6 Mental Health Nursing in Community · PDF fileand functional level have been found to be more posi-Mental Health Nursing in Community Settings. COMMUNITY SETTINGS

CHAPTER 6Mental Health Nursingin Community Settings

NANCY CHRISTINE SHOEMAKER ■ SUSAN CAVERLY

85

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The first psychiatric nurses working in the communitysetting were community health nurses who developeda specialty practice in mental health. They were able tomove within the community, were comfortable meetingwith clients in the home or neighborhood center, werecompetent to act independently, used professional judg-ment in sometimes unanticipated situations, and pos-sessed knowledge of community resources.

The heritage of these nurses can be traced back tothe European women who cared for the sick at homeand American women who organized into religiousand secular societies during the 1800s to visit the sick

in their homes. By 1877, trained nurses worked as pub-lic health nurses visiting the homes of the poor innortheastern cities and generalist nurses made com-munity visits to rural areas for health promotion andcare of the sick (Smith, 1995).

CONTEXT FOR PSYCHIATRICNURSING IN THE COMMUNITY

In 1963, President Kennedy signed into law theCommunity Mental Health Centers Act, thus solidify-ing the shift of mental health care from the institution

KEY TERMS and CONCEPTS

The key terms and concepts listed here appear incolor where they are defined or first discussed in thischapter.barriers to treatment, 95

continuum of psychiatric mental health treatment, 90

deinstitutionalization, 86

ethical dilemmas, 95

seriously mentally ill, 86

OBJECTIVES

After studying this chapter, the reader will be able to1. Explain the evolution of the community mental health

movement.

2. Identify elements of the nursing assessment that are criti-cally important to the success of community treatment.

3. Distinguish between the hospital and community settingswith regard to characteristics, goals of treatment, and nurs-ing interventions.

4. Compare and contrast the roles of the nurse in communitymental health according to the nurse’s educational prepa-ration.

5. Explain the role of the nurse as the biopsychosocial caremanager in the multidisciplinary team.

6. Discuss the continuum of psychiatric treatment.

7. Describe the role of the psychiatric nurse in four specificsettings: partial hospitalization program; psychiatric homecare; assertive community treatment; and community men-tal health center.

8. Identify two resources to assist the community psychiatricnurse in resolving ethical dilemmas.

9. Discuss barriers to mental health treatment.

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86 UNIT TWO Foundations for Practice

to the community and heralding the era of deinstitu-tionalization. Media focus raising public awarenessregarding the horrors of psychiatric institutions, themental health care needs presented by returning ser-vicemen, and the development of psychopharmaco-logical agents all acted as catalysts for needed changein psychiatric treatment philosophy (Marcos, 1990;Rochefort, 1993).

The 1960s were also the time when federal entitle-ment programs proliferated: Social Security Disability,Supplemental Security Income, Medicaid, Medicare,housing assistance, and food stamps. These social pro-grams provided the means for moving the mentally illout of institutions and into the community. Policy-makers believed that community care would be more humane and less expensive 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. At the time, there werefew choices for outpatient treatment, mainly a com-munity mental health center or therapy in a private of-fice. Government promises to expand funding forcommunity services were not kept, and there weremore clients than resources. In 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 compliantpopulation. Despite these problems, a second wave ofdeinstitutionalization took place in the 1980s afterPresident Carter’s Commission on Mental Healthhighlighted the needs of the underserved and un-served seriously mentally ill group.

Over the past 30 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 roleof the community psychiatric registered nurse (RN)has diversified to include providing services in all ofthese treatment settings. In this chapter, you willlearn about the role of the basic level RN in differentmultidisciplinary treatment teams across this spec-trum. Many nontraditional nursing roles have devel-oped outside of the recognized treatment sites.Psychiatric needs are well known in the criminal jus-tice system and in the homeless population. In 1999,the U.S. Department of Justice estimated that 16% ofpeople in jail (those in for short stays as opposed tothe long-term prison population) reported a historyof an emotional problem (McQuistion et al., 2003, p.671). Repeated studies since the 1980s suggest thatone third to one half of homeless people have severepsychiatric illness (McQuistion et al., 2003, p. 669).Psychiatric RNs are actively involved in forensic set-tings and in creative outreach efforts in publicplaces.

School-based clinics have increased as communitieshave recognized the need for early detection and treat-ment for children. In addition to performing screeningand mental health teaching, psychiatric RNs are a partof crisis teams that respond to episodes of school vio-lence, either adolescent suicide or mass homicide. Theissue of increasing violence has had great impact oncommunity nurses in all settings, especially with theemergence of terrorism and bioterrorism (see Chapter14). Educators now believe that all nurses need corecompetencies in emergency preparedness to be readyfor human-created disasters (Gebbie & Qureshi, 2002).One example of this need for quick action was in theaftermath of the September 11, 2001, terrorist attack inNew York City. The state department of mental healthimmediately established a program to provide free cri-sis counseling services to all city residents (Rudenstineet al., 2003).

As noted earlier, community psychiatric nursespractice in diverse settings among people who may ormay not be diagnosed with a mental illness. The prin-ciples of the public health concept of prevention areuseful to support all of these interventions. Primaryprevention activities are directed to healthy popula-tions to provide information and to teach coping skillsto reduce stress, with the goal of avoiding mental ill-ness. For example, a nurse may teach parenting skillsin a well-baby clinic. Secondary prevention involvesthe early detection and treatment of psychiatric symp-toms with the goal of minimizing impairment. For ex-ample, a nurse may conduct screening for depressionat a work site. Tertiary prevention involves those ser-vices that address residual impairments in psychiatricclients, in an effort to promote the highest level ofcommunity functioning. For example, a nurse mayprovide long-term treatment in a clinic. Box 6-1 pre-sents examples of community practice sites for thepsychiatric mental health nurse.

ASPECTS OF COMMUNITYNURSING

Psychiatric nursing in the community setting differsmarkedly from psychiatric nursing in the hospital. Thecommunity setting requires flexibility on the part ofthe psychiatric nurse and knowledge about a broad ar-ray of community resources. Clients need assistancewith problems related to individual psychiatric symp-toms, family and support systems, and basic livingneeds such as housing and financial support. Outsideof a traditional clinic or office, the setting is the realmof the client rather than of the health care provider.Community treatment hinges on enhancing clientstrengths in the same environment in which daily lifemust be maintained, which makes individually tai-lored psychiatric care imperative. The hospital repre-


sents a controlled setting and promotes stabilization,but strides made during hospitalization can be lostupon return home. Treatment in the community per-mits clients and those involved in their support tolearn new ways of coping with symptoms or situa-tional difficulties. The result can be one of empower-ment and self-management, to the extent possiblegiven the client’s disability.

Psychiatric Nursing AssessmentStrategiesAssessment of the biopsychosocial needs and capaci-ties of clients living in the community requires expan-sion of the general psychiatric nursing assessment. Forthe hospitalized client, the nurse must understandcommunity living challenges and resources to assesspresenting problems as well as to plan for discharge.The community psychiatric RN must also develop acomprehensive understanding of the client’s ability tocope with the demands of living in the community, tobe able to plan and implement effective treatment. Box6-2 identifies the areas covered in a biopsychosocialassessment.

Four key elements of this assessment are stronglyrelated to the probability that the client will experience

successful outcomes in the community. Problems inany of these areas require immediate attention beforeother treatment goals are pursued.

■ Housing adequacy and stability—If a client facesdaily fears of homelessness, it is not possible to fo-cus on other treatment issues.

■ Income and source of income—A client must havea basic income, whether from an entitlement, arelative, or other sources, to obtain necessarymedication and to meet daily needs for food andclothing.

■ Family and support system—The presence of afamily member, friend, or neighbor supports theclient’s recovery and also gives the RN a contactperson, with the client’s consent.

■ Substance abuse history and current use—Oftenhidden or minimized during hospitalization, substance abuse can be a destructive force under-mining medication effectiveness and interferingwith community acceptance and procurement ofhousing.

Individual cultural characteristics of clients are alsovery important to assess. For example, working with a

Mental Health Nursing in Community Settings CHAPTER 6 87

BOX 6-1

Possible Community Mental HealthPractice Sites

Primary PreventionAdult and youth recreational centersSchoolsDay care centersChurches, temples, synagogues, mosquesEthnic cultural centers

Secondary PreventionCrisis centersShelters (homeless, battered women, adolescents)Correctional community facilitiesYouth residential treatment centersPartial hospitalization programsChemical dependency programsNursing homesIndustry/work sitesOutreach treatment in public placesHospices and acquired immunodeficiency syndrome pro-

gramsAssisted living facilities

Tertiary PreventionCommunity mental health centersPsychosocial rehabilitation programs

BOX 6-2

Elements of Biopsychosocial NursingAssessment

Presenting problem and referring partyPsychiatric history, including symptoms, treatments, med-

ications, and most recent service utilizationHealth history, including illnesses, treatments, medications,

and allergiesSubstance abuse history and current use*Family history, including health and mental health disorders

and treatmentsPsychosocial history, including:

■ Developmental history■ School performance■ Socialization■ Vocational success or difficulty■ Interpersonal skills or deficits■ Income and source of income*■ Housing adequacy and stability*■ Family and support system*■ Level of activity■ Ability to care for needs independently or with assis-

tance■ Religious or spiritual beliefs and practices

Legal historyMental status examinationStrengths and deficits of the clientCultural beliefs and needs relevant to psychosocial care

*Strongly related to the probability that the client will experience successful out-comes in the community.


person for whom Spanish is the primary language re-quires 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 fromthe family, is essential when the nurse and client speakdifferent languages (see Chapter 7).

Psychiatric Nursing Intervention StrategiesIn the hospital setting, the focus of care is on stabiliza-tion, as defined by staff. In the community setting,treatment goals and interventions are negotiatedrather than imposed on the client. Community psychi-atric nurses must approach interventions with flexibil-ity and resourcefulness to meet the broad range ofneeds of clients. The complexity of navigating themental health system and the social service fundingsystems is often overwhelming to clients. Not unex-pectedly, client outcomes with regard to mental statusand functional level have been found to be more posi-tive and to be achieved with greater cost effectivenesswhen the community psychiatric RN integrates casemanagement into the professional role (Chan,Mackenzie, & Jacobs, 2000; Chan et al., 2000).

Differences in characteristics, treatment outcomes,and interventions between inpatient and communitysettings are outlined in Table 6-1. Note that all of theseinterventions fall within the practice domain of the ba-sic level RN.

ROLES AND FUNCTIONSOF THE COMMUNITYPSYCHIATRIC NURSE

As noted in Chapter 4, psychiatric mental healthnurses are educated at a variety of levels: associate,diploma, baccalaureate, masters, and doctoral.Perhaps the most significant distinction among themultiple levels of preparation is the degree to whichthe nurse acts autonomously and provides consulta-tion to other providers both inside and outside of theparticular agency. The nurse practice acts of individualstates grant nurses authority to practice, and the stan-dards of psychiatric nursing developed by theAmerican Nurses Association in collaboration withpsychiatric groups also define levels of practice. Table6-2 describes the roles of psychiatric nurses accordingto level of education.

Member of Multidisciplinary CommunityPractice TeamThe concept of using multidisciplinary treatmentteams originated with the Community Mental HealthCenters Act of 1963. Psychiatric nursing practice wasidentified as one of the core mental health disciplines,along with psychiatry, social work, and psychology.This recognition permitted the allocation of resources


TABLE 6-1

Characteristics, Treatment Outcomes, and Interventions by Setting

Inpatient Setting Community Mental Health Setting

Characteristics

Unit locked by staff Home locked by client24-hour supervision Intermittent supervisionBoundaries determined by staff Boundaries negotiated with clientMilieu with food, housekeeping, security services Client-controlled environment with self-care, safety risks

Treatment Outcomes

Stabilization of symptoms and return to community Stable or improved level of functioning in community

Interventions

Develop short-term therapeutic relationship. Establish long-term therapeutic relationship.Develop comprehensive plan of care with attention to Develop comprehensive plan of care for client and support

sociocultural needs of client. system with attention to sociocultural needs.Enforce boundaries by seclusion or restraint, as needed. Negotiate boundaries with client.Administer medication. Encourage compliance with medication regimen.Monitor nutrition and self-care with assistance as needed. Teach and support adequate nutrition and self-care with

referrals as needed.Provide health assessment and intervention as needed. Assist client in self-assessment with referrals for health

needs in community as needed.Offer structured socialization activities. Use creative strategies to refer client to positive social

activities.Plan for discharge with family/significant other with regard to Communicate regularly with family/support system to assess

housing and follow-up treatment. and improve level of functioning.


to educate psychiatric nurses and emphasized theirunique contributions to the team.

In team meetings, the individual and discipline-specific expertise of each member is recognized.Generally, the composition of the team reflects theavailability of fiscal and professional resources in thearea. Similar to the team defined in Chapter 5, thecommunity psychiatric team may include psychia-trists, nurses, social workers, psychologists, dual-diagnosis specialists, and mental health workers.Recognition of the ability of nurses to have an equalvoice in team treatment planning with other profes-sionals was novel at the time the team approach wasimplemented in community mental health practice.This level of professional performance was later usedas a model for other nursing specialties.

Some writers believe that the multidisciplinaryteam approach dilutes the nursing role, because nursesadopt the language of psychiatry and social services.But ideally, the nurse is able to integrate a strong nurs-ing identity into the team perspective. At the basic oradvanced practice level, the community psychiatricRN is in a critical position to link the biopsychosocialand spiritual components relevant to mental healthcare for the individual. The RN also communicates ina manner that the client, significant others, and mem-bers of the team can accept and understand. In partic-ular, the management and administration of psy-chotropic medications have become a significant taskthe community RN is expected to perform. There is ev-idence that medications are most effective when thenurse approaches drug therapy seeking to empowerthe individual client (Marland & Sharkey, 1999).

Biopsychosocial Care ManagerThe role of the community psychiatric RN includes thecoordination of mental health, physical health, spiri-tual health, social service, educational service, and vo-

cational realms of care for the mental health client. Thereality of community practice in the new millenniumis 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 substanceabuse, poverty, and stress. In addition, repeated stud-ies show that the mentally ill have a higher risk formedical disorders than the general population (Dickeyet al., 2002).

The 1980s brought increased emphasis on imple-menting case management as a core service in treatingthe seriously mentally ill client. In the private domain,case management or care management has also founda niche. The intent is to charge case managers with de-signing individually tailored treatment services forclients and tracking outcomes of care. Case manage-ment includes the following functions: assessing clientneeds; developing a plan for service; linking the clientwith necessary services; monitoring the effectivenessof services; and advocating for the client, as needed(Shoemaker, 2000). Nursing and medicine are the onlymental health disciplines possessing the knowledge,skill, and legal authority to provide the full range ofmental health care interventions. This scope of prac-tice, coupled with issues of personnel cost and avail-ability, underscores the critical need for communitypsychiatric RNs to participate in coordination of careactivities.

A successful life in the community is more likelywhen medications are taken as prescribed. Nurses arein a position to help the client to manage medication,recognize side effects, and be aware of the interactionsamong drugs prescribed for physical illness and men-tal illness. Client-family education and behavioralstrategies, in the context of a therapeutic relationshipwith the clinician, have been shown to significantly in-crease compliance with the medication regimen (Lacro& Glassman, 2004).


TABLE 6-2

Community Psychiatric Nursing Roles Relevant to Educational Preparation

Role Advanced Practice (MS, PhD) Basic Practice (Diploma, AA, BS)

Practice Nurse practitioner or clinical nurse specialist; manage Provide nursing care for consumer and assist with consumer care and prescribe or recommend inter- medication management as prescribed, under direct ventions independently supervision

Consultation Consultant to staff about plan of care, to consumer Consult with staff about care planning and work with and family about options for care; collaborate with nurse practitioner or physician to promote health community agencies about service coordination and and mental health care; collaborate with staff from planning processes other agencies

Administration Administrative or contract consultant role within mental Take leadership role within mental health treatment health agencies or mental health authority team

Research and Role as educator or researcher within agency or mental Participate in research at agency or mental health au-education health authority thority; serve as preceptor to undergraduate nursing

students


COMMUNITY SETTINGSMany community psychiatric RNs originally practicedon site at community mental health centers. As finan-cial, health care, regulatory, cultural, and populationchanges have occurred, the practice locations havechanged. Nurses are providing primary mental healthcare at therapeutic day care centers, schools, partialhospitalization programs, and shelters. In addition tothese more traditional environments for care, psychi-atric RNs are also entering forensic settings and drugand alcohol treatment centers. Mobile mental healthunits have been developed in some service areas. In agrowing number of communities, mental health pro-grams are collaborating with other health or commu-nity services to provide integrated approaches to treat-ment. A prime example of this is the growth ofdual-diagnosis programming at both mental healthand chemical dependency clinics. Technology has be-gun to contribute to the venues for providing commu-nity care: telephone crisis counseling, telephone out-reach, and even the Internet are being used to enhanceaccess to mental health services (Wilson & Williams,2000).

In the following sections, you will find descriptionsof four different community psychiatric settings, withillustrations of the practice of the basic level RN ineach team. Nursing interventions in these settings in-clude most of those defined for basic practice, for ex-ample:

■ Counseling—assessment interviews, crisis inter-vention, problem solving in individual, group, orfamily sessions.

■ Promotion of self-care activities—fostering ofgrooming, instruction in use of public transporta-tion, budgeting; in home settings, the RN may di-rectly assist as necessary.

■ Psychobiological interventions—medication ad-ministration, teaching of relaxation techniques,promotion of sound eating and sleep habits.

■ Health teaching—medication use, illness charac-teristics, coping skills, relapse prevention.

■ Case management—communication with family,significant others, and other health care or com-munity resource personnel to coordinate an effec-tive plan of care.

Figure 6-1 presents the continuum of psychiatricmental health treatment. Movement along the contin-uum is fluid, from higher to lower levels of intensity,and changes are not necessarily step by step. Upondischarge from acute hospital care or a 24-hour super-vised crisis unit, many clients need intensive servicesto maintain their initial gains or to “step down” incare. Multiple studies show that failure to follow up inoutpatient treatment increases the likelihood of rehos-

pitalization and other adverse outcomes (Kruse &Rohland, 2002).

Other clients with a preexisting community treat-ment team may return directly to their communitymental health center or psychosocial rehabilitationprogram. Homeless clients may be referred to a shelterwith linkage to intensive case management or as-sertive community treatment. Clients with a substan-tial problem with substance abuse may be transferreddirectly into a residential substance abuse treatmentprogram (see Chapter 27). It is also notable that clientsmay pass through the continuum of treatment in thereverse direction; that is, if symptoms exacerbate, alower intensity service may refer the client temporar-ily to a higher level of care in an attempt to prevent to-tal decompensation and hospitalization.

Partial Hospitalization ProgramPartial hospitalization programs (PHPs) offer inten-sive, short-term treatment similar to an inpatient levelof care, except that the client is able to return homeeach day. Criteria for referral to a PHP include theneed for prevention of hospitalization for serioussymptoms 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,


Locked inpatient unit

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Partial hospitalization program (PHP)

Psychiatric home care

Assertive community treatment (ACT)

Intensive substance abuse program

Psychosocial rehabilitation program (PRP)

Clinical case management

Community mental health center (CMHC)

Private therapist offfice

FIGURE 6-1 The continuum of psychiatric mental healthtreatment.


2000). Referrals come from inpatient or outpatientproviders. Transportation is usually provided, andclients receive 5 to 6 hours of treatment daily.Programs operate up to 7 days a week, and the lengthof stay is approximately 1 month. The multidiscipli-nary team consists of at least a psychiatrist, RN, andsocial worker. The RN is supervised by the psychia-trist.

Treatment outcomes related to nursing care in aPHP, in the language of the Nursing OutcomesClassification (NOC) may include the following(Moorhead, Johnson, & Maas, 2004):

■ Client identifies correct name of medications.■ Client identifies precursors of depression.■ Client exhibits impulse control.■ Client perceives support of health care providers.The following vignette illustrates the role of the

psychiatric RN in a PHP.

■ ■ ■ VIGNETTE

Jane Tyson is an RN who works in a PHP in a rural county.The PHP is part of the only community mental health centerin this region, which has one state hospital and one privateinpatient unit. Jane worked for 3 years in the state hospitalbefore transferring to the PHP. Jane is the nurse member ofthe team, and today her schedule is as follows.

8:30-9:00: Jane arrives at the PHP and prepares a teachingoutline for her coping skills group.

9:00-10:00: Jane meets with eight clients to teach aboutcoping with depression, using a five-page outline to explainsteps to decrease negative thinking. All group membershave a diagnosis of major depression and are encouragedto ask questions and to give feedback to each other.Throughout the session, Jane assesses each client’schanges in mood and behavior since the previous day.

10:00-10:30: Jane briefly checks with all the clients to en-sure that they have taken their morning medications. Threeclients have brought their medication boxes with them be-cause she needs to directly observe them take their med-ication.

10:30-11:30: Jane has an intake interview with a newly ad-mitted client. Ms. Brown is a 50-year-old woman with a his-tory of major depression who was hospitalized for 1 week af-ter a drug overdose following an argument with herboyfriend. Jane completes the extensive 10-page standard-ized interview form, paying extra attention to risk factors forsuicide. When asked about substance abuse, Ms. Brownadmits that she has been drinking heavily for the past 2years, including the night that she took a drug overdose.When the interview is completed, the client is referred to thepsychiatrist for a diagnostic evaluation.

12:00-1:00: During the client lunch period, Jane meets withthe team for daily rounds. She presents the newly admittedclient, and the team develops an individual treatment plan.In this treatment plan, the team notes discharge planningneeds for referrals to a community mental health center andalcohol treatment program.

1:00-2:00: Jane co-leads a therapy group with the socialworker for eight clients with a variety of diagnoses. Due tothe short-term nature of the group with almost daily turnover,the leaders take a psychoeducational approach with a de-fined topic for each session. Today’s group focuses onsymptoms of psychosis, and members are invited to de-scribe their individual experiences.

2:00-2:30: Next, Jane has a discharge meeting with Mr.Jones. He is a 48-year-old man with a diagnosis of schizo-phrenia who was referred to the PHP by his clinic therapistto prevent hospitalization due to increasing paranoia andagitation. After 2 weeks in the PHP, he has restabilized andrecognizes that he must be 100% compliant with his an-tipsychotic medication regimen. Jane finalizes his medica-tion teaching and confirms his aftercare appointments withhis previous therapist and psychiatrist.

2:30-3:00: Jane meets with Ms. Brown before she goeshome to share the individual treatment plan and to begin adiscussion of resources for alcohol treatment, includingAlcoholics Anonymous.

3:00-4:30: After all clients leave, Jane completes her notesand discharge summary. She also makes case manage-ment telephone calls to arrange for community referrals, tocommunicate with families, and to report to managed be-havioral care programs for utilization review.

■ ■ ■

Psychiatric Home CarePsychiatric home care was defined by Medicare regu-lations in 1979 as requiring four elements: (1) home-bound status of the client, (2) presence of a psychiatricdiagnosis, (3) need for the skills of a psychiatric RN,and (4) development of a plan of care under orders ofa physician.

“Homebound” refers to the client’s inability toleave home independently to access community men-tal health care because of physical or mental condi-tions. Psychiatric RNs are defined to include a range ofnursing personnel from basic level RNs with a certainnumber of years of experience to advanced practiceRNs (APRNs) (Carson, 1998). Other payers besidesMedicare also authorize home care services. Clientsare referred to psychiatric home care following anacute inpatient episode, either psychiatric or somatic,or to prevent hospitalization. The psychiatric RN visitsthe client one to three times per week for approxi-mately 1 to 2 months, and usually sees five or sixclients daily.

Family members or significant others are closely in-volved in most cases. Because many clients are olderthan 65 years of age, there are usually concurrent so-matic illnesses to assess and monitor. The RN acts ascase manager to coordinate all specialists involved inthe client’s care, for example, physical therapist, occu-pational therapist, and home health aide. The RN is



supervised by an APRN team leader, who is alwaysavailable by telephone.

Boundaries become important in the home setting,where there is inherently a greater degree of intimacybetween nurse and client. It may be important for theRN to begin a visit informally, by chatting about clientfamily events or accepting refreshments offered. Thisinteraction can be a strain for the RN who struggles tomaintain a professional distance. However, there isgreat significance to the therapeutic use of self in suchcircumstances, to establish a level of comfort for theclient and family.

Treatment outcomes related to nursing care in psy-chiatric home care setting, in the language of the NOC,may include the following:

■ Client uses relaxation techniques to reduce anxi-ety.

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

■ Client upholds a suicide contract.■ Client recognizes hallucinations or delusions.The following vignette illustrates a typical day for

the psychiatric home care RN.


Natalie Beaumont is an RN employed by a home careagency in a large rural county. She worked for 2 years in thestate psychiatric hospital before joining the psychiatrichome care agency. She visits clients in a radius of 50 milesfrom her home and has daily telephone contact with her su-pervisor. She stops by the office weekly to drop off paper-work, and she attends the team meeting once a month. Theteam includes her team leader, other field RNs, team psy-chiatrist consultant, and social worker. Natalie chooses tomake her visits from 8 AM to 3:30 PM and then completes herdocumentation at home.

8:00-9:00: Her first client is Mr. Johnson, a 66-year-old manwith a diagnosis of major depression after a stroke. He wasreferred by his primary care physician due to suicidalideation. Natalie has met with him and his wife three timesper week for the past 2 weeks. He has contracted for safetyand has been compliant in taking his antidepressant. Todayshe teaches the couple about stress management tech-niques. Case management responsibilities for Mr. Johnsoninclude supervision of the home health aide who helps himwith hygiene and coordination with the physical and occu-pational therapists who also treat him.

9:30-11:30: Natalie has an intake interview scheduled withMs. Barker, a 45-year-old single woman with a diagnosis ofschizophrenia who lives with her mother. She was referred bythe inpatient psychiatrist after an involuntary hospitalizationfor repeatedly calling 911 with bizarre reports of violence inher back yard. She had not been in the hospital for 5 yearsbut recently had dropped out of treatment when her privatepsychiatrist of 15 years retired. Natalie completes the exten-sive structured intake interview, including the mother’s feed-back. She teaches them about the new antipsychotic med-ication Ms. Barker is taking and sets up the weeklymedication box. Natalie explains that she will visit two times

a week for the next 2 months. Her case management role willinclude identification of a new community psychiatrist for theclient and a possible family support group for the mother.

12:30-1:30: Next, Natalie sees Ms. Graves, a 62-year-oldwidow diagnosed with major depression after the death of herhusband and a move into an assisted living facility. Ms.Graves has diabetes and is wheelchair bound due to an am-putation. She was referred by the nurse director of the as-sisted living facility. Natalie has met with her two times perweek for the past 4 weeks, teaching about depression, grief,medications, and coping skills. Today her focus is on identi-fying a new social system, including increased contact withlong-distance relatives, social activities at the facility, andspiritual support. With input from the director, Natalie learns ofa grief counseling group at the local church run by a pastoralcounselor and she recommends that resource to Ms. Graves.

2:00-3:00: Natalie’s last client for the day is Mr. Cooper, a55-year-old single man with a diagnosis of panic disorderwith agoraphobia. Mr. Cooper lives with his older brotherand was referred by the brother’s primary care physician af-ter the physician found out that the client had not been outof the house for 5 years since the death of his mother.Natalie has been working with Mr. Cooper for 7 weeks andhas decreased visits to once a week. She has taught Mr.Cooper about his illness, medication, and relaxation tech-niques. He has progressed to being able to walk outside for15 minutes at a time. Today’s plan is to attempt riding in thecar with his brother for 10 minutes, in preparation for dis-charge when he will have to ride for 30 minutes to reach thecommunity mental health center.

Following this visit, Natalie returns home to complete docu-mentation, to call in a report to her team leader and thephysicians, and to make other case management telephonecontacts for community referrals.

■ ■ ■

Assertive Community TreatmentAssertive community treatment (ACT) teams or mo-bile treatment units have sprung up in various areasthroughout the United States to respond to those men-tally ill clients who cannot effectively use traditionaloutpatient mental health services. Professional staffpursue and “woo” clients and support treatment inwhatever settings clients find themselves in—at homeor in a public place. Clients may be assessed andtreated in fast food restaurants, receive one of the de-canoate medications (e.g., Haldol, Prolixin) in a restau-rant bathroom, and at the close of a “session” be of-fered a milkshake and a meal as a reward. If adherenceto a prescribed medication regimen is a problem re-lated to understanding, medications are packaged andlabeled with the time and date they are to be taken.Creative problem solving and interventions are hall-marks of care provided by mobile teams. TheEvidence-Based Practice box describes clinical re-search related to ACT teams.



Clients are referred to ACT teams by inpatient oroutpatient providers because of a pattern of repeatedhospitalizations with severe symptoms, along with aninability to participate in traditional treatment. Care isprovided by a multidisciplinary team, and the psychi-atric RN may manage a caseload of 10 clients whom heor she visits three to five times per week. The RN is su-pervised by a psychiatrist or APRN. Length of treat-ment may extend to years, until the client is ready toaccept transfer to a more structured site for care. Thereis a 24-hour on-call system to allow the client to reachthe team during an emergency.

Treatment outcomes related to nursing care throughan ACT team, in the language of the NOC, may in-clude the following:

■ Client avoids alcohol and recreational drugs.■ Client adheres to treatment regimen as pre-

scribed.■ Client uses health services congruent with need.■ Client exhibits reality-based thinking.The following vignette describes the role of the psy-

chiatric RN on the ACT team.


Susan Green is a nurse who works on an ACT team at alarge inner-city university medical center. She had 5 years ofinpatient experience before joining the ACT team, and sheworks with an APRN, two social workers, two psychiatrists,and a mental health worker. She is supervised by the APRN.

8:00-9:00: Susan starts the day at the clinic site with teamrounds. Because she was on call over the weekend, she up-dates the team on three emergency department visits: two

clients were able to return home after she met with them andthe emergency department physician; one client was admit-ted to the hospital because he made threats to his caregiver.

9:30-10:30: Her first client is Mr. Donaldson, a 35-year-oldman with a diagnosis of bipolar disorder and alcohol de-pendence. He lives with his mother and has a history of fivehospitalizations with noncompliance with outpatient clinictreatment. Except during his manic episodes, he isolateshimself at home or visits a friend in the neighborhood atwhose house he drinks excessively. Today he is due for hisbiweekly decanoate injection. Susan goes first to his houseand learns that he is not at home. She speaks with hismother about his recent behavior and an upcoming medicalclinic appointment. Then she goes to the friend’s house andfinds Mr. Donaldson playing cards and drinking a beer. Heand his friend are courteous to her, and Mr. Donaldson co-operates in receiving his injection. He listens as Susan re-peats teaching about the risks of alcohol consumption, andshe encourages his attendance at an Alcoholics Anon-ymous meeting. He reports that he did go to one meetingyesterday. Susan praises him and encourages him and hisfriend to go again that night.

11:00-1:00: The next client is Ms. Abbott, a 53-year-old sin-gle woman with a diagnosis of schizoaffective disorder andhypertension. She lives alone in a senior citizen building andhas no contact with family. Ms. Abbott was referred by herclinic team because she experienced three hospitalizationsover 1 year for psychotic decompensation, despite receiv-ing monthly decanoate injections. The ACT team is now thepayee for her Social Security check. Today, Susan has totake Ms. Abbott out to pay her bills and to go to her primarycare physician for a checkup. Ms. Abbott greets Susanwarmly at the door, wearing excessive makeup and inap-propriate summer clothing. With gentle encouragement, she


EVIDENCE-BASED PRACTICE

Assertive Community Treatment

BackgroundOver the past 20 years since deinstitutionalization, much re-search has focused on community treatment for schizophre-nia and other severe mental illness (SMI). Clients with SMIhave significant difficulties with self-care, social relationships,work, and leisure. There is now a body of evidence demon-strating that psychosocial treatment can improve the long-term outcomes for these clients.

StudiesMore than 25 controlled studies have evaluated the effects ofassertive community treatment (ACT) on clients with SMI. ACTis a model for case management to serve clients who are non-compliant with standard outpatient treatment. Elements of themodel include provision of services in the community insteadof on site in a clinic, use of multidisciplinary treatment teamswith low client-to-staff ratio (10:1) and high frequency of con-tact (three to five times per week), shared caseloads with clini-cians, and 24-hour coverage for emergencies.

Results of StudiesMost of the studies were conducted in urban settings with ap-proximately 100 clients and follow-up over 18 months. ACTwas compared to standard case management for effects onhousing stability, time spent in the hospital, social adjustment,and cost effectiveness. With regard to housing stability, 12studies showed positive effects of ACT. Time spent in the hos-pital was reduced by the use of ACT in 14 studies. Social ad-justment was not consistently improved by ACT, with onlythree studies showing benefits. Because ACT considerably re-duced hospital use, it was considered cost effective in the ma-jority of studies.

Implications for Nursing PracticeThe nurse is a member of the ACT team and administers med-ication, teaches skills in self-care and health maintenance,coordinates access to medical care, and makes referrals tocommunity services such as housing. These interventions re-quire the nurse to establish a supportive relationship with theclient and to collaborate with the other team members to en-sure 24-hour continuity of care.

Mueser, K. T., Bond, G. R., & Drake, R. E. (2001). Community-based treatment of schizophrenia and other severe mental disorders: Treatment outcomes. Medscape General Medicine6(1), 1-31.


agrees to wear warmer clothes. She is reluctant to showSusan her medication box and briefly gets irritable whenSusan points out that she has not taken her morning med-ications. As they stop by the apartment office to pay therent, Susan talks with the manager briefly. This apartmentmanager is the only contact person for Ms. Abbott, and shecalls the team whenever any of the other residents reportany unusual behavior. Over the next 11⁄2 hours, Susan andMs. Abbott drive to various stores and go to Ms. Abbott’s so-matic appointment.

2:00-4:30: The last client visit for today is with Mr. Hunter, a60-year-old widowed man diagnosed with schizophreniaand cocaine dependence. Mr. Hunter was referred by theemergency department last year after repeated visits due topsychosis and intoxication. Initially, he was homeless, buthe now lives in a recovery house shelter and has been cleanof illegal substances for 6 months. He receives a monthlydecanoate injection and is socially isolated in the house.Now that he has received his Social Security Disability in-come, he is seeking an affordable apartment. Today, Susanhas two appointments to visit apartments. After greetinghim, Susan notes that he is wearing the same clothes that hehad on 2 days earlier, and his hair is uncombed. She sug-gests that he shower and change his clothes before they goout, and he agrees.

At the end of the day, Susan jots down information that shewill use to write her progress notes in clients’ charts on thenext day when she returns to the clinic.

■ ■ ■

Community Mental Health CenterCommunity mental health centers were created in the1960s and have since taken center stage for those whohave no access to private care. The range of servicesavailable at such centers varies, but generally they pro-vide emergency services, adult services, and children’sservices. Common components of treatment at com-munity mental health centers include medication ad-ministration, individual therapy, psychoeducationaland therapy groups, family therapy, and dual-diagnosistreatment. A clinic may also be aligned with a psy-chosocial rehabilitation program that offers a struc-tured day program, vocational services, and residen-tial services. Some community mental health centershave an associated intensive case management serviceto assist clients in finding housing or obtaining entitle-ments.

There is a multidisciplinary team, and the psychi-atric RN may carry a caseload of 60 clients, whom shesees one to four times per month. The basic level RNis supervised by an APRN. Clients are referred to theclinic for long-term follow-up by inpatient units orother providers of outpatient care at higher intensitylevels. Clients may attend the clinic for years or bedischarged when they improve and reach desiredgoals.

Treatment outcomes related to nursing care in acommunity mental health center, in the language ofthe NOC, may include the following:

■ Client describes self-care responsibility for ongo-ing treatment.

■ Client describes actions to prevent substanceabuse.

■ Client refrains from responding to hallucinationsor delusions.

■ Client keeps appointments with health care pro-fessionals.

The following vignette provides an example of onework day for the RN in a community mental healthcenter.


Mary Smith is an RN who works at a community mentalhealth center in a large university hospital in an urban set-ting. She has been an RN for 10 years and transferred to theclinic 2 years ago from the inpatient unit at the same univer-sity. She is a nurse on the adult team and carries a caseloadof clients diagnosed with chronic mental illness. She is su-pervised by an APRN.

8:30-9:00: Upon arriving at the clinic, she finds a voice mailmessage from Ms. Thompson, who is crying and saying thatshe is out of medication. Mary consults with the psychiatristand calls Ms. Thompson to arrange for an emergency ap-pointment later that day.

9:00-9:30: Mary’s first client is Mr. Enright, who is a 35-year-old man diagnosed with schizophrenia, in treatment at theclinic for 10 years. During their 30-minute counseling ses-sion, she assesses him for any exacerbation of psychoticsymptoms (he has a history of grandiose delusions), for eat-ing and sleep habits, and for social functioning in the psy-chosocial rehabilitation program that he attends 5 days perweek. Today he presents as stable. Mary gives him his de-canoate injection and schedules a return appointment for 1month, reminding him of his psychiatrist appointment the fol-lowing week.

10:00-11:00: Mary co-leads a medication group with a psy-chiatrist. This group consists of seven clients with chronicschizophrenia who have been compliant in attending bi-weekly group sessions and receiving decanoate injectionsfor the past 5 years. She leads the group discussion as thepsychiatrist writes prescriptions for each client, becausemost of the members also take oral medication. Today Maryasks the group to explain relapse prevention to a new mem-ber. She teaches significant elements, including compliancewith the medication regimen and healthy habits. As groupmembers give examples from their own experiences, sheassesses each client’s mental status. At the end of thegroup, she administers injections and gives members ap-pointment cards for the next group session. After the clientsleave, she meets with the psychiatrist to evaluate the ses-sion and to discuss any necessary changes in treatment.

11:00-12:00: Mary documents progress and medicationnotes, responds to telephone calls, and prepares for thestaff meeting.



12:00-2:00: All adult team staff attend the weekly intakemeeting, at which new admissions are discussed and indi-vidual treatment plans are written with team input. Mary pre-sents a client in intake, reading from the standardized inter-view form. She also gives nursing input about treatment forthe other five newly admitted clients. The new client she pre-sented is assigned to her, and she plans to call him later inthe afternoon to set up a first appointment.

2:00-3:00: Mary co-leads a dual-diagnosis therapy groupwith the dual-diagnosis specialist, who is a social worker.The group is made up of seven clients who have concurrentdiagnoses of substance abuse and a major psychiatric ill-ness. The leaders take a psychoeducational approach, andtoday’s planned topic is teaching about the physical effectsof alcohol on the body. Mary focuses on risks associatedwith the interaction between alcohol and medications, andanswers the members’ specific questions. Because this isan ongoing group, members take a more active role, anddiscussion may vary according to members’ needs insteadof following planned topics. After the session, the co-leadersdiscuss the group dynamics and write progress notes.

3:30-4:00: Mary meets with Ms. Thompson, who arrives atthe clinic tearful and agitated. Ms. Thompson says that shemissed her appointment this month because her son diedsuddenly. Mary uses crisis intervention skills to assess Ms.Thompson’s status, for example, any risks for her safety re-lated to her history of suicidal ideation. After helping Ms.Thompson clarify a plan to increase support from her family,Mary notes that insomnia is a new problem. She takes Ms.Thompson to the psychiatrist who is covering “emergencyprescription time” for that day and explains the change inthe client’s status. The psychiatrist refills Ms. Thompson’susual antidepressant and adds a medication to aid sleep.Mary makes an appointment for the client to return to seeher in 1 week instead of the usual 1 month, and also sched-ules her to meet with her assigned psychiatrist that sameday.

4:00-4:30: Mary completes all notes and makes necessarytelephone calls, for example, to other staff in the psychoso-cial rehabilitation program who are working with her clientsand to her new client to schedule an appointment.

■ ■ ■

ETHICAL ISSUESAs community psychiatric RNs assume greater auton-omy and accountability for the care they deliver, ethi-cal concerns become more of an issue. Ethical dilem-mas are common in disciplines and specialties thatcare for the vulnerable and disenfranchised.

Psychiatric RNs have an obligation to develop amodel for assessing the ethical implications of theirclinical decisions. Each incident requiring ethical as-sessment is somewhat different, and the individualRN brings personal insights to each situation. The roleof the nurse is to act in the best interests of the clientand of society, to the degree that this is possible.

In most organizations that employ RNs, there is adesignated resource for consultation regarding ethicaldilemmas. For example, hospitals (with associatedoutpatient departments) are required by regulatorybodies to have an ethics committee to respond to cli-nicians’ questions. Home care agencies or other inde-pendent agencies may have an ethics consultant in the administrative hierarchy of the organization. Pro-fessional nursing organizations and even boards ofnursing can be used as a resource by the individualpractitioner. Refer to Chapter 8 for more discussion ofethical guidelines for nursing practice.

FUTURE ISSUESDespite the current availability and variety of commu-nity psychiatric treatments in the United States, manyclients in this country in need of services still are notreceiving them. The National Survey on Drug Use andHealth in 2002 estimated that 17.5 million adults hadserious mental illness (Aquila & Emanuel, 2003, p. 3).Less than half, however, received treatment in 2001(Aquila & Emanuel, 2003, p. 6). Barriers to treatmenthave been identified by many authors and studies. Thestigma of mental illness has lessened over the past 40years; there is increased recognition of symptoms dueto brain disorders, and well-known people have comeforward to admit that they have received psychiatrictreatment. Yet, many people still are afraid to admit toa psychiatric diagnosis (Pardes, 2003). Instead, theyseek medical care for vague somatic complaints fromprimary care providers, who too often fail to diagnoseanxiety (or depressive) disorders (Rollman et al., 2003).

In addition to stigma, there are geographic, finan-cial, and systems factors that impede access to psychi-atric care. Mental health services are scarce in somerural areas, and many American families cannot affordhealth insurance even if they are working. PresidentGeorge W. Bush’s New Freedom Commission onMental Health identified national system and policyproblems in 2002: fragmented care for children andadults with serious mental illness, high unemploy-ment and disability among the seriously mentally ill,undertreatment of older adults, and lack of nationalpriorities for mental health and suicide prevention(President’s commission, 2002).

To meet the challenges of the twenty-first century,Price and Capers (1995, p. 27) suggested that, in train-ing the associate degree nurse, “educators must in-crease their focus on leadership development, includeprinciples of home health nursing, increase content ongerontology, and introduce basic community healthconcepts.” Those RNs who elect to work with elderlypsychiatric clients will be more and more in demandas the population ages, and the health care needs ofthis subgroup are increasingly complex (Hedelin &



■ The basic level community psychiatric nurse practices inmany traditional and nontraditional sites.

■ There are significant differences between inpatient psychi-atric nursing and community psychiatric nursing.

■ In the multidisciplinary team, the community mental healthnurse functions as a biopsychosocial care manager.

■ The continuum of psychiatric treatment includes numerouscommunity treatment alternatives with varying degrees of in-tensity of care.

■ The community psychiatric nurse needs access to resourcesto address ethical dilemmas encountered in clinical situa-tions.

■ There are still barriers to mental health care that the commu-nity psychiatric nurse may be able to diminish through dailypractice.

Visit the Evolve website at http://evolve.elsevier.com/Varcarolis for a postteston the content in this chapter.


Svensson, 1999). Community psychiatric RNs may col-laborate more with primary health care practitionersto fill the gap in existing community services (Walker,Barker, & Pearson, 2000). Certainly, community psy-chiatric RNs need to be committed to teach the publicabout resources for mental health care, whether forlong-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. Forexample, one study offered treatment to depressedwomen in a supermarket setting using a conferenceroom; participants stated that they preferred that to aclinic because it was more private or convenient(Swartz et al., 2002).

KEY POINTS to REMEMBER

■ Community mental health nursing has historical roots datingto the 1800s and has been significantly influenced by publicpolicies.

■ Deinstitutionalization brought promise and problems for thechronically mentally ill population.

Critical Thinking and Chapter ReviewVisit the Evolve website at http://evolve.elsevier.com/Varcarolis for additional self-study exercises.

CRITICAL THINKING

1. You are a community psychiatric mental health nurse workingat a local mental health center. You are doing an assessmentinterview with a single male client who is 45 years old. He re-ports that he has not been sleeping and that his thoughtsseem to be “all tangled up.” He informs you that he hopesyou can help him today because he does not know howmuch longer he can go on. He does not make any direct ref-erence to suicidal intent. He is disheveled and has beensleeping at shelters. He has little contact with his family andstarts to become agitated when you suggest that it might behelpful for you to contact them. He refuses to sign any releaseof information forms. He admits to recent hospitalization atthe local veterans hospital and reports previous treatment ata dual-diagnosis facility even though he denies substanceabuse. In addition to his mental health problems, he says thathe has tested positive for human immunodeficiency virus andtakes multiple medications that he cannot name.

A. What are your biopsychosocial and spiritual con-cerns about this client?

B. What is the highest-priority problem to address be-fore he leaves the clinic today?

C. Do you feel that you need to consult with any othermembers of the multidisciplinary team today aboutthis client?

D. In your role as case manager, what systems of carewill you need to coordinate to provide quality carefor this client?

E. How will you start to develop trust with the client togain his cooperation with the treatment plan?

CHAPTER REVIEW

Choose the most appropriate answer.1. A significant influence allowing psychiatric treatment to

move from the hospital to the community was

1. television.

2. the discovery of psychotropic medication.

3. identification of external causes of mental illness.

4. the use of a collaborative approach by clients andstaff focusing on rehabilitation.

2. For psychiatric nurses, a major difference between caring forclients in the community and caring for clients in the hospi-tal is that

1. treatment is negotiated rather than imposed in thecommunity setting.

2. fewer ethical dilemmas are encountered in thecommunity setting.

3. cultural considerations are less important duringtreatment in the community.

4. the focus in the community setting is solely onmanaging symptoms of mental illness.



Critical Thinking and Chapter Review—cont’dVisit the Evolve website at http://evolve.elsevier.com/Varcarolis for additional self-study exercises.

3. A typical treatment goal for a client with mental illness beingtreated in a community setting is that the client will

1. experience destabilization of symptoms.

2. take medications as prescribed.

3. learn to live with dependency and decreased op-portunities.

4. accept guidance and structure of significant others.

4. Assessment data that would be considered least relevant todeveloping an understanding of the ability of a persistentlymentally ill 65-year-old client to cope with the demands ofliving in the community are

1. strengths and deficits of the client.

2. school and vocational performance.

3. client health history and current mental status.

4. client home environment and financial status.

5. Which action on the part of a community psychiatric nursevisiting the home of a client would be considered inappro-priate?

1. Turning off an intrusive TV program without theclient’s permission

2. Facilitating the client’s access to a communitykitchen for two meals a day

3. Going beyond the professional role boundary tohang curtains for an elderly client

4. Arranging to demonstrate the use of public trans-portation to a mental health clinic

STUDENTSTUDYCD-ROM

Access the accompanying CD-ROM for animations, interactive exercises, reviewquestions for the NCLEX examination, and an audio glossary.

REFERENCES

Aquila, R., & Emanuel, M. (2003, September 25). Managingthe long-term outlook of schizophrenia. MedscapePsychiatry & Mental Health, 1-10.

Carson, V. B. (1998). Designing an effective psychiatric homecare program. Home Healthcare Consultant, 5(4), 16-21.

Chan, S., Mackenzie, A., & Jacobs, P. (2000). Cost-effective-ness analysis of case management versus a routine com-munity care organization for patients with chronic schizo-phrenia. Archives of Psychiatric Nursing, 14(2), 98-104.

Chan, S., et al. (2000). An evaluation of the implementationof case management in the community psychiatric nurs-ing service. Journal of Advanced Nursing, 31(1), 144-156.

Dickey, B., et al. (2002). Medical morbidity, mental illness,and substance use disorders. Psychiatric Services, 53(7),861-867.

Gebbie, K. M., & Qureshi, K. (2002). Emergency and disasterpreparedness: Core competencies for nurses. AmericanJournal of Nursing, 102(1), 46-51.

Hedelin, B., & Svensson, P. (1999). Psychiatric nursing forpromotion of mental health and prevention of depressionin the elderly: A case study. Journal of Psychiatric andMental Health Nursing, 6(2), 115-124.

Kruse, G. R., & Rohland, B. M. (2002). Factors associatedwith attendance at a first appointment after discharge

from a psychiatric hospital. Psychiatric Services, 53(4), 473-476.

Lacro, J., & Glassman, R. (2004). Medication adherence.Medscape Psychiatry & Mental Health, 9(1), 1-4.

Marcos, L. R. (1990). The politics of deinstitutionalization. InN. L. Cohen (Ed.), Psychiatry takes to the streets: Outreachand crisis intervention for the mentally ill (pp. 3-15). NewYork: Guilford Press.

Marland, G. R., & Sharkey, V. (1999). Depot neuroleptics,schizophrenia, and the role of the nurse: Is practice evi-dence based? A review of the literature. Journal ofAdvanced Nursing, 30(6), 1255-1262.

McQuistion, H. L., et al. (2003). Challenges for psychiatry inserving homeless people with psychiatric disorders.Psychiatric Services, 54(5), 669-676.

Moorhead, S., Johnson, M., & Maas, M. (2004). Nursing out-comes classification (NOC) (3rd ed.). St. Louis, MO:Mosby.

Pardes, H. (2003). Psychiatry’s remarkable journey: The past40 years. Psychiatric Services, 54(6), 896-901.

President’s commission finds fragmented system, outdatedtreatments, incentives for dependency [Editorial News &Notes]. (2002). Psychiatric Services, 53(12), 1644-1645.

Price, C. R., & Capers, E. S. (1995). Associate degree nursingeducation: Challenging premonitions with resourceful-ness. Nursing Forum, 30(4), 26-29.

Rochefort, D. A. (1993). From poorhouses to homelessness: Policyanalysis and mental health care. Westport, CT: AuburnHouse.

Rollman, B. L., et al. (2003). A contemporary protocol to as-sist primary care physicians in the treatment of panic andgeneralized anxiety disorders. General Hospital Psychiatry,25, 74-82.

Rudenstine, S., et al. (2003). Awareness and perceptions of acommunity wide mental health program in New York


City after September 11. Psychiatric Services, 54(10), 1404-1406.

Shoemaker, N. (2000). The continuum of care. In V. B. Carson(Ed.), Mental health nursing: The nurse-patient journey (2nded., pp. 368-387). Philadelphia: Saunders.

Smith, C. M. (1995). Origins and future of community healthnursing. In C. M. Smith & F. A. Maurer (Eds.), Communityhealth nursing: Theory and practice (pp. 30-52).Philadelphia: Saunders.

Swartz, H. A., et al. (2002). A pilot study of community men-tal health care for depression in a supermarket setting.Psychiatric Services, 53(9), 1132-1137.

Walker, L., Barker, P., & Pearson, P. (2000). The required roleof the psychiatric-mental health nurse in primary healthcare: An augmented Delphi study. Nursing Inquiry, 7(2),91-102.

Wilson, K., & Williams, A. (2000). Visualism in communitynursing: Implications for telephone work with serviceusers. Qualitative Health Research, 10(4), 507-520.



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