*    Ethics
–    Study of philosophical beliefs about what is considered right or wrong in society
*    Bioethics
–    Ethical questions arising in health care
*    Principles of bioethics
–    Beneficence: duty to act to benefit others
–    Autonomy: respecting rights of others to make decisions
–    Justice: duty to distribute resources equally
–    Fidelity: maintaining loyalty and commitment to patient
–    Veracity: duty to communicate truthfully

Civil Rights and Due Process
Civil rights: people with mental illness are guaranteed same rights under federal/state laws as any other citizen
-    Due process in civil commitment: courts have recognized involuntary commitment to mental hospital is “massive curtailment of liberty” requiring due process protection, including:
–    Least restrictive alternative policy: mandates least extreme means be taken to achieve specific purpose

-    Historically patients with mental illness had few rights and were institutionalized and  treated inhumanly.
-    Major change- 1963, “Community mental   Health Act”
-    During the 1970’s increased awareness of the need to provide humane treatment for mental patients that respects civil rights brought the enactment of the “Baker Act”
-    1980’ Mental Health System act- “Patient’s Bills of Rights” by U.S. Congress

-    Individual dignity and respect
-    Treatment- receive, quality, give or refuse, in the least restrictive environment
-    Participation in treatment and discharge planning
-    Express and informed consent
-    Communication
-    Abuse reporting
-    Care and supervision of personal effects
-    All civil rights such as voting in elections
-    and legal representation
-    Confidentiality and privacy
-    Separation of children from adults
-    Written copy of rights on admission
* Signed by patient and copies to others
-    Discussion of rights during hospitalization
-    Posting of rights and phone numbers
•    Abuse Registry/Hot line and advocacy
•     center for persons with disabilities
-    Liability for violation of rights

The person must be:
-     Willing to seek treatment and agree to be hospitalized
-    Competent to provide express and informed consent
-    Be suitable for treatment
-     Be provided with:
* reason for admission
•    treatment, purpose,
approx. length and side effects
* alternate treatment
* consent may be revoked anytime

-    Notice of rights to request release on admission
-    Ask for for discharge release within 24 hours

-    Clients hospitalized against
their will (Danger to self or
others and or unable to care for self)
-    Does not have the right to leave the hospital but all other rights remain intact

May be initiated by:
1.    Court order- the circuit court
may issue an ex-parte order
1.    A law enforcement officer
2.    A mental health professional (physician, clinical psychologist, psychiatric nurse (ARNP, CNS) and clinical social worker)

-    Responsible for providing safe, competent,
legal and ethical care
-    Provides guidance and outlines

-    Ethical considerations
-    Legal considerations
–    Health Insurance Portability and Accountability Act (HIPAA)
–    Client’s employer
–    Rights after death
–    Client privilege and human immunodeficiency virus status
-    Exceptions to the rule
–    Duty to warn and protect third parties
–    Child and elder abuse reporting statues

TORTS
-    Unintentional
-    Negligence
-    Malpractice    -    Intentional
-    Assault
-    False Imprisonment
-    Punitive damages
Common Liability Issues
-    Protection of clients
-       Defamation of character
–    Libel
–    Slander
-    Supervisory liability
-    Short-staffing issues

-    Duty to intervene
The psychiatric mental health nurse has a duty to intervene when the    safety or well-being of the client or another person is obviously at risk.
-    Duty to report
-    Unethical or illegal practices

-    Nurses must protect themselves in institutional or community settings
-    Employers are not typically held responsible for employee injuries caused by violent client behavior
-    Nurses have placed themselves knowingly in the range of danger by agreeing to care for unpredictable clients
-    Good judgment means not placing oneself in a potentially violent situation

1.    Practice within the state laws and the Nursing Practice Act
2.    Collaborate with colleges to determine the best course of action
3.    Use established practice standards and hospital manual to guide decisions and actions
1.    Always place the patient’s rights and welfare first.
2.    Develop effective interpersonal relationships with patients and families.
3.    Document care accurately through all the steps of the nursing process

   A record’s usefulness is determined by evaluating when the record is read later, how accurately, objectively and completely it portrays the client’s behavioral status at the time it was written.

  Each individual:
-    Has intrinsic worth and dignity and each person is worthy of respect.
-    Has the potential to change.
-    Has common, basic human needs…
-    Varies in their coping capacities
-
    Each individual(s):
-    Behavior is meaningful…
-    Has a right to equal opportunity for adequate health care.
-    Has the right to participate in decision making regarding their care.
-    Has the right to self-determination…
The fundamental premise is:
The goal of nursing care is to promote wellness, maximize integrated functioning….nursing care is based on mutually determined needs and expected treatment outcomes..
An interpersonal relationship can produce change and growth within the individual….

The knowledge base of the psychiatric/mental health nurse is grounded in the integration of the biological, psychological, spiritual, social and environmental realms of the human experience.
-    Broad context of care
-    Requires purposeful use of self as a therapeutic tool
-    “Knowing you, Knowing me”  (Awareness of self) Barker, Jackson & Stevenson (1999)
-    Requires great sensitivity to the social environment & advocacy needs of clients/families
-    Requires careful consideration of legal & ethical issues
-    Milieu management
-    Assessing, planning, implementing & evaluating care
-    Pharmacological interventions
-    Documentation/Administration
-    Legal requirements
-    Educating/supervision
-    Coordination/Multidisciplinary team member

-     Exposure to clients with mental health problems or illness in any area of practice
-    Skills will assist the nurse to provide comfort to clients who may be experiencing a myriad of emotions. I.e. grief, anxiety, anger, cognitive deficits and subsequent behavior, and diagnosed mental illness
-    Mental state assessment skills
-    Early intervention – reduced stays, improved recovery rates. Improved client outcomes
-    Nurse more comfortable, confident in working with clients with mental illness

-    Oral Stage
-    Anal Stage
-    Phallic Stage
-    Latency Stage
-    Genital Stage

-    Denial. The source of distress is not acknowledged or perceived because it is too threatening.  The person refuses to admit being frightened by an event or action of another individual.
-    Repression. Unacceptable or anxiety-provoking thoughts or feelings are blotted out of consciousness.  People forget threatening occurrences.
-    Displacement. Emotions are transferred from the original person or object to a less formidable, or safer, target.  It is the “kick the cat” defense.
-    Projection.  Rejecting an unacceptable thought or feeling by blaming it on another person.  By attributing it to someone else, the unacceptable thought or feeling is removed from the person.
-    Sublimation. Directing a socially unacceptable desire or activity into a socially acceptable one.  For example, releasing sexual urges though dance.
-    Rationalization.  A socially acceptable reason is given to avoid having to face a non acceptable belief about oneself.
-    Intellectualization. Painful emotions or feelings associated with an event are explained away by the use of a rational explanation.

-    The client and helper must be in psychological contact. A therapeutic relationship or emotional connection between the helper and client is essential.
-    The client must be in a state of incongruence…If   a client feels no anxiety, she or he is unlikely to be motivated enough to engage in the helping process.
-    The helper must be congruent (genuine) or integrated in the relationship…The helper cannot be phony in the helping relationship.
-    The helper must feel unconditional positive regard for the client…Essentially, a helper is trying to understand a client’s feelings and experience but is not trying to judge whether the person “should” or “should not” have the feelings or whether the feelings are “right” or “wrong.”
-    The helper must experience empathy for the client…We can distinguish empathy from sympathy, in which the helper feels pity for the client and often acts from a one-up power position rather than as an equal.
-    The client must experience the helper’s congruence, unconditional positive regard, and empathy. If the client does not experience the facilitative conditions, for all practical purposes they do not exist for the client and the sessions are not likely to be helpful.

Diagnostic systems of psychiatric disorders
-    ICD-10 (International Classification of Diseases)
-    the World Health Organisation : used world wide
-    In USA: Diagnostic and Statistical Manual of Mental Disorders ( DSM IV-TR) 2000)
DSM :has five axes

-     Axis I: Psychiatric disorders
-    Axis II: Personality disorders / mental retardation
-    Axis III: General medical conditions
-    Axis IV: Social functioning and impact of symptoms
-    Axis V: Global Assessment of Functioning (described using a scale from (1 to 100(
Psychiatric treatment
-    In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years
-    Today, most psychiatric patients are managed as outpatients
-    Average hospital stay is around 2-3 weeks (with only a small number of cases involving long-term hospitalization.

-    ‘Mental illness’ is a general term that refers to a group of illnesses affecting the mind, in the same way that physical illness refers to illnesses which affect the body.
-    They are associated with distress or impaired functioning.
-    The term mental health problem refers to signs and symptoms of mental illnesses that do not fit criteria for a specific disorder

-    Psychiatrists
-    Psychologists
-    Psychotherapists
-    Psychiatric nurses
-    Clinical social workers
-    Occupational therapists

-    Psychopharmacology
-    Neuropsychiatry
-    Psychoneuroendocrinology
-    psychoneuroimmunology
-    Cross cultural psychiatry
-    Community psychiatry
-    Social psychiatry