Autonomy and Consent in Mental Health Nursing - Assignment Example

Running Head: AUTONOMY AND CONSENT IN MENTAL HEALTH NURSING Autonomy and Consent in Mental Health Nursing of the of the institution] Table of Contents Autonomy and Consent in Mental Health Nursing Introduction The paper emphasises the role of autonomy and consent in mental health nursing. This paper includes the legislation acts and the role of mental health professional in this field. Mental health nurse researchers have pointed out that within mental health care settings, the unavailability of physicians means that nurses are often the initial health care provider, increasing the autonomy of mental health nurses. Mental health nurses themselves cite professional autonomy as a leading reason that they prefer this practice specialty. Practicing nursing in a mental health setting is a bit like stepping through Legislation Act Mental health act (1983) is essential for the nurses and clinicians; in regard of the area of mental health. The nurses have to make it to ensure that clients or patients' civil liberties are not broken and they are in the obeyed side of this issue. (Blair, 2000) As a result the Mental Health Act (1983) and the various processes in this concern are essential elements as far as the day-to-day practice of nurses is concerned. Up till now this could be come across by defending the society from the mentally ill individuals who for the reason that of their mental sickness can cause countless damage. Mental Health Act of 1983 shows patient autonomy by the freedom to choose for oneself, the ability to make options which others will admire. The concept is currently reflected in the guiding principles limited in the Code of Practice, which states at para 1.1 that people to whom the 1986 Mental Health Act applies should be treated and cared for in such a way as to promote to the greatest practicable degree their self determination and personal responsibility, consistent with their own needs and wishes.'(Blair, 2000) Under the new legislation, (which will be applied next year) as in the 1983 Act, there will be a limit to the length of time that a patient who is topic to care and treatment under required powers may be given treatment without consent. If the plan of care and treatment comprises treatment without consent the clinical supervisor will be required to position for a second view to be obtained inside 3 months of the start of the care and treatment order unless the Tribunal has stipulated a shorter or longer period. (Department of Health, 2005) New legislation will also make conditions for sure treatments to require either the consent of the patient or the agreement of a doctor from the expert panel fixed to counsel the Tribunal before the treatment is undertaken. The list of treatments covered will comprise electro-convulsive therapy (ECT) provided as part of a care and treatment plan. (Department of Health, 2005) Similar provisions will apply under new legislation, with the autonomous opinions provided by people from the panel of people appointed to provide expert facts to the Tribunal. But there will be stipulation for the case of a patient who, because of enduring or potentially long-standing incapacity, is not able to consent to be referred to the High Court for approval if there is clear proof that he or she might benefit from psychosurgery. Such cases are likely to be very rare. The Human Rights Act 1998 (HRA) incorporates much of the European Convention on Human Rights (ECHR) into domestic law. The right to private life under Article 8 ECHR protects autonomy interests and would be at the centre of any claim now made by mature minors who believe their refusal of treatment should not be overridden. (Mike, 2000) A more complicated evaluation of competence may help in acknowledging this autonomy wellbeing. But there is a need to extend this area so that the right to privacy becomes a "stand alone" right since it covers wider notions of autonomy interests. (Mike, 2000) Autonomy Interpretations of these aspects of autonomy have changed in recent years. The picture painted at the start of this piece suggests that patients make decisions in a flawlessly self-governing way, as if no others were part of the reasoning. In practice, of course, life is not like that. John Rawls's theory of "justice as fairness" and the extension one of us has made of it to health care, probing the resources of that theory to address these issues. Rawls's (extended) theory provides, albeit unintentionally, a defensible account of how to distribute the social determinants of health fairly. In A Theory of Justice John Rawls sought to leverage the relatively broad liberal agreement on principles guaranteeing certain equal basic liberties into an agreement on a principle limiting socioeconomic inequalities--a matter on which liberals disagree considerably. (Rawls, 1999) His strategy was to show that a social contract designed to be fair to free and equal people ("justice as [procedural] fairness") would not only justify the choice of those equal basic liberties but would also justify the choice of principles guaranteeing equal opportunity and limiting inequalities to those that work to make the worst-off groups fare as well as possible. Rawlsian ideal of democratic equality also involves conformity with a principle guaranteeing a fair distribution equality of opportunity. A number of nurse researchers have reported that nursing autonomy (defined as the power and ability to get things done) must come from a specialised knowledge base and some combination of expert knowledge and experience. (Batey, 1982) Implicit in nursing autonomy is that nurses be competent. Mental health nurse authors have called for formal continuing education that supports assessment skills and decision-making capabilities, increases formal education of mental health nurses, including a specialty track for forensic or mental health nursing at the graduate level and a strong educational basis in research to be used to further explore and define mental health nursing.(Cutts, 1999) The setting in which mental health nurses practice is unique and challenging. When nurses begin work at a mental health facility, they enter a closed world where health care is no longer the priority, where their nursing actions may be viewed with suspicion and their activities may be severely restricted. This may be compounded by a sense of professional isolation because mental health nurses may be stigmatised by society due to their association with inmates and because they may be seen as being unsuccessful as nurses in more traditional health care settings. (Cutts, 1999) It has been pointed out that mental health nurses may contribute to these perceptions because they do not assert their identity and do not publish their experiences. Independent Practice Autonomous nurses must be able to carry out their duties independently, and have a role that is firmly based in nursing theory and that is independent of outside influence. (Cutts, 1999) Some of the more difficult challenges confronting mental health nurses include maintaining a professional identity as a nurse by maintaining nursing standards, developing therapeutic relationships with inmate patients that do no violate security concerns and avoiding role ambiguity. (Keenan, 1999) Even so, independence is not absolute and does not equal isolation.(Keenan, 1999) Mental health nurses must work collaboratively with security staff, prison administrators and other disciplines within the complex environments encountered in mental health settings.(Keenan, 1999) Advocacy Patient Advocacy There is general agreement that a fundamental duty of nursing is patient advocacy. Patient advocacy in the mental health setting can be particularly controversial. Even liberal nurse authors acknowledge that some inmates can be manipulative and untrustworthy. (Blair, 2000) Furthermore, mental health nurses can face some sort of violence nearly every day, manifested as actual physical harm, real or implied threats and a constant barrage of obscenities. In spite of the very real barriers to patient advocacy, many mental health nurses do feel an obligation to care for their inmate patients and develop ways to "care ethically" about them. One nurse author noted, "Prison nursing simply takes more commitment, not less." (Blair, 2000) Capacity to Decide For a nurse to make an autonomous decision they must have the capacity (otherwise, and less usefully, known as competence) to do so. If understanding is undermined by clinical conditions, such as severe mental illness, the person may not be capacious and would therefore not be capable of fully autonomous decisions. Informed Consent There are especially important issues connected with consent and it is important that you refresh your memory about basic ethics in this area, such as: * The four elements of clinical consent: -- Information -- Capacity -- Freedom from coercion -- Dynamic status * Consent in children, including the Gillick competence * Consent in the intellectually disabled. Three examples of ethical dilemmas in clinical practice are: * Do I need to get a written consent for a smear test * Can I vaccinate a child if only one parent consents * Can I take a blood test from this intellectually disabled patient The Ethics of Consent When a patient consents to a nursing procedure, or indeed any procedure, moral and legal autonomy is given to the nurse to proceed. The two aspects are separate, if closely related. A morally legitimate consent is an autonomous decision by the patient. It is fairly easy to describe this in terms of three elements, outlined below. (Schutzenhofer, 1987) These principles should not be confused with the more procedural aspects of good practice on consent. Interventions should be recorded as consensual, in writing. An Informed Decision The decision must be informed, which indicates that the patient must know something, at least, about the intervention planned. It can become more contentious when deciding what level of information should be offered, let alone understood by a patient. Most authorities would suggest a level of information appropriate to the intervention, so a serious intervention would merit a higher degree of information transfer than a less serious one. For example, a nurse might expect to explain far more about an impending haemodialysis session than a wound care treatment. (Schutzenhofer, 1987) Lawful consents need to be informed, where attention is given to the nature, purpose, risks, benefits and alternatives of a procedure. They should be decisions of individuals only, acting freely, and should be taken by legally capacious individuals. Freedom from Coercion Decisions should be free, and uncoerced by other people. So clinicians should not perform interventions on patients who are being coerced by others, such as relatives, even if they seek to act for what they take to be the patient's welfare. These factors taken together reveal autonomous decisions to be representative of a form of self-governance about ourselves. In fact, the idea that clinicians should make decisions on behalf of a person appears outrageous to healthcare professionals today, showing us how far clinical ethics have come in the past 20 or 30 years. (Schutzenhofer, 1987) But the process of obtaining consent for nursing procedures may need some review, or at least updating -- as a recent study has revealed. . (Aveyard, 2005) NMC code The NMC is the largest health care regulator in the world and their job is to ensure the nursing profession in the UK maintains the highest possible standards. It is this mission to ensure nurses adhere to the strictest code of conduct that is resulting in an increasing number of allegations against the profession more than 1,500 in the past year. (Aveyard, 2005) It is also part of a nurse's code of conduct that if they have any concerns about the behavior of a colleague they must report this. If they do not, the public is not being protected. The NMC guidance says that: "You are responsible for any decision that you make to release confidential information because you think that this is in the public's best interest; if you choose to break confidentiality because you believe that this is in the public's best interest, you must have considered the situation carefully enough to justify that decision." (Aveyard, 2005) The NMC Code of Professional Conduct states clear guidelines on this topic. There are legitimate causes to break privacy if not to do so may harm the patient or the public. The NMC Code of Professional Conduct may be observed as a useful yardstick against which professional decisions in connection with Aftercare under Supervision may be measured: Every registered nurse, midwife and health surveyor shall act, at all times, in such a way as to; safeguard and build the interests of society justify public trust and confidence and uphold and enhance the good standing and reputation of the professionals. (Aveyard, 2005) Related to Practice This experience influenced my Practice in a sense that I feel nurses need certain physical resources to support and promote their practice. Obviously, they need adequate equipment to conduct assessments and to provide treatment. They also need sufficient space and a physical layout that promotes privacy for health care encounters. Additionally, previous research has shown that mental health nurses do face potential violence. Therefore, it is vital that the workplace design promotes efficient and effective care provision and personal safety for nurses to enable them to safely have close contact with inmates. The mental health setting is a formidable system that has profound influence upon all staff working within it and one that is additionally very different from most systems that employ nurses. Mental health administrators must clearly define the professional boundaries that exist between mental health nurses and security staff and must reinforce the treatment role of mental health nurses. However, collaboration with security staff is essential. Mental health nurses must be able to interact positively and confidently with security staff and they must be able to function within a secure setting in a manner that does not place themselves or others at risk. Finally, mental health nurses must be able to develop therapeutic relationships with inmates that do not violate professional boundaries or security concerns. How has this Experience Influenced My Practice Since mental health nursing is a nursing specialty with very unique features, it is very important that the educational programs developed for these nurses have a mental health emphasis. The educational and training needs of mental health nurses include effective ways of interacting with inmates, ways of developing therapeutic relationships with inmates that maintain safety and security within the institution, strategies for conducting assessments and delivering treatment within a secure setting, effective ways of interacting and collaborating with security staff, and the importance of maintaining a professional identity that is treatment oriented. I think particular attention must be paid to the legal implications of professionally autonomous mental health nursing practice and nursing scope of practice issues. Within mental health care settings, the unavailability of physicians means that nurses are often the initial health care provider, increasing the autonomy of mental health nurses. The temptation exists for mental health nurses to make decisions concerning the diagnosis and treatment of inmate patients that is beyond their scope of practice. A balance must be achieved between not fully using knowledge and expertise of mental health nurses and extending them beyond their legal scope of practice for convenience. To me, it is also important that clinical decision-making models be designed to tailor to mental health nursing practice. While it is acknowledged that many decision-making models exist and many of the decisions that mental health nurses make are the same types made by mainstream nurses, mental health nursing has unique features that warrant decision-making models designed just for this specialty area. Particular study and attention must be given to the development of ethical caring models to delineate the boundaries of nurse and inmate-patient clinical relationships and provide mental health nurses with the skills needed to objectively assess the real needs of inmate patients. References Aveyard H. Informed consent to nursing care procedures. Nursing Ethics 2005; 12 (1): 19-29 Batey, M.V. and F.M. Lewis. 1982. Clarifying autonomy and accountability in nursing service: Part I. The Journal of Nursing Administration, 12(1): 13-17. Blair, P. 2000. Improving nursing practice in mental health settings. Journal of Nursing Law, 7(2):19-32. Cutts, B. 1999. Specialist nursing: Autonomy and the developing role of the clinical nurse specialist. British Journal of Nursing, 9(22): 1500-1506. Department of Health. Report of the Expert Committee: Review of the Mental Health Act 1983. London: Stationery Office, 2005. Droes, N.S. 1994. Mental health nursing practice. Journal of Community Health Nursing, 11 (4):201-210. Gillick v West Norfolk and Wisbech Area Health Autonomy [1986] AC 112 In Re. Vaccination/MMR Litigation: A v B: D v E (2003) EWCA Civ 1148 Keenan, J. 1999. A concept analysis of autonomy. Journal of Advanced Nursing, 29(3):556-562. Mike Cole. Education, Equality, and Human Rights; Falmer Press, 2000. Rawls John. A Theory of Justice. Belknap Press; Revised edition (September 30, 1999) Schutzenhofer, K. 1987. The measurement of professional autonomy, Journal of Professional Nursing, 25(3):278-283. Read More