Chapter 6

Legal and Ethical Aspects

What it means
to you

Prepare nurses to abide by legal and

ethical principles in the practice of nursing:
Protection of themselves and clients
Enhance quality of care
Introduce ethics as basic and obvious
moral truths that guide delivery of care
Emphasize the importance of professional
boundaries when working in therapeutic
relationships

Legal Issues in PMH Nursing

Care

Nurse Practice Acts and the expanding role of nursing

Malpractice
Obtaining legal counsel
Basic rights of clients receiving psychiatric
nursing care

w
a
L

Evolving legal rights

Client status and specific legal issues (commitments)
Special client populations (forensic, minors, elderly)
Nurse user/abuser

Scope of Each States

Nurse Practice Act
Written documents that outline minimum
expectations for safe nursing care
Define nursing and judicial system looks up
to them during cases of malpractice
Describe the scope of nursing for each
state
Identify the limits of nursing

Virginia
Nurse
Practice
Act

Malpractice

Is professional negligence
Comes under Tort
Consumer is plaintif
Professional is a defendant
Battery
Assault
Libel-written
Slander

Tort Law Applied to

Psychiatric Settings
Protection of patients: legal issues common
in psychiatric nursing are related to failure
to protect & maintain patients safety or
safe environment
Protection of self
Nurses must protect themselves in both
institutional and community settings
Important for nurses to participate in
setting policies that create safe
environments

Negligence/Malpractice
Negligence or malpractice is an act or an omission
to act that breaches the duty of due care and
results in or is responsible for a persons injuries.
Nurse must ensure professional behavior- always
reflects statutory & professional standards.
Elements necessary to prove negligence
Duty; nurse owed client duty of due care
Breach of duty owed client (below or deviation
from standard)
Proximate cause
Injury
Damages Cause in fact
Evaluated by asking except for what the nurse
did, would this injury have occurred?

Negligence/Malpractice
(contd)

Proximate cause or legal cause

Evaluated by determining whether there were
any intervening actions or individuals that
were in fact the causes of harm to patient
Damages
Include actual damages as well as pain and
sufering
Foreseeability of harm
Evaluates likelihood of outcome under
circumstances

Elements of Nursing Negligence

The nurse professional owed a duty of due care
toward the plaintif
The nurse professionals performance breached the
duty owed to the plaintif by falling below or
deviating from the accepted standard of care
The nurse professionals act was the proximate
cause of the plaintifs injury, and that it was
foreseeable that it would cause an injury
The plaintif consumer sustained injury or harm
If found liable, usually employer is too (respondent
superior)

Rights Retained by Clients with

Psychiatric Disorders
Communicating with an attorney
Sending and receiving mail without censorship
Having visitors; supervised visitation
Receiving basic necessities of life
Being protected from harm
Refuse treatment- only if they came in
voluntarily.
Power and opportunity to revoke consent at
anytime during treatment

Application of Restraints and

Use of Seclusion
Considered high-risk, dangerous modalities
that can result in injury or even death
Must be used when everything else has
failed
Legally, they are high risk because they
greatly inhibit the right to freedom
Clients may perceive this as a form of
punishment

Rights Regarding Restraint and

Seclusion
Doctrine of least restrictive means restraint for
shortest time is always the rule
Legislation provides strict guidelines for use
When behavior is physically harmful to
patient/others
When least restrictive measures are
insufficient
When decrease in sensory overstimulation
(seclusion only is needed)
When patient anticipates that controlled
environment would be helpful and requests
seclusion

Rights Regarding Restraint

and Seclusion (contd)
Recent legislative changes have further
restricted use of these means and some
facilities have instituted restraint free
policies
Seclusion: Involuntary confinement in a room
or an area where the person is physically
prevented from leaving (excludes timeout)
If you threaten a pt with seclusion if they
get out of bed, you are restraining them
and this is considered false imprisonment

Promoting Advocacy for Clients

Discussing rights within treatment team
Including these rights in nursing care plans
Ensuring that facility and unit policies and
procedures include methodologies for
protecting client right

Elements of Informed Consent: you

get it either from the pt or court

Informed consent; agreeability to treatment by recipient of

healthcare after receiving sufficient information that
enables recipient to understand proposed Tx or procedure
The way the treatment or procedure will be administered
The prognosis if the treatment or procedure is done
Side efects
Risks
Possible consequences of refusing the treatment or
procedure
Other alternatives
*Treatment without consent is battery
Client must be mentally competent to give and voluntarily

Elements of Informed
Consent
(Contd)Act requires
Patient Self-Determination

healthcare facilities to provide clear

written information to every client
concerning his/her legal rights to make
healthcare decisions, including the right to
refuse or accept treatment
When a client cannot give informed
consent independently a substituted
consent must be obtained from another
person a healthcare proxy (next of kin,,
court-appointed guardian)

Health Insurance Portability

and Accountability Act
Nurses have a professional and an ethical duty to
use information gained about clients only to
enhance client care (not gossip, curiosity)
HIPAA outlines guidelines for appropriate use and
disclosure of health information
Misuse of identifiable heath information.
Breach of confidentiality by nurses and other
healthcare personnel include; diagnosis, symptoms,
behaviors and outcomes of TX (have negative
impact on clients employment, promotion,
insurance benefits,
relationships, etc)

HIPPA (Confidentiality)

Responsible record keeping

JCAHO requires each client to have a
medical record
Documentation may be narrative, SOAP, or
clinical pathways
Records may be kept manually or
electronically

Patient Confidentiality
Ethical considerations
Confidentiality is right of all patients
ANA Code of Ethics for Nurses (2001)
asserts duty of nurse to protect
confidentiality of patients
Legal considerations
Health Insurance Portability and
Accountability Act (HIPAA), 2003
Health information may not be released
without patients consent, except to
those people for whom it is necessary
in order to implement the treatment
plan

Patient Confidentiality
(contd)
Exceptions

Duty to Warn and Protect Third Parties

Tarasof v. Regents of University of California
(1974) ruled that psychotherapist has duty
to warn patients potential victim of
potential harm
Most states have similar laws regarding duty
to warn third parties of potential life threats
Staf nurse reports threats by patient to the
treatment team
Cases of abuse to children and elderly

Evolving Legal Rights

Right to treatment
Right to treatment in least restrictive
environment
Right to refuse treatment
Right to aftercare to ensure continuity
of care to prevent revolving door
phenomenon

Client Status and Specific Legal

Issues
Civil commitment admissions:
Voluntary admissions
Client who requests or agrees to
hospitalization
Mentally competent
Emergency admissions
Client who acts in a way that indicates he
is mentally ill and may be a threat to self
or others

Client Status and Specific Legal

Issues (contd)
Involuntary admissions
Types of Procedures: judicial, administrative, Agency
Nature &purpose of Involu Adm.: Observational or
temporary (TDO), emergency, long-term
Client who refuses hospitalization or treatment but
poses a danger to self or others and is mentally ill
Type of admission determines the type of treatment
Doctrines that apply to all admissions: 1. Habeus
Corpus; 2. Least restrictive alternative

Special Client Populations: Forensic

Clients
Competency to stand trial
Ability to assist the attorney with their
defense
Understanding of the nature and
consequences of the charge against him or
her
Understanding of courtroom procedures
Pleas of insanity or mental illness
Admitted involuntarily to a psychiatric facility
for a statutorily defined evaluation period

Special Client Populations: Minors

Under 18 years of age
Limits on hospitalization to statutory
requirements for admission
The court balanced the competing interests
of the rights of parents and guardians to
control the lives of their children with the
right of children to due process before their
liberty is limited

Child and Elder Abuse

Reporting Statutes
All states have enacted child abuse
reporting statutes
Many states specifically require nurses to
report suspected child, and elder abuse

Numerous states have also enacted

elder abuse reporting statutes
Agencies receiving federal funding (i.e.,
Medicare/Medicaid) must follow strict
guidelines for reporting abuse of older
adults

Avoiding Liability
Respond to the client in a timely
manner, respectful
Educate the client
Professional behavior must always reflect
the statutory and professional standards
Supervise care
Adhere to the nursing process
Document carefully
Sa
Follow up and evaluate
Ro fety
un
ds
Maintain a good interpersonal
relationship with client and family

Ethical Principles
Principles that serve as codes of conduct about right
and wrong behaviors to guide the action of individuals
Study of philosophical beliefs about what is considered
right or wrong in a society
Bioethics- ethical concerns related to client care

Everyday Ethics

Focus on interpersonal relationships

Demand confirmation of positive regard
Request the search for human dignity
Responsibility and accountability are key
ANA Code of Ethics for Nurses guides nurses'
decision-making

Bioethical Principles in PMH

Care
Autonomy: right to make ones own decisions
Beneficence: principle of doing good, promoting
good
Paternalism: intent to do good, but the professional
defines how to do good (not always positive)
Veracity: systematic behavior of honesty and
truthfulness in speech (telling the truth)
Fidelity: faithfulness to duties, obligations, and
promises
Justice: equitableness of benefits, treating others
fairly and equally

Boundaries in Ethical Nursing

Care
Boundaries must be maintained in
therapeutic relationships with clients
Boundary violations are insidious
Nurses must take responsibility for
evaluating and maintaining the boundaries
in a nurseclient relationship
Clients with psychiatric disorders
are highly vulnerable

Chapter 8
The Nursing Process in
PsychiatricMental
Healthcare & Nursing
Interventions
Ch 7

Nursing Process
Directs Collection, analysis and interpretation of data
Decision making
Goal setting
Prioritization
Selection of appropriate interventions
Implementations
Evaluations
Framework for critical thinking about nursing care
When applied to nursing practice, helps to solve clinical
problems and plan systematic care

Nursing Process in PsychiatricMental Health

Nursing

First Step of the Nursing Process:

Assessment

Assessment establishes a database about a client

It is the act of gathering data, classifying, categorizing,
analysing, and documenting information about a
clients health status .
Data collected; current problem, self care abilities,
nutrition, elimination, sleep patterns, harm self or
others, support system, substance use (what, how, last
used), MSE, medical history, psychiatric history,
pharmacology, alternative therapies, allergies
Observation; behavior, afect, cognition, interpersonal
relationships, physical assessment
Psychosocial assessment; definition of problem, history
of current problem , hx of coping, family and social hx
Mental status exam; provides specific information about
clients appearance, activity speech, emotional state,
cognitive function and perception

Sources of Assessment Data

Interview with clients and their families

History and physical examination

Mental status examination (MSE)

Records from other healthcare facilities or prior

treatments

Laboratory and psychological tests

Assessments by other professionals

and paraprofessionals (psychiatrists,
psychologists, SW)

Second Step of the Nursing Process:

Diagnosis
Def. Clinical judgment about clients response to
actual or potential health problems/life
processes (identifying a problem or unmet
needs). This clinical judgment forms the basis for
Tx and leads to the achievement of outcomes for
which nurses are accountable.
Analysis of data collected during assessment,
which leads to diagnosis, or identification of the
clinical problem (unmet need) to address. Client
problem is defined using accepted nsg terms
Can be real (actual) or potential or risk
Actual problem with three parts; problem,
etiology (R/T) and supporting data
,manifestations (S/S, AEB)

Nsg. Diagnosis (Contd)

Ex.I: Inefective coping R/T dysfunctional

behavioral patterns secondary to alcohol use as
evidence by use alcohol use during stressful
times, inability keep a job, disruption in marital
relationships
Ex. II: Risk for suicide R/T depressed mood AEB
stating I cant go on like this, giving away
personal possessions, dangerous behavior
(drinking and driving)
Ex. III: Risk for injury related to bending substance
withdrawal
Ex. IV: Inefective health maintenance related to
continued alcohol use AEB deteriorating health
status including underweight, gum disease,
cirrhosis

Third Step of the Nursing Process:

Planning
Creating strategies for achieving the desired
outcomes
Identifying outcomes and selecting interventions
(evidence based)
Realistic, measurable, with a time-frame
Flow from nursing diagnoses
Stated in a behavioral terms and used to set goals
Must be positive
Refer to client behavior (client focused)

Third Step of the Nursing Process:

Planning (contd)
Selecting interventions

Dependent on nurses level of practice

Targeted toward helping client achieve
outcome
Standardized care plans
Clinical or critical pathways
Focuses on nurse behavior rather
clients.
Is followed by implementation

Fourth Step of the Nursing Process:

Implementation

Occurs when nurses perform planned nursing actions

theoretically and evidence-based and consistent with
collected data

Continuity in carrying out specific interventions is

critical to achieving desired outcomes

Levels of intervention
Primary
Secondary
Tertiary

Fifth Step of the Nursing Process:

Evaluation
Determining the value of each intervention or the
attainment of desired outcomes
Centres on the changes experienced by clients and the
quality or the efectiveness of the nursing care itself
Outcomes not met:
- Additional data gathering
- Reassessment
- Revise plan

Focus of the Evaluation Step

An on going process for maintaining,

modifying or expanding the nursing care plan

Changes experienced by the client

Quality or efectiveness of the nursing care

itself

Standards of Care

Standard I -- Assessment (Rapport, current

problem, cl. current level of psychological
functioning, identify goals, perform MSE, identify
behaviors, beliefs, areas of cl. To be modified to
efect change, use of standardized assessment
tools, diagnostic tests and lab

Standard II --Formulating a nursing diagnosis

Standard III-- Determining outcomes

Standards of Care Contd

Standard IV Planning- Identifying nsg interventions

to meet the outcomes and are appropriate for cl.s
level of functioning, safe, scientific, individualized.
NIC is a research-based standardized language of
approximately 500 interventions nurses can use
Standard V Implementation:
Basic Level; counseling, milieu management,
promotion of self-care, psychopharm, health
teaching, case management, health promotion
and health maintenance
Advanced Level; psychotherapy, prescriptive
authority, and consultation plus basic level
interventions

Standards of Care
(Contd)

Standard VI-- Evaluation

Is on going throughout all the phase
Three possible outcomes (met, unmet, partially met)
Client behavior must be recorded as evidence
Documentation; accurate, objective, include steps of
nursing process

Intervention Strategies for Beginning

Practitioners
Problem solving
Crisis intervention
Stress management
Behavior modification