chapter 6, 10, 11

beneficence

The health care provider uses knowledge of science and incorporates the art of caring to develop an environment in which individuals achieve maximum health care potential.

fidelity

Faithfulness to obligations and duties

justice

Duty to treat all fairly, distributing the risks and benefits equally.

nonmaleficence

The duty to cause no harm, both individually and for all.

nursing process

The basis of clinical decision-making for evidence-based practice

paternalism

The belief that knowledge and education authorizes professionals to make decisions for the good of the patient.

reflection

Continual self-evaluation through observing, monitoring, and judging nursing behaviors with the goal of providing ideal interventions

standardized nursing language

Language readily understood by all nurses to describe care in order to provide a common means of communication

veracity

The duty to tell the truth

PMH nursing practice is guided by what?

*Code of Ethics for Nurses with Interpretive Statements*

*Code of Ethics for Nurses states:*

1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
2. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.
3. The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
4. The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.
5. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
9. The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

**what are some Basic Questions for Ethical Decision-Making?**

* What do I know about this patient situation?
* What do I know about the patient’s values and moral preferences?
* What assumptions am I making that need more data to clarify?
* What are my own feelings (and values) about the situation, and how might they be influencing how I view and respond to this situation?
* Are my own values in conflict with those of the patient?
* What else do I need to know about this case, and where can I obtain this information?
* What can I never know about this case?
* Given my primary obligation to the patient, what should I do to be ethical?

what is the purpose of the code of ethics?

Provides a framework for ethical decision making

Four primary health care **ethical principles**

respect for autonomy, beneficence, nonmaleficence, and justice

The principle of **respect for autonomy**

* understanding that each person has the fundamental right to make voluntary decisions about their health care and life decisions
* Persons are to be regarded as self-determining
* gives rise to expectations for ethical conduct, namely, the use of informed consent in health care practices
* privacy
* give consent to a treatment or procedure, a person must have the needed relevant information, be able to rationally deliberate, and not be forced into a decision.

principle of __**beneficence**__

* (goodness) rests on the assumption that professionals have a duty to act in ways that benefit a patient or community, and that they take steps necessary to minimize harm


* __**Nonmaleficence**__ is the duty one has to never intentionally harm another

The principle of __**justice**__ encourages

providers to consider how the goods of a society, including health care, are distributed. As noted in the first provision of the *Code of Ethics for Nurses*, providers have an ethical duty to treat all people with dignity, respect, and fairness.

Mental health services are often not readily available to those most in need, a violation of the principle of

justice

a patient may decide to stop taking a medication (autonomy), but the nurse wants to avoid the harm that could likely come to the patient or others when the patient discontinues medication use is an example of what?

one principle may be in tension with one or more of the other principles

Two secondary ethical principles

veracity and fidelity

giving others more information than is necessary, even if that information is true, could cause an excess of fear, anxiety, and harm is an example of what?

__**Veracity**__

**scope and standards of practice** are defined by

the nursing profession and describe the responsibilities to which nurses are legally, professionally, and ethically held accountable

Six **standards of practice** define the parameters of PMH nursing and are organized according to the nursing process steps:

assessment, diagnosis, outcome identification, planning, implementation, and evaluation

The 10 standards for professional performance

ethics, education, evidence-based practice and research, quality of practice, communication, leadership, collaboration, professional practice evaluation, resource utilization, and environmental health

PMH-RN

whose educational preparation is at the bachelor’s or associate’s degree level. The PMH-APRN receives educational preparation at the master’s or doctoral level.

PMH-APRN

can practice as a psychiatric–mental health clinical nurse specialist or as a psychiatric–mental health nurse practitioner

**Clinical Activities of PSYCHIATRIC–MENTAL HEALTH REGISTERED NURSE**

* Health promotion and health maintenance


* Intake screening, evaluation, and triage


* Case management


* Provision of therapeutic and safe environments


* Milieu therapy


* Promotion of self-care activities


* Administration of psychobiologic treatment and monitoring responses


* Complementary interventions


* Crisis intervention and stabilization


* Psychiatric rehabilitation

**Clinical Activities of Advanced Practice Registered Nurse**

* Psychopharmacologic interventions
* Psychotherapy
* Community interventions
* Case management
* Program development and management
* Clinical supervision
* Consultation and liaison

biopsychosocial framework

well-recognized, holistic model for organizing nursing practice. Each of the model’s three domains—biologic, psychological, and social—has an independent knowledge and treatment focus but interacts and is mutually interdependent with the other domains.

*biologic* domain

consider vital functional health patterns, essential when assessing a person’s mental health: exercise, elimination patterns, sleep, and nutrition. Neurobiologic theories serve as a basis for understanding and administering pharmacologic agents

*psychological* domain

* thoughts, feelings, and behavior (intrapersonal dynamics) that influence one’s emotion, cognition, and behavior. understanding and assessment of patients’ mental health symptoms and responses to treatment


* symptoms are experienced
* behavioral interventions, including cognitive approaches, behavior therapy, and patient education. In using therapeutic communication and in developing therapeutic relationships,

*social* domain

* theories that describe the influence of social forces on the patient, family, and community within cultural settings
* illustrate how social connections within families and communities influence mental health, treatment, and recovery
* Psychiatric disorders are not caused solely by social factors, but their mental health manifestations and treatment can be significantly affected by the society in which a patient lives
* Community forces, including cultural and ethnic groups within larger communities, shape the patient’s manifestation of disorders, response to treatment, and overall view of mental illness.

most important tool of psychiatric nursing is

the self

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Through relationship building, patients learn to trust the nurse who then guides, teaches, and advocates for quality care and treatment

Sound **clinical judgment** depends on

critical thinking skills and reflection

critical thinking skills

problem-solving and decision-making, nurses analyze, evaluate, explain, infer, and interpret biopsychosocial data

Reflective skills

used to enhance all aspects of PMH nursing practice, including self-awareness, nurse–patient interactions, and evaluating systems of care

The challenges of PMH nursing

New knowledge is being generated, technology has radically transformed health care, and nursing practice is becoming more specialized, evidence based, and autonomous

Match the **EXAMPLES OF THE RELATIONSHIP OF THE BIOPSYCHOSOCIAL MODEL TO STRUCTURED NURSING LANGUAGES**

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**Nursing Language:** Clinical Care Classification

*Diagnosis:* Sleep pattern disturbance

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**Interventions: Biologic, Psychological, Social**

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Teach sleep pattern control

Care related to improving pattern of sleep.

Manage sleep pattern control.

* **Biologic:** Care related to improving pattern of sleep
* **Psychological:** Teach sleep pattern control
* **Social:** Manage sleep pattern control

Match the **EXAMPLES OF THE RELATIONSHIP OF THE BIOPSYCHOSOCIAL MODEL TO STRUCTURED NURSING LANGUAGES**

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**Nursing Language:** Omaha System

*Diagnosis:* Insomnia

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**Interventions: Biologic, Psychological, Social**

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Use community resources

Take medication therapy as prescribed. Establish routine

Use guided imagery

**Biologic:** Take medication therapy as prescribed.

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**Psychological**Establish routine. Use guided imagery.

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**Social:** Use community resources.

**A standardized nursing language**

* Nurses improve patient care by using this when communicating with nurses and other disciplines, giving visibility to nursing activities, enhancing data collection, communicating outcome evaluations, and documenting adherence to standards of care


* is readily understood by all nurses to describe care. It provides a common means of communication.

active listening

Focusing on what the patient is saying in order to interpret and respond to the message in an objective manner while using techniques such as open-ended statements, reflection, and questions that elicit additional responses from the patient

boundaries

* Limits in which a person may act or refrain from acting within a designated time or place. Invisible barriers with varying permeabilities that surround family subsystems

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* defining limits of individuals, objects, or relationships.
* mark territory, distinguishing what is “mine” from what is “not mine.”

communication blocks

Interruptions in the content flow of communication, such changes in topic that either the nurse or patient makes

content themes

Repetition of concerns or feelings that occur within the therapeutic relationship. Themes may emerge as symbolic representations of fears

countertransference

The therapist or nurse’s reactions to a patient that are based on interpersonal experiences, feelings, and attitudes. It can significantly interfere with the nurse–patient relationship

defense mechanisms

Coping styles; the automatic psychological process protecting the individual against anxiety and creating awareness of internal or external dangers or stressors

deteriorating relationship

A type of nontherapeutic relationship with several defined phases during which the patient and nurse feel very frustrated and keep varying their approach with each other in an attempt to establish a meaningful relationship

empathy

The ability to experience, in the present, a situation as another did at some time in the past; the ability to put oneself in another person’s circumstances and feelings

introspective

The self-examination of personal beliefs, attitudes, and motivations

nontherapeutic relationship

A nontrusting relationship between the nurse and patient. Both feel very frustrated and keep varying their approach with each other in an attempt to establish a meaningful relationship

nonverbal communication

The gestures, expressions, and body language used in communications

orientation phase

The first phase of the nurse–patient relationship in which the nurse and the patient get to know each other. During this phase, the patient develops a sense of trust

passive listening

A nontherapeutic mode of interaction that involves sitting quietly and allowing the patient to talk without focusing on guiding the thought process; includes body language that communicates boredom, indifference, or hostility

process recording

A verbatim transcript of a verbal interaction usually organized according to the nurse–patient interaction. It often includes analysis of the interaction

rapport

Interpersonal harmony characterized by understanding and respect that is established through interpersonal warmth, a nonjudgmental attitude, and a demonstration of understanding.

self-disclosure

The act of revealing personal information about oneself

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telling the patient personal information, generally is not a good idea

symbolism

The use of a word or a phrase to represent an object, event, or feeling

transference

The unconscious assignment to a therapist or nurse of a patient’s feelings and attitudes that were originally associated with important figures such as parents or siblings

verbal communication

The use of the spoken word, including its underlying emotion, context, and connotation.

working phase

The second phase of the nurse–patient relationship in which patients can examine specific problems and learn new ways of approaching them

Self-awareness

* is the process of understanding one’s own beliefs, thoughts, motivations, biases, and limitations and recognizing how they affect others

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* Without it, nurses will find it impossible to establish and maintain therapeutic relationships with patient

“Know thyself”

is a basic tenet of psychiatric–mental health nursing

* What physical problems or illnesses have you experienced?


* What significant traumatic life events (e.g., divorce, death of significant person, abuse, disaster) have you experienced?
* What prejudiced or embarrassing beliefs and attitudes about groups different from yours can you identify from your family, significant others, and yourself?
* Which sociocultural factors in your background could contribute to your being rejected by members of other cultures?
* How would the above experiences affect your ability to care for patients?

The patient perceives the biologic dimension of the nurse in terms of physical characteristics:

age, gender, body weight, height, ethnic or racial background, and any other observed physical characteristics

a nurse who has just learned that her child is using illegal drugs and who has a patient with a history of drug use may inadvertently project a judgmental attitude toward her patient is an example of

An emotional state or behavior can inadvertently influence the therapeutic relationship

In analyzing patient–nurse communication, ___ behaviors and gestures are communicated first

nonverbal

**Principles of Therapeutic Communication**

* The patient should be the primary focus of the interaction.
* A professional attitude sets the tone of the therapeutic relationship.
* Use self-disclosure cautiously and only when the disclosure has a therapeutic purpose.
* Avoid social relationships with patients.
* Maintain patient confidentiality.
* Assess the patient’s intellectual competence to determine the level of understanding.
* Implement interventions from a theoretic base.
* Maintain a nonjudgmental attitude. Avoid making judgments about the patient’s behavior.
* Avoid giving advice. By the time the patient sees the nurse, they have had plenty of advice.
* Guide the patient to reinterpret their experiences rationally.
* Track the patient’s verbal interaction through the use of clarifying statements.
* Avoid changing the subject unless the content change is in the patient’s best interest.

a patient says that they feel fine but has a sad facial expression and is slumped in a chair away from others, the message of sadness and depression, rather than the patient’s report of feeling fine, should be accepted is an example of what?

Nonverbal Communication

a nurse tells a patient “I am happy to see you” but the nurse’s facial expression communicates indifference, the patient will receive the message that the nurse is bored is an example of what?

Nonverbal Communication

in some cultures, it is considered disrespectful to look a person straight in the eye. In other cultures, not looking a person in the eye may be interpreted as “hiding something” or as having low self-esteem. Whether one points with the finger, nose, or eyes and how much hand gesturing to use are other examples of

nonverbal communication that may vary considerably among cultures

how should a nurse use body language

* use positive body language, such as sitting at the same eye level as the patient with a relaxed posture that projects interest and attention.


* Leaning slightly forward helps engage the patient.
* the nurse should not cross their arms or legs during therapeutic communication because such postures pose a barrier to interaction.


* Uncrossed arms and legs project openness and a willingness to engage in conversation

**Therapeutic communication**

the ongoing process of interaction through which meaning emerges.

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the nurse focuses on the patient and patient-related issues. Activities should have a definite purpose, and conversation should focus only on the patient. The nurse must not attempt to meet their own social or other needs during the activity

a male patient who was struggling with the implications of marriage and fidelity asked a male nurse if he had ever had an extramarital affair. The nurse interpreted the patient’s statement as seeking role-modeling behavior for an adult man and judged self-disclosure in this instance to be therapeutic. He honestly responded that he did not engage in affairs and redirected the discussion back to the patient’s concerns is an example of what?

Limiting Self-Disclosure

**SELF-DISCLOSURE IN THERAPEUTIC VERSUS SOCIAL RELATIONSHIPS**

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A patient asks the nurse if she had fun over the weekend

response: “It was great. My boyfriend and I went to dinner and a movie.”

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**Appropriate Therapeutic Response or Inappropriate Social Response?**

**Inappropriate Social Response.***This self-disclosure has no therapeutic purpose. The response focuses the conversation on the nurse, not the patient.)*

**SELF-DISCLOSURE IN THERAPEUTIC VERSUS SOCIAL RELATIONSHIPS**

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A patient asks the nurse if she had fun over the weekend

response: “The weekend was fine. How did you spend your weekend?”

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**Appropriate Therapeutic Response or Inappropriate Social Response?**

**Appropriate Therapeutic Response**

**SELF-DISCLOSURE IN THERAPEUTIC VERSUS SOCIAL RELATIONSHIPS**

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A patient asks a student nurse if she has ever been to a particular bar.

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response: “Many people go there. I’m wondering if you have ever been there?”

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**Appropriate Therapeutic Response or Inappropriate Social Response?**

**Appropriate Therapeutic Response**

**SELF-DISCLOSURE IN THERAPEUTIC VERSUS SOCIAL RELATIONSHIPS**

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A patient asks the nurse if she had fun over the weekend

response: “Oh yes—all the time. It’s a lot of fun.”

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**Appropriate Therapeutic Response or Inappropriate Social Response?**

**Inappropriate Social Response** *(Sharing information about outside activities is inappropriate.)*

**SELF-DISCLOSURE IN THERAPEUTIC VERSUS SOCIAL RELATIONSHIPS**

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A patient asks a nurse if mental illness is in the nurse’s family.

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response: “Mental illnesses do run in families. I’ve had a lot of experience caring for people with mental illnesses.”

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**Appropriate Therapeutic Response or Inappropriate Social Response?**

**Appropriate Therapeutic Response**

**SELF-DISCLOSURE IN THERAPEUTIC VERSUS SOCIAL RELATIONSHIPS**

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A patient asks a nurse if mental illness is in the nurse’s family.

response: “My sister is being treated for depression.”

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**Appropriate Therapeutic Response or Inappropriate Social Response?**

**Inappropriate Social Response** *(This self-disclosure has no purpose, and the nurse is missing the meaning of the question.)*

**SELF-DISCLOSURE IN THERAPEUTIC VERSUS SOCIAL RELATIONSHIPS**

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While shopping with a patient, the nurse sees a friend, who approaches them.

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response: To her friend: “I know it looks like I’m not working, but I really am. I’ll see you later.”

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**Appropriate Therapeutic Response or Inappropriate Social Response?**

**Appropriate Therapeutic Response**

**SELF-DISCLOSURE IN THERAPEUTIC VERSUS SOCIAL RELATIONSHIPS**

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While shopping with a patient, the nurse sees a friend, who approaches them.

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response: “Hi, Bob. This is Jane Doe, a patient.”

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**Appropriate Therapeutic Response or Inappropriate Social Response?**

**Inappropriate Social Response** *Introducing the patient to the friend is very inappropriate and violates patient confidentiality.)*

In prioritizing interventions, ____ listening is one of the first to use

active listening

**VERBAL COMMUNICATION TECHNIQUES**

Acceptance, Confrontation, Doubt, Interpretation, Observation, Open-ended statements, Reflection, Restatement, Silence, Validation

Acceptance definition

Encouraging and receiving information in a nonjudgmental and interested manner

what is this an example of?

*Patient:* I have done something terrible.

*Nurse:* I would like to hear about it. It’s OK to discuss it with me.

Acceptance

what is Used in establishing trust and developing empathy?

Acceptance

Confrontation definition

Presenting the patient with a different reality of the situation

what is this an example of?

*Patient:* My doctor won’t talk to me.

*Nurse:* I was in the room yesterday when you refused to speak with him.

Confrontation

what is Used cautiously to immediately redefine the patient’s reality. However, it can alienate the patient if used inappropriately. A nonjudgmental attitude is critical for confrontation to be effective?

Confrontation

Doubt definition

Expressing or voicing doubt when a patient relates a situation

what is this an example of?

*Patient:* My best friend hates me. She never calls me.

*Nurse:* From what you have told me, that does not sound like her. When did she call you last?

Doubt

what is Used carefully and only when the nurse feels confident about the details. It is used when the nurse wants to guide the patient toward other explanations.

Doubt

Interpretation definition

Putting into words what the patient is implying or feeling

what is this an example of?

*Patient:* I could not sleep because someone would come into my room and rape me.

*Nurse:* It sounds like you were scared last night

Interpretation

what is Used in helping the patient identify underlying thoughts or feelings?

Interpretation

Observation definition

Stating to the patient what the nurse is observing

what is this an example of?

*Nurse:* You are trembling and perspiring. When did this start?

Observation

what is Used when a patient’s behaviors (verbal or nonverbal) are obvious and unusual for that patient

Observation

Open-ended statements definition

Introducing an idea and letting the patient respond

what is this an example of?

*Nurse:* Trust means…

*Patient:* That someone will keep you safe.

Open-ended statements

what is used when helping the patient explore feelings or gain insight?

Open-ended statements