Nurses may play a role in forensic psychiatry. The role of the forensic nurse varies according to legal status of the client, treatment setting, and ANA Standards for Practice in the Cor- rectional Setting. The forensic nurse may function as a staff nurse in an emergency room or correctional setting, a nurse scientist, a nurse investigator, an expert witness, or an inde- pendent consulting nurse specialist. The roles of health educa- tor, client advocate, and counselor are also fulfi lled. (This role is discussed more fully in Chapter 6.)
Whatever his or her function, the nurse must be familiar with the law and legal provisions related to the area in which care is rendered. An ethical dilemma could occur because the duty to the legal system (not the client) could confl ict with the issue of confi dentiality. Informing the client of the limits of confi dentiality is similar to the Miranda warning, in which a person who is arrested is informed of his or her legal rights.
In other words, the client is aware, before the onset of care, that the nurse may be legally required to repeat anything the client has discussed in a confi dential manner. Security stan- dards must be maintained at all times.
The forensic nurse must adhere to principles of honesty, strive for objectivity, and maintain professional skills, inter- est, and empathy. Clients may present as seriously mentally ill individuals manifesting psychoses. They may exhibit severe psychiatric disturbances such as personality disorders, violent or suicidal behavior, alcoholism, or substance abuse. Special populations may include minorities, the elderly, women, and clients with HIV or AIDS. It is important to provide culturally competent care to all clients.
Because of the changing nature of the legal system, foren- sic nurses need continual updates of information. Continuing education and professional development efforts are necessary to provide nurses with ongoing, specifi c and relevant infor- mation and are critical to the promotion and advancement of forensic psychiatric nursing as a specialty practice. Conversely, if the forensic practitioner does not feel well informed or sup- ported, the practitioner may retreat from the institutional scene in haste, frustration, or anger.
Elements of Mental Competency to Stand Trial
The client
has mental capabilities to appreciate his or her
•
presence in relation to time, place, and things;
has elementary processes enabling him or her to
•
comprehend that he or she is in a court of justice, charged with a criminal offense;
comprehends that there is a judge on the
•
bench;
comprehends that a prosecutor will try to convict
•
him or her of a criminal charge;
comprehends that he or she has a lawyer who
•
will undertake to defend him or her against the charge;
comprehends that he or she will be expected to
•
tell his or her lawyer the circumstances, to the best of his or her mental ability, and the facts sur- rounding him or her at the time and place of the alleged law violation;
comprehends that there is or will be a jury pres-
•
ent to pass upon evidence adduced as to his or her guilt or innocence of such charges; and has memory suffi cient to relate those things in his
•
or her own personal manner.
BOX 5.7
SELFAWARENESS PROMPT
A young male client with a history of mental illness has been brought to the emergency room by the police for a psychiatric evaluation. During the initial assessment, he tells you that he was
“manhandled” by the police and that he is being held against his will. What are his rights as an individual receiving emergency care? What course of action should you take?
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60 UNIT II Special Issues Related to Psychiatric–Mental Health Nursing
Critical Thinking Questions
1. You are working the evening shift in a psychiatric facility when you are asked to admit a new client. As you begin your assessment, the client informs you that he has been brought there against his will and does not intend to stay.
You notice that neither the voluntary admission form nor the consent for treatment has been signed. You excuse yourself and inform the charge nurse of your fi ndings.
Ignoring your concerns, she says, “Don’t worry, get him admitted and then I’ll talk to him.” What do you do?
2. While working in a long-term care facility, you begin to admit a new client. She informs you that she is under the care of a psychiatrist, but states, “Don’t worry, my hallucinations are mostly controlled.”
Keeping in mind the OBRA of 1987, explore the actions that you must take.
The Forensic Nurse as a Legal Nurse Consultant and an Expert Witness
The legal nurse consultant (LNC) is a specialty fi eld within the scope of forensic nursing. LNCs play an invaluable role in advocating patient rights and safety. According to the Ameri- can Association of Legal Nurse Consultants (AALNC), the LNC evaluates, analyzes, and renders informed opinions on the delivery of health care, including professional conduct, docu- mentation in medical records, and medication errors, and the resulting outcomes (Sanders, 2001a). For example, an LNC may serve as a consultant for a law fi rm that specializes in mal- practice claims, testify as an expert witness in court, or review and respond to issues included in affi davits.
The task of the forensic nurse serving as an expert witness is to combine empathy with a willingness to translate complex, scientifi c, and psychiatric fi ndings into clear and pertinent meaning. Factors that determine expert witness status include
level of education, clinical training, licensure, specialty board certifi cation, experience, and reputation. Scholarship, or the participation in workshops and the publication of articles in leading journals, adds to one’s reputation as an expert witness.
In today’s medical–legal environment, the expert witness also must be familiar with courtroom procedures, the subtle- ties of expert testimony, and the limitations of his or her own potential liability. An expert witness may serve as a consul- tant about the quality of care provided in a malpractice claim (eg, Were the standards of care met?), may conduct evaluations of hospital policies and procedures, or may provide testimony in court. For example, a client may be seeking a fi nancial judg- ment because a practitioner prescribed the wrong medication for treatment. The expert witness may be asked to provide information about whether the nursing care associated with the administration of the medication refl ected adherence to the standards of nursing care.
KEY CONCEPTS
The practice of psychiatric nursing involves ethical deci-
•
sions regarding such issues as when to hospitalize a client involuntarily, when to use pain-medication management on a substance abuse unit, and when genetic testing or clinical research would be of benefi t to a client. A code of ethics has been developed by the ANA to guide nurses to employ cer- tain principles when faced with such ethical challenges.
Psychiatric nursing demands knowledge of the law as it
•
pertains to client rights, client legal status, and the quality of care rendered. The ANA developed a Bill of Rights for Registered Nurses identifying the rights needed to provide high-quality client care in a safe work environment.
Nurses are subject to malpractice liability, such as for medica-
•
tion errors, improper use of equipment, and failure to follow physician orders or established protocols. Intentional torts such as assault and battery, defamation, and false imprison- ment are also classifi ed as forms of professional malpractice.
The use of technology such as computers, PDAs, e-mail,
•
and fax machines has contributed to breaches of client confi dentiality and privacy.
The landmark Supreme Court case
• Tarasoff v. Regents of the
University of California has reshaped the confi guration of
psychiatric practice and altered the relationship between clinicians and public authorities. The duty to warn takes precedence over the duty to protect confi dentiality.
The civil rights of psychiatric clients are protected by law.
•
Clients who voluntarily seek help retain civil rights during hospitalization. Those clients who are involuntarily com- mitted to treatment (civil commitment) lose the right to liberty. State laws govern the legal rights of minors admit- ted to a psychiatric facility.
The judicial system has guarded the right of accused per-
•
sons to receive a fair, impartial criminal trial by determin- ing competency to stand trial. Pleas that may be entered include diminished capacity, not guilty by reason of insan- ity, or guilty but mentally ill.
The role of the forensic nurse is challenging because the
•
nurse must be familiar with the law and legal provisions for clients in the clinical setting. Ethical dilemmas may occur because the nurse’s primary responsibility is to the legal system, not the client.
For additional study materials, please refer to the Student Resource DVD-ROM located in this textbook.
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CHAPTER 5 Ethical and Legal Issues 61
3. For several days you have been caring for a 15-year-old girl who was admitted for episodes described by her parents as “outbursts of rage.” She confi des in you that her parents forced her to come to the hospital and she feels like a prisoner. What do you need to consider before taking action?
Refl ection
Review the quote presented at the beginning of the chapter and then imagine the following: You are providing care for a client undergoing a clinical research drug study. The client informs you that she suspects that she is pregnant but has not seen a doctor to confi rm the pregnancy. What informed and effective care decisions do you need to make before taking action?
NCLEX-Style Questions
1. Nurses must become knowledgeable about genetics and the issues surrounding genetic testing. What is the potential positive ethical impact of genetic testing of psychiatric patients?
a. improved time of diagnosis b. better treatment options
c. ability to predict disease progression d. development of pharmaceutical agents e. all of the above
f. none of the above
2. A client has signed the consent for electroconvulsive therapy (ECT) treatments scheduled to begin in the morning. The client tells the nurse, “I really don’t know why I need this procedure, but everybody has been tell- ing me that it is the best thing.” The basis for the ethical dilemma facing the nurse in this situation most likely involves which of the following?
a. determining whether client has given informed consent and whether it’s the nurse’s role to further explain the treatment
b. identifying whether client and family disagree on treatment
c. deciding whether client is expressing anxiety about treatment
d. judging whether treatment team is following ethical principles
3. The nurse fails to assess a client in physical restraints according to the frequency stipulated in the hospital’s policy. The nurse’s behavior could legally constitute which of the following?
a. false imprisonment b. breach of client privacy c. defamation
d. negligence
4. Which of the following represents inappropriate mainte- nance of client confi dentiality and a potential breach of HIPAA by the psychiatric nurse?
a. discussing client’s current problems and past history in treatment team meeting
b. explaining to client’s visitor that it is inappropriate to discuss client’s care
c. sending copy of client records to referring agency without client’s written consent
d. telling a coworker that it is inappropriate to discuss client’s problems in the cafeteria
5. Which of the following represents appropriate criteria for the involuntary admission of a client into a psychiatric facility?
a. client who is competent but refuses admission b. client who has threatened suicide
c. client who has a long history of mental illness d. client whose family has requested admission 6. A client on a day pass from a psychiatric inpatient unit
runs a red light while driving and is involved in an acci- dent resulting in the death of another. The client’s lawyer subpoenas the nurse to testify at the trial that the client was delusional when released for the day pass. The nurse understands that the lawyer is attempting to establish the legal defense of which of the following?
a. diminished capacity b. guilty but mentally ill
c. not guilty by reason of insanity d. special circumstances of responsibility
REFERENCES
American Nurses Association. (1985). Code of ethics for nurses with interpretive statements. Washington, DC: Author.
American Nurses Association. (2001a). Bill of rights for registered nurses. Washington, DC: Author.
American Nurses Association. (2001b). Code of ethics for nurses with interpretive statements (revised). Washington, DC: Author.
Bosek, M. S. D., Ring, M. E., & Cady, R. F. (2008). Do psychiatric advance directives protect autonomy? JONA’s Healthcare Law, Ethics, and Regulation, 10(1), 17–24.
Chally, P. S., & Loriz, L. (1998). Ethics in the trenches: Decision making in practice. American Journal of Nursing, 98(6), 17–20.
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62 UNIT II Special Issues Related to Psychiatric–Mental Health Nursing Charles, S. C. (2007). Malpractice distress: Help yourself and others
survive. Current Psychiatry, 6(7), 23–24, 27–28, 30, 33–35.
Croke, E. M. (2003). Nurses, negligence, and malpractice. American Journal of Nursing, 103(9), 54–64.
Daly, B. J. (1999). Ethics: Why a new code? American Journal of Nursing, 99(6), 64.
Dunegan, L. J. (2000). The ethics of pain management. Annals of Long-Term Care, 8(11), 23–26.
Eskreis, T. R. (1998). Seven common legal pitfalls in nursing. American Journal of Nursing, 98(4), 34–40.
Grant, J. (2006). To protect and serve: Psychiatrists’ duty to patients.
Current Psychiatry, 5(12), 149–150, 152–154.
Harbet, S. C. (2003). Emancipated minors. Retrieved April 3, 2003, from http://chhd.csun.edu/shelia/436/lecture0405. html
Joint Commission on Accreditation of Healthcare Organizations.
(2002). JCAHO–Sentinel events and alerts. Retrieved July 23, 2005, from http://www.jointcommission.org/Sentinel Events/
SentinelEventAlert
Juvenile Law Center. (2008). Emancipation in the United States.
Retrieved December 29, 2008, from http://www.jlc.org/ factsheets/
emancipations/
Karigan, M. (2001). Ethics in clinical research. American Journal of Nursing, 101(9), 26–31.
Kirn, T. E. (2007). Involuntary commitment and medical patients.
Clinical Psychiatry News, 35(8), 66.
Lachman, V. D. (2006). Psychiatric advance directives. ADVANCE for Nurses, 7(3), 3–17.
Miranda, F., Saliba, G., Cerimele, R., Lowery, K., & Riegel-Gross, K.
(2004). Risk management. ADVANCE for Nurses, 5(24), 13–14.
Morrison, H., & Bagalio, S. (2004). Being a good Samaritan. ADVANCE for Nurses, 5(21), 15–16.
Perlin, M. L. (1999). Tarasoff at the millennium: New directions, new defendants, new dangers, new dilemmas. Psychiatric Times, 16(11), 20–21.
Sanders, C. (2001a). Forensic nursing part two: Legal nurse consultants and sexual assault nurse examiners. Vital Signs, 11(13), 13–18.
Sanders, C. (2001b). Genetic testing—What health care professionals need to know. Vital Signs, 11(22), 13–16.
Schipske, G. (2002). The difference between negligence and malprac- tice. ADVANCE for Nurse Practitioners, 10(5), 26.
Sheehy, K. A. K. (2006). Standards of care: Ethical and legal issues. In S. M. Nettina (Ed.), The Lippincott manual of nursing practice (8th ed., pp. 12–21). Philadelphia, PA: Lippincott Williams & Wilkins.
Silberstein, N. (2003). Genetic technology training. ADVANCE for Nurses, 4(23), 25–26.
Spahis, J. (2002). Human genetics: Constructing a family pedigree.
American Journal of Nursing, 101(7), 44–50.
Starr, D. S. (2004). Mental health confi dentiality. Clinical Advisor, 7(3), 93.
White, G. (2001). The code of ethics for nurses. American Journal of Nursing, 101(10), 73–75.
SUGGESTED READINGS
Bauer, E. M. (2007). Principles of practice: Home hospice nurses encounter broad range of ethical issues. ADVANCE for Nurses, 8(24), 32–33.
Bauman, T. (2007). Complex interplay: Human Genome Project continues research on genetic variations associated with diseases.
ADVANCE for Nurses, 8(22), 25–26.
Buppert, C. (2003). HIPAA patient privacy. American Journal for Nurse Practitioners, 7(1), 17–22.
Calabro, M. D., & Tukosi, B. (2003). Participative ethical decision- making: A model for primary care. ADVANCE for Nurse Practi- tioners, 11(6), 83.
Coakley, C. (2007). Review of informed consent. ADVANCE for Nurse Practitioners, 15(9), 17.
Curtin, L. (2007). When patient privacy endangers staff. American Nurse Today, 2(1), 16–18.
Dembrow, M. (2007). Ethics concerns grow for NPs and PAs. Clinical Advisor, 10(4), 95–98.
Deshaies, K. (2008). Morality check. ADVANCE for Nurses, 9(18), 17–18.
Grace, P. J., Fry, S. T., & Schultz, G. S. (2003). Ethics and human rights issues experienced by Psychiatric Mental Health and Substance Abuse RNs. Journal of the American Psychiatric Nurses Association, 9(1), 17–23.
Grady, P. A., & Collins, F. S. (2003). Genetics and nursing science:
Realizing the potential. Nursing Research, 52(2), Editorial Page.
Horner, S. D. (2004). Ethics and genetics. Clinical Nurse Specialist, 18(5), 228–236.
Hughes, R. G. (2004). First, do no harm: Avoiding near misses.
American Journal of Nursing, 104(5), 81–84.
Kalemba, J. (2007). Joint Commission standards: Meeting the chal- lenge of constant readiness: Ethics, rights & responsibilities.
ADVANCE for Nurses, 8(6), 20.
Kopishke, L. (2007). Legal nurse consultant: A career at the cross- roads of health care and the law. American Nurse Today, 2(12), 11–12.
Lachman, V. D. (2007). Caught in the middle. ADVANCE for Nurses, 8(6), 32–33.
Martin, R. (2007). Heading off liability claims. ADVANCE for Nurse Practitioners, 15(3), 18.
Martin, R. (2007). HIPAA privacy complaints. ADVANCE for Nurse Practitioners, 15(6), 23.
Murray, J. S. (2007). Creating ethical environments in nursing.
American Nurse Today, 2(10), 48–49.
Smith, M. H. (2007). What you must know about minors and informed consent. American Nurse Today, 2(5), 49–50.
West, S., & Noffsinger, S. (2006). Is this patient competent to stand trial? Current Psychiatry, 5(6), 36–38, 41–42.
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6
63
6
e-practice
Forensic Nurse’s Code of Ethics
Forensic nursing education Forensic nursing practice Genomic health care International Association of
Forensic Nurses (IAFN) Pharmacogenomics Scope of forensic nursing
practice
Sexual assault nurse examiner (SANE)
Standards of Care
Standards of Forensic Nursing Practice
Standards of Professional Performance
KEY TERMS LEARNING OBJECTIVES
After studying this chapter, you should be able to:
1. Articulate the history of forensic nursing practice.
2. Discuss the purpose of the International Association of Forensic Nurses (IAFN).
3. Analyze the scope of forensic nursing practice.
4. Interpret the Forensic Nurse’s Code of Ethics.
5. Distinguish three different educational programs available to nurses who desire to become forensic nurses.
6. Explain the rationale for Standard III of the forensic nurse’s Standards of Professional Performance.
7. Compare and contrast four practice areas of forensic nursing.
Forensic nursing is the cutting edge issue in education, practice, and research as we prepare for issues in health care in the 21st century.
—INTERNATIONAL ASSOCIATION OF FORENSIC NURSES, 2005d
Forensic Nursing Practice
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64 UNIT II Special Issues Related to Psychiatric–Mental Health Nursing
(IAFN, 2005c). Three years later, the Scope and Standards of Nursing Practice in Correctional Facilities was published (ANA, 1995). When the IAFN requested that the ANA recognize forensic nursing as a specialty, the ANA responded to this request and jointly created the Scope and Standards of Forensic Nursing Practice with the IAFN in 1997.
Each year, the IAFN holds a Scientifi c Assembly at which experts present topics on the latest advances in the fi eld of forensic science and nursing. Papers are accepted for poster presentation at the meeting. Associate members of the IAFN include physicians, criminologists, law enforcement offi cials, paramedic/emergency technicians, and other interested profes- sionals. The organization also provides a quarterly publication, On the Edge (IAFN, 2005b). This publication, which is avail- able online (http://www.forensicnurse.org), features excellent forensic nursing articles related to abuse, violence, and various psychiatric diagnoses. Current information regarding forensic nursing and the law, certifi cation, forensic clinical programs, and book reviews is also provided.