These and like criteria remain problematic, however. Performing an abortion is legal but may not be considered ethical by other health care professionals or … Violation of ethical principle and law. The scope of nursing has evolved from the early role of a nurse carrying out orders at a doctor’s bidding. Master’s, post-master’s or doctoral preparation is required for entry-level practice (AANP, 2006). Ulysses further ordered his sailors not to release him from the mast until they were safely past the Sirens. The insured was not working on the day of the suicide attempt. 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 ). It is therefore important that nurses are equipped with the skills and knowledge to understand ethics within their practice. It teases out the ethical challenges that mental health nurses can face on a daily basis. 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. Discuss critically the notions of ‘surrogate / substitute decision-making’ and ‘supported decision-making’ in the case of people deemed to be rationally incompetent. The health care professional in turn could be judged, criticised and possibly even censured on grounds of having infringed the patient’s rights. patient autonomy. They argue in defence of this decision that the patient’s condition is deteriorating rapidly, and that if he does not receive the medication prescribed he will ‘spiral down into a psychiatric crisis’ (in other words a total exacerbation of his condition), which would be even more intolerable and harmful than the unpleasant side effects he has been experiencing as a result of taking the psychotropic drugs in question. Despite this reticence, the PAD is increasingly being regarded as an important instrument that enables respect of not only the patient’s wishes, but also their values (i.e. The American Psychiatric Nurses Association (APNA) is your resource for psychiatric-mental health nursing. To put this more simply, PADs stand to serve the basic functions of: prescription (advance consent to treatment options), proscription (advance refusal or rejection of treatment options), surrogate decision-maker designation 4 (identification and advance nomination of substitute decision-makers). Here objections can be raised concerning just how sophisticated a patient’s understanding needs to be. Mental health statement of rights and responsibilities ( Australian Government Department of Health 2012 : 3)). 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 plaintiff sought economic, noneconomic and punitive damages, as well as plaintiff’s attorney fees. This article will examine some of the ethical and legal issues correctional nurses must address in their practice. During such periods, the mentally ill can also be at risk of harming themselves and / or others. Identify eight domains deemed relevant to the rights and responsibilities of both users and providers of mental health care services. 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 ). A number of objections can be raised here. Relevant state law imposed a limitation on noneconomic damage awards in medical malpractice claims for physicians (psychiatric) and limits attorney fees. 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. The growing role of psychiatric mental health nurse practitioners is discussed. The round-the-clock day care he required was given by family members and friends who had received special training in how to care for him. The nurse practitioner assessed the patient shortly after her admission. Ethical decision making concerning in nursing practice environment. 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. This prompted the general practitioner who was medically responsible for him to inform the senior nursing assistant that: During one incident, while at home, John McEwan was observed to be angry at having been reconnected to the ventilator against his wishes. cessation of medication, remaining out of hospital and not being the subject of an involuntary admission to a psychiatric facility) ( Sellars et al 2017 ). Conclusions A proposal for a code of ethics for NPs is presented. Violation of ethical principle and law. 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. Other barriers that have been identified include: concerns about the ‘legal and ethical issues relating to the liability for implementing or overriding (PAD) statements’. Family nurse practitioners (FNPs) often are the first to see patients with mental health issues. The scope of nursing has evolved from the early role of a nurse carrying out orders at a doctor’s bidding. It teases out the ethical challenges that mental health nurses can face on a daily basis. 4 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. Third, even when persons with mental illness later acknowledge the need for their earlier involuntary or non-voluntary admission to hospital, they are sometimes left feeling very dissatisfied with the situation – not least because they feel that their humanity and dignity have been violated in the process. Following a family visit, the patient attempted suicide, wounding herself in the neck. Ethics is an important aspect of healthcare and is very common in theme in nursing (Beidler, 2005). 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. 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. This, in turn, may be counter-therapeutic because of the harmful emotional effects of the dehumanisation and dignity violation that are sometimes experienced as well as the undermining of trust in the professional–client relationship ( Belcher et al 2017 ; Borckardt et al 2007 ; Cusack et al 2018 ; Gustafsson et al 2014 ). The nurse maintains competence in nursing. Individual Coverage 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. • FNPs should be aware of treating outside the scope of practice for mental illness. The nurse assumes responsibility and accountability for individual nursing judgements and actions. Nursing staff of many specialities are taking on and developing their roles in new and advanced practice areas. In summary, the notion of ‘rational competency’ is problematic because there is no precise definition of, or agreement on, what it is. a. 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 ). 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). 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. First published in 1991, with a 2012 revised edition of the statement launched in early 2013, this document stands as an influential guide for other public policy initiatives and statements such as the National mental health policy (released in 2008 and committed to by all Australian governments), and successive national mental health plans (including the most recent Fifth national mental health and suicide prevention plan released in 2017 , the National standards for mental health services 2010 and the National carer strategy in 2011 ( Australian Government Department of Health 2010 , 2011 , 2017 ) and other documents (e.g. For many, the answer lies in the systematic development and formal adoption of psychiatric advance directives (PADs). This chapter explores mental health nursing practice within an ethics context. ETHICAL CODES FOR PSYCHIATRIC NURSE PRACTITIONERS Paul D. Friedman, M.A., Ph.D., J.D. 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’. In a nutshell, a nurse must: Discharge orders included a home care referral for wound care and assessment of perceived changes in the patient’s mental status. However, these arguments were rejected. The origin of the term ‘Ulysses contract’ is not clear although it probably originated in a commentary by Ennis (1982 : 854) in which reference is made to ‘Odysseus at the mast’, published in response to Szasz’s (1982) original article on ‘The psychiatric will’ (see also Hastings Center Report 1982a ). There was no reason to suspect that John McEwan’s wishes were irrational. 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 iThese d… 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. For instance, there remains the problem of how to determine what is a harm, what is a low / minimal and high / maximal risk of harm, and who properly should decide these things – the answers to which involve complex value judgments. 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. Such nurses need guidance direction and information to assist them in their new roles. Moreover, there is little evidence showing that PADs have, in fact, achieved their intended purpose ( Campbell & Kisely 2009 ). The quality of the patient’s choice in this instance is irrelevant. Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. Legal and ethical issues are prevalent in the health care industry, and in particular for the nursing practice, where nurses have daily individual contact. 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. Nonetheless PADs have been touted as having the capacity to realise a number of benefits including: ‘decrease hospitalizations, reduce coercion in treatment, and improve relationships between consumers, families and clinicians’ ( Peto et al 2004 ; Sellars et al 2017 ; Zelle et al 2015a ), and destigmatising patients with mental illness on account of giving them the same rights to refuse psychiatric treatment as patients who wish to refuse general medical treatment ( Atkinson et al 2004 ). This myth has been taken by PAD proponents as analogously justifying psychiatric patients abdicating their ‘freedom’ to substitute decision-makers during periods of incapacitation: although restrained during these periods, like Ulysses, their autonomy nonetheless remains intact. 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 ). acute psychiatry. 250 Legal & Ethical Issues that Health Care Professionals Face. Within his scope of practice, he was able to make a determination of mental illness. As noted earlier, SDM places the person who is being supported at the front of the decision-making process ( ALRC 2014 ). ethics. A second consideration is that many people with mental illness have experienced high rates of trauma during their lifetime. Before his accident he had been a committed sportsman and for him the life of a helpless quadriplegic was intolerable. [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 … Students in the Advanced Clinical Nursing class that I taught were assigned to write a paradigm case--a story that reflected an ethical dilemma that they had experienced in their clinical practice. 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). Explore ways in which the nursing profession might improve its advocacy of people with mental health problems and severe mental illnesses. 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. However, re-trying any of those matters would not necessarily change the result, in light of the plaintiff’s obvious mistreatment and grievous injuries. 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). 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. These providers are likely to be confronted with a variety of ethical issues … She was treated with pain medication and antidepressants. The insured was a board certified psychiatric nurse practitioner who was working as an independently contracted (i.e., non-employed) nurse practitioner for the co-defendant facility. The legal ramifications and violation of law for practicing PAD are as followed; FNP’s cannot legally or ethically make the diagnosis to determine terminal illness, for the purpose of qualification in PAD (Stokes, F., 2017. Many a time nurse practitioners find themselves in ethical dilemmas about what to do in certain situations and tend to follow their instincts as the best course of action to pursue, and this could help to … Although barriers to the implementation of PADs persist, research has found that consumers continue to have a high interest in and demand for PADs. By taking these steps, Ulysses was able to investigate the power of the Sirens without being seduced to his death by them as well as ensure the safety of his ship and his crew as they sailed past them. they help to remind all stakeholders (patients / consumers, service providers, caregivers and the community at large) that their relationships with each other are ethically constrained and are bound by certain correlative duties. 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. With reference to the idea of psychiatric advance directives in mental health: define what a psychiatric advance directive is, discuss critically the different theoretical frameworks and forms that psychiatric advance directives can take, discuss critically the different functions that psychiatric advance directives might serve, examine the purpose of ‘Ulysses contracts’. [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 psychiatric medicine… It should be noted, however, that these two models are not necessarily mutually exclusive and indeed could, in some instances, be mutually supporting (a man contemplating a violent suicide involving others is a danger not only to himself but also to the innocent others he plans to ‘take with him’). 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. discuss critically the possible risks and benefits of psychiatric advance directives. Nevertheless, Buchanan and Brock (1989) provide an important basis for identifying the following three factors which need to be taken into consideration when deciding whether to override a mentally ill person’s decisions, namely: (1) whether the person is a danger to herself or himself, (2) whether the person is in need of care and treatment, and (3) whether the person is a danger to others. 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 ). Health care professionals practice in an environment that is complex, with many regulations, laws and standards of practice. the capacity to communicate the decision made (after Kerridge et al 2013 : 384–6). 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. 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. Depending on the state, FNPs could face legal implications for prescribing to family and friends. In defence of their position, they argue that the patient’s complaints are justified – the adverse side effects of his psychotropic drugs have indeed been ‘awful’, and are commonly experienced by other patients as well; and that he has experienced a decline in his psychiatric condition before, and hence knows what to expect. 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. Variously named ‘psychiatric wills’, ‘self-binding directives’ (SBDs), ‘advance directives’, ‘advance statements’, ‘advance agreements’, ‘advance instructions’, ‘crisis cards’ and ‘Ulysses contracts’, the idea of notifying treatment preferences in advance, or making a ‘psychiatric will’ (a term that is analogous to ‘living wills’), is credited with originating in the work of the eminent American psychiatrist, Thomas Szasz (1982) , and the identified need for psychiatric patients to have an instrument that enabled them to refuse unwanted treatment. Although ‘gold standard’ evidence is lacking, the authors of a 2009 Cochrane Database Systematic Review on ‘Advance treatment directives for people with severe mental illness’ nonetheless concluded that advance directives were ‘well suited to the mental health setting for the purpose of conveying patients’ treatment preferences should they become unable to articulate them in the future’ ( Campbell & Kisely 2009 : 10). Such nurses need guidance direction and information to assist them in their new roles. The plaintiff’s family filed a lawsuit on behalf of the plaintiff, naming the alcohol and drug rehabilitation facility and healthcare professionals responsible for her care, including the insured nurse practitioner. 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). VI. This case study involves a nurse practitioner working in a medical clinical environment. in clinical contexts) usually refer to a person’s competence to do something , in this instance, to choose and make decisions ; according to this view, competence is, therefore, ‘choice and decision-relative’. 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. The growing role of psychiatric mental health nurse practitioners is discussed. When told of this risk she replied, happily: ‘I hope I am the one!’. It is perhaps easy to think of competency in cases such as this in purely medical or psychiatric terms. 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. 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). 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. Rather, it tends to be only in cases of ‘treatment refusals, especially those that appear to be irrational, that the question of a patient’s competence most frequently and appropriately arises’ ( Gert et al 1997 : 142; see also Light et al 2016 ). • Recommendations to ensure best practices and avoid legal issues are suggested. 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). Ethics regards standards of moral judgement and professional conduct. Nevertheless, as Buchanan and Brock’s highly cited work Deciding for others: the ethics of surrogate decision-making (1989) has shown, it is possible to devise at least a prima-facie working framework to guide professional ethical decision-making in this sensitive, complex and problematic area. The facility required full payment at the time of admission and asserted that it was capable of caring for and treating her multiple problems and symptoms. Besides, they make decisions that lead to deterioration of a patient’s health instead of ensuring recovery. Roth and colleagues (1977 : 282), for example, cite the case of a 49-year-old psychiatric patient who was informed that there was a one-in-three-thousand chance of dying from ECT. Ethical issues happen when choices need to be made, the answers may not be clear and the options are not ideal. (Whether or not the risk of suicide does provide strong grounds for overriding a patient’s decision to refuse hospitalisation and treatment is another question, and one which is considered shortly in this chapter.). • Liability risks for psychiatric mental health nurse practitioners are reviewed. Psychiatry is no exception. Comparable studies conducted in Australia and New Zealand have had similar findings. This case study involves a nurse practitioner in an in-patient alcohol/drug treatment setting. It is important to acknowledge that, despite their envisaged benefits, PADs are not without risk. Attention will also be given to the vexed issue … ethics. 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. 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. Findings: The results indicated that nurses needed additional education in psychiatric ethics. 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. Email: service@nso.com 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 ). This case study involves a nurse practitioner in an in-patient alcohol/drug treatment setting. 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. The MSN Psychiatric Mental Health Nurse Practitioner track includes 18 courses totaling 45 credit hours. The program begins with nine, three-credit core courses that focus on specific roles of the advanced nurse in the healthcare system prior to transitioning into specialty courses specific to the track.. Within contemporary medical ethics recognition of the principle of self governance or respect for autonomy has altered the nature of interactions between patients and health professionals in all sectors of the health system. 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’. Like Gert and colleagues (1997) , cited earlier, they argue that statements of competence (i.e. They go on to warn that there is no magical definition of competency, and that the problems posed by so-called ‘incompetent’ persons are very often problems of personal prejudices and social biases, or of other difficulties associated with trying to find the ‘right’ words. In either case, timely and effective psychiatric treatment and care are imperative. Significantly the issue of competency rarely arises in contexts where the patient agrees with and consents to a doctor’s recommended or prescribed treatment. mental disorders. 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. 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. 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. Arguably the most profound change (described as an ‘evolving revolution’ by Callaghan and Ryan 2016 ) has occurred in Australian jurisdictions. 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. • FNPs should be aware of treating outside the scope of practice for mental illness. 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 ). 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. Rights and responsibilities of carers and support persons – encompassing the rights and responsibilities of carers and support persons in relation to the rights to: respect the human worth and dignity of people; privacy and confidentiality; seek and receive appropriate training and support; participate in and contribute to the development of social, health and mental health policy. Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. 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 . • Recommendations to ensure best practices and avoid legal issues are suggested. This test asks how well the patient has actually understood information which has been disclosed. 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. 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 ). Family nurse practitioners (FNPs) often are the first to see patients with mental health issues. Later, after recovering from this incident, the patient was, as predicted by the less experienced nursing staff, grossly mistrustful of the nursing staff on the ward, and even less willing to comply with his oral medication prescription. Historically the critical issue in developing tests of competency is how to strike a contented balance between serving a rationally incompetent person’s autonomy and also serving that person’s health care, nursing care and medical treatment needs . 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. Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. As previously indicated in this section, an integral and controversial component of psychiatric practice is involuntary care and 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. Ethical code or nursing care -related problems included (a) neglect, (b) rude/careless behavior, (c) disrespect of patient rights and human dignity, (d) … Conclusions A proposal for a code of ethics for NPs is presented. The patient was a 59-year old female who had undergone inpatient bilateral salpingo-oophorectomy three days before being discharged to home care. Besides, they make decisions that lead to deterioration of a patient’s health instead of ensuring recovery. 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. Findings: The results indicated that nurses needed additional education in psychiatric ethics. 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. #LegalCases 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. 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. 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. 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. This is so even in jurisdictions which have progressive legislative provisions enabling patients to determine in advance their ‘will and preferences’ apropos care, treatment and supported decision-making options ( Callaghan & Ryan 2016 ; Hem et al 2018 ; Molodynski et al 2014 ; Tingleff et al 2017 ). Advanced practice registered nurses (APRNs) are active in a variety of clinical, educational, and executive roles, with varying degrees of involvement in and influence over clinical practice. 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. 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 ). 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. It is therefore important that nurses are equipped with the skills and knowledge to understand ethics within their practice. Findings: The results indicated that nurses needed additional education in psychiatric ethics. 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. This framework is expressed diagrammatically in Fig. Defense experts placed the value at $2.7 million. The claim of a moral right usually entails that another person has a corresponding duty to respect that right. Basically, it asks whether a given choice is the product of ‘mental illness’ or whether it is the product of prudent and critically reflective deliberation. 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 )). The patient’s bill of rights calls for full disclosure of a medical error ( … The primary objective of the 2012 revised version of the Mental health statement of rights and responsibilities document is to inform stakeholders of the rights of people experiencing a mental illness to have access ‘to timely assessment, individualised care planning, treatment and support’ and the related rights and responsibilities that consumers, carers, support persons, service providers and the community all have in relation to these rights ( Australian Government Department of Health 2012 : 3). The nurse practitioner demonstrated appropriate concern for the patient and reported his findings regarding her past and current use of narcotic pain drugs to his supervising psychiatrist. 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). As previously explained, a moral right can be defined as a special interest or entitlement which a person has and which ought to be protected for moral reasons. 3 An estimated 77 percent of U. S. counties are reporting a significant shortage of professionals who can prescribe and manage medications. ETHICAL CODES FOR PSYCHIATRIC NURSE PRACTITIONERS Paul D. Friedman, M.A., Ph.D., J.D. Findings: The results indicated that nurses needed additional education in psychiatric ethics. 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). 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). 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 ). In contrast, the correctional nurse may face ethical situations daily. The higher and more severe the risks involved, the higher and more rigorous should be the standards for determining the patient’s decision-making capacity, and the more certain attending health care professionals should be that the patient has met these standards. : 3 ) ) is your resource for psychiatric-mental health nursing practice within an ethics context insured not. 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