Mental Health

Introduction, Patient Rights

Types of admission:

  • Voluntary admission: Patient can sign themselves in and out

  • Involuntary admission: shows signs of threat to themselves or others or is gravely disabled (e.g. mental illness prevents them from taking care of themselves with basic things like eating, drinking, showering, etc.)

    • If admission is involuntary, typically requires at least 2 physicians for justification of admission BUT can vary depending on state

  • Emergency Admission: poses an imminent (about the happen) threat to themselves or others

    • Requires court hearing in 24-48 hours to determine if patient can be d/c or involuntary admission is needed which will vary by state

Patient rights for admission:

  • Right to voluntary: protected by HIPAA. Information about patient CANNOT be handed or given to anyone outside of patient’s health care team UNLESS given permission by patient

    • Exception: Duty to warn in where a patient poses risk s to a third party (e.g. patient states “I am going to kill someone when I get out of here”.) then the nurse has a duty to warn that said third party because of safety concern

  • Right to refuse treatment: case varies depending on if patient is voluntary or involuntary admitted. (e.g. if patient refusing to take their bipolar medications, as a nurse we have duty to discuss risks and benefits of taking the meds BUT at the end of the day IT IS the patient’s decision

    • Exception: Emergency situation where patient is getting too violent and posing harm to themselves or others the medications may need to be provided regardless of if patient is consenting or not

  • Patient has right to the LEAST restrictive environment: Restrains and seclusions should only be used as a last resort and for the shortest duration of time possible. Try other alternatives prior to resorting in retraining or secluding the patient.

Note: even patients who was admitted involuntary has the RIGHT to REFUSE any treatment

Informed Consent, Nursing ethical principles

Obtaining Informed Consent:

  • Providers needs to be the one EXPLAINING the procedure, risks, benefits, provide alternative solution to problems that exists and provide the risks and benefits of those alternative solutions

    • Needs to make sure patient fully understands the information and answer any questions they have

  • Nurse DOES NOT explain the procedure, risks, benefits. They are RESPONSIBLE for signing the consent form as a WITNESS and making sure patient received all information from providers, patient is competent to give the consent, and patient gave their consent voluntarily

    • Competent patient to give consent: Has to be at least 18 or over and not impaired (e.g. patient that are under influence of drug, alcohol, having hallucinations, schizophrenic, dementia cannot give informed consent)

      • Exception of the at least 18 or over rule: patient who are emancipated, in military or married can provide informed consent. Minors who are seeking mental health services can do so without parental consent in most states

  • Once patient has signed the consent form, they have the right to change their mind prior to procedure.

  • Note: if you are going to get the consent signed by patient and patient reports “I have more concerns and questions about the procedure” then it is not your responsibility to answer those questions. You need to CALL the provider back to answer those questions.

Ethical Principles:

  • Autonomy: patient’s right to autonomy, be able to make their own healthcare decisions. Has the right to refuse medications or procedures

  • Beneficence: promote good. Help patient and assists them in therapeutic way.

  • Non-maleficence: avoid causing harm to patient. (e.g. check medication 3 times to avoid medication error)

  • Justice: treat patients fairly and equally. Distribute care among patient in an equitable care

  • Fidelity: being faithful and loyal to patients

  • Advocacy: something a nurse ALWAYS does for the patient. (e.g. if a nurse sees a concerning or alarming condition, reach out to HCP to get the patient help)

  • Veracity: tell the truth all the time

Nurse/Client Relationship, Therapeutic Communication

  • Four phases of Nurse-Client relationship:

    • Pre-orientation: Nurse is preparing for a meeting with patient. Chart review will be done. Examine thoughts and feelings about working with patient.

    • Orientation: Perform introductions, establish report with patient. stablish the nurse-patient relationship as well as boundaries. Ensure and discuss patient confidentiality. Set mutually agreeable goals. Set a date, time, place and duration of meetings.

    • Working phase: gather date, identify and practice problem solving skills and coping skills. Provide patient education, evaluate progress towards the goals

    • Termination Phase: Summarize goals that were achieved or the progress made towards the goal that is being achieved. Discuss incorporations of new coping mechanism and problem-solving skills into their life. Discuss discharge plans. Provide time for patient to share their feeling regarding termination of their relationship (why? can elicit a sense of grief for patient).

Transference v. Countertransference:

  • Transference: patient redirects or transfers their feelings about person from their pass to the nurse (e.g. nurse reminds patient about their abusive mom, causing them to treat nurse in negative way)

  • Countertransference: Nurses feeling and response to patient are influenced by their past relationships. (e.g. patient reminded the nurse of someone from their pass, then the nurse might treat the patient differently).

Therapeutic Communication:

  • Broad opening remarks: “What would you like to talk about today?” helps enagge patient and get them talking

  • Open-ended questions: “tell me more about the voices you are hearing” important to get the patient talking and giving out more details about the voices they are hearing to determine if they are at risk of self harm or to others

  • Sharing observations: “you seem a little sad for me today”. opens the door for patient to share more about their feelings or why they are feeling that way

  • Clarification: “Do I understand you correctly when you say this ____”. aka validation where seek understanding for something that is vague or confusing.

  • Reflection: “Well, what are your thoughts on it” refer a question back to the patient

  • Offering self: make yourself available to patient (e.g. Nurse finished with wound care, patient about to get a vascular access done and is scared, nurse states she will wait for them here while they are getting it done”

  • Restating: Repeat what patient