Walden University Week 2 Ethical and Legal Foundations Discussion

The topic I chose for this discussion is child and elder abuse reporting. As healthcare providers and especially as healthcare providers in a specialty that focuses on how the past affects everyday thoughts, actions, and decisions, it is imperative that we are aware and thoroughly knowledgeable on how to manage and navigate through certain occurrences such as reporting child and elderly abuse.

Legal and Ethical Considerations of Reporting Child Abuse

The first article I selected is a user manual that discusses the expectations for a mental health professional when managing the care of an abused child, specifically incidents such as reporting child abuse and neglect, referring children for medical evaluations, and establishing quality assurance practices and standards. (Peterson & Urquiza, 1993). The primary reason for reporting abuse is to protect children from abuse and neglect. It is required by law for the mental health practitioner report abuse if any reasonable suspicion is discovered. Luckily, the nurse is protected by state law from any civil lawsuits and identity is also protected.

The second article I selected discusses the ethical considerations of reporting child abuse and neglect as a healthcare professional. In a recent study, it was discovered that health care providers would not have reported 21% of suspected maltreatment cases that child abuse experts would have reported—leaving children potentially at risk. (Hlady & Allchurch, 2015). Failure to report a case of suspected abuse or neglect can stem from lack of training or providers being reluctant to address the concerns with the family. Failure to report abuse or neglect can lead to further injury and even death.

Legal and Ethical Considerations of Reporting Elderly Abuse

Nursing consultant, Dolores Alford, wrote an article discussing the legal issues within gerontological nursing in relation to abuse and neglect and emphasized on the consequences of not reporting suspected abuse/neglect. When working with the geriatric population, Alford (2006) states that it is imperative to be alert and constantly assess for abuse or neglect, whether it be physical, emotional, sexual, or financial because this population is at high risk for these circumstances. Nurses must first educate themselves about the use of appropriate screening and intervention measures. Next, nurses must incorporate screening for mistreatment as part of the comprehensive assessment performed in their specific practice setting. (Alford, 2006).

Clients may ask that abuse is not reported in fear of the abuser, but this is why building a rapport with the client is essential. Building a relationship and comfortableness with the client and/or family will allow for the client to feel that the nurse has their safety and well-being as priority. (Dolores, 2006). Failure to report any suspected form of abuse or neglect can result in discipline by the board of nursing, the nurse’s employer, or even legal action taken against them. (Dolores, 2006).

The second article covers ethical dilemmas within reporting abuse of elder adults and focuses on the duties of the healthcare provider when abuse has not occurred but the caregiver has voiced concerns of potential abuse. Does the healthcare provider report this? Bergeron and Gray (2003) recommend that the practitioner be knowledgeable of their state’s reporting laws, develop rapport with elder abuse specialists to refer to, and develop clear expectations to confidentiality guidelines in order to guide the client’s disclosure (Bergeron & Gray, 2003).

The learned information from these four articles is very useful and can be applied during my practice because there will be occurrences where client’s express concern for their wellbeing or express traumas and it is important as a healthcare provider to be knowledgeable in how to manage these situations in order to protect not only the client but also my licensure as well. In Texas, it is required by law for the professional to report the suspected abuse within 48 hours and failure to report is a class A misdemeanor. (Rape, Abuse, Incest, and Neglect Network, n.d.)

Alford, D. (2006). Legal issues in gerontological nursing. Part 1: abuse and neglect of older adults. Retrieved from: https://eds-b-ebscohost-com.ezp.waldenulibrary.org/eds/pdfviewer/pdfviewer?vid=3&sid=4f584baf-be01-46b0-922a-bcf3f78ac348%40pdc-v-sessmgr03

Bergeron, R. & Gray, B. (2003). Ethical dilemmas of reporting suspected elder abuse. Retrieved from: https://eds-a-ebscohost-com.ezp.waldenulibrary.org/eds/pdfviewer/pdfviewer?vid=1&sid=b5758935-1164-4024-8e2f-34e857417d60%40sdc-v-sessmgr02

Hlady, L.J., & Allchurch, H.E. (2015). A multidisciplinary approach to child maltreatment: suspected child abuse and neglect. Retrieved from: https://eds-a-ebscohost-com.ezp.waldenulibrary.org/eds/pdfviewer/pdfviewer?vid=11&sid=d00d337f-8af1-48d0-a575-b1fc24f80e2c%40sessionmgr4007

Peterson, M., & Urquiza, Anthony. (1993). The role of mental health professionals in the prevention and treatment of child abuse and neglect. Retrieved from: https://files.eric.ed.gov/fulltext/ED363995.pdf

RAINN.org (n.d.) The laws in your state. Retrieved from: https://www.rainn.org/laws-your-state-texas

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-STUDENT #2

–Ethical and Legal Foundations of PMHNP Care-Informed assent/consent and capacity

While I am interested in many of the legal/ethical topics listed in this week’s lesson, I am especially interested in the topic of informed assent/consent and capacity as it relates to mental health and my practice as a PMHNP. I currently work at a voluntary facility and I often wonder where the line is as far as is this person who is floridly psychotic, truly able to consent to treatment? I often feel torn when some patients are accepted to our facility and arrive confused or disoriented but are still able to sign themselves in. Adolescents are another population where consent is often discussed and questioned- in the state of Arizona, a child is signed in by their parent, as a voluntary patient, whether they want to be admitted or not- often, the child does not want to be admitted, so it does not feel voluntary. In contrast, as a travel RN I have worked in states where minors can be petitioned for involuntary treatment by the county or be admitted by their parent but only if they are voluntary for treatment. When I was first exposed to ethics in the nursing world, I was taught that when something feels off or wrong, it is usually related to our own ethical code and values. This discussion will provide a summary of scholarly articles that touch on this topic, relating to legal and ethical considerations of adults as well as children and adolescents.

Article 1- Legal & Ethical Considerations for Incarcerated Adults

Deinstitutionalization has long been a topic of interest to me- working in state-level facilities highlights the need for an asylum-like setting for many individuals with serious mental illness (SMI) to achieve their highest quality of life. Segal, Frasso, & Sisti (2018) discuss the shift of mentally ill people into jails and prisons, noting that nearly between 20% and one-quarter of incarcerated individuals in the United States suffer from a SMI. This article covers a variety of topics of concern related to incarcerated individuals with mental illness, including a section on capacity or the ability to consent for mental health treatment. While the line between voluntary and involuntary treatment can sometimes be muddied in the community, it seems that it is more clear-cut within a jail or prison- even someone who is obviously suffering psychosis or mania due to a SMI may refuse treatment (Segal, Frasso, & Sisti, 2018). Without falling down the rabbit hole of the discussion of the lack of beds to meet the needs of this volume of mentally ill individuals, this writer will focus on the cycle experienced by SMI-individuals who refuse treatment while incarcerated. In the state of Arizona, if any individual in the community and is a danger to themselves (DTS), a danger to others (DTO), or gravely disabled (GD)/Persistently acutely disabled (PAD) because of their mental illness, they can be petitioned by the county and if the petition is upheld following an initial evaluation period, the individual will receive forced treatment. Conversely, an incarcerated person may meet criteria for involuntary treatment but be allowed to refuse treatment because they are an inmate (Segal, Frasso, & Sisti, 2018). This is a perfect example of ethics versus law- these individuals should be subject to the same laws as civil individuals but because of the legal system, they are not; is it acceptable for someone in state or federal custody to be left to decompensate when they can be helped?

Article 2- Ethical & Legal Considerations of Elderly Adults

Capacity to consent and ethics are two issues commonly experienced by mental health professionals. Considering elderly adults, this issue may be one that is a frequent challenge and one not quickly resolved. While it the role of the health care provider to encourage autonomy and to advocate for our patients, it is important to be able to recognize deterioration of mental status that is affecting the individual’s ability to make a sound decision. Cliff & McGraw (2018) note that a lack of capacity, or the ability to consent, may be a result of a developmental delay, injury to the brain, mental illness, dementia, or altered levels of consciousness at end-of-life. The article discusses the experiences of 14 allied health professionals in assessing an individual’s capacity to consent and how to carry out assessments within the home and with family members. This topic is increasing relevant, given the aging population in the United States. I would like to find articles that take a more in-depth look at how to navigate the concept of consent among the elderly with mental illness or dementia/Alzheimer’s process occurring.

Article 3- Ethical Considerations and Forced Treatment of Adolescents

Tucker, et al. (2018), highlight the ethical chasm that exists within the mental health community, with regards to whether adolescents should be forced into treatment, either by their parents or by some other formal process (I.e., by the county and designated mental health professionals). This article evaluates the effects of minors being transported voluntary or forced via a third-party transportation service, to wilderness therapy programs in the United States. Wilderness therapy programs include interventions such as immersion into the wilderness in groups, the education and preparedness that goes along with living outdoors, as well as individual and group therapy, and other therapeutic programming (Tucker, et al., 2018). Tucker, et al. (2018) describe that participation in these programs is usually involuntary, although participants are said to develop acceptance of their situation while in treatment and do achieve a reduction in mental health symptoms. With regards to the use of transport services, an estimated 30% of both private and state-run programs are found to be utilizing them, although they seem to be more widely used among private-pay programs (Tucker, et al., 2018). Transport via a third-party service usually involves two adult staff apprehending and transporting the adolescent to the wilderness site; transportation may last anywhere from several hours to a few days (Tucker, et al., 2018). The staff are trained in crisis management, including therapeutic holds/restraints, as well as therapeutic communication and support, and CPR/BLS (Tucker, et al., 2018). While this topic is unique, and the topic of wilderness camps specific, it does bring the ethical issue of a minor consenting to mental health treatment to the foreground- is it ethical to force a minor into treatment?

Article 4- Legal Consideration for the Minimum Age of Consent to Mental Health Treatment

As I mentioned previously, adolescents are a wild card when it comes to voluntary versus involuntary treatment, whether they are forced into treatment by a parent or some greater body or designee. This article examines the minimum age of consent to obtain mental health services, comparing it with the minimum age of criminal responsibility. I found this article especially interesting as it takes on a global perspective and because it looks at children or adolescents being able to seek out mental health treatment for themselves and without a parent. Noroozi, Singh, & Fazel (2018) begin by offering this statistic- globally, about 10%-15% of the child/adolescent population is experiencing some form of mental illness, yet only a small percentage can access appropriate care (Noroozi, Singh, & Fazel, 2018). On a national level, it is estimated that as many as 75% of 2 million minors who have some level of interaction with the justice system also experience mental illness. Of course, there are many different barriers to treatment include overall access to care; parental consent can also become a barrier to care, if the parent is unable to, or does not wish to, provide consent for treatment of their child (Noroozi, Singh, & Fazel, 2018). Nationally, in states where the minimum age of mental health consent (MAMHC) is not legislated on a state level, age 18 is used; however, MAMHC as low as age 7 exist (Noroozi, Singh, & Fazel, 2018). In contrast, there are many nations where mental health laws do not exist at all, while many of these same countries have minimum age for criminal responsibility well-defined (Noroozi, Singh, & Fazel, 2018). This article causes one to consider- should a minor be allowed to consent for mental health treatment, and if so, at what age should this be allowed to occur?

Conclusion

These articles have each provided information on the topic of informed assent/consent and capacity in some respect, each bringing their own perspective on the topic. While we may each decide to take strikingly different paths once we begin our careers as PMHNPs, we should always be aware of ethical and legal dilemmas as they relate to our specialty. In examining the legal and ethical considerations for adults, I was reminded of my keen interest in bringing mental health law into prisons and jails. Researching adolescent issues with consent opened my eyes to the concept of a minor being able to consent for mental health treatment, especially when it is compared to a minor being culpable for crimes committed at a specific age. I look forward to continuing research in legal and ethical challenges related to mental health treatment of both adults and adolescents.

Reference

Cliff, C., & McGraw, C. (2016). The conduct and process of mental capacity assessments in home health care settings. British Journal of Community Nursing, 21(11), 570.

Noroozi, M., Singh, I., & Fazel, M. (2018). Evaluation of the minimum age for consent to mental health treatment with the minimum age of criminal responsibility in children and adolescents: a global comparison. EVIDENCE-BASED MENTAL HEALTH, 21(3), 82–86. https://doi-org.ezp.waldenulibrary.org/10.1136/ebm…

Segal, A. G., Frasso, R., & Sisti, D. A. (2018). County Jail or Psychiatric Hospital? Ethical Challenges in Correctional Mental Health Care. Qualitative Health Research, 28(6), 963–976. https://doi-org.ezp.waldenulibrary.org/10.1177/104…

Tucker, A. R., Combs, K. M., Bettmann, J. E., Chang, T.-H., Graham, S., Hoag, M., & Tatum, C. (2018). Longitudinal Outcomes for Youth Transported to Wilderness Therapy Programs. Research on Social Work Practice, 28(4), 438–451. https://doi-org.ezp.waldenulibrary.org/10.1177/104…

Articles

Article 1 adult County Jail or Psychiatric Hospital_ Ethical Challenges in Correctional Mental Health Care – Andrea G. Segal, Rosemary Frasso, Dominic A. Sisti, 2018.html

Article 2 elderly adults_ The conduct and process of mental capacity assessments in home health care settings.pdf

Article 3 – widlerness therapy.pdf

article 4-Evaluation_of_the_minimum_age_.pdf