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3.6 Taking Action

After gathering assessment data, establishing hypotheses, and formulating outcomes, the nurse moves to take action. The Implementation Standard of Practice by the American Nurses Association (ANA) states, “The registered nurse implements the identified plan.”[1] Review the competencies for the Implementation Standard of Practice for registered nurses in the following box.

ANA’s Implementation Competencies[2]

The registered nurse:

  • Demonstrates caring behaviors to develop therapeutic relationships.
  • Provides care that focuses on the health care consumer.
  • Advocates for the needs of diverse populations across the life span.
  • Uses critical thinking and technology solutions to implement the nursing process to collect, measure, record, retrieve, trend, and analyze data and information to enhance health care consumer outcomes and nursing practice.
  • Partners with the health care consumer to implement the plan in a safe, effective, efficient, timely, and equitable manner.
  • Engages interprofessional team partners with implementation of the plan through collaboration and communication across the continuum of care.
  • Uses evidence-based interventions and strategies to achieve mutually identified goals and outcomes specific to the problem or needs.
  • Delegates according to the health, safety, and welfare of the health care consumer.
  • Delegates after considering the circumstance, person, task, direction or communication, supervision, and evaluation.
  • Considers the state’s Nurse Practice Act regulations, institution, and regulatory entities while maintaining accountability for the care.
  • Documents implementation and any modifications, including changes or omissions, of the identified nursing care plan.

Implementation of nursing interventions should first focus on the highest priorities for the patient, generally any condition that carries risk for life-threatening outcomes. Safety is often the highest priority in mental health settings. The nurse will plan interventions that keep patients safe from self-injury or from aggressive behaviors that may injure others.

Pharmacological, Biological, and Integrative Therapies

Nurses need to be competent in all aspects of medication and related therapies administration. Biological therapies are “any form of treatment for mental disorders that attempts to alter physiological functioning, including drug therapies, electroconvulsive therapy, and psychosurgery.” [3] . Medication administration is covered thoroughly in other texts, but a brief discussion is merited. Nurses need to know the actions and side effects of medication and why a given patient is receiving it. Lab values and vital signs linked to the medication need to be monitored.  The nurse also needs to understand what medication information should be shared with the healthcare team, for example, sedating medications may cause changes in behavior.  Patients in acute care settings may not be compliant with medication regimens, necessitating additional interventions by the nurse to enhance trust and to ensure the patient does not cheek or spit out the medication. Most importantly, the nurse needs to understand how and when to educate the patient about the medication.

In addition, nurses need to knowledgeable about the range of therapies offered by other health professionals. Although these therapies are not within the scope of RN practice, patients will need information and may ask the nurse questions about the particular therapy. Integrative therapies are defined by the American Psychiatric Association (APA) as the combination of conventional medical treatments and complementary therapies.[4] .Psychotherapy interventions include “all generally accepted and evidence-based methods of brief or long-term therapy, including individual therapy, group therapy, marital or couples therapy, and family therapy. These interventions use a range of therapy models, including, but not limited to, psychodynamic, cognitive, behavioral, and supportive interpersonal therapies to promote insight, produce behavioral change, maintain function, and promote recovery.”[5] Review the competencies for this Standard of Care in the box below.

The American Nurses Association and the American Psychiatric Nurses Association established additional subcategories for registered nurses working in psychiatric/mental health settings: Pharmacological, Biological, and Integrative Therapies;

 

APNA’s Pharmacological, Biological, and Integrative Therapies Competencies[6]

“The psychiatric-mental health registered nurse (PMH-RN) incorporates knowledge of pharmacological, biological, and complementary interventions with applied clinical skills to restore the health care consumer’s health and prevent future disability.”[7]

The PMH-RN:

  • Applies current research findings to guide nursing actions related to pharmacology, other biological therapies, and integrative therapies.
  • Assesses the health care consumer’s response to biological interventions based on current knowledge of pharmacological agent’s intended actions, interactive effects, potential untoward effects, and therapeutic doses.
  • Includes health teaching for medication management to support health care consumers in managing their own medications and adhering to a prescribed regimen.
  • Provides health teaching about mechanism of action, intended effects, potential adverse effects of the proposed prescription, ways to cope with transitional side effects, and other treatment options, including the selection of a no-treatment option.
  • Directs interventions toward alleviating untoward effects of biological interventions.
  • Communicates observations about the health care consumer’s response to biological interventions to other health clinicians.

Health Teaching and Health Promotion, and Coordination of Care

Beyond biological therapies, nurses have knowledge and skills to engage in a number of actions to promote health improvement. Patients in mental health settings often have knowledge deficits in areas of self-care and adapting to challenges. The nurse can design or coordinate interventions that address these areas. For example, a patient may need access to resources for inexpensive or free food. The American Nurses Association have created competencies in these areas:

ANA’s Health Teaching and Health Promotion Competencies[8]

The registered nurse:

  • Provides opportunities for the health care consumer to identify needed health promotion, disease prevention, and self-management topics such as:
    • Healthy lifestyles
    • Self-care and risk management
    • Coping, adaptability, and resiliency
  • Uses health promotion and health teaching methods in collaboration with the health care consumer’s values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status.
  • Uses feedback from the health care consumer and other assessments to determine the effectiveness of the employed strategies.
  • Uses technologies to communicate health promotion and disease prevention information to the health care consumer.
  • Provides health care consumers with information and education about intended effects and potential adverse effects of the plan of care.
  • Engages consumer alliance and advocacy groups in health teaching and health promotion activities for health care consumers.
  • Provides anticipatory guidance to health care consumers to promote health and prevent or reduce risk.

Review the competencies for the Coordination of Care Standard of Care in the following box.

ANA’s Coordination of Care Competencies[9]

The registered nurse:

  • Collaborates with the health care consumer and the interprofessional team to help manage health care based on mutually agreed-upon outcomes.
  • Organizes the components of the plan with input from the health care consumer and other stakeholders.
  • Manages the health care consumer’s care to reach mutually agreed-upon outcomes.
  • Engages health care consumers in self-care to achieve preferred goals for quality of life.
  • Assists the health care consumer to identify options for care and navigate the health care system and its services.
  • Communicates with the health care consumer, interprofessional team, and community-based resources to effect safe transitions in continuity of care.
  • Advocates for the delivery of dignified and person-centered care by the interprofessional team.
  • Documents the coordination of care.

Read more about medications in the “Psychotropic Medications” chapter.

Milieu Therapy

A therapeutic milieu is defined by the American Psychiatric Nursing Association as, “A safe, welcoming, supportive, and functional physical treatment environment.” Milieu therapy includes nursing interventions used to assist patients and other health care consumers to make positive change and promote recovery in a therapeutic milieu. Nursing interventions include providing empathy, assisting in problem-solving, acting as a role model, demonstrating leadership, confronting discrepancies, encouraging self-efficacy, decreasing stimuli when necessary, and manipulating the environment so that the above interventions can be effective. [10] Review the APNA competencies for this Standard of Care in the following box.

APNA’s Milieu Therapy Competencies[11]

“The psychiatric-mental health registered nurse (PMH-RN) provides, structures, and maintains a safe, therapeutic, recovery-oriented environment in collaboration with health care consumers, families, and other health care clinicians.”[12]

The PMH-RN:

  • Orients the health care consumer and family to the care environment, including the physical environment, the roles of the different health care providers, self-involvement in the treatment and care delivery processes, schedules of events pertinent to their care and treatment, and expectations regarding safe and therapeutic behaviors.
  • Orients health care consumers to their rights and responsibilities particular to the treatment or care environment.
  • Establishes a welcome, trauma-informed environment using therapeutic interventions, including, but not limited to, sensory or relaxation rooms.
  • Conducts ongoing assessments of the health care consumer in relation to the environment to guide nursing interventions in maintaining a safe environment.
  • Selects specific activities (both individual and group) that meet the health care consumer’s physical and mental health needs for meaningful participation in the milieu and promotion of personal growth.
  • Advocates that the health care consumer is treated in the least restrictive environment necessary to maintain the safety of the individual and others.
  • Informs the health care consumer in a culturally sensitive manner about the need for limits related to safety and the conditions necessary to remove the restrictions.
  • Provides support and validation to health care consumers when discussing their illness experience and seeks to prevent complications of illness.

Therapeutic Relationship and Counseling

The American Nurses Association states, “Nursing integrates the art and science of caring… It facilitates healing and alleviates suffering through compassionate presence… The act of caring is the first step in the power to heal.”[13] Jean Watson’s Human Caring Science Theory emphasizes the therapeutic relationship between the patient and nurse and highlights the role of the nurse in defining the patient as a unique human being to be valued, respected, nurtured, understood, and assisted.[14] In a caring, therapeutic relationship, the nurse implements interventions to promote interpersonal connection, such as listening attentively, making eye contact, using verbal reassurances, and using professional touch with permission.[15] Nurses use several therapeutic techniques during a nurse-client relationship. Read more information in the Chapter 4.3.

Read the APNA competencies regarding therapeutic relationship and counseling in the following box.

APNA’s Therapeutic Relationship and Counseling Competencies[16]

“The psychiatric-mental health registered nurse (PMH-RN) uses the therapeutic relationship and counseling interventions to assist health care consumers in their individual recovery journeys by improving and regaining their previous coping abilities, fostering mental health, and preventing mental disorder and disability.”[17]

The PMH-RN:

  • Uses therapeutic relationship and counseling techniques to promote the health care consumer’s stabilization of symptoms and personal recovery goals.
  • Uses the therapeutic relationship and counseling techniques, both in the individual and group setting, to reinforce healthy behaviors and interaction patterns and helps the health care consumer discover individualized health care behaviors to replace unhealthy ones.
  • Documents counseling interventions, including, but not limited to, communication and interviewing techniques, problem-solving activities, crisis intervention, stress management, supportive skill building and educational groups, relaxation techniques, assertiveness training, and conflict resolution.

Taking Actions

Implementation of interventions requires the RN to use critical thinking and clinical judgment. After the initial plan of care is developed, continual reassessment of the patient is necessary to detect any changes in the patient’s condition requiring modification of the plan. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing safe care.

During this phase, the nurse prioritizes planned actions, assesses patient safety while implementing interventions, delegates actions as appropriate, and documents actions performed.

Prioritizing implementation of actions follows a similar method as to prioritizing nursing hypotheses. Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation are used to establish top priority interventions. When possible, least restrictive interventions are preferred, for example, a patient who is not exhibiting threatening behaviors should be allowed to move freely on the unit, not confined to a room.

It is essential to consider patient safety when implementing actions. At times, patients may experience a change in condition that makes a planned nursing action or provider prescription no longer safe to implement. For example, a nursing care plan for a patient states, “The patient will attend 2 group meetings each morning with reminder from staff.” However, during assessment this morning, the patient reports feeling dizzy today after starting a new medication, and their blood pressure is 90/60. Using critical thinking and clinical judgment, the nurse decides to not implement the planned action and notifies the provider of suspected side effects of the patient’s medication. This decision, supporting assessment findings, and notification of the provider should be documented in the patient’s record and also communicated during the shift handoff report.

  1. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  2. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  3. American Psychological Association. (n.d.). Biological therapy. APA Dictionary of Psychology. https://apa.org/biological-therapy ↵
  4. American Psychological Association. (n.d.) Integrative medicine. APA Dictionary of Psychology. https://.apa.org/integrative-medicine  ↵
  5. American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org ↵
  6. American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org ↵
  7. American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org ↵
  8. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  9. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  10. American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org ↵
  11. American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org ↵
  12. American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org ↵
  13. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  14. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  15. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  16. American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org ↵
  17. American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org ↵
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