Learning Objectives
By the end of this section, you will be able to:
- Discuss special considerations within the nursing scope of practice in mental health nursing
- Discuss the challenges that nurses face in adhering to the scope of practice
As a specialty practice area, psychiatric-mental health nursing requires a skill set specific to client needs. The American Nurses Association sets standards for all nursing practice, which address safety, ethical practice, health-care advocacy, public health, and the well-being of nurses. The American Psychiatric Nurses Association sets standards for the specialty of psychiatric-mental health (PMH) nursing through the lifespan, including addictions care. These standards employ the nursing process, specifically including the therapeutic relationship, multiple therapies and treatment modalities, and treatment settings. The PMH standards separately address professional performance to include ethical behaviors, evidence-based practice, leadership, interprofessional collaboration, and recovery-oriented care.
Special Considerations within PMH Nursing Scope of Practice
One of the first hurdles in nursing care of individuals with mental health or addiction challenges is to accept the nature of these conditions as physiological and not behavioral. Nurses must expand their own awareness to eliminate the blame that can exist when persons are expected to “behave better.”
Review the imagination exercise in Table 13.2 and think about the impact of treating physical illness like one might treat mental illness.
| Imagine someone saying: | To a person who is: |
|---|---|
| “I don’t see that you’re even trying to get better!” | Having coffee-ground emesis |
| “Well, staying in bed all the time is not helping, is there something else you could do?” | In traction for pelvic fracture |
| “Aren’t you afraid that medicine is changing the real you?” | Injecting their insulin |
| “I understand that you have this infection, but could you just do a little more to help yourself?” | Hospitalized for severe sepsis with fever |
| “Look, just don’t give in to this problem!” | Diagnosed with inoperable brain cancer |
Based on limited specialized clinical education in nursing programs, the next concern may be that nurses new to the specialty of PMH may wonder what there is to do for the clients. Talking with the client may happen when the work is done in medical settings, but in the mental health setting, talking with the clientis the work. Some nurses may feel at a loss without their own props of stethoscope, alcohol wipes, hemostat clamps, marking pens, or IV start kits. It can be a transition for the nurse to conceptualize self as the instrument.
Psychopharmacology may pose another learning curve for the nurse new to mental health care. Medications are one of the essential components of treatment, and it is critical for the PMH nurse to become familiar with medication indications and potential side effects.
The Professional Nurse as Milieu Manager
The milieu is the treatment area, a safe place created to promote coping, relationships, and recovery. The psychiatric-mental health nurse is the milieu manager, meaning they are in charge of the therapeutic value of the environment. This may be as literal as the placement of furniture or the volume of the television, or as conceptual as the attitudes of the staff. The professional nurse must be physically present in the treatment area, rounding, interacting, teaching, observing, and role modeling.
Link to Learning
View the ANA’s Principles for Delegation for nurses, which includes a decision tree for delegation decisions.
Delegation and supervision are components of the professional nurse role in most all settings. In mental health treatment, nursing staff may be composed of the RN, LPN/LVN, and mental health worker or unlicensed assistive personnel, as well as clerical workers. Delegation guidelines apply for the professional nurse as outlined in state Nurse Practice Acts and by the American Nurses Association (ANA), which acknowledges that evolving health-care expectations require professional vigilance.
Link to Learning
The NCSBN and ANA’s National Guidelines for Nursing Delegation detail the licensed nurse’s responsibilities as well as responsibilities of the delegate (the one to whom duties are assigned).
Professional Boundaries
Professional boundaries are the guidelines that frame the therapeutic relationship, and they are particularly important considerations in PMH nursing. Nurses recognize the significance of this as distinct from a social relationship. Professional boundaries set the limits of the relationship so that it remains focused on the client’s needs. Self-disclosure from the nurse is used at a minimum to show the nurse’s familiarity with the client’s concerns, such as in acknowledging frustration with decision-making, though this is redirected back to the client, for example, “I did struggle with school. What’s it been like for you?” Nurses should seek peer feedback and mentoring to enhance skills and awareness in setting and maintaining professional boundaries.
Link to Learning
Review A Nurse’s Guide to Professional Boundaries published by the National Council of State Boards of Nursing for important information on maintaining professional boundaries.
Challenges in Scope of Practice
In all care settings, nurses must provide holistic care. The person in care for a medical illness has psychosocial needs and the person in care for mental health has physiological needs. A phenomenon of clinical bias called diagnostic overshadowing may occur in mental health treatment when symptoms are attributed to the psychiatric diagnosis and medical comorbidities are missed, increasing mortality for these clients (Hallyburton, 2022).
Nurses may struggle to keep a focus on the physiological stability of the client in mental health care, such as hydration, nutrition, sleep, and activity. Ongoing medical conditions, such as diabetes, cancer, or heart disease require the nurse’s surveillance. A person in mental health crisis may lose the ability to self-monitor for medical conditions.
Research by Joubert and Bhagwan (2018) found other challenges in mental health nursing to be denial of diagnosis by clients, clients’ refusal of medications, and clients’ unpredictable behaviors. Nurses experienced frustration with clients’ aggression and expressed need for ongoing skills support. Leaders in nursing education are called to incorporate curriculum revisions to capture these challenges before and as they arise (Joubert & Bhagwan, 2018).
Treatments provided through measures that prevent client control and autonomy, coercive measures, were worrisome to PMH nurses, according to research by Manderius et al. (2023). Coercive measures may begin with involuntary hospitalization within legal guidelines. Nurses identify difficulty with upholding the ethical principles of dignity and autonomy in client care, as well as the concept of do no harm, wherein interventions may be withheld if harm ensues. For instance, nurses may use seclusion (involuntary confinement to a secured area), though considered a restrictive intervention. The most restrictive intervention, restraint, entails applying devices to restrict the person’s physical movement; nurses can use restraints when the client is self-injuring or a threat to others. Seclusion and restraint are to be utilized for the minimal time with a provider’s order and should be combined with medication administration and supportive nursing interaction. Table 13.3 lists nursing strategies to address identified ethical concerns (Manderius et al., 2023).
| Ethical Concerns | Nursing Strategies |
|---|---|
| Imbalance of power, client vulnerability | Guard physical exposure, manage environment, select staff members to participate. |
| Client autonomy | Promote advance directives on admission. Prior to the need, discuss preferences for calming, and inquire as to measures that have been effective in the past for stress or during a crisis. |
| Seclusion and restraint | Monitor client status, use preventative interventions, such as comfort measures, oral medications, and exercise. If client is able, allow client to select site for injection and who may administer. Stay with or near client for support. Ensure opportunity for client to express feelings after the restrictive intervention. Offer praise for client’s ability to regain control. |
| Nurses’ feelings of isolation in ethical decision-making | Departmental and organizational awareness of nurses’ ethical concerns. Leaders to inquire during staff meetings and employee evaluations. Leaders to routinely solicit nurses’ suggestions for effective interventions. Leaders to institute ethics rounds or ethics in-service opportunities and support group activities for nurses. |
Delegation and Supervision Issues
The RN (registered nurse) to LPN/LVN (licensed practical/vocational nurse) relationship functions well in most PMH settings. Medication administration is such an important aspect of mental health care and the LPN/LVN is frequently assigned in this role. The role of nursing assistants in mental health care, however, was found by Roche et al. (2021) to lack standardization and differ across settings. Noted is the impact on RN workload for supervision and the need for identification of outcomes of care delivered by nursing assistant staff in mental health settings.
Similarly, Wilson et al. (2023) conducted a scoping review of delegation practice and found a knowledge gap in client outcomes. This research cited a professional implication of delegation decisions made at the service level, which was, in effect, reassignment of nursing duties and not true delegation.
In hospital, care center, and treatment facility settings, the nursing workforce hierarchy defines roles and relationships. This is generally intended to support decision-making for collaboration between team members, meaning that expertise at every level is appropriately and effectively applied. The workplace culture should be one of collaboration toward safe client care with staff members at all levels encouraged to contribute to safety and quality.
A hierarchy that feels more oriented toward power, with rigid, disrespectful, or dismissive interactions between levels of staff, can negatively impact communication. This may have the effects of increasing risk and compromising safety, decision-making, and staff engagement overall.
According to the Joint Statement of the NCSBN and the ANA (2019), delegation is an essential skill. Registered nurses in leadership roles may delegate to other RNs. LPN/LVNs are under the direction and delegation of the RN. LPN/LVN staff may provide direction and supervision to UAP (unlicensed assistive personnel, who may be titled mental health workers or psychiatric technicians, or be certified nursing assistants). UAP do not have delegation authority.
Delegation is appropriate when the direction fits the scope of practice. For example, the UAP may be directed to provide basic hygiene for a stable client or monitor clients on routine safety rounds. The LPN/LVN may be assigned blood glucose monitoring and ordered insulin administration with report to the RN. RNs may perform all client care, though they are best able to manage unstable clients, admissions, discharges and transfers, and collaborate with medical providers if a functional team of nursing staff is in place. Delegation is inappropriate when UAP are assigned to determine treatment decisions, for example, moving clients to restrictive care, or when LPN/LVN are asked to independently revise the client’s plan of care.
Professional Burnout, Incivility, and Stress
Kanitha and Naik (2021) surveyed fifty nurses and found almost all had experienced incivility (disrespectful or offensive behaviors) on the job. Moreover, Dall’Ora et al. (2020) noted that job stressors of work intensity and workload, extended work shifts, inadequate staffing, and nurses’ inability to influence these issues resulted in burnout, which is a psychological phenomenon characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment related to one’s work. The ANA acknowledges workplace stressors and calls for system-level mental health promotion for nurses. Melnyk et al. (2021) specifically endorse:
- creation of more positive work environments
- creation of more positive learning environments
- reduction of administrative burden for working nurses
- provision of technology solutions and support
- investment in nursing research