Many decisions nurses must make each day are affected by laws and ethical principles. It is important to be familiar with federal and state laws pertaining to nursing practice in general, and with those that have implications for the practice of psychiatric nursing in particular.
Mental disorders sometimes affect a person’s ability to make decisions about his or her health and well-being. Whenever possible, client autonomy and liberty must be ensured by treatment in the least restrictive setting possible and by active client participation in treatment decisions. The challenge for nurses is maintaining the client’s personal freedom in situations where public welfare and/or the client’s best interests are threatened.
Legal aspect of mental health nursing
Physically or mentally ill individuals are in a dependent position when hospitalized. Accordingly, the legal systems in various states have instituted laws design to safeguard their well-being. Laws regarding mentally ill people differ from state to state, so it is important that nurses obtain spesific information about the statutes affecting their delivery of care during orientation programs in their respective institutions or agencies.
Laws are developed by a society as an outcome of personal and professional values and ethics. A single instance of violation of another’s well-being does not usually result in a law designed to forbid its recurrence. Instead, repetition of similar types of violations causes people to respond with indignation and call for a law to control and punish its continued occurrence.
1. Client’s Rights
Clients do not lose their constitutional or legal rights when they are admitted to a facility for treatment for a mental disorder. Clients must be informed of the potential risks of psychotropic medications and the rights to refuse such medications. If a client refuses medication and the physician believes it is essential for affective treatment, the physician may take the case to the courts for a decision.
Outcames of client medication decisions
Client may be hospitalized voluntarily or involuntarily
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Physician or nurse determines that medication is appropriate
Client consent Client refuses
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If client is competent, If client is believed to be incompetent,
client is medicated there is a judicial hearing
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Judge reviews :
Appropriateness of treatment
Client’s competency
Client’s best interest or substituted judgment
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If treatment is appropriate and client is incompetent, treatment may be administered if in the client’s best interest or if a competent client would have accepted it
Source : Adapted from Applebaum, 1988
Most commonly adopted client rights :
1) Right to treatment in the least restrictive alternative
2) Right to confidentiality of records
3) Right to freedom from restraints and seclusion
4) Right to give or refuse consent to treatment
5) Right to access to personal belongings
6) Right to daily exercise
7) Right to heve visitors
8) Right to use of writing materials and uncensored mail
9) Right to use of telephone
10) Right to access courts and attorneys
11) Right to employment compensation
12) Right to be informed of rights
13) Right to refuse electroconvulsive therapy or psychosurgery
2. Right to Treatment
All people who are hospitalized for mental illness have the right to treatment. As the result of lawsuits brought to court during the 1960s and 1970s, mental health professionals are increasingly aware of their legal responsibilities to clients. A court decision of the mid-1960s (Rouse v Cameron) (373 F. 2d 451 [D.C. Cir. 1966]) declared that a mentally ill person has the following rights to treatment:
A treatment plan that is continuously reviewed by a qualified mental health professional and modified, if necessary
A mental examination and review of a client’s care plan every 90 days by a qualified mental health professional other than the professional responsible for supervising and implementing the plan
A statement of client problems and needs
A statement of the last restrictive treatment conditions necessary
Intermediate and long-range goals and a timetable for implementing them
A statement of rationale for the plan
A description of proposed staff involvement
Criteria for release to a less restrictive environment and discharge
Notation of therapeutic tasks to be performed by the client
3. Right to Privacy (Confidentiality)
The client in the mental health setting has many rights to safeguard his or her well-being. These include the right to confidentiality. Confidentiality requires that the nurse’s knowledge of all aspect of the client’s condition belong, in essence, to the client. The nurse cannot reveal this information publicly without the client’s informed consent. Obviously, the nurse’s documentation revealed in the nurse-client realtionship falls within this guideline.
The circle of Confidentiality
Lawyers
Family Outside Therapists
Uninvolved Health- Univolved Health-
Care Professionals Care Students
Police
In the nurse-client relationship, the client may share sensitive or potentially damaging information with the nurse. It is important that the nurse be aware of the specific guidelines regarding documentation of verbal reporting of this information developed by the institution in which he or she is working. A wise rule is that, if in doubt, do not chart such material until the situation is discussed with a supervisor.
It is also important to remember that a client’s chart can be used at any time in a legal proceeding. The client’s chart should contain accurate documentation using guidelines established by the institution in which the nurse is working. Upon changing institutions, it is important for the nurse to determine what information is recorded in what manner in the new setting. Guidelines can vary among different institutions. If it should be necessary to change any charted material, the following recommendations should be closely followed:
The record should never be erased
A line should be drawn through the erroneous material in the chart and the corrected version substituted
The correction should be dated and initialed
A chart should never be altered after material has been subpoenaed in a lawsuit. This may be considered tampering with evidence and could result in a serious penalty
Another important aspect of confidentiality or privacy is the disclosure of information by a client who requests that the nurse not share it with anyone else. It is unwise for the nurse to agree to such a request. Because the nurse is a member of a treatment team, such information should be shared verbally with the director of the team, whose clinical judgment forms the basis of the decisions about whether and how this information should be shared with the team. Inexperienced students or nurses sometimes may want to maintain this requested confidentiality, but it can sometimes have tragic consequences if the information would have averted danger to the client or others. In addition, a request for confidentiality is often an attempt by the client, conscious or otherwise, to split the members of the health care team.
4. Right to Keep Personal Items
When a client enters treatment in a facility–hospital, board-and-care home, halfway house, or nursing home–the client still maintains rights to his personal property. When storage of items becomes difficult, the client can be asked to leave some of his items at home. However, if a client has items of value, the nurse is obligated to document the items and store them in the safe or other secure place. Removing items from a client may be considered theft if the nurse takes them away and either loses them or refuses to return them. In situations where the nursing staff have professional justification to remove potentially harmful objects such as knives, guns, or scissors, the nurse must recognize that the objects are still owned by the client and can be removed only during the time of hospitalization or treatment.
5. Right to Enter into Legal Contracts
A client maintains his legal rights as a citizen. Thus, if an adult, the client has a right to vote, get married, sign for a mortgage, write a personal last will and testament, and manage personal financial affairs or control personal funds. Clients who have legal charges pending againts them must be informed that their medical records may be requested by the court.
6. Reporting Laws
All states make it mandatory for nurses to report suspected cases of child abuse or neglect. Failure to report these cases subjects the nurse to both criminal penalties and civil liability. Reporting protects the nurse from being sued by the parents or guardian. Some states have enacted similar adult abuse laws.
7. Duty to Disclose
The duty to disclose is the health care professional’s obligation to warn identified individuals if a client has made a credible threat to kill them. The duty to disclose supersedes the client’s right to confidentiality. In some states, the duty to disclose also includes threats againts property. The general rule is to warn identified persons of believable threats when the client is not confined to the hospital.
8. Informed Consent
Consent is a person’s agreement to an act that will affect his or her body or to disclosure of information about himself or herself. There are four general types of consent. Informed consent is the agreement by a competent person who has been given the information necessary to weigh the advantages and disadvantages of the treatment that is being proposed to him or her. Implied consent is the consent a person gives when allowing himself or herself to undergo routine laboratory work or x-rays, or to take medications administered by a caregiver. Presumed consent comes into play when an unconscious person is given life-saving treatment in a life-threatening situation. Vicarious consent is given by parents, guardians, or conservators when a person is incapable of deciding for himself or herself.
In addition to decisions regarding treatment, another type of informed consent (particularly important to a person with past or present mental illness) refers to the release of information about a client’s outpatient treatment or hospitalization. Such consent is usually sought so that health care insurance firms, future employers, or the legal system can obtain information about the client. Because such information can be potentially damaging to a client, he or she has the right to know exactly what information will be given and why it is needed. The person explaining the informed consent procedure should be knowledgeable and serve as a client advocate.
9. Competency
Competency is a peson’s mental status that renders him or her capable of sound decision making and management of his or her own life circumstances. The concept of competency is subject to different legal definitions, depending on circumstances and the particular state in which a person lives.
The decison to obtain a court decision on mental competency is usually made when family members or caregivers have serious concerns about a person’s judgment and ability to handle his ar her own affairs. If sufficient data are presented to the judge, he or she can order that a guardian, conservator, or committee be appointed to make and implement decisions that will safeguard all aspect of the client’s well-being.
The case described below is one that can cloud an interpretation of competency.
Mary is a 52-year-old, single schoolteacher who was diagnosed with acute leukimia 3 years ago. Since that time she has undergone two rounds of chemotherapy, which caused excessive nausea, fatigue, and alopecia (baldness). Although her mental status has not deteriorated, she was physically weakened. Following the second round of chemotherapy she had to resign her teaching position, which was a major focus in her life. Because of other medications she is receiving, her bones have become brittle. She has broken her collarbone, femur, and humerus in falls in her home. She is excessively trail and lives in near isolation.
It is possible that a physician could attempt to treat this client with a third round of chemotherapy. The client could refuse, choosing instead to allow the natural evolution of death.
In some medical-surgical care settings, the rule of maintaining life, no matter what the cost to the mental health or quality of life of the client and his or her family, may appear to be the only factor considered in making treatment dicisions. In such hospitals, when a terminally ill, but mentally competent, client refuses to undergo prolonged or painful treatment, the physicians may try to obtain a legal ruling of mental incompetence in order to give the client such treatment.
Values in our society are shifting to include consideration of quality of life in the decision about radical treatment. As a result, the medical and legal systems are more often responding with sensitive and thoughtful decisions that support the needs of clients and their families.
It is important to know that the client has a right to review his or her own chart. It is recommended and required in many institutions that such a request by a client be forwarded to his or her physician. It is wise for the physician to be present when the client is reading the chart in order to answer any questions and clarify any misunderstandings.
10. Types of Admission
Voluntary Commitment
The vast majority of persons with a mental health problem seek help voluntarily. Specific procedures vary from hospital to hospital, but basically persons or their therapists request admission and sign the appropriate documents. When persons are ready to leave the treatment setting, they sign themselves out. Most states have a grace period that allows professional staff the time and opportunity to assess patients before they leave voluntarily. Voluntary patients who want to sign themselves out rather frequently can be placed on an involuntary commitment status because the staff’s assessment indicates a need for further treatment.
Involuntary Commitment
Most people who are mentally ill recognize their need for treatment and are relieved when they are hospitalized. Others, whose sense of reality and judgment are markedly altered, do not submit to hospitalization. When lack of treatment poses a danger to the client or others, it is often necessary to obtain a court order for commitment. The state is empowered by law to fulfill its obligation to protect its citizens.
Each state has adopted different definitions of the mental state that constitutes dangerousness. Generally, it is a serious mental condition that has existed during the previous 30 days. The person must be examined by a psychiatrist when commitment is believed necessary. If suicide, homicide, serious bodily harm to self or others is believed by the examining psychiatrist to be a potential outcome, emergency commitment can be carried out immediately. The case must be reviewed by a judge with strong supporting evidence submitted for a continued court-ordered hospitalization.
11. Right to Habeas Corpus
If a person is being held in a hospital against his or her will, he or she may apply for a writ of habeas corpus. A writ of habeas corpus has the purpose of requiring an immediate court hearing to determine a person’s sanity. If the person is declared sane, then he or she must be released from the institution immediately.
12. Right to Refuse Treatment
Most of the rights of clients have been established because of legal precedents that were determined when former mental clients went to court to sue former caregivers for denial of their rights when they were hospitalized. Two of the most common treatments that have potentially negative side effects are electroshock treatment (EST) and all psychotropic medications. Phenothiazine medications have been specifically identified in lawsuits because of the permanent side effect called tardive dyskinesia, Psychopharmacology and Electroshock Treatment of Mental Disorders. Mentalli ill hospitalized clients, whether voluntarily or involuntarily admitted, have the right to information about these treatments and the right to refuse them.
In conclusion, the knowledge regarding ethics and legal issues in mental health nursing is expanding rapidly. As the issues of client rights became more urgent, nurses began to review their own ethical responsibilities to clients. One of the major reasons for the increase in knowledge of legal issues was consumer awareness that their needs were not being adequately met by the mental health care system. Lawsuits that mandated change in particular states often had effects beyond the boundaries of those states. Other states, in viewing the outcomes of these lawsuits, began to review anf revise some of their own questionable practices.
The ethics of mental health nursing
There are two broad ethical theories that can guide the development of professional ethics: the theories of utilitarianism and deontology. Utilitarianism is based on the principle that an ethical decisons serves to pruduce the greatest good for the greatest number of persons involved. While many ethical theorists endorse utilitarian thinking, many nursing ethicists find deontological analysis more helpful in approaching common clinical dilemmas. Deontology looks at human duties to others and tries to analyze the principles on which these duties are based. The basic deontological principles are autonomy, beneficence, fidelity, justice, and nonmaleficence. Autonomy refers to the client’s right to self-determination and independence. Beneficence is the view that all treatments must be for the client’s good. Fidelity is an individual’s obligation to be faithful to commitments and contracts. Justice is the principle ensuring fairness, equity, and honesty in decisions. Nonmaleficence is the view that, above all, care providers must do no harm.
Ethical Principles
• autonomy
• beneficence (do good)
• justice/fairness
• equity
• equality
• sanctity • avoidance of paternalism (informed consent)
• non-maleficence (avoid harm)
• rights
• respect for persons
• dignity
• quality of life
Ethical principles assert that mental health professionals adopt an attitude of respect for persons, ensure that clients make their treatment decisions without coercion (the principle of autonomy), and work for their clients’ well-being (the principle of beneficence). Ethical standards typically endorse the importance of professional behavior and responsibility (the principle of fidelity). Certain activities—for example, sexual realtionships with clients—are prohibited as being explicitly unethical because these activities could bring harm to the client (the principle of nanmaleficence). The principle of justice is less prominent in professional codes of ethics than are the other principles. Perhaps this is because in America society, neither health nor mental health care has been defined to be a universal right.
Making ethical decisions, step of value analysis model :
1) Identify and clarify the value question
2) Assemble purported facts
3) Assess the truth of purported facts
4) Clarify the relevance of the facts
5) Arrive at a tentative value decisions
6) Test the value principle implied by the decision
Does the value principle fit in the current situation?
Does the value principle fit in other, similar situations?
Would the value principle fit if the client were your mother? Your father? Your spouse? Your child?
Would the value principle fit if you were the client?
Because the primary function of mental health nursing is realting with people, it is important to review the way in which nursing “care” occurs. Richards has examined the concepts of “caring for” versus “caring about”. When a person cares for another, the implication is that the other is like a child and is incapable of self-care; he or she is dependent and cannot make any contributions to his or her own well-being. Caring about, on the other hand, demonstrates respect for the other as a full human being. Although a client may be temporarily incapacitates (to a greater or lesser degree), the nurse should continually relate to him or her in a manner that promotes self-acceptance, ability to care for self, and ultimate restoration of health.
It can be helpful to review one’s own philosophy of client care to determine which approach to use in practice. Consistent use of the caring-for approach described above does not contribute to the ultimate well-being or potential autonomy of clients.
Caring : a prerequisite to ethical behavior. Caring is being respectful of people’s choices as to the best course of action to be taken. Caring is accepting people as they are and envisioning what they may become. Caring is honoring each person’s wholeness of being-mind, body, emotions, and spirit. People who are in a caring relationship are likely to behave in an ethical manner toward each other. Nurses have identified the following behaviors as being the most significant to a caring relationship (Wolf, 1986) :
attentive listening
providing comfort
honesty
patience
responsibility
providing adequate information
touch
sensitivity
respect
calling the client by name
That Code of Nursing Practice noted earlier describes the ethical realtionship that ideally exists between a nurse and a mental health client. These ethical codes, although clearly stated, can sometimes create internal conflicts in the nurse. Because nursing practice deals with all aspects of human existence, it cannot consist of circumstances that fit within perfect guidelines. In actual practice, it is possible to be caught between a personal belief and a professional ethic or a law that causes strong disagreement and consternation. If this occurs and the dilemma seems unresolvable, it can be helpful to seek the counsel of someone in the profession who is knowledgeable about the issues involved.
ANA Nursing Code of Ethics (1985) :
1) The nurse provides services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
2) The nurse safeguards the client’s right to privacy by judiciously protecting information of a confidential nature.
3) The nurse acts to safeguard the client and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person.
4) The nurse assumes responsibility and accountability for individual nursing judgments and actions.
5) The nurse maintains competence in nursing.
6) The nurse exercises informed judgment and uses individual competence and qualification as criteria in seeking consultation, accepting responsibilities, and delegating nursing activities to others.
7) The nurse participates in activities that contribute to the ongoing development of the profession’s body of knowledge.
8) The nurse participates in the profession’s efforts to implement and improve standards of nursing.
9) The nurse participates in the profession’s efforts to establish and maintain conditions of employment conducive to high-quality nursing care.
10) The nurse participates in the profession’s effort to protect the public from misinfomation and misrepresentation to maintain the integrity of nursing.
11) The nurse collaborates with members of the health professions and other citizens in promoting community and national efforts to meet public health needs.
American holistic nurses’ association code of ethics
We believe thet the fundamental responsibilities of the nurse are to promote health, facilitate healing and alleviate suffering. The need for nursing is universal. Inherent in nursing is the respect for life, dignity, and right of all persons. Nursing care is given in a context mindful of the holistic nature of humans, understanding the body-mind-spirit connection. Nursing care is unrestricted by considerations of nationality, race, creed, color, age, sex, sexual preference, politics or social status. Given that nurses practice in culturally diverse settings, professional nurses must have an understanding of the cultural background of clients in order to provide culturally appropriate interventions.
Nurses render services to clients who can be individuals, families, groups or communities. The client is an active participant in health care and should be included an all nursing care planning decisions.
In order to provide services to others, each nurse has a responsibility toward him self. In addition, nurses have defined responsibilities toward the client, co-workers, nursing practice, the profession of nursing, society, and the environment.
Code of Ethics for Holistic Nurses, by American Holistic Nurses’ Association (1995):
1) Nurses and Self
The nurse has a responsibility to model health behaviors. Holistic nurses strive to achieve harmony in their own lives and assist others striving to do the same.
2) Nurses and Client
The nurse’s primary responsibility is to the client needing nursing care. The nurse strives to see the client as a whole, and provides care which is professionally appropriate and culturally consonant. The nurse holds in confidence all information obtained in professional pratice, and uses professional judgment in disclosing such information. The nurse enters into a relationship with the client that is guided by mutual respect and a desire for growth and development.
3) Nurses and Co-Workers
The nurse maintains cooperative relationship with co-workers in nursing and other fields. Nurses have a responsibility to nurture each other, and to assist nurses to work as a team in the interest of client care. If a client’s care is endangered by a co-worker, the nurse mst take appropriate action on behalf of the client.
4) Nurses and Nursing Practice
The nurse carries personal responsibility for practice and for maintaining continued competence. Nurses have he right to utilize all appropriate nursing interventions, and have the obligation to determine the efficacy and safety of all nursing actions. Wherever applicable, nurses utilize research findings in directing practice.
5) Nurses and The Profession
The nurse plays a role in determining and implementing desirable standards of nursing practice and education. Holistic nurses may assume a leadership position to guide the profession toward holism. Nurses support nursing research and the development of holistically oriented nursing theories. The nurse partipates in establishing and maintaining equitable social and economic working conditions in nursing.
6) Nurses and Society
The nurse, along with other citizens, has responsibility for initiating and supporting actions to meet the health and social needs of the public.
7) Nurses and The Environment
The nurse strives to manipulate the client’s environment to become one of peace, harmony, and nurturance so that healing may take place. The nurse considers the health of the ecosystem in relation to the need for health, safety and peace af all persons.
REFERENCES
Barry, Patricia D. 1998. Mental Health and Mental Illness–6th ed–. Philadelphia, New York : Lippincott
Fontaine, Karen Lee. 1999. Mental Health Nursing–4th ed–. Menlo Park, California : Addison Wesley
Frisch, Noreen Cavan and Lowrence E. Frisch. 2006. Psychiatric Mental Health Nursing–3th ed–. Colorado, Spring Colorado : Thomson Delmar Learning
Varcarolis, Elizabeth M, et.al. 2006. Foundations of Psychiatric Mental Health Nursing : A Clinical Approach–5th ed–. St. Louis, Missouri : Saunders Elsevier
Kaplan, Harold I, et.al. 1995. Comprehensive Textbook of Psychiatry/VI–6th ed–. Baltimore, Maryland : Williams and Wilkins
Clinton, Michael. 1996. Mental Health and Nursing Practice. Australia. Australia : Prentice Hall, a division Simon and Schuster
Antai-Otong, Deborah. 1995. Psychiatric Nursing : Biological and Behavioral Concept. Philadelphia, Pennsylvania : W. B. Saunders Company
Worret, Fortinash Holoday. 2007. Psychiatric Nursing Care Plans–5th ed–. St. Louis, Missouri : Mosby Elsevier
Varcarolis, Elizabeth M. 1994. Foundations of Psychiatric – Mental Health Nursing–2th ed–. United States of America : W. B. Saunders Company
Stuart and Sundeen. 1995. Principles and Practice of Psychiatric Nursing–5th ed–. St. Louis, Missouri : Mosby–Year Book, Inc
Keltner, Norman L. 1995. Psychiatric Nursing–2th ed–. St. Louis, Missouri : Mosby-Year Book, Inc
Haber, Judith, et.al. 1982. Comprehensive Psychiatric Nursing—2th ed—. United States of America : McGraw-Hill, Inc
(from: yuliantikusniyah)
