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Consumer input into standards revision: changing practice


  1. Senior Professional Advisor, Toronto, Ontario,
  2. Clinical Nurse Specialist Mental Health, St. Paul’s Hospital, Vancouver, British Columbia,
  3. Community Mental Health Nurse, Dartmouth, Nova Scotia,
  4. Clinical Nurse Educator, Mental Health Resources Team, Nova Scotia Hospital, Dartmouth, Nova Scotia,
  5. Director of Senior Mental Health Programs, Community Hospitals and Continuing Care, Charlottetown, Prince Edward Island,
  6. Adjunct Professor,School of Nursing, University of British Columbia, Vancouver, British Columbia,
  7. Associate Professor, School of Nursing, Ryerson University, Toronto, Ontario, Canada

G. Beal
314 Albany Avenue
Toronto, ON
Canada M5R 3C9

Journal of Psychiatric and Mental Health Nursing 14, 13–20
Consumer input into standards revision: changing practice

As part of ongoing quality improvement initiatives, the Canadian Standards for Psychiatric-Mental Health Nursing were recently revised. For the first time since the standards were published in 1995, the input of consumers of mental health services was sought. Thirty-one consumers from across Canada participated in focus groups, and answered questions related to the domains of practice as identified in the standards document. Through this input, consumers were able to inform the committee regarding areas of satisfaction and dissatisfaction from their unique perspective. Through this article, the process of consumer collaboration is illustrated in relation to how it shaped Standards revision, and finally how it affected the practitioners involved.

Keywords: consumers, psychiatric mental health nursing, quality improvement, standards for practice


Incorporating new trends in the field of psychiatric mental health nursing practice has always been a priority for Canadian nurses. In keeping with this priority, the ongoing development, critique and revision of standards for practice is considered a vital part of the work of the Canadian Federation of Mental Health Nurses (CFMHN). In general, Standards for Practice: (1) document specific expectations of a professional group (Austin et al. 1996); (2) articulate to others what is the desired achievable level of performance (Canadian Nurses Association 2002); and (3) inform professional bodies about the development of rules and regulations that guide practice (American Psychiatric Nurses Association 2000). As such, standards define boundaries for professional practice and can inform the public about what the practice entails. In an era which calls for measurable competencies, standards set the pace for identification of these competencies (McCabe 2002). The Canadian Standards for Psychiatric-Mental Health Nursing (Canadian Federation of Mental Health Nurses 2006) provide a guide for the continuous evaluation of psychiatric and mental health nursing practice, which is inclusive of professional and ethical principles. They reflect the current state of knowledge and understanding within nursing, and are, contextual and dynamic.

Standards speak to the expected behaviours of professional nurses, by incorporating vital information and new trends in the field, and linking these to expected outcomes. Another important aspect of expected behaviours, well documented in the literature, is the focus on including consumers in every aspect of the diagnostic and treatment process (Krauss 2000, Howard et al . 2003, Smoyak 2004). The third edition of the Canadian Standards for Psychiatric-Mental Health Nursing (Canadian Federation of Mental Health Nurses 2006) reflects these principles. As part of a quality improvement project, consumers of psychiatric services, from across the country, were asked for their input on the CFMHN’s standards for practice. This feedback informed the development of the third edition of the Standards.


The first edition of the Canadian Standards for Psychiatric-Mental Health Nursing was developed by experts in psychiatric mental health nursing and published in 1995 (Austin et al. 1996). A major contribution was the development of standards organized within Benner’s (1984) ‘domains of practice’ framework. The current standards continue to reflect this important contribution and acknowledge the novice to expert approach, typified by a nurse with 2- or 3-year experience within the specialty. Specific competencies are identified to reflect the seven domains: the therapeutic relationship, systematic assessment and decision making, the administering and monitoring of therapeutic interventions, effective management of rapidly changing situations, the teaching/coaching function, monitoring and ensuring the quality of health-care practices, and organizational and work role competencies.

The second edition of the standards (and the first revision), focused on a community mental health and community development model, and included the input of practitioners from across the country. This work was completed by the then Standards Committee in 1998 (Buchanan et al. 1998). During the 2003 Canadian Federation of Mental Health Nurses National Conference, the Board of Directors for the Federation determined that it was time to once again review the standards in light of the many new developments in the field, which led to the creation of the third edition. The conference provided an ideal opportunity to engage delegates in initial discussions surrounding revision of the second edition, to be followed up with more formal input from the provincial psychiatric mental health nursing interest groups.

The third edition, builds upon the earlier editions while encompassing current issues that affect the practice of psychiatric mental health nursing. In addition to the input sought from nurses as discussed previously, the Standards Committee determined that input from consumers was also vitally important to inform revision to the Standards, and as part of a quality improvement project, focus group meetings with consumers from across the country was proposed and implemented.

The past decade has seen a growing recognition that consumers of mental health care have a vital role in contributing to the organization, delivery and evaluation of mental health services (Craig et al. 2004). Cutcliff et al. (1997) surveyed service users regarding their views of a continuing care in a community mental health service. They found that while many service users were generally satisfied with their care, less than half reported being involved in the development of their plan of care. Concerns over the failure of nurses to listen attentively to their concerns and involve them in the plan of care were common responses.

Adams et al. (2003), in a study addressing services provided by Community Mental Health Nurses, found that what was most valued by users was the interpersonal nature of the relationships with the nurse. This finding concurs with a large body of research, which continues to emphasize the importance of the interpersonal relationship. The development of this relationship, some would argue, means enabling understanding of the complexities and diverse qualities of behaviour (McCabe 2002). Nurses are seen as working in partnership with those they serve, their families, and their significant others. Individuals are viewed as whole persons and experts about themselves. Autonomy, respect and self-determination are part of the relationship (Ridgway 2001). Additionally, the need for professionals to advocate for consumers, to be respectful of their cultural beliefs, to ensure their dignity, and to be cognizant and respectful of human rights is also emphasized in the literature (Joint commission 2004). Emphasis is also placed upon organizational policies and structure, which must exist in order to support safe, partner-centred care (Krauss 2000, Srivastava in press). Consumers want strong connections with staff and it is through these connections, that care is influenced (Thomas et al. 2002), length of stay is impacted (Forchuck 2002), and treatment is adhered to (Dearling 2004). Survival rates in cardiac patients have also been attributed to such connections (Castillo 2005). All care and cure flow through this relationship and its importance can never be underestimated (Krauss 2000).

Despite this literature, the desired emphasis on the therapeutic relationship between nurses and consumers often remains less than ideal. Any effort on the part nurses to involve individuals and seek their feedback about the care that they receive further enhances understanding of mental health and mental illness, and provides for mutuality in practice.