Canadian Standards for
Psychiatric-Mental Health Nursing
Standards of Practice
4th Edition March 2014
Canadian Federation of Mental Health Nurses • www.cfmhn.ca
Canadian Standards for PsychiatricMental Health Nursing
4th Edition (2014)
Authors
Gloria McInnis-Perry, RN, PhD, DNSc, CNS, CPMHN(C) (PEI), Chair
Ann Greene, RN, MEd, CPMHN(C) (BC), Co-chair
Elaine Santa Mina, RN, PhD (ON) Co-chair
Sue Chong, RN, MSN., BA., CPMHN(C) (BC)
Marlee Groening, RN, BSN, MN (BC)
Gwen Campbell MacArthur, RPN, RN, BScN, MN (BC)
Kathy Wong, RN, BScN, MEd, CPMHN(C) (ON)
Sylvie Buisson, RN, MEd, CPMHN(C) (QC)
Edna Carloss, RN, BScN (NS)
Robert Meadus, RN, PhD (NL)
Acknowledgements
Leigh Blaney, RN, BSN, MA, CPMHN(C) (BC)
Margaret Osborne, RN, PhD (AB)
Brittany Schutte, RN, BScN (AB)
Robb Desrocher, RN, BA (MB)
Carrie McCallum, RN, BScN, CPMHN(C) (ON)
Mari-M Gagnon, RN, MN, CPMHN(C) (QC)
Joanna Cox, RN, BScN, BA (NS)
Aboriginal Nurses Association of Canada (ANAC)
Reference: Canadian Federation of Mental Health Nurses. (2014).
Canadian Standards for Psychiatric-Mental Health Nursing (4th Ed.). Toronto, ON.
Author. Gloria McInnis-Perry (PhD), Ann Greene (MEd), Elaine Santa Mina (PhD), et al.
© 2014 Canadian Federation of Mental Health Nurses.
How to reach us:
Canadian Federation of Mental Health Nurses
c/o First Stage Enterprises
1 Concorde Gate, Suite 109
Toronto, ON M3C 3N6
Tel: 416.426.7229
Fax: 416.426.7280
E-mail: info.mental.health@firststageinc.com
www.cfmhn.ca
Table of Contents
Introduction........................................................................................................................3
Standards Development.....................................................................................................4
Purpose of Standards.........................................................................................................4
Current Issues....................................................................................................................5
Beliefs/Values.....................................................................................................................5
Standards...........................................................................................................................7
Standard I: Provides Competent Professional Care Through the Development of a
Therapeutic Relationship....................................................................................................7
Standard II: Performs/Refines Client Assessments Through the Diagnostic and Monitoring
Function.............................................................................................................................8
Standard III: Administers and Monitors Therapeutic Interventions........................................9
Standard IV: Effectively Manages Rapidly Changing Situations..........................................10
Standard V: Intervenes Through the Teaching-Coaching Function.....................................11
Standard VI: Monitors and Ensures the Quality of Health Care Practices...........................11
Standard VII: Practices Within Organizational and Work-Role Structure............................12
Glossary...........................................................................................................................13
References.......................................................................................................................14
Appendix..........................................................................................................................16
Canadian Standards of Psychiatric-Mental Health Nursing
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2
Canadian Standards of Psychiatric-Mental Health Nursing
Introduction
Psychiatric-mental health nurses provide mental health care to individuals, families, groups,
communities, and populations in many settings. Over time, psychiatric-mental health
nursing practice responds to changes in the needs of patients and clients, an expansion of
knowledge about health care and nursing, and a growing array of alternative care delivery
technologies (Fritzsche, 2008). Psychiatric-mental health nurses adapt to change by
expanding their knowledge and understanding of mental health and mental illness while
delivering competent, evidenced-informed, safe, and ethical care.
Changes in government legislation and policy also affect the field of mental health
tremendously since Canada’s mental health system operates under the provisions of federal,
provincial, and territorial Mental Health Acts and related legislation. Psychiatric-mental health
nurses have long advocated for improvements to Canada’s mental health system and are
pleased with the Mental Health Commission’s recent Mental Health Strategy for Canada
(2012) entitled Changing Directions, Changing Lives. This strategy document, informed
by consumers, families, and health professionals, provides a framework for change of the
mental health system through six key recommendations. In general, the report recommends
establishing diverse community-focused services that use a recovery-based approach. All
nurses, including psychiatric-mental health nurses, support Canada’s mental health strategy
and collaborate with others to facilitate implementation.
To maintain quality care in a changing professional field, the Canadian Standards of
Psychiatric-Mental Health Nursing provide direction to all nurses and to the public on
acceptable practices of a psychiatric-mental health nurse. Revision of the Standards is
necessary to ensure that psychiatric-mental health nursing remains contemporary, relevant,
and responsive to the current needs of individuals, families, communities, and the health
care system.
We begin the fourth edition of the Canadian Standards of Psychiatric-Mental Health
Nursing with a brief discussion of the Standards development process, the purpose of the
Standards, various current issues, and the beliefs and values which inform the Standards.
We then present the revised practice standards, a glossary, and an appendix. In the
appendix, we include a historical overview of psychiatric-mental health nursing since it
provides context to the evolution of our practice and standards.
Canadian Standards of Psychiatric-Mental Health Nursing
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Standards Development
The Canadian Federation of Mental Health Nurses (CFMHN) published the first edition
of the Canadian Standards of Psychiatric-Mental Health Nursing in 1995 (Austin, Gallop,
Harris, & Spencer, 1996). Subsequent editions reflected the evolution of practice. The
second edition focused on a community mental health and community development model
(Buchanan, Harris, Greene, Newton, & Austin, 1998). The third edition (2006) addressed
issues important at that time and included consumer input. This fourth edition builds upon
previous revisions and includes survey feedback from psychiatric-mental health nurses
across Canada.
In the spring of 2012, the Standards Committee of the Canadian Federation of Mental Health
Nurses developed a national survey for CFMHN members which requested input regarding
potential Standards revisions. A majority of the respondents reported that the Standards remain
relevant to practice, education, and teaching. Approximately 43% suggested changes to the
Standards, while 36% suggested no change. The main themes from those who requested
changes to the Standards were requests for the fourth edition to:
• reflect more of the primary health care principles;
• enhance the recovery model;
• increase the language of ethics (autonomy, empowerment, engagement);
• enhance the importance of the therapeutic relationship (language);
• support the reduction of stigma;
• reflect the work of the Mental Health Commission of Canada;
• articulate the need for future research;
• update the literature to support the Standards;
• make the Standards accessible to different groups of expert psychiatric-mental health
nurses who practice across all sectors, from academic to clinical and research settings.
The fourth edition reflects the integration of the themes stemming from the survey results,
supports the current issues that affect the practice of psychiatric-mental nurses, and
addresses the need for Standards that are supported by current relevant literature.
The Standards continue to use Benner’s (1984) “domains of practice” as the conceptual
framework (Austin, Gallop, Harris, & Spencer, 1996). The competencies are classified under
seven domains: the therapeutic relationship, systematic assessment and decision making,
the administering and monitoring of therapeutic interventions, effective management of rapidly
changing situations, the teaching/coaching function, monitoring and ensuring the quality of
health care practices, and organizational and work role competencies.
Purpose of Standards
“The primary purpose of having standards is to provide direction for professional practice in
order to promote competent, safe and ethical service for clients” (CNA, 2008a, p. 9). The
standards enable nurses to articulate and be accountable to the desired and achievable
level of performance in this specialty area. Psychiatric-Mental Health Nursing Practice
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Canadian Standards of Psychiatric-Mental Health Nursing
Standards provide a guide for the evaluation of psychiatric-mental health nursing practice
within a professional and ethical framework.
Current Issues
Professional standards reflect the current state of knowledge and understanding of
a discipline and are therefore contextual and dynamic. The theoretical framework for
understanding practice influences how the individual psychiatric-mental health (PMH) nurse
achieves the accepted standards of practice. Psychiatric-mental health nurses’ embrace
the social, cultural, economic, and political contexts for caregiving, which strongly influence
nursing practice (CNA, 2002b). The social justice paradigm goes further to consider the
social determinants of health, and values equity and the empowerment of the individual
in recovery as well as in health care. Various contextual forces can challenge psychiatricmental health nurses to provide service from a social justice paradigm. Current issues
considered in the Standards include:
• inequities in population demographics and increases in cultural diversities (e.g., age,
gender, ethnicity, race, sexual orientation, language, socio-economic status, and
spirituality);
• inequities in financial allocation of acute and chronic care resources;
• increased prevalence of concurrent disorders (addictions);
• a trend toward policy and program planning for the integration of addictions and mental
health;
• multiple morbidities that result in increased acuity and complexity;
• a focus on determinants of health in understanding psychiatric-mental health issues and
needs;
• an expanded view of the health care team to include partnership/collaborative
relationships with clients and their natural support systems and with advocacy and selfhelp groups;
• stigma and discrimination;
• promotion of recovery and well-being;
• support of Canada’s mental health strategy, Changing Directions, Changing Lives;
• increased psychiatric-mental health nursing research that is evidence-informed and/or
presents best practices in psychiatric-mental health care.
Beliefs/Values
Psychiatric-mental health nursing is a specialized area of nursing practice, education,
and research. The PMH nurse uses evidence-informed and experiential knowledge from
nursing and related health sciences. This practice is grounded in the values as stated in the
Canadian Nurses Association Code of Ethics (CNA, 2008a). Practice involves the promotion
of mental health and the prevention, treatment, and management of mental disorders.
Psychiatric-Mental Health Nurses believe in:
• the centrality of therapeutic nurse-client relationships, based on trust and mutual
respect, to practice;
Canadian Standards of Psychiatric-Mental Health Nursing
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• the alleviation of stigma and discrimination;
• the promotion of recovery and well-being for people of all ages living with mental health
problems and illnesses;
• the conduct and utilization of research for improvement in care;
• social action to promote political and social awareness to influence health and
organizational policy;
• working in collaborative relationships with the individual, family, community, different
populations, and social agencies;
• a holistic approach that is essential to understanding the unique experience of the client;
• equitable access to culturally competent care;
• reflective ethical practice and a commitment to continuous learning;
• the protection of human rights in the context of civil commitment and relevant aspects
of jurisprudence;
• advocating for practice environments that facilitate and ensure safe and positive work
relationships;
• fostering a legacy of moral and visionary psychiatric-mental health nursing leaders.
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Canadian Standards of Psychiatric-Mental Health Nursing
Standards
Standard I: Provides Competent Professional
Care through the Development of a
Therapeutic Relationship
A primary goal of psychiatric-mental health nursing is the promotion of mental health and the
prevention or diminution of mental disorder. The development of a therapeutic relationship is
the foundation from which the psychiatric-mental health nurse can “enter into partnerships
with clients, and through the use of the human sciences, and the art of caring, develop
helping relationships” (RNAO, 2002b).
The nurse:
1. assesses and clarifies the influences of personal beliefs, values, and life experience
on the therapeutic relationships and distinguishes between social and therapeutic
relationships;
2. works in partnership with diverse and heterogeneous populations, families, and relevant
others to determine goal-directed needs and to establish an environment that is
conducive to goal achievement;
3. uses a range of therapeutic verbal and non-verbal communication skills that include
empathy, active listening, observing, genuineness, and curiosity;
4. recognizes the influence of age, culture, class, ethnicity, language, stigma, and social
exclusion on the therapeutic process and negotiates care that is sensitive to these
influences;
5. mobilizes and advocates for resources that improve community integration and increase
the ability of diverse and heterogeneous populations and their families, including those
isolated geographically, to access mental health services;
6. understands and responds to human reactions to distress and loss of control that may
be expressed as anger, anxiety, fear, grief, helplessness, hopelessness, and humour;
7. recognizes and respects the client’s expert and unique knowledge, and facilitates the
client’s behavioural, developmental, emotional, or spiritual change while acknowledging
and supporting the client’s participation, responsibility, and choices in his/her care;
8. respects the client’s and family’s lived expertise and unique knowledge in promoting
recovery;
9. fosters mutuality of the relationship by reflectively critiquing therapeutic effectiveness
through client and family responses and feedback, clinical supervision, and selfevaluation;
10. understands the nature of chronic illness and applies the principles of health promotion
and disease prevention when working with clients and families in the promotion of
recovery.
Canadian Standards of Psychiatric-Mental Health Nursing
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Standard II: Performs/Refines Client
Assessments through the Diagnostic and
Monitoring Function
Effective assessment, diagnosis, and monitoring is central to the nurse’s role and depends
upon theory as well as upon understanding the meaning of the health or illness experience
from the perspective of the client. The nurse explains the assessment process to the client
and provides feedback. Knowledge is integrated with the nurse’s conceptual model of
nursing practice, which provides a framework for processing client data and for developing
client-focused plans of care. The nurse makes professional judgements based upon
evidence, and recognizes and includes the client as a valued partner.
The nurse:
1. collaborates with clients and with other members of the health care team to gather
holistic, client-centered assessments through observation, engagement, examination,
interview (using respectful, recovery focussed language), and consultation while
attending to confidentiality and pertinent legal statutes;
2. assesses, documents, and analyzes data to identify health status, potential for wellness,
health care deficits, potential for risk to self and others; alterations in thought content
and/or process, affect behaviour, communication and decision-making abilities;
substance use and dependency; and history of trauma and/or abuse (emotional,
physical, neglect, sexual, or verbal);
3. formulates and documents a plan of care in collaboration with the client, family, and
mental health team that supports recovery and reintegration/social inclusion in the
community through discharge planning and provision for ongoing support, all while
recognizing variability in the client’s ability to participate in the process;
4. refines and expands client assessment information by assessing and documenting
significant change(s) in the client’s status, and by comparing new data with the baseline
assessment and client goals;
5. assesses and anticipates potential needs and risks, collaborating with the client to
examine his/her environment for risk factors such as self-care, housing, nutrition,
economic support, psychological state, and social interactions;
6. determines the most appropriate and available therapeutic modality that meets the
client’s needs, and assists the client to access necessary resources.
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Canadian Standards of Psychiatric-Mental Health Nursing
Standard III: Administers and Monitors
Therapeutic Interventions
The nature of mental health problems and mental disorders raises specific practice issues
for the psychiatric-mental health nurse in the assessment and the administration of
therapeutic interventions. Many clients are at risk for harm to self or others, either directly or
through neglect (including self-neglect). Every effort will be made to include the client in all
aspects of decision-making. The PMH nurse will be alert and respond to adverse reactions.
The nurse:
1. utilizes and evaluates evidence-based interventions to provide ethical, culturally
competent, safe, effective, and efficient nursing care consistent with the mental,
physical, spiritual, emotional, social, and cultural needs of the individual;
2. provides information to clients and families/significant others in accordance with relevant
legislation;
3. assists, educates, and empowers clients to select choices which support informed
decision-making and provides information about the possible consequence(s) of the
choice;
4. supports clients to draw on their own assets and resources for self-care, daily living
activities, resource mobilization, and mental health promotion;
5. determines clinical intervention, using knowledge of client’s responses;
6. uses technology appropriately to perform safe, effective, and efficient nursing
intervention;
7. uses knowledge of age-specific implications of psychotropic medications and
administers medications accurately and safely, monitoring therapeutic responses,
reactions, untoward effects, toxicity, and potential incompatibilities with other
medications or substances and provides medication education with appropriate
content;
8. utilizes therapeutic elements of group process;
9. incorporates knowledge of family dynamics, cultural values, and beliefs in the provision
of care;
10. collaborates with the client, health care providers, and community members to access
and coordinate resources such as employment, education, and volunteering, and seeks
feedback from the client and others regarding interventions;
11. encourages and assists clients to seek out mutual support groups and to strengthen
social support networks as needed;
12. seeks out the client’s response to, and perception of, nursing and other therapeutic
interventions and incorporates it into practice;
13. ensures care for individuals of different populations (e.g., incarcerated individuals,
individuals with intellectual disabilities) from therapeutic and rehabilitative perspectives.
Canadian Standards of Psychiatric-Mental Health Nursing
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Standard IV: Effectively Manages Rapidly
Changing Situations
The effective management of rapidly changing situations is essential in critical circumstances
that may be termed psychiatric emergencies. These situations include risk factors for
self-harm, aggressive behaviours, and rapidly changing mental and physical health states
(SERPN, 1996).
The nurse:
1. utilizes the therapeutic relationship throughout the management of rapidly changing
situations;
2. assesses the client using a comprehensive holistic approach for actual or potential
health issues, problems, risk factors, and/or crisis/emergency/catastrophic situations;
3. knows about resources required to manage actual and potential crisis/emergency/
catastrophic situations and plans access to these resources;
4. monitors client safety and utilizes continual assessment to detect early changes in client
status, and intervenes accordingly;
5. implements timely, age-appropriate, and client-specific crisis/emergency/catastrophic
interventions as necessary;
6. uses trauma-informed care when managing crisis situations with clients to minimize
further trauma and interference with recovery objectives;
7. commences critical procedures when necessary which, in an institutional setting,
includes suicide precautions, emergency restraint, elopement precautions, and
infectious disease management and, in a community setting, includes community
support systems such as police, ambulance, and crisis response resources;
8. utilizes a least restraint approach to care;
9. develops and documents the management plan of care and intervention;
10. coordinates care to prevent errors and duplication of efforts where rapid intervention is
imperative;
11. evaluates the effectiveness of the rapid responses with the client and modifies critical
plans as necessary;
12. involves, with client collaboration, the family and significant others to identify the
precipitates of the event and to plan ways to minimize risk of recurrence;
13. participates in process review with the client, family, health care team, and other service
providers as needed;
14. utilizes safety measures to protect client, self, and colleagues from potentially abusive
situations in the work environment;
15. participates in and implements activities that improve client safety in the practice setting.
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Canadian Standards of Psychiatric-Mental Health Nursing
Standard V: Intervenes through the TeachingCoaching Function
All interactions are potentially teaching/learning situations. The PMH nurse attempts to
understand the life experience of the client and uses this understanding to support and
promote learning related to health and personal development. The nurse provides health
promotion information to individuals, families, communities, and different populations.
The nurse:
1. collaborates with the client to determine learning needs, emphasizing and supporting
the client’s potential for recovery;
2. plans and implements health promotion education with the client while considering the
context of the client’s life experiences, readiness, culture, literacy, language, preferred
learning style, and available resources;
3. explores options and resources with the client to build knowledge for making informed
choices related to health needs and for accessing the system as needed;
4. incorporates knowledge of diverse learning models and principles, including the
principles of recovery, when creating learning opportunities for clients;
5. provides guidance, support, and relevant information (with appropriate critiques) to
clients, families, and significant others;
6. documents the teaching/learning process (assessment, implementation, client
involvement, and evaluation);
7. determines with the client the effectiveness of the educational process and
collaboratively develops or adapts it to meet learning needs;
8. engages in teaching/learning opportunities as a partner with clients, families, and
community agencies.
Standard VI: Monitors and Ensures the Quality
of Health Care Practices
The nurse has a responsibility to advocate for clients’ rights to receive the lease restrictive
form of care and to respect and affirm clients’ rights to self-determination in a safe
and equitable manner. The PMH nurse must be informed about relevant legislation, its
interpretation, and its implications for nursing practice.
The nurse:
1. identifies philosophies, attitudes, values, and beliefs of the workplace culture that affect
the nurse’s performance, safety, and compassion, and responds appropriately;
2. understands how the determinates of health affect community well-being and PMH
nursing practice;
3. understands relevant legislation and its implications for nursing practice, and utilizes it
appropriately;
Canadian Standards of Psychiatric-Mental Health Nursing
11
4. expands and incorporates knowledge of innovations and changes in mental
health psychiatric nursing practice to ensure safe, confidential, and effective care;
5. ensures and documents ongoing review and evaluation of psychiatric-mental health
nursing care activities;
6. participates in dialogue and critical reflection about the interdependent functions of the
team within the overall plan of care;
7. advocates for the client within the context of the health care environment;
8. advocates for continuous improvement to the organizational/systemic structures
consistent with the principles of safe, ethical, and competent care;
9. recognizes the dynamic changes in health care locally and globally and, with
stakeholders, supports strategies to manage these changes.
Standard VII: Practices Effectively within
Organizational and Work-Role Structure
Psychiatric-mental health nursing care occurs in both community and hospital settings. For the
PMH nurse, care requires a therapeutic relationship involving reflective, ethical, and evidencebased practice within complex and dynamic situations. The PMH nurse must be able to plan
and implement collaborative care, apply recovery principles, promote mental health, consult
with community members, and advocate for the mental health of their clients and others.
The nurse:
1. collaborates with clients/families/significant others and other stakeholders to facilitate
safe, supportive, and respectful environments for all persons;
2. actively participates to sustain and promote a climate which supports ethical practice
and a moral community;
3. understands and utilizes quality outcome indicators and strives for continuous quality
improvement;
4. seeks to utilize constructive and collaborative approaches to resolve differences among
members of the health care team which may impact care;
5. participates in developing, implementing, and critiquing mental health policy which
fosters recovery and continuity of care;
6. advocates and supports a nursing leadership role;
7. supports and helps to mentor and coach newly graduated nurses;
8. utilizes knowledge of collaborative strategies for social action in working with consumer
and advocacy groups;
9. pursues opportunities to reduce stigma and to promote social inclusion and community
integration for clients.
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Canadian Standards of Psychiatric-Mental Health Nursing
Glossary
These descriptions apply for the purposes of this document:
client: Individuals, families, groups, populations, or communities. Synonymous terms may be patients, beneficiaries, partners, recipients, consumers. Clients
exist in social systems that may influence the onset and duration of illness and the extent of mental health (RNAO, 2002a).
crisis: An emotional upset arising from situational, developmental, biological, psychological, socio-cultural, and/or spiritual factors. This state of emotional
distress results in a temporary inability to manage using one’s usual resources and coping mechanisms. Unless the stressors that precipitated the crisis are
alleviated and/or the coping mechanisms are bolstered, major disorganization may result. Because a crisis state is subjective, it may be defined by the client, the
family, or other members of the community (RNAO, 2002b).
contextual factors: The personal, interpersonal, and environmental variables that comprise a person’s unique life experience.
competencies: The integrated knowledge, skills, attitudes, and judgements expected of the PMH nurse (CNA, 2002b, p. 49).
cultural safety and cultural competence: Evolving and largely complementary frameworks that have been developed to address the diverse mental health needs
of people living in Canada. They encourage service providers, regardless of their cultural background, to communicate and practice in a way that considers and
respects the cultural, social, political, linguistic, and spiritual realities of the people with whom they are working. Cultural safety has its origins in the indigenous
experience of colonization, and draws attention to issues of power and discrimination as well as to structural barriers that can limit access to appropriate care for
people from diverse backgrounds. Approaches that build on cultural competence have also emphasized the necessity of addressing these dimensions (Mental
Health Commission of Canada, 2009, p. 120).
empower: To make others stronger and more confident, especially in controlling their life and claiming their rights (Empower, n.d.).
family: The significant and unique people in one’s life who are defined as family. Family members can include, but are not limited to, parents, children, siblings,
neighbours, and significant people in the community (RNAO, 2002b).
least restrictive care: The provision of safe, competent, and ethical care which respects individual rights, dignity, and autonomy with the least possible recourse
to mechanical, chemical, environmental, or physical measures to limit the activity or control the behaviour of a person or a portion of their body (Mental Health
Commission of Canada, 2009, p. 121)
marginalize: To treat (a person, group, or concept) as insignificant or peripheral (Marginalize, n.d.).
mental disorder: A health condition characterized by alterations in several factors that include mood, affect, behaviour, thinking, and cognition. The disorders are
associated with various degrees of distress and impaired functioning (Austin & Boyd, 2009, p. 23).
mental health: The capacity to feel, think, and act in ways that enhance one’s ability to enjoy life and deal with challenges. The term refers to various capacities
including the ability to understand oneself and one’s life, relate to other people, and respond to one’s environment; experience pleasure and enjoyment; handle
stress and withstand discomfort; evaluate challenges and problems; pursue goals and interests; and explore choices and make decisions (Health Canada, 2002).
mental health problem: The diminished capacities – whether cognitive, emotional, interpersonal, motivational, or behavioural – that interfere with a person’s
enjoyment of life or adversely affect interactions with society and environment (Stephens, 1999).
mental health promotion/mental illness prevention: Mental health promotion aims to foster positive mental health for all people, regardless of whether they are
living with a mental health problem or illness, while prevention focuses on measures taken to prevent mental health problems and illnesses, to the greatest extent
possible. Efforts to promote mental health and well-being can overlap with those directed at preventing mental health problems and illnesses (Mental Health
Commission of Canada, 2009, p. 122).
mental illness: A mental state characterized by alteration in thinking, mood, or behavior (or some combination thereof) and associated with significant distress
and impaired functioning over an extended period of time. The symptoms of mental illness vary from mild to severe, depending on the type of mental illness, the
individual, the family, and the socio-economic environment (Health Canada, 2002).
moral community: A community is moral when there is coherence between what a health care organization publicly professes to be (e.g., a helping, healing,
caring environment that embraces values intrinsic to the practice of health care) and what employees, patients, and others both witness and participate in
(Webster & Baylis, 2000).
rapidly changing mental health state: Severe impairments of thought and judgement constituting a medical emergency, which can occur in association with
acute psychosis (a clinical syndrome that may be caused by disorders such as mania, schizophrenia, or drug abuse).
recovery: A process in which people with mental health problems and illnesses are empowered and supported to engage actively in their own journey of wellbeing. The recovery process builds on individual, family, cultural, and community strengths and enables people to enjoy a meaningful life in their community while
striving to achieve their full potential (Mental Health Commission of Canada, 2009, p. 122).
self-awareness: The ability to reflect on one’s practice, thoughts, feeling, needs, fears, strengths, and weakness and to understand how these might affect one’s
actions and the nurse-client relationship (RNAO, 2002b).
significant others: Those to whom the client attributes affection, emotional ties, and a sense of belongingness (adapted from Wright & Leahey, 1994).
therapeutic relationship: A relationship grounded in an interpersonal process that occurs between the nurse and the client(s). The therapeutic relationship is a
purposeful, goal-directed relationship intended to advance the best interest and outcome of the client (RNAO, 2002b).
Canadian Standards of Psychiatric-Mental Health Nursing
13
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Appendix A
History of Canada’s Psychiatric-Mental Health Nursing
Until the late nineteenth century, people with mental illness were usually cared for by their families. From that time, institutional
care for the person with mental illness considered “dangerous to be at large” became available as provinces passed
legislation for the formal admission of this group to asylums headed by physicians titled “medical superintendents” and staffed
by lay attendants. Early in the twentieth century, several asylums in Ontario, Nova Scotia, and Quebec initiated specialized
mental health nurse training schools modeled closely on general hospital schools. Under the auspices of general nursing
leaders, mental hospital graduate nurses eventually became eligible for general nurse registration in those provinces. Asylum
training schools appeared some time later in western Canadian asylums as well, but those graduates generally were not
eligible for provincial nurse registration and eventually formed a separate registration system.
Public funding for Canada’s mental hospitals remained a challenge, and problems of limited resources and overcrowding soon
made the institutions difficult to manage, resulting in a poor reputation. Influenced by the mental hygiene movement of the
1920s, ideas about care of the person with mental illness gradually shifted to place more emphasis upon prevention of mental
illness and promotion of mental health among the general population. Following World War Two, the health care system
rapidly expanded, new psychotropic medications became available, and care of the mentally ill diversified. Large mental
hospitals remained, but as general hospitals created psychiatric departments and outpatient clinics, services expanded.
Beginning in the mid-1960s, the focus of mental health care slowly shifted from institutional to community-based care,
with a wider range of available professional services. The number of patients cared for in the provincial hospitals decreased
significantly.
Throughout the postwar years and during the transition to community care, psychiatric-mental health nursing remained
central to the care of the person with mental illness; however, the role of nurses and their education changed. In all provinces,
psychiatric-mental health nursing is now a component of generic nursing education programs that prepare graduates for
positions in this speciality as part of the professional work of nursing. Today, psychiatric-mental health nurses are an integral
part of multidisciplinary teams, providing a wide range of inpatient and community mental health care services in partnership
with consumers and their families.
(Boschma, 2003 & Tipliski, 2002)
16
Canadian Standards of Psychiatric-Mental Health Nursing
Appendix B
Standard Statement
Reference number(s)
Current Issues
1. inequities in population demographics and increases in cultural diversities (e.g., age,
gender, ethnicity, race, sexual orientation, language, socio-economic status, and spirituality)
13, 16, 34, 47
2. inequities in financial allocation of acute and chronic care resources
6, 40
3. increased prevalence of concurrent disorders (addictions)
13, 19
4. a trend toward policy and program planning of the integration of addictions and mental
health
13, 19, 49
5. multiple morbidities resulting in increasing acuity and complexity
2
6. a focus on determinants of health in understanding psychiatric-mental health issues and
needs
2, 4, 5, 13, 16, 17, 20, 34,
36, 37, 38, 39, 40, 49, 57
7. an expanded view of the health care team to include partnership/collaborative relationships 3, 4, 6, 7, 13, 35, 36, 38,
with clients and their natural support systems and with advocacy and self-help group
46
8. stigma and discrimination
6
9. promotion of recovery and well-being
6
10. support of Canada’s mental health strategy
36
11. increased psychiatric mental health nursing research that is evidence-informed and/or
presents best practices in psychiatric mental health care
6
Beliefs and Values
1.the centrality of the therapeutic nurse-client relationships, based on trust and mutual
respect, to practice
5, 6, 21, 27, 32, 34, 35, 37,
42, 43, 44, 47, 49, 50, 57
2. the alleviation of stigma and discrimination
6, 7, 12, 13, 16, 17, 35, 36,
37, 49, 50, 54
3. the promotion of recovery and well-being for people of all ages living with mental health
problems and illnesses
18, 20, 33, 35, 36
4. the conduct and utilization of research for improvement in care
12, 13, 16, 17, 21, 36, 49,
50
5. social action to promote political and social awareness to influence health and
organizational policy
13, 16, 17, 19, 20
6. working in collaborative relationships with the individual, family, community, different
populations, and social agencies
4, 6, 7, 21, 35, 13, 46, 57
7. a holistic approach that is essential to understanding the unique experience of the client
4, 5, 6, 7, 13, 17, 21, 27,
28, 30, 35, 38, 39, 44, 47,
48, 50, 54, 57
8. equitable access to culturally competent care
4, 6, 13, 16, 30, 32, 35, 38,
50, 52, 54
9. reflective ethical practice and a commitment to continuous learning
6, 21, 25, 27, 35, 42, 43,
49, 50
10. the protection of human rights in the context of civil commitment and relevant aspects of
jurisprudence
27
11. advocating for practice environments that facilitate and ensure safe and positive work
relationships
21, 27
12. fostering a legacy of moral and visionary psychiatric mental health nursing leaders
37
Canadian Standards of Psychiatric-Mental Health Nursing
17
Standard Statement
Reference number(s)
Standard I: Provides Competent Professional Care through the Development of a Therapeutic Relationship
1. assesses and clarifies the influences of personal beliefs, values and life experience on the
therapeutic relationships and distinguishes between social and therapeutic relationships
6, 7, 27, 35, 37, 44, 49, 50,
57
2. works in partnership with diverse and heterogeneous populations, families, and relevant
others to determine goal directed needs and to establish an environment that is conducive to
goal achievement
3, 6, 35, 36, 42
3. uses a range of therapeutic verbal and non-verbal communication skills that include
empathy, active listening, observing, genuineness, and curiosity
42, 43, 44
4. recognizes the influence of age, culture, class, ethnicity, language, stigma, and social
exclusion on the therapeutic process and negotiates care that is sensitive to these influences
6, 13, 35, 36, 41, 46, 47,
49, 54, 57
5. mobilizes and advocates for resources that increase the ability of diverse and
heterogeneous populations and their families to access to mental health services and that
improve community integration, including those isolated geographically
1, 2, 13, 16, 18, 20, 36,
40, 39, 49
6. understands and responds to human reactions to distress and loss of control that may be
expressed as anger, anxiety, fear, grief, helplessness, hopelessness, and humour
43, 50
7. recognizes and respects the client’s expert and unique knowledge, and facilitates the
client’s behavioural, developmental, emotional, or spiritual change while acknowledging and
supporting the client’s participation, responsibility, and choices in his/her care.
18, 42
8. respects the client’s and family’s lived expertise and unique knowledge in promoting
recovery
39, 48
9. fosters mutuality of the relationship by reflectively critiquing therapeutic effectiveness
through client and family responses and feedback, clinical supervision, and self-evaluation
7
10. understands the nature of chronic illness and applies the principles of health promotion
and disease prevention when working with clients and families in the promotion of recovery
16, 35
Standard II: Performs/Refines Client Assessments through the Diagnostic and Monitoring Function
1. collaborates with clients and with other members of the health care team to gather holistic, 21, 27, 47
client centered assessments through observation, engagement, examination, interview (using
respectful, recovery focussed language), and consultation while attending to confidentiality
and pertinent legal statutes
47
2. assesses, documents, and analyzes data to identify health status, potential for wellness,
health care deficits, potential for risk to self and others, alterations in thought content and/
or process, affect behaviour, communication and decision-making abilities, substance use
and dependency, and history of trauma and/or abuse (emotional, physical, neglect, sexual, or
verbal)
3. formulates and documents a plan of care in collaboration with the client, family, and mental 43, 47
health team that supports recovery and reintegration/social inclusion in the community
through discharge planning and provision for ongoing support, all while recognizing variability
in the client’s ability to participate in the process
4. refines and expands client assessment information by assessing and documenting
significant change(s) in the client’s status, and by comparing new data with the baseline
assessment and client goals
49, 50
5. assesses and anticipates potential needs and risks continuously, collaborating with the
client to examine his/her environment for economic, psychological, and social risk factors
such as self-care, housing, and nutrition
39, 49, 50
6. determines the most appropriate and available therapeutic modality that meets the client’s
needs, and assists the client to access necessary resources
41, 49
18
Canadian Standards of Psychiatric-Mental Health Nursing
Standard Statement
Reference number(s)
Standards III: Administers and Monitors Therapeutic Interventions
1. utilizes and evaluates evidence-based interventions to provide ethical, culturally
competent, safe, effective, and efficient nursing care consistent with the mental, physical,
spiritual, emotional, social, and cultural needs of the individual
1, 2, 3, 6, 27, 35, 46, 49,
50
2. provides information to clients and families/significant others in accordance with relevant
legislation
1, 3, 6, 18, 35, 37, 39
3. assists, educates, and empowers clients to select choices which support informed
decision-making and provides information about the possible consequence(s) of the choice
3, 6, 18, 27, 35, 49
4. supports clients to draw on their own assets and resources for self-care, daily living
activities, resource mobilization, and mental health promotion
13, 39
5. determines clinical intervention, using knowledge of client’s responses
43, 47
6. uses technology appropriately to perform safe, effective, and efficient nursing intervention
2
7. uses knowledge of age-specific implications of psychotropic medications and administers
medications accurately and safely, monitoring therapeutic responses, reactions, untoward
effects, toxicity, and potential incompatibilities with other medications or substances and
provides medication education with appropriate content
37, 49
8. utilizes therapeutic elements of group process
37, 45, 51
9. incorporates knowledge of family dynamics, cultural values, and beliefs in the provision of
care
6, 13, 18, 37, 39, 46, 57
10. collaborates with the client, health care providers, and community members to access
and coordinate resources such as employment, education, and volunteering, and seeks
feedback from the client and others regarding interventions
1, 3, 18, 42
11. encourages and assists clients to seek out mutual support groups and to strengthen
social support networks as needed
46
12. seeks out the client’s response to, and perception of, nursing and other therapeutic
interventions and incorporates it into practice
3, 6, 7, 39, 42, 51
13. ensures care for individuals of different populations (e.g., incarcerated individuals,
individuals with intellectual disabilities) from therapeutic and rehabilitative perspectives
6, 39
Standard IV: Effectively Manages Rapidly Changing Situations
1. utilizes the therapeutic relationship throughout the management of rapidly changing
situations
5, 37, 43, 50, 57
2. assesses the client using a comprehensive holistic approach for actual or potential health
issues, problems, risk factors, and/or crisis/emergency/catastrophic situations
5, 37, 50, 57
3. knows resources required to manage actual and potential crisis/emergency/catastrophic
situations and plans access to these resources
37
4. monitors client safety and utilizes continual assessment to detect early changes in client
status, and intervenes accordingly
5, 37, 50
5. implements timely, age appropriate, and client specific crisis/emergency/catastrophic
interventions as necessary
6, 35, 37, 43
6. uses trauma-informed care when managing crisis situations with clients to minimize further
trauma and interference with recovery objectives
37, 43, 44, 47, 49
7. commences critical procedures when necessary which, in an institutional setting, includes
suicide precautions, emergency restraint, elopement precautions, and infectious disease
management, and, in a community setting, includes community support systems such as
police, ambulance services, and crisis response resources
5, 6, 12, 27, 39, 50, 57
8. utilizes a least restraint approach to care
27, 37
9. develops and documents the plan and intervention
1
Canadian Standards of Psychiatric-Mental Health Nursing
19
Standard Statement
Reference number(s)
10. coordinates care to prevent errors and duplication of efforts where rapid intervention is
imperative
1, 3, 40
11. evaluates the effectiveness of the rapid responses with the client and modifies critical
plans as necessary
37
12. in collaboration with the client, facilitates the involvement of the family and significant
others to identify the precipitates of the event and to plan to minimize risk of recurrence
37, 43, 50
13. participates in process review with the client, family, health care team, and other service
providers as needed
37, 39
14. utilizes safety measures to protect client, self, and colleagues, from potentially abusive
situations in the work environment
27
15. participates in and implements activities that improve client safety in the practice setting
1, 3, 12, 27, 37, 50
Standard V: Intervenes through the Teaching-Coaching Function
1. determines client’s learning needs in collaboration with the client, emphasizing and
supporting the client’s potential for recovery
39, 42
2. plans and implements health promotion education with the client while considering the
17, 42, 57
context of the client’s life experiences, readiness, culture, literacy, language, preferred learning
style, and available resources
3. engages with the client to explore available options and resources to build knowledge to
make informed choices related to health needs and to access the system as needed
6, 7, 17, 18, 27, 35, 39, 42,
47
4. incorporates knowledge of a wide variety of learning models and principles, including the
principles of recovery, when creating learning opportunities for clients
42
5. provides relevant information (with appropriate critiques), guidance, and support to clients,
families, and significant others
39
6. documents the teaching/learning process (assessment plan, implementation, client
involvement, and evaluation)
49
7. determines with the client the effectiveness of the educational process and collaboratively
develops or adapts it to meet learning needs
42
8. engages in teaching/learning opportunities as a partner with consumers, families, and
community agencies
3, 57
Standard VI: Monitors and Ensures the Quality of Health Care Practices
1. identifies philosophies, attitudes, values, and beliefs of the workplace culture that impact
on the nurse’s ability to perform with skill, safety, and compassion and takes action as
appropriate
6, 21, 27, 36, 37, 47, 54
2. understands how the determinates of health impact on the health of the community and
affect PMH nursing practice
17, 21, 26, 36, 37, 38, 39,
49, 52, 54, 57
3. understands and utilizes current and relevant legislation and the implications for nursing
practice
3, 6, 27, 35, 37
4. expands and incorporates knowledge of innovations and changes in mental health and
psychiatric nursing practice to ensure safe, confidential, and effective care
1, 6, 35
5. ensures and documents ongoing review and evaluation of psychiatric mental health
nursing care activities
1
6. participates in dialogue and critical reflection around the interdependent functions of the
team within the overall plan of care
6, 21, 37
7. advocates for the client within the context of the health care environment
6, 13, 27, 35, 36, 40, 37,
38, 39, 48, 49
8. advocates for continuous improvement to the organizational/system structures in keeping
with the principles of delivering safe, ethical, and competent care
1, 13, 20, 21, 27, 36, 38,
40, 49
20
Canadian Standards of Psychiatric-Mental Health Nursing
Standard Statement
Reference number(s)
9. recognizes the dynamic changes in health care locally and globally and, in collaboration
with stakeholders, supports strategies to manage these changes
16, 39, 40
Standard VII: Practices within Organizational and Work-Role Structure
1. works in collaborative partnerships with clients/families/significant others and other
stakeholders to facilitate environments that ensure the safety, support, and respect for all
persons
1,2, 4, 12, 13, 16, 36, 38,
39, 42, 49
2. actively participates to sustain and promote a climate which supports ethical practice and
the establishment of a moral community
6, 21, 25, 27, 35, 36, 58
3. understands and utilizes quality outcome indicators and strives for continuous quality
improvement
1, 2, 16, 21, 27
4. seeks to utilize constructive and collaborative approaches to resolve differences among
members of the health care team which may impact care
21, 22, 27
5. participates in developing, implementing, and critiquing mental health policy which fosters
recovery and continuity of care
16, 17
6. advocates and supports a nursing leadership role
6, 35
7. supports and participates in the mentoring and coaching new graduates
38
8. utilizes knowledge of collaborative strategies for social action in working with consumer
and advocacy groups
40
9. pursues opportunities to reduce stigma and to promote social inclusion and community
integration for clients
6
Canadian Standards of Psychiatric-Mental Health Nursing
21
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Canadian Standards of Psychiatric-Mental Health Nursing
Your Federation
Helping meet your professional goals
An associate group of the Canadian Nurses’ Association (CNA),
we are a national voice for psychiatric and mental health (PMH)
nursing. Our objectives are to:
• Assure national leadership in the development and
application of nursing standards that inform and affect
psychiatric and mental health nursing practice.
• Examine and influence government policy, and address
national issues related to mental health and mental illness.
• Communicate and collaborate with national and
international groups that share our professional interests.
• Facilitate excellence in psychiatric and mental health nursing
by providing our members with educational and networking
resources.
Formed in 1988, the Federation pioneered national credentialing
in psychiatric and mental health nursing and achieved CNA
certification status seven years later.
Because of our efforts, nurses across the country can qualify
for the national psychiatric and mental health nursing credential.
Nurses with certification are eligible to use the CPMHN(C)
designation after their names and wear the official CNA
certification pin – a sign of professional achievement.
There is a National Certification Exam available to all
Mental Health Nurses through CNA. For more information
on the certification process please see www.cna-nurses.ca
CFMHN works with others to influence policy and decision making and provides expertise on community health nursing issues.
La CFMHN s’associe à d’autres organismes pour influencer les politiques et les décisions, et elle fournit des conseils sur les
questions relatives aux soins infirmiers communautaire en santé mentale.
Canadian Federation of Mental Health Nurses
Fédération Canadienne des Infirmières et Infirmiers en Santé Mentale
c/o First Stage Enterprises
1 Concorde Gate, Suite 109
Toronto, ON M3C 3N6
Tel: 416.426.7229
Fax: 416.426.7280
E-mail: info.mental.health@firststageinc.com
www.cfmhn.ca