MAMATA COLLEGE OF NURSING

KHAMMAM
Date:
Time:
SUBJECT: CLINICAL SPECIALTY PSYCHIATRY- II
GUIDE: MRS.ASHA KUMARI; ASST. PROFESSOR
PRESENTED BY: UDAYA SREE.G; M.Sc. (N) II YEAR
UNIT XXII: LEGAL AND ETHICAL ISSUES IN MENTAL HEALTH
NURSING

SEMINAR ON
LEGAL AND ETHICAL ISSUES IN MENTAL HEALTH NURSING

INTRODUCTION
Nurses are constantly faced with the challenge of making difficult
decisions regarding good and evil or life and death. Nurse who works in
the mental health setting is responsible for practicing ethically,
competently, safely, and in a manner consistent with all local, state, and
federal laws
TERMINOLOGY
Ethics: is the science that deals with the rightness and wrongness of
actions
Bioethics: is the term applied to these principles when they refer to
concepts within the scope of medicine, nursing, allied health.
Moral behaviour: is defined as conduct that results from serious
critical thinking about how individuals ought to treat others
Moral behavior reflects the way a person interprets basic respect
for other persons, such as the respect for autonomy, freedom, justice,
honesty, and confidentiality
Values: are ideals or concepts that give meaning to the individuals life
Right: is absolute when there is no restrictions whatsoever on the
individuals entitlement

ETHICAL CONSIDERATIONS
Theoretical Perspectives
An ethical theory is a moral principle or a set of moral principles
that can be used in assessing what is morally right or morally wrong.
These principles provide guidelines for ethical decision-making
i.

Ethical Subjectivism: right and wrong are determined by

what I believe

ii.

Ethical Relativism: right and wrong are determined by what

my society believes
Divine Command Theory: right and wrong are determined by
God

iii.
iv.

Ethical Egoism: a descriptive theory which states that people

always act to maximize their self-interest

v.

Utilitarianism or Consequentialism: right and wrong are

determined by the utility or consequences of an action; in most
versions of this theory, actions are right if they produce
happiness or reduce pain

vi.

Deontological or Rights-Based Ethics (or Kantian Ethics):

right and wrong are determined by whether the action is
consistent with duty and done from a motive of fulfilling ones
moral obligation; moral obligation is defined as respect for
persons

vii. virtue Ethics: determines the virtuous action according to

what an ideally virtuous person would do in a given situation
viii. Theories of Justice: determines just actions to be those that
emerge from the correct use of principles that have been
agreed to under conditions that are fair
ETHICAL DILEMMA
occurs when there are conflicting moral claims
a situation that requires an individual to make a choice between
two equally unfavorable alternatives
no one good solution
the decision made often has to be defended against those
who disagree with it

ETHICAL PRINCIPLES must be used to decide ethical issues.

These include:
1. Beneficence:
This relates to the quality of doing well and can be described as
charity. The nurse helps a newly admitted client with psychosis feel safe
in the environment of the mental health facility.
2. Autonomy:
This refers to the clients right to make his own decisions. But the
client must also accept the consequences of those decisions. The client
must also respect the decisions of others. Rather than giving advice to
the client who has difficulty making decisions, the nurse helps the
client explore all alternatives and arrive at a choice.
3. Justice:
This is defined as fair and equal treatment for all. During a treatment
team meeting, the nurse leads a discussion regarding whether or not
two clients who broke the same facility rule were treated equally.
4. Fidelity:
This relates to loyalty and faithfulness to the client and to ones
duty. Although the nurses shift is over, he stays on the unit for an extra
30min to assist a client with bipolar disorder who received distressing
news that her mother had died.
5. Veracity:
This refers to being honest when dealing with the client. A client
states, You and that other staf member were talking about me,
werent you? The nurse truthfully replies, We were discussing ways to
help you relate to the other clients in a more positive way.
6. Confidentiality
The clients right to privacy is protected by the Health Insurance
Portability and Accountability Act (HIPAA) of 2003.
Information about the client, verbal and in writing, must only be
shared with those who are responsible for implementing the
clients treatment plan.
Information may be shared with other persons not involved in the
client treatment plan by client consent only.

It is important to gain an understanding of the federal law and of

various state laws as they relate to confidentiality in specific health
care facilities/agencies.
Specific mental health issues include disclosing HIV status, the
duty to warn and protect third parties, and the reporting of child
and elder abuse.

MAKING ETHICAL DECISIONS

Chief goal
Determining right from wrong in situations where clear demarcations
do not exist or are not apparent
Steps
Collect, analyze & interpret the data
State the dilemma
Consider the choices of action
Analyze the advantages & disadvantages
Make the decision
LEGAL CONSIDERATIONS
LEGAL RIGHTS OF CLIENTS IN THE MENTAL HEALTH SETTING
Clients who have been diagnosed and/or hospitalized with a
mental health disorder are guaranteed the same civil rights as any
other citizen.
NURSE PRACTICE ACTS
The Nurse Practice Act (NPA) defines the scope of practice
specific to a registered nurse, a licensed practical nurse, an advanced
nurse practitioner and a nurse anesthetist.
It represents all laws that regulate a nurse's scope of practice in
the state in which she (or he) is licensed to work.
These laws protect patients from harm as well as lay the rules
and regulations for the specific level of a nurse's educational and
licensure requirements.

Function of nurse practice act

Each profession is responsible for protecting citizen's rights, and

nursing is no exception. This practice is called professional regulation
and it establishes standards and codes of ethics for practitioners at
diferent levels of expertise

LAW
Definition
The sum total of rules & regulations by which a society is
governed. As such, law is created by people & exists to regulate all
persons.
Law is a rule or standard of human conduct established &
enforced by authority, society, or custom
Functions of the Law in Nursing
It provides a framework for establishing which nursing actions in
the care of clients are legal.
It diferentiates the nurses responsibilities from those of other
health professionals.
It helps establish the boundaries of independent nursing action.
It assists in maintaining a standard of nursing practice by making
nurses accountable under the law.
Types of law
Types of law that are of most concern to nurses, these laws are
identified by their source or origin
Constitutional law
Legislation law (Statutory law)
Administrative law
Common law
1. Constitutional Law: The supreme law of a country, it creates legal
rights & responsibilities and a foundation of a system of justice.

2.

Legislation law (Statutory law): Enacted by any legislative

body .The regulation of nursing is a function of state law

3. Administrative law: It creates rules & regulations to enforce the

statutory laws.
4. Common Law: Laws evolving from court decisions. Interpreting &
applying the constitutional or statutory law.
There are two kinds of unlawful acts: civil and criminal. Both
statutory law and common law have civil and criminal components

Civil law
Civil law protects the private and property right of individuals and
business. Private individuals or groups may bring a legal action to court
for breach of civil law. These legal actions are of two basic types: torts
and contracts
Torts: A tort is a violation of a civil law in which an individual has
been wronged. In a tort action, one party asserts that wrongful
conduct on the part of the others has caused harm, and seeks
compensation for harm sufered.
Tort may be intentional or unintentional.
Eg: Unintentional torts are malpractice and negligence actions.
Intentional tort is the touching of another person without that
persons consent. Intentional touching (e.g. a medical treatment)
without the clients consent can result in a charge of battery, an
intentional tort.
Contracts: In a contract action, one party asserts that the other
party, in failing to fulfil an obligation, has breached the contract, and
compensation or performance of the obligation is sought as remedy.
eg. an action by a mental health professional whose clinical
privileges have been reduced or terminated in violation of an implied
contract between the professional and a hospital
Criminal Law
Criminal law provides protection from conduct deemed injurious of
those found to have engaged in such conduct, which commonly include
imprisonment, parole conditions, a loss of privilege (such as license), a
fine, or any combination of these.

Eg: Theft by a hospital employee of supplies or drugs

In 1980, the 96th congress of the United States passed the mental
health system act, which includes a patients bill of rights, for
recommendation to the states.
UNIVERSAL BILL OF RIGHTS FOR MENTAL HEALTH PATIENTS
MENTAL HEALTH SYSTEMS ACT OF 1980
Right to the least restrictive treatment alternative
Right to informed consent
Right to refuse treatment
Right to confidentiality
Right to keep personal items
Right to the least restrictive treatment alternative
o The nurse must attempt to provide treatment in a manner
that least restricts freedom
Right to informed consent
o Informed consent is the clients permission to perform treatment
o Legal liability for informed consent lies with the physician
o The nurse acts as the clients advocate to ensure informed consent
was obtained
Major Elements of Informed Consent
1. Knowledge: the client has received adequate information on which
to base his or her decision
2. Competency: the individuals cognition is not impaired to an extent
that would interfere with decision making
3. Free will: the individual has given consent voluntarily without
pressure or coercion from others
Treatment may be performed without obtaining informed consent
under these conditions:
o
The client is mentally incompetent to make a
decision and
treatment is necessary to preserve life or avoid serious harm
o Refusal endangers the life or health of another
o An emergency situation
o Client is a minor
o
Therapeutic privilege (full disclosure would complicate treatment,
cause severe psychological harm, or be so upsetting as to render a
rational decision impossible)
Right to refuse treatment

o The patient has the right to refuse treatment to the extent

permitted by law, and to be informed of the medical
consequences of his or her action
Right to confidentiality
o Pts privacy is protected by Amendments IV, V, and XIV
o Protection of client records and communications per state
statute
Right to keep personal items
o People in a hospital or other treatment facility retain the right to
keep their personal possessions
o Items must be protected and returned upon release from the
facility
Psychiatric patients have the right to freedom from restraint
or seclusion except in an emergency situation:
o Restraints or seclusion are used for an individual whose
behavior is out of control and who poses an inherent risk to the
physical safety and psychological well-being of the individual
and staf or others.

Restraints and Seclusion Guidelines

Restraints or seclusion can be initiated without a physicians

order in an emergency
Physician must be notified for an order within 1 hour of initiation
Renewal of restraint or seclusion orders
o Every 4 hours for adults
o Every 2 hours for children 9 years and older
o Every 1 hour for children younger than age 9
In-person evaluation of individual in restraints or seclusion by the
physician
o
Within 4 hours of initiating restraints or seclusion for an
adult
o Within 2 hours of initiating restraints or seclusion for a child

In-person re-evaluation of individual in restraints or seclusion by

the physician
o Every 8 hours for an adult

Every 4 hours for a child

The nurse must assess and document circulation, respiration,

nutrition, hydration, and elimination every 15 minutes

Concepts related to the Right to Freedom

False imprisonment: The deliberate and unauthorized confinement
of a person within fixed limits (can be verbal or physical)
o may include taking a clients clothes for purposes
of
detainment against his or her will
Assault: An act that results in a persons genuine fear and
apprehension that he or she will be touched without consent
Battery: The touching of another person without consent (harm or
injury may or may not occur
Documentation: It is vital to clearly and objectively document
information related to violent or other unusual episodes. The nurse
should document: Client behavior in a clear and objective manner.
Example: The client suddenly began to run down the hall with both
hands in the air, screaming obscenities. Staf response to disruptive,
violent, or potentially harmful behavior, such as suicide threats or
potential or actual harm to others. Include time lines and extent of
response.
Example: The client states, Im going to pound (other client) into the
ground. Client has picked up a chair and is standing 3 ft from other
client with chair held over his head in both hands. Client is immediately
told, Put down the chair and back away from (the other person).
Other client moved away to safe area. Five other staf members
respond to verbal call for help within 30 sec and stood several yards
from client. Client then put the chair down, quietly turned around,
walked to his room, and sat on the bed.
RESOURCES FOR SOLVING ETHICAL CLIENT ISSUES
Code of Ethics for Nurses with Interpretive Statements (revised in
2001 by the American Nurses Association)
Patient Care Partnership (formerly the Patients Bill of Rights)
The nurse practice act of a specific state Legal advice from attorney

MENTAL HEALTH FACILITY POLICIES

Other members of the health care team, including facility bioethics
committee (if available) Members of the clergy and other spiritual or
ethical counsellors
Types of Commitment to a Mental Health facility
1. Voluntary commitment
The client or clients guardian chooses commitment to a mental
health facility in order to obtain treatment. A voluntarily committed
client has the right to apply for release. This client is considered
competent, and so has the right to refuse medication and treatment.
2. Involuntary commitment
The client enters the mental health facility against her will for an
indefinite period of time. The need for commitment could be

determined by a judge of the court or by another agency. The number

of physicians required to certify that the clients condition requires
commitment varies from state to state.
3. Emergency commitment
A type of involuntary commitment in which the client is
hospitalized to prevent harm to self or others. Emergency commitment
is usually temporary (a few days), but time may be added if it is
determined that the client is too ill for discharge.
Involuntary commitment may also be either temporary or
long term, depending on the clients condition.
Temporary commitment may be for observation of the clients
mental status. The amount of time spent in a facility for either
temporary or long-term commitment can vary widely depending on
state statute.
Clients admitted under involuntary commitment are still
considered competent and have the right to refuse treatment, unless
they have gone through a legal competency hearing and have been
judged incompetent. The client who has been judged incompetent has
a temporary or permanent guardian, usually a family member if
possible, appointed by the court. The guardian can sign informed
consent for the client. The guardian is expected to consider what the
client would want if he were still competent.

LEGAL LIABILITIES IN NURSING PRACTICE

Definition of professional liability
Legal obligations arising out of a professional's errors, negligent acts, or
omissions during the course of the practice of his or her craft.
The obligation that a professional practitioner has to provide care or
service that meets the standard of practice for his/her professioni.e.
responsibility; when a professional fails to provide the standard of
practice, liability refers to the obligation to pay for damages incurred by
negligent acts
NEGLIGENCE

Definition
It refers to the commission or omission of an act, pursuant to a duty,
that a reasonably prudent person in the same or similar circumstances
would or would not do, and acting or the non-acting of which is the
proximate cause of injury to another person or his property.
The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) defines negligence as a "failure to use such care as a
reasonably prudent and careful person would use under similar
circumstances."
NEGLIGENCE ISSUES
Six major categories of negligence issues that prompted
malpractice lawsuits. Documentation describing the negligent behavior
often used terms such as failure to, lack of, incomplete, inefective, and
improper. The categories of negligence are: failure to follow standards
of care, failure to use equipment in a responsible manner, failure to
communicate, failure to document, failure to assess and monitor, and
failure to act as a patient advocate
Failure to follow standards of care
Standards such as hospital policies have evolved to protect
consumers from substandard care. In defining acceptable levels of
care-the ordinary and reasonable care required to ensure that no
unnecessary harm comes to patients
Failure to use equipment in a responsible manner
Nurses must know the safety features, capabilities, and limitations of
any equipment they use, as well as its hazards. Nurses must follow the
manufacturers' usage recommendations and refrain from modifying the
equipment. The Safe Medical Devices Act of 1990 requires that all
medical device-related adverse incidents that result in death or serious
illness or injury be reported to the manufacturer and the Food and Drug
Administration within 10 working days.
Failure to assess and monitor and failure to communicate
Changes in the health status of a patient can be gradual or sudden
and nurses are usually the first to see the changes and take action. A
nurse's accuracy in assessing and monitoring and her timely reporting
of changes in health status to a physician can often mean the
diference between life and death. Vital aspects of communication
besides timeliness in reporting the change include persistence in
notifying the physician of the change, and accuracy in communicating
the nature and degree of the change.
Failure to document

Documentation-the purpose of which is primarily to communicate

patient information among providers-must accurately reflect the
nursing process, showing evidence of nursing assessment and
diagnosis, planning for nursing intervention, implementation and
evaluation of planned interventions, and patient response.

MALPRACTICE
JCAHO defines malpractice as "improper or unethical conduct or
unreasonable lack of skill by a holder of a professional or official
position; often applied to physicians, dentists, lawyers, and public
officers to denote negligent or unskilful performance of duties when
professional skills are obligatory. Malpractice is a cause of action for
which damages are allowed."

Several factors have contributed to the increase in the number

of malpractice cases against nurses.
* Delegation. As a result of cost-containment eforts in hospitals and
HMOs, nurses are delegating more of their tasks to unlicensed assistive
personnel. Delegation of some of these tasks may be considered
negligence according to a given facility's standards of care or a state's
nurse practice act.
* Early discharge. Patients are being discharged from hospitals at
earlier stages of recovery and with conditions requiring more acute and
intensive nursing care.
* The nursing shortage and hospital downsizing have contributed
to greater workloads for nurses, increasing the likelihood of error.
* Advances in technology require nurses to have knowledge of a
variety of technologies' capabilities, limitations, and safety features.
* Increased autonomy and responsibility of hospital nurses in
the exercise of advanced nursing skills have also brought about greater
risk of error and liability.
* Better-informed consumers are more likely to be aware of
malpractice issues and to recognize insufficient or inappropriate care.
* Expanded legal definitions of liability have held all professionals
to higher standards of accountability.

REDUCING POTENTIAL LIABILITY

"Nursing judgment involves the analysis of facts and circumstances on
a case-by-case basis. To prevent malpractice, it is essential that the
nurse undertake this evaluation with regard to everything that he or
she does in the clinical setting."

Litigation is both professionally and emotionally devastating and can be

financially disastrous. Each nurse can take steps to help reduce
potential liability by using caution and common sense and by
maintaining a heightened awareness of his or her legal responsibilities.
The following can help nurses reduce potential liability.
Maintain
open,
honest,
respectful
relationships
and
communication with patients and family members.
* Patients are less likely to sue if they feel that a nurse has been caring
and professional.
* Don't ofer opinions when a patient asks what you think is wrong with
him-you may be accused of making a medical diagnosis.
* Don't make a statement that a patient may interpret as an admission
of fault or guilt.
* Don't criticize health care providers or their actions when you are with
patients.
* Maintain confidentiality in the health care setting.
Maintain competence in your specialty area of practice.
* Attend relevant continuing education classes.
* Attend relevant hospital in-service programs.
* Expand your knowledge and technical skills.
Know legal principles and incorporate them into everyday
practice.
* Keep up to date on your state's nurse practice act.
* Keep up to date on hospital policies and procedures.
Practice within the bounds of professional licensure.
* Perform only the nursing skills allowed within your scope of practice
and that you are competent to perform.
Know your strengths and weaknesses. Don't accept a clinical
assignment you don't feel competent to perform.
* Evaluate your assignment with your supervisor
* Accept only those duties you can perform competently
* Let an experienced nurse on the unit assume responsibilities for the
specialized duties.
* Document all nursing care accurately.
* If care is not documented, courts assume it was not rendered.
* When documenting care on the patient's chart, use the FACT
mnemonic:
Be factual, accurate, complete, and timely.

SUMMARY
Apply knowledge of mental health when discussing civil rights and
ethical issues as they apply to clients in the mental health setting.
Identify treatment options/decisions with the client/family/significant
other/staf. Inform clients regarding their right to treatment, right to
refuse treatment, and right to informed consent. Maintain client
confidentiality in the mental health facility. Identify the clients rights as
they apply to seclusion and restraint issues. Evaluate and document
care provided to ensure client safety.
BIBLIOGRAPHY
Varcarolis, E. M., Carson, V. B., & Shoemaker, N. C. (2006).
Foundations of Psychiatric mental health nursing: A clinical
approach (5th ed.)
St. Louis, MO: Saunders. NANDA International (2004). NANDA
nursing diagnoses: Definitions and classifcation2005-2006.
Philadelphia: NANDA.
Dr. Bimla Kapoor (2009) Text book of Psychiatric nursing, 2 nd
edition, Kumar publishers, Delhi
K.P. Neeraja (2004) Essentials of mental health and Psychiatric
nursing, 1st edition, Jaypee publications, New Delhi
R. Sreevani (2010) a guide to mental health and Psychiatric
nursing 3rd edition, Jaypee medical publishers, New Delhi
S. M. Raju (2010) Psychiatry and mental health nursing 1 st
edition, Jaypee medical publishers, New Delhi
Prameela (2009) principles and practices of Psychiatry nursing,
Vol-1, Maruthi publications
B.T. Basavanthappa (2007) Psychiatric and mental health
nursing 1st edition, Jaypee brothers medical publishers; New Delhi
Gail W. Stuart (2009) Principles and practices of Psychiatric
nursing, 9th edition, Elsevier publishers, India
Mary. Varghese (2006) essentials of Psychiatry and mental health
nursing, 3rd edition, Elsevier publishers, India
Mary C. Townsend (2007) Psychiatric mental health nursing 5 th
edition, Jaypee publications, New Delhi

MAMATA COLLEGE OF NURSING

KHAMMAM
Date:
Time:
SUBJECT: CLINICAL SPECIALTY PSYCHIATRY- II
GUIDE: MRS.ASHA KUMARI; ASST. PROFESSOR
PRESENTED BY: UDAYA SREE.G; M.Sc. (N) II YEAR
UNIT XXII: LEGAL AND ETHICAL ISSUES IN MENTAL HEALTH
NURSING
MASTER PLAN ON
LEGAL AND ETHICAL ISSUES IN MENTAL HEALTH NURSING
1. Introduction
2. Terminology
3. Ethical Considerations
a) Theoretical Perspectives
Principles Provide Guidelines for Ethical Decision-Making
I. Ethical Subjectivism
Ii. Ethical Relativism
Iii. Divine Command Theory
Iv. Ethical Egoism
V. Utilitarianism or Consequentialism
Vi. Deontological or Rights-Based Ethics (Or Kantian Ethics
Vii. Virtue Ethics
Viii. Theories of Justice
4. Ethical Dilemma
5. Ethical Principles
1. Beneficence:
2. Autonomy:
3. Justice:
4. Fidelity:
5. Veracity:
6. Confidentiality
6. Making Ethical Decisions
7. Legal Considerations
A) Nurse Practice Acts
B) Law

o Definition
o Functions Of The Law In Nursing
o Types Of Law
Constitutional Law
Legislation Law (Statutory Law)
Administrative Law

Common Law

o Civil Law
o Torts
o Contracts
o Criminal Law
C) Universal Bill Of Rights for Mental Health Patients
D) Resources for Solving Ethical Client Issues
8) Mental Health Facility Policies
A) Types of Commitment to a Mental Health Facility
1. Voluntary Commitment
2. Involuntary Commitment
3. Emergency Commitment
9) Legal Liabilities in Nursing Practice
A) Definition of Professional Liability
B) Negligence
C) Malpractice
D) Reducing Potential Liability
10)
Summary
11) Bibliography