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Ethical Issues in mental health nursing

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Sam Williams

on 2 November 2015

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Transcript of Ethical Issues in mental health nursing

Ethical Issues in Mental Health Nursing
November 2nd , 2015

Kimberly Hynes – 201027281

Aimee O’Keefe - 201121340

Define Ethics
Identify key ethical theories in the nursing practice
Discuss the four main pillars of bioethics
Identify important documents pertaining to the Nurses role in Mental Health ethics
Distinguish the difference between moral distress, moral uncertainty, moral residue
Discuss the role of a mental health nurse in relation to ethics
Identify common ethical issues in the mental health area
Identify situations that a mental health nurse may face in practice
Identify available community resources that can be utilized when faced with an ethical dilemma

• Self-awareness activity
• Define ethics & components of ethics
• Discuss three relevant moral theories used in nursing ethics
1) Deontology
2) Consequentialist
3) Virtue Ethics
• Discuss relevant ethical principles
• Review documents relevant to nursing practice (Standards of psychiatric nursing practice, World health organization ten basic principles, CNA the code of ethics)
• Identify the nursing role in relation to ethical dilemmas
• Discuss common ethical issues such as:
o The use of restraints
o Seclusion
o Coercion- CTOS & Involuntary admission
•Discuss legal considerations and liability issues that a mental health nurse may be faced with in practice

Guide how we should live
Explores values, relationships, principles, duties and our rights & responsibilities
A part of our everyday society

Moral Distress:
Arises in situations where nurses know or believe they know the right thing to do, but for various reasons do not or cannot take the right action or prevent a particular harm.

Moral Uncertainty
Occurs when a nurse feels indecision or a lack of clarity, or is unable to identify what the moral problem is, while at the same time feeling uneasy or uncomfortable

Moral Residue
Is what a one experiences when An act that seriously compromises oneself or allows oneself to be compromised has occurred.

2 Central concepts

1. Reason 2. Duty
Suggests that there is an obligation to act in accordance with a particular set of rules or principles.
(Austin & Boyd, 2010)
Consequentialist Theory
Based on the belief that every person in society has the right to be happy

Virtue Ethics
Holds the belief that good people will make good decisions

Is not concerned with duties or obligations
WHO 10 Basic Principles of Mental Health Care
1. Promotion of mental health and prevention of
mental disorders.

2. Access to basic mental health care.

3. Mental health assessments in accordance with internationally accepted principles.

4. Provision of the least restrictive type of mental health care.

5. Self-determination.

6. Right to be assisted in the exercise
of self determination.

7. Availability of review procedure.

8. Automatic periodical review

9. Qualified decision maker.

10. Respect out of the rule of law.

WHO 10 Basic Principles of Mental Health Care cont.
CFMHN Standards of Practice
Standard I:
Provides Competent Professional Care Through the Development of a Therapeutic Relationship.

Standard II:
Performs/Refines Client Assessments Through the Diagnostic and Monitoring Function.

Standard III:
Administers and Monitors Therapeutic Interventions.

CFMHN Standards of Practice Cont.
Standard IV:
Effectively Manages Rapidly Changing Situations.

Standard V:
Intervenes Through the Teaching-Coaching Function.

Standard VI:
Monitors and Ensures the Quality of Health Care Practices.

Standard VII:
Practices Within Organizational and Work-Role Structure.

CNA Code of Ethics
The foundation of nursing practice
1. Providing Safe Compassionate, Competent and Ethical Care

2. Promoting Health and well-being

3. Preforming and respecting informed decision making

4. Preserving dignity

5. Maintain privacy and confidentiality

6. Promoting Justice

7. Being accountable

The Four Principles of Mental Health Nursing
1. Respect for Autonomy
The use of Restraints in Practice
The application to some level of restriction to physical movement or state of mental awareness
A last resort, used only if and when a patient presents a clear threat to themselves or others.

The use of Restraints in Practice
temporarily used as a restriction of
patients movement
the use of medications with an intention
of managing behaviour
Physical or Mechanical
devices/ techniques which physically restrict or subdue the movements of the patient

Types of Restraints:
(Halter, 2014: Happell & Harrow, 2010)
Environmental restraint

A practice that continues to be used in mental health settings although there is ongoing debate about the ethical issues of this practice.

May create a negative power relationship between health care provider and patient; hindering a therapeutic relationship
Restraints and Ethics
To use:
Patient safety
used to prevent a patient from harming themselves or others

Not to use:
Can cause physical or emotional harm to patient
Violation of human rights

Which Ethical Principle would the unnecessary use of restraints violate?

A) Autonomy
B) Benefience
D) Justice
Implications for Nursing Practice
(Austin & Boyd, 2010)
(Austin & Boyd, 2010)
Methods to Facilitate the Expression of Anger
- establish basic trust and rapport with the client

- use a calm, reassuring approach

- limit the clients access to frustrating situations until he or she can express anger adaptively

- monitor for trigger situations and intervene before its expressed

- assist the client identifying his or her triggers

- establish expectation that the client can control their behavior

- assist the client to develop appropriate planning strategies to prevent inappropriate expression of anger
Environmental Management
-remove potential weapons for the environment

- search the environment routinely to maintain hazard free environment

- search the clients belongings during inpatient admission

- monitor the safety of items visitors bring to the environment

- monitor client when using potential weapons (i.e) razors

- lock utility and storage rooms

- provide ongoing surveillance
(Austin & Boyd, 2010)
De-Escalation Techniques
-respond as early as possible

-assess for personal safety

-maintain calmness for self and client (use calm, clear tone of voice)

-assess client and situation for stressors

- maintain the clients self-esteem and dignity

-maintain a large personal space

-make options clear

-be assertive NOT aggressive

(Halter, 2014)
Seclusion and restraints should only be used if the client presents a clear danger to themselves or others. Restraints of any kind should be used when alternatives fail to protect the client and others from harm.
Nurses must be familiar with how and when to use involuntary treatment and CTOs
We hope that this seminar has helped you to understand ethical dilemmas and how to resolve them
There are many ways that nurses can effectively address the ethical issues that may arise in mental health nursing.



(Halter, 2014)
A nurse in practice has a duty and responsibility to stay up to date with current education and resources related to ethics and ethical issues.

Nurses should be stay educated on:
How to properly apply restraints
The dangers and risks of restraint use
Alternatives to restraint use
Understand Situations in which restraint use is necessary
Information regarding the appropriate use of CTOs
How to educated patients to make informed decisions in their care
(Austin & Boyd, 2010: Halter, 2014)
Nurse managers and administrators have a duty to ensure that employees have the necessary information to carry out appropriate practice.

Policy implementation
ie. Eastern Health "Use of Physical Restraints"
Inform employee of any changes in practice regarding legal documents
Ensure adequate number of staff
Ensure staff are educated on policies

All possible interventions are explored before applying restraint:


Setting limits

Medication to manage symptoms (not as a control procedure)

Always offer oral medication before giving an IM
The Least Restraint Approach :
(Austin & Boyd, 2010: Halter, 2014)
Mental Health Acts in Canada
A written legal document that allows for the violation of ones human rights for a person with a mental illness.
12 in Canada
Each of the province and territories has developed their own mental health act
Each act is individualized however there are three primary areas of difference:
1. Involuntary admission criteria
2. The right to refuse treatment
3. Who has the authority to authorize treatment

Involuntary Admission Criteria
An individual must have a mental disorder
Are at risk for causing harm to themselves or others
Unable to fully appreciate the nature of their disorder
Exhibit limited decision making ability
Involuntary Admission Criteria
A description of the facts upon which the person who has conducted the psychiatric assessment is also needed and must include:

1) the time and date when the assessment was completed

2) the dated signature of the person completing the certificate of involuntary admission

3) another matter required by the regulations

(Department of Health and Community Services 2006)
(Department of Health and Community Services, 2006)
Community Treatment Orders
True or
Nurses do not need to explain to the patients their reason for using a restraint.
The nurses role in the use of restraints is to explain:
Why the restraint was used
Provide the patient with a debriefing

Liability Issues
(Halter, 2014)
Intentional Torts
• assault
• battery
• false imprisonment

Unintentional Torts
• negligence/malpractice

A legal mechanism in which an individual with a history of mental illness, non-compliance, and is at risk for violence is mandated to undergo psychiatric care in the community.

Research shows that the debate concerning the ethical implications for the use of CTOs is an international issue.

Ethical Issues: infringe on human rights and freedom, and have a high level of coercion.
(Mfoafo-M'carthy & Shera, 2013; Snow & Austin, 2009)
(Strout, 2010)
2. Non-Maleficence

3. Beneficence
4. Justice
In order to maintain ethical boundaries and therapeutic relationships within nursing practice a nurse must be in understanding of his or hers own beliefs, thoughts, biases.
Self-awareness and self reflection are key concepts when dealing with ethical issues including the use of restraints and seclusion - a nurse must be an advocate for patient safety
-(ex) a nurse may be required to put a client in seclusion if they are at risk to harm others
-a nurse may have to use put an elderly client with an unsteady gait in a geri-chair (which is also a form of restraint) to prevent injury
Throughout the research for this presentation it was concluded that more research needs to be done within this topic and the ethical issues surrounding it

Much of the research on CTOs is conducted by other disciplines such as

according to Austin & Boyd (p. 95) the lack of research could be related to the tainted history surrounding psychiatric research in Canada. Where client were "brainwashed" without their consent.
one research article found that "when a client exhibits harmful behavior, an assessment of possible risks and implementation of interventions (non-restraints) that aim to de-escalate a situation" (Laiho et al., 2013)
(Austin & Boyd, 2010: Halter, 2014)
(Halter, 2014)
(Halter, 2014)
(Halter, 2014)
(Austin & Boyd, 2010)
(Austin & Boyd, 2010)
(Halter, 2014)
(Halter, 2014)
Involuntary Hospital Admission
Austin, W., & Boyd, M. A. (2010).
Psychiatric and mental health nursing for
Canadian practice
(2nd ed.). Philadelphia, PA: Lippincott Williams and Wilkins

Canadian Federation of Mental Health Nurses. (2006).
Canadian standards
of psychiatric mental health nursing practice
(3rd ed.) Toronto: Author

Canadian Nurses Association. (2008).
Code of ethics for registered nurses
(2008 Centennial Edition). Ottawa, ON. Canadian Nurses Association

Department of Health and Community Services. (2006).
Mental health care and treatment act.
Newfoundland and Labrador: Author


Halter, M. J. (2014). Varcarolis’s Canadian psychiatric mental health nursing:
A clinical approach (lst ed.). Toronto, ON: Elsevier Inc.

Happell, B., & Harrow, A. (2010). Nurses’ attitudes to the use of seclusion: A
review of the literature.
International Journal of Mental Health Nursing 19
, 162-168. Doi:10.111/j.1447-0349.2010.00669.x

Laiho, T., Kattainen, E., Astedt-kurki, P., Putkonen, H., Lindberg, N., Kylma, J. (2013). Clinical
decision making involved in secluding and restraining an adult psychiatric patient: an integrative literature review.
Journal of Psychiatric and Mental Health Nursing, 20
, 830-839.
Doi: 10.1111/jpm.12033

Laresen, I. B., & Terkelsen, T.B. (2014). Coercion in a locked psychiatric ward: Perspectives of
patients and staff.
Nursing Ethics, 21
(4), 426-436. Doi: 10.1177/0969733013503601

M’Carthy, M. M., & Williams, C. C. (2010). Coercion and community treatment orders
(CTOs): One step forward two steps back?
Canadian Journal of Community Mental Health 29,

Mcguinness, D., Dowling, M., & Trimble, T. (2013).

Experiences of involuntary admission in an
approved mental health centre.
Journal of Psychiatric and Mental Health Nursing, 20,
Doi: 10.1111/jpm.12007

Snow, N., & Austin, W. J. (2009).

Community treatment orders: The ethical balancing act in
community mental health.
Journal of Psychiatric and Mental Health Nursing, 16, 177- 186.

Strout, T. (2010).
Perspectives on the physically restrained: an integrative review of the
qualitative literature. International Journal of Mental Health Nursing, 19(6), 416-427.

Stuen, H. K., Rugkasa, J. Landheim, A. & Wynn, R. (2015). Increased influence and
collaboration: a qualitative study of patients’ experiences of community treatment orders within an assertive community treatment setting.
BMC Health Services Research
15, 409. Doi: 10.1186/s12913-015-1083-x.

Case Study Activity

You are a newly graduated nurse working in the acute care setting and you witness a client refuse to take their medications, the assigned nurse tells the client “You have to take your medication, they are good for you” the client refuses again, the nurse then places the cup in front of the clients mouth and forcefully presses it against the clients lips.

1. Which ethical principles is the nurse not following in this situation?

2. What action, if any, should you take?

3. Identify alternative ways in which the nurse could have dealt with this situation.
Case Study #1

A 19 year old patient is brought to the emergency department by her parents with suspension that she is suffering from anorexia nervosa. The family feels she should be admitted because “they are concerned about her health” she is 90 pounds and refuses to eat. The patient refuses to stay, stating “it is my choice if I want to eat or not, you can’t force me to be here” the patient does not meet the criteria for involuntary consent. The nurse understands that she cannot force the patient to stay, or to eat but feels that she has a moral responsibility to help the patient

1. which two ethical principles are opposing each other in this situation?

2. What intervention could the nurse implement in regards to the client?
educate the client on the serious health issues relating to anorexia nervosa in a non-judgmental way?

3. What is the best plan of action can the nurse provide for the client’s family.

Case Study #2
Case Study #3
An elderly patient is admitted to an acute care floor and is extremely agitated.The patient has a unsteady gait and unable to ambulate without two person assist. However in his confused state he continues to try and stand while sitting in his geri-chair. A staff nurse puts the table top on the geri chair to prevent the patient from falling due to his unsteady gait. He does not have a history of psychiatric illness, and his wife states “this is so unlike my Frank, I don’t know what is wrong with him”. The doctor orders Seroquel (quetiapine) 25mg BID for agitation. The nurse knows that this is an anti psychotic drug and frequently misused for its sedative properties.

1. Is this an ethical dilemma?

2. What are type(s) of restraints are being used or have the potential of being used?

3. Should the nurse administer the medication? Explain?

Case Study #4
A Registered nurse who has been practicing for a long time realizes that her CPR training certificate is soon to expire, however she neglects to find the time to register for a training program. Eventually, the nurses CPR expires and she neglects to inform her employer- which principle is the nurse not following by failing to renew her CPR? The nurse confides in a co-worker that her CPR is expired and will not be able to renew it until the end of the month when a course available.

1. Which principle is the nurse not following by failing to renew her CPR?

2. What should the co-worker do in this situation?

3. The nurse was disciplined and not allowed to work on the floor until recertified, the nurse now blames the co-worker for blabbing. What would be an appropriate response to educate the nurse on ethics?

Case Study #5
On a geriatric psychiatry unit, a patient is strapped into a chair with a tray attached during meal time. Once he has finished, he indicates to have the tray removed and the straps unfastened. You check with a senior nurse who tells you to leave him in the chair, if not he will constantly pace the unit. An hour later you notice he is still in the chair and becoming increasingly frustrated.

Concerned with balancing the rights of an individual while protecting the community
Ethical problems arise when perceived coercive measures are used
View the experience as humiliating for the individual
Studies have found that there is a perceived lack of information surrounding the admission process for those admitted
(Mcguinness, Dowling & Trimble, 2012)
Case Study #6
A nursing student is required to complete a mental status exam as part of their clinical course requirements with their assigned patient who is preparing for discharge. Through therapeutic conversation, the patient reveals evidence that they are posing as a homicidal threat to others unit.

1. What should the student do first?

2. The client ends up being put in seclusion based on the data you collected, how does this make you feel?

3. What ethical issues arises here?
Self- Awareness Activity
1. Is this an ethical issue? Why?

2. What action, if any should you take?

3. How does this situation makes you feel?

Education Cont.
Nurses must be up to date with all legal documents pertaining to mental health practice

Documents such as the mental health act, Codes of ethics etc. should be a part of all entry level nursing curriculum

It is important for educational workshops on the common issues that nurses face in practice to be offered and utilized so that nurses can stay up to
Practice Cont.
In Nursing Practice it is essential that nurses are informed on proper procedures, are kept up to date with their education and training as well as their registration.

Failure to do any of the above may result in ethical or moral dilemmas
ex. A nurse does not complete her training on a new type of pump used for a patient NG feed, and proceeds with the feed anyway.

Nurses have a duty to ensure that appropriate documentation is up to date and completed on time
Who do you call?
Dr. Rick Singleton, Regional Director of
Pastoral Care and Ethics
Telephone: 709-777-8940
Pager: 709-570-9322
Fax: 709-777-7612
Email: rick.singleton@easternhealth.ca
True or
It is the responsibility of the interdisciplinary team alone to determine the plan of treatment for an individual who holds a CTOs.
Coercion and CTOS
Positive Powers:

Negative Powers:
Forced intent
Absence of fairness

(M'carthy & Williams, 2010)
The Role of the Nurse
Moral Agent




(Halter, 2014)
Clients Views: (CTOs)
Research identifies that patients have verbalized feeling left out of their plan of care

view plan of care based solely on diagnosis and history

Violation of autonomy

Initial feelings are fear, which eventually subsides

Perceived Coercion

( M'Carthy & Williams, 2010;Steun et al., 2015)
Two certificates must be completed
The first can be completed and signed by a family doctor, nurse practitioner, or another who is authorized to do so under the act

The second signature must be obtained within a 72 hour period and by a psychiatrist after they have completed their assessment.
Ethics are used to guide mental health nursing practice and self-awareness is a key component of this.
There are many legal documents and theories that nurses should be familiar with
Standards of Practice
CNA Code of ethics
Mental Health Act
Nurses should understand the principles of autonomy, beneficence, non-maleficence, and justice and how they may clash in practice
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