Community Mental Health &
Substance Abuse Services
of St. Joseph County
Subject:
Psychiatric Services
Psychiatric Nursing Standards of Care
Application:
Operating
Procedure
44.10
All Departments
Effective
5/96
Reviewed
3/15/01
11/30/04
1/24/14
Revised
7/96
6/29/01
1/12/08
05/07/11
Policy
It is the policy of Community Mental Health and Substance Abuse Services of St. Joseph
County that all nursing services rendered will be consistent with established nursing standards.
Purpose
1. To establish guidelines for a nursing practice which will provide direction in achieving
excellence in care, and promote, maintain, or restore physical and psychosocial health to
the clients’ optimal level of functioning.
2. To delineate standards which reflect the current state of nursing knowledge and are
consistent with the American Nurses Association’s standards of professional practice.
3. To provide measurable criteria for evaluating the delivery of quality nursing care.
Procedure
1. During orientation each registered nurse will receive a copy of the PIA Psychiatric Nursing
Standards.
2. Nursing care standards will be monitored through the Medical Committee and Quality
Improvement Activities.
3. The Psychiatric Nursing Standards of care will serve as a guide for professional nursing
performance evaluations.
PSYCHIATRIC NURSING STANDARDS
Standard I: Data Collection
The Nurse systematically collects comprehensive and accurate data on an ongoing
basis.
Structure Criteria: Provides a systematic method of gathering data to ensure a
comprehensive assessment of the patient’s initial and ongoing needs.
Process Criteria:
1. A nursing assessment will be done.
a. Initiated as requested by CMHSAS-SJC physicians and/or CMHSAS-SJC clinicians.
b. Completed by a Registered Nurse. RN to co-sign LPN assessments.
Page 1 of 3
Approved
Operating Procedure
Subject:
44.10 Psychiatric Services/
Psychiatric Nursing Standards of
Care
2. The holistic needs of patients are assessed through obtaining the following:
a. patient rationale for CMHSAS-SJC treatment
b. homicidal and/or suicidal potential
c. history of substance abuse
d. daily living situation including: ADL’s, occupation, changes in activity level, living
arrangements, diet, coping skills and support systems.
e. biophysical status, including a complete review of systems.
f. significant data from the client, family, significant others, healthcare team, and/or
pertinent individuals in the community.
Standard II: Problem Identification
The nurse identifies actual or potential health problems that are supported by the
recorded assessment data.
Structure Criteria: Provides a method to identify the patient’s immediate health care,
condition, and needs.
Process Criteria:
1. The Nurse will identify actual or potential healthcare problems in regard to:
a. ability to remain safe and not be a danger to oneself and others
b. client’s central complaint, symptoms, or focus of certain
c. physical, developmental, cognitive, mental and emotional health status.
d. history of health patterns and illness.
e. family, social, cultural, and community systems
f. daily activities, functional health status, substance use, health habits, and social roles,
including work and sexual functioning
g. interpersonal relationships, communication skills, and coping patterns
h. spiritual or philosophical beliefs and values.
i. economic, political, legal, and environmental factors affecting health
j. significant support systems, both available and under utilized
k. health beliefs and practices
l. knowledge, satisfaction, and motivation to change, related to health
m. strengths and competencies that can be used to promote health.
n. other contributing factors that influence health.
2. The nurse collects and documents sufficient data to verify a problem and make
recommendations for improvement.
Standard III: Planning
The nurse functions as a member of the multidisciplinary team in developing a plan with
specific goals and interventions delineating nursing action unique to each patient’s
needs.
Structure Criteria:
1. A registered nurse is present at multidisciplinary team meetings as requested by Case
Manager.
2. During the Multidisciplinary Treatment Team meeting the nurse has opportunities to
collaborate with others in the development of the Multidisciplinary Treatment Plan.
3. The nurse is provided with opportunities for ongoing planning and revisions of the
Multidisciplinary Treatment Plan.
Page 2 of 3
Operating Procedure
Subject:
44.10 Psychiatric Services/
Psychiatric Nursing Standards of
Care
Process Criteria:
1. The nurse collaborates with patients, their significant others, and team members in the
establishing nursing goals and interventions on the Multidisciplinary Treatment Plan.
2. In Treatment Planning, the nurse participates with other team members to:
a. identify priorities of care
b. identify behavioral manifestations of the presenting problem
c. define patient strengths which will be utilized in the treatment plan
d. state realistic short and long term goals in measurable terms with an expected
accomplishment
e. use identifiable psychotherapeutic principles and interventions
f. identifiable health teaching needs of patients
g. indicate which interventions will be a nursing responsibility and those which will be the
responsibility and those which will be the responsibility of other team members.
Standard IV: Intervention
The Nurse implements nursing actions, to implement nursing actions which promote,
maintain, or restore physical and psychosocial health to the patient’s optimal level of
functioning.
Structure Criteria:
1. Independent nursing interventions are promoted within the Multidisciplinary Team approach.
2. Professional staffing patterns in the psychiatric health care setting are determined by the
documented health care needs of the population served.
Process Criteria:
1. The Nurse:
a. act to ensure that healthcare needs are met either by using nursing skills or by obtaining
assistance from other team members when indicated.
b. acts as the patient’s advocate when necessary to facilitate the achievement of health.
c. reviews and modifies intervention based on patient needs.
Adapted from: “Standards of Psychiatric and Mental Health Nursing Practice”, American Nurses
Association.
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