After studying Module 1: Lecture Materials & Resources, discuss the following:
The unlawful restraint of a patient can be a legal pitfall for the PMHNP. K.W. was found eating hamburgers out of a Mcdonald’s dumpster and drinking water from an old water hose. She had not taken a bath in weeks. She refused to live in an apartment because she wants to “live off the fat of the land.”
Legal Aspects of Psychiatry and the Role of the Psychiatric Mental Health Nurse Practitioner
(PMHNP)
Psychiatric Management 1| NUR 620
Major Concepts
▪
Scope and Standards of Psychiatric Mental Health Nursing
▪
Laws that guide care and treatment of the mentally ill
▪
Cultural Issues
History of the NP Role
▪ 1952 Hildegard Peplau
▪ Published her Theory of Interpersonal Relations
▪ 1965 Loretta C. Ford and Henry Silver
▪ Registered Nurses with advanced education
▪ Perform clinical duties traditionally performed by MDs
▪ 1965 The first NP program opened at the University of Colorado.
▪ 1967 Hildegard Peplau
▪ Developed the clinical nurse specialist role with the ANA in the document
“Statement of Psychiatric Nursing Practice.”
▪ 1973 ANA
▪ Development of scope and standards of Psychiatric-Mental Health Practice
◼ NURSING THEORIES SPECIFIC TO PSYCHIATRIC
NURSING
▪ Hildegard Peplau
– Considered founder of psychiatric nursing
– Developed theory of interpersonal relationships in early 1950s
– Described six roles for the nurse
– Four phases of the interpersonal nursing process
1. Orientation
2. Identification
3. Exploitation
4. Resolution
1.14
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History of the NP Role
▪ 2008 The License, Accreditation, Certification and Education consensus Model finalized four Advanced
practice roles
▪ Certified Registered Nurse Anesthetist (CRNA)
▪ Certified Nurse Midwife (CNM)
▪ Clinical Nurse Specialist (CNS)
▪ Certified Nurse Practitioner (CNP)
▪ 2011 Psychiatric Mental Health Nurse Practitioner (PMHNP) prepared across the lifespan.
▪ 2015 All other PMH advanced roles retired.
◼ ADVANCED PSYCHIATRIC-MENTAL HEALTH
NURSING PRACTICE
▪ United States
– American Nurses Association
– National Organization of Nurse Practioner Faculties (NONPF)
▪ United Kingdom
– No universal advanced nursing role equivalent to that in the United
States
– Nursing and Midwifery Council (NMC)
1. Teaching
2. Specialist practice
3. Prescribing
◼ CONCORDANCE
▪ Concordance
– Working together with people
– Not a synonym of compliance or adherence
•
Often used interchangeably in literature
– Study by Latter, Maben, Myall, and Young (2007)
• Degreed nurses were practicing concordance principles
Latter, S., Maben, J., Myall, M., & Young, A. (2007). Perceptions and practice of concordance in nurses prescribing consultations: Findings from a national questionnaire survey and case studies of practice in England.
International Journal of Nursing Studies, 44, 9–18. doi: 10.1016/j.ijnurstu.2005.11.005
Roles of the PMHNP
▪ Scholarly Activities
▪ Publishing
▪ Lecturing
▪ Presenting
▪ Preceptorship
▪ Continuing Education
▪ Mentoring
▪ Works with a junior colleague
▪ Mutual respect by both mentor and mentee
▪ Client Advocacy
▪ Reduce mental health stigma
▪ Empower and advocate for patients
▪ Support advocacy through professional organizations
Roles of the PMHNP
▪ Health Policy
▪ Participate in activities that promote health care policy
▪ Actively contribute with
▪ Presenting
▪ Preceptorship
▪ Continuing Education
▪ Case Management
▪ Coordinating and monitoring care
▪ Promoting quality and cost effective outcomes
▪ Risk Assessment
▪ Continuously monitor for risk
▪ Risk Management
▪ Interventions to reduce the risk of injury
▪ Advance Directives
▪ Durable Power of Attorney for Health Care
▪ Living Will
Scope and Standards of Practice
▪ State laws
▪ Grant legal authority of NP in the state
▪ Decides who can be called an NP
▪ Defines the role of the NP
▪ Restrictions
▪ Permissions
▪ Collaborative agreement
▪ Define disciplinary actions
Scope and Standards of Practice
▪
▪
▪
▪
▪
▪
▪
▪
▪
Scientific Foundations
Leadership
Quality
Practice Inquiry
Technology and Information Literacy
Policy
Health Delivery System
Ethics
Independent Practice
Scope and Standards of Practice
▪ Licensing
▪ Process used by an agency to grant permission to practice
▪ Credentialing
▪ Ensure minimum level of competency
▪ Certification▪ ANCC
▪ Provides protection of using the title
▪ Grant legal authority of NP in the state
▪ Scope of practice
▪ Gives assurance to the public of minimum level of mastery
Scope and Standards ARNP
▪
Psychotherapy
▪
Psychopharmacological Interventions
▪
Case Management
▪
Consultation-Liaison
▪
Clinical Supervision
The APN Therapist
PSYCHOTHERAPY: Builds trust and develops a therapeutic alliance
Types of Therapeutic Interventions
▪
▪
▪
▪
Individual
Group
Family
Couples
Examples of Modalities
•
•
•
•
•
•
Psychodynamic
Interpersonal
CBT
Insight Oriented
Motivational Interviewing
Mindfulness
Role of the PMHNP
Psychopharmacology
▪
▪
▪
▪
Prescribing medications
Ordering lab work and Diagnostic tests
Collaborative with the Patient/Family/Group
Considering genetics, current research and technology
Case Management
▪
▪
▪
▪
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Organizes and coordinates care
Population
Legal and ethical considerations
Collaborative with the Patient/Family/Group
Identifies real or potential problems then intervenes
Role of the PMHNP
COLLABORATION
▪ Consensus Model: Licensing, Accreditation, Credentialing and Education
▪ Collaborative physician
▪ Primary Care
▪ Collaboration with other healthcare providers
▪ Integrated MH care in Primary Care Setting
▪ MH Care in a co-location
▪ Refers patients
▪ Healthcare Policy
▪ Advocates for patient and family rights
Role of the PMHNP
CLINICAL SUPERVISION
▪ Individual or Group
▪ Planned meetings
▪ In-depth reflection on complex issues
▪ Develops awareness, acceptance and impulse containment
Standards of Practice
▪
Assessment
– Performs comprehensive psychiatric examinations
– Uses evidence based clinical practice guidelines
– Orders and interprets diagnostic tests and procedures
– Conducts a multigenerational family assessment
▪
Diagnosis
– Compares normal and abnormal findings to formulate a diagnosis
– Evaluates the health impact on the individual and family
Standards of Practice
▪
Outcomes Identification
– Identifies outcomes that are achievable
– Considers the cost and clinical effectiveness of the treatment plan
– Orders and interprets diagnostic tests and procedures
– Involves the client, family and other health providers in outcome
▪
Planning
– Provides individualized care including client’s values and belief system
– Offers care in the least restrictive environment
– Provides culturally relevant care
Standards of Practice
▪
Implementation
– Implements age appropriate, culturally and ethnically sensitive care
– Collaborates with nursing colleagues and health providers
– Manages psychiatric emergencies
– Incorporates innovative strategies for care
▪
Health Teaching and Promotion
– Teaching based on situation, developmental stage, readiness, language
– Includes intended effects and potential adverse effects
– Uses health information resources to increase patient’s access to care
Areas of Practices
▪
Psychiatric crisis
▪
Community-based care
▪
Acute in-patient
▪
Assertive Community Treatment
▪
Intermediate and long term setting
▪
Tele-psychiatry
▪
Residential
▪
Collaborative practice
▪
Partial hospitalization
▪
Private practice
PMHNP Professional Links
Florida Board of Nursing, Nurse Practice Act
American Psychiatric Nurses Association
American Nurses Credentialing Center
Legal, Ethical and Cultural Issues in
Psychiatric Mental Health Nursing
💧
Patient Rights-Civil
▪
Vote
▪
Civil service ranking
▪
▪
▪
Driver’s license
Enter contractual relationships
Press charges
▪
Human care and treatment-medical ,
dental, psychiatric
▪
Religious freedom
▪
Social interaction
▪
Recreational opportunities
Inpatient Rights
▪
Confidentiality
▪
Informed consent
▪
Least restrictive setting
▪
Visitation
▪
Communication
▪
Privacy
Involuntary Admissions
Florida Mental Health Act aka Baker Act
Florida Alcohol and Other Drug Services Act aka Marchman Act
Involuntary Admission
▪
Ex parte order by a judge following petition from family or health care professional
▪
Law enforcement officer deems behavior falls under danger to self and/or others
▪
Psychiatric mental health care professional certifies need for admission due to
danger to self or others
▪
Law enforcement takes person to a Baker Act Facility
Involuntary Admission
▪
Patient may be kept for observation for 72 hours excluding weekends and holidays
▪
After 72 hours, patient is released or placed in front of court under Habeas Corpus
▪
Judge makes decision on least restrictive setting
Major Legal Decisions
▪
Right to Refuse Treatment
▪
Right to Treatment
▪
Duty to Warn & to Protect
Right to Refuse Treatment
O’Connor v. Donaldson (1975) RIGHT TO LIBERTY
– Supreme court ruling that harmlessly mentally ill cannot be confined against their
will if they can survive outside.
– Confined 15 years in Florida for paranoid delusions
– Involuntary confinement must be based on danger to self or others
Right to Refuse Medication
Right to Guardianship
Rennie v. Klein (1979) New Jersey Supreme Court decision
RIGHT TO MEDICATION
Rogers v. Okin (1981) Massachusetts Supreme Court
RIGHT TO GUARDIANSHIP
Right to Treatment
Rouse v. Cameron (1966) Washington D.C.
– Treatment must be offered and in the
LEAST RESTRICTIVE SETTING
Wyatt v. Stickney (1971) Alabama
Mental health patients must be offered adequate care and treatment at a
minimum
* Most states a court order needed to administer medications and or
electroconvulsive therapy
Duty to Warn and to Protect
Tarasoff 1 (1976) THE DUTY TO WARN AND PROTECT
– Tarasoff v. Regents of University of California. California Supreme Court A potential victim
must be warned.
Tarasoff 2 (1982)
– Tarasoff v. Regents of University of California. California Supreme Court A dangerous
person must be reported to police.
Ethics
NP have moral duties, obligations and responsibilities to their patients:
▪
Justice: Doing what’s fair
▪
Beneficence: Promoting well being, doing good
▪
Non-maleficence: Do no harm
▪
Fidelity: Being true and loyal
▪
Autonomy: Doing for self
▪
Veracity: Telling the truth
▪
Respect: Treating everyone with equal respect
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