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Psychiatric-Mental Health Nursing

13.1 Clinical Guidelines and Standards

Psychiatric-Mental Health Nursing13.1 Clinical Guidelines and Standards

Learning Objectives

By the end of this section, you will be able to:

  • Outline the governing entities of nursing that have the authority to set nursing standards
  • Describe the role of state boards of nursing
  • Provide examples of how standards are set at the federal and local levels

A range of governing entities oversees nurses, as health-care professionals, in order to ensure that they are complying with the required standards of practice; these standards may be federal, state, local, or institutional. The understanding of nursing standards and regulations begins during nursing education and is continued through the licensure process, and for the length of the nurse’s career. To ensure that nurses maintain and uphold these standards, the regulations developed for nursing practice are set, and compliance is monitored, by professional bodies, federal and state governmental bodies, and the health-care organizations themselves.

Standards of Nursing Practice

The standards of nursing practice are developed to ensure best practices and expectations in nursing care. These standards can be utilized to compare the nurse’s performance with the current standard of nursing care and are used to maintain safety and competent nursing practice. Specifically, standards of nursing practice help to guide the provision of care to clients by nurses, give organizations rules by which to evaluate nursing care, and allow for accountability for clinical decisions and actions. Several organizations develop professional standards of practice, such as the American Nurses Association (ANA) and the American Psychiatric Nurses Association (APNA). Standards of practice are established for the generalist nurse as well as specialty nursing areas, including psychiatric-mental health nursing.

The American Nurses Association

The American Nurses Association (ANA) is a professional organization that advances and protects the nursing profession. The nurse will find many valuable tools on the ANA website that can be applied to their practice and improve the care of clients. Founded in 1896, the ANA intends to: “foster high standards of nursing practice; promoting a safe and ethical work environment; bolstering the health and wellness of nurses; and advocating on health care issues that affect nurses and the public” (ANA, n.d.-a, para 3). The ANA partners with the Standards for Excellence Institute to provide resources for best practice (ANA, 2015). Professional standards published by the ANA are meant to provide direction to nurses across the nation, influence legislation, and implement a framework to evaluate nursing excellence (ANA, 2015).

The ANA standards include the Code of Ethics for Nurses, which guide nursing responsibilities and ethical obligations. The ANA Nursing Standards also include the scope and standards of practice describing the art and science of nursing, as well as Standards of Professional Performance. The nursing process is a critical thinking model, which includes six components as reflected in the first six standards (Figure 13.2):

    • Standard 1. Assessment: The registered nurse collects pertinent data and information relative to the health-care consumer’s health or the situation.
    • Standard 2. Diagnosis: The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.
    • Standard 3. Outcomes Identification: The registered nurse identifies expected outcomes for a plan individualized to the health-care consumer or the situation.
    • Standard 4. Planning: The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes.
    • Standard 5. Implementation: The registered nurse implements the identified plan.
      • Standard 5A. Coordination of Care: The registered nurse coordinates care delivery.
      • Standard 5B. Health Teaching and Health Promotion: The registered nurse employs strategies to promote health and a safe environment.
    • Standard 6. Evaluation: The registered nurse evaluates progress toward attainment of goals and outcomes.
Chart of a nursing critical thinking process with arrows connecting steps, which include Assessment, Diagnosis, Outcomes Identification, Planning, Implementations, and Evaluation, that lead back to Assessment, and go around again.
Figure 13.2 The nursing process is a critical thinking model based on a systematic approach to client-centered care. (modification of work from Clinical Nursing Skills. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The ANA Position Statements describe the stance of the ANA on various topics that may arise. These topics include artificial intelligence in nursing practice, racism in nursing, risk and responsibility in providing nursing care, nursing role and workforce issues, and technology in health care. The ANA Principles for Nursing Practice describe the more day-to-day guidelines as “aimed at giving you practical information for your professional practice” (ANA, n.d.-b, para 10). Areas addressed include documentation processes, delegation, and staffing. They also address nursing pay and offer solutions of changing insurance reimbursement to health-care organizations through a pay for quality process.

Councils for State Boards of Nursing (NCSBN)

The National Council of State Boards of Nursing (NCSBN) is composed of the state nursing regulatory bodies (NRB) whose mission is to protect the public by ensuring licensed nurses provide safe and competent care (NCSBN, 2023). The NCSBN, which is the body that affiliates all of the NRB, guides the NRB on topics like risk analysis, monitoring of nursing education programs for curriculum content, pass rates, and employment rates. The nursing regulatory bodies are the state boards of nursing in all 50 states, the District of Columbia, and four U.S. territories. The NRB’s role is to “monitor licensees’ compliance to jurisdictional law and take action against the licenses of those nurses who have exhibited unsafe nursing practice” (NCSBN, n.d., para 2). Each state board of nursing enforces the Nurse Practice Act of each jurisdiction. Each act contains qualifications for licensure, including what titles may be used; defines the nurses’ scope of practice; and outlines the outcomes if the nurse does not follow the law. The guiding principle of the NRB is to “develop policy, design regulation, administer and enforce regulatory law and rules to accomplish their mandates of protecting the safety of the public” (NCSBN, 2022, para 2). Moreover, the NRB develops regulations based upon the NCSBN Model Act (2021) whose purpose is to protect the health, safety, and welfare of the public. The NCSBN Model Act defines the scope of practice for all levels of nursing, from licensed practical/vocational nurses and registered nurses to advanced practice registered nurses, and each is different. The NCSBN also defines the makeup of the membership of each individual board of nursing to include members from each licensure field as well as a member from the public. One specific role of state boards of nursing is to assure the public of nursing competency. Nurse licensure ultimately serves to protect the public, as defined by law. Therefore, non-nurse members of the public serve on state boards (NCSBN, 2021).

The NCSBN also developed the Clinical Judgment Measurement Model (CJMM) to guide decision-making on the nurse licensure exam Table 13.1. The ANA Standards apply to clinical reasoning nurses must utilize in practice. Terminology may differ, as indicated in the following table, but the concepts are synonymous. Both the CJMM and the ANA Standards outline a cyclical process strategy to ensure a competent level of nursing care and to evaluate that process—whether by testing or in actual practice. The overall term nursing process is the nurse’s thinking that drives nursing action.

ANA Standards NCSBN CJMM Meaning in Nursing Process
Assessment Recognizing cues Collecting data and noticing which are relevant to care
Diagnosis Analyzing cues Determining what could be contributing to the relevance of the data
Outcomes identification Prioritizing hypotheses Deciding which to address first and what are the goals or desired results
Planning Generating solutions Formulating what to do
Implementation Taking actions Doing what has been planned
Evaluation Evaluating outcomes Summarizing success of the plan; revising if necessary
Table 13.1 Comparison of Terminology—ANA Standards, CJMM and Nursing Process

The American Psychiatric Nurses Association

The American Psychiatric Nurses Association (APNA) is a professional organization that provides leadership in issues related to all nurses working in the mental health field in all practice settings. The APNA publishes the Psychiatric-Mental Health Nursing, Scope and Standards of Practice, Third Edition. These standards were developed in collaboration with the ANA and the International Society of Psychiatric-Mental Health Nurses (ISPN). The standards are authoritative statements that describe the responsibilities for which its practitioners are held accountable (APNA-ISPN Scope and Standards Revision Joint Task Force, 2022) for psychiatric mental-health nurses. There are seventeen standards published and each standard has associated competencies. These standards outline the nursing process and coordination of care, health teaching and literacy, as well as pharmacological and biological, complementary/integrative therapies, and milieu therapy. They discuss the importance of therapeutic relationships, counseling and psychotherapy, and evaluation. The standards also cover professional performance, including ethics, cultural humility, communication, professional collaboration, leadership and education, evidence-based practice, and research as well as quality, professional practice evaluation, resource utilization, recovery-oriented care, and environmental health.

Psychosocial Considerations

American Psychiatric Nurses Association Standard Regarding Cultural Humility

The APNA’s Scope and Standards of Practice (2022) indicate that a Psychiatric-Mental Health Registered Nurse (PMH-RN) must practice from a perspective of cultural humility.

Awareness, through self-reflection, is important so that nurses can open their thinking to consider inclusivity; one good place to start is through collaborating with colleagues of different cultures. Nurses can also accomplish this by reading professional publications, such as Minority Nurse, Journal of the National Black Nurses Association, and The Journal of Transcultural Nursing, or scholarly articles, such as “Health Inequities in LGBT People and Nursing Interventions to Reduce Them: A Systematic Review” by J. Medina-Martínez et al., published in the International Journal of Environmental Research and Public Health (2021).

Exposure to this information may enable the nurse to recognize personal views that may have been obstacles to cultural humility. Next, the nurse should seek opportunities to attend culturally diverse presentations and events. A good starting place is the recorded presentations available from the U.S. Department of Health and Human Services.

National League for Nursing (NLN)

The National League for Nursing (NLN) was the first nursing organization in the United States, started in 1893. The NLN’s mission and focus is on nursing education, specifically to promote “excellence in nursing to build a strong and diverse nursing workforce to advance the health of our national and the global community” (NLN, n.d., para 1). The NLN reports its core values as caring, integrity, diversity and inclusion, and excellence. Its commitment includes enhancing the NLN both at a national and international level as a leader in nursing education. The NLN reports a commitment to, and seeks to be the voice of, nurse educators in all specialties, including performing and publishing research and evidence regarding nursing education and teaching. For nurse faculty, the NLN offers professional development opportunities, access to data and grants, and certification as a Certified Nurse Educator (CNE). Students benefit from the NLN’s efforts to contain costs and facilitate access to nursing education, diversify the nursing workforce, and ease transition to higher degree programs (NLN, 2011).

Quality and Safety Education for Nurses (QSEN)

The Quality and Safety Education for Nurses (QSEN) initiative addresses the knowledge, skills, and attitudes (KSA) required to improve the quality and safety of the health-care system. Its website provides information on the QSEN competencies, KSAs, teaching strategies, and faculty development to support safety and quality in health care.

In 2000, the Institute of Medicine published reports calling for systems redesign in health care to address safety and quality. In 2005, the Robert Wood Johnson Foundation provided funding for nursing leaders to develop quality and safety competencies for nursing. These competencies were included in nursing education curricula, and now are incorporated into the ANA’s Nursing Alliance for Quality Care.

QSEN utilizes the Institute of Medicine competencies, QSEN faculty, and a national advisory panel to define quality and safety competencies for nursing both at the graduate and undergraduate levels. QSEN focuses on KSAs in the areas of client-centered care, teamwork and collaboration, evidenced-based practice, quality improvement, safety, and informatics.

QSEN competencies are integrated into nursing education programs to ensure that students are adequately prepared to meet the challenges of providing safe, high-quality care in a rapidly evolving health-care landscape. The QSEN initiative emphasizes the importance of interprofessional education and collaboration, recognizing that safe and effective care requires a team-based approach. The aim of incorporating QSEN principles is to provide client-centered care, work effectively in teams, utilize evidence-based practice, contribute to quality improvement efforts, prioritize client safety, and leverage informatics to support decision making.

Boards of Nursing

The Boards of Nursing are the regulatory bodies that oversee the practice of nursing within a certain jurisdiction, such as a state or territory. In the United States, each state, including the District of Columbia, American Samoa, Guam, the Northern Mariana Island, and the Virgin Islands, has an individual board of nursing that, together, make up the NCSBN. Puerto Rico is an associate member of the NCSBN and has its own Board of Nurse Examiners.

The function of state boards is to evaluate licensure applicants, issue licenses when appropriate, renew licensures, ensure each participant is in good standing, and take disciplinary action when needed. State boards of nursing are governed by the laws in each individual state’s Nurse Practice Act. Each individual state board of nursing has the ability to enforce the law; nurses must understand the law and how it can affect their practice.

Licensing and Accreditation of Nursing Programs

Registered nurses receive their education through either an accredited bachelor’s degree program in nursing (BSN), which typically takes four years; an associate’s degree program in nursing (ADN), which takes two to three years; or a diploma in nursing, typically for licensed vocational nurses, which is not as common. Nursing education programs are required to provide the knowledge, skills, and abilities (KSAs) set forth by the NLN. The American Association of Colleges of Nursing (AACN) establishes quality standards for nursing education. The AACN utilizes a national consensus–based process to develop “essential documents that outline competency expectations for graduates of baccalaureate, master’s, and Doctor of Nursing Practice programs” (AACN, n.d., para 4). Utilizing these essential documents, the AACN ensures consistently high standards of nursing education programs. The AACN publishes The Essentials: Core Competencies for Professional Nursing Education, which outlines different domains and competencies that must be included and taught in nursing curricula. Nursing education programs must adhere to these standards and undergo an accreditation process to maintain their approval from the AACN. The AACN also has several arms to help improve the education of nurses, including health policy advocacy, research and data services, conferences and webinars for faculty development, leadership development, programs on diversity and inclusion, and special education projects such as end-of-life nursing care. The Commission on Collegiate Nursing Education (CCNE) is an accrediting arm of the AACN, developed to advocate for baccalaureate, and higher, nursing degree-granting programs in the United States. The CCNE promotes self-regulation and peer review by nursing programs and the accreditation is voluntary.

Two other accrediting agencies oversee nursing programs: the Accreditation Commission for Education in Nursing (ACEN) and the National League of Nurses Commission for Nursing Education Accreditation (CNEA). Both entities help to establish standards of accreditation, peer evaluation of nursing programs, and resources to ensure quality education that meets the expectations and core competencies for future nurses.

The Nurse Practice Act

The Nurse Practice Act (NPA) is a set of state laws and regulations that govern the practice of nursing within a specific jurisdiction. Specific details of each NPA may vary between jurisdictions. The NPA governs licensure and certification, such as criteria for education requirements for licensure, as well as continuing education requirements. The NPA for each area defines the activities and responsibilities that fall within the scope of nursing practice, outlining what nurses are allowed and not allowed to do, or activities that may require collaboration with other health-care professionals. The NPA establishes the standards of care that nurses must adhere to and encompasses such items as client safety, confidentiality, documentation, and ethical considerations. The NPA also sets the grounds for disciplinary action against any nurse who violates the law or fails to meet professional standards. This may include misconduct, negligence, substance misuse, or other behaviors that jeopardize the safety of the client or violate the standards of practice.

Real RN Stories

Nurse: Brenda B., ADN, RN
Years in Practice: Four
Clinical Setting: Medical-surgical floor of a small, rural hospital
Geographic Location: Tennessee

Brenda is a nurse working in a small rural hospital on the medical-surgical floor. Brenda encountered a client with a large wound on their lower extremity that will require extensive surgery. Brenda used her phone to take a photo of the client’s wound without the client’s permission and posted the photo on her social media page. The client and their family were notified by other members of the community who were able to identify the client based on the social media photo. The family notified the hospital administration and obtained a lawyer to bring charges against both Brenda and the hospital due to a breach of confidentiality. Brenda was fired from her position at the hospital, the State Board of Nursing temporarily suspended her license, and she was required to face the State Board of Nursing hearing board. After six months and continuing education, the board reinstated her license. Brenda learned a valuable lesson regarding the importance of client confidentiality.

Standards Set by Institutions, Federal Regulations and Programs, and Accrediting Bodies

Nursing practice standards and legal regulations for nursing care are outlined by the Nurse Practice Act (NPA), which in turn informs professional organizations, federal regulators, and state boards of nursing. These standards and regulations include authoritative statements that describe scope of and competence in practice.

Standards Set by Employers and Agencies

Individual employers, agencies, and institutions also set standards and guidelines for nursing practice. These guidelines may reflect state laws or they can be more restrictive than the state laws, but they cannot be more lenient than the standards and laws set by state boards of nursing. Guidelines set by individual institutions to guide nursing care are normally developed to help nurses practice within the scope of their licensure. These guidelines may be posted as institutional policies, practices, protocols, or procedures to follow.

Federal Regulations

Nurses must also be aware of the federal influence on the practice of nursing. There are several federal agencies and programs, along with their guiding laws and regulations, that intimately affect nursing care. For example, the Department of Health and Human Services, Centers for Medicare and Medicaid Services, Healthy People 2030, and the Occupational Safety and Health Administration play a role in most health-care institutions. They help to establish criteria for reimbursement and quality measures for care of clients.

Department of Health and Human Services

The Department of Health and Human Services (HHS) is a department of the United States government that is responsible for the health of all residents of the United States. The HHS works with various federal, state, and local agencies, as well as private organizations, that influence public health, health care, social services, and medical research. The HHS administers various health-care programs, including Medicare and Medicaid, which provide health coverage to older adults, low-income individuals, and those with disabilities. HHS addresses public health emergencies; helps to prevent and control the spread of diseases by research, policymaking, and making information available for health-care providers; conducts research on diseases; and promotes healthy behaviors.

Centers for Medicare and Medicaid Services

It is important for nurses to understand federal insurance coverage, run by the Centers for Medicare and Medicaid Services (CMS), that may impact their clients. CMS is under the direction of the Department of Health and Human Services. It is dedicated to advancing health equity, expanding coverage, and improving health outcomes. CMS offers insurance coverage for three groups of individuals: people aged sixty-five or older, individuals under age sixty-five with certain disabilities, and people of all ages with end-stage renal disease. Medicare part A covers care in hospitals and skilled nursing facilities as well as hospice care and some home health care. Medicare part B helps to cover doctor’s office fees and community care, as well as some medical supplies; it requires a monthly fee. Medicare part D is a prescription drug coverage service available for those who qualify for Medicare and want to purchase a plan. CMS also offers insurance coverage to low-income adults, children, pregnant women, older adults, and people with disabilities through the Medicaid program. This program is jointly funded by individual states and the federal government.

Healthy People 2030

Nurses must have a vested interest in the problems affecting the health of the nation. The Healthy People 2030 initiative is a program in the United States that sets objectives and goals to improve the nation’s health over a specified period. The Healthy People 2030 initiative is sponsored by the U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. It sets health-care priorities based on leading health indicators, as well as overall health and well-being measures. Priority areas for 2030 include the elimination of health disparities and equality for people to live healthy lives. This includes health equity but also an increase in health literacy and addressing the social determinants of health across the nation. Healthy People 2030 also publishes evidence-based resources to help those working in health care identify sources to improve health. For the mental health nurse, Healthy People 2030 provides links to pertinent information on mental health, such as screening for anxiety in children and adults, and an evidence-based practices resource center.


The Occupational Safety and Health Administration (OSHA) is a regulatory agency in the United States that operates under the Department of Labor. OSHA’s main purpose is to ensure safe and healthy working conditions for employees in various industries. OSHA develops and enforces workplace safety and health regulations. These standards cover a wide range of industries, including hospitals and other medical facilities. OSHA addresses specific hazards and risks to protect workers’ safety and well-being. An example for nursing includes the use of safety needles to avoid unnecessary needlesticks. OSHA may regulate hazardous materials in the workplace and have specific guidelines for using and disposing of such materials.

OSHA conducts inspections of workplaces to ensure compliance with safety and health regulations. These may be routine inspections or may be in response to a reported incident. OSHA provides training programs and educational materials as well as resources to employers and workers to raise awareness about workplace hazards, prevention strategies, and workers’ rights.

The Joint Commission on Accreditation of Healthcare Organizations

Many public service and health-related entities, such as hospitals, schools, and universities, have accreditation programs. The Joint Commission for Accreditation of Healthcare Organizations (JCAHO), or the Joint Commission, an independent, nonprofit organization, accredits and certifies health-care organizations and programs in the United States. It focuses on quality improvement and client safety. The Joint Commission surveys hospitals for compliance with its set of standards in health care. These standards may change each survey year and are related to areas, such as safety. Surveys may include such items as policy and procedure review, protocols in place for medical diagnoses, such as myocardial infarctions or deep vein thrombosis, and equipment examination.

National Patient Safety Goals

The National Patient Safety Goals (NPSGs) are one set of standards the Joint Commission establishes for ensuring safety for client care. The NPSGs, revised regularly, focus on promoting surgical safety and prevention of infections, preventing medication errors, and addressing suicide risk and specific clinical harm. Client safety and prevention of adverse events in the health-care setting are a priority for nursing. The NPSGs are designed to promote client safety and prevent adverse events in health-care settings. These goals serve as a framework for health-care organizations to improve the quality and safety of client care.

The Joint Commission established the NPSGs in an effort to promote client health and safety in inpatient and outpatient settings. Some common goals for NPSGs include identifying clients correctly through the use of two identifiers, such as name and date of birth. NPSGs focus on improved communication between health-care providers, including the use of effective handoff communication during transitions of care. Medication safety is a top priority for NPSGs and includes ensuring the safe use of high-alert medications. Evidence-based practice is also a priority and includes such items as handwashing, proper use of personal protective equipment to prevent infections, and adherence to infection prevention guidelines. Other areas of focus include prevention of falls, by assessing risks for each client and implementing interventions; prevention of surgical errors, by implementing safety measures; and improving clinical alarm safety, by addressing things like alarm fatigue.


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