CHAPTER 6

Mental Health Nursing

in Community Settings
NANCY CHRISTINE SHOEMAKER

SUSAN CAVERLY
KEY TERMS and CONCEPTS
The key terms and concepts listed here appear in color
where they are defined or first discussed in this chapter.
barriers to treatment, !
"ontin##m o$ %s&"'iatri" menta( 'ea(t' treatment, )
deinstit#tiona(i*ation, +6
et'i"a( di(emmas, !
serio#s(& menta((& i((, +6
O,-ECTIVES
After studying this chapter, the reader will be able to
1. E.%(ain t'e e/o(#tion o$ t'e "omm#nit& menta( 'ea(t'
mo/ement0
2. Identi$& e(ements o$ t'e n#rsin1 assessment t'at are "riti2
"a((& im%ortant to t'e s#""ess o$ "omm#nit& treatment0
3. 3istin1#is' bet4een t'e 'os%ita( and "omm#nit& settin1s
4it' re1ard to "'ara"teristi"s, 1oa(s o$ treatment, and n#rs2
in1 inter/entions0
4. Com%are and "ontrast t'e ro(es o$ t'e n#rse in "omm#nit&
menta( 'ea(t' a""ordin1 to t'e n#rse5s ed#"ationa( %re%a2
ration0
5. E.%(ain t'e ro(e o$ t'e n#rse as t'e bio%s&"'oso"ia( "are
mana1er in t'e m#(tidis"i%(inar& team0
6. 3is"#ss t'e "ontin##m o$ %s&"'iatri" treatment0
7. 3es"ribe t'e ro(e o$ t'e %s&"'iatri" n#rse in $o#r
s%e"i$i" settin1s6 %artia( 'os%ita(i*ation %ro1ram7
%s&"'iatri" 'ome "are7 asserti/e "omm#nit& treatment7
and "omm#nit& men2 ta( 'ea(t' "enter0
8. Identi$& t4o reso#r"es to assist t'e "omm#nit& %s&"'iatri"
n#rse in reso(/in1 et'i"a( di(emmas0
9. 3is"#ss barriers to menta( 'ea(t' treatment0
Visit t'e E/o(/e 4ebsite at 'tt%688e/o(/e0e(se/ier0"om8Var"aro(is $or a %retest on t'e "ontent in t'is "'a%ter0
The first psychiatric nurses working in the community
setting were community health nurses who developed a
specialty practice in mental health. They were able to move
within the community, were comfortable meeting with
clients in the home or neighborhood center, were competent
to act independently, used professional udg! ment in
sometimes unanticipated situations, and pos! sessed
knowledge of community resources.
The heritage of these nurses can be traced back to the
"uropean women who cared for the sick at home and
#merican women who organi$ed into religious and secular
societies during the %&''s to visit the sick
in their homes. (y %&)), trained nurses worked as pub! lic
health nurses visiting the homes of the poor in northeastern
cities and generalist nurses made com! munity visits to
rural areas for health promotion and care of the sick
*Smith, %++,-.
CONTE9T :OR PSYCHIATRIC
NURSIN; IN THE COMMUNITY
.n %+/0, 1resident 2ennedy signed into law the
Community Mental Health Centers #ct, thus solidify! ing
the shift of mental health care from the institution
85
86 UNIT TWO 3oundations for 1ractice
to the community and heralding the era of deinstitu-
tionalization. Media focus raising public awareness
regarding the horrors of psychiatric institutions, the mental
health care needs presented by returning ser! vicemen, and
the development of psychopharmaco! logical agents all
acted as catalysts for needed change in psychiatric
treatment philosophy *Marcos, %++'4 5ochefort, %++0-.
The %+/'s were also the time when federal entitle! ment
programs proliferated6 Social Security 7isability,
Supplemental Security .ncome, Medicaid, Medicare,
housing assistance, and food stamps. These social pro!
grams provided the means for moving the mentally ill out
of institutions and into the community. 1olicy! makers
believed that community care would be more humane
and less e8pensive than the historic hospital!based care.
Caring for seriously mentally ill *also called chron!
ically mentally ill- clients in the community, however,
presented many challenges. #t the time, there were few
choices for outpatient treatment, mainly a com! munity
mental health center or therapy in a private of! fice.
9overnment promises to e8pand funding for community
services were not kept, and there were more clients than
resources. .n addition, many seri! ously mentally ill clients
resisted treatment with avail! able providers, and providers
began to use scarce re! sources for the less disabled but
more compliant population. 7espite these problems, a
second wave of deinstitutionali$ation took place in the
%+&'s after 1resident Carter :s Commission on Mental
Health highlighted the needs of the underserved and
un! served seriously mentally ill group.
;ver the past 0' years, with advances in psy!
chopharmacology and psychosocial treatments, lev! els of
psychiatric care in the community have multi! plied into a
continuum with many choices. The role of the
community psychiatric registered nurse *5N- has
diversified to include providing services in all of these
treatment settings. .n this chapter, you will learn about the
role of the basic level 5N in different multidisciplinary
treatment teams across this spec! trum. Many
nontraditional nursing roles have devel! oped outside of
the recogni$ed treatment sites. 1sychiatric needs are well
known in the criminal us! tice system and in the
homeless population. .n %+++, the <.S. 7epartment of
=ustice estimated that %/> of people in ail *those in for
short stays as opposed to the long!term prison population-
reported a history of an emotional problem *Mc?uistion
et al., @''0, p.
/)%-. 5epeated studies since the %+&'s suggest that one
third to one half of homeless people have severe
psychiatric illness *Mc?uistion et al., @''0, p. //+-.
1sychiatric 5Ns are actively involved in forensic set!
tings and in creative outreach efforts in public places.
School!based clinics have increased as communities
have recogni$ed the need for early detection and treat! ment
for children. .n addition to performing screening and mental
health teaching, psychiatric 5Ns are a part of crisis teams
that respond to episodes of school vio! lence, either
adolescent suicide or mass homicide. The issue of
increasing violence has had great impact on community
nurses in all settings, especially with the emergence of
terrorism and bioterrorism *see Chapter
%A-. "ducators now believe that all nurses need core
competencies in emergency preparedness to be ready for
human!created disasters *9ebbie B ?ureshi, @''@-. ;ne
e8ample of this need for Cuick action was in the aftermath
of the September %%, @''%, terrorist attack in New Dork
City. The state department of mental health immediately
established a program to provide free cri! sis counseling
services to all city residents *5udenstine et al., @''0-.
#s noted earlier, community psychiatric nurses practice
in diverse settings among people who may or may not be
diagnosed with a mental illness. The prin! ciples of the
public health concept of prevention are useful to support all
of these interventions. 1rimary prevention activities are
directed to healthy popula! tions to provide information and
to teach coping skills to reduce stress, with the goal of
avoiding mental ill! ness. 3or e8ample, a nurse may teach
parenting skills in a well!baby clinic. Secondary prevention
involves the early detection and treatment of psychiatric
symp! toms with the goal of minimi$ing impairment. 3or
e8! ample, a nurse may conduct screening for depression at
a work site. Tertiary prevention involves those ser! vices
that address residual impairments in psychiatric clients, in
an effort to promote the highest level of community
functioning. 3or e8ample, a nurse may provide long!
term treatment in a clinic. (o8 /!% pre! sents e8amples of
community practice sites for the psychiatric mental health
nurse.
ASPECTS O: COMMUNITY
NURSIN;
1sychiatric nursing in the community setting differs
markedly from psychiatric nursing in the hospital. The
community setting reCuires fle8ibility on the part of the
psychiatric nurse and knowledge about a broad ar! ray of
community resources. Clients need assistance with
problems related to individual psychiatric symp! toms,
family and support systems, and basic living needs such as
housing and financial support. ;utside of a traditional
clinic or office, the setting is the realm of the client rather
than of the health care provider. Community treatment
hinges on enhancing client strengths in the same
environment in which daily life must be maintained, which
makes individually tai! lored psychiatric care imperative.
The hospital repre!
,O9 62<
E(ements o$ ,io%s&"'oso"ia( N#rsin1
Assessment
Presentin1 %rob(em and re$errin1 %art&
Ps&"'iatri" 'istor&, in"(#din1 s&m%toms, treatments, med2
i"ations, and most re"ent ser/i"e #ti(i*ation
Hea(t' 'istor&, in"(#din1 i((nesses, treatments, medi"ations,
and a((er1ies
S#bstan"e ab#se 'istor& and "#rrent #se=
:ami(& 'istor&, in"(#din1 'ea(t' and menta( 'ea(t' disorders
and treatments
Ps&"'oso"ia( 'istor&, in"(#din16

3e/e(o%menta( 'istor&

S"'oo( %er$orman"e

So"ia(i*ation

Vo"ationa( s#""ess or di$$i"#(t&

Inter%ersona( s>i((s or de$i"its

In"ome and so#r"e o$ in"ome=

Ho#sin1 ade?#a"& and stabi(it&=

:ami(& and s#%%ort s&stem=

Le/e( o$ a"ti/it&

Abi(it& to "are $or needs inde%endent(& or 4it'
assis2 tan"e

Re(i1io#s or s%irit#a( be(ie$s and %ra"ti"es
Le1a( 'istor&
Menta( stat#s e.amination
Stren1t's and de$i"its o$ t'e "(ient
C#(t#ra( be(ie$s and needs re(e/ant to %s&"'oso"ia( "are
,O9 62@
Possib(e Comm#nit& Menta( Hea(t'
Pra"ti"e Sites
Primary Prevention
Ad#(t and &o#t' re"reationa( "enters
S"'oo(s
3a& "are "enters
C'#r"'es, tem%(es, s&na1o1#es, mos?#es
Et'ni" "#(t#ra( "enters
Secondary Prevention
Crisis "enters
S'e(ters A'ome(ess, battered 4omen, ado(es"entsB
Corre"tiona( "omm#nit& $a"i(ities
Yo#t' residentia( treatment "enters
Partia( 'os%ita(i*ation %ro1rams
C'emi"a( de%enden"& %ro1rams
N#rsin1 'omes
Ind#str&84or> sites
O#trea"' treatment in %#b(i" %(a"es
Hos%i"es and a"?#ired imm#node$i"ien"& s&ndrome %ro2
1rams
Assisted (i/in1 $a"i(ities
Tertiary Prevention
Comm#nit& menta( 'ea(t' "enters
Ps&"'oso"ia( re'abi(itation %ro1rams
sents a controlled setting and promotes stabili$ation, but
strides made during hospitali$ation can be lost upon return
home. Treatment in the community per! mits clients and
those involved in their support to learn new ways of coping
with symptoms or situa! tional difficulties. The result can
be one of empower! ment and self!management, to the
e8tent possible given the client:s disability.
Pyc!iatric N"rin# $ement
Strate#ie
#ssessment of the biopsychosocial needs and capaci! ties
of clients living in the community reCuires e8pan! sion of
the general psychiatric nursing assessment. 3or the
hospitali$ed client, the nurse must understand
community living challenges and resources to assess
presenting problems as well as to plan for discharge. The
community psychiatric 5N must also develop a
comprehensive understanding of the client:s ability to cope
with the demands of living in the community, to be able to
plan and implement effective treatment. (o8
/!@ identifies the areas covered in a biopsychosocial
assessment.
3our key elements of this assessment are strongly
related to the probability that the client will e8perience
=Stron1(& re(ated to t'e %robabi(it& t'at t'e "(ient 4i(( e.%erien"e s#""ess$#(
o#t2 "omes in t'e "omm#nit&0
successful outcomes in the community. 1roblems in any of
these areas reCuire immediate attention before other
treatment goals are pursued.

Housing adeCuacy and stabilityE.f a client faces
daily fears of homelessness, it is not possible to fo! cus
on other treatment issues.

.ncome and source of incomeE# client must have a
basic income, whether from an entitlement, a
relative, or other sources, to obtain necessary
medication and to meet daily needs for food and
clothing.

3amily and support systemEThe presence of a
family member, friend, or neighbor supports the
client:s recovery and also gives the 5N a contact
person, with the client:s consent.

Substance abuse history and current useE;ften
hidden or minimi$ed during hospitali$ation,
substance abuse can be a destructive force under!
mining medication effectiveness and interfering with
community acceptance and procurement of housing.
.ndividual cultural characteristics of clients are also very
important to assess. 3or e8ample, working with a
person for whom Spanish is the primary language re! Cuires
the nurse to consider the implications of lan! guage and
cultural background. The use of an inter! preter or cultural
consultant, from the agency or from the family, is essential
when the nurse and client speak different languages *see
Chapter )-.
Pyc!iatric N"rin# Intervention Strate#ie
.n the hospital setting, the focus of care is on stabili$a! tion,
as defined by staff. .n the community setting, treatment
goals and interventions are negotiated rather than imposed
on the client. Community psychi! atric nurses must
approach interventions with fle8ibil! ity and
resourcefulness to meet the broad range of needs of
clients. The comple8ity of navigating the mental health
system and the social service funding systems is often
overwhelming to clients. Not une8! pectedly, client
outcomes with regard to mental status and functional level
have been found to be more posi! tive and to be achieved
with greater cost effectiveness when the community
psychiatric 5N integrates case management into the
professional role *Chan, Macken$ie, B =acobs, @'''4 Chan
et al., @'''-.
7ifferences in characteristics, treatment outcomes, and
interventions between inpatient and community settings are
outlined in Table /!%. Note that all of these interventions
fall within the practice domain of the ba! sic level 5N.
ROLES AN3 :UNCTIONS
O: THE COMMUNITY
PSYCHIATRIC NURSE
#s noted in Chapter A, psychiatric mental health nurses are
educated at a variety of levels6 associate, diploma,
baccalaureate, masters, and doctoral. 1erhaps the most
significant distinction among the multiple levels of
preparation is the degree to which the nurse acts
autonomously and provides consulta! tion to other
providers both inside and outside of the particular agency.
The nurse practice acts of individual states grant nurses
authority to practice, and the stan! dards of psychiatric
nursing developed by the #merican Nurses #ssociation
in collaboration with psychiatric groups also define levels
of practice. Table
/!@ describes the roles of psychiatric nurses according to
level of education.
%em&er o' %"(tidici)(inary *omm"nity
Practice T eam
The concept of using multidisciplinary treatment teams
originated with the Community Mental Health Centers #ct
of %+/0. 1sychiatric nursing practice was identified as one
of the core mental health disciplines, along with psychiatry,
social work, and psychology. This recognition permitted
the allocation of resources
TA,LE 62@
C'ara"teristi"s, Treatment O#t"omes, and Inter/entions b& Settin1
In)atient Settin# *omm"nity %enta( +ea(t! Settin#
*!aracteritic
Unit (o">ed b& sta$$ Home (o">ed b& "(ient
<C2'o#r s#%er/ision Intermittent s#%er/ision
,o#ndaries determined b& sta$$ ,o#ndaries ne1otiated 4it' "(ient
Mi(ie# 4it' $ood, 'o#se>ee%in1, se"#rit& ser/i"es C(ient2"ontro((ed en/ironment 4it' se($2"are, sa$et& ris>s
Treatment O"tcome
Stabi(i*ation o$ s&m%toms and ret#rn to "omm#nit& Stab(e or im%ro/ed (e/e( o$ $#n"tionin1 in "omm#nit&
Intervention
3e/e(o% s'ort2term t'era%e#ti" re(ations'i%0 Estab(is' (on12term t'era%e#ti" re(ations'i%0
3e/e(o% "om%re'ensi/e %(an o$ "are 4it' attention to 3e/e(o% "om%re'ensi/e %(an o$ "are $or "(ient and s#%%ort
so"io"#(t#ra( needs o$ "(ient0 s&stem 4it' attention to so"io"#(t#ra( needs0
En$or"e bo#ndaries b& se"(#sion or restraint, as needed0 Ne1otiate bo#ndaries 4it' "(ient0
Administer medi"ation0 En"o#ra1e "om%(ian"e 4it' medi"ation re1imen0
Monitor n#trition and se($2"are 4it' assistan"e as needed0 Tea"' and s#%%ort ade?#ate n#trition and se($2"are 4it'
re$erra(s as needed0
Pro/ide 'ea(t' assessment and inter/ention as needed0 Assist "(ient in se($2assessment 4it' re$erra(s $or 'ea(t'
needs in "omm#nit& as needed0
O$$er str#"t#red so"ia(i*ation a"ti/ities0 Use "reati/e strate1ies to re$er "(ient to %ositi/e so"ia(
a"ti/ities0
P(an $or dis"'ar1e 4it' $ami(&8si1ni$i"ant ot'er 4it' re1ard to Comm#ni"ate re1#(ar(& 4it' $ami(&8s#%%ort s&stem to assess
'o#sin1 and $o((o42#% treatment0 and im%ro/e (e/e( o$ $#n"tionin10
TA,LE 62<
Comm#nit& Ps&"'iatri" N#rsin1 Ro(es Re(e/ant to Ed#"ationa( Pre%aration
,o(e $dvanced Practice -%S. P!/0 1aic Practice -/i)(oma. $$. 1S0
Pra"ti"e N#rse %ra"titioner or "(ini"a( n#rse s%e"ia(ist7 mana1e Pro/ide n#rsin1 "are $or "ons#mer and assist 4it'
"ons#mer "are and %res"ribe or re"ommend inter2 medi"ation mana1ement as %res"ribed, #nder dire"t
/entions inde%endent(& s#%er/ision
Cons#(tation Cons#(tant to sta$$ abo#t %(an o$ "are, to "ons#mer Cons#(t 4it' sta$$ abo#t "are %(annin1 and 4or> 4it'
and $ami(& abo#t o%tions $or "are7 "o((aborate 4it' n#rse %ra"titioner or %'&si"ian to %romote 'ea(t'
"omm#nit& a1en"ies abo#t ser/i"e "oordination and and menta( 'ea(t' "are7 "o((aborate 4it' sta$$ $rom
%(annin1 %ro"esses ot'er a1en"ies
Administration Administrati/e or "ontra"t "ons#(tant ro(e 4it'in menta( Ta>e (eaders'i% ro(e 4it'in menta( 'ea(t' treatment
'ea(t' a1en"ies or menta( 'ea(t' a#t'orit& team
Resear"' and Ro(e as ed#"ator or resear"'er 4it'in a1en"& or menta( Parti"i%ate in resear"' at a1en"& or menta( 'ea(t' a#2
ed#"ation 'ea(t' a#t'orit& t'orit&7 ser/e as %re"e%tor to #nder1rad#ate n#rsin1
st#dents
to educate psychiatric nurses and emphasi$ed their uniCue
contributions to the team.
.n team meetings, the individual and discipline!
specific e8pertise of each member is recogni$ed.
9enerally, the composition of the team reflects the
availability of fiscal and professional resources in the area.
Similar to the team defined in Chapter ,, the community
psychiatric team may include psychia! trists, nurses, social
workers, psychologists, dual! diagnosis specialists, and
mental health workers. 5ecognition of the ability of nurses
to have an eCual voice in team treatment planning with
other profes! sionals was novel at the time the team
approach was implemented in community mental health
practice. This level of professional performance was later
used as a model for other nursing specialties.
Some writers believe that the multidisciplinary team
approach dilutes the nursing role, because nurses adopt the
language of psychiatry and social services. (ut ideally, the
nurse is able to integrate a strong nurs! ing identity into the
team perspective. #t the basic or advanced practice level,
the community psychiatric 5N is in a critical position to
link the biopsychosocial and spiritual components relevant
to mental health care for the individual. The 5N also
communicates in a manner that the client, significant
others, and mem! bers of the team can accept and
understand. .n partic! ular, the management and
administration of psy! chotropic medications have become
a significant task the community 5N is e8pected to
perform. There is ev! idence that medications are most
effective when the nurse approaches drug therapy seeking
to empower the individual client *Marland B Sharkey,
%+++-.
1io)yc!oocia( *are
%ana#er
The role of the community psychiatric 5N includes the
coordination of mental health, physical health, spiri! tual
health, social service, educational service, and vo!
cational realms of care for the mental health client. The
reality of community practice in the new millennium is
that few clients seeking treatment have uncompli! cated
symptoms of a single mental illness. The sever! ity of
illness, especially in the public sector, has in! creased and
is correlated with increased substance abuse, poverty, and
stress. .n addition, repeated stud! ies show that the mentally
ill have a higher risk for medical disorders than the general
population *7ickey et al., @''@-.
The %+&'s brought increased emphasis on imple!
menting case management as a core service in treating the
seriously mentally ill client. .n the private domain, case
management or care management has also found a niche.
The intent is to charge case managers with de! signing
individually tailored treatment services for clients and
tracking outcomes of care. Case manage! ment includes the
following functions6 assessing client needs4 developing a
plan for service4 linking the client with necessary services4
monitoring the effectiveness of services4 and advocating for
the client, as needed *Shoemaker, @'''-. Nursing and
medicine are the only mental health disciplines possessing
the knowledge, skill, and legal authority to provide the full
range of mental health care interventions. This scope of
prac! tice, coupled with issues of personnel cost and avail!
ability, underscores the critical need for community
psychiatric 5Ns to participate in coordination of care
activities.
# successful life in the community is more likely when
medications are taken as prescribed. Nurses are in a
position to help the client to manage medication, recogni$e
side effects, and be aware of the interactions among drugs
prescribed for physical illness and men! tal illness. Client!
family education and behavioral strategies, in the conte8t
of a therapeutic relationship with the clinician, have been
shown to significantly in! crease compliance with the
medication regimen *Facro
B 9lassman, @''A-.
M
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Partia( 'os%ita(i*ation %ro1ram APHPB
Ps&"'iatri" 'ome "are
Asserti/e "omm#nit& treatment AACTB
Intensi/e s#bstan"e ab#se %ro1ram
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Comm#nit& menta( 'ea(t' "enter ACMHCB
Pri/ate t'era%ist o$$$i"e
COMMUNITY SETTIN;S
Many community psychiatric 5Ns originally practiced on
site at community mental health centers. #s finan! cial,
health care, regulatory, cultural, and population changes
have occurred, the practice locations have changed.
Nurses are providing primary mental health care at
therapeutic day care centers, schools, partial hospitali$ation
programs, and shelters. .n addition to these more traditional
environments for care, psychi! atric 5Ns are also entering
forensic settings and drug and alcohol treatment centers.
Mobile mental health units have been developed in some
service areas. .n a growing number of communities, mental
health pro! grams are collaborating with other health or
commu! nity services to provide integrated approaches to
treat! ment. # prime e8ample of this is the growth of
dual!diagnosis programming at both mental health and
chemical dependency clinics. Technology has be! gun to
contribute to the venues for providing commu! nity care6
telephone crisis counseling, telephone out! reach, and even
the .nternet are being used to enhance access to mental
health services *Gilson B Gilliams,
@'''-.
.n the following sections, you will find descriptions
of four different community psychiatric settings, with
illustrations of the practice of the basic level 5N in
each team. Nursing interventions in these settings in!
clude most of those defined for basic practice, for e8!
ample6

CounselingEassessment interviews, crisis inter!
vention, problem solving in individual, group, or
family sessions.

1romotion of self!care activitiesEfostering of
grooming, instruction in use of public transporta!
tion, budgeting4 in home settings, the 5N may di!
rectly assist as necessary.

1sychobiological interventionsEmedication ad!
ministration, teaching of rela8ation techniCues,
promotion of sound eating and sleep habits.

Health teachingEmedication use, illness charac!
teristics, coping skills, relapse prevention.

Case managementEcommunication with family,
significant others, and other health care or com!
munity resource personnel to coordinate an effec!
tive plan of care.
3igure /!% presents the continuum of psychiatric
mental health treatment. Movement along the contin!
uum is fluid, from higher to lower levels of intensity,
and changes are not necessarily step by step. <pon
discharge from acute hospital care or a @A!hour super!
vised crisis unit, many clients need intensive services
to maintain their initial gains or to Hstep downI in
care. Multiple studies show that failure to follow up in
outpatient treatment increases the likelihood of rehos!
2I3U,4 651 T'e "ontin##m o$ %s&"'iatri" menta( 'ea(t'
treatment0
pitali$ation and other adverse outcomes *2ruse B 5ohland,
@''@-.
;ther clients with a pree8isting community treat! ment
team may return directly to their community mental health
center or psychosocial rehabilitation program. Homeless
clients may be referred to a shelter with linkage to intensive
case management or as! sertive community treatment.
Clients with a substan! tial problem with substance abuse
may be transferred directly into a residential substance
abuse treatment program *see Chapter @)-. .t is also notable
that clients may pass through the continuum of treatment in
the reverse direction4 that is, if symptoms e8acerbate, a
lower intensity service may refer the client temporar! ily to
a higher level of care in an attempt to prevent to! tal
decompensation and hospitali$ation.
P artia( +o)ita(i6ation Pro#ram
Partial hospitalization programs (PHPs) offer inten!
sive, short!term treatment similar to an inpatient level of
care, e8cept that the client is able to return home each day.
Criteria for referral to a 1H1 include the need for
prevention of hospitali$ation for serious symptoms or step!
down from acute inpatient treat! ment and the presence of a
responsible relative or care! giver who can assure the
client:s safety *Shoemaker,
@'''-. 5eferrals come from inpatient or outpatient
providers. Transportation is usually provided, and clients
receive , to / hours of treatment daily. 1rograms operate
up to ) days a week, and the length of stay is appro8imately
% month. The multidiscipli! nary team consists of at least a
psychiatrist, 5N, and social worker. The 5N is supervised
by the psychia! trist.
Treatment outcomes related to nursing care in a
1H1, in the language of the Nursing ;utcomes
Classification *N;C- may include the following
*Moorhead, =ohnson, B Maas, @''A-6

Client identifies correct name of medications.

Client identifies precursors of depression.

Client e8hibits impulse control.

Client perceives support of health care providers.
The following vignette illustrates the role of the
psychiatric 5N in a 1H1.
VI GNETTE
-ane T&son is an RN 4'o 4or>s in a PHP in a r#ra( "o#nt&0
T'e PHP is %art o$ t'e on(& "omm#nit& menta( 'ea(t' "enter
in t'is re1ion, 4'i"' 'as one state 'os%ita( and one %ri/ate
in%atient #nit0 -ane 4or>ed $or D &ears in t'e state 'os%ita(
be$ore trans$errin1 to t'e PHP0 -ane is t'e n#rse member o$
t'e team, and toda& 'er s"'ed#(e is as $o((o4s0
+6D)26))6 -ane arri/es at t'e PHP and %re%ares a tea"'in1
o#t(ine $or 'er "o%in1 s>i((s 1ro#%0
6))2@)6))6 -ane meets 4it' ei1't "(ients to tea"' abo#t
"o%in1 4it' de%ression, #sin1 a $i/e2%a1e o#t(ine to e.%(ain
ste%s to de"rease ne1ati/e t'in>in10 A(( 1ro#% members
'a/e a dia1nosis o$ maEor de%ression and are en"o#ra1ed
to as> ?#estions and to 1i/e $eedba"> to ea"' ot'er0
T'ro#1'o#t t'e session, -ane assesses ea"' "(ient5s
"'an1es in mood and be'a/ior sin"e t'e %re/io#s da&0
@)6))2@)6D)6 -ane brie$(& "'e">s 4it' a(( t'e "(ients to en2
s#re t'at t'e& 'a/e ta>en t'eir mornin1 medi"ations0 T'ree
"(ients 'a/e bro#1't t'eir medi"ation bo.es 4it' t'em be2
"a#se s'e needs to dire"t(& obser/e t'em ta>e t'eir med2
i"ation0
@)6D)2@@6D)6 -ane 'as an inta>e inter/ie4 4it' a ne4(& ad2
mitted "(ient0 Ms0 ,ro4n is a !)2&ear2o(d 4oman 4it' a 'is2
tor& o$ maEor de%ression 4'o 4as 'os%ita(i*ed $or @ 4ee>
a$2 ter a dr#1 o/erdose $o((o4in1 an ar1#ment 4it'
'er bo&$riend0 -ane "om%(etes t'e e.tensi/e @)2%a1e
standard2 i*ed inter/ie4 $orm, %a&in1 e.tra attention to ris>
$a"tors $or s#i"ide0 F'en as>ed abo#t s#bstan"e ab#se,
Ms0 ,ro4n admits t'at s'e 'as been drin>in1 'ea/i(& $or
t'e %ast < &ears, in"(#din1 t'e ni1't t'at s'e too> a
dr#1 o/erdose0 F'en t'e inter/ie4 is "om%(eted, t'e "(ient
is re$erred to t'e %s&"'iatrist $or a dia1nosti" e/a(#ation0
@<6))2@6))6 3#rin1 t'e "(ient (#n"' %eriod, -ane meets 4it'
t'e team $or dai(& ro#nds0 S'e %resents t'e ne4(& admitted
"(ient, and t'e team de/e(o%s an indi/id#a( treatment %(an0
In t'is treatment %(an, t'e team notes dis"'ar1e
%(annin1 needs $or re$erra(s to a "omm#nit& menta( 'ea(t'
"enter and a("o'o( treatment %ro1ram0
@6))2<6))6 -ane "o2(eads a t'era%& 1ro#% 4it' t'e
so"ia( 4or>er $or ei1't "(ients 4it' a /ariet& o$ dia1noses0
3#e to t'e s'ort2term nat#re o$ t'e 1ro#% 4it' a(most dai(&
t#rno/er, t'e (eaders ta>e a %s&"'oed#"ationa( a%%roa"'
4it' a de2 $ined to%i" $or ea"' session0 Toda&5s 1ro#%
$o"#ses on s&m%toms o$ %s&"'osis, and members are
in/ited to de2 s"ribe t'eir indi/id#a( e.%erien"es0
<6))2<6D)6 Ne.t, -ane 'as a dis"'ar1e meetin1 4it'
Mr0 -ones0 He is a C+2&ear2o(d man 4it' a dia1nosis o$
s"'i*o2 %'renia 4'o 4as re$erred to t'e PHP b& 'is "(ini"
t'era%ist to %re/ent 'os%ita(i*ation d#e to in"reasin1
%aranoia and a1itation0 A$ter < 4ee>s in t'e PHP, 'e 'as
restabi(i*ed and re"o1ni*es t'at 'e m#st be @))G
"om%(iant 4it' 'is an2 ti%s&"'oti" medi"ation re1imen0
-ane $ina(i*es 'is medi"a2 tion tea"'in1 and "on$irms 'is
a$ter"are a%%ointments 4it' 'is %re/io#s t'era%ist and
%s&"'iatrist0
<6D)2D6))6 -ane meets 4it' Ms0 ,ro4n be$ore s'e 1oes
'ome to s'are t'e indi/id#a( treatment %(an and to be1in a
dis"#ssion o$ reso#r"es $or a("o'o( treatment, in"(#din1
A("o'o(i"s Anon&mo#s0
D6))2C6D)6 A$ter a(( "(ients (ea/e, -ane "om%(etes 'er notes
and dis"'ar1e s#mmar&0 S'e a(so ma>es "ase
mana1e2 ment te(e%'one "a((s to arran1e $or "omm#nit&
re$erra(s, to "omm#ni"ate 4it' $ami(ies, and to re%ort to
mana1ed be2 'a/iora( "are %ro1rams $or #ti(i*ation re/ie40

Pyc!iatric +ome *are
Psychiatric home care was defined by Medicare regu!
lations in %+)+ as reCuiring four elements6 *%- home!
bound status of the client, *@- presence of a psychiatric
diagnosis, *0- need for the skills of a psychiatric 5N, and
*A- development of a plan of care under orders of a
physician.
HHomeboundI refers to the client:s inability to leave
home independently to access community men! tal health
care because of physical or mental condi! tions. 1sychiatric
5Ns are defined to include a range of nursing personnel
from basic level 5Ns with a certain number of years of
e8perience to advanced practice 5Ns *#15Ns- *Carson,
%++&-. ;ther payers besides Medicare also authori$e
home care services. Clients are referred to psychiatric
home care following an acute inpatient episode, either
psychiatric or somatic, or to prevent hospitali$ation. The
psychiatric 5N visits the client one to three times per week
for appro8i! mately % to @ months, and usually sees five or
si8 clients daily.
3amily members or significant others are closely in!
volved in most cases. (ecause many clients are older than
/, years of age, there are usually concurrent so! matic
illnesses to assess and monitor. The 5N acts as case
manager to coordinate all specialists involved in the
client:s care, for e8ample, physical therapist, occu! pational
therapist, and home health aide. The 5N is
supervised by an #15N team leader, who is always
available by telephone.
(oundaries become important in the home setting,
where there is inherently a greater degree of intimacy
between nurse and client. .t may be important for the 5N
to begin a visit informally, by chatting about client family
events or accepting refreshments offered. This interaction
can be a strain for the 5N who struggles to maintain a
professional distance. However, there is great significance
to the therapeutic use of self in such circumstances, to
establish a level of comfort for the client and family.
Treatment outcomes related to nursing care in psy!
chiatric home care setting, in the language of the N;C, may
include the following6

Client uses rela8ation techniCues to reduce an8i! ety.

Client describes actions, side effects, and precau!
tions for medications.

Client upholds a suicide contract.

Client recogni$es hallucinations or delusions.
The following vignette illustrates a typical day for
the psychiatric home care 5N.
VIGNETTE
Nata(ie ,ea#mont is an RN em%(o&ed b& a 'ome "are
a1en"& in a (ar1e r#ra( "o#nt&0 S'e 4or>ed $or < &ears in
t'e state %s&"'iatri" 'os%ita( be$ore Eoinin1 t'e
%s&"'iatri" 'ome "are a1en"&0 S'e /isits "(ients in a radi#s
o$ !) mi(es $rom 'er 'ome and 'as dai(& te(e%'one "onta"t
4it' 'er s#2 %er/isor0 S'e sto%s b& t'e o$$i"e 4ee>(& to
dro% o$$ %a%er2 4or>, and s'e attends t'e team meetin1
on"e a mont'0 T'e team in"(#des 'er team (eader, ot'er
$ie(d RNs, team %s&2 "'iatrist "ons#(tant, and so"ia(
4or>er0 Nata(ie "'ooses to ma>e 'er /isits $rom + AM to
D6D) PM and t'en "om%(etes 'er do"#mentation at 'ome0
+6))26))6 Her $irst "(ient is Mr0 -o'nson, a 662&ear2o(d man
4it' a dia1nosis o$ maEor de%ression a$ter a stro>e0 He 4as
re$erred b& 'is %rimar& "are %'&si"ian d#e to s#i"ida(
ideation0 Nata(ie 'as met 4it' 'im and 'is 4i$e t'ree times
%er 4ee> $or t'e %ast < 4ee>s0 He 'as "ontra"ted $or sa$et&
and 'as been "om%(iant in ta>in1 'is antide%ressant0 Toda&
s'e tea"'es t'e "o#%(e abo#t stress mana1ement te"'2
ni?#es0 Case mana1ement res%onsibi(ities $or Mr0 -o'nson
in"(#de s#%er/ision o$ t'e 'ome 'ea(t' aide 4'o 'e(%s 'im
4it' '&1iene and "oordination 4it' t'e %'&si"a( and o""#2
%ationa( t'era%ists 4'o a(so treat 'im0
6D)2@@6D)6 Nata(ie 'as an inta>e inter/ie4 s"'ed#(ed 4it'
Ms0 ,ar>er, a C!2&ear2o(d sin1(e 4oman 4it' a dia1nosis o$
s"'i*o%'renia 4'o (i/es 4it' 'er mot'er0 S'e 4as re$erred
b& t'e in%atient %s&"'iatrist a$ter an in/o(#ntar&
'os%ita(i*ation $or re%eated(& "a((in1 @@ 4it' bi*arre
re%orts o$ /io(en"e in 'er ba"> &ard0 S'e 'ad not been in
t'e 'os%ita( $or ! &ears b#t re"ent(& 'ad dro%%ed o#t o$
treatment 4'en 'er %ri/ate %s&"'iatrist o$ @! &ears retired0
Nata(ie "om%(etes t'e e.ten2 si/e str#"t#red inta>e
inter/ie4, in"(#din1 t'e mot'er5s $eed2 ba">0 S'e tea"'es
t'em abo#t t'e ne4 anti%s&"'oti" med2 i"ation Ms0
,ar>er is ta>in1 and sets #% t'e 4ee>(& medi"ation
bo.0 Nata(ie e.%(ains t'at s'e 4i(( /isit t4o times
a 4ee> $or t'e ne.t < mont's0 Her "ase mana1ement ro(e
4i(( in"(#de identi$i"ation o$ a ne4 "omm#nit& %s&"'iatrist $or
t'e "(ient and a %ossib(e $ami(& s#%%ort 1ro#% $or t'e
mot'er0
@<6D)2@6D)6 Ne.t, Nata(ie sees Ms0 ;ra/es, a 6<2&ear2
o(d 4ido4 dia1nosed 4it' maEor de%ression a$ter t'e deat'
o$ 'er '#sband and a mo/e into an assisted (i/in1
$a"i(it&0 Ms0 ;ra/es 'as diabetes and is 4'ee("'air bo#nd
d#e to an am2 %#tation0 S'e 4as re$erred b& t'e n#rse
dire"tor o$ t'e as2 sisted (i/in1 $a"i(it&0 Nata(ie 'as met
4it' 'er t4o times %er 4ee> $or t'e %ast C 4ee>s, tea"'in1
abo#t de%ression, 1rie$, medi"ations, and "o%in1 s>i((s0
Toda& 'er $o"#s is on identi2 $&in1 a ne4 so"ia( s&stem,
in"(#din1 in"reased "onta"t 4it' (on12distan"e re(ati/es,
so"ia( a"ti/ities at t'e $a"i(it&, and s%irit#a( s#%%ort0 Fit'
in%#t $rom t'e dire"tor, Nata(ie (earns o$ a 1rie$ "o#nse(in1
1ro#% at t'e (o"a( "'#r"' r#n b& a %astora( "o#nse(or and
s'e re"ommends t'at reso#r"e to Ms0 ;ra/es0
<6))2D6))6 Nata(ie5s (ast "(ient $or t'e da& is Mr0 Coo%er,
a
!!2&ear2o(d sin1(e man 4it' a dia1nosis o$ %ani" disorder
4it' a1ora%'obia0 Mr0 Coo%er (i/es 4it' 'is o(der
brot'er and 4as re$erred b& t'e brot'er5s %rimar& "are
%'&si"ian a$2 ter t'e %'&si"ian $o#nd o#t t'at t'e "(ient 'ad
not been o#t o$ t'e 'o#se $or ! &ears sin"e t'e deat'
o$ 'is mot'er0 Nata(ie 'as been 4or>in1 4it' Mr0 Coo%er
$or H 4ee>s and 'as de"reased /isits to on"e a 4ee>0
S'e 'as ta#1't Mr0 Coo%er abo#t 'is i((ness, medi"ation,
and re(a.ation te"'2 ni?#es0 He 'as %ro1ressed to bein1
ab(e to 4a(> o#tside $or
@! min#tes at a time0 Toda&5s %(an is to attem%t ridin1 in t'e
"ar 4it' 'is brot'er $or @) min#tes, in %re%aration $or dis2
"'ar1e 4'en 'e 4i(( 'a/e to ride $or D) min#tes to rea"' t'e
"omm#nit& menta( 'ea(t' "enter0
:o((o4in1 t'is /isit, Nata(ie ret#rns 'ome to "om%(ete do"#2
mentation, to "a(( in a re%ort to 'er team (eader and
t'e %'&si"ians, and to ma>e ot'er "ase mana1ement
te(e%'one "onta"ts $or "omm#nit& re$erra(s0

$ertive *omm"nity Treatment
Assertive community treatment (AC) teams or mo! bile
treatment units have sprung up in various areas throughout
the <nited States to respond to those men! tally ill clients
who cannot effectively use traditional outpatient mental
health services. 1rofessional staff pursue and HwooI
clients and support treatment in whatever settings clients
find themselves inEat home or in a public place. Clients
may be assessed and treated in fast food restaurants,
receive one of the de! canoate medications *e.g., Haldol,
1roli8in- in a restau! rant bathroom, and at the close of a
HsessionI be of! fered a milkshake and a meal as a reward.
.f adherence to a prescribed medication regimen is a
problem re! lated to understanding, medications are
packaged and labeled with the time and date they are to be
taken. Creative problem solving and interventions are hall!
marks of care provided by mobile teams. The "vidence!
(ased 1ractice bo8 describes clinical re! search related to
#CT teams.
EVI3ENCE2,ASE3 PRACTICE
$ertive *omm"nity
Treatment
1ac7#ro"nd
O/er t'e %ast <) &ears sin"e deinstit#tiona(i*ation, m#"' re2
sear"' 'as $o"#sed on "omm#nit& treatment $or s"'i*o%'re2
nia and ot'er se/ere menta( i((ness ASMIB0 C(ients 4it'
SMI 'a/e si1ni$i"ant di$$i"#(ties 4it' se($2"are, so"ia(
re(ations'i%s, 4or>, and (eis#re0 T'ere is no4 a bod& o$
e/iden"e demon2 stratin1 t'at %s&"'oso"ia( treatment "an
im%ro/e t'e (on12 term o#t"omes $or t'ese "(ients0
St"die
More t'an <! "ontro((ed st#dies 'a/e e/a(#ated t'e e$$e"ts o$
asserti/e "omm#nit& treatment AACTB on "(ients 4it' SMI0 ACT
is a mode( $or "ase mana1ement to ser/e "(ients 4'o are
non2 "om%(iant 4it' standard o#t%atient treatment0 E(ements
o$ t'e mode( in"(#de %ro/ision o$ ser/i"es in t'e "omm#nit&
instead o$ on site in a "(ini", #se o$ m#(tidis"i%(inar&
treatment teams 4it' (o4 "(ient2to2sta$$ ratio A@)6@B and 'i1'
$re?#en"& o$ "on2 ta"t At'ree to $i/e times %er 4ee>B, s'ared
"ase(oads 4it' "(ini2 "ians, and <C2'o#r "o/era1e $or
emer1en"ies0
,e"(t o' St"die
Most o$ t'e st#dies 4ere "ond#"ted in #rban settin1s 4it' a%2
%ro.imate(& @)) "(ients and $o((o42#% o/er @+ mont's0 ACT
4as "om%ared to standard "ase mana1ement $or e$$e"ts on
'o#sin1 stabi(it&, time s%ent in t'e 'os%ita(, so"ia( adE#stment,
and "ost e$$e"ti/eness0 Fit' re1ard to 'o#sin1 stabi(it&, @<
st#dies s'o4ed %ositi/e e$$e"ts o$ ACT0 Time s%ent in t'e
'os2 %ita( 4as red#"ed b& t'e #se o$ ACT in @C st#dies0
So"ia( ad2 E#stment 4as not "onsistent(& im%ro/ed b&
ACT, 4it' on(& t'ree st#dies s'o4in1 bene$its0 ,e"a#se ACT
"onsiderab(& re2 d#"ed 'os%ita( #se, it 4as "onsidered "ost
e$$e"ti/e in t'e ma2 Eorit& o$ st#dies0
Im)(ication 'or N"rin# Practice
T'e n#rse is a member o$ t'e ACT team and administers
med2 i"ation, tea"'es s>i((s in se($2"are and 'ea(t'
maintenan"e, "oordinates a""ess to medi"a( "are, and
ma>es re$erra(s to "omm#nit& ser/i"es s#"' as 'o#sin10
T'ese inter/entions re2 ?#ire t'e n#rse to estab(is' a
s#%%orti/e re(ations'i% 4it' t'e "(ient and to "o((aborate 4it'
t'e ot'er team members to en2 s#re <C2'o#r "ontin#it& o$
"are0
M#eser, K0 T0, ,ond, ;0 R0, I 3ra>e, R0 E0 A<))@B0 Comm#nit&2based treatment o$ s"'i*o%'renia and ot'er se/ere menta( disorders6 Treatment o#t"omes0 Medscape General
Medicine
6A@B, @2D@0
Clients are referred to #CT teams by inpatient or
outpatient providers because of a pattern of repeated
hospitali$ations with severe symptoms, along with an
inability to participate in traditional treatment. Care is
provided by a multidisciplinary team, and the psychi! atric
5N may manage a caseload of %' clients whom he or she
visits three to five times per week. The 5N is su! pervised
by a psychiatrist or #15N. Fength of treat! ment may
e8tend to years, until the client is ready to accept transfer to
a more structured site for care. There is a @A!hour on!call
system to allow the client to reach the team during an
emergency.
Treatment outcomes related to nursing care through an
#CT team, in the language of the N;C, may in! clude the
following6

Client avoids alcohol and recreational drugs.

Client adheres to treatment regimen as pre!
scribed.

Client uses health services congruent with need.

Client e8hibits reality!based thinking.
The following vignette describes the role of the psy!
chiatric 5N on the #CT team.
VI GNETTE
S#san ;reen is a n#rse 4'o 4or>s on an ACT team at
a (ar1e inner2"it& #ni/ersit& medi"a( "enter0 S'e 'ad ! &ears
o$ in%atient e.%erien"e be$ore Eoinin1 t'e ACT team, and
s'e 4or>s 4it' an APRN, t4o so"ia( 4or>ers, t4o
%s&"'iatrists, and a menta( 'ea(t' 4or>er0 S'e is s#%er/ised
b& t'e APRN0
+6))26))6 S#san starts t'e da& at t'e "(ini" site 4it' team
ro#nds0 ,e"a#se s'e 4as on "a(( o/er t'e 4ee>end, s'e #%2
dates t'e team on t'ree emer1en"& de%artment /isits6 t4o
"(ients 4ere ab(e to ret#rn 'ome a$ter s'e met 4it' t'em
and t'e emer1en"& de%artment %'&si"ian7 one "(ient 4as
admit2 ted to t'e 'os%ita( be"a#se 'e made t'reats to 'is
"are1i/er0
6D)2@)6D)6 Her $irst "(ient is Mr0 3ona(dson, a D!2&ear2o(d
man 4it' a dia1nosis o$ bi%o(ar disorder and a("o'o(
de2 %enden"e0 He (i/es 4it' 'is mot'er and 'as a 'istor& o$
$i/e 'os%ita(i*ations 4it' non"om%(ian"e 4it' o#t%atient
"(ini" treatment0 E."e%t d#rin1 'is mani" e%isodes, 'e
iso(ates 'imse($ at 'ome or /isits a $riend in t'e
nei1'bor'ood at 4'ose 'o#se 'e drin>s e."essi/e(&0
Toda& 'e is d#e $or 'is bi4ee>(& de"anoate inEe"tion0
S#san 1oes $irst to 'is 'o#se and (earns t'at 'e is not at
'ome0 S'e s%ea>s 4it' 'is mot'er abo#t 'is re"ent
be'a/ior and an #%"omin1 medi"a( "(ini" a%%ointment0
T'en s'e 1oes to t'e $riend5s 'o#se and $inds Mr0
3ona(dson %(a&in1 "ards and drin>in1 a beer0 He and 'is
$riend are "o#rteo#s to 'er, and Mr0 3ona(dson "o2
o%erates in re"ei/in1 'is inEe"tion0 He (istens as S#san re2
%eats tea"'in1 abo#t t'e ris>s o$ a("o'o( "ons#m%tion, and
s'e en"o#ra1es 'is attendan"e at an A("o'o(i"s Anon2
&mo#s meetin10 He re%orts t'at 'e did 1o to one meetin1
&esterda&0 S#san %raises 'im and en"o#ra1es 'im and 'is
$riend to 1o a1ain t'at ni1't0
@@6))2@6))6 T'e ne.t "(ient is Ms0 Abbott, a !D2&ear2o(d sin2
1(e 4oman 4it' a dia1nosis o$ s"'i*oa$$e"ti/e disorder and
'&%ertension0 S'e (i/es a(one in a senior "iti*en b#i(din1
and 'as no "onta"t 4it' $ami(&0 Ms0 Abbott 4as re$erred
b& 'er "(ini" team be"a#se s'e e.%erien"ed t'ree
'os%ita(i*ations o/er @ &ear $or %s&"'oti" de"om%ensation,
des%ite re"ei/2 in1 mont'(& de"anoate inEe"tions0 T'e ACT
team is no4 t'e %a&ee $or 'er So"ia( Se"#rit& "'e">0
Toda&, S#san 'as to ta>e Ms0 Abbott o#t to %a& 'er bi((s
and to 1o to 'er %rimar& "are %'&si"ian $or a "'e">#%0
Ms0 Abbott 1reets S#san 4arm(& at t'e door, 4earin1
e."essi/e ma>e#% and ina%2 %ro%riate s#mmer "(ot'in10
Fit' 1ent(e en"o#ra1ement, s'e
a1rees to 4ear 4armer "(ot'es0 S'e is re(#"tant to s'o4
S#san 'er medi"ation bo. and brie$(& 1ets irritab(e
4'en S#san %oints o#t t'at s'e 'as not ta>en 'er mornin1
med2 i"ations0 As t'e& sto% b& t'e a%artment o$$i"e to
%a& t'e rent, S#san ta(>s 4it' t'e mana1er brie$(&0 T'is
a%artment mana1er is t'e on(& "onta"t %erson $or Ms0
Abbott, and s'e "a((s t'e team 4'ene/er an& o$ t'e ot'er
residents re%ort an& #n#s#a( be'a/ior0 O/er t'e ne.t @
@
J
<
'o#rs, S#san and Ms0 Abbott dri/e to /ario#s stores and 1o
to Ms0 Abbott5s so2 mati" a%%ointment0
<6))2C6D)6 T'e (ast "(ient /isit $or toda& is 4it' Mr0 H#nter, a
6)2&ear2o(d 4ido4ed man dia1nosed 4it' s"'i*o%'renia
and "o"aine de%enden"e0 Mr0 H#nter 4as re$erred b& t'e
emer1en"& de%artment (ast &ear a$ter re%eated /isits d#e to
%s&"'osis and into.i"ation0 Initia((&, 'e 4as 'ome(ess,
b#t 'e no4 (i/es in a re"o/er& 'o#se s'e(ter and 'as been
"(ean o$ i((e1a( s#bstan"es $or 6 mont's0 He re"ei/es a
mont'(& de"anoate inEe"tion and is so"ia((& iso(ated in
t'e 'o#se0 No4 t'at 'e 'as re"ei/ed 'is So"ia( Se"#rit&
3isabi(it& in2 "ome, 'e is see>in1 an a$$ordab(e a%artment0
Toda&, S#san 'as t4o a%%ointments to /isit a%artments0
A$ter 1reetin1 'im, S#san notes t'at 'e is 4earin1 t'e same
"(ot'es t'at 'e 'ad on < da&s ear(ier, and 'is 'air is
#n"ombed0 S'e s#12 1ests t'at 'e s'o4er and "'an1e 'is
"(ot'es be$ore t'e& 1o o#t, and 'e a1rees0
At t'e end o$ t'e da&, S#san Eots do4n in$ormation t'at s'e
4i(( #se to 4rite 'er %ro1ress notes in "(ients5 "'arts on t'e
ne.t da& 4'en s'e ret#rns to t'e "(ini"0

*omm"nity %enta( +ea(t! *enter
Community mental health centers were created in the
%+/'s and have since taken center stage for those who
have no access to private care. The range of services
available at such centers varies, but generally they pro!
vide emergency services, adult services, and children:s
services. Common components of treatment at com!
munity mental health centers include medication ad!
ministration, individual therapy, psychoeducational
and therapy groups, family therapy, and dual!diagnosis
treatment. # clinic may also be aligned with a psy-
chosocial reha!ilitation program that offers a struc!
tured day program, vocational services, and residen!
tial services. Some community mental health centers
have an associated intensive case management service
to assist clients in finding housing or obtaining entitle!
ments.
There is a multidisciplinary team, and the psychi!
atric 5N may carry a caseload of /' clients, whom she
sees one to four times per month. The basic level 5N
is supervised by an #15N. Clients are referred to the
clinic for long!term follow!up by inpatient units or
other providers of outpatient care at higher intensity
levels. Clients may attend the clinic for years or be
discharged when they improve and reach desired
goals.
Treatment outcomes related to nursing care in a
community mental health center, in the language of the
N;C, may include the following6

Client describes self!care responsibility for ongo! ing
treatment.

Client describes actions to prevent substance
abuse.

Client refrains from responding to hallucinations or
delusions.

Client keeps appointments with health care pro!
fessionals.
The following vignette provides an e8ample of one work
day for the 5N in a community mental health center.
VI GNETTE
Mar& Smit' is an RN 4'o 4or>s at a "omm#nit& menta(
'ea(t' "enter in a (ar1e #ni/ersit& 'os%ita( in an #rban set2
tin10 S'e 'as been an RN $or @) &ears and trans$erred to
t'e "(ini" < &ears a1o $rom t'e in%atient #nit at t'e same
#ni/er2 sit&0 S'e is a n#rse on t'e ad#(t team and "arries a
"ase(oad o$ "(ients dia1nosed 4it' "'roni" menta( i((ness0
S'e is s#2 %er/ised b& an APRN0
+6D)26))6 U%on arri/in1 at t'e "(ini", s'e $inds a /oi"e mai(
messa1e $rom Ms0 T'om%son, 4'o is "r&in1 and sa&in1
t'at s'e is o#t o$ medi"ation0 Mar& "ons#(ts 4it' t'e
%s&"'iatrist and "a((s Ms0 T'om%son to arran1e $or an
emer1en"& a%2 %ointment (ater t'at da&0
6))26D)6 Mar&5s $irst "(ient is Mr0 Enri1't, 4'o is a D!2
&ear2 o(d man dia1nosed 4it' s"'i*o%'renia, in treatment
at t'e "(ini" $or @) &ears0 3#rin1 t'eir D)2min#te
"o#nse(in1 ses2 sion, s'e assesses 'im $or an&
e.a"erbation o$ %s&"'oti" s&m%toms A'e 'as a 'istor& o$
1randiose de(#sionsB, $or eat2 in1 and s(ee% 'abits, and $or
so"ia( $#n"tionin1 in t'e %s&2 "'oso"ia( re'abi(itation
%ro1ram t'at 'e attends ! da&s %er 4ee>0 Toda& 'e
%resents as stab(e0 Mar& 1i/es 'im 'is de2 "anoate
inEe"tion and s"'ed#(es a ret#rn a%%ointment $or @ mont',
remindin1 'im o$ 'is %s&"'iatrist a%%ointment t'e $o(2 (o4in1
4ee>0
@)6))2@@6))6 Mar& "o2(eads a medi"ation 1ro#% 4it' a %s&2
"'iatrist0 T'is 1ro#% "onsists o$ se/en "(ients 4it' "'roni"
s"'i*o%'renia 4'o 'a/e been "om%(iant in attendin1 bi2
4ee>(& 1ro#% sessions and re"ei/in1 de"anoate inEe"tions
$or t'e %ast ! &ears0 S'e (eads t'e 1ro#% dis"#ssion as t'e
%s&"'iatrist 4rites %res"ri%tions $or ea"' "(ient, be"a#se
most o$ t'e members a(so ta>e ora( medi"ation0 Toda& Mar&
as>s t'e 1ro#% to e.%(ain re(a%se %re/ention to a ne4 mem2
ber0 S'e tea"'es si1ni$i"ant e(ements, in"(#din1 "om%(ian"e
4it' t'e medi"ation re1imen and 'ea(t'& 'abits0 As 1ro#%
members 1i/e e.am%(es $rom t'eir o4n e.%erien"es,
s'e assesses ea"' "(ient5s menta( stat#s0 At t'e end o$
t'e 1ro#%, s'e administers inEe"tions and 1i/es members
a%2 %ointment "ards $or t'e ne.t 1ro#% session0 A$ter t'e
"(ients (ea/e, s'e meets 4it' t'e %s&"'iatrist to e/a(#ate
t'e ses2 sion and to dis"#ss an& ne"essar& "'an1es in
treatment0
@@6))2@<6))6 Mar& do"#ments %ro1ress and medi"ation
notes, res%onds to te(e%'one "a((s, and %re%ares $or
t'e sta$$ meetin10
@<6))2<6))6 A(( ad#(t team sta$$ attend t'e 4ee>(& inta>e
meetin1, at 4'i"' ne4 admissions are dis"#ssed and indi2
/id#a( treatment %(ans are 4ritten 4it' team in%#t0 Mar& %re2
sents a "(ient in inta>e, readin1 $rom t'e standardi*ed inter2
/ie4 $orm0 S'e a(so 1i/es n#rsin1 in%#t abo#t treatment $or
t'e ot'er $i/e ne4(& admitted "(ients0 T'e ne4 "(ient s'e
%re2 sented is assi1ned to 'er, and s'e %(ans to "a(( 'im
(ater in t'e a$ternoon to set #% a $irst a%%ointment0
<6))2D6))6 Mar& "o2(eads a d#a(2dia1nosis t'era%& 1ro#%
4it' t'e d#a(2dia1nosis s%e"ia(ist, 4'o is a so"ia(
4or>er0 T'e 1ro#% is made #% o$ se/en "(ients 4'o 'a/e
"on"#rrent dia1noses o$ s#bstan"e ab#se and a maEor
%s&"'iatri" i((2 ness0 T'e (eaders ta>e a %s&"'oed#"ationa(
a%%roa"', and toda&5s %(anned to%i" is tea"'in1 abo#t t'e
%'&si"a( e$$e"ts o$ a("o'o( on t'e bod&0 Mar& $o"#ses on
ris>s asso"iated 4it' t'e intera"tion bet4een a("o'o( and
medi"ations, and ans4ers t'e members5 s%e"i$i"
?#estions0 ,e"a#se t'is is an on1oin1 1ro#%, members
ta>e a more a"ti/e ro(e, and dis"#ssion ma& /ar&
a""ordin1 to members5 needs instead o$ $o((o4in1 %(anned
to%i"s0 A$ter t'e session, t'e "o2(eaders dis"#ss t'e 1ro#%
d&nami"s and 4rite %ro1ress notes0
D6D)2C6))6 Mar& meets 4it' Ms0 T'om%son, 4'o arri/es at
t'e "(ini" tear$#( and a1itated0 Ms0 T'om%son sa&s t'at s'e
missed 'er a%%ointment t'is mont' be"a#se 'er son died
s#dden(&0 Mar& #ses "risis inter/ention s>i((s to assess Ms0
T'om%son5s stat#s, $or e.am%(e, an& ris>s $or 'er sa$et& re2
(ated to 'er 'istor& o$ s#i"ida( ideation0 A$ter 'e(%in1
Ms0 T'om%son "(ari$& a %(an to in"rease s#%%ort $rom 'er
$ami(&, Mar& notes t'at insomnia is a ne4 %rob(em0 S'e
ta>es Ms0 T'om%son to t'e %s&"'iatrist 4'o is "o/erin1
Kemer1en"& %res"ri%tion timeL $or t'at da& and e.%(ains
t'e "'an1e in t'e "(ient5s stat#s0 T'e %s&"'iatrist re$i((s
Ms0 T'om%son5s #s#a( antide%ressant and adds a
medi"ation to aid s(ee%0 Mar& ma>es an a%%ointment $or
t'e "(ient to ret#rn to see 'er in @ 4ee> instead o$ t'e
#s#a( @ mont', and a(so s"'ed2 #(es 'er to meet 4it' 'er
assi1ned %s&"'iatrist t'at same da&0
C6))2C6D)6 Mar& "om%(etes a(( notes and ma>es ne"essar&
te(e%'one "a((s, $or e.am%(e, to ot'er sta$$ in t'e %s&"'oso2
"ia( re'abi(itation %ro1ram 4'o are 4or>in1 4it' 'er "(ients
and to 'er ne4 "(ient to s"'ed#(e an a%%ointment0

ETHICAL ISSUES
#s community psychiatric 5Ns assume greater auton! omy
and accountability for the care they deliver, ethi! cal
concerns become more of an issue. "thical dilem- mas are
common in disciplines and specialties that care for the
vulnerable and disenfranchised.
1sychiatric 5Ns have an obligation to develop a model
for assessing the ethical implications of their clinical
decisions. "ach incident reCuiring ethical as! sessment is
somewhat different, and the individual 5N brings
personal insights to each situation. The role of the nurse is
to act in the best interests of the client and of society, to the
degree that this is possible.
.n most organi$ations that employ 5Ns, there is a
designated resource for consultation regarding ethical
dilemmas. 3or e8ample, hospitals *with associated
outpatient departments- are reCuired by regulatory
bodies to have an ethics committee to respond to cli!
nicians: Cuestions. Home care agencies or other inde!
pendent agencies may have an ethics consultant in the
administrative hierarchy of the organi$ation. 1ro! fessional
nursing organi$ations and even boards of nursing can be
used as a resource by the individual practitioner. 5efer to
Chapter & for more discussion of ethical guidelines for
nursing practice.
:UTURE ISSUES
7espite the current availability and variety of commu! nity
psychiatric treatments in the <nited States, many clients in
this country in need of services still are not receiving them.
The National Survey on 7rug <se and Health in @''@
estimated that %)., million adults had serious mental illness
*#Cuila B "manuel, @''0, p. 0-. Fess than half, however,
received treatment in @''% *#Cuila B "manuel, @''0, p.
/-. #arriers to treatment have been identified by many
authors and studies. The stigma of mental illness has
lessened over the past A' years4 there is increased
recognition of symptoms due to brain disorders, and well!
known people have come forward to admit that they have
received psychiatric treatment. Det, many people still are
afraid to admit to a psychiatric diagnosis *1ardes, @''0-.
.nstead, they seek medical care for vague somatic
complaints from primary care providers, who too often fail
to diagnose an8iety *or depressive- disorders *5ollman et
al., @''0-.
.n addition to stigma, there are geographic, finan! cial,
and systems factors that impede access to psychi! atric care.
Mental health services are scarce in some rural areas, and
many #merican families cannot afford health insurance
even if they are working. 1resident 9eorge G. (ush:s New
3reedom Commission on Mental Health identified national
system and policy problems in @''@6 fragmented care for
children and adults with serious mental illness, high
unemploy! ment and disability among the seriously
mentally ill, undertreatment of older adults, and lack of
national priorities for mental health and suicide prevention
*1resident:s commission, @''@-.
To meet the challenges of the twenty!first century, 1rice
and Capers *%++,, p. @)- suggested that, in train! ing the
associate degree nurse, Heducators must in! crease their
focus on leadership development, include principles of
home health nursing, increase content on gerontology, and
introduce basic community health concepts.I Those 5Ns
who elect to work with elderly psychiatric clients will be
more and more in demand as the population ages, and the
health care needs of this subgroup are increasingly
comple8 *Hedelin B
Svensson, %+++-. Community psychiatric 5Ns may col!
laborate more with primary health care practitioners to fill
the gap in e8isting community services *Galker, (arker, B
1earson, @'''-. Certainly, community psy! chiatric 5Ns
need to be committed to teach the public about resources
for mental health care, whether for long!term serious
mental illness or for short!term situ! ational stress. More
innovative efforts to locate treat! ment in neutral
community sites are still needed. 3or e8ample, one study
offered treatment to depressed women in a supermarket
setting using a conference room4 participants stated that
they preferred that to a clinic because it was more private
or convenient *Swart$ et al., @''@-.
KEY POINTS to REMEM,ER

Comm#nit& menta( 'ea(t' n#rsin1 'as 'istori"a( roots
datin1

T'e basi" (e/e( "omm#nit& %s&"'iatri" n#rse %ra"ti"es
in man& traditiona( and nontraditiona( sites0

T'ere are si1ni$i"ant di$$eren"es bet4een in%atient
%s&"'i2 atri" n#rsin1 and "omm#nit& %s&"'iatri" n#rsin10

In t'e m#(tidis"i%(inar& team, t'e "omm#nit& menta(
'ea(t' n#rse $#n"tions as a bio%s&"'oso"ia( "are mana1er0

T'e "ontin##m o$ %s&"'iatri" treatment in"(#des
n#mero#s "omm#nit& treatment a(ternati/es 4it' /ar&in1
de1rees o$ in2 tensit& o$ "are0

T'e "omm#nit& %s&"'iatri" n#rse needs a""ess to
reso#r"es to address et'i"a( di(emmas en"o#ntered in
"(ini"a( sit#a2 tions0

T'ere are sti(( barriers to menta( 'ea(t' "are t'at t'e
"omm#2 nit& %s&"'iatri" n#rse ma& be ab(e to diminis'
t'ro#1' dai(& %ra"ti"e0
Visit t'e E/o(/e 4ebsite at 'tt%688e/o(/ e 0e(se/ie r0"om8 V a r"aro(is $or a %osttest
on t'e "ontent in t'is "'a%ter0
to t'e @+))s and 'as been si1ni$i"ant(& in$(#en"ed b& %#b(i"
%o(i"ies0

3einstit#tiona(i*ation bro#1't %romise and %rob(ems $or
t'e "'roni"a((& menta((& i(( %o%#(ation0
Critical Thinking and Chapter 5eview
Visit t'e E/o(/e 4ebsite at 'tt%688e/o(/e0e(se/ier0"om8Var"aro(is $or additiona( se($2st#d& e.er"ises0
CRITICAL THINKIN;
1. Yo# are a "omm#nit& %s&"'iatri" menta( 'ea(t' n#rse
4or>in1 at a (o"a( menta( 'ea(t' "enter0 Yo# are doin1 an
assessment inter/ie4 4it' a sin1(e ma(e "(ient 4'o is C!
&ears o(d0 He re2 %orts t'at 'e 'as not been s(ee%in1 and
t'at 'is t'o#1'ts seem to be Ka(( tan1(ed #%0L He in$orms
&o# t'at 'e 'o%es &o# "an 'e(% 'im toda& be"a#se 'e
does not >no4 'o4 m#"' (on1er 'e "an 1o on0 He does
not ma>e an& dire"t re$2 eren"e to s#i"ida( intent0 He is
dis'e/e(ed and 'as been s(ee%in1 at s'e(ters0 He 'as (itt(e
"onta"t 4it' 'is $ami(& and starts to be"ome a1itated 4'en
&o# s#11est t'at it mi1't be 'e(%$#( $or &o# to "onta"t t'em0
He re$#ses to si1n an& re(ease o$ in$ormation $orms0 He
admits to re"ent 'os%ita(i*ation at t'e (o"a( /eterans
'os%ita( and re%orts %re/io#s treatment at a d#a(2dia1nosis
$a"i(it& e/en t'o#1' 'e denies s#bstan"e ab#se0 In
addition to 'is menta( 'ea(t' %rob(ems, 'e sa&s t'at 'e 'as
tested %ositi/e $or '#man imm#node$i"ien"& /ir#s and ta>es
m#(ti%(e medi"ations t'at 'e "annot name0
A0 F'at are &o#r bio%s&"'oso"ia( and s%irit#a( "on2
"erns abo#t t'is "(ientM
,0 F'at is t'e 'i1'est2%riorit& %rob(em to address
be2 $ore 'e (ea/es t'e "(ini" toda&M
C0 3o &o# $ee( t'at &o# need to "ons#(t 4it' an&
ot'er members o$ t'e m#(tidis"i%(inar& team toda&
abo#t t'is "(ientM
30 In &o#r ro(e as "ase mana1er, 4'at s&stems o$
"are 4i(( &o# need to "oordinate to %ro/ide ?#a(it&
"are $or t'is "(ientM
E0 Ho4 4i(( &o# start to de/e(o% tr#st 4it' t'e "(ient to
1ain 'is "oo%eration 4it' t'e treatment %(anM
CHAPTER REVIEF
Choose the most appropriate answer.
1. A si1ni$i"ant in$(#en"e a((o4in1 %s&"'iatri" treatment to
mo/e $rom t'e 'os%ita( to t'e "omm#nit& 4as
@0 te(e/ision0
<0 t'e dis"o/er& o$ %s&"'otro%i" medi"ation0
D0 identi$i"ation o$ e.terna( "a#ses o$ menta( i((ness0
C0 t'e #se o$ a "o((aborati/e a%%roa"' b& "(ients and
sta$$ $o"#sin1 on re'abi(itation0
2. :or %s&"'iatri" n#rses, a maEor di$$eren"e bet4een "arin1
$or "(ients in t'e "omm#nit& and "arin1 $or "(ients in t'e
'os%i2 ta( is t'at
@0 treatment is ne1otiated rat'er t'an im%osed in t'e
"omm#nit& settin10
<0 $e4er et'i"a( di(emmas are en"o#ntered in t'e
"omm#nit& settin10
D0 "#(t#ra( "onsiderations are (ess im%ortant
d#rin1 treatment in t'e "omm#nit&0
C0 t'e $o"#s in t'e "omm#nit& settin1 is so(e(&
on mana1in1 s&m%toms o$ menta( i((ness0
Critical Thinking and Chapter 5eviewEcont:d
Visit t'e E/o(/e 4ebsite at 'tt%688e/o(/e0e(se/ier0"om8Var"aro(is $or additiona( se($2st#d& e.er"ises0
3. A t&%i"a( treatment 1oa( $or a "(ient 4it' menta( i((ness bein1
treated in a "omm#nit& settin1 is t'at t'e "(ient 4i((
@0 e.%erien"e destabi(i*ation o$ s&m%toms0
<0 ta>e medi"ations as %res"ribed0
D0 (earn to (i/e 4it' de%enden"& and de"reased o%2
%ort#nities0
C0 a""e%t 1#idan"e and str#"t#re o$ si1ni$i"ant
ot'ers0
4. Assessment data t'at 4o#(d be "onsidered (east re(e/ant to
de/e(o%in1 an #nderstandin1 o$ t'e abi(it& o$ a %ersistent(&
menta((& i(( 6!2&ear2o(d "(ient to "o%e 4it' t'e demands o$
(i/in1 in t'e "omm#nit& are
@0 stren1t's and de$i"its o$ t'e "(ient0
<0 s"'oo( and /o"ationa( %er$orman"e0
D0 "(ient 'ea(t' 'istor& and "#rrent menta( stat#s0
C0 "(ient 'ome en/ironment and $inan"ia( stat#s0
5. F'i"' a"tion on t'e %art o$ a "omm#nit& %s&"'iatri" n#rse
/isitin1 t'e 'ome o$ a "(ient 4o#(d be "onsidered ina%%ro2
%riateM
@0 T#rnin1 o$$ an intr#si/e TV %ro1ram 4it'o#t
t'e "(ient5s %ermission
<0 :a"i(itatin1 t'e "(ient5s a""ess to a "omm#nit&
>it"'en $or t4o mea(s a da&
D0 ;oin1 be&ond t'e %ro$essiona( ro(e bo#ndar&
to 'an1 "#rtains $or an e(der(& "(ient
C0 Arran1in1 to demonstrate t'e #se o$ %#b(i" trans2
%ortation to a menta( 'ea(t' "(ini"
STU3ENT
STU3Y
C32ROM
A""ess t'e a""om%an&in1 C32ROM $or animations, intera"ti/e e.er"ises,
re/ie4 ?#estions $or t'e NCLE9 e.amination, and an a#dio 1(ossar&0
RE:ERENCES
#Cuila, 5., B "manuel, M. *@''0, September @,-. Managing the
long!term outlook of schi$ophrenia. Medscape
Psychiatry & Mental Health, %!%'.
Carson, J. (. *%++&-. 7esigning an effective psychiatric home
care program. Home Healthcare Consultant, 5*A-, %/!@%.
Chan, S., Macken$ie, #., B =acobs, 1. *@'''-. Cost!effective!
ness analysis of case management versus a routine com!
munity care organi$ation for patients with chronic schi$o!
phrenia. Archives of Psychiatric Nursing, 14*@-, +&!%'A.
Chan, S., et al. *@'''-. #n evaluation of the implementation of
case management in the community psychiatric nurs! ing
service. ournal of Advanced Nursing, !1*%-, %AA!%,/.
7ickey, (., et al. *@''@-. Medical morbidity, mental illness, and
substance use disorders. Psychiatric "ervices, 5!*)-,
&/%!&/).
9ebbie, 2. M., B ?ureshi, 2. *@''@-. "mergency and disaster
preparedness6 Core competencies for nurses. American
ournal of Nursing, 1#$*%-, A/!,%.
Hedelin, (., B Svensson, 1. *%+++-. 1sychiatric nursing for
promotion of mental health and prevention of depression
in the elderly6 # case study. ournal of Psychiatric and
Mental Health Nursing, %*@-, %%,!%@A.
2ruse, 9. 5., B 5ohland, (. M. *@''@-. 3actors associated
with attendance at a first appointment after discharge
from a psychiatric hospital. Psychiatric "ervices, 5!*A-, A)0!
A)/.
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