Legal and Ethical principles

Autonomy, nonmaleficence, beneficence, fidelity, veracity, and justice, as well as the rights of confidentiality, boundary

violations, informed consent (and involuntary treatment).

Nonmaleficence focuses on not doing harm, not causing pain or suffering, and refraining from offending others.
Beneficence refers to doing what may benefit or work for the good of the client. This is a significant consideration in
mental health care, as there are many treatments and medications that may benefit the client (beneficence), but there are
also aspects of treatment or medications that may result in a burden of treatment. In a mental health treatment setting, the
nurse should advocate for the client in selecting care and treatment modalities that will result in the least amount of harm
while achieving a beneficial outcome.

The principle of justice ensures that the element of fairness influences nursing decisions and care. For mental health
nurses, this could mean researching the nation’s health care system and taking actions to promote access to mental health
services for those in need of care. Nurses must care for all clients with the same level of fairness, and this includes clients
who have mental disorders. The principle of justice is important in reducing the impact of social determinants of mental
health and ensuring equitable care regardless of a client’s financial abilities, race, religion, gender, and/or sexual
orientation.  

The principle of veracity considers the importance of being truthful and authentic with clients during nurse-client
interactions. Fidelity is a principle rooted in keeping promises to clients and showing faithfulness while displaying
integrity. Veracity and fidelity in mental health nursing provide the foundations needed to fulfill nursing responsibilities to
develop therapeutic relationships that are based on trust, honesty, and genuine regard for the client. An example of fidelity
would be a nurse fulfilling their commitment to being present and providing quality care to a client who is withdrawing
from alcohol. Veracity can be demonstrated by thoughtful, thorough education of possible adverse effects of medication. In
each case, the nurse is to provide ethically sound practice for clients and families as well as in relation to colleagues.
Code of Ethics

The goal of the Code of Ethics is to guide the nurse in decision making when ethical dilemmas occur. An ethical dilemma
occurs when there is a conflict between two or more courses of action and either of these choices can cause a violation of a
moral value or ethical principle. These dilemmas can be common in mental health settings, often arising because clients
who have mental disorders lack the capacity to make decisions for themselves, or when decision making is dependent on
others who may have differing points of view. For a client who has a serious mental illness, considering their vulnerability is
part of a nurse’s ethical role.

Right to Refuse treatment

Respect for and protection of clients’ rights is a core value of nursing. Some of these basic rights include the right to privacy,
competent and respectful caregivers, access to medical records, advance directives, informed consent, and the right to
refuse treatment.
Torts

A tort is a violation of a client’s protected rights and represents a breach of the duty of the nurse. A tort can be either
unintentional or intentional.

 Unintentional Tort
o Negligence is the most common unintentional tort. Negligence is exhibited when the expected standard
of care has not been provided, or when the nurse was absent when care was needed. Examples of
negligence can include failing to provide frequent checks on the client in seclusion, failing to see a change
in a client’s mental or physical status, or failing to document.

o Malpractice is negligence, misconduct, or a breach of duty attributed to a professional such as a nurse. It

can result from a nurse’s failure to provide the “ordinary” skills or duties of a nurse, which results in an
injury or loss. Malpractice also refers to failure to follow standards of care of the profession, policies, or
procedures of the organization. A charge of malpractice is specific to health care professionals, including
providers and nurses. Examples of medical malpractice that can occur when caring for clients who have
mental illness include failure to identify suicidal ideation or failure to assess a client who is in mechanical
restraints, according to evidence-based practice standards and facility policy.

 Intentional Tort
o An intentional tort is defined as an action in which an individual deliberately acts in a way that causes
harm to another. Examples of intentional torts that most often occur in mental health treatment settings
are assault, battery, and false imprisonment.
 Assault does not require actual physical harm be done to the client; it can also be verbal harm
that causes fear or anxiety. An example of assault would be a nurse verbally threatening to
restrain a client. Another example could be a provider raising their hand in a gesture that is
perceived as preparing to hit a client.
 Battery, unlike assault, does not need to include a threat nor does the client need to be aware of
the physical contact. The contact must simply be considered offensive or unwanted by the
client for the battery to occur. An example of the battery can be a nurse shaking a client in an
attempt to awaken them. Administering treatment or medication against a client’s wishes when
there is not an emergent situation is another example of battery. A client can claim battery has
occurred regardless of whether the act resulted in injury.
 While false imprisonment usually refers to the use of seclusion or restraints, it is also applicable
when a client is held in a facility without a lawful reason. An example of this would be if a client
 presents to the emergency department for treatment and is admitted to a mental health unit
without being assessed by a provider who determines they meet the legal criteria for involuntary
admission.
 Nurses and other health care professionals can be accused of false imprisonment for the
unwarranted or otherwise inappropriate use of seclusion or restraints. This includes both
mechanical restraint and chemical restraint, such as administering an antipsychotic or
benzodiazepine. ALWAYS CHECK RESTRAINT GUIDELINES!!

Ethical principles regarding Restraints

 It is important for the nurse to weigh client and staff safety over the effect that seclusion or restraint will have on
the client. Care should always be taken to give the client as much power as possible to regain composure, change
behavior, and de-escalate emotions.
 It is a best practice to inform clients on admission about the seclusion and restraint policy, to avoid any
misunderstandings. In this way, the client takes ownership of behavior in the facility, understands boundaries and
consequences, and is empowered to avoid seclusion or restraint.
 The APNA recommends that nurses consider these two questions before deciding to use restraints:
o Have the least restrictive methods to manage behaviors been tried and unsuccessful?
o Is imminent danger posed to staff or clients?
 Protocols are focused on client safety and require that the client be checked at regular intervals, usually at least
every 15 minutes by the registered nurse when the client is chemically or physically restrained. A provider must
give an order for restraint. Restraint protocols may be initiated for client and staff safety with the expectation that
the provider will be notified as soon as possible after beginning seclusion or applying restraints. The nurse needs to
follow the facility policy, but most facility policies will require the evaluation of the client’s response and
determine if seclusion or restraints should continue within one hour of initiation of seclusion or restraints .
Careful documentation of the behavior leading up to the restraint, including who was consulted before
restraining, what was done, and who was notified, will need to be done by the nurse.
 Particular attention needs to be paid to cardiac and respiratory status, as well as also skin integrity, hydration,
injury, and sensory stimulation. If the client’s status deteriorates, the physician must be notified immediately, and
restraints may need to be removed. While the client is in restraints or in seclusion, care must include:
o Support and reassurance of their safety
o Ongoing assessment of circulation and skin integrity.
o Care of basic needs such as hydration, food, and elimination
o Range of motion.
o Medical interventions including medications.
o Evaluation of response to the intervention of seclusion or restraints and readiness for release.
 Steps before physical restraints
o Pre-briefing and Debriefing
o Timeout
o Seclusion
o Chemical restraints
Restraint Documentation

EMTALA LAW (from google)