Therapeutic Communication

Communication is a basic component of human-relationships and

nurse-client relationships
• Difficulty in conveying and grasping messages

Communication Process
1. Sender — conveys the message to another
◦ Sender must be particular in verbal & non-verbal
communication
2. Message — maybe said or written, transmitted through channels
◦ Delivered differently = understood differently
3. Receiver — the listener, or whom the message is transmitted
4. Response — feedback or message returned to sender
5. Context — the setting and situation in which communication
takes place

Modes of Communication
1. Verbal communication
• Uses gestures, facial expressions, posture/gait, body movements,
body language and physical appearance
• Is a more accurate expression of a person’s thoughts and feelings
than verbal communication
• Consider cultural influences

Alphabet of Therepeutic Communication

A — accepting
◦ The nurse acknowledges that they heard and understood what
the client said
 ◦ “Yes”
◦ “Okay.
◦ *nodding* “uhuh”
◦ *smiling* “I hear what you’re saying”
◦ “I understand”
B — broad opening
◦ The nurse invites the client to select a topic
◦ “Where would you like to begin?”
◦ “Talk more about…”
◦ “What would you like to tell me about yourself?”
◦ “Tell me what’s been in your mind”
◦ “I’m interested in hearing about issues of concern to you”
C — clarifying
◦ Often use as a question to verify what the client has said or
interpret an ambiguous statement or expression of feeling
◦ Refrain from beginning the question with “why”, make use of
“tell me” or “I don’t understand”
◦ “I’m not sure that I understand what you’re trying to say. Please
give me more information”
◦ “Could you explain more about that to me?”
◦ “I am not sure what you mean”
D — demonstrate unconditional positive regard
E — exploring
◦ The nurse asks the client to describe something in more detail
or to discuss it more fully
◦ “You said you like Carl best. Can you tell me about Carl?”
◦ “You say you get more satisfaction out of helping out at the
flower shop. I’d like to hear more about that”
 ◦ “These dreams you mentioned, what are they like?”
F — focusing
◦ The nurse selects one topic for exploration from among several
possible topics presented by the client
◦ “Give an example of what you mean”
◦ “Let’s look at this more closely”
◦ “You said you hate your brothers, tell me more about Carlo
first”
◦ “You’ve briefly mentioned three different suicide attempts. For
now, I’d like to focus on your first attempt”
G — general leads
◦ The nurse provides brief interjections that let the client know
that they are on the right track and should continue”
◦ “Go on”
◦ “Talk more about…”
◦ “Then what?”
◦ “Please go on”
◦ “And…?”
◦ “Go on I’m listening”
◦ “I hear what you’re saying”
H — here and now behavior
I — informing
◦ Provides client with the needed data, decreases level of anxiety
◦ “His name is…”
◦ “They live in…”
◦ “You are experiencing acute alcohol withdrawal, you may feel
things that aren’t real”
◦ Never disclose personal information, only information needed
 in the nurse-patient relationship
J — jargon, figure of speech avoided
◦ Unintelligible language
◦ Pretentious or meaningless language
K — keep respect
L — listen to what the person is not saying
M — master active listening
N — never advise
O — opening leads
◦ Using neutral expressions to encourage patients to continue
talking
◦ “Go on, I’m listening”
◦ “I hear what you are saying”
P — present reality/Confronting
◦ Used to point discrepancy in the words and actions, verbal and
non verbal behavior or feelings and thoughts; offering a view of
what is real or not without arguing with the patient
◦ “I see no elephant in the room; this is a hospital, not a zoo”
◦ “You said you are upset but you are smiling”
Q — questions not answerable by yes or no
◦ Using open-ended questions to achieve relevance and depth in
discussion
◦ “What?”
◦ “Who?”
◦ “What did you say?”
◦ “What happened?”
R — reflecting
◦ Focusing on the feelings of the client enabling them to express
 more, to become aware of the emotional feelings experience
◦ “I think I should take my medication” — “you think you should
take your medication?”
S — sharing of observation/making observation
◦ Commenting on what is seen or heard to encourage discussion
◦ “You seem restless”
◦ “I noticed you had trouble making a decision about…”
◦ “That’s a new hairstyle, isn’t it?”
◦ “You have drawn a picture”
T — trust
U — using silence
◦ “The nurse allows the verbal conversation to stop to provide a
time for quiet contemplation of what has been discussed, for
formulation of thoughts about how to proceed or for tension
reduction
V — validating
◦ The nurse attempts to verify with the client that a certain term
means the same thing to both parties”
◦ “You want moo moo? Moo moo means milk?”
◦ “When you say your brother is crazy, does the word crazy mean
“kind of wild”?”
◦ “Tell me if we both understand that word the same”
W — what is said is more important than why it is said
X — explore alternative rather than answer or solution
Y — you are interested in them
Z — zest up, show interest

Notes on Therapeutic Communication

Best responses:
1. Encourage clients to express more fully
2. Reflect or re-state what the client has earlier said
3. Reflect the feelings that are identified and encourage expression
of these feelings
4. Encourage hope (never with false assurance.
A. Always give emphasis as long as they are medicine compliant,
they can maintain functionality and normal socialization.
5. Clarify client’s statement
6. Acknowledge client’s non-verbal behavior
7. Use silence but expresses being there — stay present
8. Inform — only within nursing role & responsibility, only globally
accepted responses
9. Clarify and validate
Never
1. Give responses that belittle , negate or devalue — use globally
accepted responses
2. Advise or show approval or disapproval
3. Ask for explanation or “why?”
4. Avoid
5. Be defensive
Remember to
1. Focus on client — eye contact, position facing patient directly
2. Accept client as they are
3. Be honest and consistent — consistency is the cornerstone of
trust
4. Attempt to establish good relationship, rapport
5. Allow client then family to make decision — nurse only lays
 down pros & cons but patient or family makes decision.
6. Answer according to nurse action
7. Do not provide a response that implies that the client is
unworthy
8. Select the most comprehensive (global) answer
9. Focus on the feelings of client

SOMATIC THERAPY
— The treatment focusing on the body and how emotions appear
within the body (Baker)
• Posit that our body holds and expresses experiences and emotions
and traumatic events or unresolved emotional issues can become
‘trapped inside’.

1. Biophysical/Somatic Interventions
• Electroconvulsive Therapy
◦ Technique for treating psychiatric patients, in which seizures
similar to those of epilepsy are induced by passing a current of
electricity through a forehead
◦ ECT produces dramatic improvements in many psychiatric
symptoms, especially depression who do not respond to
antidepressants or those who experience intolerable side effects
◦ Loss of memory — most troublesome side effect of ECT
◦ Major Romeo Gustilo — first performed the prefrontal
lobotomy to a violent schizophrenic who was no longer
responding to ECT
◦ Methohexital (Brevital) — general anesthetic agent given prior
to ECT
 ◦ Succinyocholine (Anecctine) — skeletal muscle relaxant IV
administration before ECT

COMMON FORMS OF SOMATIC THERAPY

1. Somatic experiencing
A. Treats the body’s reaction to trauma
B. Brings up some of these painful memories
C. Focusing on how stress & trauma affect the body
2. Hakomi
A. Type of somatic therapy centered on mindfulness — the
ability to notice the present moment without judgement
B. “Hakomi is the practice of gently touching the unconscious
and inviting it to be conscious”
C. Art therapy
3. Sensorimotor Psychotherapy
A. Holistic approach to healing trauma or unhealthy attachment
patterns formed in early childhood
B. It integrates the body and movement into traditional talk
therapy to address and heal ongoing psychological and
physical difficulties
4. Neurosomatic Therapy
A. A cutting-edge form of manual therapy, uses an advanced
system of postural analysis to create a personalized treatment
plan
B. Personal plan is specifically designed to target the root causes
of pain, rather than simply treating symptoms

DIFFERENT PSYCHOTHERAPY
• Individual Psychotherapy
◦ Supportive Therapy
‣ A psychotherapeutic approach that integrates
psychodynamic, cognitive-behavioral and interpersonal
conceptual models and techniques
‣ In supportive therapy, the the therapist engages in a fully
emotional, encouraging and supportive relationship with
the patient as a method of furthering healthy defense
mechanisms, especially in the context of interpersonal
relationships
• Nurse-patient relationship therapy (process recording)
• Group therapy
• Family therapy
• Counseling
◦ Type of talking therapy
◦ Counselors are trained to listen sympathetically and can help
people deal with any negative thoughts and feelings that they
have
◦ Example: Cognitive-behavioral therapy is a type of talking
therapy that can be used to retrain a person’s way of thinking
to help them cope with stressful situations
• Mental Health Teaching/Client Education
◦ The nurse must ensure that clients and families are well
informed about progress in these areas and must also help
them to distinguish between facts and hypotheses
◦ The nurse can explain if and how research may affect a client’s
treatment and prognosis
◦ The nurse is a good source for providing information and
 answering questions
• Self Enhancement, Growth/Therapeutic Groups
◦ Self enhancement is a type of motivation that works to make us
feel good about ourselves and to maintain self-esteem
◦ This motive becomes especially prominent in situations of
threats, failure or blows to one’s self esteem
◦ Involves a preference for positive over negative self view
• Assertiveness Training
◦ Assertiveness is a communication style where we express our
personal rights and feelings more openly
◦ Techniques using statements to identify feelings and
communicate needs and concerns to others
◦ Ultimately, assists the person to take more control over life
situations
◦ 3 different communication style
‣ Aggressive
‣ Passive
‣ Assertive
• You can be assertive without being aggressive
• Stress Management
◦ Stress attacks the body, mind & spirit — management must
involve all stress areas
◦ Honest communication is crucial — start by being honest with
ourselves
◦ “We tend to mask our true emotions out of a desire to be”,
Victorious believers “who don’t want to succumb to the trials of
life”
• Behavior Modification
 ◦ Use of empirically demonstrated behavior change techniques to
improve behavior, such as altering an individual’s behaviors
and reactions to stimuli through positive and negative
reinforcement of adaptive behavior and/or reduction of
maladaptive behavior through it’s extinction, punishment and/
or therapy
• Cognitive Restructuring
◦ The process of learning to refute cognitive distortions or
fundamental ‘faulty thinking’ with the goal of replacing one’s
irrational, counter-factual beliefs with more accurate and
beneficial ones
◦ The rationale used in cognitive restricting attempts to
strengthen the client’s belief that
‣ Self talk can influence performance
‣ In particular self-defeating thoughts or negative self-
statements can cause emotional distress and interfere with
performance, a process that then repeats again in a cycle
• Mileu Therapy — The Therapeutic Community
◦ Common
◦ Safe, structured, group treatment method for mental health
issues
◦ It involves using everyday activities and a conditioned
environment to help people with interaction in community
settings
◦ Milieu therapy is a flexible treatment intervention that may
work together with other treatment methods
◦ It is a therapeutic method in which a safe, structured group
setting is used to help people learn healthier ways of thinking,
 interacting and behaving in a larger society
◦ Milieu entered English in the 1800s — comes from old French
mi (“middle”) and lieu (“place”) — the word refers to an
environment or setting
◦ 5 types of milieu
‣ Physical
‣ Emotional
‣ Social
‣ Cultural
‣ Ideological
◦ Milieu Therapy is a form of psychotherapy that involves the use
of therapeutic communities involving client’s interaction with
one another
◦ Milieu is thought to be of value in treating personality
disorders and behavioral problems
• Play therapy
◦ Method of therapy that uses play to uncover and deal with
psychological issues
◦ Can be used on it’s own, particularly with children, or along
with other therapies and medications
• Psychosocial interventions
• Psychospiritual interventions
◦ Our understanding of man created by God is that he is
composed of body, mind and soul-spirit
◦ But the soul falls ill when its right judgement is impaired and it
is overcome by the passions which cause disease — St. Neilos
the Ascetic, Philokalia I
• Alternative medicines
• Group therapy
◦ Aims to bring about reduction in symptoms such as:
‣ Negative symptoms
‣ Poor motivation
‣ Improvement in social functioning
‣ Better adjustment
‣ Improved interpersonal relationship skills
◦ In a session: the therapist may ask questions to help people
discuss their experiences and learn about what they have in
common it others. The participants may also share personal
stories or talk about their feelings while they listen to others
experiences
• Family therapy
◦ Form of psychotherapy (talk therapy) that focuses on the
improvement of relationships and behaviors among family
• Gestalt therapy
◦ Helps people focus on the present
◦ This allows individuals to discover what immediate thoughts,
feelings or behavior may make them feel anxious. Behavioral
health issues
◦ Gestalt therapy can help people with behavioral conditions like
BPD
• Client/Person centered therapy
◦ A non-directive approach to talk therapy that requires the client
to actively take the reigns during each therapy session, while
the therapist acts mainly as a guide or source of support for the
client
• Cognitive Behavioral Therapy
 ◦ Addiction
◦ Anxiety disorder
◦ BPD
◦ Low self esteem
◦ Phobia
◦ Schizophrenia
◦ Suicidal ideation
◦ Depression
• Art based therapy
◦ Allows you to express those feelings that you can’t find words
to explain
• Dance/Music therapies
◦ Dance: helps improve body image and self-esteem, decrease
fears, express anger, decrease body tensions, reduce chronic
pain and more
◦ Music: often used in hospitals and other care centers, as
effective relaxant for infants and children
• Attitude therapy
◦ An approach to psychological care that focuses on changing the
way a person thinks about a situation or issue — based on the
idea that our thoughts, feelings and behaviors are all affected
by our attitudes and beliefs
◦ Attitude: have a knowledge function, which enables individuals
to understand their environment and to be consistent in their
ideas and thinking
◦ How to develop a positive attitude:
‣ Listen to your self talk
‣ Change recurrent negative themes
 ‣ Be your own cheerleader
‣ Visualize future successes
‣ Act the part

PSYCHOPHARMACOLOGY
— The study of how drugs affect mental and behavioral functions —
Helps the mind to clear up & change behavior
1. Anti-Psychotic
A. MOA: Blocks receptor for the neurotransmitter dopamine
B. Used to treat the symptoms of psychosis such as delusions
and hallucinations seen in schizophrenia, schizoaffective
disorder and the manic phase of bipolar disorder
C. Classifications p:
a. Conventional Antipsychotics (Typical) / First generation
1. High potency:
A. Fluphenazine (Prolixin)
B. Haloperidol (Haldol)
2. Moderate Potency:
A. pherphenazine (Trilafon)
3. Low Potency:
A. Chlororomazine (Thorazine)
B. Thioridazine (Mellaril)
4. Others:
A. Mesoridazine (Serentil)
B. Triflouperazine (Stelazine)
b. Atypical Antipsychotics (New)
1. clozapine (Clozaril)
2. Risperidone (Risperidal)
 3. Olanzapine (Zyprexa)
4. Quetiapine (Seroquel)
5. Ziprasjdone (Geodon)
6. Paliparidone (Invega)
c. Novel/New Generation Antipsychotics - DSS (Dopamine
System Stabillizer) — 3rd gen
1. Aripiprazole (abilify)
D. Minor Side effects
a. Anticholinergic effects (blocking nerve impulses)
1. Blurred Vision
2. Dry mouth (lip smacking tendencies)
3. Constipation
4. Urinary retention
5. Mydriasis (fully dilated pupils)
6. Decreased sweating
b. Adrenergic effects (producing epinephrine)
1. Orthostatic Hypotension
c. Sexual side effects
1. Decreased libido
2. Impotence
3. Impaired ejaculation
d. GI Effects
1. Weight gain (pot belly)
e. Endocrine effects
1. Elevated prolactin levels
2. Amenorrhea/impotence
3. Loss of libido/lowered sperm count
4. Gynecomastia
 5. Risk for osteoporosis
6. Changes in menstrual cycle
f. Cardiac effects
1. Arrhythmias — prone to MI
g. Photosensitivity
h. Sedation
i. Agranulocytosis — decreased WBC < 3000
j. Atropine psychosis
1. Red as need — flushed fave with skin hot to touch
without fever
2. Dry as bone — dehydration
3. Mad as a hatter — altered mental state
E. MAJOR SIDE EFFECTS
a. EPS — Extrapyramidal Symptoms
1. Lacute Sutinia — acute muscular rigidity and cramping,
a stiff neck (torticollis) or thick tongue with difficulty
swallowing and in severe cases, laryngospasm and
respiratory difficulties, AKA dysgenic reactions, writers
clamp (fatigue spams), oculogyric crisis (eyes upwards)
and opisthotonus (arching of back)
2. Pseudoparkinsonism — drug induces Parkinsonism —
shuffling gait, mask like facies, muscle stiffness,
cogwheeling rigidity, drooling, resting tremor, stooped
posture, bradykinesia/akinesia (loss of movement)
3. Akathisia — intense need to move about, restless
movement, pacing, inability to stay/remain still and
client’s report of inner restlessness
4. PISA syndrome — leaning towards one side
 A. Reported with use of antipsychotics,
antidepressants, lithium, benzodiazepines,
antiemetics, cholinestrase inhibitors
B. Occurs mostly after dose changes in antipsychotic
therapy
5. Anti-EPS drugs
A. C — congentin (Benztropine)
B. A — artane (Trihexhphenidyl)
C. B — benadryl (Diphenjydrime HCL)
D. A — akineton (Biperiden)
b. Neuroleptic Malignant Syndrome
1. Potentially fatal, idiosyncratic reaction
2. Rigidity, high fever
3. Autonomic instability, unstable BP, diaphoresis, pallor,
delirium, and elevated level of enzyme creatinine
phosphokinase
4. Prone to falls & arrhythmias
c. Tardive Dyskinesia
1. A syndrome of permanent involuntary movements,
usually due to long term use of conventional
antipsychotic drugs
2. Involuntary movement of tongue, facial and neck
muscles, upper & lower extremities and truncal
musculature
3. Tongue thrusting and protruding, lip smacking,
blinking, grimacing and excessive facial movements
4. Irreversible
F. Nursing Interventions
 a. Encourage high dietary fiber and increase water intake
b. Avoid exposure to extreme heat (photosensitivity)
c. Provide sugarless candies with sips of water
d. Advise patient to report eye pain immediately
e. Encourage frequent voiding and void as soon as urge is
present
f. Help patient prepare an appropriate diet, no diet pills
g. Get out of bed or chair slowly to avoid orthostatic
hypotension
2. Medication for treating Anxiety Disorders
A. Benzodiazepines — increase the level of GABA, which
decreases stimulation of the limbic system, thereby
decreasing anxiety
a. aprazolam (Xanax)
b. chlordiazepoxide (Librium)
c. clonazepam (Klonopin)
d. lorazepam (Ativan)
B. Tricylic Antidepressants — block reuptake of
neurotransmitters (serotonin & norepinephrine), thus
allowing increased levels at synapse
a. Clomipramine (Anafranil)
b. Imipramine (Tofranil)
C. Selective Serotonin Reuptake Inhibitor (SSRI) —
selectively block serotonin reuptake at synapse, thereby
increasing serotonin levels
a. Fluoxetine (Prozac)
b. Fluvoxamine (Luvoc)
c. Paroxtine (Paxil)
 d. Sertraline (Zoloft)
D. Other Antidepressants — affect serotonin reuptake and
norepinephrine and dopamine levels
a. Venlafaxine (Effexor)
E. MAO Inhibitors — inhibit the action of enzyme monoamine
oxidase (MAO) which brings down serotonin levels
a. Phenelzine (Nardil)
F. Beta Blockers — induce peripheral beta-adrenergic blockade,
therefore reducing the physiologic effects of anxiety
a. atenolol (Tenormin)
b. propanolol (Inderal)
3. Treatment — Major Depressive Disorder
A. SSRI — Selective Serotonin Reuptake Inhibitor
a. Widely used type of antidepressant
b. Main prescribed to treat depression, particularly persistent
or severe case
c. Represents the lastest advancement in pharmacotherapy
d. Inhibits serotonin uptake
1. fluoxetine (Prozac)
2. paroxetine (Paxil)
3. sertraline (Zoloft)
4. fluvoxamine (Luvox)
B. Monoamine Oxidase Inhibitors (MAOIs)
a. 3rd major class agent
b. Used less frequently because less effective
c. Must be given for a long period before they are beneficial
d. Toxic, with longer duration of action
e. May cause severe AE
 1. isocarboxazid (Marplan)
2. phenelzine sulfate (Nardil)
3. tranylcypromine sulfate (Parnate)
f. Nursing Responsibilities
1. Monitor VE to detect potential AE (hypotension, HPN,
arrhythmia)
2. Establish safety precaution if CNS changes occurs
3. Administer medication with food to decrease GI effects
4. Monitor liver and hepatic function tests with client with
history of liver and kidney impairment
5. No thiamine — HPN crisis
g. MAOI interactions
1. OTC for colds
2. Allergies
3. TCA
4. Narcotics
5. Anti HPN
6. Sedatives
4. Intervention for Tobacco Control
A. Successful intervention — begins with identifying users and
appropriate interventions based upon the patient’s willingness
to quit
B. Goal:
a. Reduce illness
b. Disability
c. Death related to
tobacco use and
secondhand smoke
 C. Five major steps to intervention:
a. Ask about tobacco use
b. Advise tobacco users to quit
c. Assess readiness to make a quit attempt
d. Assist with the quit attempt
e. Arrange follow up care
D. 5 Rs model
a. Relevance: why is quitting important?
b. Risks: negative consequences
c. Rewards: benefits of quitting
d. Roadblocks: barriers to success
e. Repetition: repeat intervention
E. Basic intervention
a. Introduction to the drug nicotine
b. Smoking cessation VS Nicotine dependence
c. Treatment approach and holistic model
d. Physical well being
e. Emotional well being
f. Mental well being
g. Spiritual well being

STANDARDS OF PSYCHIATRIC MENTAL HEALTH NURSING

PRACTICE
Standards: the minimal professional practice expectations for any
nurse in any setting or role, which are approved by Council or
otherwise inherent in the nursing profession (Registered Nurses Act,
2006)
• The primary reason for having standards is to promote, guide,
 direct and regulate nursing practice
• Standards set practice and describe the level nurses practice
nursing safely
• Six standards of practice: define the parameters of PMH nursing
and are organized according to the nursing process steps
◦ Assessment
◦ Diagnosis
◦ Outcome definition
◦ Planning
◦ Implementation
◦ Evaluation
• Standards of Care
◦ Standard 1 — Assessment
‣ The PMH-RN collects and synthesis comprehensive health
data that are pertinent to the patient’s/client’s health and/or
situation
◦ Standard 2 — Diagnosis
‣ The PMH-RN analyzes the assessment data to determine
diagnoses, problems, areas of focus for care and treatment,
including level of risk
◦ Standard 3 — Outcome Definition
‣ The PMH-RN identifies expected outcomes based on
patient’s/client’s goals and their individual circumstances
◦ Standard 4 — Planning
‣ The PMH-RN develops a patient/client centered plan that
prescribes strategies and alternatives to attain expected
outcomes
◦ Standard 5 — Implementation
‣ The PMH-RN implements the patient/client centered plan
‣ Standard 5A — Coordination of care
• The PMH-RN coordinates care delivery
• DOH > BRGY
‣ Standard 5B — Health Teaching & Health Promotion
• The PMH-RN employs strategies to promote health and a
safe environment
‣ Standard 5C — Consultation
• The PMH-RN provides consultation to maximize
outcomes from the identifies plan, collaborate with other
clinicians to provide services to patients/clients and
contribute to systems change
‣ Standard 5D — Pharmacological/Biological Therapies and
Prescriptive Authority
• The PHM-RN incorporates knowledge of
pharmacological and biological interventions with
applied clinical skills to restore the patient’s/client’s
health and prevent further disability
• The PMH-RN uses prescriptive authority, procedures,
referrals, treatments and therapies in accordance with
state and federal laws and regulations
‣ Standard 5E — Contemporary/Integrative Therapies
• The PMH-RN incorporates knowledge of contemporary/
integrative interventions (yoga, meditation, acupuncture,
dietary supplements, art, music) with applied clinical
skills to restore the patient’s/client’s health and prevent
further disability
‣ Standard 5F — Milieu Therapy
 • The PMH-RN provides a safe, therapeutic, recovery-
oriented environment in collaboration with patients/
clients, families, and other clinicians/ancillary staff/care
partners
‣ Standard 5G — therapeutic relationship
• The PMH-RN uses therapeutic relationship as a basis for
interactions and the provision of care
‣ Standard 5H — counseling and psychotherapy
• The PMH-RN uses counseling interventions to assist
patients/clients in their individual recovery journey
• The PHM-APRN conducts individual, couples, groups and
family psychotherapy using evidence based
psychotherapeutic frameworks within the nurse-client
therapeutic relationship
◦ Standard 6 — Evaluation
‣ The PMH-RN evaluates progress toward attainment of
expected outcomes
• The Nurse — Psychiatric Nurse
◦ How to become a Psychiatric Nurse
‣ Complete a nursing program
‣ Earn your RN license
‣ Earn your certification in Psychiatric Nursing
◦ Basic level functions of the Nurse
‣ Counseling
• Intervention
• Problem Solving
‣ Milieu Therapy
• Therapeutic Environment
 ‣ Self Care activities
• Encourage independence
‣ Psychobiologic Interventions
• Medications
• Observations
‣ Health Teaching
• Teaching
‣ Care Management
• Nursing
◦ Masters & Specialty — Advance level functions
‣ Health promotion — health maintenance
‣ Psychotherapy — individual, family, group, community
‣ Prescription — medication
‣ Consultation — clinic
◦ Standards of professional performance
‣ Standard 1: Quality of care
‣ Standard 2: Performance Appraisal
‣ Standard 3: Education
‣ Standard 4: Collegiality
◦ Where do they work?
‣ Psychiatric hospitals
‣ Doctors’ office
‣ Assisted living facilities
‣ Long term care centers
‣ Rehabilitation centers
‣ Behavioral care companies
‣ Private homes
‣ Correctional facilities
 ‣ Community mental health centers
‣ Private clinics
‣ Schools
‣ Military care and hospitals
◦ Who do they work with?
‣ Children
‣ Adolescent
‣ Adults
‣ Older persons
‣ People with substance abuse disorders
‣ People with eating disorders
‣ Forensics
‣ Consultant

Related Laws in Mental Health

RA 11036 — Philippine Mental Health Act
• An act establishing a national mental health policy for the purpose
of enhancing the delivery of intergrated mental health services
• Promoting and protecting the rights of person utilizing
psychosocial health services
• Appropriate funds therefore and other purposes
• The state affirms the basic right of all Filipinos to mental
health as well as the fundamental rights of people who require
mental health services
• Rights of service users
◦ Freedom from discrimination
◦ Respect political, civil, economic, social, religious, educational
and cultural rights
 ◦ Access to evidence based treatment
◦ Affordable
◦ Humane treatment
◦ Accessible
◦ Confidentiality
◦ Informed consent
◦ Appropriate medical care
◦ Information
◦ Choose HCP & facility
◦ Self determination
◦ Religious belief
◦ Medical records
◦ To leave
◦ To refuse participation in medical research
◦ To receive visitors
◦ To express grievance
◦ To be informed of his rights and obligations as a patient

Magna Carta for Women

A comprehensive women’s humans rights law that seeks to
eliminate discrimination through the recognition, protection,
fulfillment and promotion of the rights of Filipino women
• Satient features
◦ Third level positions in the government
◦ Leave benefit of 2 months with full pay — 105 days regardless
of government/private agency
◦ Employment in the field of military, police and other similar
services
 ◦ Equal access — education, scholarship, training
◦ Women in media and film
◦ Equal status given to men & women

RA 7277 — Magna Carta for Disabled Persons

• Disabled persons are part of Philippine society
• Same rights as other persons in society
• More meaningful productive and satisfying life
• Promote welfare of the disabled persons
• Respect for disabled persons
• Remove all prejudice
• Rights
◦ Employment
◦ Education
◦ Health
◦ Social services
◦ Telecommunications
◦ Accessibility
◦ Political & civil rights
◦ Housing program

RA 7305 — Magna Carta of Public Health Workers

• Promote and improve social and economic wellbeing of the health
workers
• Develop their skills and capabilities
• Join and remain in government service
• Married public health workers
• Security of tenure
• Discrimination prohibited
• No understaffing/overloading of health staff
• Normal hours of work
• Night shift differential
• Salary & additional compensation
• Legal & ethical concepts
◦ Ethics: study of philosophical beliefs about what is considered
right or wrong in society
◦ Bioethics: ethical questions arising in health care
◦ Principals of bioethics:
‣ Beneficence: duty to act to benefit others
‣ Autonomy: respecting rights of others to make decisions
‣ Justice: duty to distribute resources equally
‣ Fidelity: maintaining loyalty and commitment to patient
‣ Veracity: duty to communicate truthfully

Mental Health Laws: Civil Rights and Due Process

• Civil rights: people with mental illness are guaranteed sa,e rights
under federal/state laws as any other citizen
◦ Due process in civil commitment : courts have recognized
involuntary commitment to mental hospital is “massive
curtailment of liberty” requiring due process protection,
including:
‣ Writ of habeas corpus: procedural mechanism used to
challenge unlawful detention
‣ Least restrictive alternative doctrine: mandates least drastic
means be taken to achieve specific purpose
Mental Health Laws: Admission to the Hospital
1. Voluntary: sought by patient or guardian
A. Patient have right to demand and obtain release
B. Many states require patient submit written release notice to
staff
2. Involuntary admission (commitment): made without patient’s
consent
A. Necessary when person is danger to self or others and/or
unable to meet basic needs as result of psychiatric condition
3. Emergency Involuntary Hospitalization
A. Commitment for specified period (1-10 days ) to prevent
dangerous behavior to self or others.
4. Observational or Temporary involuntary hospitalization
A. Longer duration than emergency commitment
B. Purpose: observation, diagnosis and treatment for mental
illness for patients posing danger to self/others

Issue of Legal Competence

1. All patients must be considered legally incompetent until they
have been declared incompetent through legal proceeding
A. Determination made by courts
B. If found competent, court-appointed legal guardian, who is
then responsible for giving or refusing consent
2. Implied consent
A. Many procedures nurse performs has element of implied
consent (e.g. giving medications)
B. Some institutions require informed consent for every
medication given
Rights regarding Restraint & Seclusion
1. Doctrine of least restrictive means of restraint for shortest time
always the rule
2. Legislation provides strict guidelines for use
A. When behavior is physically harmful to patient/others
B. When least restrictive measures are insufficient
C. When decrease in sensory overstimulation (seclusion only is
needed)
D. When patient anticipates that controlled environment would
be helpful and requests seclusion
3. Recent legislative changes have further restricted use of these
means and some facilities have instituted “restraint free” policies.

Patient Confidentiality
1. Ethical considerations
A. Confidentiality is right of all patients
B. ANA code of ethics for nurses (2001) asserts duty of nurses to
protect confidentiality of patients
2. Legal considerations
A. Health Insurance Portabiiand Accountability Act (HIPAA)
2003
a. Health Information may not be released without patient’s
consent, except to those people for whom it is necessary in
order to implement the treatment plan
3. Exceptions
A. Duty to warn and protect third parties
a. Tarasoff V. Regents of University of California (1974)
 ruled that psychotherapist has duty to warn patient’s
potential victim of potential harm
B. Most states have similar laws regarding duty to warn third
parties of potential life threats
C. Staff nurse reports threats by patient to the treatment team

Child and Elder abuse Reporting Statutes

1. All states have enacted child abuse reporting statutes
A. Many states specifically require nurses to report suspected
abuse
2. Numerous states have also enacted elder abuse reporting statutes
A. Agencies receiving federal funding (Medicare/Philhealth)
must follow strict guidelines for reporting ensue of older
adults

Tort law applied to Psychiatric Setting

1. Protection of patients: legal issues common in psychiatric
nursing are related to failure to protect safety of patients
2. Protection of self
A. Nurses must protect themselves in both institutional and
community settings
B. Important for nurses to part in setting policies that create a
safe environment

Tort Law
• Torts: wrongful acts that cause a patient to suffer harm
• Intentional Torts
◦ Assault
 ◦ Battery
◦ False imprisonment
◦ Invasion of privacy
◦ Defamation of character
• Unintentional Torts:
◦ Negligence: the failure to behave with the level of care that a
reasonable person would have exercised under the same
circumstances
◦ Malpractice: professional wrongdoing that results in injury or
damage

Negligence/Malpractice
1. Negligence or malpractice is an act or an omission to act that
breaches the duty of due care and results in or is responsible for
a person’s injuries
2. Elements necessary to prove negligence
A. Duty
B. Breach of duty
C. Cause in fact
D. Proximate cause
3. Damages cause in fact
A. Evaluated by asking “except for what the nurse did, would
this injury have occurred?”
4. Proximate cause or legal cause
A. Evaluated by determining whether there were any
intervening actions or individuals that were in fact the cause
of harm to patient
5. Damages
 A. Include actual damages as well as pain and suffering
6. Foreseeability of harm
A. Evaluates the likelihood of outcome under circumstances

Nursing Interventions
1. Most states require legal duty to report risks of harm to patient
2. Nurse has obligation to report peer suspected of being chemically
impaired
A. Report to supervisor is a requirement
3. If nurse knows physician’s orders need to be clarified or changed,
it is the nurse’s duty to intervene and protect patient
4. Abandonment
A. Legal concept may arise when nurse does not leave patient
safely back in hands of another HCP before discontinuing
treatment

Avoiding Liability
• Respond to the client
• Educate the client
• Comply with the standard of care
• Supervise care
• Adhere to the nursing process
• Document safely
• Follow up and evaluate
• Maintain a good interpersonal
relationship with client and
family
Documentation — serves as a permanent record of client
information and care
• SOAPIE: subjective & objective, information, assessment, plan,
implement, evaluate
• FDAR: focus, data, action, response
• EHR: electronic health record
◦ Huge volume of information
◦ All client information in one record
◦ Client database - add new data
‣ Create and revise care plan
‣ Document client progress
• PONR: problem oriented nurses record
• ISBARR: identify, situation, background, assessment,
recommendation, read back
• OTHERS: change of shift, incident report, referral system, health
care electronic database
• Recording
Reporting — takes place when 2 or more people share information
about client care, either face to face or by telephone
Purpose of client’s record/chart
1. Communication
2. Legal documentation
3. Research
4. Statistic
5. Education
6. Audit and quality assurance
7. Planning client care
8. Reimbursement
Types of Records
1. Admission sheet
2. Physicians order sheet
3. Medical history
4. Nurses’ notes
5. Special records/reports
Types of Reporting
1. Change of shift
A. For continuity of care
2. Telephone reports
A. When the call was made
B. Who made the call
C. Who was called
D. To whom was the information given
E. What information was received
3. Transfer reports
A. Transfer of patient from one unit to another
Recording
Characteristics of a good recording
1. Brevity
A. Entries are concise
2. Ink
A. Avoid pencil
B. Evidence in legal court
3. Accuracy
A. Facts
4. Appropriateness
A. Information pertaining for the client only
5. Completeness
 A. Chronology, organization, sequencing and timing
6. Standard terms
A. Correct spelling & grammar
B. Approved abbreviations
7. Signed
A. Affix signature at the end of charting
8. Confidence
A. Only HCP are allowed to read the chart
9. In case of error
A. Draw a single line through the error
10. Legal awareness
A. Chart only what you have done, observed, heard and felt
11. Legible
A. Writing must be clear and easily read by others
B. If not legible, then PRINT
12. Don’t use patient or Pt in the chart
A. The word “patient” is not used in the chart
B. All information in the chart pertains to the patient
Legal Considerations for Documentation of Care
DON’T
• Chart opinions
• Defame patient
• Chart before an event occurs
• Chart generalizations
• Obliterate, erase, alter or destroy a record
• Leave blank spaces
Integrity of Client’s records & Information
Health Information Privacy
1. Ethical Considerations
A. Confidentiality of care and treatment is an important right for
all patients, particularly psychiatric patients
B. Any discussion or consultation involving a patient should be
conducted discreetly and only with individuals who have a
need and a right to know this privileged information
2. Code of Ethics for Nurses
A. Nurse’s legal duty to maintain confidentiality is to protect the
patients privacy
B. You may NOT, without patient’s consent, disclose information
obtained from the patient or information in the medical
record to anyone

Filipino Culture, Value & Practices

1. Resilience
2. Take pride in families
3. Religious
4. Respectful
5. Help one another
6. Value tradition & culture
7. Love to party
8. Longest Christmas
9. Loves to eat
10. Loves to sing
11. Love art
12. Festivals

Evolution of Psychiatric and Mental Health in the Philippines

1. Pre Spanish Era
A. All maladies psychiatric or otherwise were simply believed to
be instigated by natural and supernatural occurrence
B. Manananggal, kapre, batibat, dwende
2. Spanish Era
A. Mental illness and conditions manifesting with aberrant
thinking and behavior were attributed to religious factors and
supernatural forces
B. Mangkukulam, witches, mangangaway, devil men
C. Religious factors
D. Church — for purification & exorcism
E. Prayers
F. Folk healers or herbolarios
G. Folk healers (flagellated)
H. Drink potions
I. Bulo-bulo
J. Massage
K. Hospicio de San Jose 1782
3. American Regime
A. Mental disability began to be recognized just as any other
medical illness
B. San Lazaro Hospital
C. Hospitals & Trainings
D. 1910: Philippine General Hospital
E. 1918: City Sanitarium, San Juan Del Monte
F. 1928: Insular Psychopathic Hospital
G. UST trainings in Psychiatry
4. Japanese Occupation
 A. Families of mentally ill patients brought them home
B. Electro Convulsive Therapy

Entrepreneur Opportunities in Psychiatric Mental Health

Practice
1. Sleep technician
A. Trained professionals who work in a sleep laboratory
conducting sleep studies, review the results and created
summary reports that guide the care of patients
2. Bio similar or Biological Drugs
A. A medicine that is very close in structure and function to a
biological medicine
B. A biological or biological drug, is a medicine made in living
system (yeast, bacteria, animal cells)
C. Biologists used in the treatment of cancer can work in many
ways
3. Psychiatric hospital
4. Travel agency
5. Media hub
6. Wellness clinic
7. Concierge doctor
A. A primary care physician who offers personalized care and
direct access to their patients for a fee, which can be paid
monthly or annually
8. Corporate wellness
9. Mental health and wellness podcast
A. Mental health podcast is any type of podcast that discusses
some element of psychology or mental health
 B. Topics: trauma, depression, self-love, body image, anxiety,
addiction and more
10. Yoga studio
11. Psychologist
12. Counseling service
13. Mental health and wellness blog
14. Medical records management
15. Develop a health app
16. Clinical health worker
17. Mental health magazine
18. Software to support entrepreneurs
19. Retreat center
20. Rehabilitation center
21. Alcohol & drug abuse counselor
22. Drug testing business
23. Natural remedy supplier
24. Mental health program on TV
25. Organize mental health fairs
26. General physician
27. Medical transcription services
28. Home health care agency
29. Medical insurance selling
30. Medical billing services
31. Alternative services