Irmajean Bajnok. RN, MScN, PhD

Director, International Affairs and
Best Practice Guidelines Centre
Co-Director, Nursing Best Practice
Research Centre
Registered Nurses’ Association of Ontario
Toronto, Ontario

Heather McConnell, RN, BScN, MA(Ed)

Associate Director, Guideline Implementation
and Knowledge Transfer
Registered Nurses’ Association of Ontario
Toronto, Ontario

Sabrina Merali, RN, MN

Mental Health and Addiction Resource
Development Lead
Program Manager
Registered Nurses’ Association of Ontario
Toronto, Ontario

Kyle Dieleman, BA

Project Coordinator
Registered Nurses’ Association of Ontario
Toronto, Ontario

Ashley Ahuja, BScN (candidate)

Nursing Student
York University
Toronto, Ontario

Cynthia Baker, RN, PhD

Executive Director
Canadian Association of Schools of Nursing
Ottawa, Ontario

Cheryl Forchuk, RN, PhD

Professor, Arthur Labatt Family
School of Nursing
University of Western Ontario
London, Ontario

Marlee Groening, RN, MSN

Lecturer, School of Nursing
B.C. Representative, Canadian
Federation of Mental Health Nurses
Vancouver, British Columbia

Catherine Gros, RN, MSc(A)

Assistant Professor, Ingram School of Nursing
McGill University
Montreal, Quebec

Michelle Jubin, RN, MN

Mental Health Nurse Consultant
Toronto Public Health
Toronto, Ontario

Kamini Kalia, RN, MScN, CPMHN(C)

Manager of Clinical Education and Informatics,
Professional Practice Office
President, Mental Health Nurses Interest Group
Centre for Addiction and Mental Health
Toronto, Ontario

Arlene Kent-Wilkinson, RN CPMHN(C), MN, PhD

Associate Professor, College of Nursing
University of Saskatchewan
Saskatoon, Saskatchewan

Betty-Lou Kristy

Peer Supports Substance Use Systems Lead
Consumer Survivor Lead
Mississauga Halton LHIN Enhancing &
Sustaining Peer Initiative
TEACH: Teach Empower Advocate Community
Health a peer initiative of Support &
Housing-Halton
Halton, Ontario

Wendy Panagopoulos, RN, BScN

Nurse Educator, School of Nursing
St. Francis Xavier University
Antigonish, Nova Scotia 

Elizabeth Richardson, RN, CPMHN(C)

Institutional Mental Health Nurse
Warkworth Institution
Correctional Services of Canada
Campbellford, Ontario

Deborrah Sherman

Executive Director
Ontario Peer Development Initiative
Toronto, Ontario

Amanda Vandyk, RN, PhD

Assistant Professor
Faculty of Health Sciences, School of Nursing
University of Ottawa
Ottawa, Ontario

Paula Walbourne, RN, BN, CPMHN(C)

Staff Officer, Directorate of Mental Health
Senior Practice Leader, Mental Health Nursing
Canadian Forces Health Services Group
Headquarters
Canadian Armed Forces

Leah Watts, BA, MA

Education Programs Coordinator
Canadian Association of Schools of Nursing
Ottawa, Ontario 

**Special acknowledgement to the Canadian Association of Schools of Nursing (CASN) for their contribution to this work and support for its alignment with the CASN/CFMHN competencies.

Declarations of interest that might be construed as constituting an actual, potential, or apparent conflict were made by all members of the Registered Nurses’ Association of Ontario expert panel, and members were asked to update their disclosures throughout the development process. Information was requested about financial, intellectual, personal, and other interests and documented for future reference. No limiting conflicts were identified.

Further details are available from the Registered Nurses’ Association of Ontario. 

The purpose of the RNAO Nurse Educator Mental Health and Addiction Resource is primarily to support educators with effectively integrating mental health and addiction knowledge and skills into the undergraduate nursing curriculum. The resource is based on the Canadian Association of Schools of Nursing (CASN) and the Canadian Federation of Mental Health Nurses (CFMHN) Entry- to-Practice Mental Health and Addiction Competencies for Undergraduate Nursing Education in Canada (2015) and supporting research. Each section of the resource has been intentionally aligned with the competencies. Please see Appendix A for a chart showing this alignment. Integration of core concepts, competencies and best practices found in this resource will raise the profile of psychiatric and mental health practices for nurses as an essential component and integral part of holistic person-and family-centred care across all sectors.

As such this resource is also relevant to nurse educators working in clinical environments to support nursing students, new graduate nurses and other nurses in integrating best practices related to mental health and addiction. Other beneficiaries of this resource include nursing students, nurses, other health care providers, and, ultimately, the person and their family receiving care.

The resource is designed to be user-friendly with topic areas easily accessible for review and use. Tools can be completed online or in a paper version and reproduced for curriculum and day-to- day use.

It is recommended to review this resource by examining the table of contents and bookmarking areas for further review or use at critical points in education and practice activities. On the other hand one may identify key areas right away to review in more depth and get started. Others may wish to use the resource as a reference and/or a validation resource. Regardless of how this document is used, there is much satisfaction to be found in expanding knowledge and skill levels in mental health and addiction and working to enabling others to do the same.

SECTION ONE: Introduction

Section one provides the user with the background information for the creation of this resource for nurse educators in entry-level nursing education programs, as well as nursing educators in clinical environments. The section also facilitates understanding of fundamental concepts to mental health and addiction.

SECTION TWO: Learning and Teaching Resources to Support Integration of Mental Health and Addiction in Curricula

Section two includes pre-planning assessment tools that enable educators to assess and identify areas for improvement and ongoing development of their teaching practice in a mental health context.

SECTION THREE: Nurse Faculty and Nurse Educator Teaching Modalities and Reflective Practice

Section three includes a discussion of common collaborative, student-centred and strengths- based pedagogies. This section also addresses teaching activities for mental health and addiction nursing that promote reflective practice, as well as techniques to facilitate preceptorship and mentorship.

SECTION FOUR: Student Reflective Practice and Self-Care in Mental Health and Addiction Nursing Education

Section four focuses on incorporating self-reflective practice and self-care into mental health and addiction content.

SECTION FIVE: Foundational Concepts and Mental Health Skills in Mental Health and Addiction Learning Advancement

Section five highlights mental health, illness and addiction foundational concepts and skills for incorporation into undergraduate nursing curricula.

SECTION SIX: Legislation, Ethics and Advocacy in Mental Health and Addiction Nursing Practice

Section six provides educators with information about key concepts related to mental health and addiction legislation in Canada. Aspects addressed include the relationship of legislation, human rights and autonomy within an ethical framework.

SECTION SEVEN: Clinical Placements and Simulations in Mental Health and Addiction Nursing Education

Section seven provides educators with evidence-based insights into mental health and addiction practice and simulation learning modalities.

SECTION EIGHT

Section eight provides the bibliography as a supplement to those references cited throughout the document.

SECTION NINE: Appendices and Case Studies

Section nine includes appendices, a glossary of terms and case studies. This section provides the educator with tips and tools to integrate best practices related to mental health, illness and addiction into curricula. Case studies represent a spectrum of mental health and addiction scenarios, including individuals of various ages and genders, in a range of clinical settings with an array of mental health, illness and addiction conditions.

Mental health and illness affects all Canadians of all ages, education, income levels and culture. According to the Mental Health Commission of Canada (MHCC), mental illnesses are more common than heart disease and cancer (MHCC, 2013). In fact, in Canada 2.2 million individuals are living with Type 2 diabetes while 6.7 million people are living with a mental illness (MHCC, 2013).

The impact of mental health and illness is complex and far-reaching. A report from the Canadian Chronic Disease Surveillance System (CCDSS): Mental Illness in Canada (2015) demonstrates a relationship between mental illness and chronic diseases (CCDSS, 2015). For example, a higher prevalence of asthma and chronic obstructive pulmonary disease (COPD), ischemic heart disease, diabetes and hypertension, were observed among people using health services for a mental illness than among those using services for other diseases or conditions (CCDSS, 2015). Furthermore, 20 percent of individuals who experience mental illnesses are also experiencing addiction, indicating a high rate of concurrent disorders (mental health and addiction) that presents a further complexity in care (Rush et al, 2008).

The relationship between mental illness, chronic disease and addiction is still poorly understood, despite the fact that individuals with mental illness (e.g., depression, anxiety) are more likely to have a co-morbid chronic condition (e.g., asthma, cardiovascular disease) and that individuals affected by chronic diseases are more likely to experience anxiety and/or depression (CCDSS, 2015).

Given the prevalence of mental illness across the age spectrum and the relationships associated among mental health, illness, addiction and other related conditions, it is evident that nurses across all practice settings will care for clients with mental health and illness conditions (Nadler-Moodie, 2010). Nurses are ideally situated across the continuum of care, to provide timely assessments and evidence-based interventions to individuals who may have either a diagnosed or undiagnosed mental illness.

As referred by CASN/CFMHN, “The complexity of concurrent disorders supports the need for entry-level undergraduate nursing education in Canada to prepare all new RNs to identify, care for and manage these disorders” (Kent-Wilkinson, Blaney, Groening, Santa Mina, Rodrigue & Hust, 2016, p. 8). This resource is designed to help make that a reality.

In order to effectively integrate mental health and addiction competencies into entry-level nursing curricula—and contribute to an environment that supports knowledge integration—it is important that faculty evaluate existing curricula content and engage in a personal self-assessment of mental health, illness and addiction knowledge to understand strengths and areas for improvement.

This resource provides two assessment tools, each designed to assist with identifying and addressing gaps in existing educational content, knowledge and skills. Both assessment tools have no demonstrated psychometric properties and are intended to support, stimulate and advance the ongoing development of nursing education in mental health and addiction.

• The Curriculum Assessment Gap Analysis Tool enables the assessment of content, structures and processes within current curricula in relation to the CASN/CFMHN entry-to-practice domains and competencies. The tool also assesses associated knowledge, concepts, attitudes and skills pertaining to the promotion of mental health and the prevention, assessment and management of mental illness and addiction across the lifespan.
• The Educator Self Assessment Tool enables the personal evaluation of educators knowledge and skills required for teaching and promoting mental health and for assessing, preventing and managing mental illness and addiction.

These tools are most useful to curriculum development committees to promote the integration of mental health content, concepts, attitudes and skills across all courses in the undergraduate SEC. 2 nursing program, and to nursing faculty and educators for assessment and integration of and within individual courses.

This tool aims to assist educators with evaluating existing curricula for integration of the knowledge and skills related to the use of CASN/CFMHN Entry-To-Practice Mental Health and Addiction Competencies (2015) and the content related to the RNAO Nurse Educator Mental Health and Addiction Resource in the following domains:

• Professional responsibility and accountability
• Knowledge-based practice
• Ethical practice
• Service to the public
• Self-regulation

INSTRUCTIONS: On the assessment tool (on page 19) indicate whether students are currently learning and applying the following theory, skills and tools, list courses where this is applied or planned to be applied and outline course learning objectives that align with the application and/or tool. At the end, develop an action plan to address gaps.

INSTRUCTIONS: Evaluate personal knowledge and skills regarding mental health and addiction in nursing education and practice with the following Self-Assessment Tool (on page 30). At the end, add up the score for each section and then the total score. See scoring guide at the end for assessing strengths and weaknesses. 

Mental health overview ............................................................................................................................................ /45
Mental health and illness approaches.............................................................................................................. /25
Professional responsibility and accountability............................................................................................ /25
Ethical practice............................................................................................................................................................. /20
Service to the public.................................................................................................................................................. /15
Self-regulation.............................................................................................................................................................. /20
TOTAL ...................................................................................................................................... /150 

There is great potential for ongoing learning and future growth.

Next steps:

• Knowledge development should be a priority. Recommend self-study, beginning with resources listed in this toolkit, RNAO Best Practice Guidelines and associated resources.
• Seek supervision and assistance from peer mentors with more advanced expertise.
• Solicit student feedback and guidance.
• Develop a personal learning plan that focuses on key knowledge domains.
• Use this resource to guide learning plans.

Continue to build on base knowledge and skills, and develop teaching practice.

Next steps:

• Recommend self-study focused on knowledge gaps and peer learning with more expertise.
• Develop confidence in testing out innovative, evidence informed approaches.
• Use RNAO Best Practice Guidelines and associated resources as well as this resource to build capacity.

Continue to seek challenging opportunities to maintain and advance knowledge.

Next steps:

• Be sure to share knowledge and experiences with peers.
• Engage in leadership activities.
• Offer support and encouragement to faculty with novice and intermediate-level expertise.

Best practice pedagogy underlying mental health and addiction content in nursing curricula is diverse. Some of the diversity is reflected in the nature of the language used to talk about mental health, or psychiatric nursing, or whether a medical model or psychosocial framework is used. The need to prepare nursing students for mental health and addiction practice should motivate and inspire educators’ interest in developing students’ critical thinking and skills in all areas of  mental health. In such, educators should also keep an outlook for new pedagogies to stimulate learning.

Methods of best practice teaching approaches are limited, but some approaches include the following.
1. Blended Learning: There is evidence that the blended learning model, which combines traditional face-to-face learning and e-learning, is an effective structural approach to help mental health nursing students recognize and resolve clinical, theoretical and ethical dilemmas. The practice of blended learning provides students with a useful ability to observe the process of supervision and use information technology to enhance clinical skills (Rigby et al, 2012). 

2. Problem Based Learning (PBL): Learning through the experience of solving an open-ended problem is an active pedagogy shown to be useful for teaching mental health nursing students. It may have the added benefit of impacting practice post-graduation. Furthermore, students who have been exposed to PBL may require fewer hours of theory to attain learning outcomes, such as positive attitudes toward mental illness, among others (Cooper & Carver, 2012; Happell, B., Moxham, L. & Platania-Phung, C (2009). 

3. Inquiry Based Learning (IQL): While similar to PBL in that it is open-ended learning, IQL follows different steps starting with the sudent exploring a theme and choosing a research stream to focus on; formulating a question and pursuing a plan of research that is rooted on critical thinking, which is applied to the central question. Educators play a pivotal role in IQL, assisting in a collaborative manner with planning, assessment for learning and the advancement of individual as well as classwide understanding of personally meaningful content and ideas (Fielding, 2012). 

4. Simulation: Simulation is a pedagogy that involves a range of activities that imitate something real, a state of affairs or a process to achieve educational goals (SIM-one, 2016). The purpose of simulation aims to improve safety, effectiveness and efficiency in healthcare (SIM-one, 2016). Simulation is actively used in some curricula however there is considerable variation in nursing programs in terms of: a) the amount of use; b) how it’s used and c) when in the nursing program SIMS is used. For more information, please see Section 7.2.

A range of teaching and learning opportunities and use of different pedagogy is best to impart mental health, illness and addiction knowledge to students. Some teaching approaches rely heavily on the experiential and relational component of mental health nursing in an effort to understand stigma and other attitudinal factors that are part of the mental health work of nurses (Waugh, McNay, Dewar & McCaig, 2014; Stuhlmiller, 2006). The use of case studies as well as online discussions can help facilitate experiential and relationship components (Silva, Furegato & Godoy, 2008). Most educators would agree that a relational nurse who is aware of the role that stigma plays in the experience and care of individuals with mental health concerns is not enough, and that excellence in mental health nursing includes a sound knowledge base of the current theories and best practices of mental illness, as well as the complex interplay of psycho-social-health determinants on the experience of clients and their treatment.

Nurses have a professional obligation to ensure their practice is consistent with the College of Nurses of Ontario (CNO) or local jurisdictional college standards of practice and guidelines as well as legislation. This includes maintaining competence and refraining from performing activities that they are not competent in (CNO, 2002). As well, nurses need to ensure the appropriate education, support and supervision when acquiring new knowledge and skills to ensure they provide safe,
effective and ethical care (CNO, 2002). The CNO further indicates that nurses must assume responsibility for their own professional development and participate in learning processes to enhance their own practice. In order to meet all of CNO’s requirements, it is recommended that nurses engage in reflective practice and seek opportunities to incorporate reflective practice into their practice (CNO, 2002).

Reflective practice is defined as the ability to examine ones actions and experiences with the outcome of acquiring a new understanding and appreciation of the situation, and developing one’s practice and clinical knowledge (Boud, Keogh, & Walker, 1985; Caldwell, 2013). Reflective practice is associated with positive learner outcomes including but not limited to: improved situational awareness, changed perspectives, and a greater appreciation for the value of their practice (Glaze, 2001). As well, reflective practice contributes to development of new knowledge and skills, and promotes higher levels of understanding, can decrease stigma and increase confidence (RNAO, 2015d and RNAO, 2016e).

Please see Resources in this section for more information and ideas on ways to support self reflection with nursing students. Also, see Section 4.1.

In order to effectively support nursing students in acquisition of knowledge that is evidence- and best practice-based, nursing faculty themselves must receive adequate professional development and support to be up to date on the evidence (RNAO, 2016e). Faculty and educator perceived knowledge and expertise in the subject area has been linked to playing a key role in the optimal promotion of mental health knowledge (Lang & Hahn, 2013). Educational institutions should be aware of the extent of clinical experience and education among faculty, understand whether theoretical and clinical education is current and provide ongoing professional development opportunities either through the practice setting or educational institution to promote the continued transfer of theory to practice (RNAO, 2016e).

Successful preparation of nursing educators requires a combination of education, experience, knowledge and assessment skills that must be supported through allocated time for initial and ongoing professional development (RNAO, 2016e). Professional development opportunities should incorporate education regarding best practices in theoretical components of nursing education, provide opportunities to enhance leadership skills, and provide best practices on clinical teaching strategies, adult learning theories and strategies for student evaluation. Such educational opportunities ensure faculty has the competence and confidence necessary to support students and has been demonstrated to improve quality of work satisfaction (RNAO, 2016e). Effective models of professional development can include preceptorship and mentorship for nursing faculty.

Preceptorship:

• Is assigned to facilitate a preceptee’s learning goals.
• Is assigned for a set period of time, usually short-term.
• Is assigned with a focus on learning related to knowledge and skill.
• Is acting as a role model, during regular working hours.
• Can evolve into a mentorship relationship.

Who is the preceptee?

A preceptee can be a nurse with five, 10 or even 15 years’ clinical experience, but who is new to a different teaching area, unit and to caring for a different population of patients. A preceptee may have limited clinical experience and most of those experiences are in the more supported student/school role.

Preceptor responsibilities

Preceptors act as guides or mentors to the preceptee. To facilitate the learner’s acquisition of the nursing knowledge and skills for safe, competent and ethical practice, preceptors must display certain characteristics and be able to demonstrate the competencies required to teach and role model professional behaviours, nursing skills and values.

Key characteristics of effective preceptors include:

1. Competence in the practice role.
2. Experienced in the role.
3. Strong leadership and conflict management skills.
4. Enthusiasm.
5. Strong teaching, role-modeling and facilitation skills.
6. Patience and a positive attitude.
7. Excellent oral and written communication skill.
8. An ability to coach and provide constructive feedback.

Preceptors and Clinical Supervision

Preceptors may provide clinical supervision and have a responsibility to provide clinical teaching, instruction and formal evaluation (RNAO, 2016). Clinical supervision is “a formal process of professional support and learning, which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex clinical situations” (Department of Health, 1993, p.15). It provides regular protected time for health-care practitioners to come together to reflect on clinical practice and examine areas of personal and professional growth and work towards achieving these goals. It can occur using a variety of models that include, one-on-one support, peer support, groups and include use of technology such as online supports and telephone supports. For more information on clinical supervision, please see Resources in this section.

Mentorship:

• Is chosen or selected by the mentee.
• Is usually selected by the mentee to support their professional advancement for an extended period of time.
• Focuses on individual growth and development.
• Is a nurturing and role-modeling relationship, usually during personal time.

For additional tools and resources please refer to Resources in this section.

It is important for educators to be aware of the various educational approaches and the risks they may pose to student safety and mental health. Since 20 percent of the Canadian population will experience a form of mental illness in their lifetime, this is also true for nursing students. In recent years, some social science and child education practitioners have begun to recognize the detrimental role that trauma can play in learning (Crosby, 2015). To that end, an emerging trend in education are trauma-informed educational practices that recognize the role that trauma plays in learning.

The development and application of pedagogies consistent with a ‘caring curriculum’ and with collaborative, student-centred approaches to teaching and learning, serve to promote student mental health and safety while modelling processes basic to collaborative, strengths-based clinical practice and recovery-oriented mental health care.

For more information, please see Resources in this section.

Nursing faculty should integrate persons and families with lived experience or support groups in theoretical and clinical education to understand how to meaningfully engage with these persons and their families. Lived-experience involvement has an important role to play in the education of nurses in addressing fear and demystifying the experience of mental illness (Happell, Gaskin & Byrne, 2015).

For more information, see Appendix H, which aims to support faculty in integrating lived experience.

Reflective practice is a dynamic process that integrates theory with application thereby bridging the gap between professional knowledge and the demands of real-world practice (Tomlinson., Thomlinson, Peden-McAlpine & Kirschbaum, et al.,2002). As such, reflective practice is considered among the most promising teaching and learning modalities for developing mental health nursing care.

Faculty act as facilitators and stimulators of student self-reflection aimed at offering care that is collaborative, strengths-based and recovery-oriented. Faculty should engage in “learning together” approach in which they actively engage with students in the process of critical reflection and thinking about diverse clinical situations. In any case, educators seeking to support and promote the practice of recovery-oriented mental health care should (Meyer, Sellers, Browning, McGuffie, Solomon, & Truog, 2009):

1. Create a safe and trustworthy learning environment.
2. Emphasize ethical and relational dimensions of care.
3. Suspend hierarchy among participants.
4. Value reflection and self-awareness.
5. Honour multiple perspectives.

Reflective practice may occur in individual and group formats; as well as in writing, through interactive discussions or other means. There are multiple strategies for reflection that can assist nursing students to develop the requisite knowledge, skills and competence.

The following approaches and tools may be used to support students to engage in ongoing critical reflection.

Journaling. Since the early-mid 1990s, nurse education has embraced the notion of journaling as a way to move the theory of knowledge acquisition of student nurses in active practice. To that end, student nurses have been asked to reflect on their practice in order to make the links between theory and practice and develop critical thinking skills (Epp, 2008), as well as to develop a professional identity (Shapiro, Kassman & Shaffer, 2006). Other writers have used journaling to enhance reflexive practice.

Such journaling, as a form of reflective exercise, creates a safe space for students to critically analyze situations, consider theoretical perspectives and experiences allowing for further insight (Boud, D., Keogh, R., & Walker, D. 1985; Caldwell, L., 2013; Glaze, J. E., 2001). With the increased acuity of health care today, nurses with high level of knowledge and critical application of this knowledge in the lives of patients is key, and journaling is thought of as one way to achieve this objective.

Some authors suggest journaling is a learned skill that begins with descriptions of events and moving to more phenomenological descriptions about their perspectives and analysis of events (Usher, Francis & Tollefson, 2001). This cascading skill is often seen as a hierarchy, though these same authors argue for the beneficial role that different levels of journaling play in nursing practice.

For more information, see Resources and Appendix E.

Learning circles. Learning circles promote verbal reflection in an interactive manner and involve group discussion that allows participants to critically reflect on practices, promote growth and change, provide a safe, encouraging and empowering space where students can voice concerns, reflect on their practice, and collaborate with colleagues to learn and grow (RNAO, 2016e).

Peer sharing. Peer sharing is the use of partnership dyads to allow for sharing of clinical experiences, strengthening of confidence and clinical reasoning, providing student support and socialization and increased autonomy, accountability, responsibility and self-confidence (RNAO, 2016e). 

Technology to support self-reflection. Communications via text message, online journaling, and listening to health-care stories via podcasts to generate reflections can be used as innovative strategies to promote dialogue and reflection. Nursing educational programs should ensure that adequate time, resources and opportunities (i.e., time, safe space, secure and confidential online forums) are provided to allow students to share and practice self reflection (RNAO, 2016e). For more information, see Resources in this section.

Occupational stress is a major health problem that can lead to burnout, illness, turnover, absenteeism, poor morale and performance (Coetzee, & Klopper, 2010; Nowrouzi et al., 2015). Providing opportunities for nursing students to explicitly explore and discuss occupational stress reactions and explore and practice self-care in curricula increases visibility and awareness of this important issue. It also provides a means to explore professional well-being and strategies to enhance career longevity in specialty nursing areas (i.e., mental health and psychiatric mental health practice) documented to increase the risk of experiencing greater levels of  occupational stress as a result of the therapeutic interpersonal modalities used during interactions with patients over an extended period of time (Edwards & Bernard, 2003; Nowrouzi et al., 2015).

For more information, see Resources in this section.

A “therapeutic relationship” is a relationship that occurs between a client and the nurse that is goal-directed and works towards advancing the best interest and outcomes for the client (RNAO, 2006b). Establishing therapeutic relationships recognizes that effective nursing care is dependent on the nurse coming to know his or her client and engaging in a relationship that supports recovery. Key qualities of a therapeutic relationship include active listening, trust, respect, genuineness, empathy, and responding to client concerns (RNAO, 2006b).

The phases of a therapeutic relationship (Forchuk, 2000) include orientation, working and resolution. Nurses must also be prepared to experience a series of non-therapeutic phases, which include orientation, grappling and struggling and mutual withdrawal. Respecting boundaries that define the limits of the professional role is also important in a therapeutic relationships (RNAO, 2006b). Establishing and maintaining a sense of self-awareness allows a nurse to assess when counter transference and transference—inappropriate meanings and feelings are assigned to the client or vice versa—has taken place, and to assess his or her own ability to address client dynamics (RNAO, 2006b).

Establishing therapeutic relationships works in tandem with person-centred-care principles that reflect the belief of getting to know the whole person. Caring for the ‘whole person’ entails coming to know the person with respect to all components—biological, psychological, emotional, physical, personal, social, environmental, and spiritual—and treating the person holistically rather than treating only their illness or disease (Lovering, 2012; Morgan & Yoder, 2012). According to RNAO’s Best Practice Guideline Person- and Family- Centred Care (2015):

“When optimized, health-care partnerships can improve the autonomy of individuals to make decisions related to their health care and can increase their satisfaction with care.” (RNAO, 2015, p. 21).

Recent health-care restructuring resulted in removal of organizational policies and supports that encourage the manifestation of therapeutic relationships (RNAO, 2010b). It is therefore even more important for nursing to place an emphasis on the importance of this best practice in mental health and addiction curricula. The RNAO Nursing Best Practice Guideline Establishing Therapeutic Relationships (2006) developed a Framework for Therapeutic Relationships that organizes learnings around requisite knowledge and capacities for establishing therapeutic relationships, as well as the phases of therapeutic relationships.

For more information about therapeutic practice, see Resources in this section.

The concept of “recovery” in mental health refers to living a satisfying, hopeful, and contributing life, even when mental health problems and mental illnesses cause ongoing limitations. Recovery — a process in which people living with mental health issues and mental illnesses are actively engaged in their own journey of well-being — is possible for everyone. Recovery journeys build on individual, family, cultural, and community strengths and can be supported by many types of services, supports, and treatments. Recovery includes a process of refining oneself, learning to accept one’s vulnerabilities, overcoming stigma, discrimination, looking beyond what is lacking in one’s life, regaining responsibility, control and hope in one’s life and becoming involved in meaningful social activities and community citizenship (Snow, 2010). The process for recovery requires genuine interest, and open and transparent therapeutic relationships where the client and health-care provider work in partnership to establish mutual goals (Snow, 2010). Specifically, a recovery model for mental health expands on clinical dialogues to include valued life goals, facilitates hope through education about realistic possibilities and probability of recovering to the point of having a good quality of life, is holistic and treats the person as a person, is sensitive to labeling and stigma and understands the importance of theraputic relations.

Implementing recovery-oriented practices that will enhance health outcomes and quality of life for people with lived experience and their families is at the heart of the Mental Health Commission of Canada’s Mental Health Strategy for Canada, and stands on two pillars:

1. Recovery approaches recognize that each person is unique and has a right to determine their recovery journey. Using a recovery-orientated approach, clients take an active role in determining their own treatment paths (Cirpili & Shoemaker, 2014; Mental Health Commission of Canada, 2015).
2. Recovery approaches provide recognition that individuals live in complex societies where there are many intersecting factors (biological, psychological, social, economic, cultural, and spiritual) which have an impact on health and well-being.

The nurses' role in recovery

Future nurses must understand how the recovery perspective guides nurses’ engagement with clients along the spectrum of care. Nurses can support recovery with the client by understanding the recovery perspective’s overarching guiding principles of dignity, hope, resilience, relationships, creating meaning of one’s life, and self-efficacy in each person’s unique and evolving journey (Deegan, 1988; Forchuk, 2003; Jacobson, 2012; Jacobson & Curtis, 2000). Nurses can also provide support by:

• Understanding recovery is personal and unique to each individual.
• Understanding each individual has a right to their own path and journey towards wellness.
• Honouring diversity.
• Being culturally responsive and safe.
• Facilitating interconnections between community and health-related resources for their care.
• Fostering and building positive environments that address clients’ true needs and fostering a culture and language of hope (Cirpili & Shoemaker, 2014 & Mental Health Commission of Canada, 2015).

Moreover, the perspective acknowledges that recovery is:

• A long-term process of internal change, and that these internal changes are processed through various stages (Substance Abuse and Mental Health Service Administration [SAMHSA], 2005).
• An ongoing process of refining oneself and learning to accept one’s vulnerabilities, overcoming stigma and discrimination, regaining hope, control, and responsibility in one’s life.
• Involves becoming engaged in meaningful social activities and community citizenship (Snow, 2010).

There is a concern expressed by mental health stakeholders that principles associated with the recovery approach, such as autonomy and peer accountability, will be used to limit or avoid providing services (MHCC, 2015), or, that by being assimilated into mainstream, there is a potential to turn recovery into a task which professionals ‘do’ or ‘facilitate’, rather than recovery being a process (Barker & Buchanan-Barker, 2005, p 238-239). In order to combat these obstacles to recovery, it’s important for nurses to develop and promote individualized care planning.

The Philip Barker’s Tidal Model, which emphasizes empowering interactions rooted in the lived experience of the client (Pagé, 2010), can be used to guide such strategies. Rather than conducting an assessment, the interaction is a nurse-client collaboration, where the nurses seek to understand who clients are by listening to their stories and perspectives (Barker, 2005). There are 10 commitments of the model and they include: value the voice; respect the language; develop genuine curiosity; become the apprentice; reveal personal wisdom; be transparent; use the available toolkit; craft the step beyond; give the gift of time; and, know that change is constant. Indeed, at the core of this model is change, so the nurse needs to be responding and adapting the focus to the changing needs of the client across the continuum of care (Pagé, 2010).

For more information, see Resources in this section.

Trauma is defined as an experience that overwhelms an individual’s capacity to cope (CCSA, 2012). Traumatic experiences occur at any age, and may include experiences such as child abuse and neglect to violence and war (CCSA, 2012). Trauma can interfere with a person’s sense of safety, self and self-efficacy as well as the ability to regulate emotions and navigate relationships (CCSA, 2012).

For those who have faced multiple traumatic events, repeated experiences of abuse, or prolonged exposure to abuse, trauma is overwhelming and may have a significant impact on living (CCSA, 2012; Klinic Community Health Centre, 2013; National Child Traumatic Stress Network, 2008). Moreover, people who access mental health and substance use treatments report trauma and violence as being common (CCSA, 2012). Specifically, evidence shows individuals who have experienced trauma are at greater risk for developing a substance use disorder (Macy & Goodbourn, 2012). People who have experienced trauma view their use of substances as a coping tool; however this can make them more vulnerable to substance use problems (CCSA, 2012). Trauma also affects a person’s mental health and can affect thinking, memory, attention and concentration (CAMH, 2012).

Educators in partnership with students need to develop an understanding of trauma-informed approaches to care and emphasize their use when assessing and treating all clients who use substances and/or may have a mental health condition, even when trauma is not suspected in clients (RNAO, 2015d).

Trauma-informed services focus on establishing a safe environment, where clients with trauma have choice and control; however, disclosure of trauma is not required (CCSA, 2012). Moreover, the use of trauma-informed approach in treatment does not require nurses to treat trauma, but rather a trauma-informed perspective results in a particular approach and acknowledges how common trauma is among clients who use substances, and the manifestation of trauma in their lives (RNAO, 2015d).

There are four key principles of trauma-informed approaches as outlined by the Canadian Centre on Substance Abuse. They include:

Reprinted from “Essentials of ... Trauma-informed Care,” by N. Poole, 2012, Canadian Network of Substance Abuse and Allied Professionals. Copyright 2012 by the Canadian Centre on Substance Abuse. Reprinted with permission.

Harm reduction is a pragmatic public health approach to practices, programs, and policies that aim to reduce the adverse health, social, and economic consequences of substance use without requiring individuals to abstain from substance use (CNA, 2011; Rassool, 2010).

The aim of a harm reduction approach is to reduce the negative consequences of risky behaviours, including the harmful effects of substance use (CNA, 2011; Rassool, 2010). As such, a harm reduction response recognizes that substance use is a complex phenomenon that encompasses a continuum of behaviours, ensures a non-judgmental provision of care, and advocates for equal access to resources and services for care, regardless of drug use or engagement in other at-risk practices (CNA, 2011). It also focuses on promoting harm reduction within the communities that clients live in and in the areas and conditions where substances are used, rather than in contexts that are removed from these settings (Rassool, 2010).

The dangers associated with substance use are not minimized in a harm reduction approach, which also recognizes the realities of poverty, racism, social isolation, past trauma, and other social inequalities that affect a person’s vulnerability and capacity to deal effectively with substance-related harm (Rassool, 2010). According to RNAO’s (2015) Engaging Clients Who Use Substances, harm reduction:

• Is an alternative to the disease causation model of substance use.
• Accepts that at any given time some people are not ready to choose abstinence.
• Accepts that substance use occurs in society and works to minimize its harmful effects
• Accepts that people who are substance-dependent should have a voice in the creation of programs and policies designed to serve them
• Values patient autonomy.
• Does not exclude abstinence as an option (Beirness, Jesseman, Notarandrea, & Perron, 2008; CNA, 2011).

Nurses should integrate principles of harm reduction when working with clients who use substances and when treating those at risk for or experiencing a substance use disorder, according to RNAO’s Engaging Clients Who Use Substances (2015). Harm reduction principles and approaches can also be used to support individuals physical and mental health (e.g., from engaging in unprotected sex to refraining from driving after drinking).

Applying a harm reduction framework allows nurses to tailor their approach in order to meet clients “where they are,” establish goals collaboratively with the client, and develop a client-centred plan of care, while building trust and autonomy in the nurse–client relationship (RNAO, 2009). However, before integrating the principles of harm reduction, nurses must be aware of and address their own attitudes and biases (RNAO, 2015d).

For more information, see Resources.

The definition of mental health is much more holistic than it once was. According to the Public Health Agency of Canada it is: “The capacities of each and all of us to feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional and spiritual well-being that respects the importance of culture, equity, social justice, interconnections, and personal dignity” (Public Health Agency of Canada, 2014, para 2). However, mental health and mental illness are not the same thing. Mental illness is “a recognized, medically diagnosable illness that results in the significant impairment of an individual’s cognitive, affective or relational abilities. Mental disorders result from biological, developmental and/or psychosocial factors and can be managed using approaches comparable to those applied to physical disease (i.e., prevention, screening, diagnosis, treatment and rehabilitation)” (Epp, J., 2009, p. 82).

The “mental health continuum” best describes the relationship between health and illness where they are not at opposite ends of a single spectrum but on a continuum (Keyes, 2002). Every person can flourish or languish somewhere along the mental health continuum, and this state can vary on a daily basis. Inherent in the mental health continuum is the understanding that mental health is not simply the absence of mental illness. Rather the model adopts the notion that individuals can experience complete mental health even if they have been diagnosed with a mental illness (Keyes, 2002). On the other hand, individuals who are free of a diagnosed mental illness can still experience poor mental health if they have poor coping mechanisms. A useful tool for gaining further insight is the 2015 First Nations Mental Wellness Continuum Framework, which views mental well-being as “a balance of the mental, physical, spiritual, and emotional” that gives everyone—even the most vulnerable or mentally ill—an opportunity to live whole and healthy lives (Health Canada, 2015).

There is a relationship between being resilient and having good mental health. People who are “resilient” are able to recover from difficulties or change and move forward as they were before the disruption (Khanlou & Barankin, 2007). However, people who are resilient can develop a mental illness, which may lower resiliency (Khanlou & Barankin, 2007). Because nurses working in all practice settings along the continuum of health care will care for people with varying degrees of mental health and illnesses, they should be aware of and understand ways to improve resiliency in their interactions. Furthermore, faculty should impart not only the importance of using mental and illness knowledge to care for and impact populations, but to take leadership roles in advancing mental health promotion and driving improvements in mental health care delivery (CFMHN, 2016). Promoting mental health in fact encourages the development of resilience by implementing strategies that build on community-based strengths, provide opportunities, create safe places and encourage supportive resiliency (Khanlou & Barankin, 2007, p. 10).

The Mental Status Examination (MSE)—a structured assessment of client’s behavioural and cognitive functioning—is a vital component of nursing care that assists with evaluation of mental health conditions. The MSE is analogous to the physical examination and is used to evaluate an individual’s current cogitative, affective and behavioural functioning (Varcarolis, 2014). Specifically, the MSE assesses a client’s current state including general appearance, mood and affect, speech, thought process and content, perceptual disturbances, impulse control, cognition, knowledge, judgment and insight (Lasiuk, 2015). The MSE can be used across clinical settings, not just in a psychiatric context, takes only a few minutes to administer and can generate information that is crucial for creating a plan of care (Robinson, 2008).

The acronym BEST PICK can assist with learning the main elements of an MSE (Carniaux-Moran, 2008). A brief description of the elements that are assessed includes:

• Behaviour and general appearance - age, sex, gender, cultural background, posture, dress/ grooming, manner, alertness, as well as agitation, hyperactivity, psychomotor retardation, unusual movements, catatonia, etc.
• Emotions: mood and state, emotional state and visible expression (state) including description and variability.
• Speech—rate, amount, style and tone of speech.
• Thought content and processes—abnormalities, obsessions, delusions and suicidal and homicidal thoughts and thought process as well as loose associations, tangential thinking, word salad, and neologisms, circumstantial thought, and concrete versus abstract thought.
• Perceptual disturbances—illusions and hallucinations.  
• Impulse control—ability to delay, modulate or inhibit expressions or behaviours.
• Cognition—consciousness, orientation, concentration and memory.
• Knowledge, insights and judgment—the capacity to identify possible courses of action, anticipate consequences, and choose appropriate behaviour, and extent of awareness of illness and maladaptive behaviours.

Source: Carniaux-Moran, C. (2008). The Psychiatric Nursing Assessement. In O’Brien, P.G., Kennedy, W.Z., Ballard, K.A. Psychiatric mental health nursing: an introduction to theory and practice.,Sudbury, MA: Jones & Bartlett.

Based primarily on observational data gathered by nurses and interview questions, the MSE can be used to establish a baseline, evaluate changes over time, facilitate diagnosis, plan effective care, and evaluate response to treatment in clients with mental health and addiction.

For more information, see Appendix I: Components of a Mental Status Assessment, pg. 96 in RNAO’s BPG Assessment and Care of Adults at Risk for Suicide Ideation and Behaviour.

Self-harm is the expression of inner pain, hopelessness and helplessness experienced by people. Self-harm can be due to suicidal thoughts, a coping mechanism to gain control over one’s body and to simply feel better and get relief from pain (Moore & Melrose, 2014 & CMHA, 2016). Acts of self-harm can include cutting skin, burning skin, hitting oneself to the point of injury and preventing wounds from healing (CMHA, 2016). Self-harm can affect anyone, and is experienced more frequently by adolescents and females (CMHA, 2016). Self-harm is also more likely to affect those who have experienced trauma, have issues with coping and among those with low self-esteem (CMHA, 2016). It is important for health-care professionals to recognize that self-harm behaviours pose a high risk for completed suicide. Health-care professionals must also recognize the stigma associated with self-harm and understand counter transference and trauma associated with it.

Suicide is an abrupt ending to life and is the most extreme way in which individuals respond to overwhelming situations and stress (RNAO, 2009c). Some literature indicates that suicide can be elevated among youth, elderly, indigenous peoples, LGBTQ populations and those who are incarcerated (RNAO, 2009c). Mood disorders, which includes depression, are the most common psychiatric condition associated with suicide (Jamison, 2000). According to the Centre for Addiction and Mental Health (2016), between 20 percent and 60 percent of death by suicide occurs in this community. Other high risk groups include:

• People with bipolar depression—suicide risk is 15 times that of the general population.
• People with schizophrenia—the lifetime risk of suicide is 4 to 7 percent (and a 40 percent risk of suicide attempts).
• People with concurrent addiction—experience higher suicide rates.
• Persons who use and misuse substances—they often have several other risk factors for suicide such as being depressed or having issues pertaining to social health determinants such as social or financial difficulties.

Source: Centre for Addiction and Mental Health, 2016

Suicide is a complex phenomena influenced by biological (i.e., genetics), physical, psychological, spiritual, social, economic, historical, political, cultural and environmental factors (RNAO, 2009c). Many individuals are affected by suicide in Canada. Given the pervasiveness of suicide among these communities, health-care practitioners’ ability to recognize and address suicidality can be a life-saving skill (CAMH, 2016). Specifically, nurses have a significant role in intervening when individuals express suicidal ideation and behaviour (RNAO, 2009). Understanding risk factors and warning signs may help nurses identifying clients at risk of suicide.

RNAO’s Best Practice Guideline Assessment and Care of Adults at Risk for Suicide Ideation and Behaviour states, “A comprehensive assessment of risk involves interviewing the client, reviewing the medical records and/or gathering information from family or significant others” (RNAO, 2009, p. 31). In addition to a mental status examination (MSE), a comprehensive assessment regarding suicidal ideation and plan, a clinical interview and use of valid and reliable assessment tools may be used to gather information specific to:

• Presence of risk factors.
• Lack or presence of protective factors (e.g., spirituality, hope, future orientation, cultural and/ or spiritual factors).
• Suicidal intent.
• Plan.
• Lethality.
• Access to means.
• Time frame.
• Hope.
• Previous suicide attempts.

Source: RNAO, 2009

When the risk of suicide is identified, nurses should also work to develop a therapeutic relationship with the client and their family, as appropriate (RNAO, 2009c). Furthermore, nurses need to develop safety plans in collaboration with clients.

A safety plan indicates how clients should respond to their suicidal urge by outlining coping and problem-solving skills and abilities (Centre for Applied Research in Mental Health and Addiction [CARMHA], 1996). For a template of a safety plan see Appendix F.

For more information, see Resources in this section.

A crisis is defined as: “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 cope by means of 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. It is recognized that a crisis state is subjective and as such may be defined by the client, the family or other members of the community” (Hoff, 1995; Ontario Ministry of Health and Long-Term Care, 1999ab; RNAO, 2006).

Nurses have an important role to play in delivering effective crisis intervention to meet the needs of clients experiencing a crisis (RNAO, 2006). Evidence demonstrates that crisis care should be incorporated into all areas and units of health care and used when working with clients (RNAO, 2006). It is important for nurses to recognize that crisis intervention is integral for all environments and contexts where care is provided, including hospital and community settings (RNAO, 2006).

Models of crisis intervention

A crisis intervention is defined as: “A process that focuses on resolution of the immediate problem through the use of personal, social and environmental resources (Hoff, 1995). The goals of crisis intervention are rapid resolution of the crisis to prevent further deterioration, to achieve at least a pre-crisis level of functioning, to promote growth and effective problem solving, and to recognize danger signs to prevent negative outcomes [Hoff, 1995]” (RNAO, 2006, p. 16).

Crisis theorists postulate that there are three core components to any crisis.

1. A precipitating event that produces an experience of stress;
2. Perception of the event that leads to feelings and emotions that are overwhelming or confusing.
3. Compromised coping mechanism that does not allow the individual to function emotionally, occupationally and interpersonally.

Source: RNAO, 2006.

While there are many models of crisis intervention, in any crisis intervention the focus is always on increasing the client’s level of social, occupational, cognitive and behavioural functioning (RNAO, 2006). Crisis intervention uses a client-centred approach that takes into consideration the client’s unique rights, feelings, values, perceptions and wishes (RNAO, 2006). While tools (e.g., interview guides, mental status, risk assessment etc.) may aid in assessment by providing a structured approach to the process, they are not a substitute for empathy, knowledge, clinical judgment and expertise.

It is worth noting that experienced and trained nurses usually apply all phases of the crisis framework and move beyond assessment and referral to include creative problem-solving strategies—which encompass social determinants of health (RNAO, 2006). Too often nurses assume that some clients are incapable of problem-solving and never proceed beyond risk assessment and referral. “Moving out of one’s comfort zone and making changes to one’s clinical practice involves education, risk taking and an openness to change. Nurses need to assume initiative and responsibility for lifelong learning to maintain currency and competence within their multi-faceted crisis intervention roles” (RNAO, 2006, p 31).

For more information, see Resources in this section.

Mental health and illness in Canada is greatly influenced by legal factors, among other factors including cultural, environmental, historical, physiological, psychological, spiritual and socioeconomic factors (Kent-Wilkinson, 2015). The impact of the law on individuals can be complex. For example, legislation can have effects related to access to health-care services and treatment for those experiencing mental health and/or addiction issues. Therefore it is imperative that nursing students and nurses understand legislation and their professional accountability when working with clients with mental health, illness and addiction issues.

Canada, in comparison to many other countries, has comprehensive mental health policy, programs and legislation (Austin & Boyd, 2015). In regards to policy, in 2009, the Mental Health Commission of Canada developed an initial framework for a national mental health strategy, Toward Recovery and Wellbeing (MHCC, 2009). It contends that while appropriate legislation must be in place to protect anyone at risk from people living with mental health problems and illnesses, such legislation also represents power imbalances by providing the ability for care providers to impose safety measures on them, which is the “ultimate in loss of control” (MHCC, 2009, p 30). Therefore, it states a principle of recovery-oriented mental health policy and legislation must be employed.

Across Canada, each province and territory has its own Mental Health Act (see Resources) which greatly impacts the provision of care including treatment decisions and involuntary hospitalizations for individual experiencing mental illness and/or addiction (Gray & O’Reilly, 2001). Mental Health Acts rule over decisions made regarding competence—and the evaluation of competence—and what actions can be taken in cases where a person is ruled not competent. There are differing basic criteria for involuntary admission between provinces. As well, legislation impacts access to care through mechanisms such as consent from substitute decision makers, mandatory outpatient treatment (MOT), court-ordered outpatient treatment for clients who are unlikely to be compliant without a court order, and community treatment orders (CTO), an order issued by a physician and agreed to by the client that allows them to receive care and treatment in their community (Kent-Wilkinison, 2015).

Without an understanding of provincial legislation that governs treatment decisions and involuntary hospitalization, nurses will be unable to adequately care for, or advocate on behalf, of clients with mental illness and addiction. The CFMHN’s Canadian Standards for Psychiatric-Mental Health Nursing, 4th edition, (March 2014), establishes the maintenance of quality care and provides direction for safe, competent, ethical professional practice, which includes standards that nurses have knowledge about relevant legislation and strive towards client and system level advocacy, to improve quality of care and mental health services. These standards also call for the reduction of stigma, and to promote social inclusion and community integration for clients.

For more information, see Resources in this section.

Every nurse is responsible for upholding ethical practice standards. In Canada, the Canadian Nursing Association’s (2008) Code of Ethics for Registered Nurses provides guidance regarding ethical values for nurses and their client’s health-care needs. This resource is intended for all context and domains of nursing practice, and is also an excellent resource for nurses working with clients who have mental health or illness conditions and addiction.

Because “the expression of mental illness is heavily determined by culture” (Kent-Wilkinson, 2010, p. 31), it is imperative that nursing students understand and demonstrate cultural competency and cultural safety when caring for individuals with mental illness and addiction. Cultural competency is “the application of knowledge, skills, attitudes and personal attributes required by nurses to provide appropriate care and services in relation to the cultural characteristics of their client” (CNA, 2010, p. 1). Nurses first develop an awareness of one’s self and understand that cultural differences exist. It is also important to be aware that one’s own culture is not superior to that of others. Nurses caring for people with mental illness with a whole-person and recovery-oriented view must also be willing to learn about other people’s cultures, and respect the differences in culture and be willing to incorporate that knowledge into practice and educational curricula (Kent-Wilkinson, 2015).

Due to the complex nature of mental illness, nurses may face ethical dilemmas when working with this population, such as issues relating to client autonomy and restraint. Nursing students need to be well-prepared for a variety of ethical dilemmas, including voluntary and involuntary care, that will arise when working with people with mental illness and addiction. They should be taught the skills and knowledge to proactively and reactively manage the unpredictable.

For more information, see Resources in this section.

According to the WHO, “Advocacy is an important means of raising awareness on mental health issues and ensuring that mental health is on the national agenda of governments. Advocacy can lead to improvements in policy, legislation and service development” (WHO, 2003, p. 1). Every nurse has the opportunity—and professional ethical responsibility—to advocate for improvements and advancements in health care for persons with mental health, illness and addiction.

Ensuring future nurses have knowledge of mental health legislation, and the health-care system, is vital to identifying improvements and strengthening mental health and addiction services. However, in order to advocate for change, it is also necessary to understand political and organizational culture, and its impact on the provisions of care. Establishing and maintaining collaborative processes within inter- and intra-professional practice teams, understanding person-centred care and leadership is important when caring for clients with complex mental health and addiction conditions (RNAO, 2006a). For more information, see Resources in this section.

Clinical learning experience in nursing education provides students the opportunity to consolidate theory and practice together. It is through clinical placements that nursing students develop and refine their skills in therapeutic relationship, person and family-centred nursing care, among other foundations learned in nursing school.

Mental health and psychiatric nursing clinical placements among undergraduate nursing students have been successful in generating interest in this area (O’Brien, Buxton & Gillies, 2008). Studies regarding clinical learning have demonstrated that student satisfaction with mental health content is positively correlated to performance, as well as to a correlation between clinical placement in mental health and interest post graduation in working in mental health (Spence, 2012 & Happell,
Moxham & Platania-Phung, 2009). However the current challenge with securing clinical mental health and addiction placements presents a gap in placement opportunities in acute care inpatient psychiatric settings, according to the 3rd position paper 2016: Mental health and addiction curriculum in undergraduate nursing education in Canada (CFMHN, 2016).

There are a number of factors to consider when planning a clinical placement for students. CASN, with the input of nursing educators from across Canada, has developed recommendations for clinical placements and simulation. The framework for these recommendations is applied here. Many of the concepts in the content below can be demonstrated in the placements such as community, med surgical, acute care etc.

The following themes were identified in the literature with regards to timing and length of mental health and addiction clinical practice.

1. Theory preparation prior to placement.
Prior to clinic placement, it is important for nursing students to have some theoretical preparation to support implementation of evidence-based practice. For example, nursing students should receive some theory related to medication administration and be knowledgeable of the concepts of compliance and adherence, and be comfortable with the pharmacokinetics of psychiatric medications before administering medications in a clinical setting.

2. Length of placement.
The length of the placement should be sufficient to meet the learning objectives, e.g., traditional length placement (Fiedler, Breitenstein & Delaney, 2012); and short, intensive placement (Tratnack, O’Neil, & Graham, 2011). The CFMHN recommends a stand-alone course in psychiatric/mental health and a dedicated clinical placement in a psychiatric setting (CFMHN, 2016; Happell, Gaskin, Byrne & Welch, 2015).

The literature demonstrates positive outcomes related to reduction in stigma and fear when students are provided opportunities to interact with clients who experience mental illness and/or addiction, across all settings including psychiatric settings. Students who interact with these clients report less fear and stigma towards their patients. Outcomes related to placements in mental health and addiction placements include the following:

• Improved attitudes towards patients with mental illness;
• Increased confidence in caring for people with mental illness/mental health concerns;
• Increased understanding of psychiatric nursing;
• Safe medication administration;
• Improved therapeutic communication;
• Improved assessment skills; and
• Increased use of holistic approaches to care.

Collaboration between clinical instructors, simulation coordinators and faculty members who teach mental health theory courses improves consolidation of learning. As clinical instructors and preceptors play an important role in changing students’ attitudes towards mental health psychiatric nursing, clinical instructors and preceptors should have experience in psychiatric mental health nursing where possible.

Furthermore, preceptors should:

• Encourage diverse learning experiences;
• Help identify transferable skills;
• Foster a positive image of mental health nursing;
• Have regular contact with students; and
• Give consistent and regular feedback.

Student and preceptor difficulties arise when preceptors:

• Don’t understand their role;
• Have unrealistic expectations of the student;
• Have heavy work loads that limit their ability/time to interact with students; and
• Have negative attitudes to mental health/psychiatric nursing.

Source: O’Brien et al., Oudshoorn & Sinclair, 2015; Charleston & Happell2 005, 2006; Cleary, Horsfall, & De Carlo, 2006. Such obstacles provide challenges to student placements and can also create negative perceptions, attitudes and stigma among nursing students.

Orientation
A well thought out orientation promotes a positive student placement.

• Include orientation of the unit or site prior to the placement.
• Include a review of learning objectives.

Daily pre-conferences

• Ensure that students are prepared for their patient/client assignments.
• Highlight potential learning experiences that students may be able to engage in that day.
• Address student concerns.

Daily post-conference

• Reflect on clinical experiences.
• Engage in further learning.
• Share experiences among students.

Critical incidents

• Students should be debriefed according to workplace policy.

Reflective practice

• See Section Four: Student Reflective practice and Self-Care in Mental Health Nursing Education

Source: Woodley, 2015; Ganzer & Zauderer, 2013; O’Brien, 2008; Oudshoorn & Sinclair, 2015

Other important clinical placement considerations include:

• Ensuring the practice experience supports the learning objectives (Medley & Horne, 2005; Seropian et al., 2004);
• Facilitators play an integral role in student learning; and
• Efforts should be made to develop collaborative partnerships between health-care organizations and colleges/universities; consider the use of co-creating learning objectives where possible.

For more information, see Resources in this section.

According to the CASN’s Practice Domain for Baccalaureate Nursing Education: Guidelines for Clinical Placements and Simulations (2015), the challenge of securing clinical placements for students has driven a search for alternative strategies for practice experiences. Placements have become wide-ranging (Smith, Corso & Cobb, 2010), and simulation is being increasingly used to prepare students for practice. Some educators see simulation as valuable learning opportunities that are complementary to clinical placements, others have introduced it as a substitute.

“While both clinical placements and simulation provide opportunities for students to develop practice outcome expectations, there are some important differences in the practice experiences they offer. As a result, there are also some differences in the nature of the learning they foster” (CASN, 2015, p. 9). Students in clinical placements can experience unplanned, unpredicted and uncontrolled events that can provide teachable moments. This is helpful for experiencing reallife scenarios; whereas in a controlled simulation nurses can make mistakes without real-life consequences and learn from them. The expert panel recommends that simulation should be used to augment clinical placement opportunities and not replace them.

A useful tool that shows how the differences between the experiences offered by simulation and by clinical placements affect the nature of the learning they foster can be found in the CASN’s Guidelines for Clinical Placements and Simulations (2015), Table 3.

Students should have some foundational theory based concepts prior to engaging in a simulation experience. The length of the simulation is directly related to the type of simulation and the learning objectives. The following demonstrates the type of simulations, factors to be considered and proficiency of instructors in simulation and pedagogy approaches that can be used.

Selection of the simulation

There are three major levels of simulation fidelity: low, medium and high.

• Low fidelity—used to practice psychomotor skills, e.g., a foam pad simulator used to practice intramuscular injections.
• Medium fidelity—more closely resembles reality and can be used to provide more in-depth learning opportunities, e.g., perfecting an understanding of heart sounds.
• High fidelity—sophisticated and mimics real life, e.g., computer or instructor controlled mannequins.

When using simulation, the following factors should be considered:

• Live actors should be used when possible in place of mannequins;
• Caution against student role-playing that can reinforce pre-existing stigma;
• Consider the use of multiple simulations that increase in complexity; and
• Simulation doesn’t have to be expensive to be effective.

Simulation experiences are valuable learning opportunities for students that can help to consolidate their learning. It is important for educators to remember that simulation is not a replacement to clinical practice, however provides a resource to augment theory into the practice environment (RNAO, 2016e). Educators should determine compatibility and select the level of simulation in accordance with the learning objectives for nursing students. Educators may also consider the use of co-creating learning objectives, wherever possible to provide students the opportunity to identify their learning needs. It is also imperative that students are taught the fundamental basics/concepts prior to engagement in a simulation experience.

Quality of instruction

Collaboration between clinical instructors, simulation coordinators and faculty members who teach mental health theory courses improves consolidation of learning. Instructors should be comfortable and proficient with the types of simulation or technology being used. In addition to having knowledge of the learning outcomes, they should have the mental health knowledge and skills needed to integrate theory and practice and debrief with students.

Source: Happell, Gaskin, Byrne & Welch, 2015; Oudshoorn & Sinclair, 2015; RNAO, 2016

Pre-briefing

• Familiarize students with the technology and equipment.
• Discuss the learning objectives, participant roles, and details surrounding the simulation scenario.

Actual simulation scenario

• Students work together in teams and actively participate in the decision-making processes related to the nursing care in the simulated clinical situation.

Debriefing

• Time is dedicated toward group discussion, feedback and integrated learning.
• Debriefing is an activity that aims to strengthen the positive aspects of the experience and promotes reflective student learning.

For more information, see Resources in this section.

• American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
• Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation journal, 16(4),11.
• Barker, P. & Buchanan-Barker, P. (2005). The Tidal Model: A guide for mental health professionals. East Sussex, UK: Routledge.
• Beirness, D. J., Jesseman, R., Notarandrea, R., & Perron, M. (2008). Harm Reduction: What’s in a name? Ottawa, ON: Canadian Centre on Substance Abuse.
• Bland, A. (2011). A concept analysis of simulation as a learning strategy in the education of undergraduate nursing students. Nurse Education Today. 31(7), 664-70.
• Boud, D., Keogh, R., & Walker, D. (1985). Reflection: Turning Experience into Learning. London, UK: Kogan Page.
• Browne, G., (2012). The therapeutic relationship and Mental Health Nursing: It is time to articulate what we do! Journal of Psychiatric and Mental Health Nursing. 19(9),839-843.
• Caldwell, L. (2013). The importance of reflective practice in nursing. International Journal of Caring Sciences. 6(3), 319.
• Canadian Centre on Substance Abuse. (2012). Trauma-informed Care Toolkit. Ottawa, ON: Author.
• Canadian Mental Health Association. (CMHA). (2016). Suicide. Retrieved from http://www.cmha.ca/ mental-health/understanding-mental-illness/suicide/
• Canadian Nurses Association (CNA). (2002). Achieving excellence in professional practice: A guide to developing and revising standards. Ottawa, ON: Author.
• Canadian Nurses Association (CNA). (2010). Position statement: Promoting culturally competent care. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/ps114_cultural_ competence_2010_e.pdf?la=en
• Canadian Nurses Association (CNA). (2011). Harm reduction & criminally illegal drugs: Implications for nursing policy, practice, education and research. Ottawa, ON: Author.
• Carello, J., & Butler, L. D. (2015) Practicing what we teach: Trauma-informed educational practice. Journal of Teaching in Social Work, 35(3), 262–278.
• Carniaux-Moran, C. . (2008). The Psychiatric Nursing assessment. In O’Brien, P.G., Kennedy, W.Z., Ballard, K.A. Psychiatric mental health nursing: An introduction to theory and practice. Sudbury, MA: Jones & Bartlett
• Centre for Applied Research in Mental Health and Addiction. (CARMHA). (1996). Working with the Client Who is Suicidal. A tool for adult mental health and addiction services. Retrieved from http:// www.health.gov.bc.ca/library/publications/year/2007/MHA_WorkingWithSuicidalClient.pdf
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The expert panel has compiled a list of resources and websites that may be helpful related to mental health, illness and addiction. This list is not exhaustive.

Links to websites that are external to RNAO are provided for information purposes only. The RNAO is not responsible for the quality, accuracy, reliability, or currency of the information provided through these sources. Further, the RNAO has not determined the extent to which these resources have been evaluated. Questions related to these resources should be directed to the source.

Aboriginal people

Section 35(2) of Canada’s Constitution Act, 1982, defines “Aboriginal people” as Indian (First Nations), Inuit, and Métis people (Government of Canada, 1982).

Acute Stress Reactions

A psychological condition that involves a rapid response to an abrupt, single, easily identified stressor and often responds positively to some form of intervention. For example, a person may experience acute stress in response to a negative situation such as an unexpected bereavement, conflict in the workplace or commencing a new position (Bergerman, Corabian, & Harstall, 2009; Kendall, Murphy, O’Neill & Bursnall, 2000).

Addiction

“Used as an umbrella term inclusive of substance misuse, substance abuse, substance dependence, and process addictions such as gambling” (Kent-Wilkinson et al., 2015, p. 21).

Advocacy

“Advocacy” is defined as verbal support or argument for a cause or policy. Simply put, it is telling your story to a decision maker, through various means, in order to compel that person to do something. Most commonly, advocacy is directed towards government and decision makers. In the area of mental health, individuals and organizations advocate for a wide variety of reasons, including improved access to services and improved benefits and supports for people with mental illness. A successful advocacy effort can take some time to produce results. But each time you speak on behalf of your chosen issue, you raise awareness and build support (Schizophrenia Society of Canada, 2016).

Burnout

Describes a state of being that is characterized by emotional exhaustion, depersonalization, and a reduced feeling of personal accomplishment. Burnout develops as a result of general occupational stress (National Child Traumatic Stress Network, 2016).

Clinical Supervision

The development of clinical learning within a practice setting between an experienced supervisor and a beginner or novice supervisee. “Supervision occurs in conjunction with working with patients and varies according to the supervisor, the workload of the unit and the atmosphere of the setting” (Haggman et al., 2007, p. 382).

Community Treatment Orders (CTO)

A community treatment order (CTO), a form of mandatory outpatient treatment MOT, is an order to provide a comprehensive plan of community-based treatment to someone with a serious mental disorder. CTOs are only issued for persons with severe mental illness and with a history of hospitalization who have been examined by a physician and been deemed in need of continuing treatment and care while residing in the community (Canadian Mental Health Association [CMHA], 2013). See Resources in Section 6.1. CTOs are less restrictive than being detained in a psychiatric facility and serve as an alternative to hospitalization (CMHA, 2013).

Collaborative Practice

“In health care, occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers and communities to deliver the highest quality of care across settings. Practice includes both clinical and nonclinical health-related work, such as diagnosis, treatment, surveillance, health communications and management” (World Health Organization, 2010, as cited in Registered Psychiatric Nurse Regulators of Canada [RPNRC], 2014, p. 24).

Competencies

“Competencies are complex know-acts based on combining and mobilizing internal resources (knowledge, skills, attitudes) and external resources and applying them appropriately to specific types of situations” (Tardif, 2006).

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 cope by means of 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. It is recognized that a crisis state is subjective and as such may be defined by the client, the family or other members of the community (Hoff, 1995; Ontario Ministry of Health and Long-Term Care, 1999ab; RNAO, 2006).

Crisis Intervention

A process that focuses on resolution of the immediate problem through the use of personal, social and environmental resources (Hoff, 1995). The goals of crisis intervention are rapid resolution of the crisis to prevent further deterioration, to achieve at least a pre-crisis level of functioning, to promote growth and effective problem solving, and to recognize danger signs to prevent negative outcomes (Hoff, 1995; RNAO 2006).

Critical Reflection

Critical Reflection involves looking back on experience(s) so as to learn from them and gain new or deeper understanding about practice development and/or develop alternative ways of acting when leading and/or facilitating practice development or related activities. It is also about connecting personal learning and ways of knowing with other types of learning and knowledge knowledge (Foundation of Nursing Studies [FoNS], 2013).

Culture

“Culture is commonly understood as learned traditions and unconscious rules of engagement that people use to interpret experience and to generate social behaviour” (Srivastava, 2007, p. 324). Canada’s mental health strategy has emphatically asserted that in service and treatment of mental health, culture counts (Mental Health Commission of Canada [MHCC], 2012).

Cultural Competence

Cultural competence is the application of knowledge, skills, attitudes, and personal attributes required by nurses to maximize respectful relationships with diverse populations of patients (patients may be individuals, families, groups, or populations) and co-workers. “Underlying values for cultural competence are inclusivity, respect, valuing differences, equity and commitment” (CNA, 2010; RNAO, 2007, p. 19). Cultural competence is considered an entry-to-practice competence that is evident in quality practice environments and improves health outcomes (CNA, 2010). Cultural competence is an ongoing process and requires continuous skill development, self-evaluation, and growing knowledge about different cultural groups (Kersey-Matusiak, 2012, p. 34).

Cultural Safety

Cultural competence and cultural safety are prerequisites for working effectively in global health (CNA, 2010). Cultural safety is both a process and an outcome whose goal is greater equity. It focuses on root causes of “power imbalances and inequitable social relationships in health care” (Aboriginal Nurses Association et al., 2009; Kirkham & Browne, 2006, as cited in Browne et al., 2009, p. 168).

Family

A term used to refer to individuals who are related (biologically, emotionally, or legally) to and/or have close bonds (friendships, commitments, shared households and child rearing responsibilities, and romantic attachments) with the person receiving health care. A person’s family includes all those whom the person identifies as significant in his or her life (e.g., parents, caregivers, friends, substitute decision-makers, groups, communities, and populations) (RNAO, 2015). The person receiving care determines the importance and level of involvement of any of these individuals in their care based on his or her capacity (Saskatchewan Ministry of Health, 2011).

Harm Reduction

“‘Harm Reduction’ refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community” (International Harm Reduction Association, 2010, p. 1).

Human Rights

In accordance with the objectives of the UN Charter and international agreements, a fundamental basis for mental health legislation is human rights. Key rights and principles include equality and nondiscrimination, the right to privacy and individual autonomy, freedom from inhuman and degrading treatment, the principle of the least restrictive environment, and the rights to information and participation (Kent-Wilkinson, 2015, p. 36; UN, 1991).

Mandatory Outpatient Treatment (MOT)

Mandatory outpatient treatment (MOT) involves legal provisions requiring people with a mental illness to comply with a treatment plan while living in the community (O’Reilly et al., 2003).

Mental Disorder

“A health condition characterized by alterations in several factors that include mood, affect, behaviours, thinking and cognition. The disorders are associated with various degrees of distress and impaired functioning” (Austin & Boyd, 2009, as cited in CFMHN, 2014, p. 13).

Mental Health

A term used to mean all diagnosable mental disorders (Austin and Boyd, 2010).

Mental Illness

“Characterized by alterations in thinking, mood or behaviour—or some combination thereof— associated with significant distress and impaired functioning. 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. Mental illnesses take many forms, including mood disorders, schizophrenia, anxiety disorders, personality disorders, eating disorders and addictions such as substance dependence and gambling” (PHAC, 2006, para 2).

Mental Health Act

A Mental Health Act is a law that gives certain powers and sets the conditions (including time limits) for those powers, to stipulated health-care professionals and designated institutions regarding the admission and treatment of individuals with a mental disorder. It also provides a framework for mental health delivery of services and establishes rules and procedures that govern the commitment of persons suffering from mental disorders (Government of Saskatchewan, 2013).

Mental Health Legislation

The fundamental aim of mental health legislation is to protect, promote, and improve the lives and mental well-being of citizens (WHO, 2005).

Mentoring

The act of engaging in mentorship. Mentoring is less formal than preceptoring and involves a longer-term professional relationship between a novice nurse or nursing student and a more experienced nurse. Mentoring tends to be less formally instructional and more encouraging of positively influencing those with less experience through role modeling and guidance (CNA, 2004).

Not Criminally Responsible due to a Mental Disorder (NCRMD)

Separate from mental health legislation are the legal provisions that can require people to follow treatment as a condition of probation. The law allows for persons to be found Not Criminally Responsible due to a Mental Disorder for an offence if they are suffering from a mental disorder that makes them incapable of appreciating the nature of the act or knowing that what they did was wrong. In these cases, the mentally ill offender needs to comply with treatment monitored by the Criminal Code Review Boards (Kent-Wilkinson, 2015).

Occupational Stress

An individual’s physiological and psychosocial response to work stress that can result in harm psychologically, emotionally and physically. Depending on professional, personal and workplace factors, occupational stress often influences an individual’s capacity to cope with workplace situations and function at their professional and personal capacities (WHO, 2016; Bergerman, Corabian, & Harstall, 2009).

Post Traumatic Stress Disorder

Develops as a delayed and/or deferred response to an acute stressful event or situation (either short- or long-lasting). This event usually has a particularly threatening or catastrophic nature, with the potential to cause pervasive distress in almost anyone (Nowrouzi et al., 2015).

Preceptor

An experienced nurse who provides individual guidance to a student (Bourbonnais & Kerr, 2007). A “frequently employed teaching and learning method using nurses as clinical role models. It is a formal, one-to-one relationship of pre-determined length, between an experienced nurse (preceptor) and a novice (student/preceptee) designed to assist the novice in successfully adjusting to and performing a new role” (CNA, 2004, p. 13).

Recovery

“Recovery involves a process of growth and transformation as the person moves beyond the acute distress often associated with a mental health problem or illness and develops new-found strengths and new ways of being” (MHCC, 2009; RNAO, 2015).

Recovery-Oriented Practice

A recovery-oriented approach is “inclusive, participatory, and seek involvement of patients, families, and staff to advance mental health and well-being” (MHCC, 2015). Unlike other models of care, which often involve symptom alleviation and clinical recovery, recovery-oriented health care seeks to understand the unique lived experiences of patients and families, and to personalize the recovery process (Allott & Loganathan, 2002).

Reflective Practice

Reflective practice is the process of examining ones actions and experiences for the purpose of developing one’s practice and clinical knowledge with the outcome of acquiring a new understanding and appreciation of the situation (Boud, Keogh, & Walker, 1985; Caldwell, 2013).

Role Modeling

The process of an experienced nurse demonstrating skills and behaviours to beginner or novice nursing students. Role modeling is more than simply imitation of behavior; it requires repetition, reinforcement, and reward in the form of feedback (Donaldson & Carter, 2005).

Self-care

Self-care refers to activities and practices engaged on a regular basis to reduce stress and maintain and enhance short- and longer-term health and well-being. Self-care is necessary for effectiveness and success in honouring professional and personal commitments (University at Buffalo, 2016).

Secondary Trauma

Secondary trauma refers to the emotional duress that results when an individual hears about the first-hand trauma experiences of another. Individuals affected by secondary stress may find themselves re-experiencing personal trauma or notice an increase in arousal and avoidance reactions related to the indirect trauma exposure. They may also experience changes in memory and perception; alterations in their sense of self-efficacy; a depletion of personal resources; and disruption in their perceptions of safety, trust, and independence (NCTSN, 2016).

Social Determinants of Health

The conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at the global, national and local levels. The social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries (WHO, 2014, “What are social determinants of health”, para. 1). The social determinants of heath include income and  social status, education, biology and genetics, and health services, among other determinants. Health inequities—the differences in the health of individuals that result largely from the social determinants—are socially produced (and therefore modifiable), systemic in their distribution across the population, and unfair (National Collaborating Centre for Determinants of Health, 2013).

Stigma

Stigma is the negative, unfavourable attitudes and the behaviour they produce associated with a particular trait displayed by or activity engaged in by an individual or group (MHCC, 2013a).

Substitute Decision Maker

“If a person is incapable of making a decision with respect to a treatment, consent may be given or refused on his /her behalf by another person. In order of hierarchy, the substitute decision-maker is: the incapable person’s court-appointed guardian; attorney for personal care; a representative appointed by the Consent and Capacity Board; a spouse or partner; a child or parent; a parent of the incapable person who has only a right of access; a brother or sister; or any other relative (Health Care Consent Act, 1996, s. 20[1]). The provincial Public Guardian and Trustee is the substitute decision-maker of last resort if there is no other appropriate person to act for the incapable person (Government of Ontario, 1999).

A substitute decision-maker may give or refuse consent only if he or she (Health Care Consent Act, 1996, s. 20):

1. Is capable of understanding the proposed treatment;
2. Is at least 16 years old, unless he or she is the incapable person’s parent;
3. Is not prohibited legally from having access to the incapable person or giving or refusing consent on his or her behalf;
4. Is available; and
5. Is willing to assume the responsibility of giving or refusing consent.

A patient/resident cannot name a health-care practitioner, their health team or anyone else who provides them with health care as their attorney in a power of attorney for personal care, unless that person is a spouse, partner or relative (Substitute Decisions Act, 2992, s. 46[3]). The substitute decision-maker will cease to act on behalf of an incapable person if he/she should regain capacity” (RNAO, 2011, p. 93)

Therapeutic Relationship

“A relationship grounded in an interpersonal process that occurs between the nurse and the client(s). The therapeutic relationship is purposeful, goal-directed relationship intended to advance the best interest and outcome of the client” (RNAO, 2002 b, as cited in CFMHN, 2014, p. 13).

The case study is an effective teaching strategy that is used to facilitate learning, improve critical thinking, and enhance decision-making Sprang, (2010). Below are nine case studies that educators may employ when working with students on mental illness and addiction. The case studies provided cover major concepts contained in the RNAO Nurse Educator Mental Health and Addiction Resource.

While not exhaustive, the case studies were developed and informed by the expert panel. It is recommended that educators use the case studies and tweak or add questions as necessary to impart essential information to students. Also, educators are encouraged to modify them to suit the learning objective and mirror the region in which the studies are taking place. Potential modifications include:

51. demographics (age, gender, ethnicity);
52. illness and addiction, dual diagnosis or additional co-morbidities such as cardiovascular disease; and
53. setting (clinical, community).

Suggested “Student questions” explore areas of learning, while “Educator elaborations” recommend ways to modify the case study. Discussion topics are a limited list of suggested themes.

When using these case studies, it is essential that this resource is referenced.

See Engaging Clients Who Use Substances BPG appendices for examples