Learning Objectives
By the end of this section, you will be able to:
- Define the nursing process in psychiatric-mental health care
- Use the nursing process to plan nursing care for a client with a mental health problem
Psychiatric-mental health nurse theorist and educator Ida Jean Orlando is credited with development of the nursing process in 1958 (Toney-Butler & Thayer, 2023); the nursing process is a decision-making method based in science and, just as importantly, in the art of psychiatric-mental health nursing. Specific to mental health care, nurses bring factual data and research evidence to clinical reasoning developed within the therapeutic relationship with recipients of nursing care.
The nursing process incorporates deliberate measures and actions to resolve health-care problems identified in partnership with the client. The client’s need for support determines the level of nursing involvement. The nursing process is dynamic, continues through all of the phases of the therapeutic relationship, and strives for client stability, remission, recovery, and self-care.
The Nursing Process in Psychiatric-Mental Health Care
The nursing process is a decision-making model for client care in every setting. Nurses make assessments: recognizing and prioritizing cues from the client interview and examination and from the client’s medical record, and utilizing critical thinking, a cognitive process that is learned academically and experientially on the continuum of nursing practice. Nurses then formulate hypotheses about the causes of the client’s health problem/need with proposed solutions in order of priority. Nurses then take action to resolve the identified problems and evaluate these actions for effectiveness. Actions partially effective or not effective require revision.
The therapeutic relationship, also known as nurse-client relationship, helping relationship, or therapeutic alliance, establishes nursing practice within the therapeutic environment. The therapeutic environment comprises the safe physical location, such as a hospital, clinic, or home, and the supportive conditions within that location. Within the therapeutic environment, practitioners define mental health problems and begin the process toward resolution. The therapeutic relationship is structured by the nurse to benefit the client and is time-limited, meaning that the nurse owes a duty to the client during the time they are working together. This duty comprises the promotion of health and safety.
The relationship is not a social one; it is conducted within professional guidelines and is continually evaluated by the nurse through reflection upon their practice (Figure 28.2). Reflection utilizes feedback from peers and mentors, and includes personal examination of one’s own actions and experience. Level of client participation in the relationship varies with the client’s health state.
The science in the process includes analysis of data collected by assessment and observation, which means leading the nurse to hypothesize causes, priorities, and solutions. Considering risks and benefits of available resources, the client’s ability to participate, and the nurse’s own skill and experience, the team formulates a plan of care. Decision-making from use of critical thinking in the nursing process is described as clinical judgment (Hughes, 2008). Clinical judgment utilizes five repeating components of the nursing process:
- assessment, recognizing cues
- analysis, interpreting cues, setting client-specific priorities
- planning, generating solutions/goals with client’s input
- implementation, taking action, nursing interventions
- evaluation, determining outcomes as effective or revising the plan
The process is ongoing and flexible throughout the therapeutic relationship, adapting to client needs and focused on outcomes of care. It is important to recognize risks early in the process and to evaluate plans of care continually for effectiveness. The plan of care is shared with other professionals who collaborate in the interdisciplinary team care planning process, which is a meeting of the client and those involved in the client’s care, and may include the family members.
Link to Learning
Access “Clinical reasoning: What do nurses, physicians, and students reason about?” to read insights into interprofessional collaboration in practice through interviews with nurses and nursing students, physicians, and medical students.
Assessment in Mental Health Nursing
The first step, assessment, is the collection of available data to inform care planning. Assessment in nursing is important to identify problems and develop a plan of care. Nursing Assessment and Clinical Tools addresses physical assessment for the PMH client, and Nursing Assessment and Care Plans covers use of the mental status exam.
Psychiatric-mental health nurses specifically assess clients by observing behaviors, interviewing and interacting with the client, and reviewing the health record. This process of gathering data is important in determining what the priority problems are and being able to move to the next step in the nursing process. The nurse might observe the client pacing in the hallway and ask about anxiety. They might ask about thoughts of self-harm and also look for any physical injuries. The data they collect during the assessment drives their analyses and implementation of their plans. Basic observation means taking notice of information or events, reporting them, and synthesizing the information to identify priority problems. The professional nurse recognizes cues found in observation to determine actual and potential problems. The nurse analyzes these cues to actively formulate the nursing plan of care.
Data and cues collected during assessment fall into different categories: objective, subjective, primary, and secondary. Objective data is what the nurse obtains through their abilities and senses. Nurses may see the client’s attire, listen to the client’s lung sounds, or detect a client’s hand tremor by touch during physical assessment. Sources of objective data include use of screening tools or checklists, visual observation and monitoring, or measuring vital signs. Statistical reports, such as laboratory and diagnostic testing results, constitute objective data.
Subjective data is what the client shows or says. Subjective data is obtained from the client’s expressions, whether verbal or nonverbal. Nurses may listen to client comments or notice that the client has been crying. When eliciting subjective information, the nurse must be culturally sensitive (see Cultural Considerations). Expressions, body language, and emotions should not be interpreted through a lens of the nurse’s own experience or beliefs. In order to interpret subjective data, the nurse should ask open-ended questions that do not lead the client, such as, “How can we best help you while you are here?” or “Are there customs you would like to keep or members of your family you would like involved in your care?” Sources of subjective data include use of appropriate questionnaires, interviews, or screening tools; therapeutic groups; clients’ written expressions, compositions, or artwork; and the interaction between nurse and client during one-on-one time.
Primary data is collected directly from the client by the nurse. Any information shared with, or witnessed by, the nurse from the client is primary data, so this information may be objective or subjective in nature. When clients answer the nurse’s questions or are withdrawn from interaction, these are both sources of primary data. During transfer of care, the offgoing nurse provides primary data.
Secondary data is collected or expressed by another and reviewed by the nurse. Information about the client is secondary data, such as family reports, medical records, and clinical documentation by other professionals. Secondary data may be objective or subjective in nature, for example, a discharge summary from another facility or a family member’s opinion. During transfer of care, the oncoming nurse receives secondary data and will go on to collect their own primary data.
All data collection in nursing assessment is to be done without bias and this may be a learned skill for some nurses. Without personal reflection, the nurse may draw automatic conclusions from client data that may be inaccurate. Some client behaviors, perspectives, or histories may provoke emotional responses in the nurse, which can influence the therapeutic relationship. Collaboration with colleagues of diverse backgrounds may be helpful, as may the guidance of a mentor. Every nurse should continually work to increase their self-awareness in client care.
Analysis in Mental Health Nursing
After completing the assessment and data collection, the nurse analyzes the information to partner with the client to make a determination of what the client’s problem or level of risk may be. Together, they identify the client’s strengths, such as motivation, physical health, or family support. As mentioned, the nurse approaches all client interaction and assessment with cultural sensitivity.
This type of analysis entails critically examining the meaning of identified cues that inform the nurse on necessary levels of support for the client. For example, if the nurse assesses the client’s mood as sad and observes they are tearful and the client verbalizes suicidal thoughts, the nurse would analyze this information to determine the client is at risk for suicide. This problem, or risk, will then focus the care planning and interventions. Analysis also requires prioritizing client problems and needs and creating nursing hypotheses. Partnership with the client is essential to the process because this therapeutic alliance enhances outcomes for the client.
The nurse prioritizes the urgency of identified problems and needs. For example, a client with suicidal ideation who has lost their employment has a safety need at a higher level than the social/economic need to be reemployed (though this need is to be acknowledged). To prioritize client needs, the nurse utilizes clinical judgment. This requires the nurse to construct clinical questions and create answers by analyzing assessment data. Again, partnership with the client is part of this process, which means that the nurse establishes trust with the client (and family, as indicated) and invites their participation in prioritizing the challenges presented. The nurse shares information that is relevant to the client’s care or status, and the nurse acknowledges the client as the expert on self.
Nurses may use established models to prioritize care, such as Maslow’s Hierarchy of Needs, wherein a client with panic due to an asthma attack would need respiratory support first. This is an example of prioritizing physiological needs over safety needs, though the client’s feeling of anxiety would be addressed immediately upon physical stabilization. Another consideration in prioritization is the concept of life-saving, health-saving, and health-promoting, which would prioritize interventions for blood loss, for instance, over intent for self-injury, over long-term recovery. Nurses must nevertheless remain aware of the importance to the client of all problems and needs.
Nurses should also remain self-aware for potentially inappropriate focus on tasks to complete quickly and successfully, at the expense of missing the need for more complex interventions. For example, the nurse may be more likely to first obtain and document vital signs because these tasks are easy to complete. If the client has stated a clear intent for self-harm, however, exploring the existence of a self-harm plan would take priority over obtaining the vital signs. Ultimate outcomes of care must address all aspects of clients’ well-being.
Identifying client strengths helps to build a relationship where the nurse shares the power with the client. Identification of client strengths, abilities, and available resources also extends the helping relationship toward the client’s independence. Further, this action informs nursing interventions, for example, providing printed material for clients at their reading literacy level and in their primary language, encouraging connection with community supports, or verbalizing positive feedback for a client’s efforts.
Planning in Mental Health Nursing
The next step, planning, is the cognitive process of generating solutions to identified problems, setting goals of treatment, and developing nursing interventions to accomplish these objectives. Health-care knowledge and research changes and evolves rapidly.
One part of planning is developing a nursing diagnosis. The North American Nursing Diagnosis Association developed a classification system for nursing diagnosis terminology. The organization still exists as NANDA International (NANDA-I). Rodríguez-Suárez et al. (2023) acknowledge some uncertainty of the effectiveness of this taxonomy, asserting that further research is indicated to determine current relevance to population health and health promotion.
Link to Learning
See this sample NANDA-I Diagnoses table on the National Library of Medicine website.
Another part of planning is remaining up to date on current best evidence for client care and using that evidence to inform interventions. The American Nurses Association (ANA) (2023) emphasizes nurses’ use of current scientific knowledge over tradition or nurses’ preference for client care. This approach permits the inclusion of evolving health-care knowledge (ANA, 2023). The term evidence-based practice (EBP) refers to the intersection of formal research findings, nursing competency, and the preferences of the client and family (Figure 28.3). These factors are all considered when planning client care.
In addition to evidence-based practice, health-care organizations have policies to guide procedures. These policies may be based on scientific information from pharmaceutical companies and medical research, legal aspects of data management, government safety regulations, and the organization’s mission and code of ethics. When nurses plan client care, such policies can be a source of information. Kelly et al. (2021) found little evidence to support nurses’ routine use of organizational policies, despite the policies’ proposed intent of safe practice. Over 200 direct care nurses were surveyed as to their use of policies for clinical guidance in the study. The time away from client care to review policies was cited as one reason nurses did not consult policies more frequently. The authors recommend organizational efforts to streamline and update policies to address these barriers (Kelly et al., 2021).
Nursing competency refers to the skill level of the nurse and to the skill level of any others to whom the nurse may delegate. Competency also includes consulting available mentors, preceptors, and other professionals. This consideration will enable the nurse to plan care that is safe and effective and utilize appropriate resources, such as making referrals or requesting assistance with procedures or decision-making.
Respect for client preferences is key and includes cultural considerations. The client’s engagement in treatment enhances success of the plan of care. The nurse encourages the client to express their values and beliefs and participate in goal-setting throughout the care planning process. The nurse can pose relevant queries such as, “How can we assist you from a spiritual or cultural perspective?” or “How do you see your family’s involvement in your care?”
Link to Learning
The Agency for Healthcare Research and Quality provides a Health Literacy Universal Precautions Toolkit. Guidance for considering culture, customs, and beliefs in health care is their tool #10.
Goal-Setting and Implementation in Mental Health Nursing
Goal-setting is a collaborative process with the client that entails formulating interventions customized to accomplish specific goals of treatment, or to avoid risks (NCSBN, 2019a). The step of implementation is the nursing action of putting the items from the plan of care into effect. Implementation may be through delegation, as appropriate, and may involve other members of the client’s treatment team. The nurse takes therapeutic action to implement solutions addressing the highest priority needs/problems first. These actions are interventions based on nursing knowledge, with goals planned to promote, maintain, or restore a client’s health. All aspects of the implementation phase involve team collaboration and nursing documentation.
A client may be working with the nurse on stress management, for example. In partnership with the client, the nurse develops stress-reduction strategies that include prescribed short-term use of anxiolytic medication, mindfulness exercises, and dietary modifications. The nurse must establish rationales for the interventions to provide a scientific basis and support the plan. During implementation, the nurse conducts health teaching and monitoring, and the client reports their experiences. For example, the nurse sets goals for care as: the client will teach back information about prescribed medication by (date); client will practice mindfulness exercises daily by (date); and client will verbalize a diet plan by (date). The client approves the plan, or suggests changes, and the nurse and client work together to accomplish the goals within the time frame.
Evaluation in Mental Health Nursing
Measurable responses to interventions utilized during the implementation phase of nursing care planning are called outcomes of care. The next step in the nursing process, evaluation, is the process of reviewing these outcomes of care for effectiveness, as defined by the nurse and the client together. Goals may be described as met, partially met, or unmet.
Met goals result in the client’s stability, improved functional capacity, safety and recovery, and client satisfaction with the outcome. Evaluations where goals are met include, for example, intended effects of medication, management of medication side effects, or client’s report of reduced anxiety.
Partially met goals may include client sleeps four hours each night with goal of six hours or client is able to speak with family member on the telephone with goal of client and family member face-to-face therapy session. If goals are partially met, the nurse and client should review the plan to determine if interventions need to be altered.
Unmet goals may include client being uncomfortable due to side effects of newly prescribed medication or client reporting inability to sleep. Unmet goals call for modification or revision of the plan. Goals may be considered partially met or unmet if not reached within the established time frame.
Use of the Nursing Process throughout the Therapeutic Relationship
The process of nursing care may occur over acute or extended-time situations, but no matter the situation, the nurse must continually apply clinical judgment. The therapeutic relationship has no mandated time frame. It covers the time nurses and clients work together, whether over moments or months. To review the phases of the therapeutic relationship, in the preorientation phase, the nurse learns about the client and prepares for the interaction. During orientation, the nurse establishes rapport with the client and sets the expected time frame (“During your stay here,” or “As long as you are seen in this clinic”) so the client knows what to expect. Working is the active phase where the nurse and client implement the plan of care. Termination brings the relationship to an end; the nurse and client mutually review their work together.
As nurses develop expertise and are exposed to more client care situations, they refine the cognitive components of care planning, enabling them to adapt the plans to client needs and available resources. Planning should always be individualized, include all steps of the process, and not become mechanical or habitual. This is the meaning of person-centered care, when the client is the focused recipient of nursing care.
Expert nurses who manage client care situations are not resorting to default actions. They are using clinical judgment that incorporates learned pattern recognition, rapid response abilities, and wisdom. Consider these two examples. In a crisis with a client experiencing psychosis, the nurse manages the situation within an hour. By contrast, a nurse and client working together in a community setting may review the client’s employment prospects and discuss strategies for success over scheduled weekly interactions. The similarity in these two scenarios is that the nurse uses clinical judgment to plan problem-based care. The difference is that this planning can occur in moments or over time.
Clinical Judgment Measurement Model
Sample Care Plans: Acute Time Frame and Extended Time Frame
| Sample Care Plan—Acute Time Frame | Clinical Judgment for Nursing Plan of Care (Involve client/family throughout the process.) |
Sample Care Plan—Extended Time Frame |
|---|---|---|
| Objective Data: attempting to push through window, striking with fists Subjective Data: shouting, responding to internal stimuli Primary Data: not responding to verbal redirection Secondary Data: nurse reported earlier refusal of medication |
Recognizing Cues—from all assessment data: objective, subjective, primary, and secondary data | Objective Data: presents to clinic appointment with several job applications, mild anxiety Subjective Data: “I’m not sure which one I’d be good at,” client states their medication causes drowsiness Primary Data: answers nurse’s questions about personal goals for employment Secondary Data: nurse reviews copy of client’s most recent job performance review, which cites client attendance as concern; client has history of alcohol use disorder |
| Danger to self, panic, disconnected from reality Schizophrenia diagnosis with paranoia, young adult, history of adverse childhood events |
Analyzing Cues—possible meaning of signs and symptoms, significance of medical and psychosocial history, age, culture, risk factors | Possible continued alcohol use, decreased self-esteem, possible medication side effects, unemployed adult |
| Safety is priority, reduction of stimuli, internal and external, reduction of anxiety; manage environment; manage client recovery from acute episode; reintroduce into community | Prioritizing Problems/Needs—name problems in priority order (use a prioritization model) | Substance use may be priority, promote self-esteem; investigate medication effects; refer for social services |
| Emergency medication administration Remove from community Manage environment Establish trust Avoid additional stressors |
Generating Solutions/Goal Setting—develop specific strategies to improve client’s condition, or reduce risk | Arrange referrals as indicated Use therapeutic relationship to increase self-esteem Collaborate with prescriber |
| Administer injection per order now, assist to quiet room on 1:1 observation by camera and staff now × 1 hour, assure as to safety throughout process, explain procedures in brief and repeat as needed | Taking Actions—outline independent, dependent, delegated, or collaborative interventions to resolve identified problems; set a measure and a time frame | Conduct screening assessment for alcohol use this visit, refer as indicated; provide feedback, offer support, provide medication teaching this visit, schedule appointment with prescriber; connect with employment assistance |
| Goals partially met, client resting in quiet room on 1:1 observation, anxiety moderate, remains preoccupied with internal stimuli, continue with oral medication per schedule and anxiety reduction measures as needed, ongoing nursing assessment | Evaluating Outcomes—determine if goals are met, partially met, or unmet; if met, move to next priority plan; if partially met, review plan for change; if unmet, revise plan | Goals partially met, client takes responsibility for alcohol use though expresses reluctance to return to counselor, agrees medication dose could be taken in the evening, accepts appointment with prescriber, schedules next clinic appointment for ongoing care |
| Working phase Termination phase at transfer of care |
Connection to Therapeutic Relationship | Working phase Termination phase at discharge from clinic |
Referring to the two care plan scenarios just described, the nurse-client relationship may terminate when the nurse’s assignment ends or when the client is discharged from care. The nursing process is ongoing through the point at which other professionals assume care or the client is no longer utilizing the service.
Continuous monitoring is a concept in nursing care in general, such as vital signs or physical assessments every four hours or hourly rounding. This is because clients’ conditions can change and then the nurse’s plan of care will change. This real-life complexity is now portrayed in questions on the next generation style testing on the National Council Licensure Examination (NCLEX), which began in 2023. These questions offer scenarios and unfolding case studies to better replicate actual nursing practice.