Mental Health

Learning Objectives

• Review basic concepts of client-centered communication
• Outline effective therapeutic communication techniques
• Describe barriers to effective therapeutic communication
• Explore guidelines for effective communication during teletherapy

Nurses engage in compassionate, supportive, and professional relationships with their clients as part of the “art of nursing.” This chapter reviews the nurse–client relationship, therapeutic communication, and motivational interviewing, and introduces teletherapy and telehealth as emerging approaches to mental health care delivery.

Active listening is central to therapeutic communication. Listening styles include competitive, passive, and active listening. Active listening involves verbal and nonverbal behaviors that demonstrate interest and understanding, along with verification of meaning through feedback. Nonverbal communication supports active listening and is guided by the SOLER mnemonic: sitting squarely, maintaining open posture, leaning toward the client, maintaining eye contact, and remaining relaxed.

Professional touch can communicate caring when used appropriately. Nurses use professional touch to assess, comfort, and express empathy while respecting client preferences, cultural beliefs, and boundaries. Permission should be obtained before touch, particularly for individuals with trauma histories, and touch should be avoided in situations involving agitation, mania, paranoia, or psychosis where it may escalate distress.

Therapeutic communication is purposeful and goal-directed. Therapeutic communication has historical roots in nursing practice and is defined as a professional, interpersonal, information-transmitting process that promotes client understanding and participation in care. Unlike social interaction, therapeutic communication has a clear goal, such as encouraging clients to express feelings or concerns related to their treatment.

Therapeutic communication techniques support emotional expression and coping. Nurses use a variety of techniques to help clients verbalize emotions, establish goals, and explore coping strategies. In contrast, nontherapeutic responses—such as poor nonverbal behaviors, excessive questioning, giving advice, or using medical jargon—can block communication and increase distress.

Effective therapeutic communication requires self-awareness and intentional practice. Key strategies include setting goals for conversations, observing nonverbal cues, maintaining professional boundaries, practicing patient-centered care, respecting cultural values, recognizing emerging emotional themes, and using appropriate therapeutic techniques.

Barriers to communication must be recognized and addressed. Common barriers include judgmental tone, overuse of technical language, closed-ended questioning, excessive probing, lack of self-awareness, sensory overload, advice-giving, and blurred professional boundaries.

Safety takes priority during escalation. When clients become increasingly agitated or pose a danger to themselves or others, ensuring safety becomes the nurse’s primary responsibility, and therapeutic communication strategies are temporarily suspended.

Cultural considerations shape communication and care. Cultural values influence how individuals perceive mental health, express symptoms, seek help, and engage in treatment. Nurses support culturally responsive care by encouraging clients to share their perspectives and beliefs about illness and treatment through open therapeutic dialogue.

Motivational interviewing supports patient education and health promotion. Patient education and health promotion are core nursing interventions. Motivational interviewing (MI) is a communication approach used to elicit and strengthen a client’s personal motivation for modifying behavior to improve health outcomes. MI has been shown to be effective for a variety of health concerns, including smoking cessation, diabetes management, substance use disorders, and adherence to treatment plans.

Motivational interviewing is grounded in collaboration and autonomy. The spirit of motivational interviewing is based on a collaborative partnership between nurses and clients that emphasizes patient-centered care, autonomy, and personal responsibility. MI explores a client’s motivation, confidence, and perceived barriers to change. During motivational interviewing, nurses ask open-ended questions, actively listen to client responses, and focus on the client’s current health behaviors as well as their desired future goals.

Motivational interviewing is guided by core principles. The principles of motivational interviewing include:

• Express empathy: Use reflective listening to convey acceptance and a nonjudgmental attitude. Rephrasing client statements helps demonstrate that the nurse is listening and understanding the client’s perspective.
• Highlight discrepancies: Help clients recognize the gap between their current behaviors and their personal values or goals. Present objective information that clarifies the consequences of continuing current behaviors to support motivation for change.
• Adjust to resistance: Avoid arguing or confronting resistance. Resistance may appear as defensiveness, avoidance of eye contact, interruptions, or distraction. Nurses should validate client feelings and adapt their approach rather than push for change.
• Understand motivations: Identify and build upon the client’s personal reasons for wanting to change behavior.
• Support self-efficacy: Encourage optimism and confidence in the ability to change by reinforcing past successes and supporting commitment to positive behavioral changes.
• Resist the reflex to provide advice: Avoid imposing personal opinions or solutions and instead support the client’s self-directed decision-making.

Readiness for change influences the effectiveness of motivational interviewing. When using motivational interviewing, nurses assess the client’s readiness for change. MI is particularly useful for clients in the contemplation stage, where ambivalence about change is common. The five stages of behavioral change include:

• Precontemplation: Not considering change
• Contemplation: Feeling ambivalent about change
• Preparation: Taking steps toward change
• Action: Actively engaging in change
• Maintenance: Sustaining the desired behavior

Ambivalence provides opportunities for therapeutic dialogue. Nurses can identify ambivalence by listening for statements that include the phrase “Yes, but.” The portion of the statement following the word “but” often reveals the client’s personal barriers to change. For example, a client may state, “I want to take my medication, but I hate gaining weight.” Recognizing and addressing these concerns is essential when planning outcomes and nursing interventions.

Telehealth expands access to care through digital technologies. Telehealth refers to the use of digital technologies to deliver medical care, health education, and public health services by remotely connecting users in different locations. Nurses must be aware of potential barriers to telehealth use, such as limited internet access or lack of technological support for individuals learning new systems. Nurses must also understand state and federal telehealth regulations, including licensing requirements for providing care across state lines.

Teletherapy delivers mental health care remotely. Teletherapy is the provision of mental health counseling through telephone or online videoconferencing platforms. The COVID-19 pandemic led to reduced access to in-person medical and mental health services, and teletherapy has become an important method for delivering behavioral health care. When conducting teletherapy, nurses should engage clients as if they were physically present, maintaining eye contact, using empathetic facial expressions, and fostering connection in a manner consistent with face-to-face encounters.

Telehealth supports group therapy and community connection. Group therapy can be effectively conducted via telehealth, allowing clients to connect remotely while benefiting from shared experiences. Telehealth group sessions can foster community, reduce feelings of isolation, provide new perspectives, and create a sense of belonging and mutual support.

Effective group teletherapy requires careful planning and structure. Guidelines for conducting group therapy through telehealth include:

Promote engagement: Maintaining engagement is especially important in virtual environments. Use introductions with first names only, maintain eye contact by looking into the camera, and use expressive body language. Encourage interaction through structured opportunities such as breakout rooms or paired discussions.

Prescreen group members: Clients may have differing needs, experiences, or personalities. Screening ensures that participants are appropriate for the group and that their needs align with group goals.

Require online consent forms: Group telehealth sessions occur outside controlled clinical environments and involve multiple participants. Consent forms should clearly outline risks, benefits, and limits to confidentiality.

Develop group guidelines: Establish clear expectations for participation, including camera use, attending sessions in private spaces, use of hand-raising features, and prohibitions against recording sessions to protect confidentiality. Address logistical expectations such as attendance requirements and communication with group leaders.

Select appropriate settings and technology: Choose telehealth platforms that support encryption, privacy, and user control. Review platform settings in advance to maximize confidentiality and consider tools that enhance communication, such as screen sharing or virtual whiteboards.

Learning Objectives

• Recognize nonverbal cues for physical and/or psychological stressors
• Provide patient education on stress management techniques
• Promote adaptive coping strategies
• Recognize the use of defense mechanisms
• Recognize a client in crisis
• Describe crisis intervention

Nurses support the emotional, mental, and social well-being of all clients experiencing stressful events and those with acute and chronic mental illnesses. This chapter reviews stressors, stress management, coping strategies, defense mechanisms, and crisis intervention

Everyone experiences stress during their lives. High levels of stress can cause symptoms such as headaches, back pain, and gastrointestinal symptoms. Chronic stress contributes to the development of chronic illnesses, as well as acute physical illnesses due to decreased effectiveness of the immune system. It is important for nurses to recognize signs and symptoms of stress in themselves and others, as well as encourage effective stress management strategies. This section begins by reviewing the stress response and signs and symptoms of stress and then discusses stress management techniques.

Stress Response
Stressors are any internal or external event, force, or condition that results in physical or emotional stress. The body’s sympathetic nervous system (SNS) responds to actual or perceived stressors with the “fight, flight, or freeze” stress response. During this response, the respiratory, cardiovascular, and musculoskeletal systems are activated to breathe rapidly, stimulate the heart to pump more blood, dilate blood vessels, and increase blood pressure to deliver more oxygenated blood to the muscles. The liver creates more glucose for energy. Pupils dilate to see the threat or escape route more clearly, and sweating prevents overheating from excess muscle contraction. Because the digestive system is not needed during this time of threat, oxygen-rich blood is shunted to the skeletal muscles. Hormones including epinephrine, norepinephrine, and glucocorticoids (including cortisol) are released by the endocrine system via the hypothalamic-pituitary-adrenal (HPA) axis and dispersed to sympathetic nervous system receptors on target organs. After the response to the stressful stimulus has resolved, the body returns to a pre-emergency state facilitated by the parasympathetic nervous system (PNS), which has opposing effects to the SNS.

Effects of Chronic Stress
The “fight, flight, or freeze” stress response equips the body to respond quickly to life-threatening stressors; however, exposure to long-term stress can cause serious effects on the cardiovascular, musculoskeletal, endocrine, gastrointestinal, and reproductive systems. Ongoing increases in heart rate, blood pressure, and stress hormone levels contribute to inflammation in arteries and increase the risk for hypertension, heart attack, or stroke. During chronic stress, muscles may remain in a constant state of tension, contributing to tension-type headaches, migraines, and musculoskeletal pain, particularly in the shoulders, neck, lower back, and upper extremities. Relaxation techniques and other stress-relieving activities reduce muscle tension, decrease stress-related disorders, and increase a sense of well-being. Chronic stress can impair immune function and has been linked to chronic fatigue, metabolic disorders such as diabetes and obesity, depression, and immune disorders. Stress can alter gastrointestinal functioning, leading to changes in appetite, acid reflux, diarrhea, or constipation, and may worsen conditions such as irritable bowel syndrome or inflammatory bowel disease. In males, excess cortisol can reduce testosterone production, libido, and sperm quality. In females, stress can disrupt menstruation, worsen premenstrual symptoms, reduce fertility, negatively affect pregnancy outcomes, and increase the risk of postpartum depression. Maternal stress may also negatively impact fetal development and bonding after delivery.

Adverse Childhood Experiences
Adults with adverse childhood experiences often experience ongoing chronic stress and long-term physical, mental, and social health problems. Adverse childhood experiences include sexual abuse, physical abuse, emotional abuse, physical neglect, emotional neglect, parental loss, or parental separation before the age of 18. Individuals with four or more adverse childhood experiences are at significantly higher risk of mental illness, substance use disorders, cardiovascular disease, metabolic syndrome, malignancy, and other chronic debilitating conditions. Early life stress has been associated with smoking, alcohol consumption, drug dependence, mood disorders, and anxiety disorders.

Signs and Symptoms of Stress
Nurses are often the first to notice signs and symptoms of stress and can help make clients aware of these symptoms. Common signs and symptoms of chronic stress include:

• Irritability
• Fatigue
• Headaches
• Difficulty concentrating
• Rapid, disorganized thoughts
• Difficulty sleeping
• Digestive problems
• Changes in appetite
• Feeling helpless
• A perceived loss of control
• Low self-esteem
• Loss of sexual desire
• Nervousness
• Frequent infections or illnesses
• Vocalized suicidal thoughts

Stress Management
Recognizing signs and symptoms of stress allows individuals to implement stress management strategies. Nurses can educate clients about effective strategies for reducing the stress response. Effective strategies include:

• Set personal and professional boundaries
• Maintain a healthy social support network
• Select healthy food choices
• Engage in regular physical exercise
• Get an adequate amount of sleep each night
• Set realistic and fair expectations

Setting limits is essential for effectively managing stress. Individuals should identify overwhelming commitments, prioritize essential tasks, and reduce nonessential activities. Maintaining healthy social connections provides emotional support and promotes resilience. Physical activity increases endorphin production, improves mood, and reduces anxiety. Adequate sleep, realistic expectations, and positive reframing of stressful situations can make challenges feel more manageable.

Mindfulness and Relaxation Techniques
Mindfulness is a form of meditation that uses breathing and thought techniques to increase awareness of the body and surroundings and has been shown to reduce stress, anxiety, and depression. Guided imagery may enhance relaxation by providing focused mental narration during breathing exercises.

WHO Stress Management Guide
The World Health Organization guide Doing What Matters in Times of Stress identifies five evidence-based categories that can reduce stress even when practiced briefly each day:

1. Grounding
2. Unhooking
3. Acting on our values
4. Being kind
5. Making room

Grounding
Grounding is a technique used to refocus attention on the present moment by noticing thoughts and feelings, slowing breathing, engaging the body, and using the five senses to reconnect with the environment.

Unhooking
Unhooking is used to manage unwanted or intrusive thoughts by noticing and naming the thought or feeling and then refocusing attention on the current activity.

Acting on Our Values
Acting on values means choosing behaviors that align with personal beliefs despite challenges, recognizing that even small actions can influence well-being and resilience.

Being Kind
Being kind to others and oneself can significantly improve mental health and reduce stress.

Making Room
Making room involves allowing painful thoughts and feelings to come and go without resistance, conserving energy for meaningful engagement with life.

Stress Related to the COVID-19 Pandemic and World Events
The COVID-19 pandemic and other world events have caused significant stress, particularly among health care professionals. Learning healthy coping strategies can increase resilience. Strategies include:

• Taking breaks from news and social media
• Practicing self-care such as deep breathing, healthy eating, exercise, and sleep
• Making time to unwind
• Purposefully connecting with others
• Using techniques from the WHO stress management guide

Strategies for Self-Care
Self-awareness allows individuals to implement self-care strategies to prevent compassion fatigue and burnout. The “A’s” include:

Acceptance: Embracing both strengths and imperfections

Attention: Awareness of physical, psychological, social, and spiritual health

Acknowledgement: Honest reflection on experiences and loss

Affection: Self-kindness and compassion

The health consequences of chronic stress depend on an individual’s coping styles and their resilience to real or perceived stress. Coping refers to cognitive and behavioral efforts made to master, tolerate, or reduce external and internal demands and conflicts. Coping strategies are actions, a series of actions, or thought processes used in meeting a stressful or unpleasant situation or in modifying one’s reaction to such a situation. Coping strategies are classified as adaptive or maladaptive.

Adaptive and Maladaptive Coping
Adaptive coping strategies include problem-focused coping and emotion-focused coping. Problem-focused coping typically focuses on seeking treatment such as counseling or cognitive behavioral therapy. Emotion-focused coping includes strategies such as mindfulness, meditation, and yoga; using humor and jokes; seeking spiritual or religious pursuits; engaging in physical activity or breathing exercises; and seeking social support. Maladaptive coping responses include avoidance of the stressful condition, withdrawal from a stressful environment, disengagement from stressful relationships, and misuse of drugs and/or alcohol. Nurses can educate individuals and their family members about adaptive, emotion-focused coping strategies and make referrals to interprofessional team members for problem-focused coping and treatment options for individuals experiencing maladaptive coping responses to stress.

Emotion-Focused Coping Strategies
Nurses can educate clients about many emotion-focused coping strategies, such as meditating, practicing yoga, journaling, praying, spending time in nature, nurturing supportive relationships, and practicing mindfulness.

Meditation
Meditation can induce feelings of calm and clearheadedness and improve concentration and attention. Research has shown that meditation increases the brain’s gray matter density, which can reduce sensitivity to pain, enhance the immune system, help regulate difficult emotions, and relieve stress. Meditation has been shown to be helpful for individuals with depression and anxiety, cancer, fibromyalgia, chronic pain, rheumatoid arthritis, type 2 diabetes, chronic fatigue syndrome, and cardiovascular disease.

Yoga
Yoga is a centuries-old spiritual practice that creates a sense of union within the practitioner through physical postures, ethical behaviors, and breath expansion. The systematic practice of yoga has been found to reduce inflammation and stress, decrease depression and anxiety, lower blood pressure, and increase feelings of well-being.

Journaling
Journaling can help a person become more aware of their inner life and feel more connected to their experiences. Studies show that writing during difficult times may help individuals find meaning in life’s challenges and become more resilient. When journaling, it can be helpful to focus on three basic questions: What experiences give me energy? What experiences drain my energy? Were there any experiences today where I felt alive and experienced “flow”? Individuals should be encouraged to write freely without stopping to edit or worry about spelling and grammar.

Prayer
Prayer can elicit the relaxation response and foster feelings of hope, gratitude, and compassion, which positively affect overall well-being. There are several types of prayer rooted in the belief in a higher power, which can provide comfort and support during difficult times. Research has shown that adults with clinical depression who believed their prayers were heard by a concerned presence responded better to treatment than those who did not hold this belief. Individuals may also be encouraged to seek a spiritual community such as a church, synagogue, temple, mosque, meditation center, or other group that discusses spiritual issues, as social and spiritual support can provide a sense of belonging and connection.

Spending Time in Nature
Spending time in nature is cited by many individuals as a spiritual practice that contributes to mental health. Spirituality is defined as a dynamic and intrinsic aspect of humanity through which individuals seek meaning, purpose, and transcendence and experience connection with self, family, others, community, society, nature, and the sacred. Spirituality is broader than religion and includes elements such as meaning, love, belonging, forgiveness, and connectedness.

Supportive Relationships
Individuals should be encouraged to nurture supportive relationships with family, significant others, and friends. Relationships are dynamic and require time, attention, and care. Creating shared rituals, such as regular phone calls or walks, can help maintain meaningful connections. Research shows that individuals who intentionally make time for social gatherings experience stronger relationships and more positive energy, especially in the context of busy schedules and the presence of social media.

Mindfulness
Mindfulness has been defined as awareness that arises through paying attention on purpose, in the present moment, and without judgment. It has also been described as non-elaborative, present-centered awareness in which thoughts, feelings, and sensations are acknowledged and accepted as they arise. Mindfulness helps individuals pause, gain clarity, and respond more skillfully rather than reacting automatically. When practiced regularly, mindfulness allows individuals to recognize habitual thought patterns that contribute to stress and to develop more effective responses by observing thoughts and emotions rather than reacting to them.

Coping with Loss and Grief
In addition to supporting individuals in managing stress and anxiety, nurses can apply knowledge of coping strategies to assist clients and family members as they cope with life changes, grief, and loss that may cause emotional distress and psychological difficulties.

When providing clients with stress management techniques and effective coping strategies, nurses must be aware of common defense mechanisms. Defense mechanisms are reaction patterns used by individuals to protect themselves from anxiety that arises from stress and conflict. Excessive use of defense mechanisms is associated with specific mental health disorders. With the exception of suppression, all defense mechanisms are unconscious and outside the individual’s awareness.

Conversion
Anxiety caused by repressed impulses and feelings is converted into physical symptoms. For example, an individual scheduled to see their therapist to discuss a past sexual assault experiences a severe headache and cancels the appointment.

Denial
Unpleasant thoughts, feelings, wishes, or events are ignored or excluded from conscious awareness to protect the individual from overwhelming anxiety. For example, a client recently diagnosed with cancer states that there was an error in diagnosis and that they do not have cancer. Other examples include denial of financial problems, addiction, or a partner’s infidelity.

Dissociation
Dissociation involves a feeling of being disconnected from a stressful or traumatic event or feeling that the event is not really happening in order to block out mental trauma. For example, a person experiencing physical abuse may feel as if they are floating above their body observing the situation.

Displacement
Displacement is the unconscious transfer of emotions or reactions from an original source to a less-threatening target to discharge tension. For example, an individual angry with their partner kicks the family dog, a child yells at a sibling instead of a parent, or a frustrated employee criticizes their spouse instead of their boss.

Introjection
Introjection involves unconsciously incorporating the attitudes, values, and qualities of another person’s personality. For example, a client talks and acts like one of the nurses they admire.

Projection
Projection occurs when an individual attributes their own positive or negative characteristics, feelings, or impulses to another person or group. For example, a person conflicted about expressing anger changes the thought “I hate him” to “He hates me.”

Rationalization
Rationalization involves giving logical reasons to justify unacceptable behavior in order to defend against guilt, maintain self-respect, and protect oneself from criticism. For example, a client overextended on credit cards justifies buying more clothes instead of paying rent, or a student caught cheating states, “Everybody cheats.”

Reaction Formation
Reaction formation occurs when unacceptable or threatening impulses are denied and consciously replaced with an opposite, socially acceptable impulse. For example, a client who hates their mother writes in their journal that their mother is wonderful.

Regression
Regression is a return to a prior, lower level of cognitive, emotional, or behavioral functioning when an individual is threatened by overwhelming stress. For example, a child who was previously toilet trained begins wetting their pants after their parents’ divorce.

Repression
Repression involves unconsciously excluding painful experiences and unacceptable impulses from conscious awareness as protection against anxiety. For example, a victim of incest reports always hating their brother but cannot remember why.

Splitting
Splitting occurs when people or situations that provoke anxiety are viewed as either all good or all bad. For example, a client tells a nurse they are wonderful, but after the nurse enforces unit rules, the client states the nurse is the worst person they have ever met.

Suppression
Suppression is a conscious effort to keep disturbing thoughts or experiences out of awareness or to control unacceptable impulses. Unlike repression, suppression is intentional. For example, an individual suppresses the impulse to confront their boss in order to keep their job.

Sublimation
Sublimation involves unconsciously channeling unacceptable sexual or aggressive drives into socially acceptable activities that provide indirect satisfaction. For example, an individual with aggressive impulses joins a football team, or someone with voyeuristic urges conducts scientific research involving observation.

Symbolization
Symbolization is the substitution of a symbol for a repressed impulse, feeling, or idea. For example, a client unconsciously wears red clothing due to a repressed impulse to physically harm someone.

If you were asked to describe someone in crisis, many people might think of traditional images such as someone wringing their hands, pacing, having a verbal outburst, or acting erratically. Health care professionals should be aware that while crisis may be reflected in these behaviors, it can also be demonstrated through a variety of verbal and nonverbal signs. There are many potential causes of crisis, and individuals progress through four phases as a crisis develops. Nurses and other health care professionals are often frontline providers when individuals face a crisis, making it essential to recognize signs of crisis, know what to assess, intervene appropriately, and evaluate crisis resolution.

Definition of Crisis
A crisis can be broadly defined as the inability to cope or adapt to a stressor. Early formal examination of crisis and crisis intervention models emerged in the 1960s and 1970s. Gerald Caplan defined crisis as a situation that produces psychological disequilibrium in an individual and constitutes an important problem that cannot be escaped or solved using customary problem-solving resources, emphasizing the imbalance created by situational stressors. Albert Roberts later expanded this concept, defining crisis as an acute disruption of psychological homeostasis in which usual coping mechanisms fail, accompanied by distress and functional impairment. An individual’s subjective reaction to a stressful life experience compromises their ability to cope or function.

Causes of Crisis
A crisis may emerge due to a wide variety of events, and individuals may respond differently to the same stressor. Nurses must carefully monitor each patient for signs of emerging crisis. Crises may result from anticipated life events, such as the birth of a baby, which can disrupt routines and overwhelm coping resources. Crises are more commonly associated with unexpected events such as newly diagnosed critical or life-altering illness, myocardial infarction, cancer diagnosis, or significant losses including loss of employment, housing, divorce, or death of a loved one. Crisis responses may also affect family members and loved ones. Clustering of multiple stressors can cause cumulative strain that overwhelms adaptive coping and leads to crisis.

Categories of Crises
Crises are categorized to help health care providers understand the experience and identify appropriate resources. Crises may be maturational (developmental), situational, or social (adventitious).

• Maturational (Developmental) Crisis
  • Result of normal growth and development
  • Occurs at predictable developmental periods
  • Individual vulnerability depends on equilibrium
  • Examples: birth, adolescence, marriage, death
• Situational Crisis
  • Unexpected personal stressful events with little warning
  • Less predictable
  • Threatens an individual’s equilibrium
  • Examples: accident, illness or serious injury, loss of a job, bankruptcy, relocation, divorce
• Social (Adventitious) Crisis
  • Uncommon or unanticipated events
  • Often involve multiple or extensive losses
  • May result from natural or man-made disasters
  • Examples: flood, fire, tornado, hurricane, earthquake, war, riot, violence

Phases of Crisis
Crisis development occurs in four phases, progressing from exposure to a stressor through escalating tension to a breaking point. These phases reflect a sequential progression in which intervention and resource utilization are critical.

• Phase 1: Normal Stress and Anxiety
  • Exposure to a precipitating stressor
  • Stressors perceived as minor annoyances
  • Individuals attempt previously successful problem-solving techniques
  • Anxiety begins to elevate, but individuals remain rational and in control
• Phase 2: Rising Anxiety Level
  • Problem-solving techniques are unsuccessful
  • Anxiety increases, and discomfort escalates
  • Feelings of helplessness, confusion, and disorganized thinking may occur
  • Physical signs include increased heart rate, respiration, rapid speech, and nervous habits
• Phase 3: Severe Stress and Anxiety
  • New problem-solving attempts fail
  • Functioning becomes impaired
  • Capacity to reason diminishes
  • Behaviors may include yelling, swearing, threats, pacing, clenched fists, heavy perspiration, and rapid breathing
• Phase 4: Crisis
  • Tension escalates to a critical breaking point
  • Anxiety becomes unbearable with panic and disordered thinking
  • Cognitive functioning is significantly impaired
  • Emotions are labile, and psychotic thinking may occur
  • Individuals may pose a danger to themselves or others

Crisis Assessment
Assessment begins with establishing a therapeutic nurse–patient relationship. Understanding the patient’s life context, stressors, resources, beliefs, and baseline functioning helps determine risk for ineffective coping. Nurses should monitor for signs of crisis progression, including:

• Escalating anxiety
• Denial
• Confusion or disordered thinking
• Anger and hostility
• Helplessness and withdrawal
• Inefficiency
• Hopelessness and depression
• Attempts at resolution and reorganization

Assessment of stress severity, available resources, and crisis phase guides appropriate intervention.

Crisis Interventions
Crisis intervention involves identifying, assessing, and intervening to assist individuals and families toward resolution. Goals include returning the individual to prior functioning, minimizing long-term mental health impact, and supporting coping skill development. Crisis states are time-limited, usually lasting days to weeks. Factors influencing resolution include realistic perception of events, situational support, and effective coping strategies.

Strategies for Crisis Phases 1 and 2
Early crisis interventions emphasize verbal and nonverbal communication.

• Verbal Strategies
  • Encourage expression of thoughts and concerns
  • Use empathetic statements
  • Engage in shared problem-solving
  • Use empathetic inquiry
• Nonverbal Strategies
  • Maintain calm demeanor
  • Use nonthreatening eye contact
  • Keep hands visible and posture open
  • Respect personal space
  • Avoid threatening gestures
  • Demonstrate respect and attentive listening

Strategies for Crisis Phase 3
As crisis escalates, nurses must prioritize safety. Assistance from additional staff or security may be required. Awareness of exits and use of emergency response devices are important. Verbal limit-setting can be effective when clearly stating expected behavior without making threats.

Strategies for Crisis Phase 4
Individuals in this phase often lack emotional and cognitive control and may not respond to verbal interventions. Space should be maintained, and safety prioritized. Emergency assistance may be necessary, including mental health professionals, crisis response teams, or emergency services. If calling emergency services, it is important to clearly communicate that the situation involves a mental health crisis and request trained responders. Physical or chemical restraints may be required according to organizational policy to maintain safety.

Crisis Resources
Available resources may include support groups, hotlines, shelters, counseling services, and organizations such as the Red Cross. Nurses should be familiar with community and institutional resources.

Mental Health Crisis
Individuals with mental health disorders are at ongoing risk for crisis, and suicide risk is always a priority concern. Any expression of suicidal thoughts must be taken seriously. Warning signs of a developing mental health crisis include:

• Inability to perform activities of daily living
• Rapid mood changes or sudden behavioral shifts
• Increased agitation, threats, violence, or property destruction
• Self-harm or substance misuse
• Social withdrawal
• Loss of touch with reality, hallucinations, or confusion
• Paranoia

Clients and families should be provided with clear guidance on accessing crisis support.

This section reviews the nursing process as it applies to stress and coping.

Assessments Related to Stress and Coping
Several nursing assessments are used to determine an individual’s response to stress and their strategies for stress management and coping, including:

• Recognize nonverbal cues of physical or psychological stress
• Assess for environmental stressors affecting client care
• Assess for signs of abuse or neglect
• Assess the client’s ability to cope with life changes
• Assess family dynamics
• Assess the potential for violence
• Assess the client’s support systems and available resources
• Assess the client’s ability to adapt to temporary or permanent role changes
• Assess the client’s reaction to a diagnosis of acute or chronic mental illness (e.g., rationalization, hopefulness, anger)
• Assess constructive use of defense mechanisms by the client
• Assess whether the client has successfully adapted to situational role changes (e.g., accepting dependency on others)
• Assess the client’s ability to cope with end-of-life interventions
• Recognize the need for psychosocial support for the family or caregiver
• Assess clients for maladaptive coping such as substance abuse
• Identify a client in crisis

Diagnoses Related to Stress and Coping
Nursing diagnoses related to stress and coping include Stress Overload and Ineffective Coping.

• Stress Overload
  Excessive amounts and types of demands that require action.
  Selected defining characteristics:
  • Excessive stress
  • Impaired decision-making
  • Impaired functioning
  • Increase in anger
  • Increased impatience
• Ineffective Coping
  A pattern of invalid appraisal of stressors, with cognitive and/or behavioral efforts that fails to manage demands related to well-being.
  Selected defining characteristics:
  • Alteration in concentration
  • Alteration in sleep pattern
  • Change in communication pattern
  • Fatigue
  • Inability to ask for help
  • Inability to deal with a situation
  • Ineffective coping strategies
  • Insufficient social support
  • Substance misuse
  • Increase in impatience

Outcomes Identification
An outcome is a measurable behavior demonstrated by the patient in response to nursing interventions. Outcomes should be identified before planning nursing interventions. Outcomes identification includes setting short- and long-term goals and creating specific expected outcome statements for each nursing diagnosis. Goals are broad and general, while outcomes are specific and measurable. Expected outcomes describe measurable patient actions within a specific time frame that are responsive to nursing interventions.

Expected outcome statements should include the following five components, remembered using the SMART mnemonic:

• Specific
• Measurable
• Attainable or action oriented
• Relevant or realistic
• Time frame

An example of a SMART outcome related to Stress Overload is: “The client will identify two stressors that can be modified or eliminated by the end of the week.”

An example of a SMART outcome related to Ineffective Coping is: “The client will identify three preferred coping strategies to implement by the end of the week.”

Planning Interventions Related to Stress and Coping
Common nursing interventions used to facilitate effective coping include:

• Implement measures to reduce environmental stressors
• Teach clients stress management techniques and coping strategies
• Provide caring interventions for clients experiencing grief or loss and offer resources to adjust to loss or bereavement
• Identify clients in crisis and tailor crisis intervention strategies to assist coping
• Guide clients to resources for recovery from crisis, such as social supports

Implementation
When implementing nursing interventions to enhance coping, it is important to recognize signs of crisis and maintain safety for the client, oneself, and others. Review signs of crisis and appropriate intervention strategies as needed.

Evaluation
After implementing individualized interventions, the nurse must evaluate their effectiveness. Review established SMART outcomes and timelines to determine whether goals have been met or if the plan of care requires modification.

Learning Objectives

• Apply the nursing process to mental health care
• Describe nursing assessments when providing mental health care
• Incorporate respectful and equitable practice
• Consider developmental levels when providing care
• Identify common nursing diagnoses or problems related to mental health conditions
• Promote a therapeutic environment
• Apply the subcategories of the Implementation standard of care to mental health care
• Create effective nursing care plans for clients with various mental health disorders
• Compare NCLEX Next Generation terminology to the nursing process

Psychiatric–Mental Health Nursing
Psychiatric–mental health nursing is defined as “the nursing practice specialty committed to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and comorbid conditions across the life span. Psychiatric–mental health nursing intervention is an art and a science, employing a purposeful use of self and a wide range of nursing, psychosocial, and neurobiological evidence to produce effective outcomes.”

In 2014, the American Psychiatric Nurses Association (APNA) and the International Society of Psychiatric–Mental Health Nurses (ISPN) published Psychiatric–Mental Health Nursing: Scope and Standards of Practice in alignment with the second edition of the ANA’s Nursing: Scope and Standards of Practice. This resource guides psychiatric–mental health nurses in the application of professional skills and responsibilities and should be reviewed in conjunction with state Board of Nursing policies and practices that govern nursing practice.

Standards of Practice in Psychiatric–Mental Health Nursing
The Standards of Practice for Psychiatric–Mental Health Nursing mirror the ANA Standards of Professional Nursing Practice of Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation. These standards also include additional competencies for Psychiatric–Mental Health Registered Nurse Specialists (PMH-RNs) and Advanced Practice Registered Nurse Specialists (PMH-APRNs), as well as additional components within the Implementation standard of care.

Chapter Focus
This chapter reviews how nurse generalists apply the nursing process and the ANA Standards of Professional Nursing Practice to clients experiencing mental health conditions. Assessments, nursing diagnoses, expected outcomes, and interventions related to mental health are examined while incorporating life span and cultural considerations. For condition-specific assessments, diagnoses, outcomes, and interventions, refer to the corresponding disorder-focused chapters.

he nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is grounded in the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements describing the actions and behaviors that all registered nurses—regardless of role, population, specialty, or setting—are expected to perform competently.

ADOPIE and the Nursing Process
The mnemonic ADOPIE is a helpful way to remember the six ANA standards that make up the nursing process. Each letter represents one component: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation. The nursing process is continuous and cyclic, constantly adapting to the patient’s current health status.

The Assessment Standard of Practice established by the American Nurses Association (ANA) states, “The registered nurse collects pertinent data to the health care and information relative to the health care consumer’s health or the situation.” Review the competencies for the Assessment Standard of Practice for registered nurses in the following box.

ANA’s Assessment Competencies
The registered nurse:

• Creates the safest environment possible for conducting assessments.
• Collects pertinent data related to health and quality of life in a systematic, ongoing manner, with compassion and respect for the wholeness, the inherent dignity, worth, and unique attributes of every person, including, but not limited to, demographics, environmental and occupational exposures, social determinants of health, health disparities, physical, functional, psychosocial, emotional, cognitive, spiritual/transpersonal, sexual, sociocultural, age-related, environmental, and lifestyle/economic assessments.
• Utilizes a health and wellness model of assessment that incorporates integrative approaches to data collection and honors the whole person.
• Recognizes the health care consumer or designated person as the decision-maker regarding their own health.
• Explores the health care consumer’s culture, values, preferences, expressed and unexpressed needs, and knowledge of the health care situation.
• Assesses the impact of family dynamics on the health care consumer’s health and wellness.
• Identifies enhancements and barriers to effective communication based on personal, cognitive, physiological, psychosocial, literacy, financial, and cultural considerations.
• Engages the health care consumer, family, significant others, and interprofessional team members in holistic, culturally sensitive data collection.
• Integrates knowledge from current local, regional, national, and global health initiatives and environmental factors into the assessment process.
• Prioritizes data collection based on the health care consumer’s immediate condition, the anticipated needs of the health care consumer or situation, or both.
• Uses evidence-based assessment techniques and available data and information to identify patterns and variances in the consumer’s health.
• Remains knowledgeable about constantly changing technologies that impact the assessment process (e.g., telehealth, artificial intelligence).
• Analyzes assessment data to identify patterns, trends, and situations that impact the person’s health and wellness.
• Validates the analysis with the health care consumer.
• Documents data accurately and makes accessible to the interprofessional team in a timely manner.
• Communicates changes in a person’s condition to the interprofessional team.
• Applies the provisions of the ANA Code of Ethics, legal guidelines, and policies to the collection, maintenance, use, and dissemination of data and information.
• Recognizes the impact of one’s own personal attitudes, values, beliefs, and biases on the assessment process.

Mental Health Assessment Emphasis
Nursing assessments related to mental health disorders differ from physiological assessments with a greater focus on collecting subjective data. For example, prior to administering a cardiac medication, a nurse assesses objective data such as blood pressure and apical heart rate to determine medication effectiveness. However, prior to administering an antidepressant, the nurse uses therapeutic communication to gather subjective data about how the patient is feeling to determine effectiveness. The nurse also observes behaviors, speech, mood, and thought processes as part of the assessment. Neurotransmitters cannot be directly measured in routine nursing care, so nurses ask questions to assess how the patient is feeling emotionally and perceiving the world. An example of therapeutic communication for subjective assessment is: “Tell me more about how you are feeling today.” Nurses may also use general survey techniques such as observing mood, hygiene, appearance, and movement.

Holistic Assessment and the Mental Health Continuum
Recall the mental health continuum introduced in the “Foundational Mental Health Concepts” chapter. Nurses in any setting holistically assess physical, emotional, and mental health and identify impairments impacting functioning. Nurses must recognize subtle cues of undiagnosed or poorly managed physical and mental disorders and follow up appropriately with other members of the interprofessional health care team.

Additional Mental Health Assessments
When assessing a client’s mental health, the nurse incorporates assessments in addition to the traditional physical examination. Assessments may include:

• Performing a mental status examination
• Completing a psychosocial assessment
• Reviewing the client’s use of psychotropic medications (and other medications that may cause psychiatric symptoms as side effects)
• Screening for suicidal ideation, exposure to trauma or violence, and substance misuse
• Incorporating a spiritual assessment while assessing coping status
• Incorporating life span, developmental, and cultural considerations
• Reviewing specific laboratory results related to psychotropic and other medications

Mental Status Examination
Registered nurses use clinical interviewing skills while developing a therapeutic nurse–client relationship. Assessment of suspected or previously diagnosed mental health disorders includes both verbal and nonverbal observations, and findings are compared to baseline admission data to determine if the client is improving, worsening, or unchanged. The mental status examination is a priority component of focused mental health assessment, and much of it is often performed through unstructured observations during the general survey. If cues of mental health disorders are identified, a focused mental status examination should be completed. A mental status examination assesses level of consciousness and orientation, appearance and general behavior, speech, motor activity, affect and mood, thought and perception, attitude and insight, and cognitive abilities. The examiner should also monitor personal reactions to the client.

Signs of Distress
If a client shows distress during an examination, the nurse must quickly obtain focused assessment data and seek additional assistance based on the emergency level and agency policy. For example, if a client is unresponsive, a code may be called in inpatient settings or 911 in outpatient settings as CPR is initiated. If a client has difficulty breathing, new confusion, or other signs of deterioration, rapid response or emergency assistance may be needed. Emergency administration of naloxone may be required in suspected opioid overdose.

Level of Consciousness and Orientation
Normal consciousness includes being alert and oriented to person, place, and time, and aware of the situation. Clouded consciousness is reduced awareness to stimuli. Delirium is an acute abnormal mental state with fluctuating consciousness, disorientation, irritability, and hallucinations, often linked to infection, metabolic disorders, or CNS toxins. Obtundation is moderately reduced awareness where mild to moderate stimuli do not awaken the client and responses are slow when aroused. Stupor is unresponsiveness unless vigorous stimuli are applied. Coma is unarousable unresponsiveness where even noxious stimuli may not trigger reflex motor responses. Documentation should include the type of stimulus required and the degree of response.

Appearance and General Behavior
This includes overall impressions of age appearance, grooming, dress, posture, eye contact, social interaction, and threatening behavior. Clients may appear stated age or older than stated age, be well-groomed or disheveled, have appropriate or inappropriate dress, erect or slumped posture, and good or poor eye contact. Life span and cultural considerations must be included, as some cultures view direct eye contact as disrespectful.

Speech
Speech assessment occurs as clients answer open-ended questions. Normal speech includes appropriate responses, even rate, rhythm, and tone, clear articulation, and appropriate following of instructions. Speech may be described as rapid, slow, loud, soft, include stuttering or aphasia, or be pressured, halting, circumstantial, or poverty of content.

Motor Activity
Motor activity includes noting tics or unusual mannerisms. Normal motor activity includes good balance, equal bilateral movement, and smooth gait. Slow movements or lack of spontaneity may occur with depression or dementia. Dyskinesia and akathisia may occur with extrapyramidal symptoms related to psychotropic medications. Terms include psychomotor agitation and psychomotor retardation.

Affect and Mood
Affect is emotional expression and mood is the predominant emotion. Mood may be neutral, elevated, labile, anxious, angry, sad, irritable, dysphoric, euphoric, or include feelings such as emptiness and indecisiveness. Normal affect and mood may be described as euthymic. Abnormal affect includes incongruent or inappropriate affect, subdued, tearful, labile, blunted, or flat affect. Related terms include alexithymia, anhedonia, and apathy.

Thoughts and Perceptions
Assessment focuses on how the client processes and responds to stimuli. Nurses assess whether concerns are realistic or irrational, exaggerated responses, or beliefs without basis in reality. Clients may experience delusions, obsessions, rumination, hallucinations, and illusions. Delusions are fixed false beliefs not held by cultural peers and persisting despite contradictory evidence. Grandiose delusions involve exaggerated self-importance. Paranoia involves delusions of persecution and mistrust. Obsessions are intrusive, distressing thoughts and are distinguished from everyday worries. Rumination involves repetitive obsessional thinking that interferes with other mental activity. Hallucinations are false sensory perceptions without external stimuli and may occur across all senses. Illusions are misperceptions of real stimuli. Because these feel real to clients and may be concealed, nurses may ask: “Have you ever seen or heard things that other people could not see or hear? Have you ever seen or heard things that later turned out not to be there?” Other thought process terms include racing thoughts, flight of ideas, loose associations, word salad, and clang associations. Nurses must assess for violence risk and determine whether hallucinations instruct harm. Definitions include homicidal ideation, suicidal ideation, suicide attempt, and suicide plan. Thought disorder evaluation is difficult and may require specialized expertise and additional assistance when newly observed.

Attitude and Insight
Attitude is the emotional tone displayed toward the examiner, others, or the illness and may include hostility, anger, helplessness, pessimism, overdramatization, self-centeredness, passivity, or hope toward recovery. Insight is the ability to recognize a problem and understand its nature. Nurses must be aware of transference, when clients transfer feelings onto the nurse, such as displaced anger.

Cognitive Abilities
Cognition includes thinking, knowing, remembering, judging, and problem-solving. Assessment focuses on attention and memory. Distractibility refers to attention easily pulled toward irrelevant stimuli. Memory includes immediate recall, short-term memory, and long-term storage, with short-term memory being most clinically important. Short-term memory may be assessed by repeating four unrelated objects and recalling them after 3–5 minutes following another mental task.

Examiner’s Reaction to the Client
Nurses may develop subtle feelings toward clients during assessment, such as frustration, boredom, or distraction, which clients may perceive through nonverbal communication. Nurses should examine internal reactions and remain aware of how tone of voice, posture, facial expression, and eye contact influence the interaction. Nurses must also be aware of countertransference, where the examiner transfers personal feelings onto the client, potentially influencing care.

Psychosocial Assessment
A psychosocial assessment (health history) gathers additional subjective data to identify risks, treatment opportunities, and resources. Common components include:

• Cultural assessment
• Reason for seeking health care (chief complaint)
• Thoughts of self-harm or suicide
• Current and past medical history
• Current medications
• History of diagnosed mental health disorders
• Previous hospitalizations
• Educational background
• Occupational background
• Family dynamics
• Exposure to trauma, violence, and domestic abuse
• Substance use (tobacco, alcohol, recreational drugs, misused prescription drugs)
• Family history of mental illness
• Coping mechanisms
• Functional ability/activities of daily living
• Spiritual assessment

Cultural Formulation Interview Questions
Cultural assessment is essential, and the American Psychiatric Association’s Cultural Formulation Interview (CFI) supports understanding and decision-making by clarifying the problem’s meaning, sources of help, and expectations for care. The CFI questions include:

1. What brings you here today?
2. What troubles you most about this problem?
3. Why do you think this is happening to you? What do you think is the cause of this problem?
4. Are there any kinds of support that make this problem better, such as support from family, friends, or others?
5. Are there any kinds of stresses that make this problem worse, such as difficulties with money or family problems?
6. Are there any aspects of your background or identity that make a difference to this problem?
7. What have you done on your own to cope with this problem?
8. In the past, what kinds of treatment, help, advice, or healing have you sought for this problem?
9. Has anything prevented you from getting the help you need?
10. What kinds of help do you think would be most useful to you at this time for this problem?
11. Are there other kinds of help that your family, friends, or other people have suggested that would be helpful for you now?
12. Have you been concerned about misaligned care expectations and is there anything we can do to provide the care you need?

Findings from the CFI are used to individualize the plan of care to client preferences, values, beliefs, and goals.

Reason for Seeking Health Care
The psychosocial assessment begins by obtaining the patient’s reason for seeking care in their own words. In clinics, emergency departments, or on admission, this is the chief complaint. Questions include:

• What brought you in today?
• How long has this been going on?
• How is this affecting you?

After identifying the chief complaint, focused questions explore priority concerns such as pain. The PQRSTU mnemonic is used to assess pain:

• Provocation/Palliation: What makes your pain worse? What makes your pain feel better?
• Quality: What does the pain feel like?
• Region: Where exactly do you feel the pain? Does it move or radiate?
• Severity: Rate pain 0–10.
• Timing/Treatment: When did it start? Is it constant or intermittent? What have you taken to relieve it?
• Understanding: What do you think is causing the pain?

Thoughts of Suicide
All clients aged 12 and older presenting for acute care should be screened for suicidal ideation. Many clients treated for mental health conditions have suicidal ideation, and some clients presenting with medical issues have hidden suicide risk. Universal screening supports early detection and intervention. Nurses should introduce screening in a normalized way, such as: “Now I’m going to ask you some questions that we ask everyone treated here, no matter what problem they are here for. It is part of the hospital’s policy, and it helps us to make sure we are not missing anything important.” The Patient Safety Screener (PSS-3) is a brief tool assessing depression, active suicidal ideation, and lifetime suicide attempt, reflecting different aspects of suicide risk.

Self-Injury
Non-suicidal self-injury (NSSI) refers to intentional self-inflicted destruction of body tissue without suicidal intent and for reasons not socially sanctioned. Examples include cutting, burning, scratching, or self-hitting. NSSI is considered maladaptive coping and is common among adolescents and young adults in psychiatric inpatient settings.

Family Dynamics
Family dynamics are especially important for children, adolescents, and older adults and refer to patterns of interactions, roles, relationships, and influences among relatives. Family relationships can promote stability and support or create stress and contribute to trauma. Unhealthy family dynamics are linked to adverse childhood experiences and increased risks of physical illness, depression, anxiety, and adolescent substance use. Addressing family dynamics requires interprofessional collaboration, and nurses are positioned to observe, document patterns, and respond to family concerns due to frequent contact.

Spiritual Assessment
Spiritual assessment is part of psychosocial assessment. Spirituality includes connection to something larger than oneself and a search for meaning and purpose. Basic questions include:

• Who or what provides you with strength or hope?
• How do you express your spirituality?
• What spiritual needs can we advocate for you during this health care experience?

Spiritual care and advocacy can improve health outcomes, quality of life, coping, and end-of-life experiences. The FICA Spiritual History Tool is a common approach:

• F – Faith and Belief: Determine if the patient identifies with a belief system or spirituality.
• I – Importance: Ask if the belief is important and influences health decisions.
• C – Community: Determine if the client belongs to a spiritual community and whether connection would be helpful.
• A – Address in Care: Ask what should be included in the plan of care and whether the client would like spiritual support such as a chaplain.

Based on findings, nurses may refer clients to chaplains or religious leaders for spiritual support.

Screening Tools
Screening tools are evidence-based methods used on admission and during care to assess mental health–related information, compare progress, and support treatment planning as part of the interprofessional team.

Laboratory and Diagnostic Testing
Laboratory and diagnostic testing supports assessment, including monitoring electrolytes and medication levels and identifying concerns related to nutrition, hydration, or medication effects. Specific tests are addressed in disorder-focused chapters and in the psychotropic medications chapter.

Life Span Considerations
Developmental stage influences assessment, care planning, and interventions. Mental health disorders occur across the life span and require individualized assessment. Development includes physical, social, and cognitive changes occurring across life, and individuals’ unique experiences influence development of intelligence and reasoning. Three major theories influencing nursing care include Freud’s Psychosexual Theory of Development, Erikson’s Psychosocial Stages of Development, and Piaget’s Cognitive Theory of Development.

Freud’s Psychosexual Theory of Development
Freud proposed that personality develops in early childhood and that lack of proper nurturance in developmental stages may result in fixation. He described five stages: oral, anal, phallic, latency, and genital. While much of Freud’s theory is disputed, the concept that childhood experiences influence adult personality remains.

Erikson’s Psychosocial Stages of Development
Erikson emphasized social development across eight stages: trust vs. mistrust, autonomy vs. shame, initiative vs. guilt, industry vs. inferiority, identity vs. identity confusion, intimacy vs. isolation, generativity vs. stagnation, and integrity vs. despair.

• Trust vs. Mistrust
• Autonomy vs. Shame
• Initiative vs. Guilt
• Industry vs. Inferiority
• Identity vs. Identity Confusion
• Intimacy vs. Isolation
• Generativity vs. Stagnation
• Integrity vs. Despair

Piaget’s Cognitive Theory of Development
Piaget described four stages: sensorimotor, preoperational, concrete operations, and formal operations, explaining cognitive growth as children seek equilibrium.

• Sensorimotor period
• Preoperational period
• Concrete operations period
• Formal operations period

Cognitive Impairment
Cognitive impairment refers to impairment in mental processes affecting understanding and action, ranging from mild to profound, and includes functions such as attention, judgment, memory, planning, and reasoning. Intellectual disability is a diagnostic term describing deficits in intellectual and adaptive functioning identified in the developmental period and is typically lifelong and nonprogressive, requiring multidisciplinary assessment and treatment planning.

Resilience
Resilience is the ability to overcome serious hardship or trauma. It can be visualized like a seesaw where protective experiences and coping skills counterbalance adversity. A key factor supporting resilience is at least one stable, committed relationship with a supportive adult. Resilience-related capabilities can be strengthened at any age through health-promoting activities such as exercise, stress management, and self-regulation skill-building.

Cultural Considerations
Cultures and communities may express and interpret symptoms of mental illness differently, and nurses should consider cultural, racial, ethnic, religious, and geographical context. Patient-centered care includes cultural humility and inclusiveness. The ANA established a Standard of Professional Performance called Respectful and Equitable Practice defined as practicing with cultural humility and inclusiveness. Cultural humility involves respectfully challenging personal biases and approaching cultural learning as a lifelong process. Inclusiveness involves ensuring equal access to opportunities and resources for people who may be marginalized.

ANA’s Respectful and Equitable Practice Competencies
The registered nurse:

Advances organizational policies, programs, services, and practices that reflect respect, equity, and values for diversity and inclusion.

Demonstrates respect, equity, and empathy in actions and interactions with all health care consumers.

Respects consumer decisions without bias.

Participates in life-long learning to understand cultural preferences, worldviews, choices, and decision-making processes of diverse consumers.

Reflects upon personal and cultural values, beliefs, biases, and heritage.

Applies knowledge of differences in health beliefs, practices, and communication patterns without assigning values to the differences.

Addresses the effects and impact of discrimination and oppression on practice within and among diverse groups.

Uses appropriate skills and tools for the culture, literacy, and language of the individuals and population served.

Communicates with appropriate language and behaviors, including the use of qualified health care interpreters and translators in accordance with consumer needs and preferences.

Serves as a role model and educator for cultural humility and recognition and appreciation of diversity and inclusivity.

Identifies the cultural-specific meaning of interactions, terms, and content.

Advocates for policies that promote health and prevent harm among diverse health care consumers and groups.

Promotes equity in all aspects of health and health care.