previous hospitalizations H. Coping abilities
B. Educational background 1. What does the patient do when he or she gets upset?
C. Occupational background 2. To whom can the patient talk?
1. Employed? Where? What length of time? 3. What usually helps to relieve stress?
2. Special skills 4. What did the patient try this time?
D. Social patterns I. Spiritual assessment
1. Describe family. 1. Does the patient have a spiritual or religious affiliation?
2. Describe friends. 2. What gives the patient strength and hope?
3. With whom does the patient live? 3. Does the patient participate in any spiritual/religious
4. To whom does the patient go in time of crisis? activities?
5. Who makes the decisions in your family? 4. What role does religion/spiritual practice play in the
6. Describe a typical day. patient’s life?
E. Sexual patterns 5. Do the patient’s spiritual or religious beliefs help him
1. Sexually active? Practices safe sex? Practices birth or her in stressful situations?
control? 6. Are there any restrictions on diet or medical interven-
2. Sexual orientation tions within the patient’s religious, spiritual, or cultural
3. Sexual difficulties beliefs?
F. Interests and abilities J. Cultural assessment
1. What does the patient do in his or her spare time? 1. Does the patient need an interpreter?
2. In which sport, hobby, or leisure activity does the 2. What is the first thing the patient does when he or
patient participate? she becomes ill to address the illness?
3. Does the patient excel in any particular activity or hobby? 3. How has the patient been treating this illness?
4. What gives the patient pleasure? 4. How is this condition (medical or mental) viewed in
G. Substance use and abuse the patient’s culture?
1. What medications does the patient take? How often? 5.  Are there special health care practices within the
How much? patient’s culture that address his or her medical/men-
2.  What herbal or over-the-counter drugs does the tal problem?
patient take? How often? How much? 6. What are the attitudes toward mental illness in the
3. What psychotropic drugs does the patient take? How patient’s culture?
often? How much? 7. Does the patient have culture-specific beliefs that help
4. How many drinks of alcohol does the patient take per him or her cope (with racism, prejudice, or discrim­
day? Per week? ination)?
5. What recreational drugs does the patient take? How 8.  Does the patient’s diet consist of culture-specific
often? How much? foods? If so, what foods should not be part of the
6. Does the patient identify the use of drugs as a problem? patient’s diet?

For many individuals, prayer is a source of hope, comfort, and Cultural and social assessment. Because nurses are increas-
support in healing. (Refer to Chapter 2 for examples of the cul- ingly faced with caring for culturally diverse populations, there
turally different forms of prayer.) is a growing need for nursing assessment, nursing diagnoses,
Spiritual and religious practices have been determined to and subsequent care to be planned around unique cultural
enhance healthy behaviors, social support, and a sense of mean- health care beliefs, values, and practices. It is becoming more
ing in people’s lives, all of which are linked to decreased overall evident that all mental health professionals, and perhaps espe-
mental and physical stress, which in turn relate to a decreased cially nurses, have a thorough understanding of the complexity
incidence of illness in many people. (Refer to Chapter 10 for of the cultural and social factors that influence health and ill-
the effect of stress on health and illness.) ness. Awareness of individual cultural beliefs and health care
O’Rioran (2010) in an interview with Dr. Donald Lloyd- practices can help all health care workers from stereotyping,
Jones (Northwestern University Fienberg School of Medicine, stigmatizing, and labeling patients.
Chicago, IL) quoted him as saying: For patients who have difficulty using and understanding
the English language, federal law maintains the use of a trained
In general, from the perspective of overall health, health- interpreter (Arnold & Boggs, 2011). Refer to Box 7-5 for an
care utilization, and outcomes, the suggestion has been example of a psychosocial assessment.
from some of the studies that greater religiosity, in terms After the assessment, it is useful to summarize pertinent
of participation or spirituality, is typically associated with data with the patient. This summary provides patients with
better health outcomes. reassurance that the health care provider understands their
104 UNIT 2  Tools for Practice of the Art

message, and it gives the patient an opportunity to clarify any Validating the Assessment
misinformation. The patient should be told what will happen To gain an even clearer picture of your patient, it is helpful to
next. For example, if the initial assessment takes place in the look to outside sources. Emergency department records can be
hospital, you should tell the patient who he or she will be seeing a valuable resource in understanding an individual’s present-
next. If the initial assessment was conducted by a psychiatric ing behavior and problems. Police reports may be available in
nurse in a mental health clinic, the patient should be told when cases in which hostility and legal altercations occurred. Using
and how often he or she will meet with the nurse to work on informatics is a way of checking previous admissions, validating
the patient’s problems. If you believe a referral is necessary, this current information, or adding new information to your data-
should be discussed with the patient. For patients with severe base. If the patient was admitted to a psychiatric unit in the past,
and persistent mental health issues requiring long-term care, information about the patient’s previous level of functioning
some specific assessment guidelines can be helpful. Refer to and behavior gives you a baseline for making clinical judgments.
Chapter 27. Occasionally consent forms may need to be signed by the patient
Self-awareness assessment. Self-awareness is a positive or other appropriate relative, in order to obtain access to records.
trait and a competent and effective interviewer needs to possess
a high degree of psychological, emotional, and social/cultural Using Rating Scales
self-awareness to perform optimally (Sommers-Flanagan & A number of standardized rating scales are useful for psychiat-
Sommers-Flanagan, 2009). ric evaluation and monitoring. Rating scales are often adminis-
We all have personal biases and “off days” (i.e., days we feel tered by a clinician, but many are self-administered. Table 7-1
sad or upset, for example), and we all hold our own expecta- lists some of the common scales in use today. Many of the clini-
tions of the outcome of the interview. In addition, we all come cal chapters in this book include a rating scale.
from a specific culture/subculture with inherent expectations,
traditions, and well-ingrained social beliefs. Being consciously QUALITY AND SAFETY ALERT
aware of our personal biases and emotional states can help us
Some possible QSEN competencies inherent when
become cognizant of how these traits can influence and dis-
assessing patients include the following:
tort our understanding of the patient (Sommers-Flanagan &
Patient-centered care: Elicit patient values, prefer-
­Sommers-Flanagan, 2009) as well as our patient’s experience of
ences, and expressed needs as part of the clinical
us as a safe and empathetic health care provider.
It is a good idea to be aware of cultural and social beliefs that
Informatics: Navigate the electronic health record.
may influence your interactions with a person from another
Teamwork and collaboration: Identify the need for
background with inherently different cultural, social, and
an interpreter; recognize contributions of other indi-
spiritual/religious beliefs. Also examine how you are feeling
viduals or groups to help patient/family achieve health
at the moment before an interview. We are not always aware
goals (not directly from QSEN).
of personal feelings or how they are affecting us when we first
begin an interview, with the exceptions of students who will
always feel anxious in the beginning, a very healthy sign. How STANDARD 2: DIAGNOSIS
do we obtain a good picture of ourselves in relationship to
our interviewing skills? One way is clinical supervision from a Formulating a Nursing Diagnosis
seasoned and effective psychiatric nurse or clinician. Another A nursing diagnosis is a clinical judgment about a patient’s
effective way is by the use of videotapes of ourselves during an response, needs, actual and potential psychiatric disorders,
interview (usually a very painful experience, initially). Even mental health problems, and potential comorbid (co-occurring)
seasoned interviewers can be shocked and surprised by their physical illnesses. An actual or potential problem can be related
videotapes. With a confident colleague or supervisor, although to a psychiatric disorder (e.g., self-mutilation, hopelessness),
these insights may be painful they are enormously helpful in a medical disorder (e.g., ineffective breathing pattern), or a
becoming more self-aware and they increase our awareness of potential co-occurring physical illness (e.g., impaired physical
our patient as well. Taking notes shortly after an interview of mobility). Nursing diagnoses “provide the basis for the selec-
what the patient said and what you said (process recordings) tion of nursing interventions to achieve outcomes for which
is a useful exercise because these “verbatim” notes provides the nurse has accountability” (Approved at the ninth NANDA
an overall evaluation of your interaction, which may help you conference; amended in 2009). A well-chosen and well-stated
reevaluate and review not only what you missed but also what nursing ­diagnosis is the basis for selecting therapeutic out-
you could has done differently to be more effective. Process comes and interventions (NANDA-I, 2012-2014). Refer to
recordings are also useful for reviewing alternatives to what Appendix B for list of NANDA-I–approved nursing diagnoses.
the patient has meant. Although these assessment methods
are not as popular as they were in the past in nursing educa- STANDARD NURSING DIAGNOSIS
tion, they offer the opportunity for important learning experi- A standard nursing diagnosis has three structural components:
ences in improving communication skills (refer to Applying the problem (the unmet need), the etiology (the probable
the Art features throughout the clinical chapters). cause), and the supporting data (the signs and symptoms).
CHAPTER 7  Nursing Process and QSEN: The Foundation for Safe and Effective Care 105

The Problem
TABLE 7-1 STANDARDIZED RATING The problem or unmet need describes the state of the patient at
SCALES* present. Problems that are within the nurse’s domain to treat
USE SCALE are termed nursing diagnoses. An example is self-mutilation.
Depression Beck Inventory The Etiology
Geriatric Depression Scale (GDS) The etiology includes factors that contribute to or are related
Hamilton Depression Scale to the development or maintenance of a nursing diagnosis
Zung Self-Report Inventory title. The related factors tell us what needs to be done to effect
Patient Health Questionnaire change and identifies what needs to be targeted through nurs-
(PHQ-9) ing interventions. An example is self-mutilation related to dis-
Anxiety Modified Spielberger State turb body image.
Anxiety Scale Note that the difference in identifying a plan of care for
Hamilton Anxiety Scale someone with the same nursing diagnoses is related to a
Substance use Addiction Severity Index (ASI) patients individual and unique “probable cause -related to”–
disorders Recovery Attitude and Treat- for example:
ment Evaluator (RAATE) Defining Characteristics (Supporting Data)
Brief Drug Abuse Screen Test Supporting signs and symptoms are the “defining characteris-
(B-DAST) tics” that make up the patient’s objective and measurable signs,
Obsessive-compul- Yale-Brown Obsessive-­ plus the more subject symptoms that reflect the patient’s pres-
sive behavior Compulsive Scale (Y-BOCS) ent situation. The defining characteristics may be linked to the
Mania Mania Rating Scale diagnosis and probable cause with the words as evidenced by.
Schizophrenia Scale for Assessment of Nega- Supporting data that would validate the diagnosis self-
tive Symptoms (SANS) mutilation related to disturbed body image might include the
Brief Psychiatric Rating Scale following:
(BPRS) • Poor impulse control
Abnormal Abnormal Involuntary Move- • Self-inflicted cutting
movements ment Scale (AIMS) • Ineffective coping skills
Simpson Neurological Rating • Statements like “I’m so ugly, and when I cut myself, I
Scale feel better about myself.”
General psychiatric Brief Psychiatric Rating Scale Therefore, a completed nursing diagnosis includes (1) the
assessment (BPRS) problem, which is the area that needs intervention; (2) the eti-
Cognitive function Mini-Mental State Examination ology, which is what is responsible for aggravating the problem;
(MMSE) and (3) the defining characteristics, which are the objective and
Cognitive Capacity Screening subjective data that support the validity of the diagnosis (the
Examination (CCSE) problem).
Alzheimer’s Disease Rating Self-mutilation + related to disturbed body image + as evi-
Scale (ADRS) denced by self-cutting, impulsivity, and statements that cutting
Memory and Behavior Problem helps relieve painful feelings of inadequacy.
Functional Assessment
Screening Tool (FAST) Risk diagnoses are employed when there is a high probability
Global Deterioration Scale (GDS) that a future event may occur in a vulnerable individual. “Risk
Family assessment McMaster Family Assessment for” diagnoses are made to help prevent a potential unwanted
Device or dangerous future event in an effort to ensure patient safety
Eating disorders Eating Disorders Inventory (EDI) (QSEN). For example, assessment in an elderly patient with a
Body Attitude Test recent hip replacement might warrant a nursing diagnosis of
Diagnostic Survey for Eating “risk for falls + related to (risk factors) postoperative condition
Disorders and unsteady gait will change.” For example, diagnoses of “risk
for suicide” would be appropriate for a patient like Jim who is
*These rating scales highlight important areas in psychiatric depressed, has attempted suicide in the past, has poor impulse
assessment. Because many of the answers are subjective, ex-
control, and states that he wants to die.
perienced clinicians use these tools as a guide when planning
NANDA-I suggests that when making a “risk for” diag-
care and also rely on their knowledge of their patients.
nosis, the diagnosis should include the risk diagnoses + risk
factors (risk-related behaviors) that predispose the individual
to a potential problem. Since the problem hasn’t yet arisen,
NANDA-I states that there can be no “related etiological
106 UNIT 2  Tools for Practice of the Art

factors.” Therefore, an appropriate nursing diagnosis for Jim effectiveness of nursing interventions to use long- and short-
would be risk for suicide + related to (risk factors, risk behaviors) term outcomes, often stated as goals. The use of long- and short-
states he wants to die, diagnosis of depression, and has previous term outcomes or goals is particularly helpful for teaching and
suicide attempt. learning purposes. It is also valuable for providing guidelines
for appropriate interventions. The use of goals guides nurses
Health Promotion Diagnoses in building incremental steps toward meeting the desired out-
Health promotion diagnoses are used when clinical observa- come. What might be a long-term goal for one patient might
tions and/or patient (family, group, etc.) statements indicate be a short-term goal or a middle-term goal for another patient.
a willingness and a wish to enhance specific health behaviors. All outcomes (goals) are written in positive terms following
Health promotion diagnoses are always stated in the form of the criteria established by the Standards of Practice. Table 7-3
“readiness for enhanced” and supported by the data/defining shows how a specific outcome criterion might be stated for a
characteristics. In cases of health promotion diagnoses, the suicidal individual with a nursing diagnosis of Risk for Suicide
“related to” factors are already known (motivation to improve related to depression and suicide attempt.
health status), so they are not listed in the problem statement.
An example is readiness for enhanced self-concept + (defining QUALITY AND SAFETY ALERT
characteristics) as evidenced by willingness to enhance self-­concept
Patient-Centered Care
and except imitations and strengths.
• Integrate understanding of multiple dimensions of
patient-centered care.
• Engage patients or designated surrogates (e.g., fam-
QUALITY AND SAFETY ALERT ily members) and active partnerships that promote
Suggested QSEN competencies inherent when planning health, safety and well-being, and self-remanagement.
nursing diagnoses include the following: • Plan goals that are congruent with the patient/family
Patient-centered care: Integrate understanding of and are realistic and meet patient’s needs (not directly
multiple dimensions of patient-centered care, includ- from QSEN).
ing patient’s needs, preferences, and values within
their cultural parameters.
More inpatient and community-based facilities are using stan-
STANDARD 3: OUTCOMES IDENTIFICATION dardized tools (e.g., care plans, flowcharts, clinical pathways) for
patients with specific diagnoses. Standard tools allow for inclu-
Determining Outcomes sion of evidence-based practice and newly tested interventions
Outcomes criteria are the optimal goal outcomes that reflect as they become available. They are more time-efficient, although
the maximal level of patient health that can realistically be less focused on the specific individual patient needs. Whatever
achieved through nursing interventions. Whereas nursing the care planning procedures in a specific institution, the nurse
diagnoses identify nursing problems, outcomes reflect the considers the following specific principles when planning care:
desired change. The expected outcomes provide direction for • S afe. They must be safe for the patient as well as for other
continuity of care (ANA, 2007). Outcomes need to take into patients, staff, and family.
account the patient’s culture, values, and ethical beliefs. Specifi- • A  ppropriate. They must be compatible with other thera-
cally, outcomes are stated in attainable and measurable terms and pies and with the patient’s personal goals and cultural
include a time estimate for attainment (ANA, 2007). Therefore values, as well as with institutional rules.
outcomes criteria are patient centered, geared to each individ- • I ndividualized. They should be realistic (1) within the
ual, and documented as obtainable goals. patient’s capabilities given the patient’s age, physical
Moorhead and colleagues (2013) have compiled a standard- strength, condition, and willingness to change; (2) based
ized list of nursing outcomes in Nursing Outcomes Classifica- on the number of staff available; (3) reflective of the
tion (NOC). NOC includes a total of 490 standardized outcomes actual available community resources; and (4) within
that provide a mechanism for communicating the effect of the student’s or nurse’s capabilities.
nursing interventions on the well-being of patients, families, • E  vidence based. They should be based on scientific prin-
and communities. Each outcome has an associated group of ciples when available.
indicators that is used to determine patient status in relation Using best-evidence interventions and treatments as they
to the outcome. Table 7-2 provides suggested NOC indicators become available is being stressed in all areas of medical and
for the outcome of Suicide Self-Restraint along with the Likert mental health care (as discussed in detail in Chapter 1). David
scale that quantifies the achievement on each indicator from 1 Sackett, one of the founders of evidence-based medicine,
(never demonstrated) to 5 (consistently demonstrated). had the quintessential definition of evidence-based practice:
However, NOC does not distinguish between short- “the conscientious, explicit, and judicious use of current best
and long-term outcomes. It is helpful when assessing the evidence in making decisions about the care of individual
CHAPTER 7  Nursing Process and QSEN: The Foundation for Safe and Effective Care
Personal actions to refrain from gestures and attempts at killing self
Outcome Target Rating:
Maintain at __________. Increase to __________.
Expresses feelings 1 2 3 4 5 NA
Expresses sense of hope 1 2 3 4 5 NA
Maintains connectedness in 1 2 3 4 5 NA
Obtains assistance as needed 1 2 3 4 5 NA
Verbalizes suicidal ideas 1 2 3 4 5 NA
Controls impulses 1 2 3 4 5 NA
Refrains from gathering means for 1 2 3 4 5 NA
Refrains from giving away 1 2 3 4 5 NA
Refrains from inflicting serious injury 1 2 3 4 5 NA
Refrains from using nonprescribed 1 2 3 4 5 NA
mood-altering substance(s)
Discloses plan for suicide if present 1 2 3 4 5 NA
Upholds suicide contract* 1 2 3 4 5 NA
Maintains self-control without 1 2 3 4 5 NA
Refrains from attempting suicide 1 2 3 4 5 NA
Obtains treatment for depression 1 2 3 4 5 NA
Obtains treatment for substance 1 2 3 4 5 NA
Reports adequate pain control for 1 2 3 4 5 NA
chronic pain
Uses suicide prevention resources 1 2 3 4 5 NA
Uses social support group 1 2 3 4 5 NA
Uses available mental health services 1 2 3 4 5 NA
Plans for future 1 2 3 4 5 NA
*Some clinicians question the effectiveness of making a suicide plan.
From Moorhead, S., Johnson, M., Maas, M.L., & Swanson, E. (2013). Nursing outcomes classification (NOC) (5th ed.). St Louis: Elsevier.

108 UNIT 2  Tools for Practice of the Art


1. Patient will remain free from injury a. Patient will state he or she understands the rationale and procedure of
throughout the hospital stay. unit’s protocol for suicide precautions.
b. Patient will find staff and/or friend or family member when feeling
­overwhelmed or self-destructive during hospitalization.
2. By discharge, patient will state he or a. Patient will meet with the nurse twice a day for 15 minutes to problem
she no longer wishes to die and has at solve alternatives to the situation throughout the hospital stay.
least two people to contact if suicidal b. Patient will meet with social worker to find supportive resources in his
thoughts arise. or her community on discharge.
c. By discharge, patient will state the purpose of medication, time and
dose, adverse effects, and who to call for questions or concerns.

BOX 7-6 USEFUL EVIDENCE-BASED nursing actions. Although many safe and appropriate inter-
ventions may not be included in NIC, it is a useful guide
for standardized care, but individualizing interventions to
• Academic Center for Evidence-Based Nursing (ACE): meet a patient’s special needs should always be part of the planning.
• Center for Research and Evidence-Based Practice When choosing nursing interventions from NIC or other
(CREP): sources, the nurse uses not just those that fit the nursing
research-evidenced-based-practice diagnosis (e.g., Risk for Suicide) but also those that match the
• Centre for Evidence-Based Mental Health: www. defining data. Although the outcome criteria (NOC) might be similar or the same (e.g., Suicide Self-Restraint), the safe and
• The Cochrane Collaboration: appropriate interventions may be totally different because of
• The Joanna Briggs Institute: the defining data. For example, consider the nursing diagnosis
• The Sarah Cole Hirsch Institute for Best Nursing Prac- Risk for Suicide as evidenced by (risk factors/risk behaviors) two
tice Based on Evidence: recent suicide attempts and repeated statements that “I want
tute/index.shtm to die.”
• University of Iowa, Evidence-Based Practice Guidelines: The planning of appropriate nursing interventions from Nursing Interventions Classifications (2013) might include the
based.htm following:
• University of Minnesota Evidence-Based Health Care • Consider hospitalization of a patient who is at serious
Project: risk for suicidal behavior.
• Explain suicide precautions and relevant safety issues
to the patient/family/significant others (e.g., purpose,
duration, behavioral expectations, and behavioral
patients” (Sackett et al., 2000). Evidence-based practice (EBP) consequences).
for nurses is a combination of clinical skills and the use of clini- • Initiate suicide precautions (e.g., ongoing observations
cally relevant research in the delivery of effective patient-cen- and monitoring of the patient, provision of a protective
tered care. Therefore, the use of best available research coupled environment) for the person who is at serious risk for
with patient preferences and sound clinical judgment and skills suicide.
makes an optimal patient-centered nurse-patient relationship • Search the newly hospitalized patient and personal
(Sackett et al., 2000). Box 7-6 lists several websites available for belongings for weapons or potential weapons during the
nurses to use as resources on evidence-based practice. Keep in inpatient admission procedure, as appropriate.
mind that any interventions that are chosen to be used need to • Use protective interventions (e.g., area restriction seclu-
be acceptable and appropriate to the individual patient. sion, physical restraints) if the patient lacks the restraint
to refrain from harming self, as needed.
Interventions Planning • Assign hospitalized patient to a room located near the
The Nursing Interventions Classification (NIC) (Bulechek nursing station for ease in observations, as appropriate.
et al., 2013) is a research-based standardized listing of 554 However, if the defining data are different, so will be the
interventions that the nurse can use to plan care, and reflects appropriate interventions --for example, risk for suicide related
current clinical practice. Nurses in all settings can use NIC to (risk factors behaviors) to recent loss of spouse, lack of self-
support quality patient care and incorporate evidence-based care, and statements evidencing loneliness and hopelessness.
CHAPTER 7  Nursing Process and QSEN: The Foundation for Safe and Effective Care 109

The nurse might choose the following interventions from research and seeking opportunities for feedback and effective-
NIC (2013) for this individual’s patient’s plan of care: ness of care. Health teaching includes identifying the health
• Determine presence and degree of suicidal risk. education needs of the patient and teaching basic principles of
• Use direct, nonjudgmental approach in discussing physical and mental health, such as giving information about
suicide. coping, interpersonal relationships, social skills, mental dis-
• Assist patient to identify network of supportive persons orders, the treatments for such illnesses and their effects on
and resources (e.g., clergy, family, providers). daily living, relapse prevention, problem-solving skills, stress
• Facilitate support of the patient by family and friends. management, crisis intervention, and self-care activities. The
• Consider strategies to decrease isolation and opportuni- last of these, self-care activities, assists the patient in assum-
ties to act on harmful thoughts. ing personal responsibility for activities of daily living (ADLs)
• Provide information about available community resources and is aimed at improving the patient’s mental and physical
and outreach programs. well-being.
• Chapter 23 addresses assessment of and intervention for
the suicidal patient in more depth. Milieu Therapy
Milieu therapy is an extremely important consideration for the
QUALITY AND SAFETY ALERT nurse working with a patient who should feel comfortable and
safe. Milieu management includes orienting patients to their
Some possible QSEN competencies inherent in planning
rights and responsibilities, selecting specific activities that meet
care include the following:
patients’ physical and mental health needs, and ensuring that
Patient-centered care: Respect patient preferences
patients are maintained in the least restrictive environment.
for degree of active engagement in care process toward
Among other things, it also includes that patients are informed
helping the patient meet his or her needs and goals.
in a culturally competent manner about the need for limits and
Evidence-based practice: Base individualized care plan
the conditions necessary to remove them.
on patient’s values, clinical expertise, and evidence.
Informatics: Document and plan patient care in an Pharmacological, Biological, and
electronic health record.
Integrative Therapies
Nurses need to know the intended action, therapeutic dos-
age, adverse reactions, and safe blood levels of medications
being administered. The nurse also must monitor these values
Psychiatric–Mental Health Nursing: Scope and Standards of when appropriate (e.g., blood levels for lithium). The nurse
Practice (ANA, 2007) identifies seven areas for interven- is expected to discuss and provide medication teaching tools
tion. Recent graduates and practitioners new to the psy- to the patient and family regarding drug action, adverse side
chiatric setting will participate in many of these activities effects, dietary restrictions, and drug interactions, and to pro-
with the guidance and support of more experienced health vide time for questions. The nurse’s assessment of the patient’s
care professionals. The following four interventions iden- response to psychobiological interventions is communicated to
tified in psychiatric mental health nurse (PMHN) practice other members of the mental health team. Interventions are
guidelines (ANA, 2007) are performed both by the psychi- also aimed at alleviating untoward effects of medication.
atric mental health nurse (basic education) as well as by the
advanced practice psychiatric mental health nurse (master’s Advanced Practice Interventions Only
prepared). The following three interventions are carried out by the
The basic level for the psychiatric mental health registered advanced practice registered nurse in psychiatric mental health
nurse is accomplished through the nurse-patient relationship (APRN-PMH).
and therapeutic intervention skills. The nurse implements the
plan using evidence-based interventions whenever possible, Prescriptive Authority and Treatment
utilizing community resources, and collaborating with nursing The APRN-PMH is educated and clinically prepared to pre-
colleagues. scribe psychopharmacological agents for patients with men-
tal health or psychiatric disorders in accordance with state
Basic Level and Advanced Practice Interventions and federal laws and regulations. Such prescriptions take into
Coordination of Care account the individual variables such as culture, ethnicity, gen-
The psychiatric mental health nurse coordinates the imple- der, religious beliefs, age, and physical health.
mentation of the plan and provides documentation.
Health Teaching and Health Promotion The APRN-PMH is educationally and clinically prepared to
Psychiatric mental health nurses use a variety of health teach- conduct individual, couples, group, and family psychother-
ing methods adaptive to the patient’s needs (e.g., age, culture, apy using evidence-based psychotherapeutic frameworks and
ability to learn, readiness), integrating current knowledge and nurse-patient therapeutic relationships (ANA, 2007).
110 UNIT 2  Tools for Practice of the Art

The APRN-PMH works with other clinicians to provide con-
sultation, influence the identified plan, enhance the ability of Suggested QSEN competencies inherent in the docu-
other clinicians, provide services for patients, and effect change. mentation of care include the following:
Informatics: Communicates information to the rest of
QUALITY AND SAFETY ALERT the team on the patient’s progress and employs com-
munication technologies to coordinate care for patients.
Some possible QSEN competencies for implementing
patient-centered care include the following:

Patient-Centered Care documents and may be used in a court of law (see Chapter 6).
• Provide patient-centered care with sensitivity and Besides the evaluation of stated outcomes, the chart should
respect for the diversity of human experience. record changes in patient condition, record of informed con-
• Recognize the boundaries of therapeutic relationships. sents (for medications and treatments), reaction to medication,
• Participate in building consensus or resolving conflict documentation of symptoms (verbatim when appropriate),
in the context of patient care. concerns of the patient, and any unto­ward incidents in the
health care setting. Documentation of patient progress is the
Safety responsibility of the entire mental health team.
• Do the interventions based on your care plan minimize
the risk of harm to patients and providers through both Documentation of “Noncompliance”
system effectiveness and individual performance? When patients do not follow medication and treatment plans,
they are often labeled as “noncompliant.” Applied to patients,
Teamwork and Collaboration the term noncompliant often has negative connotations because
• Initiate request for help when appropriate to the compliance traditionally referred to the extent that a patient
situation. obediently and faithfully followed health care providers’
• Integrate the contributions of others who play a role instructions. “That patient is noncompliant” often translates
in helping patient/family achieve health goals in order to into he or she is “bad” or “lazy,” subjecting the patient to blame
achieve quality patient care. and criticism. Crane (2012) cautions nurses and physicians not
to blame noncompliance on a patient’s stubbornness or bad
mood; this can leave both the nurse and the patient frustrated
STANDARD 6: EVALUATION and angry. The term noncompliant is invariably judgmental.
Unfortunately, evaluation of patient outcomes is often the Crane (2012) also emphasizes that under the Affordable
most neglected part of the nursing process. Evaluation of the Care Act, documenting “noncompliance” no longer protects
individual’s response to treatment should be systematic, ongo- the physician, nurse, manager, or hospital for bad outcomes,
ing, and criterion-based. Supporting data are included to which have led to further illness or injury. A finding of non-
clarify the evaluation. Ongoing assessment of data allows for compliance may void Medicaid or Medicare reimbursements,
revisions of nursing diagnoses, changes to more realistic out- which can lead to financial losses to the institution and damage
comes, or identification of more appropriate interventions to the facility’s reputation (Scudder, 2013).
when outcomes are not met. Furthermore, “patient did not comply” does not protect
nurses, physicians, or health care workers from malpractice
QUALITY AND SAFETY ALERT lawsuits. Crane (2012) advises that meticulous records that
document the doctor’s or nurse’s “rationale for treatment, clear
Suggested QSEN competencies inherent when evaluating explanations of what he or she wants the patient to do, and
care include the following: whether the patient actually complied with that advice” will help
prevent health care workers in the event of lawsuits. The lesson is
Quality Improvement (QI)
to treat noncompliance/nonadherence seriously. “Each compli-
• Seek information about outcomes of care populations
ance issue, large and small, must be recognized as an indicator
served in care setting.
of potential trouble and must be addressed early and appropri-
• Evaluate and monitor the patient’s outcomes (long-
ately” (Scudder, 2013). Probably the biggest issue involved in a
and short-term goals) and make changes to improve
malpractice verdict is even if the patient was given instructions
and increase the quality and safety of patient care (not
or printed information sheets, it is possible that the patient did
directly from QSEN).
not understand the instructions or didn’t realize how important
the treatment (medication, a follow-up, etc.) was to their health.
DOCUMENTATION Systems of Charting
Documentation could be considered the seventh step in the Although communication among team members and coor-
nursing process. Keep in mind that patient records are legal dination of services are the primary goals when choosing a
CHAPTER 7  Nursing Process and QSEN: The Foundation for Safe and Effective Care 111


A descriptive statement of patient status written Developed in the 1960s for physicians to reduce inefficient
in chronological order throughout a shift. Used documentation. Intended to be accompanied by a problem list.
to support assessment finding from a flow Originally SOAP, with IE added later. Emphasis is on problem
sheet. In charting by exception, narrative notes identification, process, and outcome.
are used to indicate significant symptoms,  S: Subjective data (patient statement)
behaviors, or events that are exceptions to O: Objective data (nurse observations)
norms identified on assessment flow sheet. A: Assessment (nurse interprets S and O and describes either
a problem or a nursing diagnosis)
 P: Plan (proposed intervention)
  I: Interventions (nurse’s response to problem)
 E: Evaluation (patient outcome)

Date/time/discipline Date/time/discipline
Patient was agitated in the morning and pacing in S: “I’m so stupid. Get away, get away.” “I hear the devil tell-
the hallway. ing me bad things.”
Blinked eyes, muttered to self, and looked off to O: Patient paced the hall, mumbling to self and looking off to
the side. the side. Shouted derogatory comments when approached
Stated heard voices. by another patient. Watched walls and ceiling closely.
Verbally hostile to another patient. A: Patient was having auditory hallucinations and increased
Offered 2 mg of haloperidol (Haldol) prn and sat agitation.
with staff in quiet area for 20 minutes.  P: Offered patient haloperidol prn. Redirected patient to less
Patient returned to community lounge and was stimulating environment.
able to sit and watch television.   I: Patient received 2 mg of haloperidol PO prn. Sat with pa-
tient in quiet room for 20 minutes.
 E: Patient calmer. Returned to community lounge, sat, and
watched television.

Uses a common form of expression (narrative Structured.
writing). Provides consistent organization of data.
Can address any event or behavior. Facilitates retrieval of data for quality assurance and utilization
Explains flow sheet findings. management.
Provides multidisciplinary ease of use. Contains all elements of the nursing process.
Minimizes inclusion of unnecessary data.
Provides multidisciplinary ease of use.

Unstructured. Requires time and effort to structure the information.
May result in different organization of information Limits entries to problems.
from note to note. May result in loss of data about progress.
Makes it difficult to retrieve quality assurance and Not chronological.
utilization management data. Carries negative connotation.
Frequently leads to omission of elements of the
nursing process.
Commonly results in inclusion of unnecessary and
subjective information.
*Today most charting is computerized, and each institution has its own system of updating patients’ records.
112 UNIT 2  Tools for Practice of the Art


Do’s • Chart physicians’ visits and treatments.
• Chart in a timely manner all pertinent and factual • Chart discharge medications and instructions given
information. for use, as well as all discharge teaching performed,
• Be familiar with the nursing documentation policy in and note which family members were included in the
your facility and make your charting conform to this process.
standard. The policy generally states the method, fre-
quency, and pertinent assessments, interventions, and Don’ts
outcomes to be recorded. If your agency’s policies and • Do not chart opinions that are not supported by the
procedures do not encourage or allow for quality docu- facts.
mentation, bring the need for change to the administra- • Do not defame patients by calling them names or
tion’s attention. by making derogatory statements about them (e.g.,
• Chart legibly in ink. “an unlikable patient who is demanding unnecessary
• Chart facts fully, descriptively, and accurately. attention”).
• Chart what you see, hear, feel, and smell. • Do not chart before an event occurs.
• Chart pertinent observations: psychosocial observa- • Do not chart generalizations, suppositions, or pat
tions, physical symptoms pertinent to the medical diag- phrases (e.g., “patient in good spirits”).
nosis, and behaviors pertinent to the nursing diagnosis. • Do not obliterate, erase, alter, or destroy a record. If an
• Chart follow-up care provided when a problem has been error is made, draw one line through the error, write
identified in earlier documentation. For example, if a “mistaken entry” or “error,” and initial. Follow your
patient has fallen and injured a leg, describe how the agency’s guidelines closely.
wound is healing. • Do not leave blank spaces for chronological notes. If you
• Chart fully the facts surrounding unusual occurrences must chart out of sequence, chart “late entry.” Identify
and incidents. the time and date of the entry and the time and date of
• Chart all nursing interventions, treatments, and out- the occurrence.
comes (including teaching efforts and patient responses), • If an incident report is filed, do not note in the chart
and safety and patient protection interventions. that one was filed. This form is generally a privileged
• Chart the patient’s expressed subjective feelings. communication between the hospital and the hospital’s
• Chart each time you notify a physician and record the attorney. Describing it in the chart may destroy the privi-
reason for notification, the information that was com- leged nature of the communication.
municated, the accurate time, the physician’s instruc-
tions or orders, and the follow-up activity.

system for charting, practitioners in all settings must also Computerized clinical documentation is used increasingly in
consider professional standards, legal issues, requirements for today’s medical settings. Nurses need to be trained to use these
reimbursement by insurers, and accreditation by regulatory technologies and the medical setting should be prepared to
agencies. provide further training for nurses in the use of terminology,
Information also must be in a format that is retrievable for progress notes relating to needs assessment, nursing interven-
quality assurance monitoring, utilization management, peer tions, and nursing diagnoses (Hayrinen, 2010). Any documen-
review, and research. Documentation, using the nursing pro- tation format used by a health care facility must be focused,
cess as a guide, is reflected in many of the different formats organized, and pertinent and must conform to certain legal and
that are commonly used in health care settings (Table 7-4). other generally accepted principles (Box 7-7).


• T he nursing process is a six-step problem-solving approach and collaboration, evidence-based practice (EBP), quality
to patient care to help secure safety and quality care for improvement (QI), safety, and informatics.
patients. • The primary source of assessment is the patient. Second-
• The Institute of Medicine (IOM) and QSEN faculty have ary sources of information include the family, neighbors,
established mandates to prepare future nurses with the friends, police, and other members of the health team.
knowledge, skills, and attitudes (KSAs) necessary for • The assessment interview includes gathering objective data
achieving quality and safety as they engage in the six com- (mental or emotional status) and subjective data (psycho-
petencies of nursing: patient-centered care, teamwork social assessment). A number of tools are provided in this
CHAPTER 7  Nursing Process and QSEN: The Foundation for Safe and Effective Care 113


textbook for the evaluation of cultural, spiritual/religious, • P lanning nursing actions (NIC or other sources) to achieve
and mental status. the outcomes includes the use of the following specific prin-
• Medical examination, history, and systems review complete ciples: the plan should be (1) safe, (2) evidence based when-
a comprehensive assessment. ever possible, (3) realistic, and (4) compatible with other
• An important part of planning patient-centered care is to therapies. NIC provides nurses with standardized nursing
understand how spiritual/religious beliefs play in a person’s interventions that are applicable for use in all settings.
life and how they deal with stress. • Practice in psychiatric nursing encompasses four basic-level
• Caregivers should also have an awareness of the person’s interventions: coordination of care; health teaching and
cultural background and social attachments, and how these health promotion; milieu therapy; and pharmacological,
issues affect the way a person experiences healing in his or biological, and integrative therapies.
her culture. • Advanced practice interventions are carried out by a nurse
• Assessment tools and standardized rating scales may be who is educated at the master’s level or higher. Nurses certi-
used to evaluate and monitor a patient’s progress. Emphasis fied for advanced practice psychiatric mental health nursing
needs to be placed on further evaluation of progress and can practice psychotherapy, prescribe certain medications,
sharing of this information with other members of the and perform consulting work.
health care team. • The evaluation of care is a continual process of determining
• Self-assessment is an important part of the assessment pro- to what extent the outcome criteria have been achieved. The
cess. There are a number of ways that novice interviewers plan of care may be revised on the basis of the evaluation.
can gain valuable feedback, support, and supervision. • Documentation of patient progress through evaluation
• Determination of the nursing diagnosis (NANDA-I) defines of outcome criteria is crucial. The chart is a legal docu-
the practice of nursing, improves communication between ment and should accurately reflect the patient’s condition,
staff members, and assists in accountability for care. medications, treatment, tests, responses, and any untoward
• A nursing diagnosis consists of (1) an unmet need or problem, incidents.
(2) an etiology or probable cause, and (3) supporting data. • Documenting noncompliance/nonadherence to medical
• Outcomes are variable, measurable, and stated in terms treatment no longer protects nurses doctors, other health
that reflect a patient’s actual state. NOC provides 330 stan- care professionals, and/or institutions or lawsuits went
dardized outcomes. Planning involves determining desired further harm to the patient presents itself. Careful docu-
outcomes. mentation of what has been done to help the individual
• Behavioral goals support outcomes. Goals are measurable, understand the instructions, understand the reasons behind
indicate the desired patient behavior(s), include a set time the medical advice, and follow-up on compliance issues
for achievement, and are short and specific. should be included.


1. P
 edro Gonzales, a 37-year-old Hispanic man, arrived by B.
For each of your nursing diagnoses, list one long-term
ambulance from a supermarket, where he had fallen. He outcome (e.g., the problem, what should change).
remains lethargic. On his arrival to the emergency depart- Include a timeframe, desired change, and three criteria
ment (ED), his breath smelled “fruity.” He appears con- that will help you evaluate if the outcome has been met,
fused and anxious, saying that “they put the ‘evil eye’ on not met, or partially met.
me, they want me to die, they are drying out my body… C. For each long-term outcome, list two short-term out-
it’s draining me dry…they are yelling, they are yelling… comes (goals) (the steps that need to be taken in order
no, no I’m not bad…oh God don’t let them get me.” for the goal to be accomplished), including timeframe,
When his mother arrives in the ED, she tells the staff, desired outcomes, and evaluation criteria.
through the use of an interpreter, that Pedro is a severe D. What are the four basic principles for planning nursing
diabetic and has a diagnosis of paranoid schizophrenia, interventions?
and this happens when he does not take his medications. E. What specific needs might you take into account when
In a group or in collaboration with a classmate respond to planning nursing care for Mr. Gonzales?
the following: F. Using informatics, evaluate optimal outcomes for Mr.
A. A number of nursing diagnoses are possible in this sce- Gonzalez at your current health care setting, or use the
nario. Formulate in writing at least two nursing diag- charting method employed by the institution.
noses (problems) given the preceding information, and G. Give an example of the QSEN competencies you might
include “related to” and “as evidenced by.” stress when planning care for Mr. Gonzalez.
114 UNIT 2  Tools for Practice of the Art


Choose the most appropriate answer(s). 3. initial assessment.
1. Which statement by a nurse suggests an undesirable out- 4. identifying data.
come of a psychiatric assessment interview conducted by 4. Which statement about a nursing diagnosis is correct?
the psychiatric nurse? 1. A nursing diagnosis has three structural components: a
1. “I think I was able to establish good rapport with the problem, the etiology of the problem, and supporting
patient.” data that validate the diagnosis.
2. “I believe the patient understands that my values differ 2. A nursing diagnosis is complete when the problem

from his.” statement reflects an unmet need and the etiology given
3. “I was able to obtain a good understanding of the
 reflects a probable cause.
patient’s current problem.” 3. An accurate nursing diagnosis requires a problem state-
4. “I was able to perform a complete assessment of the ment that identifies causes the nurse can treat via nurs-
patient’s level of psychological functioning.” ing interventions.
2. Assessment of an older adult patient will be facilitated if the 4. A nursing diagnosis always must be based on objective
nurse: data measured by the nurse; subjective data may be used
1. identifies and accommodates patient physical needs
 only as supporting data to validate the diagnosis.
early. 5. The purpose of the psychiatric nursing assessment is to:
2. pledges complete confidentiality of all topics to the
 (select all that apply)
patient. 1. establish rapport.
3. adheres strictly to the order of questions on the stan- 2. review physical status.
dardized assessment tool. 3. determine risk factors.
4. interprets data without regard to the patient’s spiritual 4. evaluate the care plan.
and cultural beliefs and practices.
3. Outcome criteria includes the: (select all that apply)
1. time estimated for attainment.
2. measurable terms.

American Nurses Association (ANA), American Psychiatric Nurses Kling, J. (2011). Spirituality an important component of patient care.
Association, & International Society of Psychiatric–Mental Health Retrieved July 23, 2011, from
Nurses. (2007). Psychiatric–mental health nursing: scope and stan- 738237.
dards of practice. Washington, DC: Lasater, K., & Nielsen, A. (2009). The influence of concept-based
Arnold, E. C., & Boggs, K. U. (2011). Interpersonal relationships: learning activities on students’ clinical judgment development.
professional communication skills for nurses (5th ed.). St Louis: Journal of Nursing Education, 48(8), 441–446.
Saunders. Lenburg, C. E. (2011). The influence of contemporary trends and
Brauser, D. (2011). Deadly combination of depression and diabetes issues in nursing education. In B. Cherry, & S. R. Jacob (Eds.),
doubles mortality risk. Retrieved from Contemporary nursing: issues, trends, & management (5th ed.).
viewarticle/735714?SRE=cmemp. St Louis: Elsevier.
Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Wagner, C. M. Mian, A. I., Al-Mateen, C. S., & Cerda, G. (2010). Training child and
(2013). Nursing interventions classification (NIC) (6th ed.). St Louis: adolescent psychiatrists to be culturally competent. Child and
Elsevier. Adolescent Psychiatric Clinics of North America, 19(4), 7–31.
Crane, M. (2012). Documenting noncompliance won’t protect you Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2013). Nurs-
anymore. Retrieved February 18, 2013, from ing outcomes classification (NOC) (5th ed.). St Louis: Elsevier.
viewarticle/773918. North American Nursing Diagnosis Association International
Cronenwett, L., Sherwood, G., Bronsteiner, J., Disch, J., Johnson, J., (NANDA-I). (2012-2014). Nursing diagnoses—definitions and classi-
Mitchell, P., Sullivan, D., and Water, J. (2007). Quality and safety fication 2012-2014. Copyright © 2012, 1994–2012 by NANDA Inter-
education for nurses. Nursing Outlook, 55(3), 122–131. national, Philadelphia: Author. Used by arrangement with Blackwell
Durham, C. F., & Sherwood, G. D. (2008). Education to bridge the Publishing Limited, a company of John Wiley and Sons, Inc.
quality gap: a case to study approach. Urologic Nursing, 28(6), O’Riordan, M. (2000). Religion, spirituality not associated with
431–438. better cardiovascular health. Retrieved March 16, 2012 from
Hayrinen, K. (2010). Evaluation of electronic nursing documentation—
nursing process model and standardized terminologies as key to visible Sackett, D. L., Straus, S., Richardson, W., et al. (2000). Evidence-based
and transparent nursing. International Journal of Medical Informatics, medicine: how to practice and teach EBM. London: Churchill
79(8), 554–564. Livingstone.
CHAPTER 7  Nursing Process and QSEN: The Foundation for Safe and Effective Care 115

Scudder, L. (2013). Nurses and noncompliance: a primer. Retrieved Sullivan, D. T. (2010). Connecting nursing education and practice: a
March 18, 2013, from focus on shared goals for all of me and safety. Creative Nursing,
49_print. 16(1), 37–43.
Sherwood, G., & Hicks, R. W. (2011). Quality and safety education in Valiga, T. M., & Champagne, M. (2011). Creating the future of nursing
nursing (QSEN). In B. Cherry, & S. R. Jacob (Eds.), Contemporary education: challenges and opportunities. In P. Slavik Cowen, &
nursing: issues, trends, & management (5th ed.). St Louis: Elsevier. S. Moorhead (Eds.), Current issues in nursing (8th ed.). St Louis:
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2009). Clinical inter- Mosby/Elsevier.
viewing (4th ed.). Hoboken, NJ: John Wiley & Sons.

Communication Skills: Medium
for All Nursing Practice
Elizabeth M. Varcarolis

  For additional DSM-5 criteria content, see Appendix C


cultural filters, p. 129 nontherapeutic techniques, p. 121 SELECTED CONCEPT:  Telehealth
double messages, p. 120 nonverbal communication, p. 119 Technologies
double-bind messages, p. 120 therapeutic communication, p. 117 “Telehealth is the use of electronic infor-
e-health/e-medicine, telehealth, therapeutic techniques, p. 121 mation and telecommunication tech-
p. 128 verbal communication, p. 119 nologies to support long-distance clinical
feedback, p. 118 healthcare, patient and professional health-
related education, public health and health
administration. Technologies include vid-
eoconferencing, the Internet, store-and-
forward imaging, streaming media, and
terrestrial and wireless communications.”
(HRSA Rural Health)
Since the whole area of psychiatry, psy-
chology, counseling and nursing is based
on human interaction, there still remains
a need for “human to human sensitivity,
acknowledgment, and respect for the
patient care experience” with the use of
any of the information communication
technologies (ICT).
(Malloch, 2010, p. 1) (Arnold & Boggs,

CHAPTER 8  Communication Skills: Medium for All Nursing Practice 117

1. Identify three personal and two environmental factors that 6. Demonstrate with a classmate the use of four techniques
can impede accurate communication. that can enhance communication, highlighting what
2. Discuss the differences between verbal and nonverbal com- makes them effective.
munication and demonstrate at least five areas of nonver- 7. Demonstrate with a classmate the use of four techniques
bal communication. that can obstruct communication, highlighting what
3. Identify two attending behaviors that you will work on to makes them ineffective.
increase your communication skills. 8. Role play with a classmate the techniques of “What if” and
4. Relate problems that can arise when nurses are insensitive the “Miracle Question” and then switch roles. Identify
to cultural differences in patients’ communication styles. what new information you might have learned about your
5. Compare and contrast the range of verbal and nonverbal classmate, and what new insight you might have about
communication of your cultural groups with two other yourself.
cultural groups in the areas of (a) communication style, 9. What are some advantages of telemedicine and telepsy-
(b) eye contact, and (c) touch. Give examples. chiatry in the community in which you live?

Humans have a fundamental need to relate to others, and our communication, and begin to rely on techniques they once
advanced ability to communicate gives our life sustenance and considered artificial. With continued practice, you will develop
meaning. We also share a need to be understood and form sat- your own style and rhythm, and eventually these techniques
isfying relationships with others. This is usually accomplished will become a part of the way you communicate with others.
through the use of effective communication skills. On the other Novice psychiatric practitioners are often concerned that they
hand, when stress or negative feelings occur within the relation- may say the wrong thing, especially when learning to apply thera-
ship, effective communication has a higher potential to falter, peutic techniques. Will you say the wrong thing? The answer is,
and there is a greater chance for miscommunication. Our ability yes, you probably will. That is how we all learn to find more use-
to communicate is a fundamental aspect of being human; in fact, ful and effective ways of helping individuals reach their goals. The
all of our actions, words, and expressions convey meaning to challenge is to recover from your mistakes and use them for learn-
others. It is even said that we cannot not communicate. Silence, ing and growth (Sommers-Flanagan & Sommers-Flanagan, 2009).
for example, can communicate acceptance, anger, or thoughtful- Will saying the wrong thing be harmful to the patient? This
ness. In the provision of nursing care, however, communication is doubtful, especially if your intent is honest, your approach
has a new emphasis. Just as social relationships are different from is respectful, and you have a genuine concern for the patient.
therapeutic relationships, basic communication is different from Communication is up to 90% nonverbal, and individuals pay
the professional, goal-directed, and scientifically based commu- attention to the intent, as discussed in greater detail later in this
nication we call therapeutic communication. chapter. Scientific investigations have identified special skills and
methods that can aid people in becoming more effective help-
ers. However, knowledge of skills and techniques is not enough.
COMMUNICATION Being an effective communicator, whether in nursing or in any
The development of therapeutic communication is crucial to other area of life, is not just a matter of knowing what techniques
forming a patient-centered nurse-patient relationship and is to use. Genuine respect for the individual, the ability to listen
based on human interaction. Therapeutic communication is and to understand the person’s concerns, and a desire to work
essential in nursing care regardless of the setting. Developing the with the individuals to help their situation are also key factors.
skill to determine levels of pain in the postoperative patient, to
listen as parents express feelings of fear concerning their child’s The Communication Process
diagnosis, or to understand, without hearing the words, the Communication is the process of sending and receiving mes-
needs of the intubated voiceless patient in the intensive care sages. One way of thinking about the process of communica-
unit is essential to the provision of quality nursing care. Ideally, tion is to use Berlo’s classic communication model (1960),
therapeutic communication is a professional skill you learn and which has the following basic premises:
practice early in your nursing curriculum. But in psychiatric nurs- 1. One person has a need to communicate with another (stim-
ing communication skills assume a different and new emphasis ulus). For example, the stimulus for communication can be
because psychiatric disorders cause not only physical symptoms a need for information, comfort, or advice.
(such as fatigue, loss of appetite, and insomnia) but also emo- 2. The person sending the message (sender) initiates interper-
tional symptoms (such as sadness, anger, hopelessness, and sonal contact.
euphoria) that affect a person’s very ability to relate to others. 3. The message is the information sent or expressed to
It is often in the psychiatric rotation that students discover another. The clearest messages are those that are well orga-
the importance and increase their ability to utilize therapeutic nized and expressed in a manner familiar to the receiver.
118 UNIT 2  Tools for Practice of the Art

(need for information,
comfort, advice, etc.)


Message Filters Through Can Be QUALITY
Personal Factors • Verbal
• Personal agenda/goals • Nonverbal
• Personal bias — Visual (e.g., body
• Personal relationships language) • Amount of input
• Culture — Tactile (e.g., hug) • Clarity of input
• Past experience — Smell (e.g., body odor) • Relevance of input
• Mood/attitude — Silence
• Value system • Both verbal and nonverbal
• Knowledge — May contradict
• Ability to relate to others — May substantiate
• Environmental factors
• Gender roles

FORMULATION OF Message Evaluated

FEEDBACK Through Personal Filters
• Interpretations of message
sent are influenced by the
same common factors as for
the sender
• Agrees with message
— Personal agenda/goals
• Disagrees with message
— Personal bias
• Needs clarification: “Is this
— Personal relationships
what you mean?”
— Culture
• Provides information
— Past experience
• Requests information
— Mood/attitude
• Gives feedback, which takes
— Value system
many forms
— Knowledge
— Verbal
— Ability to relate to others
— Nonverbal
— Environmental factors
— Both verbal and
— Gender roles
FIGURE 8-1 Operational definition of communication. (Adapted from Ellis, R.B., Gates, B., &
Kenworthy, N. [2003]. Interpersonal communication in nursing: theory and practice. London: Churchill
Livingstone Elsevier.)

4. The message can be sent through a variety of media, includ- sender’s message is extremely important. An accuracy check
ing auditory (hearing), visual (seeing), tactile (touch), may be obtained by simply asking the sender, “Is this what
olfactory (smell), or any combination of these. you mean?” or “I notice you turn away when we talk about
5. The person receiving the message (receiver) then inter- your going back to college. Is there a conflict there?”
prets the message and responds to the sender by provid- Figure 8-1 shows this simple model of communication along
ing feedback. The nature of the feedback often indicates with some of the many factors that affect communication.
whether the meaning of the message sent has been correctly Effective communication in helping relationships depends
interpreted by the receiver. Validating the accuracy of the on the nurse understanding what he or she is trying to convey
CHAPTER 8  Communication Skills: Medium for All Nursing Practice 119

(the purpose of the message), communicating what is really Verbal Communication

meant to the patient, and comprehending the meaning of Verbal communication consists of all words a person speaks.
what the patient is intentionally or unintentionally conveying We live in a society of symbols, and our supreme social symbols
(Arnold & Boggs, 2011). Fundamental to all of this is determin- are words. Talking is our most common activity—our public
ing the person’s viewpoint so that the nurse and patient can link with one another, the primary instrument of instruction,
start on common ground. Peplau (1952) identified two main a need, an art, and one of the most personal aspects of our pri-
principles that can guide the communication process during vate lives. When we speak, we:
the nurse-patient interview: (1) clarity, which ensures that • Communicate our beliefs and values.
the meaning of the message is accurately understood by both • Communicate perceptions and meanings.
parties “as the result of joint and sustained effort of all parties • Convey interest and understanding or insult and
concerned,” and (2) continuity, which promotes connections judgment.
among ideas “and the feelings, events, or themes conveyed in • Convey messages clearly or convey conflicting or implied
those ideas” (p. 290). messages.
Communication is complex and involves a variety of per- • Convey clear, honest feelings or disguised, distorted
sonal and environmental factors that can distort both the send- feelings.
ing and the receiving of messages. Words are often culturally perceived. Clarifying what is
meant by certain words is very important. Even if the nurse
Factors That Affect Communication and patient have the same cultural background, the mental
Personal Factors image they have of a given word may not be exactly the same.
Personal factors that can impede accurate transmission or Although they believe they are talking about the same thing,
interpretation of messages include emotional factors (e.g., the nurse and patient may actually be talking about two quite
mood, responses to stress, personal bias, relationship misun- different things. Words are the symbols for emotions as well as
derstandings), social factors (e.g., previous experience, cultural mental images.
differences, language differences, lifestyle differences), and
cognitive factors (e.g., problem-solving ability, knowledge level, Nonverbal Communication
language use). The tone and pitch of a person’s voice and the manner in
which a person paces speech are examples of nonverbal
Environmental Factors communication. It is important to keep in mind, however,
Environmental factors that may affect communication include that culture influences the pitch and the tone a person uses.
physical factors (e.g., background noise, lack of privacy, uncom- For example, the tone and pitch of a voice used to express
fortable accommodations) and societal determinants (e.g., anger can vary widely within cultures and families (Arnold
sociopolitical, historical, or economic factors; the presence of & Boggs, 2011). Other common examples of nonverbal com-
others; the expectations of others). munication (often called cues) are physical appearance, facial
expressions, body posture, amount of eye contact, eye cast
Relationship Factors (i.e., emotion expressed in the eyes), hand gestures, sighs, fidg-
Relationship factors refer to whether the participants are eting, and yawning. Table 8-1 identifies key components of
equal or unequal. When the two participants are equal, such nonverbal behaviors. Nonverbal behaviors need to be observed
as friends or colleagues, the relationship is said to be symmet- and interpreted in light of a person’s culture, class, gender, age,
rical. However, when there is a difference in status or power, sexual orientation, and spiritual norms. Cultural influences on
such as between nurse and patient or teacher and student, the communication will be discussed later in this chapter.
relationship is characterized by inequality (one participant is
“superior” to the other) and is called a complementary rela- Interaction of Verbal and Nonverbal
tionship (Ellis et al., 2007). Communication
Complementary relationships exist when there is a differ- Communication consists of verbal and nonverbal elements.
ence in status between the participants. For example, in all Although we tend to think of communication primarily in
cultures social status, age or developmental differences, gender terms of what is said, Shea (1998), a nationally renowned psy-
differences, and educational differences can be influential in chiatrist and communication workshop leader, indicates that
the communication process. communication is roughly 10% verbal and 90% nonverbal.
In the United States, capitalism intimately ties systems of Others believe that nonverbal behaviors comprise from 65%
privilege (high-power groups) with systems of oppression to 95% of a sent message. Both sets of statistics point to the
(low-power groups) through economic control. Because high- surprising degree to which nonverbal behaviors and cues influ-
status groups hold more power, they have more control over ence communication. Effective communicators pay attention
lower status groups. One way that power groups retain control to verbal as well as nonverbal cues.
(unequal) is through stereotypes, prejudice, and bias. In other Communication thus involves two radically different but
words, stigma plays a big part in keeping relationship factors interdependent kinds of symbols. The first type is the spoken
unbalanced (Hays, 2008). word, which represents our public selves. Verbal assertions
120 UNIT 2  Tools for Practice of the Art


Body behaviors Posture, body movements, gestures, The patient is slumped in a chair, puts her face in her
gait hands, and occasionally taps her right foot.
Facial expressions Frowns, smiles, grimaces, raised The patient grimaces when speaking to the nurse;
eyebrows, pursed lips, licking of lips, when alone, he smiles and giggles to himself.
tongue movements
Eye cast Angry, suspicious, and accusatory The patient’s eyes harden with suspicion.
Voice-related Tone, pitch, level, intensity, inflection, The patient talks in a loud sing-song voice.
behaviors stuttering, pauses, silences, fluency
Observable auto- Increase in respirations, diaphoresis, When the patient mentions discharge, she becomes
nomic physiological pupil dilation, blushing, paleness pale, her respirations increase, and her face
responses becomes diaphoretic.
Personal appearance Grooming, dress, hygiene The patient is dressed in a wrinkled shirt and his pants
are stained; his socks are dirty and he is unshaven.
Physical Height, weight, physique, complexion The patient appears grossly overweight and his
characteristics muscles appear flabby.

can be straightforward comments or skillfully can be used to confusing. For example, if the student does not have the books,
distort, conceal, deny, and generally disguise true feelings. skips several classes, and does not study, that is process. Here
The second type, nonverbal behaviors, covers a wide range of the student is conveying two different messages.
human activities, from body movements to responses to the Conflicting messages are known as double messages or
messages of others. How a person listens and uses silence and mixed messages. One way a nurse can respond to verbal and
sense of touch may also convey important information about nonverbal incongruity is to reflect and validate the patient’s
the private self that is not available from conversation alone, feelings. “You say you are upset that you did not pass this
especially when viewed from a cultural perspective. semester, but I notice that you look more relaxed and less con-
Some elements of nonverbal communication, such as facial flicted than you have all term. What do you see as some of the
expressions, seem to be inborn and are similar across cultures. pros and cons of not passing the course this semester?”
Matsumoto (1992) and Matsumoto & Sung Hwang (2011) Pioneers in the field of family therapy, Bateson and col-
cited studies that found a high degree of agreement in spon- leagues (1956) coined the term double-bind messages. Mes-
taneous facial expressions or emotions across 10 different cul- sages are sent to create meaning but also can be used defensively
tures. In public, however, some cultural groups (e.g., Japanese) to hide what is actually occurring, create confusion, and attack
may control their facial expressions when observers are present. relatedness (Ellis et al., 2007). A double-bind message is a mix
Other types of nonverbal behaviors, such as how close people of content (what is said) and process (what is transmitted non-
stand to each other when speaking, depend on cultural conven- verbally) that has both a neutral/nurturing aspect, as in what
tions. Some nonverbal communication is formalized and has is said, and a hurtful/negative aspect, which is often implied.
specific meanings (e.g., the military salute, the Japanese bow). For example:
Messages are not always simple and can appear to be one
thing when in fact they are another. An interaction consists of
verbal and nonverbal messages. Often, people have more con-
A 17-year-old female who lives at home with her mother
scious awareness of their verbal messages and less awareness
wants to go out for an evening with her friends. She is
of their nonverbal behaviors. The verbal message is sometimes
told by her chronically ill but not helpless mother: “Oh,
referred to as the content of the message, and the nonverbal
that’s okay, go ahead, have fun. I’ll just sit here by
behavior is called the process of the message.
myself, and I can always call 911 if I don’t feel well, but
When the content is congruent with the process, the com-
you go ahead and have fun.” The mother says this while
munication is more clearly understood and is considered
looking sad, eyes cast down, slumped in her chair, and
healthy. For example, if a student says, “It’s important that I
letting her cane drop to the floor.
get good grades in this class,” that is content. If the student has
purchased the books for the class, takes good notes, and has
a study buddy, that is process. Therefore the content and pro- The recipient of this double-bind message is caught between
cess are congruent and straightforward, and there is a “healthy” contradictory statements so that she cannot do the right thing.
message. If, however, the verbal message is not reinforced or is If she goes out for the evening, the implication is that she is
in fact contradicted by the nonverbal behavior, the message is being selfish by leaving her sick mother alone, but if she stays,
CHAPTER 8  Communication Skills: Medium for All Nursing Practice 121

the mother could say, “I told you to go have fun.” If she does Talking is highly individualized; some find the telephone a
go out, the chances are she will not have much fun. No matter nuisance, but others talk/text on their cell phones almost
what the daughter does, she just cannot win. constantly (e.g., while driving, shopping, in a restaurant with
With experience, nurses become increasingly aware of a friends, and, yes, sitting in a classroom or meeting). The nurse
patient’s verbal and nonverbal communication. Nurses can must recognize and respect individual differences in styles and
compare patients’ dialogue with their nonverbal communi- tempos of responding. People who are quiet, those who have a
cation to gain important clues about the real message. What language barrier or speech impediment, older adults, and those
individuals do either may express and reinforce or may contra- who lack confidence in their ability to express themselves may
dict what they say. As in the saying “Actions speak louder than communicate a need for support and encouragement through
words,” actions often reveal the true meaning of a person’s their silence.
intent, whether it is conscious or unconscious. Although there is no universal rule concerning how much
silence is too much, silence has been said to be worthwhile only
EFFECTIVE COMMUNICATION SKILLS as long as it is serving some function and not frightening the
patient. Knowing when to speak during the interview largely
FOR NURSES depends on the nurse’s perception about what is being conveyed
The art of communication was emphasized by Peplau to high- through the silence. Icy silence may be an expression of anger
light the importance of nursing interventions in facilitating and hostility. Being ignored or given the silent treatment is rec-
achievement of quality patient care and quality of life (Haber, ognized as an insult and is a particularly hurtful form of com-
2000). Therefore, as stated, the goals of the nurse in the mental munication. Silence among some African-American patients
health setting are to help the patient: may relate to anger, insulted feelings, or acknowledgment of a
• Feel understood and comfortable. nurse’s lack of cultural sensitivity (Smedley et al., 2002).
• Identify and explore problems relating to others. Silence may provide meaningful moments of reflection for
• Discover healthy ways of meeting emotional needs. both participants. It gives each an opportunity to contemplate
• Experience satisfying interpersonal relationships. thoughtfully what has been said and felt, weigh alternatives,
The goal for the nurse is to establish and maintain a rela- formulate new ideas, and gain a new perspective on the mat-
tionship in which the patient will feel safe and hopeful that ter under discussion. If the nurse waits to speak and allows the
positive change is possible. patient to break the silence, the patient may share thoughts and
Once specific needs and problems have been identified, the feelings that would otherwise have been withheld. Nurses who
nurse can work with the patient on increasing critical thinking feel compelled to fill every void with words often do so because
skills, learning new coping behaviors, and experiencing more of their own anxiety, self-consciousness, and embarrassment.
appropriate and satisfying ways of relating to others. To do this When this occurs, the nurse’s need for comfort tends to take
the nurse needs to have a sound knowledge of communication priority over the needs of the patient.
skills. Therefore nurses must become more aware of their own Conversely, prolonged and frequent silences by the nurse
interpersonal methods, eliminating obstructive nontherapeu- may hinder an interview that requires verbal articulation.
tic techniques and developing additional responses that maxi- Although the untalkative nurse may be comfortable with
mize nurse-patient interactions and increase the use of helpful silence, this mode of communication may make the patient
therapeutic techniques. feel like a fountain of information to be drained dry. Moreover,
Useful tools for nurses when communicating with their without feedback, patients have no way of knowing whether
patients are (1) silence, (2) active listening, and (3) clarifying what they said was understood.
Active Listening
Use of Silence People want more than just physical presence in human com-
Silence can frighten interviewers as well as patients (Sommers- munication. Most people want the other person to be there for
Flanagan & Sommers-Flanagan, 2009). In our society, and in them psychologically, socially, and emotionally. Active listen-
nursing, there is an emphasis on action. In communication we ing includes the following:
tend to expect a high level of verbal activity. Many students and • Observing the patient’s nonverbal behaviors
practicing nurses find that when the flow of words stops, they • Listening to and understanding the patient’s verbal
become uncomfortable. Silence is not the absence of commu- message
nication; it is a specific channel for transmitting and receiving • Listening to and understanding the person in the con-
messages. The practitioner needs to understand that silence text of the social setting of his or her life
is a significant means of influencing and being influenced by • Listening for “false notes” (i.e., inconsistencies or things
others, and if used judiciously, it can be a powerful listening the patient says that need more clarification)
response. • Providing the patient with feedback about himself or
In the initial interview the patient may be reluctant to speak herself of which the patient might be unaware
because of the newness of the situation, the fact that the nurse Sommers-Flanagan and Sommers-Flanagan (2009) advise
is a stranger, self-consciousness, embarrassment, or shyness. students, as well as experienced clinicians, to learn to quiet
122 UNIT 2  Tools for Practice of the Art

themselves: “They need to rein in any natural urges to help, the patient’s previous message before the interview proceeds.
personal needs, and anxieties” (p. 5). Relaxation techniques By prefacing statements with a phrase such as, “I’m not sure I
may help some before an interview with the patient (e.g., clos- understand” or “In other words, you seem to be saying…,” the
ing one’s eyes and breathing slowly for a few minutes or using nurse helps the patient form a clearer perception of what may
mindfulness training/meditation). This usually results in more be a bewildering mass of details. After paraphrasing, the nurse
concentration on the patient, and less distraction by personal must validate the accuracy of the restatement and its helpful-
worries or personal thoughts of what to say next. ness to the discussion. The patient may confirm or deny the
Effective interviewers must become accustomed to silence, perceptions through nonverbal cues or by direct response to a
but it is just as important for effective interviewers to learn to question such as, “Was I correct in saying…?” As a result, the
become active listeners when the patient is talking, as well as patient is made aware that the interviewer is actively involved
when the patient becomes silent. During active listening nurses in the search for understanding.
carefully note what the patient is saying verbally and nonver-
bally, as well as monitor their own nonverbal responses. Using Restating
silence effectively and learning to listen on a deeper, more sig- In restating, the nurse mirrors the patient’s overt and covert
nificant level—to the patient as well as to your own thoughts messages; thus this technique may be used to echo feeling as
and reaction—are both key ingredients in effective communi- well as content. Restating differs from paraphrasing in that
cation. Both skills take time to develop but can be learned; you it involves repeating the same key words the patient has just
will become more proficient with guidance and practice. spoken. If a patient remarks, “My life is empty…it has no
Some principles important to active listening are always rel- meaning,” additional information may be gained by restating,
evant, such as the following (Mohl, 2003): “Your life has no meaning?” The purpose of this technique is
• The answer is always inside the patient. to explore more thoroughly subjects that may be significant.
• Objective truth is never as simple as it seems. However, too frequent and indiscriminate use of restating
• Everything you hear is modified by the patient’s filters. might be interpreted by patients as inattention, disinterest, or
• Everything you hear is modified by your own filters. worse.
• It is okay to feel confused and uncertain. It is easy to overuse this tool so that its application becomes
• Listen to yourself, too. mechanical. Parroting or mimicking what another has said
Active listening helps strengthen the patient’s ability to may be perceived as poking fun at the person, so that use of
use critical thinking in order to solve problems. By giving the this nondirective approach can become a definite barrier to
patient undivided attention, the nurse communicates that the communication. To avoid overuse of restating, the nurse can
patient is not alone. This kind of intervention enhances self- combine restatements with direct questions that encourage
esteem and encourages the patient to direct energy toward find- descriptions: “What does your life lack?” “What kind of mean-
ing ways to deal with problems. Serving as a sounding board, ing is missing?” “Describe one day in your life that appears
the nurse listens as the patient tests thoughts by voicing them empty to you.”
aloud. This form of interpersonal interaction often enables the
patient to clarify thinking, link ideas, and tentatively decide Reflecting
what should be done and how best to do it. Active listening is Reflection is a means of assisting people to better under-
an art that develops with practice over time. stand their own thoughts and feelings. Reflecting may take
the form of a question or a simple statement that conveys
Clarifying Techniques the nurse’s observations of the patient when sensitive issues
Understanding depends on clear communication, which is are being discussed. The nurse might then describe briefly to
aided by verifying with the patient the nurse’s interpretation the patient the apparent meaning of the emotional tone of
of the patient’s messages. The nurse must request feedback the patient’s verbal and nonverbal behavior. For example,
on the accuracy of the message received from verbal as well as to reflect a patient’s feelings about his or her life, a good
nonverbal cues. The use of clarifying techniques helps both beginning might be, “You sound as if you have had many
participants identify major differences in their frame of refer- disappointments.”
ence, giving them the opportunity to correct misperceptions Sharing observations with a patient shows acceptance.
before these cause any serious misunderstandings. The patient The nurse helps make the patient aware of inner feelings and
who is asked to elaborate on or to clarify vague or ambiguous encourages the patient to own them. For example, the nurse
messages needs to know that the purpose is to promote mutual may tell a patient, “You look sad.” Perceiving the nurse’s con-
understanding. cern may allow a patient spontaneously to share feelings. The
use of a question in response to the patient’s question is another
Paraphrasing reflective technique (Arnold & Boggs, 2011). For example:
For clarity, the nurse might use paraphrasing, which means Patient: “Nurse, do you think I really need to be
restating in different (often fewer) words the basic content of hospitalized?”
a patient’s message. Using simple, precise, and culturally rel- Nurse: “What do you think, Jane?”
evant terms, the nurse may readily confirm interpretation of Patient: “I don’t know; that’s why I’m asking you.”
CHAPTER 8  Communication Skills: Medium for All Nursing Practice 123

Nurse: “I’ll be willing to share my impression with you at Asking Excessive Questions
the end of this first session. However, you’ve probably Excessive questioning, or asking multiple questions at the
thought about hospitalization and have some feelings same time, especially closed-ended questions, casts the nurse
about it. I wonder what they are.” in the role of interrogator, raising a demand for information
without respect for the patient’s willingness or readiness to
Exploring respond. This approach conveys lack of respect for and sen-
A technique that enables the nurse to examine important sitivity to the patient’s needs. Excessive questioning or asking
ideas, experiences, or relationships more fully is exploring. For multiple questions at the same time controls the range and
example, if a patient tells the nurse that he does not get along nature of the response and can easily result in a therapeutic stall
well with his wife, the nurse will want to further explore this or shut down an interview. It is a controlling tactic and may
area. Possible openers include the following: reflect the interviewer’s lack of security in letting the patient tell
• “ Tell me more about your relationship with your his or her own story. It is better to ask more open-ended ques-
wife.” tions and follow the patient’s lead. For example:
• “ Describe your relationship with your wife.” Excessive questioning: “Why did you leave your wife? Did
• “ Give me an example of how you and your wife don’t get you feel angry at her? What did she do to you? Are you
along.” going back to her?”
Asking for an example can greatly clarify a vague or generic More therapeutic approach: “Tell me about the situation
statement made by a patient. between you and your wife.”
Patient: “No one likes me.” Keep in mind that knowing a lot of facts about a person is
Nurse: “Give me an example of one person who doesn’t like not synonymous with helping. You might end up with
you.” a lot of facts, but miss the person entirely (Egan, 2010).
Patient: “Everything I do is wrong.” Giving Approval or Disapproval
Nurse: “Give me an example of one thing you do that you “You look great in that dress.” “I’m proud of the way you
think is wrong.” controlled your temper at lunch.” “That’s a great quilt you
Table 8-2 lists more examples of techniques that enhance made.” What could be bad about giving someone a pat on
communication. the back once in a while? Nothing, if it is done without carry-
ing a judgment (positive or negative) by the nurse. We often
Projective Questions: The “What If” Question give our friends and family approval when they do something
Projective questions usually start with a “what if” to help people well. However, in a nurse-patient situation, giving approval
articulate, explore, and identify thoughts and feelings. Projec- often becomes much more complex. A patient may be feeling
tive questions can also help people imagine thoughts, feelings, overwhelmed, experiencing low self-esteem, feeling unsure of
and behaviors they might have in certain situations (Sommers- where his or her life is going, and very needy for recognition,
Flanagan & Sommers-Flanagan, 2009, p. 87): approval, and attention. Yet, when people are feeling vulner-
• If you had three wishes what would you wish for? able, a value comment might be misinterpreted. For example:
• What if you could go back and change how you acted in Giving approval: “You did a great job in group telling John
(X situation/significant life event); what would you do just what you thought about how rudely he treated you.”
differently now? Implied in this message is that the nurse was pleased by the
• What would you do if you were given $1 million, no manner in which the patient talked to John. The patient then
strings attached? sees such a response as a way to please the nurse by doing the
right thing. To continue to please the nurse (and get approval),
Presupposition Questions: The “Miracle Question” the patient may continue the behavior. The behavior might be
• S uppose you woke up in the morning and a miracle hap- useful for the patient, but when a behavior is being done to
pened and this problem had gone away. What would be please another person, it is not coming from the individual’s
different? How would it change your life? own volition or conviction.
These two questions can reveal a lot about a person that can Also when the other person whom the patient needs to
be used in identifying goals that the patient may be motivated please is not present, the motivation for the new behavior
to pursue, and often get to the crux of what might be the most might not be there either. Thus the new response really is not
important issues in a person’s thinking/life. a change in behavior as much as a ploy to win approval and
acceptance from another person. Giving approval also stops
further communication. It is a statement of the observer’s
NONTHERAPEUTIC TECHNIQUES (nurse’s) judgment about another person’s (patient’s) behav-
Although people may use nontherapeutic techniques in their ior. A more useful comment would be the following:
daily lives, they can become problematic when one is working More therapeutic approach: “I noticed that you spoke up to
with patients. Table 8-3 offers samples of nontherapeutic tech- John in group yesterday about his rude behavior. How
niques and suggestions for more helpful responses. did it feel to be more assertive?”
124 UNIT 2  Tools for Practice of the Art


Using silence Gives the person time to collect thoughts or think Encourage a person to talk by waiting for
through a point. the answers.
Accepting Indicates that the person has been understood. The “Yes.”
statement does not necessarily indicate agreement but “Uh-huh.”
is nonjudgmental. However, nurses should not imply “I follow what you say.”
that they understand when they do not understand.
Giving recognition Indicates awareness of change and personal efforts. “Good morning, Mr. James.”
Does not imply good or bad, or right or wrong. “You’ve combed your hair today.”
“I notice that you shaved today.”
Offering self Offers presence, interest, and a desire to understand. “I would like to spend time with you.”
Is not offered to get the person to talk or behave in a “I’ll stay here and sit with you awhile.”
specific way.
Offering general Allows the other person to take direction in the “Go on.”
leads discussion. Indicates that the nurse is interested in “And then?”
what comes next. “Tell me about it.”
Giving broad Clarifies that the lead is to be taken by the patient. “Where would you like to begin?”
openings However, the nurse discourages pleasantries and “What are you thinking about?”
small talk. “What would you like to discuss?”
Placing the events Puts events and actions in better perspective. Notes “What happened before?”
in time or cause-and-effect relationships and identifies patterns “When did this happen?”
sequence of interpersonal difficulties.
Making Calls attention to the person’s behavior (e.g., trem- “You appear tense.”
observations bling, nail biting, restless mannerisms). Encour- “I notice you’re biting your lips.”
ages the person to notice the behavior to describe “You appear nervous whenever John
thoughts and feelings for mutual understanding. enters the room.”
Helpful with mute and withdrawn people.
Encouraging Increases the nurse’s understanding of the patient’s “What do these voices seem to be saying?”
description of perceptions. Talking about feelings and difficulties “What is happening now?”
perception can lessen the need to act them out inappropriately. “Tell me when you feel anxious.”
Encouraging Reveals recurring themes in experiences or interper- “Has this ever happened before?”
comparison sonal relationships. Helps the person clarify similari- “Is this how you felt when…?”
ties and differences. “Was it something like…?”
Restating Repeats the main idea expressed. Gives the patient Patient: “I can’t sleep. I stay awake all
an idea of what has been communicated. If the night.”
message has been misunderstood, the patient can Nurse: “You have difficulty sleeping?”
clarify it. Patient: “I don’t know…he always has
some excuse for not coming over or
keeping our appointments.”
Nurse: “You think he no longer wants to
see you?”
Reflecting Directs questions, feelings, and ideas back to the Patient: “What should I do about my
patient. Encourages the patient to accept his or her husband’s affair?”
own ideas and feelings. Acknowledges the patient’s Nurse: “What do you think you should do?”
right to have opinions and make decisions and Patient: “My brother spends all of my money
encourages the patient to think of self as a capable and then has the nerve to ask for more.”
person. Nurse: “You feel angry when this
Focusing Concentrates attention on a single point. It is espe- “This point you are making about leaving
cially useful when the patient jumps from topic to school seems worth looking at more
topic. If a person is experiencing a severe or panic closely.”
level of anxiety, the nurse should not persist until the “You’ve mentioned many things. Let’s go
anxiety lessens. back to your thinking of ‘ending it all’.”
CHAPTER 8  Communication Skills: Medium for All Nursing Practice 125


Exploring Examines certain ideas, experiences, or relationships “Tell me more about that.”
more fully. If the patient chooses not to elaborate by “Would you describe it more fully?”
answering no, the nurse does not probe or pry. In “Could you talk about how it was that you
such a case, the nurse respects the patient’s wishes. learned your mom was dying of cancer?”
Giving information Makes available facts the person needs. Supplies “My purpose for being here is…”
knowledge from which decisions can be made or “This medication is for…”
conclusions drawn. For example, the patient needs “The test will determine…”
to know the role of the nurse; the purpose of the
nurse-patient relationship; and the time, place, and
duration of the meetings.
Seeking clarification Helps patients clarify their own thoughts and “I am not sure I follow you.”
maximize mutual understanding between nurse “What would you say is the main point of
and patient. what you just said?”
“Give an example of a time you thought
everyone hated you.”
Presenting reality Indicates what is real. The nurse does not argue or “That was Dr. Todd, not a terrorist stalking
try to convince the patient, just describes personal and trying to harm you.”
perceptions or facts in the situation. “That was the sound of a car backfiring.”
“Your mother is not here; I am a nurse.”
Voicing doubt Undermines the patient’s beliefs by not reinforcing the “Isn’t that unusual?”
exaggerated or false perceptions. “Really?”
“That’s hard to believe.”
Seeking consensual Clarifies that both the nurse and the patient share mutual “Tell me whether my understanding
validation understanding of communications. Helps the patient agrees with yours.”
become clearer about what he or she is thinking.
Verbalizing the Puts into concrete terms what the patient implies, Patient: “I can’t talk to you or anyone
implied making the patient’s communication more explicit. else. It’s a waste of time.”
Nurse: “Do you feel that no one
Encouraging Aids the patient in considering people and events “How do you feel about…?”
evaluation from the perspective of the patient’s own set of “What did it mean to you when he said
values. he couldn’t stay?”
Attempting to Responds to the feelings expressed, not just the Patient: “I am dead inside.”
translate into content. Often termed decoding. Nurse: “Are you saying that you feel
feelings lifeless? Does life seem meaningless to
Suggesting Emphasizes working with the patient, not doing things “Perhaps you and I can discover what
collaboration for the patient. Encourages the view that change is produces your anxiety.”
possible through collaboration. “Perhaps by working together we can come
up with some ideas that might improve
your communications with your spouse.”
Summarizing Combines the important points of the discussion to “Have I got this straight?”
enhance understanding. Also allows the opportunity “You said that…”
to clarify communications so that both nurse and “During the past hour, you and I have
patient leave the interview with the same ideas in discussed…”
Encouraging Allows the patient to identify alternative actions for “What could you do to let anger out
formulation of a interpersonal situations the patient finds disturbing harmlessly?”
plan of action (e.g., when anger or anxiety is provoked). “The next time this comes up, what
might you do to handle it?”
“What are some other ways you can
approach your boss?”
Adapted from Hays, J.S., & Larson, K. (1963). Interacting with patients. New York: Macmillan. Copyright ©1963 Macmillan Publishing.
126 UNIT 2  Tools for Practice of the Art


Giving premature “Get out of this situation Assumes the nurse knows Encouraging problem solving:
advice immediately.” best and the patient cannot “What are the pros and cons of
think for self. Inhibits your situation?”
problem solving and fosters “What were some of the actions
dependency. you thought you might take?”
“What are some of the ways you
have thought of to meet your
Minimizing feelings Patient: “I wish I were Indicates that the nurse is Empathizing and exploring:
dead.” unable to understand or “You must be feeling very upset.
Nurse: “Everyone gets empathize with the patient. Are you thinking of hurting
down in the dumps.” The patient’s feelings or yourself?”
“I know what you mean.” experiences are being
“You should feel happy belittled, which can cause
you’re getting better.” the patient to feel small or
“Things get worse before insignificant.
they get better.”
Falsely reassuring “I wouldn’t worry about Underrates the patient’s Clarifying the patient’s message:
that.” feelings and belittles the “What specifically are you
“Everything will be all patient’s concerns. worried about?”
right.” May cause the patient to “What do you think could go
stop sharing feelings if the
“You will do just fine; you’ll wrong?”
see.” patient thinks he or she will “What are you concerned might
be ridiculed or not taken happen?”
Making value “How come you still smoke Prevents problem solving. Can Making observations:
judgments when your wife has lung make the patient feel guilty, “I notice you are still smoking
cancer?” angry, misunderstood, not even though your wife has lung
supported, or anxious to cancer. Is this a problem?”
Asking “why” “Why did you stop taking Implies criticism; often has Asking open-ended questions;
questions your medication?” the effect of making the giving a broad opening: “Tell
patient feel defensive. me some of the reasons that
led up to your not taking your
Asking excessive Nurse: “How’s your Results in the patient’s not Clarifying:
questions appetite? Are you losing knowing which question to “Tell me about your eating habits
weight? Are you eating answer and possibly being since you’ve been depressed.”
enough?” confused about what is
Patient: “No.” being asked.
Giving approval; “I’m proud of you for Implies that the patient is Making observations:
agreeing applying for that job.” “I doing the right thing—and “I noticed that you applied for
agree with your decision.” that not doing it is wrong. that job. What factors led you
May lead the patient to to change your mind about
focus on pleasing the nurse applying for that job?”
or clinician; denies the Asking open-ended questions;
patient the opportunity to giving a broad opening: “What
change his or her mind or led to that decision?”
CHAPTER 8  Communication Skills: Medium for All Nursing Practice 127


Disapproving; “You really should have Can make a person defensive. Exploring:
disagreeing shown up for the “What was going through your
medication group.” mind when you decided not
“I disagree with that.” to come to your medication
“That’s one point of view.
How did you arrive at that
Changing the subject Patient: “I’d like to die.” May invalidate the patient’s Validating and exploring:
Nurse: “Did you go to feelings and needs. Can Patient: “I’d like to die.”
Alcoholics Anonymous leave the patient feeling Nurse: “This sounds serious.
like we discussed?” alienated and isolated Have you thought of harming
and increase feelings of yourself?”
Adapted from Hays, J.S., & Larson, K. (1963). Interacting with patients. New York: Macmillan. Copyright ©1963 Macmillan Publishing.

This opens the way for finding out if the patient was scared and identify what information might be needed to attain an
or comfortable, wants to work more on assertiveness, or has informed decision. A more useful approach would be, “What
other issues to discuss. It also suggests that this was a self- do you see as some possible actions you can take?” It is much
choice the patient made. The patient is given recognition for more constructive to encourage critical thinking by the patient.
the change in behavior, and the topic is also opened for further At times the nurse can suggest several alternatives that a patient
discussion. might consider (e.g., “Have you ever thought of telling your
Disapproving is moralizing and implies that the nurse has friend about the incident?”). The patient is then free to say yes
the right to judge the patient’s thoughts or feelings. Again, an or no and make a decision from among the suggestions.
observation should be made instead.
Disapproving: “You really should not cheat, even if you Asking “Why” Questions
think everyone else is doing it.” “Why did you come late?” “Why didn’t you go to the funeral?”
More therapeutic approach: “Can you give me two examples “Why didn’t you study for the exam?” Very often “why” ques-
of how cheating could negatively affect your goal of tions imply criticism. We may ask our friends or family such
graduating?” questions, and in the context of a solid relationship the “why?”
may be understood more as “what happened?” With people we
Advising do not know—especially an anxious person who may be feeling
Although we ask for and give advice all the time in daily life, overwhelmed—a “why” question from a person in authority
giving advice to a patient is rarely helpful. Often when we ask (nurse, physician, teacher) can be experienced as intrusive and
for advice, our real motive is to discover if we are thinking along judgmental, which serves only to make the person defensive.
the same lines as someone else or if they would agree with us. It is much more useful to ask what is happening rather than
When the nurse gives advice to a patient who is having trouble why it is happening. Questions that focus on who, what, where,
assessing and finding solutions to conflicted areas in his or her and when often elicit important information that can facilitate
life, the nurse is interfering with the patient’s ability to make problem solving and further the communication process.
personal decisions. Giving a person a solution robs the patient
of self-responsibility (Egan, 2010). When the nurse offers the CULTURAL CONSIDERATIONS: NEGOTIATING
patient solutions, the patient eventually begins to think that the
nurse does not view the patient as capable of making effective
decisions. Ethnically diverse populations are a rapidly growing seg-
People often feel inadequate when they are given no choices ment of the American population. Health care professionals
over decisions in their lives. Giving advice to patients can foster are gradually becoming aware of the need to become more
dependency (“I’ll have to ask the nurse what to do about….”) familiar with the verbal and nonverbal communication char-
and can undermine their sense of competence and adequacy. acteristics of the diverse multicultural populations now using
However, people do need information to make informed deci- the health care system. The nurse’s awareness of the cultural
sions. Often the nurse can help the patient define a problem meaning of certain verbal and nonverbal communications in
128 UNIT 2  Tools for Practice of the Art

initial face-to-face encounters with a patient can lead to the with those outside their cultural group, which may explain the
formation of positive therapeutic alliances with members of distrust that many African Americans have about the American
culturally diverse populations (Kavanaugh, 2008) or lead to health care system (Eiser & Ellis, 2007). Therefore, a tendency
frustration and misunderstanding by both the nurse and the toward guarded and selective communication among African-
patient. Always assess the patient’s ability to speak and under- American patients may represent a healthy cultural adaptation
stand English well, and provide an interpreter when needed. (Smedley et al., 2002; USDHHS, 2001).
Unrecognized differences between aspects of the cultural
identities of patient and nurse can result in assessment and Eye Contact
interventions that are not optimally respectful of the patient Fontes (2008) warns that the presence or absence of eye con-
and can be inadvertently biased or prejudiced (Lu and Mezzich, tact should not be used to assess attentiveness, to judge truth-
1995). Lu and colleagues further emphasized that health care fulness, or to make assumptions on the degree of engagement
workers need to have not only knowledge of various patients’ one has with the patient. Culture dictates a person’s comfort or
cultures but also awareness of their own cultural identities. lack of comfort with direct eye contact. Some cultures consider
Especially important are nurses’ attitudes and beliefs toward direct eye contact disrespectful and improper. For example,
those from ethnically diverse populations and subcultures (e.g., Hispanic individuals have traditionally been taught to avoid
alternate lifestyles, the elderly), because these will affect their eye contact with authority figures such as nurses, physicians,
relationships with their patients. Four areas that may prove and other health care professionals. Avoidance of direct eye
problematic for the nurse interpreting specific verbal and non- contact is seen as a sign of respect to those in authority. To
verbal messages of the patient include the following: nurses or other health care workers from non-Hispanic back-
1. Communication styles grounds, however, this lack of eye contact may be wrongly
2. Use of eye contact interpreted by the interviewer as disinterest in the interview
3. Perception of touch or even as a lack of respect. Conversely, the nurse is expected
4. Cultural filters to look directly at the patient when conducting the interview
(Kavanaugh, 2008).
Communication Styles Similarly, in Asian cultures respect is shown by avoiding eye
People from some ethnic backgrounds may communicate in contact. For example, in Japan direct eye contact is considered
an intense and highly emotional manner. For example, from to show lack of respect, and to be a personal affront; preference
the perspective of a non-Hispanic person, Hispanic Americans is for shifting or downcast eyes or focus on the speaker’s neck.
may appear to use dramatic body language when describing Among many Chinese, gazing around and looking to one side
their emotional problems. Such behavior may be perceived as when listening to another is considered polite. However, when
out of control and thus viewed as having a degree of pathol- speaking to an older adult, direct eye contact is used (Kavanaugh,
ogy that is not actually present. Within the Hispanic culture, 2008). Philippine Americans may try to avoid eye contact; how-
however, intensely emotional styles of communication often ever, once it is established, it is important to return and maintain
are culturally appropriate and are to be expected (Kavanaugh, eye contact.
2008). French and Italian Americans also show animated facial Many Native Americans also believe it is disrespectful or
expressions and expressive hand gestures during communica- even a sign of aggression to engage in direct eye contact, espe-
tion that can be mistakenly interpreted by others. cially if the speaker is younger. Direct eye contact by members
Conversely, in other cultures, a calm facade may mask of the dominant culture in the health care system can and does
severe distress. For example, in Asian cultures, expression of cause discomfort for some patients and is considered a sign of
either positive or negative emotions is a private affair, and open disrespect, while listening is considered a sign of respect and
expression of emotions is considered to be in bad taste and essential to learning about the other individual (Kalbfleisch,
possibly to be a weakness. A quiet smile by an Asian American 2009; Kavanaugh, 2008).
may express joy, an apology, stoicism in the face of difficulty, On the other hand, among German Americans, direct and
or even anger (USDHHS, 2001). In general, Asian individuals sustained eye contact indicates that the person listens or trusts,
exercise emotional restating communication and interpersonal is somewhat aggressive, or, in some situations, is sexually inter-
conflicts are not directly addressed or even allowed (Arnold & ested. Russians also find direct, sustained eye contact the norm
Boggs, 2011). German and British Americans also value highly for social interactions (Giger & Davidhizar, 2007). In Haiti, it
the concept of self-control and may show little facial emotion is customary to hold eye contact with everyone but the poor
in the presence of great distress or emotional turmoil. (Kavanaugh, 2008; USDHHS, 2001). French, British, and many
It is important to understand an ethnic minority in light of African Americans maintain eye contact during conversation;
the historical context in which it evolved and its relationship to avoidance of eye contact by another person may be interpreted
the dominant culture. For example, African Americans, whose as being disinterested, not telling the truth, or avoiding the
historical background in the United States is one of slavery and sharing of important information. In some Arab cultures, for
oppression, are likely to be aware of a basic need for survival. a woman to make direct eye contact with a man may imply a
As a result of their experiences, many African Americans have sexual interest or even promiscuity. In Greece, staring in public
become highly selective and guarded in their communication is acceptable (Kavanaugh, 2008).
CHAPTER 8  Communication Skills: Medium for All Nursing Practice 129

However, unavoidably, these cultural filters also introduce var-

Touch ious forms of bias into our listening because they are bound to
The therapeutic use of touch is a basic aspect of the nurse- influence our personal, professional, familial, and sociological
patient relationship, and touch is normally perceived as a values and interpretations. If the cultural filters are strong, the
gesture of warmth and friendship. However, in some cultures likelihood for bias is increased (Egan, 2010). Bias builds a dis-
touch can be perceived as an invasion of privacy or an invi- torted understanding, and a tendency to pigeonhole a person
tation to intimacy by some patients. The response to touch is because of such factors as race, sexual orientation, nationality,
often culturally defined. For example, many Hispanic Ameri- social status, religious persuasion, or lifestyle (Egan, 2010).
cans are accustomed to frequent physical contact. Holding the We all need a frame of reference to help us function in our
patient’s hand in response to a distressing situation or giving world. The trick is to understand that other people use many
the patient a reassuring pat on the shoulder may be experi- other frames of reference to help them function in their worlds.
enced as supportive and thus help facilitate openness early in Acknowledging that others view the world quite differently
the therapeutic relationship (Kavanaugh, 2008). and trying to understand other people’s ways of experiencing
When the nurse is working with a Mexican American, for and living in the world can go a long way toward minimizing
example, often the touch of the nurse is welcome because in our personal distortions in listening. Building acceptance and
the minds of some Mexican Americans, this action can both understanding of those culturally different from ourselves is a
prevent and treat illness (Giger & Davidhizar, 2007). People skill, too.
of Italian and French backgrounds may also be accustomed to
frequent touching during conversation (USDHHS, 2001). In TELEHEALTH THROUGH INFORMATION
the Soviet Union, touch is often an important part of nonver-
bal communication used freely with intimate and close friends
(Giger & Davidhizar, 2007). However, the degree of comfort E-health/e-medicine, telehealth technology has found wide-
conveyed by touch in the nurse-patient relationship depends spread uses within the United States, and is still evolving.
on the country of origin. However, it has only recently been adopted for behavioral
Within the context of an interview, touch might easily be health and mental health care (Ryan, 2011). Telehealth is
experienced as patronizing, intrusive, aggressive, or sexu- used as a live interactive mechanism, as a way to track clini-
ally inviting. For example, among German, Swedish, and cal data and provide access to people who otherwise might
British Americans, touch practices are infrequent, although not receive good medical or psychosocial help. It is a valuable
a handshake may be common at the beginning and end of tool for consumers as well as practitioners to access current
an interaction. In India, men may shake hands with other psychiatric and medical breakthroughs, diagnoses, and treat-
men but not with women; an Asian Indian man may greet ment options (Arnold & Boggs, 2011). As ICTs advance, it is
a woman by nodding and holding the palms of his hands possible that electronic house calls, Internet support groups,
together but not touching the woman. In Japan, handshakes and virtual health examination may well be the wave of the
are acceptable; however, a pat on the back is not. Chinese future, eliminating office visits altogether (Arnold & Boggs,
Americans may not like to be touched by strangers. Some 2011; Kinsella, 2003).
Native Americans extend their hand and lightly touch the Castelli (2010) states that besides providing better health
hand of the person they are greeting rather than shake hands care for those in rural areas or for those who cannot travel, tele-
(Kavanaugh, 2008). health helps relieve the impending nursing shortage. Nursing
Even among people of the same culture, the use of touch has schools are having a difficult time meeting the nursing shortage
different interpretations and rules when the touch is between because of a decrease in financial resources and retiring faculty
individuals of different genders and classes. Students are urged (Castelli, 2010). The use of telehealth/tele–home care technol-
to check the policy manual of their facility because some facili- ogies allows nurses to monitor patients’ vital signs, including
ties have a “no touch” policy, particularly with adolescents and lung sounds, and identify changes in patients’ physiological
children who may have experienced inappropriate touch and states. Clinicians can conduct remote physical assessment and
would not know how to interpret the touch of the health care consults, which are especially helpful in facilities that have lim-
worker. ited nursing resources, including schools, prisons, health clin-
ics, or rural hospitals (Castelli, 2010).
Cultural Filters Essentially, “Telehealth is the use of electronic information
It is important to recognize that it is impossible to listen to and telecommunication technologies to support long-distance
people in an unbiased way. In the process of socialization we clinical health care, patient and professional health-related edu-
develop cultural filters through which we listen to ourselves, cation, public health and health administration. Technologies
others, and the world around us. Cultural filters are a form include videoconferencing, the Internet, store-and-forward
of cultural bias or cultural prejudice that determines what we imaging, streaming media, and terrestrial and wireless commu-
notice and what we ignore (Egan, 2010). nications” (USDHHS-HRSA, 2011). Ryan (2011) states that one
We need these cultural filters to provide structure for our- in four adults could be diagnosed with a mental health issue. It
selves and to help us interpret and interact with the world. could be anxiety, stress, marital issues, depression, or substance
130 UNIT 2  Tools for Practice of the Art

abuse. Most of these mental health issues are not addressed service members screened positive for mental health concerns.
because of the fear of stigma, the scarcity of health care providers These technologies can be used for telepsychiatric appoint-
in remote areas, or problems with transportation (e.g., because ments ranging from treating posttraumatic stress disorder and
of anxiety, physical limitations, or lack of transportation). The depression to providing wellness and resiliency interventions,
consequences of not seeking help can be significant. For exam- especially in rural areas (Weckerlein, 2011).
ple, consequences can range from problems at work to domestic Because the practices of psychiatry, psychology, counsel-
violence, increased depression, and suicide—consequences that ing, and nursing are based on human interaction, there still
can result in a host of other ramifications (Joch, 2008). remains a need for “human to human sensitivity, acknowl-
The U.S. Department of Defense is particularly interested edgment, and respect for the patient care experience” (Arnold
in implementing and expanding the use of these technolo- & Boggs, 2011; Malloch, 2010, p. 1). (See the Examining the
gies because, according to Weckerlein (2011), up to 25% of Evidence box.)


Telehealth—The Long-Distance Patient-Centered Relationship
What exactly is “telehealth” and can it help a person Also, the University of Colorado Hospital is working with
deal with the problems of mental illness? If so, are children/families with autism spectrum disorder and anxi-
insurance companies willing to pay for it? ety utilizing videoconferencing and Skype. Many rural par-
This is a fast-moving trend in today’s information com- ents had felt disconnected from services because expert
munication technology (ICT). This new type of innovative interventions were not available to them in rural areas.
communication is transforming the frontlines of health Parents are now provided with webinars on specific top-
care. Telehealth can deliver therapy and manage and moni- ics and/or small group discussions via videoconferencing
tor disease (GSM, 2011). “Tele” is a prefix meaning “at (Kaiser, 2011).
a distance.” With the use of telehealth, services can be Although telehealth’s improved health outcomes regu-
delivered via telecommunications that may involve opti- larly show cost savings for patient payers and the nation
cal, sound, or visual media technologies (Glasper, 2011). as a whole, one significant barrier to broad-scale tele-
Telehealth has already shown that it can maximize health health delivery is the current lack of reimbursement for
and improve patient disease management skills and confi- remote patient monitoring by third-party payers. A tele-
dence with the disease process (Suter, 2011). monitoring visit is not counted as a visit by payers (Suter,
For those with mental health issues, Intel has developed 2011). In the future, however, Medicare will be looking at
a mobile phone application that mirrors cognitive behav- formulas that reward quality. Utilizing electronic media to
ioral techniques for people to use who cannot or do not routinely check on recently discharged patients to ensure
want to see a therapist or as an adjunct to weekly face-to- their recovery is on track enhances quality and, thus,
face therapy sessions. The Touchscreen Mood Map aimed rewards (payments). Studies have shown that patients
for Android and iPhone invites people to plot their mood greatly appreciate the added contact after discharge
throughout the day and view trends to investigate what (Augustine, 2011).
circumstances spark a drop or rise in mood. Based on their As the health care sector is increasing its use of infor-
emotional state, individuals can select from a variety of mation technology, health care professionals need to
self-directed therapeutic applications involving cognitive maintain appropriate skills, in particular communication
restructuring and relaxation exercises. The Mind Scan techniques to enhance delivery of care to patients (Warm,
exercise encourages cognitive reappraisal of thoughts 2011). Nurses must continue to utilize therapeutic tech-
that can lead to anger and depression. One prompt asks, niques—those pertaining to both verbal and nonverbal
“May I be exaggerating the urgency of a situation?” In a communication. Whether in person or at a distance, it is
breathing exercise of the application a blue circle expands essential that trust is developed with each patient, that
and contracts slowly to encourage deliberate and slower professional boundaries are maintained, and that the ther-
breathing to reduce anxiety. Participants described greater apeutic relationship continues to be a major tool of the
self-awareness of their emotional patterns (GSM, 2011). nurse.

Augustine, J. (2011). With patient satisfaction under increasing scrutiny, consider patient callbacks, ED Management, 23(7), 81-83.
Glasper, A. (2011). Telehealth care—where is it going? British Journal of Nursing, 20(12), 714.
Kaiser, K. (2011). Telehealth: families finding ways to connect in rural Colorado, EP Magazine, April.
Research Activities Newsletter (GSM). (2011). Social media use is one of many innovations in care delivery transforming the
frontlines of care, Agency for Healthcare Research and Quality, No. 11, pp. 2-5.
Suter, P. (2011). Theory-based telehealth and patient empowerment. Population Health Management, 14(2), 87-92.
Warm, T. (2011). A review of the effectiveness of the clinical informaticist role. Nursing Standards, 25(44), 35-38.
Contributed by Lois Angelo.
CHAPTER 8  Communication Skills: Medium for All Nursing Practice 131


Instructions: Periodically during your clinical experience, use this checklist to identify areas where growth is needed and prog-
ress has been made. Think of your clinical client experiences. Indicate the extent of your agreement with each of the following
statements by marking the scale: SA, strongly agree; A, agree; NS, not sure; D, disagree; SD, strongly disagree.

1. I maintain good eye contact. SA A NS D SD

2. Most of my verbal comments follow the lead of the other SA A NS D SD
3. I encourage others to talk about feelings. SA A NS D SD
4. I am able to ask open-ended questions. SA A NS D SD
5. I can restate and clarify a person’s ideas. SA A NS D SD
6. I can summarize in a few words the basic ideas of a long SA A NS D SD
statement made by a person.
7. I can make statements that reflect the person’s feelings. SA A NS D SD
8. I can share my feelings relevant to the discussion when SA A NS D SD
appropriate to do so.
9. I am able to give feedback. SA A NS D SD
10. At least 75% or more of my responses help enhance and SA A NS D SD
facilitate communication.
11. I can assist the person to list some alternatives available. SA A NS D SD
12. I can assist the person to identify some goals that are SA A NS D SD
specific and observable.
13. I can assist the person to specify at least one next step that SA A NS D SD
might be taken toward the goal.

FIGURE 8-2  Facilitative skills checklist. (Adapted from Myrick, D., & Erney, T. [2000]. Caring and sharing
[2nd ed., p. 168]. Copyright © 2000 by Educational Media Corp., Minneapolis, MN.)

EVALUATION OF CLINICAL SKILLS patients (e.g., numbers 11 through 13 may not be possible when a
After you have had some introductory clinical experience, you patient is highly psychotic). Self-evaluation of clinical skills is a way
may find the facilitative skills checklist in Figure 8-2 useful for to focus on therapeutic improvement. Role playing can be a useful
evaluating your progress in developing interviewing skills. Note tool for preparation for the clinical experience as well as a practice
that some of the items might not be relevant for some of your in acquiring more effective and professional communication skills.


• K nowledge of communication and interviewing techniques communication consists of the behaviors displayed
is the foundation for development of any patient-centered by an individual, in addition to the actual content of
relationship. Goal-directed professional communication is speech.
referred to as therapeutic communication. • Communication has two levels: the content level (verbal)
• Communication is a complex process. Berlo’s commu- and the process level (nonverbal behavior). When content
nication model has five parts: stimulus, sender, message, is congruent with process, the communication is said to be
medium, and receiver. Feedback is a vital