Nurses, therapists, and other health care workers are

expected to make informed and effective patient care

decisions quickly by utilizing rational problem solving
skills. —ROSS, 2001

Presented by Suharsono,MN
Learning Objectives

After studying this chapter, you should

be able to:
 Construct the six-step model of ethical
nursing care designed by Chally and
Loriz.
 Recognize five forms of nursing
malpractice.
 Compare the legal rights of adults and
minors admitted to psychiatric facilities.
Ethics
 Ethics has been defined as a branch of philosophy
that refers to the study of values or values-laden
decisions that conform to moral standards of a group
or a profession (Kelly, 1998).
 Four primary principles to guide ethical decisions.
Governing the relationship between nurse and client,
these principles include the client's right to autonomy,
the right to beneficence (doing good) by the nurse, the
right to justice or fair treatment, and the right to
veracity (the truth) regarding the client's condition and
treatment
Model of Ethical Nursing Care

 Nurses think that they know what is best for

their clients, often imposing their own methods
for care and treatment decisions.
 This behavior, referred to as paternalism,
may occur in the psychiatric clinical setting
where clients exhibit clinical symptoms of
confusion, depression, or anxiety or when
clients are unable to communicate their needs
due to communication disorders or mental
retardation.
Cont…

During the implementation of this model,

the nurse must :
 respect the individuality of all clients,
protect clients from harm,
 treat all clients equally, and
 evaluate the result of full disclosure
regarding treatment.
Voluntary and involuntary admission

 Voluntary admission
It indicates that the patient acknowledges
problems in living, seeks help in coping with
them and will actively participate in finding
solutions.
 Involuntary admission
It indicates that the patient did not request
hospitalization and may have opposed it or
was indecisive and did not resist it.
Aspects of dangerousness is useful to
make decision –making guide for nurses
 Nature of harm or conduct.
Does the person threaten bodily harm, harm to
property, or psychological harm?
 Magnitude of the harm
Does the person threaten murder, assault, or verbal
abuse?
 Probability
How likely is it that the harmful act will occur?
 Imminence
When will the threatened action take place?
 Frequency
How often will the threatened action take place?
The steps of Chally and Loriz's model:

1.Clarify the ethical dilemma

By evaluating whose problem it is, who should
make the decision, who is affected by the
decision, and what ethical principles are
related to the problem.
For example:
A client exhibits clinical symptoms of major
depression and verbalizes suicidal thoughts
but refuses to take antidepressant medication.
Cont…
2.Gather additional data,
Including any legal issues related to the
ethical dilemma.
For example,
 Does the client have a suicide plan?
 Is anyone else aware of the client's
depression, or does the client wish to keep
the information confidential?
 Who would be responsible if the client did
commit suicide?
Cont…
3.Identify options
To determine what alternate, acceptable
solutions are available.
For example,
Does the client have a significant other or
support group?
Is the client agreeable to a suicide contract?
Should the client be admitted to an inpatient
psychiatric program?
What options does the client propose?
Cont…

4.Make a decision
To determine which option is the most
acceptable and therapeutic.
Discuss this decision with the client,
considering risks and benefits.
Cont…

5.Act or carry out the decision.

Collaboration with others may be
necessary.

6.Evaluate the impact of the decision

regarding what went right or what went
wrong.
Malpractice

 Conduct that falls below the standard of care

established by law for the protection of others
and involves an unreasonable risk of harm to a
client is referred to as negligence.
 Malpractice is a type of negligence that
applies only to professionals, such as licensed
nurses (Schipske, 2002; Calloway, 1986a).
Nursing malpractice law is generally based on
fault.
The following four elements must be
present to constitute nursing malpractice

 Failure to act in an acceptable way

 Failure to conform to the required standard of
care
 Approximate cause, which requires that there
be a reasonably close connection between the
defendant's conduct and the resultant injury
(ie, the performance of the health care
provider caused the injury)
 The occurrence of actual damage
Incidents as malpractice could occur in
the psychiatric clinical setting.

 Client falls;
 Failure to follow physician orders or
established protocols;
 Medication errors;
 Improper use of equipment;
 Failure to remove foreign objects;
 Failure to provide sufficient monitoring;
 Failure to communicate.
Other forms of malpractice

 Intentional torts refer to willful or

wanton conduct to do a wrongful act with
disregard of the interests of others.
 Assault is an act that puts another
person in apprehension of being touched
or of bodily harm without consent.
 Battery is unlawful touching of another
without consent.
Cont….
For example,
 During the involuntarily admission of a client to
a psychiatric–mental health facility (ie, has not
signed the voluntary admission form or
consent for treatment),
 Emergency orders are necessary to provide
any type of nursing intervention. Touching the
client, giving medication, or completing a
physical examination could result in a
malpractice suit based on a complaint of
assault and battery.
Cont….
 Defamation involves injury to a person's
reputation or character through oral (slander)
or written (libel) communications to a third
party.
 For example,
If a physician tells the administration of a
hospital that a nurse is unfit to care for clients
in a psychiatric–mental health facility, the
nurse could sue the physician for defamation,
possibly being rewarded with a financial
judgment.
Cont…
 False imprisonment is the intentional and
unjustifiable detention of a person against his
or her will. Detention can occur with the use of
physical restraint, barriers, or threats of harm
For example,
Suppose a client with alcohol abuse voluntarily
admits himself to a substance abuse treatment
center. He attempts to leave and is forcibly
restrained. The client could sue for false
imprisonment and be awarded a financial
judgment.
Breaches of Client Confidentiality and
Privacy

 Breaches of client confidentiality and privacy

are two forms of malpractice that have
become increasingly common because of the
widespread use of computers or personal
digital assistants (PDAs), e-mail, fax
machines, copy machines, pagers, and cell
phones to share client information with other
health care professionals (Badzek & Gross,
1999).
Cont….
 Client confidentiality refers to the
nondisclosure of private information related by
one individual to another, such as from client
to nurse.
 Client privacy is defined as the right to be left
alone and free from intrusion or control by the
public or, in this situation, health care
providers.
Only health care workers taking care of a
client are able to review the client's medical
records. Sharing information with anyone else
requires the client's informed consent.
Potential Legal Issues in Psychiatric–
Mental Health Nursing

 Abandonment:
Premature termination of a professional relationship
with a client or withdrawal of services without
adequate notification, leaving the client unattended
when health care is still needed
 Diversion of narcotics:
Writing or calling in fraudulant prescriptions for
narcotics or diverting controlled substances from a
health care facility
 Falsification of medical records:
Entering information into a client's medical record that
is known to be inaccurate
Cont…
 Impairment:
Professional misconduct due to chemical,
mental, or physical impairment
 Negligence:
Failure to act, or conduct falls below the
accepted standard of care established by law,
resulting in an injury or loss to the client
 Unprofessional practice:
Departure from, or failure to conform to,
minimum standards of nursing practice
HIPAA Privacy Provisions Rule

 Patient records are secure, not readily

available to those who do not need them
to carry out treatment, payment, or
health care operations activities;
 Employees have access to only the
minimum patient information that is
necessary to do their job;
Cont…
 Disclosure is made only to individuals who
need to know the information to treat the
patient, conduct the practice's operations, or
obtain payment for services;
 Patients are aware of their rights under the
Privacy Rule; and
 A patient's written authorization is obtained
before disclosing the patient's information for
any purpose other than treatment, payment, or
practice/facility operations.
Cont…
Patients' rights include:
 setting boundaries on the use and release of health
records;
 requesting and obtaining audits of how a health care
provider used or disclosed the patient's information in
the past 6 years;
 examining their records; obtaining copies and
requesting correction of their own records;
 requesting to receive confidential communications at
alternate locations or by alternate means; and
 filing complaints about a suspected violation of
privacy, which may trigger an investigation.
Self-Awareness Prompt

 How would you react to a client's

complaint of breach of client
confidentiality?
 What course of action would you take?
 What are the legal implications of such a
complaint?
Bill of Rights for Psychiatric–Mental
Health Clients

 Psychiatric clients who voluntarily seek

help retain civil rights during
hospitalization.
 Conversely, those who are committed
involuntarily lose the right to leave the
hospital during treatment unless the
attending clinician writes an order for a
leave of absence or discharge from the
facility.
Cont…
 Receive treatment, including (a) treatment in a
humane psychological and physical environment; (b)
adequate treatment in a least restrictive environment;
(c) a current, written, individualized treatment plan;
and (d) informed consent concerning one's condition,
progress, explanations of procedures, risks involved,
alternative treatments, consequences of alternative
treatments, and any other information that may help
the client to make an intelligent, informed choice.
 Refuse treatment, unless such action endangers
others, or withdraw from treatment if risks outweigh
benefits.
Cont….
 Have a probable cause hearing within 3 court days of
admission to secure a speedy recovery from
involuntary detention if found sane in a court of law .
 Maintain client privacy and confidentiality: Information,
records, and correspondence may be disclosed only
with the client's written consent. The exception occurs
when the public becomes endangered; the client is
transferred to another facility; the client's attorney, law
enforcement officers, or a court requests information;
the client participates in research; or insurance
companies require information to complete insurance
claims.
Cont….
 Communicate freely with others by letter,
telephone, or visits, unless such activities are
specifically restricted in one's treatment plan.
 Have personal privileges: (a) wearing one's
own clothing; (b) maintaining personal
appearance to individual taste; and (c)
receiving the basic necessities of life.
 Maintain one's civil rights, including the right to
(a) be legally represented; (b) be employed;
(c) hold public office; (d) vote; (e) execute a
will; (f) drive; (g) marry; (h) divorce; or (i) enter
into a contract.
Cont….
 engage in religious freedom and education.
 maintain respect, dignity, and personal identity.
 maintain personal safety and assert grievances.
 be transferred and receive continuity of care.
 access own records.
 obtain an explanation of cost of services.
 obtain aftercare: Individuals discharged from mental
health facilities have the right to adequate housing and
aftercare planned by professional staff.
Legal influences on psychiatric nursing practice

Nurse as
citizen

Nurse as
provider
Patient
Nurse as right
employee
Further readings
 Kaplan, B & Sadock (2005) Comprehensive Texbooks
of Psychiatry, Philadelphia
 Mohr, WK (2006) Psychiatric –Mental Health Nursing,
Philadelphia, Lippincott Williams & Wilkins, pp 3-16.
 Shives, R (2005), Basic Concept of Psychiatric Mental
Health Nursing, pp 47-76
 Stuart, GW & Laraia, MT (1998), Principles and
Practice of Psychiatric Nursing, Philadelphia, Mosby
pp 155-176