Class 3- Historical trauma Inter-generational trauma Violence and oppression Trauma of racism, discrimination, and stigma Loss & grief Resilience and hope Move from what's wrong to with the person → what has happened to the person

Canadian Federation of mental health nurses standards of practice (2023) 

1. Providing competent professional care through the development of therapeutic relationships 

2. Performing/refining client assessments

3. Administering and monitoring therapeutic interventions 

4. Effectively managing rapidly changing situations 

5. Intervening through the teaching/coaching function 

6. Monitoring and ensuring quality of health care practices 

7. Practicing within organizational work role structure 

Therapeutic communication skills

• Effective interpersonal communication skills are the building blocks of all successful therapeutic relationships 

• Mental health and substance use nurses need to learn a wide range of communication skills and be able to apply these appropriately in interactions with their clients 

Some important principles of therapeutic communication

• Client is primary focus 

• Professional attitude sets the tone 

• Use self-disclosure cautiously  & only when it serves a therapeutic purpose 

• Avoid social relationships with clients

• Maintain client confidentiality 

• Assess competence to determine level of understanding 

• Non-judgemental attitude 

• Guide client 

• Use clarifying statements

The communication process

• Self-awareness 

• Verbal 

• Non-verbal

• Empathic linkages 

Therapeutic communication skills: Non-verbal

• Silence 

• Active listening 

• Gestures 

• facial expressions 

• Body language

• Leaning forward 

Therapeutic communication skills: Verbal

• Offering a general lead 

• Accepting 

• Sharing observations 

• Broad general statements 

• Giving recognition 

• Reflecting 

• Providing information 

• Paraphrasing 

• Reframing 

• Seeking clarification 

• Restating 

• Verbalization implied thoughts and feelings 

• Seeking consensual validation 

• Encourage evaluation 

• Placing the event in time or sequence

• Encouraging comparison 

• Encouraging description of perception 

• Reflecting 

Potential blocks to therapeutic communication

• Giving advice 

• Asking personal questions/probing 

• Automatic responses/cliches 

• Giving approval/disapproval 

• agreeing/ disagreeing 

• Asking for explanations/ “why” questions 

• Inappropriate self-disclosure

• Defensive responses 

• Changing the subject 

• Arguing 

Personal relationships

• Social communication

• Personal or intimate relationship 

• Identification of needs may not occur 

• Personal goals may or may not be discussed 

• Constructive or destructive dependency may occur

• No specialized skills required 

Therapeutic relationships

• Therapeutic communication 

• Professional relationship with defined boundaries 

• Needs are identified by the client or with the help of the nurses as required 

• Personal goals are set by the client 

• Independence is promoted 

• Specialized nursing skills are used 

Essential conditions for establishing, maintaining & terminating therapeutic relationships in nursing 

• Unconditional positive regard:Acceptance and caring 

• Congruence:Genuineness and realness 

• Empathy:Being listened to and being understood 

Therapeutic nurse client relationship stages & tasks (Peplau, 1952) 

• Orientation phase

• Working phase

• Termination phase

Orientation phase (Therapeutic nurse client relationship stages & tasks Peplau, 1952) 

• First meeting 

• Build trust & Rapport 

• Confidentiality in the relationship 

• Setting parameters 

• Testing the relationship 

Working phase (Therapeutic nurse client relationship stages & tasks Peplau, 1952) 

• Problems and issues are identified 

• Plans are made to address problems and act on them 

• Ongoing assessment 

Termination phase (Therapeutic nurse client relationship stages & tasks Peplau, 1952) 

• Last meeting 

• Celebrate goals that have been met 

• Acknowledge loss that may accompany ending of therapeutic relationship 

• Validate plans for the future 

What’s therapeutic about therapeutic nurse-client relationships (Shatter, Starr & Thomas, 2007) 

• Knowing the whole person

• What services recipients find therapeutic and therapeutic relationships

Knowing the whole person (What’s therapeutic about therapeutic nurse-client relationships Shatter, Starr & Thomas, 2007) 

• Therapeutic relationships require in-depth personal knowledge of service recipients which is acquired only with time, understanding and skill 

• Knowing the whole person is key to enhancing the therapeutic potential of relationships 

What service recipients find therapeutic and therapeutic relationships (What’s therapeutic about therapeutic nurse-client relationships (Shatter, Starr & Thomas, 2007) 

Relate to me 

• Show acceptance 

• Understanding 

• Validation 

Get to know me 

• Listen attentively 

Get to the solution 

• Confidence 

• Emotional support and care 

• Appropriate education and referrals 

Transference

• A client's expectations, feelings and desires for a person in their past unconsciously transferring and being redirected to a nurse counsellor 

• When transference occurs, the client may start to interact with the nurse as though they are the individual in their past 

• Common types of transference include maternal transference, paternal transference,sibling transference and non-familial transference 

Countertransference

• A nurse’s expectations, feelings and desires for a person in their past unconsciously transferring and being redirected to a client 

• When countertransference occurs, the nurse may start to interact with the client as though they are the individual in their past 

• Common types of counter transference include maternal countertransference, paternal counter transference, sibling countertransference, and non-familial countertransference

Managing transference & counter transference in therapeutic relationships

• Mindfulness 

• Empathy 

• Peer support 

• Continual self-reflection 

• Clear boundaries

Bio/psycho/social/ spiritual assessment 

• Biological factors

• Psychological factors 

• Social factors 

• Spiritual factors 

Biological factors (Bio/psycho/social/ spiritual assessment)

Physical, physiological, chemical, neurological, or genetic conditions/factors

• Health status 

• Physical examination 

• Physical function 

• Pharmacologic 

Psychological factors (Bio/psycho/social/ spiritual assessment)

Factors related to psychological processing of thoughts, feelings, and behaviour sense of self and well-being 

• Responses to mental health problems 

• Mental status 

• Behaviour

• Self-concept 

• Stress and coping 

• Risk assessment 

Social factors (Bio/psycho/social/ spiritual assessment)

Factors that account for the influence of social forces encompassing the patient, family, and community within cultural settings 

• Functional status 

• Social systems

• Cultural 

• Family 

• Community 

• Spiritual 

• Occupation 

• Leegal 

• Quality of life 

Spiritual factors (Bio/psycho/social/ spiritual assessment)

Relates to the core of whom we are; th essence of our being 

• What gives life meaning? 

• Believes in sacred power? 

• Participated in religious activities 

Assessment as a process

• A purposeful, systematic, and dynamic process that is ongoing throughout the nurse’s relationship with individuals in her or his care 

• Involves the collection, validation, analysis, synthesis, organization, and documentation of client health illness information 

Comprehensive assessment

• Includes a complete health history, physical, and diagnostic testing 

• Screening: recognize symptoms, risk factors, or emotional difficulties 

• Develops a holistic understanding of the individual's problems 

Focused assessment

• A collection of specific information about a particular need 

• Briefer, narrower in scope, and more present oriented 

• Two key factors

Two key factors (Focused assessment) 

The immediate needs of the client and the practice setting 

Techniques of data collection (assessment)

• Observations

• Examinations

• Interview

• Collaboration with colleagues 

Observations (Techniques of data collection assessment)

• Verbal and nonverbal

Examinations (Techniques of data collection assessment)

• Physical and mental status 

Interview (Techniques of data collection assessment)

• May also include family and friends 

• Factors that facilitate effective interviewing and barriers 

Components of a psychiatric interview

1. Chief complaint 

2. History of present illness 

3. Psychiatric review of symptoms 

4. Psychiatric history 

5. Suicide and homicide risk assessment 

6. Medical history 

7. Family history 

8. Social history 

9. Substance use 

10. Mental status examination 

Biopsychosocial/psychiatric/spiritual Mental health nursing assessment 

Begins with assumptions that humans are whole, integrated beings who live in constant and reciprocal relationship with their physical and social environments

Types of sources of information 

• Objective data (also called signs): are directly observable and measurable

• Subjective data (symptoms): are neither directly observable nor measurable 

Documentation

Generally speaking, there are two common approaches to documentation 

• Source oriented 

• Problem oriented 

Information may be entered in the client record in several ways. 

• Includes fill-in forms, flow sheets, checklists, and narrative notes 

• Electronic medical records are becoming more common 

Mental health examination

• The mental status examination (MSE) is a set of standardized observations and questions designed to evaluate sensorium, perception, thinking, feeling and behaviour 

• The MSE records observed behaviour, cognitive abilities and inner experiences expressed during a psychiatric interview 

• The MSE yields information that is critical for making a diagnostic assessment and initiating or modifying a course of treatment 

Information assessed in mental status examination (MSE) 

• General observations- appearance, psychomotor behaviour/activity, attitude toward interviewer 

• Mood and affect- expressed feeling, facial expression, euthymic, euphoric, dysphoric 

• Speech- rate, rhythm, tone, amount

• Perception- visual, olfactory, sensory, auditory

• Thought- content, delusions

• Sensorium- LOC, Orientation, memory, concentration

• Judgement- Good, fair, poor

• Insight- Good, fair, poor, etc

Assessing Risk and protective factors: suicide assessment

Risk factors

• Protective factors 

• Promotive factors 

Involves garnering specific details regarding:

• Suicidal ideation 

• Threats of suicide

• Suicide attempt

Assaultive or homicidal indirections 

ABC (Mental status examination Mneumonic)

• Appearance 

• Behaviour 

• Cooperation with interview 

STAMP (Mental status examination Mneumonic)

• Speech 

• Thought process and though content

• Affect 

• Mood 

• Perception 

LICKER (Mental status examination Mneumonic)

• Level of consciousness

• Insight

• Cognition

• Knowledge

• Endings

• Reliability/Judgement 

Self-awareness

• Self- examination by the nurse of their own emotions, motivation and beliefs to determine how these factors shape their behaviour

• Social biases can be particularly problematic for nurse-client relationship  

• Nurse needs to avoid projecting personal feelings and beliefs onto clients 

Diagnostic and statistical manual of Mental disorders-5 (APA,2013) 

• The DSM-5 is the standard classification of mental disorders used by mental health professionals in North America 

• It contains descriptions, symptoms and other criteria for diagnosing mental disorders 

• It provides a common language for clinicians to communicate about clients

• It establishes consistent and reliable diagnoses that can be used in research on mental disorders 

Substance use nursing competencies for Entry-to-Practice

Screening for substance use concerns 

Assessment of substance use 

• Point-in-time

• Lifetime

Level 1 Screening (Standardized substance use screening)

• Index of suspicion 

• Ask a few questions

Level 2 screening (Standardized substance use screening)

• CAGE

• CAGE-AID

• Alcohol use scale (AUS)

• Drug use scale (DUS)

• Substance abuse treatment scale (SATS)

• Readiness to change (RTC)

• Alcohol use disorder identification test (AUDIT) 

Point-in-time assessment (Standardized substance use assessment)

• Drug and alcohol lifetime inventory (DALI)

• Drug abuse screening test (DAST) 

• Michigan Alcohol screening test (MAST)

• Timeline follow back interview (TFBI) 

Lifetime assessment screening (Standardized substance use assessment)

• Addictions severity index (ASI) 

Standardized substance use assessment

• Point in time assessment

• Lifetime assessment screening