Power Differentiation between the Nurse and Client in Mental Health Nursing Care - Term Paper Example

Power Differentiation between the Nurse and Client in Mental Health Nursing Care Student’s Name: Name of Institution: Instructor’s Name: Course Code: Date of Submission: Introduction The concept of ‘power differentiation’ in health care focuses on the boundaries between health service providers (e.g. nurses) and their clients (Peternelj-Taylor & Yonge, 2003). These boundaries define the relationships between the two parties as well as the role that each plays in the achieving the main goal, which is to give the best treatment and care to the patients. This paper will view this concept, focusing on nurses and clients in the mental health nurse care. In the years that preceded mid-1960s, the approach to decision making in medical treatment was largely paternalistic, i.e. it was the physician/nurse who commanded, and the patient was only to obey. This rested on the assumption that the physician/nurse knew what is best for the patient. The patient was therefore to put all faith in the physician/nurse and follow the decisions made without question. But since the mid-1960s, this approach faced a paradigm shift. This saw decision making transferred from the physician/nurse to the patient. The physician/nurse would only recommend options of treatment based on the wishes of the patient. In other words, this was a move towards granting the patient autonomy (Barker, 2000; Barker & Buchanan-Barker, 2004; Westphal & Teresa, 2005; MHLC 2012), for instance, insists that it is only the patient who knows best the experiences of his/her illness, and decisions made on their behalf by others are only second to their own. However, the observation of such boundaries, including idea of client autonomy, becomes more complicated when that very client is rendered incapable of making autonomous treatment decisions as is the case in mental illness (Peternelj-Taylor & Yonge, 2003; Westphal & Teresa, 2005; MHLC, 2012). This paper aims to evaluate power differentiation between the nurse and the patient in mental health nursing care. This evaluation will view this case from professional, legal and ethical perspectives. Professional Perspective Creating and maintaining professional treatment relationships and boundaries between the nurse and client is among the key competencies required and expected of mental health nurses. But while this requirement is easy to proclaim, it is not that easy and simplistic in practice. There is the risk that over time, in the course of care, both the nurse and client may develop a certain level of familiarity and trust. Add to this the seductive attractiveness likely to be experienced in the course of care and helping, the complexity of treatment needs of patients and lack of understanding of the boundary theory, the integrity of the professional relationship between a nurse and client is likely to be threatened, as much as the boundaries therein are likely to be violated. The irony here is that a nurse may overstep their professional boundaries by engaging their clients during the course of professional caring relationship (Peternelj-Taylor & Yonge, 2003; Cleary, 2003). The attention that the nursing profession has turned to professional boundaries, for instance, is largely attributed to reports of sexual exploitation of clients by nurses and therapists in the course of treatment (Norris et al 2003). Sexual exploitation, many professionals of mental health agree, is an extreme violation of nurse-client boundary. The question is, who should be responsible for establishing and maintaining the relational and therapeutic boundaries between nurses and their clients, and what are the justification for this? Nurses do work in settings that constantly test their relationships with their clients, either by the nurses’ own behaviors and actions or through the behavior and actions of the clients. How they respond to these tests are issues of professional integrity. CRNBC (2005; 2006) acknowledges the existence of power imbalance between the nurse and the client, which then causes client vulnerability. As it were, the nurse holds the position of power, while the client has lesser power, and is merely dependent. The nurse’s power is characterized by his/her broad scope of competencies (e.g. authority and influence, knowledge and access to important and privileged information on and for the client. On the other hand, the client has limited control over situations, and is thus at a disadvantage. He/she may depend on the nurse for a lot of things, e.g. basic needs, companionship, especially when there are no family members or friends, and safety. Equally, the client may perceive the nurse as the one who could offer health and well-being. This vulnerability is especially stronger for clients with mental health problems. Between the two, it is the nurse who is more aware of the imbalance of power. Infact, the client may not perceive this imbalance at all. The nurse is therefore expected to recognize the possibility of the client to feel intimidated and establish a suitable therapeutic relationship. This awareness becomes the first step towards establishing and maintaining appropriate relational and therapeutic relationship (Norris et al, 2003; CRNBC, 2006). In such cases, nurses are expected- by virtue of their profession and the inherent ethical codes- ‘to do what is right’. Unfortunately, it is never clear what ‘doing what is right’ really means. In other words, the ‘right thing’ is not clearly defined, neither is it as simplistic in practice as it is in theory. Even further, most literature on contemporary nursing in relation to therapeutic boundaries of treatment are merely anecdotal, and lack in-depth inquiries and critical analysis (Peternelj-Taylor & Yonge, 2003) Because of these difficulties, nursing has turned to other disciplines on mental health to find more knowledge on the role of therapeutic relationships boundaries. Although this move has provided more knowledge on general treatment boundaries, there is still much dilemma concerning how these treatment boundaries are supposed to be managed. Legal and Ethical Perspectives, and Advance Directives While the professional perspective challenges the nurse to instinctively abide by the relational and therapeutic boundaries of his/her role, the legal and ethical perspectives take it upon themselves to ensure that such boundaries are respected. One step towards this is the recognition of the fact that mentally ill persons may lack the capacity to make decisions regarding their relationship with the nurses or treatment and care. In other words, the case of patients suffering mental problems presents a two-way dilemma: one, now that the patient ‘cannot’ make ‘sound’ decisions regarding his/her care, to whom is the responsibility transferred, and what part does the patient play in the process of choosing the ‘whom’?; and two, there is the risk that the nurse may take advantage of such a vacuum, which would mean a violation of the patient’s dignity, autonomy and control. How does the nurse deal with these cases? Many have proposed Advance Directives as the best tool by which the mentally ill patients can still retain their autonomy and capacity for decision making, and protect them from potential boundary violation by the nurses (Westphal & Teresa, 2005; MHLC, 2012). There are two main types of advance directives: Living Will and Medical Power of Attorney. Living Will expresses a person’s wishes regarding medical treatment at death. It is mainly used in situations of permanent unconsciousness and terminal illness. Medical Power of Attorney, unlike the Living Will, allows one to pick a partner to express his/her wishes in an event that he/she is incapacitated, and is valid whenever a person lacks the capacity to make a decision (Westphal & Teresa, 2005; MHLC, 2012). Ultimately, Advance Directives are thought to be a major formal tool by which mental patients can still retain their autonomy and self-determination in making decisions related to their treatment and care. Equally, advance directives provide the means by which mental health services are informed on the preferences and wishes of every individual, as well as every consumer. Legal Perspective The basic legal principle in most states asserts that every individual with the capacity to make a sound decision has the right to either accept or refuse medical treatment irrespective of whether such decision(s) could cause his/her death. Even further, the legal system protects the right to autonomy and self-determination in cases where one losses the capacity to make a decision through an advance directive (Widdershoven & Berghmans, 2001). The role of the nursing service providers in all this is to find out if a client/patient has an advance directive, provide information for the preparation of an informed advance directive and include the written advance directive in the patients’ medical records (Westphal & Teresa, 2005). The premise that every individual has the right to determine the kind of treatment he/she gets and that this should be permitted whenever or wherever possible is passed through the United Nations Principles and National Mental Health Standards, even in cases where such ‘individual preferences’ are deemed as ‘involuntary’ under legislations on mental health (MHLC, 2012). However, there are still certain problems that surround the ‘individual preference’ versus Advance Directive. These issues are expressed through various legal acts. In Victoria, for instance, the Mental Health Act (MHA) is thought to overrule the self-determination rights of patients when they have been admitted as involuntary patients. This ability of the MHA to trounce other legal provisions must be considered during discussions regarding Advance Directives and should be clarified to consumers/clients who are considering writing Advance Directives for themselves. It is therefore important for patients/clients to understand the legal mechanisms of their states concerning their rights vis-à-vis Advance Directives (MHLC, 2012). A nurse who administers or provides a particular treatment or care to a ‘competent’ patient without their permission is thought to have committed the violation of the client’s autonomy, and could be liable for criminal charges. As an extension to the right to autonomy, a patient may choose to develop Advance Directives or refuse treatment. But these are only valid when a person has been declared to lack the capacity to make choices. This question of ‘capacity versus incapacity’ has become a major issue in the debate on the choice of treatment and care for mentally ill patients. According to the definition laid out by the UK Mental Incapacity Bill, ‘capacity’ is to be understood only on the basis of the specific decision to be taken. In other words, individuals are not termed as ‘incapable’. Instead, they are said to be lacking capacity to make certain decisions at certain times. Otherwise, the argument is that individuals should still make their own choices and decisions when and where possible. The underlying assumption is that an individual always has the capacity to make decisions. The Bill therefore calls for ‘all practicable steps’ to be taken to assist individuals make their own decisions before they are declared as lacking the capacity for it (Department for Constitutional Affairs UK 2003 cited in MHLC, 2012). In this case, therefore, patient competency depends on the impact(s) that the decision(s) made would cause. In other words, higher competency levels would be needed where more important decisions are to be made. But this argument still present questions rather than a solution to the problem. For instance, is it the place of the nurse to decide the level competency required? What is the criterion for deciding the capacity level? Indeed, there is the danger that a nurse may view a decision that does not seem like such a good one as evidence of one’s incompetence at making a decision. While making good and bad decisions is normal in everyday life, this fact may be overlooked under the Mental Health Act. Ultimately, the autonomy of the client to make choices faces limitation in the professional ‘high table’ of the nurse(s) and other therapists. Ethical Principles Essentially, ethical principles refer to the fundamental truths (i.e. doctrines, laws and other motivating factors) that inform and influence decision-making (CAN, 2002; Chris & Robert, 2003). The one limitation that autonomy in decision-making faces is that it should not cause harm to others. This autonomy principle mainly rests on the on the premise that every individual deserves to be treated with respect, i.e. as a person of moral agency and worth. The implication here is that every individual has an inherent right to decide the kind of care he/she needs, i.e. he/she becomes an active part of his/her own care (CAN, 2002; Lloyd & King, 2003). Against this backdrop, nurses are required to respect the choices that their clients/patients make regarding their lives. This respect of client autonomy and providing support involves allowing and giving clients’ access to all relevant information. These pieces of information should be technically accurate and providing all possible alternatives of care available, as well as the benefits and possible burdens or limitations. When patients are denied this access to information, then it is said that their dignity, autonomy and control have been compromised. This veracity (i.e. telling the truth) becomes a key moral consideration for nurses as they help their patients complete their advance directives (Westphal & Teresa, 2005). This veracity involves the nurses clarifying the patient’s questions and fears, and their choices relating to healthcare. To assist these efforts, nurses need to consider the patients’ cultural or ethnic and religious backgrounds. However, the nurse remains obliged to providing care. This mainly rests on the principle of beneficence. This principle ensures the nurse’s activities offer only benefits to patients. This is judged on the basis of: ensuring the patient is inflicted no harm; preventing any possible harm to the patient; removing any harm experienced by the patient; and doing or promoting good (Westphal & Teresa, 2005). As alluded to above, in cases where patients are not sober enough to make decisions, there is a possible risk that nurses will impose their own morals and values upon the client/patient when discussing issues regarding advance directives (Moore, 2004). It is possible that such assumptions in the part of the nurse will be informed and influenced by their own cultural or ethnic backgrounds. The European-American context and culture, for instance, may make the following assumptions: that the client/patient would like to make an independent/autonomous decision; that the patient expects nothing short of full disclosure from the patient so as to make an informed decision; that the patient has put his/her trust in the nurse; that the patient is not supposed to suffer; and that the patient looks forward to the future (Westphal & Teresa, 2005). However, these cultural assumptions may not reflect the assumptions of the client’s/patient’s culture. Nurses must therefore consider the cultural backgrounds of their patients in the process of providing care. Indeed, concepts relating to illness and health are culturally constructed, and thus influence how patients/clients respond to diagnosis, treatment and care (Pacquiao, 2001). For example, individualism, the concept of mutual independence and self-reliance, is based on the American culture. However, other cultures consider the family as the smallest unit of identity, and decision making cannot therefore be assessed and carried out by an individual outside the family (Pacquiao, 2001). Based on this background, decision making therefore rests with the family. Therefore, in the American context, for instance, cultural conflict may arise between family and individualism- the latter being interpreted as detachment from culture, family obligations, religious doctrines, and spirituality. Another example of cultural conflict regards the disclosure of diagnosis and prognosis. While the American medical system values full disclosure of information relating to patient diagnosis and prognosis, viewing it as an essential component of good care, some cultures do not. On the contrary, they only prefer full disclosure to family members, who then filter the news to make it sound less worse. To these people, blunt truth is rude and disrespectful, and patient should not be burdened with it. Related to this is the assumption in many cultures that discussing death with patients causes them much physical and emotional harm and thus hastens their death (Pacquiao, 2001). Related to these are personal beliefs on the relationship between illness and suffering, and God. Some people believe illness and death are God’s will. Others, in relation to this, believe illness and death are natural and one should not try to manipulate or control them. And some cultural groups believe nurses are experts who know it all, and can therefore make decisions on behalf of the patients (Pacquiao, 2001). It is for this reason that nurses must assess and understand the basic attitudes and values of the patient and his/her family. Equally, the nurse should understand the patients’ beliefs on his/her illness, health in general, death and decision-making on end-of-life. This assessment should take into consideration the roles of both the family members and nurse’s role in the process of providing care (Westphal & Teresa, 2005). Ultimately, while providing care, nurses must take into account the client’s/ patient’s culture and ethnicity, socioeconomic and religious backgrounds (Cunningham, 2000). Conclusion This paper has evaluated the concept of power differentiation or imbalance between the nurse and client in the mental health nursing care. The main aim was to show the dilemmas that the current discussions and literature regarding law and ethics- on mental health nursing care as a profession- still present. But the debate on these issues is still on-going. However, many agree that the nurse is still in a position of power from which, in relation to the issues discussed here, the client is at great power disadvantage. References Barker, P. (2000). ‘The Tidal Model: The Lived Experience in Person-Centred Mental Health Care’, Nursing Philosophy, vol. 2, no. 3, pp. 213-223 Barker, P. & Buchanan-Barker, P. (2004). Bridging – Talking Meaningfully About the Care of People at Risk. Retrieved 18th May, 2012, http://www.tidal- model.com/Bridging.htm Canadian Nurses Association (CNA). (2002). Code of Ethics for Registered Nurses. Ottawa: Author. Cleary, M. (2003). ‘The Challenges of Mental Health Care Reform for Contemporary Mental Health Nursing Practice: Relationships, Power and Control’, International Journal of Mental Health Nursing, vol. 12, no. 2, pp. 139-47 College of Registered Nurses of British Columbia (CRNBC). (2005). Professional Standards for Registered Nurses and Nurse Practitioners. Vancouver: Author. 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