Objectives

1. Differentiate among ethics, morals, values and rights.

2. Discuss ethical theories including utilitarianism, Kantianism, Christian ethics,

natural law theories, and ethical egoism.
3. Define ethical dilemma.
4. Discuss the ethical principles of autonomy, beneficence, nonmaleficence, veracity,
and justice.
5. Use an ethical decision-making model to make an ethical decision.
6. Describe ethical issues relevant to psychiatric/mental health nursing.
7. Define statutory law and common law.
8. Differentiate between civil law and criminal law
9. Discuss legal issues relevant to psychiatric/mental health nursing.
10. Differentiate between malpractice and negligence.
11. Identify behaviors relevant to the psychiatric/mental health setting for which
specific malpractice action could be taken.

Legal and Ethical Issues

Nurses

are constantly faced

with the challenge of making
difficult decisions regarding
good and evil or life and death.

Legislation

determines what
is right or good within a
society.

ANA

Code of Ethics

http://www.nursingworld.org/MainMenuCategories/EthicsStandar
ds/CodeofEthicsforNurses/2110Provisions.aspx

Ethical Principles
Autonomy - This principle

emphasizes the status of

persons as autonomous
moral agents whose rights to
determine their destinies
should always be respected.
Beneficence - This refers to
ones duty to benefit or
promote the good of others.
Nonmaleficence
abstaining from negative
acts toward another; includes
acting carefully to avoid
harm

Justice principle based on

the notion of a hypothetical

social contract between free,
equal, and rational persons.
The concept of justice reflects a
duty to treat all individuals
equally and fairly.

Veracity principle that

refers to ones duty to be

truthful always.

Ethical Issues in Psychiatric/Mental

Health Nursing
http://www.nami.org/
Confidentiality/Right
Informed

to Privacy

Consent
The right to refuse medication
The right to the least restrictive treatment
alternative
Restraint/ Seclusion

Legal Considerations

Nurse Practice Act defines

the legal parameters of
professional and practical
nursing.
Types of Laws

Statutory law

Common law

Classifications Within Statutory

and Common Law
Civil Law - protects

the private and

property rights of
individuals and
businesses
Tort
Contracts
Criminal law provides protection from
conduct deemed
injurious to the public
welfare

Confidentiality and

right to privacy
Doctrine of privileged
communication

Informed consent
Restraints and

seclusion
False imprisonment

Legal Issues in Psychiatric/Mental

Health Nursing

Commitment issues

Voluntary commitment

Involuntary commitment

Emergency commitment

The mentally ill person in need of treatment

Involuntary outpatient commitment

The gravely disabled client

https://www.youtube.com/watch?v=1begEzNdLlU

Common Issues in Psychiatry

Tarrasoff-

Duty to warn
Assessment for Danger
and /Violence
History of violent acts
Non-compliance with
treatment
Current substance
abuse
Antisocial personality
Disorder

Incompetence
Has

mental disorder
It causes defect in
judgment
Makes the person
incapable of handling
affairs
Court appoints legal
guardian

An involuntarily committed client is verbally abusive to the staff

and repeatedly threatening to sue. The client records the full names
and phone numbers of the staff. Which nursing action is most
appropriate to decrease the possibility of a lawsuit?
A. Verbally redirect the client, and then limit one-on-one
interaction.
B. Involve the hospitals security division as soon as possible.
C. Notify the client that documenting personal staff
information is against hospital policy.
D. Continue professional attempts to establish a positive
working relationship with the client.

An inpatient client with a known history of violence suddenly

begins to pace. Which client behavior should alert a nurse to
escalating anger and aggression?
A. The client requests prn medications.
B. The client has a tense facial expression and body language.
C. The client refuses to eat lunch.
D. The client sits in group therapy with back to peers.

After years of dialysis, an 84-year-old states, Im exhausted,

depressed, and so over these attempts to keep me alive. Which
question should the nurse ask the spouse when preparing a
discharge plan of care?
A. Has there been had any appetite or sleep changes?
B. How often is your spouse left alone?
C. Has your spouse been following a diet and exercise
program consistently?
D. How would you characterize your relationship with
your spouse?

client has been brought to the emergency department for signs

and symptoms of Chronic Obstructive Pulmonary Disease (COPD).
The client has a history of a suicide attempt 1 year ago. Which
nursing intervention would take priority in this situation?

.Assessing the clients pulse oximetry and vital signs

B.

Developing a plan for safety for the client

C.

Assessing the client for suicidal ideations

D.

Establishing a trusting nurseclient relationship

Relationship Development

Objectives
Describe

the relevance of a therapeutic nurseclient

relationship.

Discuss

the dynamics of a therapeutic nurseclient

relationship.

Discuss

the importance of self-awareness in the nurse

client relationship.

Identify

goals of the nurseclient relationship.

Identify

and discuss essential conditions for a therapeutic

relationship to occur.

Describe

the phases of relationship development and the

tasks associated with each phase.

Introduction
The

nurse-client relationship is the foundation on which

psychiatric nursing is established.

therapeutic relationship is an interaction between two

people (usually a caregiver and a care receiver) in which
input from both participants contributes to a climate of
healing, growth promotion, and illness prevention.

Role of the Psychiatric Nurse

Nursing

has evolved through various roles from custodial

caregiver and physicians handmaiden to recognition as a
unique, independent member of the professional health-care
team.

Role of the Psychiatric Nurse

Peplau
The

identified seven subroles within the role of the nurse:

stranger. In the beginning, nurse and client are strangers to each

other.
The resource person. The nurse provides information related to the
clients health care.
The teacher. The nurse identifies learning needs and provides
information required by the client or family to improve the health
situation.
The leader. Democratic leadership allows the client to be an active
participant in planning his or her care.
The surrogate. For the client, the nurse fulfills basic needs, which is
associated with mothering.
The technical expert. The nurse possesses the clinical skills
necessary to perform the interventions that are in the clients best
interest.
The counselor. The nurse uses interpersonal techniques to help
clients learn to adapt to difficulties or changes in life experiences.

Role of the Psychiatric Nurse

Peplau

believed that the emphasis in psychiatric nursing

should be on the counseling subrole.

Peplau

emphasized the importance of relationship

development in the provision of emotional care.

Dynamics of a Therapeutic
Nurse-Client Relationship
Therapeutic

nurse-client relationships can occur only when

each views the other as a unique human being. When this
occurs, both participants have needs met by the relationship.

Therapeutic

relationships are goal oriented and directed at

learning and growth promotion.

Goals

are often achieved through use of the problem-solving

model:
Identify

the clients problem.

Promote discussion of desired changes.
Discuss aspects that cannot realistically be changed and ways to
cope with them more adaptively.
Discuss alternative strategies for creating changes the client desires
to make.

Dynamics of a Therapeutic
Nurse-Client Relationship
Problem-solving
model

Weigh benefits and consequences

of each alternative.
Help client select an alternative.
Encourage client to implement
the change.
Provide positive feedback for
clients attempts to create change.
Help client evaluate outcomes of
the change and make
modifications as required.

Which is the primary nursing goal when

establishing a therapeutic relationship with
a client?
A. To promote client growth
B. To develop the nurses personal identity
C. To establish a purposeful social
interaction
D. To develop communication skills

Therapeutic Use of Self

Definition:

The ability to use ones personality consciously and in

full awareness in an attempt to establish relatedness and to
structure nursing interventions

Nurses

must possess self-awareness, self-understanding, and a

philosophical belief about life, death, and the overall human
condition.

Gaining Self-Awareness
Values

clarification is one process by which an individual may

gain self-awareness.

Beliefs

are ideas that one holds to be true. They may be:

Rational
Irrational
Held on faith
Stereotypical

Attitudes

are frames of reference around which an individual

organizes knowledge about his or her world.
Attitudes

have an emotional component. They may be judgmental,

selective, and biased.
Attitudes may be positive or negative.

Gaining Self-Awareness
Values

are abstract
standards, positive or
negative, that represent
an individuals ideal
mode of conduct and
ideal goals.
Values

differ from
attitudes and beliefs in
that they are action
oriented or action
producing.
Attitudes and beliefs
become values only when
they have been acted on.
Attitudes and beliefs flow
out of ones set of values.

Conditions Essential to Development

of a Therapeutic Relationship
Rapport
Trust
Respect
Genuineness
Empathy

Phases of a Therapeutic NurseClient Relationship

Pre-interaction Phase
Obtain

information about the client from chart, significant others,

or other health team members.

Examine

ones own feelings, fears, and anxieties about working

with a particular client.

Phases of a Therapeutic NurseClient Relationship

Orientation (Introductory) Phase
Create

an environment for trust and rapport.

Establish
Gather

contract for intervention.

assessment data.

Identify

clients strengths and weaknesses.

Formulate
Set

nursing diagnoses.

mutually agreeable goals.

Develop

a realistic plan of action.

Explore

feelings of both client and nurse.

Phases of a Therapeutic NurseClient Relationship

Working Phase
Maintain

trust and rapport.

Promote clients insight and perception of reality.
Use problem-solving model to work toward achievement of
established goals.
Overcome resistance behaviors.
Continuously evaluate progress toward goal attainment.
Transference
Occurs

when the client unconsciously displaces (or transfers) to the

nurse feelings formed toward a person from the past

Countertransference
Refers

to the nurses behavioral and emotional response to the client

Phases of a Therapeutic Nurse-Client

Relationship
Termination Phase
Therapeutic
Progress

conclusion of relationship occurs when:

has been made toward attainment of the goals.

A plan of action for more adaptive coping with future stressful
situations has been established.
Feelings about termination of the relationship are recognized and
explored.

A client threatens to kill himself, his wife, and their

children if the wife follows through with divorce
proceedings. During the preinteraction phase of the nursepatient relationship, which interaction should the nurse
employ?
A.
Acknowledging the client's actions and encouraging
alternative behaviors.
B.

Establishing rapport and developing treatment goals.

C.
Providing community resources on aggression
management.
D.
Exploring personal thoughts and feelings that may
adversely impact the provision of care.

Boundaries in the Nurse-Client

Relationship
Professional

boundaries limit and outline expectations for

appropriate professional relationships with clients.

Professional

as:

boundary concerns commonly include issues such

Self-disclosure
Gift-giving
Touch

Friendship

or romantic association

Boundaries in the Nurse-Client

Relationship
Warning

signs that indicate that professional boundaries of the

nurse-client relationship may be in jeopardy:
Favoring

a clients care over anothers

Keeping secrets with a client
Changing dress style for working with a particular client
Swapping client assignments to care for a particular client
Giving special attention or treatment to one client over others
Spending free time with a client
Frequently thinking about the client when away from work
Sharing personal information or work concerns with the client
Receiving of gifts or continued contact/communication with the client
after discharge

Cultural and Spiritual Concepts

Relevant to Psychiatric/Mental
Health Nursing

Cultural Concepts
Culture

describes a particular societys entire way of living;

it encompasses shared patterns of beliefs, feelings, and
knowledge that guide peoples conduct and are passed from
generation to generation.

Ethnicity

relates to people who identify with each other

because of a shared heritage.
Nurses must understand these cultural concepts because
cultural influences affect human behavior, the interpretation
of human behavior, and the response to human behavior.

Cultural Concepts
Caution

must be taken not to assume that all individuals

who share a culture or ethnic group are the same. This
constitutes stereotyping and must be avoided. All
individuals must be appreciated for their uniqueness.

How Do Cultures Differ?

Communication

Has its roots in culture

Is expressed through language, paralanguage, and gestures

Space (the place where the communication occurs)

Territoriality
Density
Distance
Social organization
Social organizations are the groups within which individuals are
enculturated, acquiring knowledge and internalizing values.
Examples of social organizations are families, religious groups,
and ethnic groups.

How Do Cultures Differ? (cont.)

Time

Some cultures place great importance on values that are measured by

time, whereas others are actually scornful of clock time.
Whether individuals perceive time in the present orientation or future
orientation influences many aspects of their lives.

Environmental
Has

Control

to do with the extent to which individuals perceive they have

control over their environment
Cultural beliefs and practices influence how individuals respond to their
environment during periods of wellness or illness.

How Do Cultures Differ? (cont.)

Biological

Variations

Differences among people in various racial groups include body

structure, skin color, physiological responses to medication,
electrocardiographic patterns, susceptibility to disease, and
nutritional preferences and deficiencies.

Spiritual Concepts
Spirituality
Refers

to the human quality that gives meaning and sense of purpose to

an individuals existence
Exists within each individual regardless of belief system and serves as a
force for interconnectedness between the self and others, the
environment,
Spiritual Needs
Meaning and purpose in life
Having

a purpose in life gives one a sense of control and the feeling that life is
worth living.

Faith

Spiritual Needs

The acceptance of a belief in the absence of physical or empirical

evidence
Studies show that faith, combined with conventional treatment and an
optimistic attitude, can be a very powerful element in the healing
process.

Hope

A special kind of positive expectationan energizing force

Hope may promote healing, facilitate coping, and enhance quality of
life.

Love

May be lifes most powerful force and the greatest spiritual need.
May be an important key in the healing process by having a positive
effect on the immune system.
Studies have shown that individuals can overcome the effects of a
deleterious lifestyle if they have the benefit of a strong, loving
relationship.

Forgiveness

Spiritual Needs

The ability to release from the mind all the past hurts and failures, all
sense of guilt and loss
Long-held feelings of bitterness and resentment can have a
detrimental effect on an individuals health.
Forgiveness offers freedom and peace of mind, and enables a person to
begin the pathway to healing.

Spiritual Concepts
Religion
The practices are usually grounded in the teachings of a
spiritual leader.
There are more than 6500 religions in the world.
Affiliation with a religious group has been shown to be a healthenhancing endeavor.
Studies indicate that individuals who have a religious faith or
attend church regularly experience:
Increased chance of survival following serious illness
Less depression and other mental illness
Longer life
Overall better physical and mental health

Spiritual Concepts
Religion
A religious commitment has been correlated with:
Lower suicide rates
Lower drug use and abuse
Less juvenile delinquency
Lower divorce rates
Improved mental illness outcomes

May be correlated with strong support network found in

religious organizations

Spiritual Concepts
Assessment
Nurses

of Spiritual and Religious Needs

must consider spiritual and religious needs when planning care

for their clients.
A spiritual assessment tool may be used to gather needed information.

Diagnosis/Outcome
Nursing

Identification

diagnoses that may be used when addressing spiritual and

religious needs of clients include:
Risk

for Spiritual Distress

Spiritual Distress
Readiness for Enhanced Spiritual Well-being
Risk for Impaired Religiosity
Impaired Religiosity
Readiness for Enhanced Religiosity