acute psychiatry. Attention will also be given to the vexed issue … Findings: The results indicated that nurses needed additional education in psychiatric ethics. a. Ethical code or nursing care -related problems included (a) neglect, (b) rude/careless behavior, (c) disrespect of patient rights and human dignity, (d) … Psychiatric mental health nurse practitioners (PMHNPs) are assuming increasing clinical responsibilities in the treatment of individuals with mental illness as the shortage of psychiatrists and their maldistribution continues to persist in the United States. This article will examine some of the ethical and legal issues correctional nurses must address in their practice. Defense experts and the defense attorneys judged the nurse practitioner’s actions to be appropriate and within the standard of care, deeming his potential liability in the matter to be 2 percent or less. 1). On the basis of educated skill and past experience, the health professional is usually able to ascertain the level at which the patient has understood the information received and what data gaps or misunderstandings remain. Given this, determining competence in health care contexts fundamentally involves determining a person’s ability to make particular choices and decisions under particular conditions ( Buchanan & Brock 1989 : 311–65; see also Light et al 2016 )). A second consideration is that many people with mental illness have experienced high rates of trauma during their lifetime. Findings: The results indicated that nurses needed additional education in psychiatric ethics. As noted earlier, SDM places the person who is being supported at the front of the decision-making process ( ALRC 2014 ). The moral force of the right’s claim in this instance is such that if an attending health care professional does not uphold or violates the patient’s decision in regard to the treatment options considered, that patient would probably feel wronged or that an injustice had been done. Also, although applying the criteria developed may inevitably result in a health care professional assuming the essentially paternalistic role of being a surrogate decision-maker for a given patient, this need not be problematic provided the model of surrogate decision-making used is patient centred – that is, committed to upholding the patient’s interests and concerns insofar as these can be ascertained. As discussed in the previous chapter under the subject heading ‘The analytic components and elements of an informed consent’, an essential criterion to satisfying the requirements of an informed consent is competency to decide . An involuntary psychiatric patient refuses to take the psychotropic medication he has been prescribed. The nurse maintains competence in nursing. On closer examination, however, the practical guidance that this statement can offer is also limited – like other codes and statements, they cannot tell people what to do in particular cases . She was treated with pain medication and antidepressants. There are three primary duties for nurses, among many others, which are the duty of autonomy, confidentiality, and duty of care to all patients. Other barriers that have been identified include: concerns about the ‘legal and ethical issues relating to the liability for implementing or overriding (PAD) statements’. moral/ethical issues encountered by a PMHNP essay example. Upon the completion of this chapter and with further self-directed learning you are expected to be able to: Discuss critically why a charter of rights and responsibilities specific to mental health care is required. In order to provide quality and safe mental health treatment, a number of challenges must be addressed, including inadequate numbers of psychiatrists and psychiatric nurse practitioners. In a more recent work on competency, Light and colleagues (2016 : 34) argue that ‘all definitions of capacity [for decision-making] involve intrinsically normative judgments and inevitably reflect the influence of context and values’. One reason for this is the systemic barriers to their use including a ‘lack of resources deployed to assist patients in preparing PADs (unless assistance is provided, completion rates for PADs tend to be low), and a lack of “buy-in” and acceptance of PADs by clinicians’ ( Swanson et al 2007 : 78). Psychiatry is no exception. As a result, discussion ensued about appealing the jury’s decision. The nurse maintains competence in nursing. What else then should health care professionals do? Patients will be offered new services from highly skilled advanced nurse practitioners. Depending on the legal regulations governing a given PAD, a directive can contain provisions for either ‘opting-out’ (refusing) treatment (both general and specific – e.g. On this point, with reference to the provisions contained on the CRPD, Callaghan and Ryan (2016 : 610) explain: Several years ago, a consumer advocate pleaded: It has taken a very long time but, it would seem, this advocate’s plea is at last being heard. Throughout his hospitalisation, he repeatedly asked to be allowed to die. Attention will also be given to the vexed issue of the ethics of suicide prevention, suicide intervention and suicide postvention. Meeting the insurance needs of nursing professionals for more than 40 years. Health care professionals practice in an environment that is complex, with many regulations, laws and standards of practice. In a 2013 systematic review of the literature on the subject, Nicaise and colleagues (2013) identified three main theoretical frameworks or rationales for PADs: improvement in the therapeutic alliance between the users and clinicians. At four o’clock in the morning on 3 April 1986, John McEwan was found dead by his nursing attendant. Specifically, an approach is required that places strong emphasis on consolidating the mental health interests of those who have or who are at risk of developing mental illnesses and which also emphasises the ‘special’ responsibilities that health care providers have towards this vulnerable group. Widdershoven and Berghmans (2001 : 92) explain that: Later works have consistently reaffirmed this view ( Ouliaris & Kealy-Bateman 2017 ; Sellars et al 2017 ; Zelle et al 2015a ). Coercive measures commonly used in mental health care contexts have been classified as basically involving four types: ‘seclusion, mechanical constraint, physical restraint / holding, and forced medication’ ( Krieger et al 2018 ; Tingleff et al 2017 ); these can be imposed in either institutional or community health care settings (e.g. The lack of conceptual clarity in this instance risks ‘pushing ethics to their limits’ – especially in cases ‘where patients have not reached out for help’ yet treatments are imposed without their informed consent ( Gustafsson et al 2014 : 176). Case Study: Failure to manage the patient’s care in order to maximize individual recovery and quality of life, Failure to advocate and promote a system and climate that is conducive to providing ethical care, Failure to utilize ethical principles to advocate for access and parity of services for mental health problems, psychiatric disorders… Ethical Codes for Psychiatric Nurse Practitioners [Compatibility Mode] 1. For example, contrary to popular medical opinion, there is nothing to suggest that a person’s decision to suicide is always the product of mental disease or depression. Specifically, Buchanan and Brock (1989 : 84–6) suggest that the whole issue hinges on: setting and applying accurately standards of competency to choose and decide; and. The inability to get ‘quick determinations’ of illness and competency – and hence healing treatment – has also been identified as a risk that could serve ultimately to undermine the effectiveness of PADs ( Cuca 1993 : 1178; see also Nicaise et al 2013 ). Ethical code or nursing care -related problems included (a) neglect, (b) rude/careless behavior, (c) disrespect of patient rights and human dignity, (d) … achieving a balance between (i) protecting and promoting the patients’ wellbeing (human welfare), (ii) protecting and promoting the patients’ entitlement to and interest in exercising self-determining choices, and (iii) protecting others who could be harmed by patients exercising harm-causing choices. Claire Zilber, M.D., is the author of the Psychiatric News column “Ethics Corner” and has written about a number of contemporary ethics issues that psychiatrists commonly encounter. Rights and responsibilities of the community – encompassing the responsibility of communities to be adequately informed and educated about mental health issues, and to uphold the rights of mental health consumers and their carers. While drawing primarily on the Australian experience, this discussion nonetheless has relevance for nurses working in other countries. Although practised under the rubric of benevolent paternalism, the tenets of involuntary treatment have nonetheless seriously challenged and, in many instances, infringed the rights of mentally ill persons – particularly those whose decision-making capacity has been seriously compromised by their illness – to make informed and self-determining decisions about their care and treatment. accepted ethical themes (deontological, teleological, and areteological), the ethical triangle by Potter, the American Academy of Nurse Practitioners (AANP) standards of practice for NPs, and codes of ethics from the American Nurses Association (ANA) and the American Medical Association (AMA). “Nurse Practitioner Perspective on Education and Post- Graduate Training,” and believes the principles espoused in that document apply to all APRN roles. Decisions that would cause “concern” might include refusing medication that would prevent an adverse outcome, refusing prevention or treatment that is standard of care, refusal to follow recommended diet, refusal to follow safe sex practices, or refusal of continuous positive airway pressure. Violation of ethical principle and law. In order to provide quality and safe mental health treatment, a number of challenges must be addressed, including inadequate numbers of psychiatrists and psychiatric nurse practitioners. Depending on the state, FNPs could face legal implications for prescribing to family and friends. In this chapter an attempt will be made to contribute to this positive project by providing an overview of stated rights and responsibilities in mental health care. Examine the notions of competency and its implications for persons with impaired decision-making capacity. A little over a year after his accident, and despite still being ventilator dependent, John McEwan was discharged home. Since then a substantive paradigm shift has occurred, which has seen PADs incorporated into mental health legislation in the Australian Capital Territory (2015), Queensland (2016), Victoria (2014) and Western Australia (2014), with the Australian Capital Territory legislation regarded by commentators as the most progressive (see comparative table in Ouliaris & Kealy-Bateman 2017 : 576). Philosophical disputes about what constitutes ‘rationality’ and ‘competency to decide’ have particular ramifications for people who have what has been termed ‘fringe decision competence’ ( Hartvigsson et al 2018 ), who are cognitively impaired and / or who, because of the manifestations of severe mental illness, are involuntarily admitted to psychiatric facilities for treatment. It is to providing a brief overview of PADs – their origin, their rationale, their basic function, the perceived risks and benefits of adopting them, and the possible enablers and disablers to their uptake – that this discussion now turns. Progress has been slow, however. Thus, there is an ever-present risk that, when admitted to a psychiatric facility as an involuntary or non-voluntary patient, their institutional experiences may trigger previous trauma, provoke feelings of fear, anxiety and anger and thereby aggravate their psychiatric symptoms (a burden which others who do not have a history of trauma or mental illness do not carry) ( Cusack et al 2018 ; Goulet et al 2017 ; McKenna et al 2017 ). The American Psychiatric Nurses Association (APNA) is your resource for psychiatric-mental health nursing. Findings: The results indicated that nurses needed additional education in psychiatric ethics. However, in compliance with the provisions contained in the CRPD, there is now recognition that ‘persons with disabilities enjoy legal status on an equal basis with others in all aspects’ and that this requires recognition that competent persons, at least, have the right to refuse psychiatric treatment ( Maylea & Ryan 2017 : 88). Healthcare providers have an ethical obligation to disclose information that patients need for informed decision making. Further, they argue, if he is given the medication against his will, an even greater harm will follow: specifically, he will trust the nursing staff even less than he does already, and will be even less willing to comply with his oral medication prescription than he is now. This can be established by asking patients probing questions and inviting them to reiterate the information they have received. [emphasis original]. The objective test here is similar to that employed in law, and involves asking the question: ‘What would a reasonable person in like circumstances consider to be a reasonable outcome?’ The reliability of this measure is, of course, open to serious question – as might be objected, what one person might accept as reasonable another might equally reject. injuries sustained as a result of a road traffic accident, an acute appendicitis, complications of diabetes, renal failure, etc.). Fulfilling a corresponding duty can involve either doing something ‘positive’ to benefit a person claiming a particular right or, alternatively, refraining from doing something ‘negative’ which could harm a person claiming a particular right. One problem with this test, however, is whether, say, the blinking of a patient’s eyelids can be relied upon as evidencing a choice; in a life-and-death situation one would need to be very sure that a patient’s so-called ‘evidencing a choice’ is more than just a reflex. DRAFT Psychiatric–Mental Health Nursing: Scope & Standards of Practice 6 2012 workgroup SCOPE DRAFT for National Review 11/20/12 Preface1 2 In 2011, the American Psychiatric Nurses Association (APNA) and the International 3 Society of Psychiatric–Mental Health Nurses (ISPN) appointed a joint task force to 4 begin the review and revision of the Scope and Standards of Psychiatric–Mental Health Within his scope of practice, he was able to make a determination of mental illness. mental disorders. She survived the attempt, but suffered severe anoxia and permanent brain damage. In relation to these criteria, he goes on to clarify that the patient’s task in consent situations is to: clearly indicate their preferred treatment options; grasp the fundamental meaning of the information being communicated by their attending doctor (apropos the nature of patient’s condition, nature and purpose of proposed treatment, possible benefits and risks of that treatment, and alternative approaches (including no treatment) and their benefits and risks); acknowledge (have insight into) their medical condition and likely consequences of the treatment option available (noting that ‘delusions or pathologic levels of distortion or denial are the most common causes of impairment’); engage in a rational process of manipulating [sic] the relevant information (this criterion focuses on the process by which a decision is reached, not the outcome of the patient’s choice, since patients have the right to make ‘unreasonable’ choices). More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). Also, in another incident shortly before his death, he talked openly with his general practitioner about ‘hiring someone to blow his [John McEwan’s] brains out or kill him as he felt his wish to die was being frustrated’ ( Social Development Committee 1987 : 316). Because one of the most ethically confronting issues in mental health care is the coercive treatment 2 of persons admitted as involuntary or non-voluntary patients to a psychiatric facility or program, particular attention will also be given to the issues of informed consent and competency to decide, and ongoing proposals to develop and operationalise ‘psychiatric advance directives’ (PADs) in jurisdictions around the world. PMHNPs encounter such unethical dilemmas, since they compromise the legal rights of a patient (Annamalai, & Tek, 2015). This is especially likely in cases where involuntary or non-voluntary hospitalisation involves unconsented, coercive institutional procedures such as seclusion, restraints, forced medication and forced feeding ( Borckardt et al 2007 ; Cusack et al 2018 ). Before his accident he had been a committed sportsman and for him the life of a helpless quadriplegic was intolerable. Just which model or models are appropriate, and under what circumstances they should be used, will, however, depend ultimately on the people involved (and the relationships between them), the moral interests at stake, the context in which these moral interests are at stake, the resources available (human and otherwise) to protect and promote the moral interests that are at risk of being harmed, and, finally, the accurate prediction of possibilities and probabilities in regard to the achievement of desirable and acceptable moral outcomes. Of those who reported they did not support PADs, the key rationale was concern for the ‘clinical profile of the patient and the professional imperative regarding the psychiatrist’s duty of care’ ( Sellars et al 2017 : 70). A 23-year old woman with no significant prior medical history presented to the emergency room with complaints of generalized body ache of two weeks duration and a fever of 102.6. These risks may be accentuated in cases where the PADs are ‘competence-insensitive’ and service providers wrongly judge the point at which a PAD applies and apply it prematurely ( Bielby 2014 ). Earlier in this chapter, under the discussion of competency to decide, the case was given of an involuntary psychiatric patient who was held down and given an intramuscular injection of psychotropic medication against his will (see pp 213–14 ). It should be noted that competency is a key issue not just in psychiatric care, but in any health care context where judgments of competency are critical to deciding: (1) whether a patient can or should decide and / or be permitted to decide for herself or himself, and (2) the point at which another or others will need to or should decide for the patient – that is, become what Buchanan and Brock (1989) term surrogate decision-makers and what is variously referred to in Australian jurisdictions as involving ‘substitute decision-making’ and ‘supported decision-making’, with the latter placing the person who is being supported ‘at the front of the decision-making process’ ( Australian Law Reform Commission (ALRC) 2014 : 51). Governance – encompassing the responsibility of governments and other stakeholders to ensure that mental health initiatives (including service provision, mental health legislative reform, and other forensic matters) are appropriately resourced and supported. They are registered nurses with specialized, advanced education and clinical competency to provide health and medical care for diverse populations in a variety of primary care, acute and long-term care settings. It will be recalled that this incident resulted in the patient being left highly mistrustful of nursing staff and even less willing to comply with his prescribed oral medication. Ethical issues are wide-ranging, from organ donation, genetic engineering, assisted suicide, withholding treatment in end-of-life care, or. Research conducted by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA), (Cook, 2013) reports recent graduates of accredited certified registered nurse anesthetist An important problem here, particularly in psychiatric contexts, is that severe mental illness can significantly affect the capacities needed for competent decision-making (for instance, understanding, reasoning and applying values), and hence the ability generally of severely mentally ill persons to make sound decisions about their own wellbeing – including the need for care and treatment. Since the publication of the foundational works by Grisso and Appelbaum (1998) and Appelbaum (2007) , a number of competency assessment tools have been developed 3 ( Wang S-B et al 2017 ). According to media reports, this act led to a psychiatrist certifying him as rationally incompetent, thereby enabling John McEwan to be treated (fed) against his will. All co-defendants to whom the damage caps applied settled or were dismissed from the case, with the CNA/NSO-insured nurse practitioner as the sole remaining defendant. The MSN Psychiatric Mental Health Nurse Practitioner track includes 18 courses totaling 45 credit hours. The result could be declines in the quality of patient care; problematic clinical relationships; and moral distress, which is defined as knowing the right thing to do but not being allowed or able to do it. The quality of the patient’s choice in this instance is irrelevant. • Liability risks for psychiatric mental health nurse practitioners are reviewed. Non-discrimination and social inclusion – encompassing the rights to: privacy and confidentiality; health, safety and welfare; equal opportunities to access and maintain health and mental health care, and other social goods; contribute to and participate in the development of social, health and mental health policy and services. This question becomes even more problematic when it is considered that persons deemed ‘rationally incompetent’ (or, at least, cognitively impaired) can still be quite capable of making ‘reasonable’ self-interested choices, and, further, that the choices they make – even if ‘irrational’ – are not always harmful ( Williams 2002 ; see also Light et al 2016 ; Stier 2013 ). Decisions that would cause “concern” might include refusing medication that would prevent an adverse outcome, refusing prevention or treatment that is standard of care, refusal to follow recommended diet, refusal to follow safe sex practices, or refusal of continuous positive airway pressure. Not only is there the problem of how to determine accurately what a harm is and how a given harm should be weighted morally when evaluating whether a patient’s choices should be respected or overridden; there is the additional problem that attending health care professionals may disagree radically among themselves about how these things should be determined – to a point that may even cause rather than prevent harm to the patient, as happened in this case. PMHNPs encounter such unethical dilemmas, since they compromise the legal rights of a patient (Annamalai, & Tek, 2015). #Malpractice A number of objections can be raised here. At one point, desperate to achieve his wish, he went on a hunger strike and instructed his solicitor to draw up a ‘living will’, which stated ‘that he did not wish to be revived if and when he fell into a coma’ ( Bioethics News 1985 : 2). [1,8] Ethical issues related to PMH nursing in the literature can be summarized as: obtaining informed consent from the patient; compulsory treatment and hospitalization; using seclusion and restraint; respect for patients’ privacy and confidentiality; and research in … In defence of his refusal, the patient argues ‘reasonably’ that the adverse side effects of the drugs he is being expected to take are intolerable, and that he would prefer the pain of his mental illness to the intolerable side effects of the drugs that have been prescribed to treat his mental illness. As Gibson (1976) pointed out in an early article on the subject, rationality cannot escape the influences of the social patterns and institutions around it and, for this reason, any value-neutral account of rationality is quite inadequate. There is room to speculate that, had a PAD been in force at the time for this patient, a very different outcome might have resulted in this case. Following a family visit, the patient attempted suicide, wounding herself in the neck. The settlement monies with defense cost were greater than $1 million. Ethical Concerns For the nurse in a traditional medical setting, ethical decisions occur occasionally and at times the nurse may face ethical dilemmas. Assessing risk and permitting choices of patients deemed ‘rationally incompetent’, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), United Nations General Assembly’s adoption in 1991, Australian Health Ministers Advisory Council (AHMAC) 2013, Australian Government Department of Health 2010, Australian Government Department of Health 2012, Australian Law Reform Commission (ALRC) 2014, Ethics, dehumanisation and vulnerable populations, Moral theory and the ethical practice of nursing, Nursing ethics futures – challenges in the 21st century, Ethics, bioethics and nursing ethics : Some working definitions. The promotion of mental health and the prevention of mental illness – encompassing the responsibilities of governments and health service providers to: promote mental health; support, develop, implement and evaluate programs for preventing mental health problems and illnesses; support the ongoing development of comprehensive, flexible, integrated, and accessible community, primary health and hospital-based social support, health and mental health services. These providers are likely to be confronted with a variety of ethical issues … In Australian, New Zealand and other common-law jurisdictions, legislative provisions also enable psychiatrists to override a person’s will and preferences and admit (‘commit’) them involuntarily to hospital for treatment, which, in effect, grants psychiatrists the authority to ‘act as substitute decision-makers, rather than as advisers and service providers’ ( McSherry 2012 : 1). 4 Also of critical concern is finding a competency test which is comprehensive enough to deal with diverse situations, which can be applied reliably and which is mutually acceptable to health care professionals, lawyers, judges and the community at large. Underpinning the selection of this model is the view that ‘all people have fundamental human rights’ and that people with mental health problems or mental illness should not be precluded from having or exercising these rights just because of their mental health difficulties. Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. A little over a decade later, in the cultural context of Australia, the need to assure the rights of people with mental illness and the ‘provision of recovery-orientated practice in mental health services’ was positioned as a core principle in the Australian Commonwealth Government’s National framework for recovery-oriented mental health services ( Australian Health Ministers Advisory Council (AHMAC) 2013 ) and the Council of Australian Governments’ (2012) Roadmap for national mental health reform 2012–2022 . Enforced treatments in such cases may, however, compound their distress and make future treatment difficult, especially if the patient later feels (i.e. This, in turn, has contributed to a lack of competence on the part of both health service providers and service users to honour and implement PADs (Nicaise et al 2013: 2). Whatever the faults, weaknesses and difficulties of such statements, they nevertheless achieve a number of important things; like bills and charters of patient rights generally, they help to remind mental health patients / consumers, service providers, caregivers and the general community that people with mental health problems (including mental illnesses and mental health problems) have special moral interests and entitlements that ought to be respected and protected, they help to inform stakeholders (patients / consumers, service providers, caregivers and the community) of what these special entitlements are and thereby provide a basis upon which respect for and protection of these can be required, they help to delineate the special responsibilities that stakeholders (patients / consumers, service providers, caregivers and the community) all have in ensuring the promotion and protection of people’s moral interests and entitlements in mental health care and in promoting mental health generally. with patients. instruments provided for by this legislation can only be used to refuse rather than to give consent to treatment) ( Meredith 2005 : 9; Swartz et al 2006 ). The growing role of psychiatric mental health nurse practitioners is discussed. This case study involves a nurse practitioner in an in-patient alcohol/drug treatment setting. A New Zealand survey of 110 mental health service users and 175 clinicians had similar findings ( Thom et al 2015 ). First, as discussed previously in Chapter 6 , people with mental illness are among the most stigmatised, discriminated against, marginalised, disadvantaged and hence vulnerable individuals in the world. Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. • Scope of practice shapes what FNPs can do when diagnosing/treating mental illness. Conclusions A proposal for a code of ethics for NPs is presented. Besides, they make decisions that lead to deterioration of a patient’s health instead of ensuring recovery. He believed that an alcohol and drug program was not appropriate for the patient, who needed psychiatric inpatient treatment. Besides, they make decisions that lead to deterioration of a patient’s health instead of ensuring recovery. Nurses are guided by a code of ethics that provide them with the basis to make ethical decisions. This, in turn, will depend on the competence, experience, wisdom and moral integrity of the decision-makers, and the degree of commitment they have to: (1) ensuring the realisation of morally just outcomes and (2) protecting and promoting the wellbeing and moral interests of those made vulnerable not just by their mental illnesses, but also by the inability of their caregivers to respond to the manifestation of their illnesses in an informed, morally sensitive, humane, therapeutically effective and culturally appropriate way. The plaintiff sought economic, noneconomic and punitive damages, as well as plaintiff’s attorney fees. People with serious mental illnesses can often experience periods of profound distress during which their capacity to make prudent and self-interested decisions about their care and treatment options can be seriously compromised. Case Study: Failure to manage the patient’s care in order to maximize individual recovery and quality of life, Failure to advocate and promote a system and climate that is conducive to providing ethical care, Failure to utilize ethical principles to advocate for access and parity of services for mental health problems, psychiatric disorders, and substance use disorder services, (Monetary amounts represent only the payments made on behalf of the treating nurse practitioner.). Just what such a framework would – or indeed should – look like is, however, a matter of some controversy. Dresser further cautions that, in the absence of an opportunity for patients to withdraw consent to treatment, PADs in reality could well stand as a ‘coercive treatment mode that would take us a step backward – or at least sideways – from a more sensitive and realistic solution to a very difficult situation’ ( Dresser 1982 : 854). The MSN Psychiatric Mental Health Nurse Practitioner track includes 18 courses totaling 45 credit hours. They make the additional value judgment that it would be ‘better’ for the patient if his psychiatric condition were prevented from deteriorating, and that their decision to administer his prescribed medication forcibly against his will is justified on these grounds. Some studies have suggested that, overall, clinicians are broadly supportive of the ‘advance-consent’ function of PADs (termed ‘prescriptive function’); however, clinicians are more reticent about their ‘advanced-refusal’ function (termed ‘proscriptive function’) – especially if used to refuse all future treatment ( Swartz et al 2006 ). When told of this risk she replied, happily: ‘I hope I am the one!’. The nurse practitioner assessed the patient shortly after her admission. This story is used controversially in philosophy to demonstrate the difference between freedom and autonomy: in this case, although Ulysses had his freedom constrained (i.e. Because of unresolved uncertainties concerning how the concept of competency is to be interpreted and applied by clinicians, and the tendency to overlook what Banner describes as the ‘inherent normativity of judgments made about whether a person is using or weighing information in the decision-making process’, there remains the ever-present risk of patients failing on the criteria ‘to the extent that they do not appear to be handling the information given in an appropriate way, on account of a mental impairment disrupting the way the decision process ought to proceed’ ( Banner 2012 : 3078; see also Stier 2013 and Light et al 2016 – both referred to earlier). The rights and responsibilities of people who seek assessment, support, care, treatment, rehabilitation and recovery – encompassing the right of people (including children) to ‘participate in all decisions that affect them, to receive high-quality services, to receive appropriate treatment, including appropriate treatment for physical or general health needs, and to benefit from special safeguards if involuntary assessment, treatment or rehabilitation is imposed’ (p 12). He further clarifies that the doctor’s commensurate task in consent situations is to: ask the patient to indicate a treatment choice; encourage the patient to paraphrase disclosed information regarding their medical condition and treatment options; ask the patient to describe their views of medical conditions, proposed treatment and likely outcomes; ask the patient to compare treatment options and consequences and to offer reasons for selection of the option chosen. The nurse exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibility and delegating nursing activities to two others.(p. Moreover, the nurse practitioner suffered emotional distress and anxiety from the entire matter and was eager to settle the claim without further legal action. Such nurses need guidance direction and information to assist them in their new roles. To complicate this matter further, there is also no substantial agreement on what constitutes rationality , which, as has been argued elsewhere, is very much a matter of subjective interpretation. He determined that while the patient had a long-past history of alcohol use and required medication for pain management, she did not have a current substance abuse disorder. Objective: To identify ethical concerns and conflicts NPs and PAs encounter related to managed care in the delivery of primary care to patients and the factors that influence ethical conflict. For example, in Australian jurisdictions, ascertaining whether a patient has the capacity to make informed decisions requires that the following processes be examined and shown: the comprehension and retention of information about the treatment, the capacity to formulate a reasonable belief about the information that has been given, the capacity to weigh up that information in the balance so as to arrive at a prudent choice. There is, however, one notable caveat to this stance: because the rights of people with mental illness are disproportionately vulnerable to being infringed in health care contexts (both psychiatric and non-psychiatric), a more nuanced approached to the issue is required. In a UK study, whereas 89% of voluntary organisations and more than two-thirds of stakeholder groups surveyed thought that PADs were needed, only 28% of psychiatrists surveyed thought they were ( Atkinson et al 2004 ). The result could be declines in the quality of patient care; problematic clinical relationships; and moral distress, which is defined as knowing the right thing to do but not being allowed or able to do it. Research conducted by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA), (Cook, 2013) reports recent graduates of accredited certified registered nurse anesthetist Phone: 1-800-247-1500 Moreover, there is little evidence showing that PADs have, in fact, achieved their intended purpose ( Campbell & Kisely 2009 ). These providers are likely to be confronted with a variety of ethical issues … Phone: 215-660-0241 Claire Zilber, M.D., is the author of the Psychiatric News column “Ethics Corner” and has written about a number of contemporary ethics issues that psychiatrists commonly encounter. Ethical issues happen when choices need to be made, the answers may not be clear and the options are not ideal. In such instances, because of the psychiatric imperatives to treat their conditions (particularly if extremely distressed and ‘out of control’), the mentally ill are vulnerable to having medical treatments paternalistically imposed on them against their will. This case scenario demonstrates the difficulties that can be encountered when accepting / rejecting a patient’s ability to choose and decide care and treatment options, and deciding when and how to override a patient’s preferences. ETHICAL ISSUES IN ADVANCED PRACTICE NURSING. 3 An estimated 77 percent of U. S. counties are reporting a significant shortage of professionals who can prescribe and manage medications. 8.1 . Nurses, like any other healthcare worker, must follow a predefined code of ethics in their practice.But what is the code of ethics for nurses? John McEwan, a former Australian water-skiing champion, was left a ventilator-dependent quadriplegic after a diving accident at Echuca, Victoria. More insights from some of the best minds in nursing. Arguably the most profound change (described as an ‘evolving revolution’ by Callaghan and Ryan 2016 ) has occurred in Australian jurisdictions. Practice/Business Coverage Roth and colleagues (1977) suggest that competency tests proposed in the literature basically fall into five categories: The test of evidencing a choice is as it sounds, and is concerned only with whether a patient’s choice is ‘evident’; that is, whether it is present or absent . Like Gert and colleagues (1997) , cited earlier, they argue that statements of competence (i.e. The patient’s bill of rights calls for full disclosure of a medical error ( … In response to the insured, the psychiatrist indicated that the patient’s diagnosis was his responsibility and he would manage her care. Psychiatric mental health nurse practitioners (PMHNPs) are assuming increasing clinical responsibilities in the treatment of individuals with mental illness as the shortage of psychiatrists and their maldistribution continues to persist in the United States. In this case, the more experienced staff outnumbered the less experienced staff, and the patient was held down and forcibly given an intramuscular injection of the medication he had refused. Nurses are highly accountable to patients, the public, employers, and the entire profession. Ethical Concerns For the nurse in a traditional medical setting, ethical decisions occur occasionally and at times the nurse may face ethical dilemmas. With regard to setting and applying accurately standards of competency to choose and decide, Buchanan and Brock suggest that, among other things, ethical professional decision-making in this problematic area should be guided by the following considerations (1989: 85): In other words, the extent to which an attending health care professional is bound morally to respect the choices of a person deemed ‘rationally incompetent’ depends primarily on the severity of the risks involved to the patient if her or his choices are permitted. Findings: The results indicated that nurses needed additional education in psychiatric ethics. An instructive example of this can be found in the much-publicised Australian case of John McEwan that occurred in the mid 1980s and which sparked an unprecedented public inquiry into the so-called ‘right to die with dignity’ ( Social Development Committee 1987 ). Dr. Zilber is chair of the Ethics Committee of the Colorado Psychiatric Society, a consultant to APA’s Ethics Committee, and a private practitioner in Denver. 1). This annual award was established in 2019 in recognition of … Of these, the MacArthur Competence Assessment Tools (MacCATs) developed and trialled by Appelbaum and Grisso ( Appelbaum & Grisso 1995 ; Grisso & Appelbaum 1995 ; Grisso et al 1995 , 1997 ) are generally regarded ‘as having the most reliability and validity for assessing competence related to functional abilities, and have been widely used in psychiatry’ ( Wang S-B et al 2017 : 56). Such nurses need guidance direction and information to assist them in their new roles. Criteria stipulated in other jurisdictions are reflective of these original proposals. Psychiatry is … The nurse assumes responsibility and accountability for individual nursing judgements and actions. In an early work on the subject, Roth and colleagues (1977) argue, however, that the concept of competency is not merely a psychiatric or medical concept, as some might assume, but is also fundamentally social and legal in nature. The test of ability to understand , on the other hand, asks whether the patient is able to comprehend the risks, benefits and alternatives to a proposed medical procedure, as well as the implications of giving consent. Further, although PAD instruments should not ‘replace deliberation about possible future changes in the patients’ condition’ ( Widdershoven & Berghmans 2001 : 93), they are nonetheless seen as having an important role to play in eliciting and guiding communication about such matters (see also Spellecy 2003 ). The psychiatrist’s judgment was revoked a few days later, however, when John McEwan ‘agreed to end his hunger strike and accept a course of antidepressants’ (p 2). Conclusions A proposal for a code of ethics for NPs is presented. The Journal for Nurse Practitioners is proud to announce the Marilyn Edmunds JNP Writing Award, which honors excellence in writing and encourages writing for publication.. Congratulations to Cinthya Sotelo, DNP, FNP-C, for her article “Ovarian Ectopic Pregnancy: A Clinical Analysis” in the March 2019 issue. irrevocability during a crisis (also known as a ‘Ulysses contract’ – see below) ( Swartz et al 2006 : 67). Defense counsel vigorously contended to the court that the nurse practitioner should be included within the statutory framework, as he was being supervised by a covered professional. Given the nurse practitioner’s positive expert reviews and the plaintiff’s unreasonable settlement demand, the decision was made to vigorously defend this case, and the trial commenced. In one US study, for example, although 66%–77% of consumer respondents stated they would like to complete a PAD if given the opportunity and assistance to do so, only 4%–13% had actually done so ( Swanson et al 2006b ). The nurse practitioner maintains accurate, legible, and confidential records. Being a patient advocate and acting ethically is one of the foundations of nursing (Kalb & O’Connor-Von, 2007). The enactment of formal legislation regulating PADs has a protracted history dating back to the USA, which has the longest history of their use, with Minnesota in 1991 becoming the first American state to enact legislation giving recognition to the ‘advance psychiatric directive’ allowing its citizens to ‘draft directives for intrusive mental health treatments’ ( Cuca 1993 : 1165). This paradigm shift in mental health is challenging traditional evaluation criteria and conventional justifications for involuntary treatment. To this end, the document addresses the following eight domains: Inherent dignity and equal protection – encompassing the right of all people to respect the human worth and dignity of people with mental illnesses, and to support people who are mentally ill or intellectually disabled to exercise their rights when their own capacity to do so is impaired. The judgment amount could have been in excess of $4 million. Background: More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). Mental health statement of rights and responsibilities ( Australian Government Department of Health 2012 : 3)). This is in contrast with a non-patient or ‘other’-centred decision-making model, which would have as its rationale preventing harm to others , and which embraces an ethical framework ‘for deciding about others for others’ benefits ’ ( Buchanan & Brock 1989 : 327, 331). Nurse practitioners because of their education and training, understand their … For example, if a patient with severe mental illness decides to refuse hospitalisation, the extent to which an attending health professional is obliged morally to respect this decision will depend on how severe the risks to the patient are of not being hospitalised – for instance, whether a failure to hospitalise the patient will result in her or him suiciding, or will result only in her or him being left in a state of moderate, although not life-threatening, depression. It was made clear that they needed to write something they could share with others, as we would set aside class time to read their stories aloud. Being a patient advocate and acting ethically is one of the foundations of nursing (Kalb & O’Connor-Von, 2007). Ethical decision making concerning in nursing practice environment. Moreover, despite the efforts of mental health consumer groups and other mental health advocates, people with mental health problems and psychosocial disabilities continue to experience the infringement of many of their basic human rights (including the right to mental health and to mental health care). In a later appraisal and application of this test, Appelbaum (2007 : 1835) reiterates that legal standards for assessing the decision-making capacity of patients still generally embody ‘the abilities to communicate a choice, to understand the relevant information, to appreciate the medical consequences of the situation, and to reason about treatment choices’. Ethics is an important aspect of healthcare and is very common in theme in nursing (Beidler, 2005). Ethical issues happen when choices need to be made, the answers may not be clear and the options are not ideal. This chapter explores mental health nursing practice within an ethics context. An important question to arise here is: ‘If statements on mental health rights and responsibilities fall short of providing clear-cut guidance in cases of this nature, is there any point in having them?’ The short answer to this question is, yes. VI. A review of the literature has found that the information and options most frequently cited by users when preparing a PAD are: contact details of the user, the consultant, the general practitioner, the psychiatric nurse and the nominee (trusted person nominated by the user). It teases out the ethical challenges that mental health nurses can face on a daily basis. DRAFT Psychiatric–Mental Health Nursing: Scope & Standards of Practice 6 2012 workgroup SCOPE DRAFT for National Review 11/20/12 Preface1 2 In 2011, the American Psychiatric Nurses Association (APNA) and the International 3 Society of Psychiatric–Mental Health Nurses (ISPN) appointed a joint task force to 4 begin the review and revision of the Scope and Standards of Psychiatric–Mental Health Also, although some studies have suggested that clinicians are broadly supportive of the ‘advance-consent’ function of PADs (termed ‘prescriptive function’), clinicians are more reticent about their ‘advance-refusal’ function (termed ‘proscriptive function’) – especially if used to refuse all future treatment ( Swartz et al 2006 ). In attempting to secure protection of the rights of the mentally ill from abuse and neglect, a human rights model of mental health care ethics has been adopted. It is therefore important that nurses are equipped with the skills and knowledge to understand ethics within their practice. 250 As previously indicated in this section, an integral and controversial component of psychiatric practice is involuntary care and treatment. Because one of the most ethically confronting issues in mental health care is the coercive treatment 2 of persons admitted as involuntary or non-voluntary patients to a psychiatric facility or program, particular attention will also be given to the issues of informed consent and competency to decide, and ongoing proposals to develop and operationalise ‘psychiatric advance directives’ (PADs) in jurisdictions around the world. Here very practical questions arise of what, if anything, can be done to strike a balance between respecting the patient’s autonomous wishes and constraining their freedom where its exercise could be harmful to themselves and / or to others? Notwithstanding his minor role in the care of the patient, as well as the fact that there were positive expert opinions regarding the care he provided, the plaintiff’s attorney was unwilling to release the insured from the case or even to offer a reasonable settlement demand. This annual award was established in 2019 in recognition of … The patient’s permanent condition dictates that she cannot be left alone and requires full-time assistance with all aspects of her personal care. Rights and responsibilities of people who provide services – encompassing rights and responsibilities in regards to upholding the highest possible standards of mental health care, including the development and implementation of social, health and mental health policy and service delivery policies and guidelines. #LegalCases Certified Registered Nurse Anesthetists (CRNAs), Compensation and Other Disclosure Information. Ulysses further ordered his sailors not to release him from the mast until they were safely past the Sirens. A similar stance was taken in New Zealand with the Ministry of Health releasing its Rising to the challenge: the mental health and addiction service development plan 2012–2017 (New Zealand Ministry of Health 2012 ). This is in contrast to clinicians, who have consistently been found to be somewhat ambivalent about and even afraid of them ( Amering et al 1999 ; Appelbaum 2004 , 2006 ; Atkinson 2004 ; Atkinson et al 2004 ; Elbogen et al 2006 ; Hobbs 2007 ; Kaustubh 2003 ; Kim et al 2007 ; Puran 2005 ; Srebnik & Brodoff 2003 ; Swanson et al 2006a , 2006b , 2006c , 2007 ; Swartz et al 2006 ; Varekamp 2004 ). The question remains, however, of how these things can be decided in a morally sound and just way. The scope of nursing has evolved from the early role of a nurse carrying out orders at a doctor’s bidding. In many instances, people with serious mental illnesses might not comply with, and might even refuse altogether to accept, recommended psychiatric treatment (e.g. In regard to the consideration of being a danger to self, Buchanan and Brock (1989 : 317–31) correctly argue that what is needed are stringent criteria of what constitutes a danger to self ; in the case of the need for care and treatment, that what is needed are stringent criteria for ascertaining deterioration and distress ; and in the case of harm to others, that what is needed are stringent criteria of what constitutes a danger to others . 300 W. Clarendon, Suite 400 Phoenix, Arizona 85013-3424 (602) 252-8888 WWW.EXPERTETHICS.COM pfriedman@expertethics.com 2. acute psychiatry. This framework is expressed diagrammatically in Fig. This need of protection has also been recognised at an international level as evident from the United Nations General Assembly’s adoption in 1991 of the Principles for the protection of persons with mental illness and for the improvement of mental health care and, a decade later, by the World Health Organization’s release of The world health report 2001: mental health: new understanding, new hope ( WHO 2001a ). Being previously warned of the evil intentions of the Sirens, Ulysses took the precaution of commanding his sailors to bind him to the mast of his ship (effectively restraining him), and to plug their ears with wax so that they could not hear and hence be seduced to their deaths by the Sirens. Thus, the right to make informed and self-determining decisions has the distinction of provoking controversy in the field – a controversy that has been classically described as: On account of the tension between patient autonomy and therapeutic paternalism in psychiatric contexts – and the extraordinarily difficult and sometimes tragic situation in which this has often placed people (consumers and caregivers alike) – advocates and commentators have searched for ways to reconcile or at least accommodate the opposing values at issue ( Dresser 1982 ). Discuss critically the notions of ‘surrogate / substitute decision-making’ and ‘supported decision-making’ in the case of people deemed to be rationally incompetent. Although barriers to the implementation of PADs persist, research has found that consumers continue to have a high interest in and demand for PADs. In seeking to redress the implications of these considerations, mental health advocates have increasingly sought to emphasise and champion a suite of rights and responsibilities that are specific to the context of mental health care. It has long been recognised at a social, cultural and political level that people suffering from mental illnesses and other mental health-related problems need to have their moral interests as human beings protected from abuse and neglect, which, for a variety of reasons, are especially vulnerable to being violated. Health care professionals practice in an environment that is complex, with many regulations, laws and standards of practice. Even if there were agreement on what constitutes rational competency, there remains the problem of ‘whereby the definition of competence changes in different clinical situations’ ( Gert et al 1997 : 135). Counsel determined that there were several appealable matters related to the trial and the judge’s rulings. For example, an elderly demented resident may be deemed competent to eat his / her evening meal alone, but deemed not competent to refuse treatment – for example, surgery for a fractured hip. Only a few countries (e.g. This chapter explores mental health nursing practice within an ethics context. Legal and ethical issues are prevalent in the health care industry, and in particular for the nursing practice, where nurses have daily individual contact. For many, the answer lies in the systematic development and formal adoption of psychiatric advance directives (PADs). While Buchanan and Brock’s (1989) ‘sliding scale’ framework is useful, it is not free of difficulties. The growing role of psychiatric mental health nurse practitioners is discussed. As a result of the defense’s counsel’s strategy, the claim was resolved. Nurse practitioners (NPs) are licensed, independent practitioners who provide primary and/or specialty nursing and medical care in ambulatory, acute and long-term care settings. 3 An estimated 77 percent of U. S. counties are reporting a significant shortage of professionals who can prescribe and manage medications. during a moment of restored competency to decide) that the fiduciary nature of the professional–client relationship has been violated. Alternatively, a depressed and so-called ‘irrational’ person might refuse a particular psychiatric treatment, such as psychotropic drugs, electroconvulsive therapy or psychosurgery, out of a very ‘rational’ and well-founded fear of what undesirable effects these treatments might ultimately have. Case Study: Failure to manage the patient’s care in order to maximize individual recovery and quality of life, Failure to advocate and promote a system and climate that is conducive to providing ethical care, Failure to utilize ethical principles to advocate for access and parity of services for mental health problems, psychiatric … In the weeks following his discharge from hospital, John McEwan continued to express his wish to be allowed to die ( Social Development Committee 1987 : 310–11). Determining whether a person has the competency to make an informed decision about whether to accept or reject a recommended treatment is not a straightforward matter, however. Australia, Austria, Germany, Canada, Switzerland, the Netherlands and the United Kingdom) have introduced or are working to introduce and uphold PADs or ‘psychiatric wills’ ( Amering et al 1999 ; Atkinson et al 2003 ; Varekamp 2004 ). community treatment order (CTO) contexts) ( Corring et al 2017 ; Nagra et al 2016 ; Molodynski et al 2014 ). This is so despite what Callaghan and Ryan (2016 : 601) describe as a ‘revolutionary paradigm shift’ that is occurring as a result of Article 12 of the UN Convention of the Rights of Persons with Disabilities (CRPD) 1 ‘objecting to the automatic use of substituted decision-making whenever a person fails to meet a functional test of decision-making capacity’. 4 The Journal for Nurse Practitioners is proud to announce the Marilyn Edmunds JNP Writing Award, which honors excellence in writing and encourages writing for publication.. Congratulations to Cinthya Sotelo, DNP, FNP-C, for her article “Ovarian Ectopic Pregnancy: A Clinical Analysis” in the March 2019 issue. The test of reasonable outcome of choice is again as it sounds, and focuses on the outcome of a given choice, as opposed to the mere presence or absence of a choice. Due to state joint and several liability laws, if the nurse practitioner were found personally responsible for as little as 1 percent of the patient’s damages, he could theoretically be held personally liable for the entire amount of any jury verdict. Responsibility as Patient Advocate . This article will examine some of the ethical and legal issues correctional nurses must address in their practice. Some commentators are especially worried about their moral authority (particularly if patients change their minds at some point) and their vulnerability to being abused and misused ( Spellecy 2003 ). 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