Section Five

Foundational Concepts and Mental Health Skills in Mental Health and Addiction Nursing

Foundational Concepts and Mental Health Skills in Mental Health and Addiction Nursing
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Section Five

The Entry-to Practice Mental Health and Addiction Competencies (2015) developed by CASN/ CFMHN supports the development of knowledge and skill in mental health, illness and addiction nursing including four core nursing foundational concepts and four areas for mental health skill development. This section provides useful information about each foundational concept and skill, focusing on teaching tools and learning advancement that integrate the corresponding mental health and addiction competencies in curricula.

 

Four Foundational Concepts

Four Mental Health Skills
5.1 Theraputic Relationships 5.5 Mental Health and Illness
5.2 Recovery Oriented Approach 5.6 Mental Status Examination (MSE)
5.3 Trauma-Informed Care 5.7 Suicide Risk Assessment and Self-Harm
5.4 Harm Reduction 5.8 Crisis Intervention

 

Therapeutic Relationships Teaching activities and resources

Therapeutic Relationships Teaching activities and resources

Outcomes

Purpose

This section supports educators with the knowledge and skills required to incorporate the foundational concept of therapeutic relationships into mental health and addiction entry-level nursing curricula.

Outcomes

At the end of this section, the educator will:

  • At the end of this section, the educator will ensure students achieve the following:
  • Identify the definition, purpose and theories which inform the nurse-client therapeutic relationship.
  • Recognize and understand different phases of the therapeutic and non-therapeutic relationship.
  • Recognize professional boundaries, counter transference, transference, and power dynamics of the nurse-client therapeutic relationship.
  • Understand concepts of therapeutic use of self in providing care (i.e., health promotion, prevention, supportive care).
  • Understand and implement effective therapeutic communication skills (i.e., listening, respect, empathy) in assessment and care planning.
  • Promote cultural competency and safety (i.e., creating inclusive, safe space) in therapeutic relationships.

CASN/CFMHN Competencies

2.8, 3.1, 3.2

Therapeutic Relationships

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).

Therapeutic relationships are of critical importance to nursing practice and help promote awareness and growth to work through difficulties (RNAO, 2010b). Therapeutic relationships were originally highlighted in psychiatric nursing literature (RNAO, 2010b) before being recognized as fundamental to all nursing (Orlando, 1961; Peplau, 1952; Sundeen, Stuart, Rankin, & Cohen, 1989) and focus on the value associated of developing therapeutic relationships (Brown, 2012).

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.

Teaching and Learning Activities

The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to therapeutic relationships.

  • Process recordings (Appendix B, C, and D)
  • Case studies (Section 9.3)
  • Communication labs
  • Simulation (standardized patients; lived client experience/family experience, peer support)
  • Appendix E).Reflective assignments (pre- and post-clinical practice; portfolios; logs; diaries; journals–
  • to death across all health-care settings and situations.interventions. Applicable for mental health promotion of and well-being in clients from birth Group role play: Learning exercise for the application to practice of relational care
  • Clinical supervision/peer supervision
  • Peer learning
  • Handouts (reflective questions)
  • Lived client experience/family experience— Appendix H
  • Arts-based approaches
    • Theatre
    • Photography
  • Narratives/stories

Learner Engagement Questions

The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding establishing therapeutic relationships. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.

  • How would you know that you have established a therapeutic relationship?
  • Can we have therapeutic relationships with anybody?
  • What do therapeutic boundaries look like in different settings/situations? Which boundaries never change?
  • When is it okay to touch? When is it okay to use humour?
  • How do you terminate the therapeutic relationship? How do you say “Goodbye”?
  • How would you determine if it’s your needs and/or the client’s needs that are being met?
  • How do you address observed boundary violations between other clinicians and clients?
  • How long can you sit without saying anything? Describe the importance of silence.
  • What would it be like to be a patient in this setting?

Evaluation and Self-reflection

The following tools can be used to evaluate students in their understanding and application of therapeutic relationships:

  • Process recordings (Appendix B, C, and D)
  • Assignments, such as analysis of a video to determine understanding of concepts related to therapeutic/non-therapeutic relationships
  • Questions on exams regarding theoretical concepts

SELF-REFLECTION

  • Journaling (Appendix E)
  • Portfolios
  • Pre- and post-clinical placement reflections
  • Process recordings (Peplau, 1952; 1988; 1989) (Appendix B, C, and D)

Resources

WEBSITES

VIDEOS AND FILMS

RNAO RESOURCES

REFERENCE MATERIALS

  • Alex, M. R., Whitty-Rogers, J., & Panagopoulos, W. (2013). The Language of Violence in Mental Health: Shifting the Paradigm to the Language of Peace. Advances in Nursing Science, (3), 229-242.
  • Lasiuk, G., (2015) Mental Status Exam (Chapter 11). In W. M.A.,Psychiatric & mental health nursing for Canadian practice (3rd Canadian ed., pp175-197). Philadelphia, PA: Wolters Kluwer.
  • Bouchard, L., Montreuil, M., & Gros, C.P. (2010). Peer support among inpatients in an adult mental health setting. Issues in Mental Health Nursing, 31(9), 589-598.
  • College of Nursing Standards
  • Eliason, M. J., Dibble, S., DeJoseph, J. (2010). Nursing’s silence on Lesbian, gay, bisexual, and transgender issues: The need for emancipatory efforts. Advances in Nursing Science, 33(3), 206-218.
  • Goldberg, L., Ryan, A., & Sawchyn, J. (2009). Feminist and queer phenomenology: a framework for perinatal nursing practice, research, and education for advancing lesbian health. Health Care For Women International, 30(6), 536-549.
  • Gros, C.P., Jarvis, S., Mulvogue, T., Wright, D., (2012), Les interventions infirmières estimées bénéfiques par les adolescents à risque de suicide Santé mentale au Québec, (37) 2, 193-207
  • Lasiuk, G. (2015). The assessment process. In W. Austin & M. A. Boyd (Eds.), Psychiatric & mental health nursing for Canadian practice (3rd ed., Chapter 10, pp. 148–164). Philadelphia, PA: Wolters Kluwer.
  • McGibbon, E.A. (Ed.). (2012). Oppression: A Social Determinant of Health. Black Point, NS: Fernwood.
  • McGibbon, E.A., & Etowa, J.B. (2009). Anti-Racist Health Care Practice. Toronto, On: Canadian Scholars’ Press.
  • Montreuil, M., Butler, K., Stachura, M., & Gros, C. P. (2015). Exploring helpful nursing care in pediatric mental health settings: The perceptions of children with suicide risk factors and their parents. Issues in Mental Health Nursing, 36(11), 849-859.
  • Orlando, I. (1961). Orlando’s Dynamic Nurse-Patient Relationship: Function, process and principles. New York: Putman.
  • Orlando, I. (1972). The discipline and teaching of nursing process, an evaluation study. New York: Putnam.
  • Peplau, H.E. (1952). Interpersonal Relations in Nursing. New York: G.P. Putnam’s Sons.
  • Wright, D & Gros, C.P. (2010) Let’s Talk About Sex: Promoting Staff Dialogue on a Mental Health Nursing Unit. Journal for Nurses in Staff
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Recovery Oriented Approach Teaching activities and resources

Recovery Oriented Approach Teaching activities and resources

Outcomes

Purpose

This section supports educators with the knowledge and skills required to incorporate the foundational concept of a recovery-oriented perspective into mental health and addiction entry-level nursing curricula.

Outcomes

At the end of this section, the educator will:

  • Identify definitions, relevant theories and principles of recovery.
  • Understand concepts related to dignity, hope, empowerment and resilience.
  • Identify differences between medical model versus recovery models.
  • Identify barriers and facilitators to recovery. Acknowledge the importance of experiential knowledge (i.e., lived client experience/family experience).
  • Understand the nurse’s role in adopting a recovery perspective, including identify strategies to promote recovery.

CASN/CFMHN Competencies

2.2, 2.3, 2.10, 3.2, 3.3, 3.4, 3.7, 4.1, 4.2, 4.3

Recovery Perspectives

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.

Teaching and Learning Activities

The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to recovery oriented approaches.

  • Yale Program for Recovery and Community Health, The Recovery Knowledge Inventory (other recovery self-assessments)
  • Narratives
  • Case studies across lifespan, life transitions, and with different populations/contexts (Section 9.3)
  • Review of films portraying mental health/illness and examining use of recovery-oriented perspectives
  • Lived client experiences/family experience (Appendix H)
  • Arts-based approaches
    • Photography
    • Music
    • Poetry

Learner Engagement Questions

The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding using recovery perspectives. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.

  • Who defines recovery?
  • Does recovery mean that you no longer have an illness?
  • What is the difference between traditional medical care versus recovery care?
  • What are the benefits of peer support?
  • What is positive risk taking?
  • How would you promote informed choice and options to clients in relation to care planning?
  • How do you balance autonomy with beneficence?
  • How do we promote recovery to a client who is hospitalized against their will (i.e., by court order)?
  • How would you engage in a conversation about what brings meaning to someone’s life?
  • What is relapse prevention?

Evaluation and Self-reflection

The following tools can be used to evaluate students in their understanding and application of recovery perspectives:

SELF-REFLECTION

Reflection question: If you had depression/anxiety, what would you want that would be unique to your background/experience/knowledge/strengths?

Resources

Websites

Videos

GUIDES AND GUIDELINES

REFERENCE MATERIALS

  • Deegan, P. (1996). Coping with: Recovery is a journey to the heart. Psychiatric Rehabilitation Journal. 19(3), pp 91-97.
  • Forchuk, C., (2007). The Transitional Discharge Model: comparing implementation in Canada and Scotland. Journal of Psychosocial Nursing Mental Health Services,. (11), 31-8.
  • Reynolds, W., (2004). The effects of a transitional discharge model for psychiatric patients. Journal of Psychiatric Mental Health,. 11 (1), 82-8.
  • Snow, S. (2010). Psychiatric and mental health nursing interventions. In W. Austin & M.A. Boyd (Eds.), Psychiatric and mental health nursing for Canadian practice (2nd ed.) (pp. 198-213). Philadelphia, PA: Lippincott Williams & Wilkins.
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Trauma-Informed Care Teaching activities and resources

Trauma-Informed Care Teaching activities and resources

Outcomes

Purpose

This section provides educators with the knowledge and skills required to understand and implement trauma-informed approaches to care in mental health and addiction curricula.

Outcomes

At the end of this section, the educator will:

  • Understand trauma and the impacts on health.
  • Identify the principles of trauma-informed care.
  • Understand and implement trauma-informed approaches to care.
  • Relate trauma-informed approaches to care to universal precautions, cultural competence and safety, and creating safe space.

CASN/CFMHN Competencies

2.11, 2.12, 3.7

Trauma-Informed Care

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).

Trauma-Informed Approaches

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:

Trauma Awareness All services taking a trauma-informed approach begin with
building awareness among staff and clients of: how common
trauma is; how its impact can be central to one’s development;
the wide range of adaptations people make to cope and
survive; and the relationship of trauma with substance use,
physical health and mental health concerns. This knowledge
is the foundation of an organizational culture of traumainformed
care.
Emphasis on Safety and Trustworthiness Physical and emotional safety for clients is key to trauma-informed
practice because trauma survivors often feel
unsafe, are likely to have experienced boundary violations and
abuse of power, and may be in unsafe relationships. Safety
and trustworthiness are established through activities such
as: welcoming intake procedures; exploring and adapting
the physical space; providing clear information about the
programming; ensuring informed consent; creating crisis
plans; demonstrating predictable expectations; and scheduling
appointments consistently.
The needs of service providers are also considered within a
trauma-informed service approach. Education and support
related to vicarious trauma experienced by service providers
themselves is a key component.
Opportunity for choice, collaboration and connection Trauma-informed services create safe environments that
foster a client’s sense of efficacy, self-determination, dignity
and personal control. Service providers try to communicate
openly, equalize power imbalances in relationships, allow
the expression of feelings without fear of judgment, provide
choices as to treatment preferences, and work collaboratively.
In addition, having the opportunity to establish safe
connections – with treatment providers, peers and the wider
community – is reparative for those with early/ongoing
experiences of trauma. This experience of choice, collaboration
and connection is often extended to client involvement in
evaluating the treatment services, and forming consumer
representation councils that provide advice on service design,
consumer rights and grievances.
Strengths based and skill building Clients in trauma-informed services are assisted to identify
their strengths and to further develop their resiliency and
coping skills. Emphasis is placed on teaching and modelling
skills for recognizing triggers, calming, centering and staying
present. In her Sanctuary Model of trauma-informed
organizational change, Sandra Bloom described this as
having an organizational culture characterized by ‘emotional
intelligence’ and ‘social learning.’ Again, parallel attention
to staff competencies and learning these skills and values
characterizes trauma-informed services.

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.

Teaching and Learning Activities

The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to trauma-informed approaches to care.

  • Trauma-informed safety plan—Appendix F
  • Case study suggestions (Section 9.3):
    • A person with a diagnosis of schizophrenia begins heavy alcohol use after a sexual assault: Where do you start?
    • A person who has had a close friend or relative die by suicide.
    • A refugee who has witnessed or experienced violence.
    • A veteran who has recurrent nightmares and substance use after returning from service.
  • Simulation
  • Lived client experience/family experience—Appendix H
  • Planning a physical environment that does not re-traumatize
  • Handout with Learner Engagement Questions (below)
  • Arts-based approaches
    • Photography
    • Music
    • Poetry

Learner Engagement Questions

The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding using trauma-informed approaches to care. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.

  • What is the impact of different restraints in relation to trauma?
  • What is the difference between trauma therapy and trauma-informed care?
  • How might someone dull the pain of trauma in ways that could be helpful and not helpful?
  • How are residential schools related to trauma for First Nations, Aboriginal, Inuit and Métis people?
  • How can trauma be experienced on the intergenerational level and over the individual and family lifespan?
  • What is the relationship between trauma and homelessness (and other social determinants of health)?
  • When is a good time to discuss trauma? How do you engage in this topic? When might you delay the discussion?
  • What is a trigger and how would you recognize that someone is experiencing trauma-related distress?
  • How might a person with a history of trauma have behaviour that could be interpreted as “noncompliance” or non-adherence?
  • Who is vulnerable to trauma?

 

Evaluation and Self-reflection

The following tools can be used to evaluate students in their understanding and application of trauma-informed approaches:

  • Care plans reflecting trauma-informed approaches to care
  • Tests of theoretical concepts
  • Applications with case studies

SELF-REFLECTION

  • Reflection question: What personal experience do you have of trauma and how might this influence your care?
  • Journaling experiences—Appendix E

Resources

Websites

The Sanctuary Model by Dr. Sandra L. Bloom

Government of Nova Scotia - Trauma Informed Practices – Discussion Guides

 

RNAO TOOLS

GUIDES

BOOKS

Poole, N. & Greaves, L. (2012). Becoming Trauma Informed. Toronto: ON. Centre for Addiction and Mental Health.

Mate, G. (2009). In the realm of hungry ghosts. Berkely, CA: North Atlantic Books.

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Harm Reduction Teaching activities and resources

Harm Reduction Teaching activities and resources

Outcomes

Purpose

This section supports educators with knowledge and skills to integrate harm reduction philosophy in mental health and addiction curricula.

Outcomes

At the end of this section, the educator will:

  • Define and understand the philosophy and key principles of harm reduction.
  • Identify key areas of harm reduction in policies and practice.
  • Identify harm reduction approaches in other areas of health and safety.

CASN/CFMHN Competencies

2.3, 2.4, 2.5, 2.6, 2.8, 2.9, 3.1, 3.3, 3.4, 3.5, 3.7, 3.8

Harm Reduction

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.

Teaching and Learning Activities

The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to harm reduction principles and approaches.

  • Design a learning activity that includes a variety of program/policy options. Have students in small groups determine which option has a harm reduction approach and present to a group how and why they have come to that conclusion. Debrief using examples.
  • Bring together a panel of people who can speak to harm reduction approaches from a personal/community/professional perspective (e.g., AIDS coalitions, condoms programs, methadone maintenance programs, needle exchanges, peer administered Naloxone, Housing First, etc.)
  • Group Activity that asks students to identify different types of harm reduction practices.
  • Narratives
  • Case studies across lifespan, life transitions, and with different populations/contexts—or use the template in Section 9.3
  • Videos—see Resources
  • Lived client experiences/family experience—Appendix H
  • Arts-based approaches
    • Photography
    • Music
    • Poetry

Learner Engagement Questions

The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding harm reduction theory and approaches. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.

  • What are the benefits and barriers of a harm reduction approach?
  • What are the ethical implications for nursing practice of not providing care to those in need?
  • Supervised injection site in my backyard – thoughts?
  • What is the difference, similarity, and relationship between harm reduction and abstinence?
  • What is the relationship between housing first strategies and harm reduction strategies?
  • What is an example of harm reduction safe sexual practices?
  • Does handing out condoms promote sexual activity?
  • Do needle exchange programs promote drug use?

Evaluation and Self-reflection

The following tool can be used to evaluate students in their understanding and application of harm reduction theory and approaches:

  • Assignment on policy review

SELF-REFLECTION

Reflection questions: Do you choose your illness? What are your values and beliefs regarding harm reduction approaches? Does harm reduction save lives?

Resources

RNAO E-LEARNING MODULES

VIDEOS

RNAO BEST PRACTICE GUIDELINES

WEBSITES

REFERENCE MATERIALS

  • O’Grady, C. P., & Skinner, W. J. W. (2007). A family guide to concurrent disorders. Toronto, ON: Centre for Addiction and Mental Health.
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Mental Health, Illness and Addiction Teaching activities and resources

Mental Health, Illness and Addiction Teaching activities and resources

Outcomes

Purpose

This section supports educators with increased knowledge and skills to integrate mental health and screening, assessment and interventions related to mental illnesses in mental health and addiction curricula.

Outcomes

At the end of this section, the educator will ensure students achieve the following:

  • Understand the continuum of mental health.
  • Understand the concept of resiliency and mental health (i.e., concepts of stress, coping, adaptation, etc.).
  • Understand mental health promotion, and prevention of mental illness.

Educators will use the Resource Section to:

  • Understand the purpose of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in nursing, and identify DSM-5 diagnostic categories and criteria for the following conditions.
    • Bipolar disorders
    • Depressive disorders
    • Anxiety disorders
    • Substance-related and addictive disorders
    • Trauma- and stressor-related disorders
    • Personality disorders
    • Delirium and Dementia
    • Schizophrenia and other psychotic disorders
  • Understand treatment and management of mental illness.
  • Learn about co-morbidities, severity, and levels of disability related to mental disorders.

CASN/CFMHN Competencies

2.1, 2.2, 2.3, 2.4, 2.5, 2.6

Mental Health Continuum

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).

Further research required: 

There are many different types of mental illnesses. Knowledge of the American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)—a classification and diagnostic tool for mental illness—is key for nurse educators to teach students about mental illness pathology in order to understand treatment and interventions related to specific mental illness. It may not be imperative to teach about every mental illness, but rather the educator’s role is equally important to have students learn where to find credible, reliable resources.

Teaching and Learning Activities

The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to mental health and illness.

  • Lived client and family experience—Appendix H
  • Case studies—Section 9.3
  • Simulation—Section 7.2
  • Discussion of each illness conditions, causes, prevalence, and treatment/management
  • Broad discussion on:
    • Individual counseling
    • Group therapy
    • Family counseling
    • Pharmacological therapy
    • Complementary therapy
    • Other Psychosocial interventions

Learner Engagement Questions

The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding mental health and illness. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.

  • What causes mental illness (e.g., depression)? Give examples from neuroenzyme, hormonal, medication side effects, sociological, psychological, economic, relationship, social determinants, equity, co-morbidities.
  • Can you have good mental health with a mental illness?
  • What other conditions/illnesses are you at higher risk of because of a mental illness?
  • What mental illness(es) are you at higher risk of because of other conditions/illnesses (e.g., diabetes, cardiac, cancer)?
  • What is a concurrent disorder?
  • How do the social determinants of health influence mental health and illness?
  • What community and hospital-based mental health services/resources are available?
  • What is the difference between mental health, mental illness and mental disability?
  • What complementary therapies might be employed?
  • What is the nurse’s role in the acute phase of illness? What is the nurse’s role in rehabilitation?
  • What is the nurse’s role in the hospital and community mental health?
  • What assessments are completed to determine changes in the mental status (e.g., Mental Status Examination)?
  • What are the benefits and risks of diagnosis to the person?

Evaluation and Self-reflection

The following tools can be used to evaluate students in their understanding and application of mental health and illness.

  • Test knowledge (e.g., conditions, signs and symptoms, treatment)
  • Paper (e.g., students to write papers on certain mental illness/conditions, mental health, current controversies, etc)
  • In-class presentations on different illnesses

SELF-REFLECTION

  • Reflection questions: What mental illnesses have touched your life?
  • How does this influence your care?

Resources

Websites

VIDEOS

MANUALS

RNAO BEST PRACTICE GUIDELINES

RESOURCE MATERIALS

  • American Psychological Association (APA). (2013). Cultural Formulation and Cultural Formulation Interviews. In American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
  • Keyes, C. (2002). The mental health continuum: From languishing to flourishing in life. Journal of Health and Social Research, 43(June): 207-222.
  • Peplau, H.E. (1999). On semantics. Perspectives in Psychiatric Care. 35(3), 13.
  • Frances, Allen. (2013). Saving Normal. New York, NY: Harper Collins.
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Mental Status Examination (MSE) Teaching activities and resources

Mental Status Examination (MSE) Teaching activities and resources

Outcomes

Purpose

This section provides educators with increased understanding regarding the purpose and implementation of the Mental Status Examination (MSE) across the lifespan and in different types of populations/contexts.

Outcomes

At the end of this section, the educator will:

  • Understand the purpose of the MSE.
  • Understand the MSE in relation to health assessment and care planning.
  • Identify the different components and terminology of the MSE.
  • Be able to perform and document a MSE.

CASN/CFMHN Competencies

2.7

The Mental Status Examination (MSE)

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).

MSE Elements

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.

 

Teaching and Learning Activities

The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of the MSE.

  • Video demonstration
  • Simulation—Section 7.2
  • Case studies (across lifespan; different populations)—Section 9.3
  • Group discussion
  • Assignments related to MSE
  • Quick reference cards with questions
  • Practice application

Learner Engagement Questions

The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding MSE. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.

  • What are the benefits and challenges of conducting a MSE?
  • When should the MSE be conducted?
  • Discuss how the MSE contributes to the health assessment.
  • What elements of the MSE relate to risk?
  • Why are some components of the MSE observed and other components inquired?

Evaluation and Self-reflection

The following tools can be used to evaluate students in their understanding and application of MSE

  • Return demonstration
  • Documentation

SELF-REFLECTION

Self-reflection questions: How did you feel when conducting MSE? How did you feel in the client role?

Resources

TOOLS

Mental Status Exam

VIDEO

Voice Hearing – Eleanor Longden TED TALK

REFERENCE MATERIALS

  • Butler, K. (2015). On the Frontline with voices - A grassroots handbook for voice-hearers, carers and clinicians. London, UK: Speechmark Publishing Limited.
  • Erwin, E. H., & Colson, C. W. (2014). Disorders of children and adolescents. Adapted by R. J. Meadus. In M. J. Halter, Varcarolis’s Canadian psychiatric mental health nursing: A clinical approach. C. L. Pollard, S. L. Ray, & M. Haase (Eds.), (First Canadian ed., chapter 29, pp. 586–612). Toronto, ON: Elsevier Canada. Mental Status Exam (chapter 29, p. 592–593).
  • Halter (2014). Mental Status Exam. In M. J. Halter, Varcaroli (Eds.). Canadian psychiatric mental health nursing: A clinical approach (1st ed.) (pp. pp. 138 & pp. 592 – 593). Toronto, ON: Elsevier Canada.
  • Jarvis, C. (2014). Physical examination & health assessment. Toronto: Elsevier Canada.
  • Lasiuk, G. (2015). The assessment process. In W. Austin & M. A. Boyd (Eds.), Psychiatric & mental health nursing for Canadian practice (3rd ed., Chapter 10, pp. 148–164). Philadelphia, PA: Wolters Kluwer.
  • Robinson, D. (2008). The Mental Status Exam Explained, 2nd Edition. London, ON: Rapid Psychler Press. ISBN (13) 978-1-894328-25-8 (2015).
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Suicide Risk and Self-Harm Assessment Teaching activities and resources

Suicide Risk and Self-Harm Assessment Teaching activities and resources

Outcomes

Purpose

This section supports educators with knowledge and skills to integrate suicide risk, self-harm assessment and developing a safety plan in mental health and addiction curricula.

Outcomes

At the end of this section, the educator will:

  • Understand the prevalence, risk factors, and language of suicide and self-harm.
  • Understand the purpose of and differences between suicidal ideation/behaviours and self-harm behaviours.
  • Identify the components of the suicide risk/self-harm assessment.
  • Perform and document a suicide risk assessment/self-harm assessment.
  • Understand suicide risk in the context of Mental Health Act and other legislation.
  • Develop a safety plan in collaboration with the client (Appendix F).

CASN/CFMHN Competencies

2.9

Self-harm

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

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.

Assessment of risk

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.

 

Teaching and Learning Activities

The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to suicide risk/ assessment and self-harm.

  • Safety Plan Template—Appendix F
  • Case study examples:
    • Physical exam where you find different layers of scarring on arms/legs.
    • Person who on leaving states, “You may not see me again.”
  • Simulation—Section 7.2
  • Lived client experience/family experience—Appendix H
  • Handout with reflective questions.
  • Students might work independently first, and then in small groups, and/or come back to larger class.
  • Narratives
  • Arts-based approaches
    • Photography
    • Music
    • Vision boards
    • Poetry

Learner Engagement Questions

The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding suicide risk/assessment and self-harm. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.

  • How would you explore the client’s spiritual and beliefs about death?
  • Do people have the right to kill themselves when it is related to mental illness (including addiction)?
  • Does age, gender, or additional health concerns make a difference in terms of attitude regarding suicide?
  • How might our beliefs about the individual’s right to suicide play out in our interactions with patients/clients?
  • How do our professional standards help to guide us in working with individuals presenting with suicidal ideation/behaviour?
  • How do our professional standards fit with the current move to legalize assisted death/suicide?
  • Do some people deserve to die?
  • Can talking about suicide cause suicide?
  • What’s the difference between suicidal ideation/behaviour and self-harm behaviour?
  • What might it mean if a person is engaging in “cutting behaviours” to deal with stress?

Evaluation and Self-reflection

The following tools can be used to evaluate students in their understanding and application of suicide and self-harm risk/assessment:

  • Return demonstration
  • Documentation

SELF-REFLECTION

Self-reflection question: What are my own beliefs about suicide, death and choice? Also, reflect on lived client experience of someone who has lost a friend/family/colleague to suicide

Resources

WEBSITES

VIDEO

GUIDES AND HANDBOOKS

REFERENCE MATERIALS

  • De Silva, Stefanie; Parker, Alexandra; Purcell, Rosemary; Callahan, Patrick; Liu, Ping; Hetrick, Sarah (2013). Mapping the evidence of prevention and intervention studies for suicidal and self-harming behaviors in young people. Crisis: The Journal of Crisis Intervention & Suicide Prevention, 34(1),223-232.
  • Einfeld SL; Beard J; Tobin M; Buss R; Dudley M; Clarke AR; Knowles M; Hamilton B (2002). Evidence-based practice for young people who self harm: can it be sustained and does it improve outcomes? Australian Health Review, 25(4): 178-188.
  • Gros, C.P., Jarvis, S., Mulvogue, T., Wright, D., (2012), Les interventions infirmières estimées bénéfiques parles adolescents à risque de suicide, Santé mentale au Québec, (37) 2, 193-207.
  • Jacobs, D. G. (2007). A resource guide for implementing the Joint Commission 2007 patient safety goals on suicide. Wellesley Hills, MA: Screening for Mental Health, Inc.
  • Mental Health Commission of Canada. (2012). Changing directions, changing lives: The mental health strategy for Canada. Calgary, AB: Author.
  • Moore, S. & Melrose, S. (2014). Suicide. In M. J. Halter, Varcaroli (Eds.). Canadian psychiatric mental health nursing: A clinical approach (1st ed.) (pp. 509- 525). Toronto, ON: Elsevier Canada.
  • Montreuil, M., Butler, K., Stachura, M., & Gros, C. (2015). Exploring helpful nursing care in pediatric mental health settings: The perceptions of children with suicide risk factors and their parents. Issues in Mental Health Nursing, 36(11), 849-859.
  • Murray, B. L., & Austin, W. (2015). Self-harm and suicidal behaviour. In W. Austin & M. A. Boyd (Eds.), Psychiatric & mental health nursing for Canadian practice (3rd ed., Chapter 19, pp. 340–363). Philadelphia, PA: Wolters Kluwer.
  • Patrick L. Kerr, PhD, Jennifer J. Muehlenkamp, PhD, and James M. Turner, DO (2010). Nonsuicidal Self-Injury: A Review of Current Research for Family Medicine and Primary Care Physicians. Journal of American Board of Family Medicine, 23 (2), 240-259.
  • Perlman, C. M., Neufeld, E., Martin, L., Goy, M., & Hirdes, J. P. (2011). Suicide Risk Assessment Inventory: A Resource Guide for Canadian Health Care Organizations. Toronto: Ontario Hospital Association and Canadian Patient Safety Institute.
  • Randy A. Sansone, MD, and Lori A. Sansone, MD (2010). Measuring Self-Harm Behavior with the Self-Harm Inventory. Psychiatry (Edgemont), 7(4):16–20.
  • Registered Nurses’ Association of Ontario. (2009). Assessment and Care of Adults at Risk for Suicidal Ideation and Behaviour. Toronto: ON, Registered Nurses’ Association of Ontario.
  • Sakinofsky, I. (2005). Suicide and suicidality. In D. S. Goldbloom (Ed.), Psychiatric Clinical Skills (pp. 167–185). Philadelphia, PA: Elsevier Mosby.
  • Wright, D., & Gros, C.P. (2012). Theory inspired practice for end-of-life cancer care: an exploration of the McGill Model of Nursing. Canadian Oncology Nursing Journal. 182-189. Summer 2012.
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Crisis Intervention Teaching activities and resources

Crisis Intervention Teaching activities and resources

Outcomes

Purpose

This section provides educators with the knowledge and skills required to understand and identify crisis states and support people through crises.

Outcomes

At the end of this section, the educator will ensure students achieve the following:

  • Identify the definition of a psychiatric/mental health/addiction crisis and relevant theories, and frameworks regarding crisis intervention.
  • Identify mental distress.
  • Have a basic understanding of mental health first aid.
  • Have the ability to intervene to support a client experiencing a crisis.
  • Identify individualized triggers, strengths, resources, resilience, and preventative strategies.
  • Understand care planning strategies to prevent and support people through crises.

CASN/CFMHN Competencies

2.3, 2.9, 2.11, 2.12, 3.1

Crisis Intervention

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.

Teaching and Learning Activities

The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to crisis intervention.

  • Self-reflection on personal past crises and coping strategies
  • Develop a safety and comfort plan—Appendix F
  • Case study—Section 9.3
  • Simulation—Section 7.2
  • Lived client experience/family experience—Appendix H
  • Class assignment that explores local community crisis intervention resources
  • Review of films portraying crisis and examining use of crisis interventions
  • Lived client experiences/family experiences
  • Narratives
  • Arts-based approaches
    • Photography
    • Music
    • Poetry

Learner Engagement Questions

The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding crisis intervention. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.

  • What makes a crisis? Who defines it?
  • What is the relationship between crisis and transition points? Provide examples.
  • At what point does a crisis become an emergency? What is the relationship to the Mental Health Act and Legislation?
  • What is the relationship between the social determinants of health and crises? See RNAO Social Determinants of Health.
  • What would be the issues with developing standardized crisis plans?
  • How would you engage in a conversation about crisis prevention and management?
  • What happens to your attention span when you are in crisis?
  • What are the implications for client care?
  • What community resources and options can you offer a client in crisis?
  • Should you drive a person who is in crisis?
  • What risk assessments might you perform on a client in crisis?
  • What opportunities might unfold as a result of a crisis?

Evaluation and Self-reflection

The following tools can be used to evaluate students in their understanding and application of crisis intervention.

  • Completed safety and comfort plan—Appendix F
  • Test questions
  • Ability to perform risk assessments and strengths assessments
  • Group assignment to resolve a crisis
  • Paper that looks at different theories to crisis
  • Completed client debrief post-crisis

SELF-REFLECTION

  • Reflect on your own crisis and strategies to prevent/resolve crisis
  • Written/in-person debrief after a client has experienced crisis

Resources

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