Legal Issues & CrisisLegal Issues & Crisis

Elisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS

ProfessorProfessor

Ethical PrinciplesEthical Principles AutonomyAutonomy

– Independence & Self DeterminationIndependence & Self Determination BeneficenceBeneficence

– Promote the good of othersPromote the good of others NonmaleficenceNonmaleficence

– Avoiding harmAvoiding harm JusticeJustice

– Treat all equally & fairlyTreat all equally & fairly VeracityVeracity

– Tell the truthTell the truth FidelityFidelity

– Honor commitments & contractsHonor commitments & contracts

Nurse Practice ActNurse Practice Act

Defines legal parameters of professional & Defines legal parameters of professional & practical nursing.practical nursing.– Provide safe, competent, legal & ethical care.Provide safe, competent, legal & ethical care.– Meet standards of care:Meet standards of care:

What any RN would do in a similar situation.What any RN would do in a similar situation.

Recognizes independent vs. dependent Recognizes independent vs. dependent areas.areas.

New York State Practice ActNew York State Practice Act– www.nysna.org– Must know the definition!Must know the definition!

American Nurses’ AssociationAmerican Nurses’ AssociationCode of Ethics for NursesCode of Ethics for Nurses

1.1. Compassion, respect & dignity for Pt.Compassion, respect & dignity for Pt.2.2. RN responsibility to the Pt.RN responsibility to the Pt.3.3. Pt. AdvocacyPt. Advocacy4.4. Accountability for own practice.Accountability for own practice.5.5. Competence & professional growthCompetence & professional growth6.6. Improve health care environmentsImprove health care environments7.7. Advance profession via education & Advance profession via education &

researchresearch8.8. CollaborationCollaboration9.9. Articulate values, maintain integrity & Articulate values, maintain integrity &

shape social policyshape social policy

Mental Health AdmissionMental Health Admission VoluntaryVoluntary

– Self admits, seeks helpSelf admits, seeks help– Consents to treatment Consents to treatment – Can refuse therapy and request dischargeCan refuse therapy and request discharge

Involuntary/EmergentInvoluntary/Emergent– Mental illness impairs cognitive functionMental illness impairs cognitive function– ↑ ↑ Self-Harm or dangerous to othersSelf-Harm or dangerous to others– Detain Pt. against willDetain Pt. against will– Time limited –court hearing in 72 HTime limited –court hearing in 72 H– Observation, Evaluation, & TreatmentObservation, Evaluation, & Treatment

Involuntary-Indefinite (2 PC)Involuntary-Indefinite (2 PC)– Mandated treatment to ease suffering or save lifeMandated treatment to ease suffering or save life– Pt. gravely disabledPt. gravely disabled– Extended & mandated outpatientExtended & mandated outpatient carecare

↑ ↑ Pt. support = ↑ Pt. compliancePt. support = ↑ Pt. compliance ↓ ↓ Pt’s return after releasePt’s return after release

ConfidentialityConfidentiality Primary reason for Pts to be honest & Primary reason for Pts to be honest &

open.open. Pt. information is privileged material.Pt. information is privileged material. Health Insurance Portability & Health Insurance Portability &

Accountability Act. (HIPAA) 1996Accountability Act. (HIPAA) 1996– Put into effect April 14, 2003Put into effect April 14, 2003– Security & privacy of health informationSecurity & privacy of health information– Standards for enforcementStandards for enforcement– Severe fines $25,000 per incidentSevere fines $25,000 per incident

ConfidentialityConfidentiality Right to PrivacyRight to Privacy

– Can not reveal Pt. information to others.Can not reveal Pt. information to others.– Record keepingRecord keeping

Only those actively involved in Pt’s care Only those actively involved in Pt’s care should have access to chart.should have access to chart.

Limit computer access via passwords.Limit computer access via passwords. Privileged communicationPrivileged communication

– Clergy, Attorneys, MDs, Psychologists & Clergy, Attorneys, MDs, Psychologists & RNs RNs

– Only Pt. can waive that privilegeOnly Pt. can waive that privilege– ExceptionsExceptions

Child AbuseChild Abuse– Intent to harm a child < 18 years.Intent to harm a child < 18 years.

Duty to DiscloseDuty to Disclose– MD obligated to warn individual when MD obligated to warn individual when

Pt has made a credible threat to kill.Pt has made a credible threat to kill.

Basic Rights of Mental Health Basic Rights of Mental Health Pts.Pts.

1.1. Right to TreatmentRight to Treatment Individualized NCP with periodic reviewIndividualized NCP with periodic review Inform Pt of potential risks, benefits & alternatives.Inform Pt of potential risks, benefits & alternatives.

2.2. Least Restrictive EnvironmentLeast Restrictive Environment Humane; free from restraint or seclusionHumane; free from restraint or seclusion AssaultAssault – Threat to touch & no consent – Threat to touch & no consent Battery Battery – Touching & no– Touching & no consent consent False ImprisonmentFalse Imprisonment - Confinement → Seclusion - Confinement → Seclusion

3.3. Right to Refuse TreatmentRight to Refuse Treatment Free to refuse to participate in researchFree to refuse to participate in research Voluntary written consentVoluntary written consent

4.4. Right to AftercareRight to Aftercare Follow-up & outpatient services after dischargeFollow-up & outpatient services after discharge Referrals, transportation, support groups, medications.Referrals, transportation, support groups, medications.

5.5. Retain constitutional & legal rights.Retain constitutional & legal rights. Vote, receive & send mail, manage finances, wear own clothes, Vote, receive & send mail, manage finances, wear own clothes,

receive visitors,receive visitors, Seek advice of attorneySeek advice of attorney

Treatment SettingsTreatment Settings Inpatient HospitalInpatient Hospital

– Rapid assessment, stabilization and discharge (DC) planning Rapid assessment, stabilization and discharge (DC) planning for:for: Severely depressed and/or suicidalSeverely depressed and/or suicidal Severely psychoticSeverely psychotic ETOH or drug withdrawalETOH or drug withdrawal Behaviors that require close supervision in a safe Behaviors that require close supervision in a safe

environmentenvironment

– Client-centered multidisciplinary approach to facilitate a Client-centered multidisciplinary approach to facilitate a brief stay.brief stay.

– Case management begins @ admission.Case management begins @ admission. Liaison between client, community resources, home care Liaison between client, community resources, home care

& insurance.& insurance.– Scheduled intermittent or long term stays for severe & Scheduled intermittent or long term stays for severe &

persistent mental illness.persistent mental illness.– Clinicians assist clients toClinicians assist clients to

Recognize symptoms, identify + coping skills andRecognize symptoms, identify + coping skills and choose choose DC supports.DC supports.

Identify long-term issues for client to pursue in Identify long-term issues for client to pursue in outpatient therapy.outpatient therapy.

Milieu TherapyMilieu Therapy

Entire social structure is a Entire social structure is a positivepositive living experience living experience– Physical facilities are conducive to therapyPhysical facilities are conducive to therapy– Atmosphere of mutual respectAtmosphere of mutual respect– Democratic form of self governmentDemocratic form of self government– Pt. is accountable for behavior and environmentPt. is accountable for behavior and environment– Learn adaptive coping, interaction & Learn adaptive coping, interaction &

communication skills.communication skills.– Inappropriate behaviors are addressed ASAPInappropriate behaviors are addressed ASAP

Nurse’s RoleNurse’s Role– Establish an open, dignified & confirming Establish an open, dignified & confirming

environmentenvironment– Meet all Pt needs; Meds, education & set limits.Meet all Pt needs; Meds, education & set limits.

Partial Hospitalization Partial Hospitalization ProgramProgram

Facilitates successful gradual transition Facilitates successful gradual transition to independent community livingto independent community living

Intensive treatment & short term (4-6 Intensive treatment & short term (4-6 weeks)weeks)– Individual & group therapyIndividual & group therapy– Structured activities & educationStructured activities & education– Learn to structure timeLearn to structure time– Develop social skillsDevelop social skills– Obtain meaningful workObtain meaningful work

Stabilize symptomsStabilize symptoms Monitor drug effectivenessMonitor drug effectiveness Stabilize living environmentStabilize living environment Improve ADLsImprove ADLs

Transition to CommunityTransition to Community Discharge Obstacles:Discharge Obstacles:

– ETOH & drug abuseETOH & drug abuse– Criminal or violent behaviorCriminal or violent behavior– Noncompliance with medicationsNoncompliance with medications– Suicidal ideationSuicidal ideation

Successful DC planningSuccessful DC planning– Communication between inpatient & Communication between inpatient &

outpatient staff outpatient staff – Client visits or begins outpatient program a Client visits or begins outpatient program a

DC.DC.– Family members/support system involved in Family members/support system involved in

care.care.– Social services, housing and day treatment = Social services, housing and day treatment =

same goal: same goal: Compliance, Rehabilitation & Independent living.Compliance, Rehabilitation & Independent living.

Community Mental HealthCommunity Mental Health

1963 Community Mental Health Act = 1963 Community Mental Health Act = DeinstitutionalizationDeinstitutionalization– Proactive oriented community based Proactive oriented community based

approachapproach– Identify and Identify and ↓stress in community↓stress in community– Provide treatment in least restrictive Provide treatment in least restrictive

settingssettings Closed state hospitalsClosed state hospitals Shelters and group homesShelters and group homes

– Need ↑↑ follow up care & outpatient servicesNeed ↑↑ follow up care & outpatient services– Case Management = optimal outcomeCase Management = optimal outcome– Freedom of choiceFreedom of choice

↑↑ ↑↑ Community reintegrationCommunity reintegration

Prevention ModelsPrevention Models Primary PreventionPrimary Prevention

– Promote Health & Promote Health & ↓ Incidence of mental disorder↓ Incidence of mental disorder– Identify stressful life events & @ risk populationsIdentify stressful life events & @ risk populations

EX: Stress management & teen pregnancy classesEX: Stress management & teen pregnancy classes

Secondary PreventionSecondary Prevention– Early diagnosis & treatmentEarly diagnosis & treatment– ↓ ↓ Duration of illnessDuration of illness

EX: Medication, ECT, counseling (in or out PT)EX: Medication, ECT, counseling (in or out PT)

Tertiary PreventionTertiary Prevention– Rehabilitate & restore to optimal health & Rehabilitate & restore to optimal health & ↓relapse↓relapse– ↓ ↓ residual effects of severe or chronic mental illnessresidual effects of severe or chronic mental illness

EX: Vocational skills training, Halfway HouseEX: Vocational skills training, Halfway House

Residential SettingsResidential Settings Vary according to the level of Vary according to the level of

supervision, structure, and services supervision, structure, and services provided.provided.– Adult foster homeAdult foster home– Halfway houseHalfway house– Group homeGroup home– Supervised apartment livingSupervised apartment living

Facilitates:Facilitates:– Recovery Recovery – Personal growth Personal growth – EmpowermentEmpowerment– ↑ ↑ IndependenceIndependence

Rehabilitation ProgramRehabilitation ProgramClubhouse ModelClubhouse Model

A place to come to: leisure activitiesA place to come to: leisure activities Meaningful work (employment)Meaningful work (employment) Meaningful relationshipsMeaningful relationships A place to return to (Lifetime A place to return to (Lifetime

membership)membership)– Participate in maintaining clubhouseParticipate in maintaining clubhouse– Encouraged to use local psych servicesEncouraged to use local psych services

Assertive Community Assertive Community Treatment (ACT)Treatment (ACT)

Successful community-based Successful community-based outreachoutreach– ACT programs go to the client!ACT programs go to the client!– Problem solving orientationProblem solving orientation– Directly provide services (not Directly provide services (not

referrals)referrals)– Intense > 3 face-to-face contacts per Intense > 3 face-to-face contacts per

weekweek– Team approach not 1 case managerTeam approach not 1 case manager– Long term (indefinite services)Long term (indefinite services)

Multidisciplinary TeamMultidisciplinary TeamCollaboration of disciplines to provideCollaboration of disciplines to provide

organized, comprehensive, and effectiveorganized, comprehensive, and effective

services.services. PsychiatristPsychiatrist

– Diagnosis and prescribes treatmentDiagnosis and prescribes treatment PsychologistPsychologist

– Individual/Group therapyIndividual/Group therapy– Interprets psychological testsInterprets psychological tests– ResearchResearch

Multidisciplinary TeamMultidisciplinary Team Psychiatric Nurse RNPsychiatric Nurse RN

– Holistic approachHolistic approach– Provide interventions: Meds, counseling, Provide interventions: Meds, counseling,

education & evaluate efficacy of careeducation & evaluate efficacy of care Psychiatric Social WorkerPsychiatric Social Worker

– Works with families, community support & Works with families, community support & referralsreferrals

Occupational TherapistOccupational Therapist– Improve functional abilities (ADLS)Improve functional abilities (ADLS)

Recreational TherapistRecreational Therapist– Encourage communication and socialization Encourage communication and socialization

via crafts and recreationvia crafts and recreation

Group TherapyGroup TherapyA leader and a group of Pts with a shared commonA leader and a group of Pts with a shared commoninterest.interest.

– Content oriented: Goals & tasksContent oriented: Goals & tasks Standards of behaviorsStandards of behaviors

– Process oriented: Interpersonal relationsProcess oriented: Interpersonal relations Communication skillsCommunication skills

Members contribute to group and expect Members contribute to group and expect to benefit from it.to benefit from it.– Socialization, support & empowermentSocialization, support & empowerment– ↑ ↑ Acceptance & ↑ HopefulnessAcceptance & ↑ Hopefulness

Nurse’s RoleNurse’s Role– Establish guidelines & facilitate discussionEstablish guidelines & facilitate discussion– Encourage participation by all membersEncourage participation by all members– Summarize highlightsSummarize highlights

Family TherapyFamily Therapy

Family is a social unit with unique norms Family is a social unit with unique norms & values, roles and support system.& values, roles and support system.– Family may be resistant to recognize their Family may be resistant to recognize their

contribution.contribution.– Vague/indirect communicationVague/indirect communication– Inflexible rules, different rules for each Inflexible rules, different rules for each

member.member. Change in one member affects the Change in one member affects the

entire family.entire family.– Identified member experiences symptoms.Identified member experiences symptoms.

Use genogram to identify relationships, Use genogram to identify relationships, conflicts and support system.conflicts and support system.

Self-AwarenessSelf-Awareness Recognition of one’s own existenceRecognition of one’s own existence

– Via behavior, feelings, thoughts & beliefs Via behavior, feelings, thoughts & beliefs

– Identification of factors that influence Identification of factors that influence themthem Attitude, Interaction styles, Values & Attitude, Interaction styles, Values &

MotivationMotivation Self-EsteemSelf-Esteem

– Personal EvaluationPersonal Evaluation Self-IdealSelf-Ideal

– Personal standards, goals & realistic Personal standards, goals & realistic expectationsexpectations

Body ImageBody Image– Mental representationMental representation

Johari WindowJohari Window A self awareness toolA self awareness tool

↑ ↑ Insight to behavior and potential changesInsight to behavior and potential changes

Known to Known to SelfSelf

Not Known to Not Known to SelfSelf

Known to Known to

OthersOthers1.1. PublicPublic

(Open)(Open)2. 2. Semi-PublicSemi-Public

(Unaware)(Unaware)

Not Known Not Known

to Othersto Others3. 3. Private Private

(Hidden)(Hidden)4. 4. InnerInner

(Unknown)(Unknown)

Sociocultural IssuesSociocultural Issues CultureCulture

– Learned patterns of values, beliefs, attitudes Learned patterns of values, beliefs, attitudes & customs.& customs.

– Provides basis for thinking and daily rules.Provides basis for thinking and daily rules.– Guides conduct and passed down from Guides conduct and passed down from

generation to generation.generation to generation.– Shared heritage & traditions.Shared heritage & traditions.– Health care attitudes & actions.Health care attitudes & actions.

EthnocentrismEthnocentrism– Judge others by one’s own cultural Judge others by one’s own cultural

standards.standards.– Thus different behavior is inappropriate or Thus different behavior is inappropriate or

bad.bad.

Cultural Assessment ToolCultural Assessment ToolIdentifies patients’ belief system and Identifies patients’ belief system and

their their

usual life practices.usual life practices. CommunicationCommunication Physical spacePhysical space Social organizationSocial organization Time orientationTime orientation Environmental controlEnvironmental control Biologic variationsBiologic variations Social classSocial class

Cultural CompetenceCultural Competence Process where the RN proficiently Process where the RN proficiently

develops;develops;– Cultural awarenessCultural awareness– Specific cultural knowledge & health practicesSpecific cultural knowledge & health practices– Ability to relate to different ethnic Ability to relate to different ethnic

backgroundsbackgrounds– Insight regarding wide variations among Insight regarding wide variations among

members of a cultural group.members of a cultural group.– ““How would you like to be cared for?”How would you like to be cared for?”– ““Are there any specific cultural, spiritual or Are there any specific cultural, spiritual or

health practices that we need to consider and health practices that we need to consider and follow?”follow?”

RN Promotes effective and appropriate RN Promotes effective and appropriate health care.health care.

Cultural PatternsCultural Patterns African AmericansAfrican Americans

– Strong, large, extended familyStrong, large, extended family– Matriarch (head of household)Matriarch (head of household)– Traditional medicines & healersTraditional medicines & healers– Conversation animatedConversation animated– Handshakes & direct eye contact Handshakes & direct eye contact

convey interest & respectconvey interest & respect

– View mental illness as View mental illness as a spiritual imbalance or a spiritual imbalance or punishment for sinpunishment for sin

Cultural PatternsCultural Patterns American Indians or Native AmericansAmerican Indians or Native Americans

– Family & community orientedFamily & community oriented– Wellness oriented & relationship with Wellness oriented & relationship with

Supreme beingSupreme being– Speak slowly with many pausesSpeak slowly with many pauses– Prefer a light-touch handshake and minimal Prefer a light-touch handshake and minimal

direct eye contactdirect eye contact– View mental illness RTView mental illness RT

Loss of harmony with environmentLoss of harmony with environment Ghosts/Breaking taboosGhosts/Breaking taboos

– RN should allow Pt to keepRN should allow Pt to keep Medicine bag or other healing objectsMedicine bag or other healing objects RN should not touch or question itemsRN should not touch or question items..

Cultural PatternsCultural Patterns Latino AmericansLatino Americans

– Nuclear structureNuclear structure Strong, large, extended familyStrong, large, extended family

– Strong church & community tiesStrong church & community ties– ↑ ↑ Tactile, hugs/embraceTactile, hugs/embrace– Expect direct eye contact = Expect direct eye contact =

respect/honestyrespect/honesty– Physical illness is hereditary or Physical illness is hereditary or

punishmentpunishment– Mental illness is hereditary & social Mental illness is hereditary & social

stigmastigma ““Lost soul RT evil eye”Lost soul RT evil eye”

Cultural PatternsCultural Patterns ChineseChinese

– Shy in unfamiliar surroundingsShy in unfamiliar surroundings Silence = respectSilence = respect Minimal self-disclosureMinimal self-disclosure

– Keep a respectful distanceKeep a respectful distance Nodding = politeness (and may not be Nodding = politeness (and may not be

agreement)agreement)– Eldest male may be family spokespersonEldest male may be family spokesperson– Traditional medicines, healers & herbsTraditional medicines, healers & herbs– ↑ ↑ Devotion to traditionsDevotion to traditions– View mental illness RTView mental illness RT

Disharmony of emotionsDisharmony of emotions Evil spirits Evil spirits ShamefulShameful

Cultural PatternsCultural Patterns Arab AmericansArab Americans

– Greet others with a smile and handshakeGreet others with a smile and handshake– Eldest male may be family spokespersonEldest male may be family spokesperson

Men are breadwinners, protectors, Men are breadwinners, protectors, decision makersdecision makers

– Women care & educate childrenWomen care & educate children Modesty (cover body to protect moral Modesty (cover body to protect moral

character)character)– Dietary restrictions (Muslims)Dietary restrictions (Muslims)

Halal meat No pork, gelatin or ETOHHalal meat No pork, gelatin or ETOH– View mental illness RTView mental illness RT

Fear, manipulation, God, loss of countryFear, manipulation, God, loss of country, , family or friendsfamily or friends

Stigma, only seek help as last resortStigma, only seek help as last resort

CrisisCrisis

Psychological DisequilibriumPsychological Disequilibrium Severe disorganizationSevere disorganization Short term 4 – 6 weeksShort term 4 – 6 weeks Sudden perceived internal threatSudden perceived internal threat

– Stressful situation/specific Stressful situation/specific identifiable eventidentifiable event

– Hazardous circumstanceHazardous circumstance Inadequate decision Inadequate decision

making/problem solvingmaking/problem solving ↑↑ ↑↑ AnxietyAnxiety

Types of CrisisTypes of Crisis MaturationalMaturational

– Anticipated, predictable life eventsAnticipated, predictable life events– Role transitions: Graduation, marriage, Role transitions: Graduation, marriage,

familyfamily SituationalSituational

– Unanticipated events that disrupt life Unanticipated events that disrupt life stylestyle

– Unemployment, homelessUnemployment, homeless AdventitiousAdventitious

– Accidental, multiple lossesAccidental, multiple losses– Extensive environmental changesExtensive environmental changes

9-11 WTC, 12/04 Tsunami, Oklahoma 9-11 WTC, 12/04 Tsunami, Oklahoma bombingbombing

Gerald Caplan’s TheoryGerald Caplan’s Theory Phase 1Phase 1

– Exposure to stressor = anxietyExposure to stressor = anxiety

Phase 2Phase 2– Usual problem solving is ineffective =Usual problem solving is ineffective = ↑ ↑

anxietyanxiety

Phase 3Phase 3– ↑ ↑ efforts &efforts & resources used; seeks help resources used; seeks help

Phase 4Phase 4– All prior efforts unsuccessful All prior efforts unsuccessful – Severe anxiety = Major DisorganizationSevere anxiety = Major Disorganization– Breaking PointBreaking Point– Intervention is essential!Intervention is essential!

Crisis InterventionsCrisis Interventions STAT care!STAT care!

– Debriefing & stabilize victimsDebriefing & stabilize victims– Gather facts & listen to understand impact Gather facts & listen to understand impact – Have Pt. objectively describe event to Have Pt. objectively describe event to

identify:identify: Communication & coping skills, Communication & coping skills, Support systemSupport system Perception of eventPerception of event

– Provide education to Provide education to ↓ stress & ↑ coping↓ stress & ↑ coping– Only focus on current problemOnly focus on current problem– Provide follow-up referrals & support groupProvide follow-up referrals & support group

OutcomeOutcome– Improved CopingImproved Coping– Return to prior functioning levelReturn to prior functioning level– Decreased copingDecreased coping

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