Section Nine

Appendices and Case Studies

Appendices and Case Studies
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Section Nine

Access the appendices in the menu to the right.


Appendices admin Fri, 10/06/2017 - 18:29

Alignment between CASN/ CFMHN Entry-to-Practice Mental Health and Addiction Competencies and Sections in the Nurse Educator Mental Health and Addiction Resource

Alignment between CASN/ CFMHN Entry-to-Practice Mental Health and Addiction Competencies and Sections in the Nurse Educator Mental Health and Addiction Resource

Every effort was made to develop educational content and tools that would support the CASN/ CFMHN (2015) competencies in mental health and addiction. The following table shows how each section of the guide aligns with various competencies.


PDF: Alignment between CASN/ CFMHN Entry-to-Practice Mental Health and Addiction Competencies and Sections in the Nurse Educator Mental Health and Addiction Resource

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Process Recording

Process Recording

Process Recording

Process recording. (2016). In C. Forchuk, Arthur Labatt Family School of Nursing course work. London, ON: University of Western Ontario. Adapted with permission.

PDF: Process Recording

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Criteria for Validation: Process Recording

Criteria for Validation: Process Recording

Criteria for Validation: Process Recording

Criteria for validation: Process Recording. (2016). In C. Forchuk, Arthur Labatt Family School of Nursing course work. London, ON: University of Western Ontario. Adapted with permission

PDF: Criteria for Validation: Process Recording

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Criteria for Phase of Relationship: Process Recording

Criteria for Phase of Relationship: Process Recording

Criteria for Phase of Relationship: Process Recording

Criteria for phase of relationship: Process recording. (2016). In C. Forchuk, Arthur Labatt Family School of Nursing course work. London, ON: University of Western Ontario. Adapted with permission

PDF: Criteria for phase of relationship: Process Recording

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Journaling Activity

Journaling Activity

Journaling Activity

Journaling activity. (2016). In C. Forchuk, Arthur Labatt Family School of Nursing course work. London, ON: University of Western Ontario. Adapted with permission.

Reflect on a life experience that involved significant joy, sadness, conflict, anger. Situate the experience historically, personally and socially by asking yourself: What were the circumstances? What events preceded the experience? Utilize the life world existential—lived space, lived body, lived time, and lived human relation—as guides to reflection.

Begin to write the story. Try to be as clear and descriptive as you can.

When you feel that you have completed the story, put it down. Walk away from it for awhile. Then return to it and reread it. Does it seem true to life? Do other memories surface as you revisit it? Add them if they do.

Reflect on the following and write a journal to summarize the following:

  • What themes emerged within your story? How do those themes speak to you of your life experience?
  • What did you become sensitive to within yourself through the process of reflecting upon and writing this story?
  • Why do you believe that you chose this particular story? Why did these memories emerge? How do they speak to you of your life and of the significance of your experience to whom you are today?

Come to class prepared to share your process and the critical reflection revealed to you within your journal.

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Safety and Comfort Plan Template

Safety and Comfort Plan Template

Safety and Comfort Plan

Reprinted from “Safety and comfort plan” by the Professional Practice Office, 2016, Centre for Addiction and Mental Health (CAMH). Reprinted with permission.

Form is intended to capture the client’s perspective.

PDF: Safety and Comfort Plan

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Advocacy Groups for Mental Health in Canada

Advocacy Groups for Mental Health in Canada

Canadian Alliance on Mental Illness and Mental Health (CAMIMH)

The Canadian Alliance on Mental Illness and Mental Health (CAMIMH) is Canada’s largest mental health advocacy group. It is an alliance of mental health organizations comprised of health care providers as well as of the mentally ill and their families.

Canadian Mental Health Association (CMHA)

The Canadian Mental Health Association (CMHA) is a national voluntary organization that promotes mental health and serves consumers and others through education, public awareness, research, advocacy, and direct services.

Disability Rights International (DRI)

Disability Rights International (DRI) is an advocacy organization dedicated to the recognition and enforcement of rights of people with mental disabilities.

Mental Health Commission of Canada (MHCC)

The Mental Health Commission of Canada (MHCC) is a non-profit organization created to focus national attention on mental health issues, to work to improve the mental health of Canadians, and to reduce the stigma associated with this disease.

Schizophrenia Society of Canada

This toolkit provides support and basis information regarding core concepts of advocacy and working with the media. It provides practical steps that are required by people living with mental illness, caregivers and supporters to start advocating (SSC, 2007).

World Federation for Mental Health (WFMH)

The World Federation for Mental Health (WFMH) is the only international, multidisciplinary, grassroots advocacy and education mental health organization.

World Health Organization (WHO)

The World Health Organization (WHO) is the United Nations agency for health. The objective set out in its constitution is the attainment, by all peoples, of the highest possible level of health.

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Tips for Engaging Lived Experience

Tips for Engaging Lived Experience

Engaging Lived Experience

Tips for how educators can work with persons with lived experience, support groups and how to engage with them.

Prepared by Betty-Lou Kristy, Lived Experience/‘Family’ Advocate- Mental Health, Addiction, Trauma & Bereavement (2016)

Engaging lived or family experience to share journeys of struggle and/or recovery with mental health and addiction issues can be one of the most powerful and humanizing ways to pass on knowledge to nursing students. Personal lived experience journeys (stories) and the journeys of the supporting self-defined family members (caregivers) are great examples of personal experiences and demonstrate the impact of the broader determinants of health. Specifically, lived experience of people and families can speak to the complex reality people living with mental health and substance use issues, and help to break down stigma, misperceptions, fears and myths, while breathing life into knowledge exchange.

Some of the potential outcomes of sharing lived experience include:
»» Evidence of qualitative data, such as facts and mitigating emotions, that leads to more
fulsome evidence of human tragedy and resilience, what loss of hope and dignity can do to
a person and the power of human spirit; and
»» Profound teaching moments that express the feelings behind events, enabling learners to
experience how a situation feels.

Planning tips

Here are some things that need to be considered if you are inviting lived or family experience to become part of your choices for teaching, according to the Centre for Addiction and Mental Health’s Strengthening Your Voice Speakers Training.


Ensure you inform speakers of the following items:

  • The intent of the event;
  • The topic you would like them to talk about—this could include specific content you would like them to include or content you prefer they stay away from;
  • How much time you are allotting them to speak;
  • Who else will be speaking and what their role is (for example, peers with similar experiences, health care workers, parents, youth);
  • Who the audience is (for example, general public, health care workers or students at a certain level or in a particular class);
  • The date and time of the event;
  • The location of the event and detailed directions to get there;
  • Whether you can provide them with and set up any equipment they might need (for example, computer and screen);
  • How you will let them know how much time they have left to speak, or that it is time to stop speaking; and
  • That you appreciate their contribution to making the event a success.

Provide speakers with:

  • A contact name and details of how and when they can reach that person;
  • Practice time with the microphone during the setup; and
  • Encouragement.


Provide speakers with:

  • Water;
  • Tissues; and
  • Any help they might need (for example, with the microphone or other equipment, with the question-and-answer part of the event).


Provide speakers with:

  • An honorarium; and
  • Reimbursement of their travel costs (for example, mileage, parking, public transportation) or any other expenses they may have incurred related to participating in the event. If possible, provide bus fare before the event.


  • Ask them, for example, how they’re feeling personally and how they’re feeling about the event itself.
  • Give speakers feedback about how you think the event went, including feedback about their presentation. Make constructive comments about what worked well and why.
  • If it is not possible to debrief immediately after the event, tell speakers you will call them the following day to debrief.

Honorarium and/or expense reimbursement

Consider the follow recommendations regarding honorarium and expense reimbursement.

  • Ensure ahead of the event that the person’s travel, accommodation, event registration costs (if applicable), and meal needs related to the event are covered up front (if needed). Keep in mind that many people with lived experience can not afford to wait 30 to 60 days to be reimbursed.
  • Offer support and flexibility in how an honorarium is given. Frequently people with lived experience have money concerns so it is helpful to make it clear that it is up to the person to report the income or not. Cash is best where feasible and safe. If they are really leery to accept money, you can negotiate things like grocery cards instead—as long as gift cards are a fallback tactic and not the default go-to method.


Reflection considerations

Invited speakers may not been trained in peer support, lived experience speaking, facilitating, sharing their journey, group facilitation. Lived experienced speakers may also not have participated in many different modalities that involve sharing their journey. It is important to encourage them to use technique of reflection to answer the following questions:

  • Are they ready?
  • Have they considered the gains and risks of sharing their story?
  • Are they aware of triggers?
  • Are they aware of personal wellness?

Other elements educators may wish to provide guidance in include: preparation, questions to ask, how to know your audience, being neutral and professional, being trauma-informed, developing your story, presentation styles, taking care of yourself, managing audiences etc.


Centre for Addiction and Mental Health: Strengthening Your Voice Public Speakers Guide

Centre for Addiction and Mental Health. (2013). Strengthening your voice: A public speaking guide for people with lived experience of problems with prescription pain medication.

Newfoundland: CHANNAL Consumers Health Awareness Network Newfoundland and Labrador

Nova Scotia Self Help Connection

The Ontario Peer Development Initiative (OPDI)
Mississauga Halton Enhancing & Sustaining Peer Support, TEACH
Manitoba is focused on LGBTQetc Peer Support Groups | Rainbow Resource Centre

Support Groups

Youth Peer-to-Peer Support | Together to live

Mood Disorders Association of Manitoba

Saskatchewan: generalized peer support cross-disability

Peer Support | North Saskatchewan Living Centre

Calgary Peer Support Meetings

Peer Support Centre

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Glossary of Terms

Glossary of Terms

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).


“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” 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).


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 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).


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 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).


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).


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).


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 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 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 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).

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Case Studies

Case Studies

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:

  1. demographics (age, gender, ethnicity);
  2. illness and addiction, dual diagnosis or additional co-morbidities such as cardiovascular disease; and
  3. 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

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Case Study 1

Case Study 1

Teresa is a 32-year-old woman in your practice who frequently misses her appointments, and at other times shows up without an appointment, often in crisis. She currently uses alcohol and tobacco, and has started to use street drugs.

As you have developed a therapeutic relationship with Teresa, you learn that she grew up in a household with a violent father who frequently assaulted her mother, her siblings and herself. Although now estranged from her father, the impact of his violence presents itself on a daily basis as Teresa struggles to cope with the trauma she experienced.

Teresa left school early, has few marketable skills and has never been able to hold a job for more than three months. Teresa receives $606 per month from Ontario Works and has no money left for food or other essentials at the end of the month. She is currently in a relationship with a man whom you suspect may be violent

Student Questions

What are your next steps with Teresa? How do you go about providing trauma-informed care?

  • Is a crisis intervention required?
  • What are some other interventions you could take to improve Teresa’s health in this situation that include addressing health inequities and structural drivers of the conditions of daily life, such as the inequitable distribution of power, money and resources?

Educator elaborations

  • Assess Teresa’s mental status and history of mental health care; explore her substance use and whether it places her at high risk for self medication and suicide; explore issues of violence in her life, income support and her housing situation.

Discussion Topics

  • Cultural competency and mental illness
  • Trauma informed care
  • Crisis intervention
  • Social determinants of health


content.editor Thu, 01/04/2018 - 08:34

Case Study 2

Case Study 2

Joseph is a 55-year-old First Nations man on Ontario Disability Support Program due to a physical back injury in the factory he worked in. Despite his injury, he still receives work health benefits and is able to perform some amount of activities of daily living. Due to his chronic back pain, his doctor has prescribed Oxycodone which he uses occasionally (prn), as prescribed. However, he also uses marijuana daily because it makes him feel more in control. He is recently divorced, lives alone and is finding it hard to cope with this loss. Joseph presents at the clinic reporting of increasing pain. During your conversation you discover that he is gradually increasing the amount of marijuana he is using to combat his pain and feelings of isolation.

Student questions:

  • What are your next steps with Joseph?
  • How would you conduct a motiva-tional interview?
  • What do you suggest talking about with Joseph at his next appointment?
  • What strategies could you provide that would support a recovery oriented approach?
  • What strategies could you provide that assist with harm reduction?

Educator elaborations

Change the ethnicity of Joseph and layer in cultural nuances. Pose questions that teach cultural competency.

Discussion Topics

  • Culture and diversity as it relates to mental health
  • The relationship between addiction and mental health
  • Grief and loss
content.editor Thu, 01/04/2018 - 08:47

Case Study 3

Case Study 3

Thomas, a 16-year-old high school student, visits you during class in distress. He tells you that he’s being bullied at school because the kids think he is gay. Thomas tells you he thinks he might be transexual, but that he is scared to tell anyone, and voices suicide ideation. He is not supported at home: his mother and father, both professionals, work long hours and his older sister picks on him. Thomas’s best friend since the age of 10 recently told him he didn’t want to hang out with him anymore because he was “weird.” A few months ago another friend who was picked on more than Thomas went missing. Rumour in the school indicates that he ended his life.

Student questions:

  • What are your next steps with Thomas?
  • Do you have any immediate con-cerns in terms of Thomas’s safety?
  • How do you conduct a Mental Status Exam?
  • Howdo you conduct a suicide risk assessment?
  • Is a crisis intervention required?
  • What kinds of community-based support strategies would you recommend?
  • Do you approach Thomas’s family? If so, how?
  • What your role in terms of mental health advocacy and promotion?
  • How does organizational culture influence the current provision of mental health care for students; how might that culture impact any changes you propose?
  • What kinds of strategies can you develop?
  • Who might be on an inter and intra-professional team?
  • What kinds of stakeholders are available to assist with policy or program development?

Educator elaboration

  • As school nurse, you want to prevent incidences of bullying and address the systemic issues related to student mental health.

Discussion Topics

  • The impact of bullying on youth
  • Diversity as it related to mental health
  • Sexuality and its impact on mental health, (e.g., sexuality is not an illness)
  • Stigma and its impact on mental health
  • Developmental psychology/child and youth
  • Family-centred-care
content.editor Thu, 01/04/2018 - 08:52

Case Study 4

Case Study 4

Gladys, an 84-year-old widow, is close to being discharged from outpatient services after breaking her hip from a fall. She uses alcohol, and tells you that she has been drinking more heavily since her husband passed away more than a year ago to help her cope with grief. She won’t tell you how often or how much she drinks, but admits that she’s lost over 25 pounds in the past year.

Student questions

  • How do you establish a therapeutic relationship with Gladys?
  • What supports can you provide for Gladys?
  • What are some key risk considerations?
  • When would you consider a harm reduction approach?
  • How do you develop a risk assessment?
  • What are the suicide considerations in this scenario?
  • What are interventions that would tackle the immediate risks in daily live, such as housing situation or ambulation?
  • What are the key medication considerations, especially give her age and alcohol use?
  • What other considerations may you have to maintain her safety?
  • How would you use a harm reduction approach with Gladys?
  • What accommodations at home may she need?

Educator elaborations

Give Gladys an acute scenario, for example, she is in withdrawal from alcohol and experiencing delirium.

Discussion Topics

  • Aging and mental illness and addiction
  • Coping with grief and loss
  • Mental health and illness and addiction; plus concurrent health disorders
content.editor Thu, 01/04/2018 - 08:57

Case Study 5

Case Study 5

Anthony, 29, is under the jurisdiction of your local provincial Mental Health Review Board on your acute care ward. He’s in breach of a disposition because of repeated alcohol and marijuana use; Anthony is also diagnosed with bipolar disorder and is currently prescribed olanzapine 10 mg and lithium 800 mg daily. He experiences mania when he uses substances, and the incident that led to his review occurred when he was under the influence (he racked up over $100,000 in property damages). He uses substances and alcohol due to the negative side effects (weight gain) from his prescribed medications. Anthony is divorced and recently obtained regular visits with his kids. He holds down a steady job in construction, but he’s worried about losing his employment because he sometimes misses shifts.

Student questions

  • What is the relationship between addiction and mental illness?
  • What is the relationship between the drug and alcohol use and Anthony’s diagnosis?
  • What assessments would be completed?
  • What medications and lab work should be done (e.g., Lithium levels)?
  • In terms of Anthony’s stay on the unit, what are some safety precautions? How is a forensic general/acute unit different than a non-forensic unit?
  • How does one balance custody vs. care?
  • What is the legislation that pertains to Anthony’s rights?
  • What is the criteria for involuntary admission in your jurisdiction?
  • How do you evaluate Anthony’s capacity?
  • How do you prepare for the hearing that will decide whether Anthony will continue to be committed/detained?
  • What is the role of the nurse in Anthony’s case?
  • And the role of the community ACT Team?
  • Examine your values and beliefs: How do you balance issues of transference and countertransference?
  • If you don’t support Anthony’s release, how will you maintain a therapeutic relationship or respond to him when he expresses a sense of betrayal during your day-to-day care?
  • How might self-reflection help you? What are your ethical responsibilities to the Anthony and the public?

Discussion Topics

  • Mental health and illness legislation
  • Ethics and professional responsibilities
  • Personal safety
content.editor Thu, 01/04/2018 - 09:00

Case Study 6

Case Study 6

You arrive at work to find out that Rajat, a 48-year-old client diagnosed with chronic schizophrenia, abused his roommate because he thought he was making gestures at him. Rajat was admitted overnight involuntarily when a neighbour who he has a relationship with encouraged him to go to emergency. Rajat was extremely confused and not making any sense. The community he lives is purported to have a high amount of IV drug use. Rajat spends the government provided disability support he gets on rent and the rest on drug use and cigarettes (he has been smoking since he was 8, which he informs you is common in India). He is also obese with metabolic syndrome.

Student questions

  • What are your first steps?
  • How do you develop a safety plan?
  • How do you assess Rajat?
  • What are the results of your assessment and how do they impact care?
  • What about the link with Schizophrenia and drug use?
  • What is the most important aspect you would work on with Rajat?
  • How would you prioritize his care?
  • How does Rajat’s culture impact influence his illness?
  • How do you establish a therapeutic relationship with Rajat?
  • What kinds of strategies can you put in place for him when he is eventually discharged?

Educator elaboration

  • Give Rajat a specific ethnicity and explore culture competence as it relates to mental illness.

Discussion Topics

  • Metabolic syndrome and its impact mental illness and treatment
  • Social determinants of health
  • Mental health and illness legislation
content.editor Thu, 01/04/2018 - 09:10

Case Study 7

Case Study 7

You visit Melanie, 58, in her home for a post-hospital discharge visit. She is visibly lethargic and when you ask how she is feeling, she tells you she is grieving for her son who died more than a month ago. Moreover, she worries how her life choices contributed to her son’s problems. As the child of alcoholic and violent parents, she felt alone, and constantly frightened. She ran away at the age of 16, and eventually married an abusive alcoholic, who was the father of her son. She and her son escaped with police help, but at the age of 25, childhood traumas flooded her, and she began to drink and use drugs to cope. Her second husband aided her drug use, which included cocaine, prescription barbiturates and marijuana. At that point, Melanie says she had been in and out mental health hospitals for breakdowns and suicide attempts. Not only was she anorexic, but she also cut herself. Her diagnoses included rapid cycling bipolar disorder, acute anxiety and panic disorders, personality disorders, obsessive compulsive disorders and post-traumatic stress disorders and “the list goes on.” She was treated with medications and rounds of bilateral shock treatments that she says she never wanted. “The worst part was being labeled an alcoholic and drug addict,” she adds, which diminished her true needs. She tells you that she has been alcohol and drug free for over 10 years thanks to meeting her third husband who is very supportive. And that she has had therapy to assist with her past traumas. But none of it was enough to help her help her son who died of an accidental drug overdose caused by a lethal combination of opioids mixed with the newly prescribed high powered psychiatric drugs.

Student questions

  • What are you next steps with Melanie?
  • How do you assess her risk for re-lapse?
  • What kinds of support strategies can you provide?

Discussion Topics

  • Recurring trauma and its influence pre-existing mental health illness and substance use disorders
  • Community supports necessary to ensure ongoing mental health and wellness for clients with diagnoses
content.editor Thu, 01/04/2018 - 09:13

Case Study 8

Case Study 8

John, 23, is checked into emergency with severe gastro-intestinal pain. This is his sixth visit to the same ER with the same symptoms. He is visibly in discomfort, and requires opioid pain medications. John tells you he has been taking opioids for years to deal wth the flare-ups, which include vomiting and diarrhea, and have led to a 40-pound weight loss and five colonoscopies. This latest flare up occurred after he ran out of his pain medication and couldn’t get a refill. John gets very angry and defensive when the staff suggest he is addicted to pain killers. He contends that he wouldn’t be on the pain killers if the doctors could figure out what is wrong with him. When he calms down, you are able to learn a little more about his past: He tells you he has battled anxiety and panic attacks since he was a kid and diagnosed with learning disabilities. Currently, he feels the only relief for his emotional and physical pain is pain medication and that “he is trapped in this situation.” Finally, he adds that lately he’s experienced auditory, sensory and visual hallucinations. Schizophrenia runs his family.

Student questions

  • Is John in crisis?
  • How do you initiate a crisis intervention?
  • How do you implement a harm reduction approach?
  • How do you use trauma-informed approaches with John

Discussion Topics

  • Age and linkages with schizophrenia
  • Withdrawal symptoms
  • Stigma and learning disabilities
  • Stigma and substance use and its impact on mental health attitudes and interventions
content.editor Thu, 01/04/2018 - 09:16

Case Study 9

Case Study 9

Below is an anecdotal scenario that seeks to prepare students for a typical inpatient work day. It is structured into three phases and begins with arrival at work.

You’ve just arrived at your shift on a mental health unit and are reviewing your client case load.

Student questions

  • How do you prioritize the client case load?
  • Provide the rationale for the prioritization.
  • What information is missing before you can move forward?

Next, you hone in on one patient, a 61-year-old, Caucasian female, with bipolar disorder who is mildly agitated. You review the night shift vital stats, as well as medications including her lithium levels.

Student questions:

  • What are you most worried about?
  • What should your immediate action be?
  • How do the client assessment results impact care?

Despite your interventions, the patient’s agitation is escalating. You would describe her as aggressive.

Student questions

  • How do you intervene in a non-confrontational way?
  • What psychosocial interventions should you consider?
  • When do you use medications, and what PRN medication do you choose and why?
  • Which intramuscular site do you choose, what size syringe do you use and how do you prevent a needle stick injury?
  • What assessment do you do after you’ve administered PRN?
content.editor Thu, 01/04/2018 - 09:21