Nursing Process and Standards of Care Quiz

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Questions and Answers

Which of the following are components of the nursing process?

Assessing (correct)

Diagnosing (correct)

Implementing (correct)

Evaluating (correct)

Planning (correct)

Patient-centered care recognizes the healthcare provider as the source of control.

False

What does EBP stand for?

Evidence-based practice

The acronym ADPIE stands for Assessing, Diagnosing, Planning, Implementing, and ______.

Evaluating Signup and view all the answers

What is the primary source of data in patient-centered care?

The patient Signup and view all the answers

What are the steps of assessment in psychiatric mental health nursing?

Establish rapport, understand current problems, review physical status, assess risk factors, perform mental status exam, assess psychosocial status, identify goals, formulate plan, document. Signup and view all the answers

Which term on an assessment is broader?

Spirituality Signup and view all the answers

A nurse's understanding of the initial action associated with assessing a patient's spiritual beliefs includes ______.

asking the patient what role spirituality plays in their daily life Signup and view all the answers

What standardized rating scale should be included for a patient with major depressive disorder?

Beck Inventory Signup and view all the answers

Transference refers to the nurse displacing feelings related to significant figures in their past onto the patient.

False Signup and view all the answers

What does the acronym SOAPIE stand for in nursing documentation?

Subjective, Objective, Assessment, Plan, Intervention, Evaluation Signup and view all the answers

Which of the following are phases of group development? (Select all that apply)

Termination Phase Signup and view all the answers

A Heterogeneous group has members that share central traits.

False Signup and view all the answers

What role does an Energizer play in group participation?

Gives examples and follows up the meaning of ideas. Signup and view all the answers

The ______ phase is when feedback can be resolicited periodically during the life of the group.

Evaluation & follow up Signup and view all the answers

Which leadership style supports extensive group interaction in problem solving?

Democratic Leader Signup and view all the answers

Which ethical principle involves the duty to act to benefit or promote the health and well-being of others?

Beneficence Signup and view all the answers

What question is helpful in managing a monopolizing member of a group?

Who else would like to share feelings about this issue? Signup and view all the answers

Informed consent is an ethical issue for group therapy.

True Signup and view all the answers

What is not an appropriate action for handling a silent member?

Ignoring them completely. Signup and view all the answers

Which of the following is a role function example of an Encourager?

Encourages the group to make decisions. Signup and view all the answers

Match the following leadership styles with their characteristics:

Autocratic Leader = Exerts control over the group Democratic Leader = Supports extensive group interaction Laissez-Faire Leader = Allows members to behave freely Signup and view all the answers

Voluntary commitment determines a patient's ability to make informed decisions.

False Signup and view all the answers

What must be established for involuntary admission?

Diagnosed mental illness Signup and view all the answers

What is the primary purpose of involuntary emergency commitment?

Observation, diagnosis, and treatment of patients at risk of hurting themselves or others. Signup and view all the answers

Which of the following is NOT a patient's right?

Right to be subjected to lobotomies Signup and view all the answers

The term for a patient’s right to challenge unlawful detention is called a ______.

writ of habeas corpus Signup and view all the answers

What is required for conditional discharge?

Outpatient treatment for a specific time Signup and view all the answers

Patients have the right to refuse treatment in all circumstances.

False Signup and view all the answers

What must a patient be informed of to give informed consent?

The nature of the condition, proposed treatment, risks and benefits, alternative options, and probability of success. Signup and view all the answers

Match the following types of torts with their definitions:

Intentional Tort = Willful acts violating another person's rights Unintentional Tort = Unintended acts causing injury or harm Negligence = Failure to take proper care in doing something Malpractice = Improper or negligent professional behavior Signup and view all the answers

Nurses can only document care after it is completed.

False Signup and view all the answers

Quality improvement in nursing aims to evaluate and ______ ways to improve healthcare.

improve Signup and view all the answers

Which response by the nurse demonstrates the existence of a therapeutic relationship?

Let's talk and see if you and I have any interests in common. Signup and view all the answers

Which patient outcome is directly associated with the goals of a therapeutic nurse-patient relationship?

Patient will engage in at least one social interaction with the unit population daily. Signup and view all the answers

What is the greatest trigger for the development of a patient's nurse-focused transference?

The degree of authority the nurse has over the patient. Signup and view all the answers

Which patient statement demonstrates a value held regarding children?

Nothing is more important to me than the safety of my children. Signup and view all the answers

Listening to Mary describe the problems, the nurse displays therapeutic communication in which response?

I understand you are in a difficult situation. Signup and view all the answers

Which nursing action describes attending behavior?

Sitting with the patient and taking cues for when to talk or when to remain silent. Signup and view all the answers

Which is the best initial response by the student when a male patient frequently inquires about her personal life?

She limits sharing personal information and stresses the patient-centered focus of the conversation. Signup and view all the answers

What should Morgan focus on after becoming tearful with a patient expressing sadness?

Using empathy to demonstrate respect and validation of the patient's feelings. Signup and view all the answers

Emily and Jenna's situation reflects:

Boundary blurring. Signup and view all the answers

Which statement made by the nurse demonstrates the best understanding of nonverbal communication?

When my patient responds to my question, I check for congruence between verbal and nonverbal communication to help validate the response. Signup and view all the answers

Which nursing statement is an example of reflection?

So you are saying that life has no meaning. Signup and view all the answers

When should a nurse be most alert to the possibility of communication errors resulting in harm to the patient?

Change of shift report. Signup and view all the answers

Which channels of information communication should the nurse monitor during an admission assessment?

Tactile Signup and view all the answers

What principle about nurse-patient communication should guide a nurse's fear about 'saying the wrong thing'?

Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation. Signup and view all the answers

Which response would be most therapeutic when a patient reports experiencing demons?

You seem upset. Please tell me more about what you experienced last night. Signup and view all the answers

Which technique is not considered therapeutic?

Asking 'why' questions Signup and view all the answers

How should Carolina respond when a patient prefers a therapy app over her appointments?

That sounds exciting, would you be willing to visit and show me the app? Signup and view all the answers

Which of the following phases is NOT part of group development?

Evaluation Phase Signup and view all the answers

What characterizes a heterogeneous group?

A range of differences among members Signup and view all the answers

What is the main function of an elaborator in group roles?

Gives examples and follows up the meaning of ideas Signup and view all the answers

A laissez-faire leader allows group members to behave in any way they choose.

True Signup and view all the answers

Which leadership style supports extensive group interaction?

Democratic Leader Signup and view all the answers

Which ethical principle involves respecting the rights of others to make their own decisions?

Autonomy Signup and view all the answers

What is the purpose of psycho-educational groups?

To provide members with the knowledge and skills to manage psychiatric symptoms Signup and view all the answers

The nurse's primary commitment is to the ______.

patient Signup and view all the answers

Which of the following indicates a potentially disruptive member?

A member who monopolizes the conversation Signup and view all the answers

What does the term 'veracity' refer to in bioethics?

The duty to communicate truthfully Signup and view all the answers

Which of the following is an example of a support group?

Grief Support Signup and view all the answers

What determines a patient's ability to make informed decisions in voluntary commitment?

It is not determined by voluntary commitment. Signup and view all the answers

What are the reasons for involuntary admission? (Select all that apply)

Posing a danger to self or others Signup and view all the answers

Involuntary emergency commitment requires a court hearing.

True Signup and view all the answers

Patients have the right to which of the following? (Select all that apply)

Privacy Signup and view all the answers

What can patients petition for if they believe their detention is unlawful?

Writ of habeas corpus Signup and view all the answers

What must patients be informed about for informed consent? (Select all that apply)

The nature of the problem Signup and view all the answers

The person must have a serious mental illness and lack the ability to make a __________ decision about treatment.

reasoned Signup and view all the answers

Name one of the elements to prove negligence.

Duty Signup and view all the answers

Match the following rights with their descriptions:

Right to treatment = Right to be free from excessive or unnecessary medication Right to refuse treatment = Only in emergency situations can institutions medicate the patient Right to informed consent = Patient is given basic information about treatment risks and benefits Right to confidentiality = Protected under HIPAA and includes exceptions for safety Signup and view all the answers

Medical staff have a duty to warn and protect third parties.

True Signup and view all the answers

What is the primary purpose of emergency admission?

Observation, diagnosis, and treatment of patients at risk of harm. Signup and view all the answers

Which of the following is a component of the nursing process?

All of the above Signup and view all the answers

What is the primary source of data during the assessment phase?

The patient Signup and view all the answers

Quality improvement in nursing involves using data to monitor outcomes.

True Signup and view all the answers

The acronym ADPIE stands for Assessing, Diagnosing, Planning, Implementing, and ______.

Evaluating Signup and view all the answers

What are the steps of assessment in psychiatric mental health nursing?

<ol> <li>Establish rapport 2. Understand current problems 3. Review physical status 4. Assess risk factors 5. Perform mental status examination 6. Assess psychosocial status 7. Identify mutual goals 8. Formulate a plan of care 9. Document data</li> </ol> Signup and view all the answers

What is one key aspect of patient-centered care?

Recognize the patient as a source of control Signup and view all the answers

What is the role of an interpreter in patient assessment?

An interpreter translates spoken language and assists in communication between the healthcare provider and the patient. Signup and view all the answers

Which nursing diagnosis would begin with the phrase 'at risk for'?

At risk for self-mutilation Signup and view all the answers

Match the nursing interventions to their descriptions:

Coordination of care = Facilitating the transfer of information between healthcare providers Health teaching = Educating patients about their condition and treatments Milieu therapy = Creating a safe and therapeutic environment Therapeutic relationship = Building trust and rapport with the patient Signup and view all the answers

Which intervention demonstrates a nurse's understanding of assessing a patient's spiritual beliefs?

Asking the patient what role spirituality plays in their life Signup and view all the answers

Countertransference involves a nurse displacing feelings related to significant figures onto the patient.

True Signup and view all the answers

Which assessment tool is used to evaluate a patient diagnosed with major depressive disorder?

Beck Inventory Signup and view all the answers

What constitutes the most important patient outcome for a nursing diagnosis of self-mutilation?

Refrain from self-harm Signup and view all the answers

Why is proper documentation in nursing crucial?

All of the above Signup and view all the answers

Which response by the nurse demonstrates the existence of a therapeutic relationship?

Let's talk and see if you and I have any interests in common. Signup and view all the answers

Which patient outcome is directly associated with the goals of a therapeutic nurse-patient relationship?

Patient will engage in at least one social interaction with the unit population daily. Signup and view all the answers

What is the greatest trigger for the development of a patient's nurse-focused transference?

The degree of authority the nurse has over the patient Signup and view all the answers

Which patient statement demonstrates a value held regarding children?

Nothing is more important to me than the safety of my children. Signup and view all the answers

Listening to Mary describe her problems, which response by the nurse displays therapeutic communication?

I understand you are in a difficult situation. Signup and view all the answers

Which nursing action describes attending behavior for a patient grieving?

Sitting with the patient and taking cues for when to talk or when to remain silent Signup and view all the answers

Which is the best initial response by the student nurse when a male patient frequently inquires about her personal life?

She limits sharing personal information and stresses the patient-centered focus of the conversation. Signup and view all the answers

What should Morgan focus on instead of showing sympathy during her interaction with an older patient?

Using empathy to demonstrate respect and validation of the patient's feelings Signup and view all the answers

What does the situation between Emily and Jenna reflect when they discuss meeting after discharge?

Boundary blurring Signup and view all the answers

Which statement made by the nurse demonstrates the best understanding of nonverbal communication?

When my patient responds to my question, I check for congruence between verbal and nonverbal communication to help validate the response. Signup and view all the answers

Which nursing statement is an example of reflection?

So you are saying that life has no meaning. Signup and view all the answers

When should a nurse be most alert to the possibility of communication errors that could harm the patient?

Change of shift report Signup and view all the answers

During an admission assessment, which channels of communication should the nurse be monitoring? Select all that apply.

Visual Signup and view all the answers

Which principle about nurse-patient communication should guide a nurse's fear about saying the wrong thing?

Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation. Signup and view all the answers

Which response would most likely be therapeutic when a patient expresses anxiety about meeting a new psychiatrist?

You say you look forward to the meeting, but you appear anxious or unhappy. Signup and view all the answers

Which student behavior is consistent with therapeutic communication?

Summarizing the essence of the patient's comments in your own words. Signup and view all the answers

Which response would be most therapeutic when a patient reports experiencing demons?

You seem upset. Please tell me more about what you experienced last night. Signup and view all the answers

Which of the following techniques is not considered therapeutic?

Asking 'why' questions Signup and view all the answers

How should Carolina respond when her patient prefers a therapy app over regular sessions?

That sounds exciting, would you be willing to visit and show me the app? Signup and view all the answers

Study Notes

The Nursing Process and Standards of Care

ADPIE is a standardized framework for the nursing process, which comprises: Assessing, Diagnosing, Planning, Implementing, and Evaluating.
Assessing involves collecting patient information, reviewing history, examining physical signs, and evaluating mental status.
Diagnosing identifies the patient's problems, their cause, and provides supporting data.
Planning sets specific, achievable goals and creates plans to achieve outcomes.
Implementing involves carrying out interventions based on the care plan.
Evaluating assesses the effectiveness of interventions, monitors progress toward goals, and modifies plans accordingly.
Quality and Safety Education for Nurses (QSEN) competencies focus on patient-centered care, quality improvement, safety, informatics, teamwork and collaboration, and evidence-based practice.

Therapeutic Relationships

Patient-centered care is a fundamental element of therapeutic relationships and focuses on respecting patient's preferences, values, and needs.
Therapeutic relationships are specifically focused on the patient's needs and problems, unlike personal ones which may be driven by mutual needs.
Overinvolvement can compromise therapeutic relationships and includes boundary crossing, boundary violations, and professional misconduct.
Transference is when a patient unconsciously projects feelings and behaviors from past relationships onto the nurse.
Countertransference is when a nurse unconsciously projects their feelings from past relationships onto the patient.

Peplau's Model of Nurse/Patient Relationship

The Preorientation Phase involves preparing for the interaction, reviewing patient information, and anticipating potential issues.
The Orientation Phase includes introductions, establishing rapport, outlining confidentiality, and specifying the relationship's parameters.
The Working Phase focuses on Gathering Data, identifying problem-solving skills, facilitating self-esteem, providing education, and evaluating progress.
The Termination Phase includes summarizing achievements, reviewing education, discussing coping strategies, exchanging memories, and facilitating closure.

Key Factors in Therapeutic Relationships

Genuineness is characterized by honesty, authenticity, and openness.
Empathy involves understanding the patient's perspective and feelings.
Positive regard signifies the nurse's respect, care, and worthiness towards the patient.

Critical Thinking and Documentation

Documentation is crucial in mental health settings as it serves as a legal record, aids in continuity of care, and supports reimbursement.
SOAPIE format is a common documentation method, which encompasses: Subjective data, Objective data, Assessment, Plan, Interventions, and Evaluation.

Therapeutic Communication

Focus: Patient-centered, goal-directed, and scientifically based.
Benefits: Increased feelings of safety, satisfaction with care, recovery rates, and treatment adherence.
Theoretical Models of Communication
- Communicator: Sender and receiver, roles are fluid, interdependent
- Message: Content and ideas, relational, communicated verbally and nonverbally
- Channel: Method of communication (e.g., spoken words, written text)
- Feedback: Constant exchange of information between communicators
- Encoding/Decoding: Individuals develop (encode) messages and determine (decode) the meaning of received messages.
- Context: Influences interactions
  - Social Context: Rules or norms that guide communication.
  - Relational Context: Interpersonal history and type of relationship.
  - Cultural Context: Influences from culture, gender, race, ethnicity, nationality, sexual orientation, socioeconomic class
- Noise: Factors that interfere with communication
  - Physical Noise: Loud units, background music.
  - Physiological Noise: Biological factors, such as headache, illness, fatigue.
  - Psychosocial Noise: Preoccupation or unwillingness to communicate.
Peplau's Interpersonal Theory
- Guiding Principles:
  - Clarity: Ensuring accurate message reception.
  - Continuity: Connecting ideas, feelings, events, and themes.
Factors Affecting Communication:
- Personal Factors: Depression, cognition, language, cultural barriers.
- Environmental Factors: Background noise, setting, privacy, seating.
- Relationship Factors: Levels of equality in the relationship.
Verbal Communication: Spoken words conveying beliefs, values, perceptions, and meaning.
Nonverbal Communication: Tone of voice, emphasis, physical appearance, facial expressions, body posture, eye contact, hand gestures, proximity.
Interaction of Verbal and Nonverbal Communication:
- Nonverbal behavior often reveals more than spoken words.
- Double-bind messages can be confusing and contradictory.
Communication Skills for Nurses:
- Using silence.
- Active listening.
- Clarifying techniques.
- Paraphrasing.
- Restating.
- Reflecting.
- Exploring.
Therapeutic Communication Questions:
- Open-ended: To elicit experiences, perceptions, and responses.
- Close-ended: To gather specific information.
- Projective: "What if" questions to help patients articulate thoughts and feelings.
- The miracle question: To help patients imagine a future without the problem.
Non-therapeutic Communication Techniques:
- Excessive questioning.
- Giving approval or disapproval.
- Giving advice.
- Asking "why" questions.

Cultural Considerations

Telecommunication Technologies: Telehealth, video health, internet sources, phone consultations, image transmission, interactive video sessions.
Mobile Applications: Monitoring, diagnosing, treating, and communicating with patients.
Concerns of Technology Communication:
- Privacy and confidentiality.
- Lack of data for efficacy.
- Liability issues.
- Need for further research and professional/ethical guidelines.

Preparing for the Clinical Patient Interview

Pace: Allow patient to set the pace.
Setting: Ensure a safe and comfortable environment.
Introductions: Begin with welcoming questions.

Tactics to Avoid

Arguing, minimizing, or challenging the patient.
Giving false reassurance.
Interpreting or speculating.
Probing sensitive areas.
Trying to steer the patient towards acceptance of treatment.
Joining in attacks on others.
Participating in criticizing other staff members.

Behaviors that Support Counseling

Kinesics Communication: Nonverbal communication through body language.
Vocal Quality: Paralanguage (e.g., tone, pitch, pace).
Proxemics: Spatial distance between individuals.
- Intimate distance: 18 inches apart.
- Personal distance: 18 inches to 4 feet.
- Social distance: 4 feet to 12 feet.
- Public distance: 12 feet or more.

Clinical Supervision and Debriefing

Process Recording: Written record of a nurse-patient session to identify communication patterns.

Therapeutic Groups

Definition: A group of people who meet for personal development and psychological growth.
Advantages:
- Simultaneous treatment for multiple members.
- Benefits from diverse perspectives.
- Safe space for practicing new skills.
- Promotes feelings of cohesiveness.
Disadvantages:
- Privacy concerns.
- Disruptions.
- Discouraging group norms can hinder personal expression.
Concepts Common to All Groups:
- Therapeutic Factors: Curative and crucial for therapeutic change.
- Group Work: Focuses on both surface and underlying dynamics.
- Group Norms: Expectations that develop over time.
- Group Themes: Recurring patterns and common threads.
- Feedback: Providing information on how group members influence one another.
Phases of Group Development:
- Planning Phase: Planning and outlining the group structure.
- Orientation Phase: Forming the group.
- Working Phase: Communication flow and conduct.
- Termination Phase: Reviewing personal experiences and accomplishments.

Chapter Review

Therapeutic Communication: The foundation of a patient-centered interview.
- Nontherapeutic techniques: Asking "why" questions.
Technology Communication:
- Use caution and consider potential ethical and safety implications.
- Consult patients to understand their preferences.
Group Therapy:
- Can help individuals develop social skills, cope with stress, and make changes in their lives.

Evaluation & Follow Up

Feedback can be requested periodically while the group is active and during termination of the group.

Roles of Group Members/Group Membership

Heterogenous Group: Members possess a range of differences.
Homogenous Group: Members share core characteristics.
Closed Group: New members are admitted as others leave.
Subgroup: Isolated from the larger group for specific needs.

Group Participation Roles

Task Roles

Elaborator: Provides examples and expands on the meaning of ideas.
Energizer: Encourages group decision-making and action.
Information giver: Provides facts and expertise.
Opinion giver: Shares opinions (often to influence group values).
Orienter: Monitors group progress towards goals.

Maintenance Roles

Compromiser: Yields during conflict to maintain group harmony.
Encourager: Praises and seeks input from others.
Follower: Agrees with the group's flow.
Gatekeeper: Monitors member participation for equal communication.
Standard setter: Defines group standards.

Individual Roles

Aggressor: Criticizes and attacks others' ideas and feelings.
Blocker: Disagrees and halts group progress.
Help seeker: Seeks sympathy from the group.
Recognition seeker: Seeks attention through boasting.
Self-confessor: Shares personal feelings beyond the group topic.

Theoretical Frameworks for Groups

Humanism: Focuses on self-actualization, subjective experiences.
Cognitive behavioral: Addresses maladaptive behaviors.
Psychodynamic: Aims to resolve intrapsychic conflicts.
Educational: Provides practical support.
Systems: Examines social interactions.

Virtual Groups

Most virtual groups adhere to HIPAA guidelines.
Useful for online cognitive behavioral therapy (CBT) groups.
Potential for negative impacts on therapeutic relationships.
Clinicians may experience a sense of loss of control, unable to observe facial expressions and body language.

Nurse Group Leaders

Registered nurses (RNs) with degrees and holistic training, education, and leadership skills, can facilitate therapeutic groups in various settings.
RNs lead activity, educational, and support groups.
Advanced practice registered nurses (APRNs) can also lead specialized group treatments, including psychotherapy, requiring more complex skills.

Support and Self-Help Groups

Support Groups:
- Bereavement
- Suicide survivor
- National Alliance on Mental Illness (NAMI) patient families
- Career support
- Virtual support
- Veterans support
- Twelve Step
- Gamblers Anonymous
- Narcotics Anonymous
- Adult Children of Alcoholics
- Recovery International/Mental Illness
- National Mental Health Consumers Self-Help Clearinghouse

Styles of Leadership

Autocratic leader: Maintains control over the group and discourages interaction.
Democratic leader: Encourages group interaction in problem-solving.
Laissez-Faire leader: Allows members to behave without control.

Benefits of Group Leadership

Critical feedback
Enhanced professional growth
Management of transference and countertransference
Outside perspective
Support for therapeutic goals
Training opportunities
Debriefing
Role modelling

Ethical Issues in Group Therapy

Informed consent
Confidentiality and exceptions to confidentiality
Rules about leaving and socializing outside the group
Considerations for member removal (last resort)
Appropriate training and credentials
American Nurses Association (ANA)'s scope of practice
Evidence-based practices (e.g., Cognitive Behavioral Therapy (CBT) for Major Depressive Disorder (MDD) and anxiety disorders; combined CBT with pharmacotherapy for ADHD symptom reduction).

Dealing with Challenging Members

Monopolizing member: Remind the group to contribute equally, address the member privately if necessary.
Disruptive member: Listen objectively, inquire about the cause of anger in private, empathize in a matter-of-fact manner.
Silent member: Identify the cause, provide extra time for a response, check back later.

Expected Outcomes

Medication Groups

Awareness of side effects
Awareness of interactions
Identification of medication time and dosage

Therapy Groups

Insights
Behavior changes
Symptom reduction

Chapter Review

Choose all of the correct responses.
- Which outcome would be appropriate for a group session on medication education?
  - Patient will identify three side effects of prescribed medication.
  - Patient will verbalize the purpose of taking the medication.
  - Patient will correctly identify time of day and dose for each prescribed medication.
  - Patient will list two potential drug-drug and drug-food interactions for prescribed medications.
Answer: a, b, d, e
Choose the best response.
- What question by the nurse leader is helpful in managing a monopolizing member of a group?
  - "Would you tell us about experiences that have frightened you?"
  - "Would you tell us about experiences that have frightened you?"
  - "Who else would like to share feelings about this issue?"
Answer: d
Choose all of the correct responses.
- What advantages does group therapy have over individual therapy?
  - Groups are less expensive than one-on-one therapy.
  - Groups provide an opportunity to learn from others.
  - Feedback is available from the group leader and group members.
  - Interpersonal skills can be practiced in a safe environment.
Answer: a, b, d, e
Choose the best response.
- What group would benefit most from a laissez-faire leader?
  - Art group
Answer: a
Choose the best response.
- The nurse describes the purpose of psycho-educational groups as providing group members with the knowledge and skills necessary to manage psychiatric symptoms. Which phase of group development is represented?
  - Orientation phase
Answer: b
Choose all of the correct responses.
- Group dynamics can vary widely, and sometimes members disrupt the group process. Which of the following participant traits may indicate a need for additional support for a new nurse facilitator?
  - A member with paranoid delusions
  - A quietly tearful participant expressing suicidal thoughts
Answer: a, b
Choose all of the correct responses.
- The advanced practice nurse is assigned a group of patients. Which patient would not be appropriate to consider for inpatient group therapy?
  - The patient who is experiencing acute mania
  - The patient who is preparing for discharge tomorrow
Answer: b, d
Choose the best response.
- Group members are having difficulty deciding what topic to cover in today's session. Which nurse leader response reflects autocratic leadership?
  - "We are talking about fear of rejection today."
Answer: a
Choose the best response.
- A patient continues to dominate the group conversation despite having been asked to allow others to speak. What is the group leader's most appropriate response?
  - "When you speak out of turn, I am concerned that others will not be able to participate equally."
Answer: d
Choose the best response.
- The nurse is planning the care of patients on her unit, which includes a dual-diagnosis group. Which patient would be appropriate for this group? The patient with
  - Schizophrenia and alcohol use disorder
Answer: d

Legal and Ethical Considerations

Ethical concepts: Examine beliefs about right and wrong in society.
Bioethics: Focuses on ethical questions in healthcare.

6 Principles of Bioethics

Autonomy: Respecting the right to make independent decisions.
Beneficence: Acting to benefit the well-being of others.
Nonmaleficence: Doing no harm.
Justice: Fairly distributing resources and care regardless of personal factors.
Fidelity: Maintaining loyalty and commitment to patients.
Veracity: Communicating truthfully.

Code of Ethics for Nursing

The code emphasizes compassion, respect for individual dignity, patient-centered care, promoting patient safety, professional responsibility, and ongoing learning.

Evolving Ethical Issues in Psychiatric Care

Pharmacogenetic Testing: Genetic testing for medication responses is not FDA approved due to lack of research and evidence.
Predictive Psychiatry: Genetic testing for mental health conditions raises concerns about potential stigma and impacts on job prospects.
Genome Testing: Testing can reveal genetic variants for diseases without cures, potentially causing emotional distress and altering physiology.

Mental Health Laws

Hospital Admission Procedures:
- Voluntary Admission: Sought by patient or guardian; patients can request to leave.
- Involuntary Admission: Court-ordered without consent, requires specific criteria: diagnosed mental illness posing a danger to self or others, gravely disabled, or in need of treatment prevented by the illness.
- Involuntary Emergency Commitment: Temporary admission or emergency hospitalization, usually 24-96 hours; used for patients who cannot make decisions or require immediate care.
Due Process:
- Patients can petition for a writ of habeas corpus to challenge unlawful detention.
- They can also challenge hospitalization based on the least restrictive alternate doctrine, which mandates the least drastic action to achieve a specific purpose.
Discharge Procedures:
- Unconditional Release: Termination of the patient-institution relationship.
- Release Against Medical Advice (AMA): Discharge against clinician recommendations,
- Conditional Release : Requires outpatient treatment for a specific period; evaluation of medication adherence, basic needs, and community reintegration.
- Assisted Outpatient Treatment (AOT): Court-ordered outpatient treatment.

Patient Rights

Right to Treatment:
- Free from excessive or unnecessary medication
- Privacy
- Least restrictive environment
- Attorney, clergy, and private care providers
- Not subject to lobotomies, ECT, or other treatments without informed consent.
Right to Refuse Treatment: Unless in an emergency situation where a person could seriously harm themselves or others.

Involuntary Commitment

A person can be involuntarily committed to a psychiatric facility if they have a serious mental illness, their function is deteriorating, they are exhibiting threatening behavior, the benefits of treatment outweigh the harm, they lack the capacity to make a reasoned decision about treatment, and less restrictive services have been found inadequate.

Patients must be informed of the nature of their problem or condition, the nature of the proposed treatment, the risks and benefits of treatment, alternative treatment options, the probability of treatment success, and the risk of not consenting to treatment.

Rights Regarding Psychiatric Advanced Directives

Patients with severe mental illness can express their treatment preferences in advance.
This can include the designation of a physician or therapist, appointment of someone to make mental health decisions, medication preferences, consent for admission to a psychiatric facility, preferred and unacceptable facilities, consent for ECT, and preferred visitors.

Rights Regarding Restraints and Seclusion

Non-restrictive interventions should be tried first, such as verbal interventions, reducing stimulation, active listening, providing diversion, and offering PRN medications.
Orders for restraints or seclusion must be written soon after a patient is placed in these interventions.

Rights Regarding Confidentiality

The Health Insurance Portability and Accountability Act (HIPAA) protects patient confidentiality.
Confidentiality applies to social media, after death, and professional communications.

Duty to Warn and Protect Third Parties

Medical staff have a duty to warn and protect third parties if a patient poses a threat.

Child and Elderly Abuse Reporting Statutes

Nurses are mandated reporters of suspected child and elderly abuse.

Failure to Protect Patients

Nurses have a responsibility to protect patients from harm

Tort Law

Tort is any wrongful act, intentional or accidental, that results in injury.

Intentional Torts

Willful and intentional acts that violate another person's rights or property
Includes assault, battery, false imprisonment, invasion of privacy, and defamation of character.

Unintentional Torts

Unintended acts against another that produce injury or harm
Includes negligence and malpractice

Negligence

Five elements must be present to prove negligence: duty, breach of duty, cause in fact, proximate cause, and damages.

Standards for Nursing Care

Nurses are held to a basic standard of care based on what other nurses with similar skills and knowledge would do in the same situation.
This standard is determined by the state board of nursing, professional associations, institutional policies and procedures, and custom.

Acting on Questionable Practice

Nurses have a duty to intervene and report incompetence, impairment, criminal activity, and negligence.
Documentation should be clear and accurate.

Documentation of Care

Documentation should be accurate, complete, facilitate continuity of care, serve as a means of interprofessional communication, and allow patients to review their records.

Medical Records and Quality Improvement

Quality improvement is a key goal in healthcare.
Medical records can be used to evaluate and improve care, provide evidence for lawsuits, manage risk, and support reimbursement from health insurance.

Medical Records as Evidence

Medical records can be used as evidence in lawsuits, abuse cases, disability cases, and workers compensation cases.

Guidelines for Electronic Documentation

Electronic documentation manages data and communication, reduces errors, and facilitates decision-making.
Federal privacy laws govern access to electronic records.
If something is not documented, it is assumed it did not happen.
Specific rules and timeframes for correcting errors may be dictated by the electronic health record (EHR) system.

Violence in the Psychiatric Setting

Nurses participate in setting policies to create a safe environment.
Always document patients' potential for violence.
Nurses should communicate observations to colleagues.
New laws enhance criminal charges and penalties for striking nurses and other healthcare workers in the course of duty.

Therapeutic Communication

Patient centered
Goal directed
Scientifically based

Benefits of Therapeutic Communication

Safer feelings
Increased satisfaction with care
Improved recovery rates
Increased adherence to treatment

Theoretical Models of Communication

Communicators are senders and receivers, makes role more fluid.
Communicators are interdependent (communication is not occurring if the receiver is not listening)
Message is the content and ideas that are being exchanged.
Channels: Methods by which communication takes place.
Feedback: Takes place in a constant feedback being given by both parties.
Encoding/Decoding: Interacting individuals encode (develop) messages, and decode (determine the meaning of) messages received.
Context: Frames and influences our communications.

Peplau's Interpersonal Theory

Guiding principles in communication: clarity ensures the meaning of the message is accurately understood by both parties.
Continuity: Promotes connections among ideas, feelings, events, and themes.

Factors that Affect Communication

Personal Factors: Depression, cognition, and language.
Cultural Barriers: Impact communication.
Environmental Factors: Background noise, the setting, and lack of privacy can affect communication.
Relationship Factors: Levels of equality in the relationship can affect communication.

Verbal Communication

Consists of all the words a person speaks.
Communicates beliefs, values, perceptions, and meaning.

Nonverbal Communication

Tone of voice
Emphasis on certain words
Physical appearance
Facial expressions
Body posture
Amount of eye contact
Hand gestures
Proximity to another person

Communication Skills for Nurses

Using silence
Active listening
Clarifying technique
Paraphrasing
Restating
Reflecting
Exploring

Therapeutic Communication Questions

Open ended: Explore experiences, perceptions, and responses.
Close ended: Obtain specific information.
Projective: Use "what if" scenarios to help the patient articulate thoughts and feelings.
The miracle question: To help patients set goals and envision what the future would look like if the problem vanished.

Nontherapeutic Communication Techniques

Excessive questioning
Giving approval or disapproval
Giving advice
Asking "why" questions

Cultural Considerations

Use of electronic information and communication technology to support long distance healthcare.
Telehealth
Video Health
Internet Sources
Phone Consultation
Image Transmission
Interactive Video Sessions
Mobile Applications: Monitor, diagnose, treat, and communicate with patients. Mobile phones are used at a high rate, many quickly adaptive apps available.
Concerns of Technological Communication: Privacy/Confidentiality, lack of data for efficacy, liability issues.

Preparing for the Clinical Patient Interview

Setting: Security enhances feelings, the nurse should be in the same vertical space as the patient.
Introductions: Opening questions to initiate the interview.

Tactics to Avoid

Arguing with, minimizing, or challenging the patient.
Giving false reassurance.
Interpreting or speculating.
Probing into sensitive areas the patient doesn't want to discuss.
Trying to get the patient to accept treatment.
Joining in attacks the patient launches at others.
Participating in criticizing other staff members.

Behaviors that Support Counseling

Kinesics Communication: Nonverbal communication made by body language.
Vocal Quality: Paralanguage qualities of speech that do not involve language.
Proxemics: Intimate distance, 18 inches apart.

Clinical Supervision and Debriefing

Communication and interviewing are acquired skills.
Fosters professional growth, helps maximize the development of nontherapeutic nurse-patient relationships.

Process Recording

Written records that reflect as closely as possible the verbal or nonverbal behaviors of both the patient and the nurse.
A useful tool to identify communication patterns.

Therapeutic Groups

Any group of people who meet for personal development and psychological growth.

Advantages of Therapeutic Groups

Treat multiple members simultaneously
Members benefit from other viewpoints
Safe place to practice new skills
Promote feelings of cohesiveness

Disadvantages of Therapeutic Groups

Privacy concerns
Disruptions
Discouraging group norms can hinder personal expression

Concepts Common to All Groups

Therapeutic factors are aspects of the group experience that leaders and members have identified as curative and crucial for therapeutic change.
Group work recognizes what happens on the surface as well as underneath.
Group norms: Expectations that develop over time.
Group themes: Findings that recur and share a common thread.
Feedback: Providing the group with feedback on how they affect one another.

Phases of Group Development

Planning Phase:
- Group name
- Group objectives
- Types of individuals
- Group schedule
- Physical Setting
- Seating configuration
- Leader and member responsibilities
- Methods of evaluating outcomes
Orientation Phase: The group is forming.
Working Phase: Communication flow of group process and group conduct.
Termination Phase: Ensure each member summarizes personal experiences and accomplishments, shares new insights, and identifies personal goals.

Evaluation & Follow Up Phase

Feedback can be provided during the group's existence and upon termination.

Roles of Group Members/Group Membership

Heterogeneous Group: Multiple differences exist among members.
Homogeneous Group: Members share central traits.
Closed Group: New members join as others leave.
Subgroup: A smaller group isolated for specific needs within a larger group.

Group Participation Roles

Task Roles: Focus on completing the group's task. Examples include elaborating, providing information, giving opinions, and orienting the group.
Maintenance Roles: Focus on maintaining group harmony and positive relationships. Examples include compromising, encouraging, following, setting standards, and acting as a gatekeeper.
Individual Roles: Focus on individual needs, often disrupting group function. Examples include aggression, blocking, seeking help or recognition, self-confession.

Theoretical Framework for Groups

Humanism: Emphasizes self-actualization, subjective experiences.
Cognitive Behavioral: Focuses on maladaptive behaviors.
Psychodynamic: Seeks to resolve intrapsychic conflicts.
Educational: Provides practical supports.
Systems: Highlights social interactions.

Virtual Groups

Typically comply with HIPPA guidelines.
Helpful for online cognitive behavioral therapy groups (CBT).
May have negative impacts on therapeutic relationships.
Clinicians may feel a loss of control due to lack of visual cues.

Nurse Group Leaders

RNs with degrees, holistic training, and leadership skills can lead therapeutic groups.
RNs lead activities, educational tasks, and support groups.
APRNs may lead specialized treatments including psychotherapy, requiring advanced skills.

Support and Self-Help Groups

Support Groups: Focus on shared experiences and understanding for specific needs. Examples include bereavement, suicide survivor, veterans, career support, and mental health consumers groups.
Twelve-Step Groups: Focus on a 12-step program for addiction recovery, examples include Gamblers Anonymous and Narcotics Anonymous.

Styles of Leadership

Autocratic Leader: Exerts control, limits group interaction.
Democratic Leader: Encourages group interaction and problem solving.
Laissez-Faire Leader: Minimizes involvement, allows group autonomy.

Ethical Issues for Group Therapy

Informed Consent: Patients must understand and agree to group participation.
Confidentiality: Maintaining privacy is crucial, but exceptions apply (e.g., harm to self or others).
Group Rules: Clarifying expectations for leaving, socializing outside the group.
Member Removal: Last resort, for disruptive or unsafe behavior.
Training/Credentialing: Leaders require appropriate skills and qualifications.
Scope of Practice: Adhering to ANA guidelines for nursing practice.
Evidence-Based Practice: Emphasizing effective interventions like CBT.

Dealing with Challenging Members

Monopolizing Member: Remind members of equal participation, speak directly to the member when necessary.
Disruptive Member: Objectively listen, inquire about the cause of anger, empathize when appropriate.
Silent Member: Determine the cause of silence, provide time for reflection, encourage participation.

Expected Outcomes

Medication Groups: Increased awareness of side effects, interactions, and dosages.
Therapy Groups: Insights, behavior changes, symptom reduction.

Legal and Ethical Considerations

Ethical Concepts: Philosophical beliefs about right and wrong.
Bioethics: Ethical dilemmas in healthcare.
6 Principles of Bioethics:
- Autonomy: Respecting individual rights and choices.
- Beneficence: Acting to benefit patients.
- Nonmaleficence: Avoiding harm to patients.
- Justice: Fair distribution of resources and care.
- Fidelity: Loyalty and commitment to patients.
- Veracity: Truthful communication.

Code of Ethics for Nursing

Focuses on patient-centered care, professional responsibility, and ethical practice.

Evolving Ethical Issues in Psychiatric Care

Pharmacogenetic Testing: Genetic testing for medication responses is not approved by the FDA due to lack of evidence.
Predictive Psychiatry: Genetic testing for potential mental health disorders raises concerns about stigma and autonomy.
Genome Testing: Testing for untreatable diseases can cause emotional distress and may alter physiology.

Mental Health Laws

Hospital Admission Procedures: Admissions require a diagnosis of a mental illness, a threat to self or others, or inability to meet basic needs.
Voluntary Admission: Sought by the patient, allows for the right to leave.
Involuntary Admission: Court-ordered without consent, must meet specific criteria.
Involuntary Emergency Commitment: Temporary admission for immediate observation, diagnosis, and treatment.
Due Process: Patients have the right to challenge unlawful detention through legal procedures.

Patients' Rights

Right to Treatment: Includes access to adequate and ethical care.
Right to Refuse Treatment: Applies unless the patient is a danger to themselves or others.

Chapter Review

Medication groups: Focus on promoting medication knowledge and management.
Group Dynamics: Understanding and addressing challenging group dynamics.
Ethical Considerations in Group Therapy: Applying ethical principles and guidelines.
Legal Considerations: Understanding and respecting patients' legal rights.

Involuntary Commitment

Criteria for involuntary commitment include: serious mental illness, decline in function, potential harm to self or others, outweighing of benefits over risk, lack of capacity to make treatment decisions, and insufficient less restrictive services.

Patients need to receive information regarding risks and benefits of proposed treatment: nature of problem, treatment description, risks and benefits, alternatives, success probability, and risks of refusing.

Psychiatric Advanced Directives

Patients with severe mental illness can express treatment preferences through advanced directives.
These directives may include: designating a physician/therapist, appointing a decision-maker, medication preferences, facility admissions, ECT consent, and visitation preferences.

Restraints and Seclusion

Before resorting to restraints and seclusion, less restrictive measures like verbal interventions, reducing stimulation, active listening, diversion, and PRN medications should be employed.
Restraint and seclusion orders should be obtained promptly, and standing or PRN orders are not permitted.

Confidentiality

HIPAA regulations govern the protection of patient information.
Confidentiality extends to social media interactions and after death.
Confidentiality of professional communications is also crucial.

Duty to Warn

Healthcare workers have an obligation to warn and protect third parties when a patient poses a threat to them.

Child and Elder Abuse Reporting

Mandatory reporting statutes exist for child and elder abuse, requiring healthcare professionals to report suspected cases.

Failure to Protect

Healthcare providers can be held responsible for failing to protect patients from foreseeable harm.

Legal Principles for Psychiatric Nursing

Tort Law: encompasses any wrongful act, intentional or accidental, resulting in injury.
Intentional Tort: deliberate actions violating another person's rights or property, including assault, battery, false imprisonment, invasion of privacy, and defamation.
Unintentional Tort: unintended actions causing injury or harm, categorized as negligence and malpractice.
Negligence: involves five elements: duty, breach of duty, cause in fact, proximate cause, and damages.

Standards for Nursing Care

Nurses are held to a standard of care comparable to other skilled professionals in similar situations.
This standard is influenced by: state board of nursing regulations, professional association guidelines, institutional policies and procedures, and customary practices.

Acting on Questionable Practice

Nurses have an ethical obligation to intervene and report: incompetence, impairment, criminal activity, and issues requiring documentation.
Immediate intervention is necessary when the supervisor is unavailable to protect patient safety.

Documentation of Care

Accurate and complete documentation is essential for: continuity of care, interprofessional communication, patient access to records, and institutional record ownership.

Medical Records and Quality Improvement

Medical records contribute to quality improvement initiatives by providing data for evaluation and improvement strategies.
They serve as evidence, support risk management, and facilitate reimbursement.

Medical Records as Evidence

Medical records can be used in legal cases to demonstrate: patient damages and suffering, the nature and extent of injuries, physical or mental disabilities, and injury/rehabilitation in workers' compensation claims.

Guidelines for Electronic Documentation

Electronic documentation systems manage data, communication, reduce errors, and facilitate decision-making.
Federal privacy laws regulate electronic access.
The principle "if it is not documented, it did not happen" applies to electronic records.
Corrections require specific procedures and may be governed by the HER system.

Violence in the Psychiatric Setting

Nurses are integral in establishing policies promoting a safe environment.
Documenting potential for violence is critical.
Communicating observations to colleagues ensures proactive safety measures.
Current laws enhance criminal charges and penalties for assaults on healthcare personnel during their duties.

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Test your knowledge of the nursing process using the ADPIE framework. This quiz covers crucial components including assessing, diagnosing, planning, implementing, and evaluating patient care. Additionally, understand the importance of QSEN competencies and establishing therapeutic relationships in nursing.