Ethical issues in mental health nursing: What psychiatric nurses need to know

Mental health nursing is one of the most complex yet rewarding specialties that medical graduates can pursue in the modern age. With a broader awareness of mental health afflictions than ever before – and with more and more people taking advantage of self-care and diagnosis to help relieve symptoms – we live in an age when ‘invisible illnesses’ are no longer swept away and forgotten about.

To that end, psychiatry and mental health nurses need to keep a few key ethical issues and points in mind. While following ethical guidelines is vital in treating all patients with the levels of care and respect they deserve, psychiatry poses its own unique challenges.

Ultimately, mental health nurses must always do what is morally, ethically, and medically right for their patients. In psychiatric cases, complete autonomy may not always be available. Therefore, nurses will – more so than ever – have to think on their feet.

Let’s take a closer look at why following ethical codes of conduct in mental health nursing is so important.

Why are ethics important in mental health nursing and psychiatry?

Applying ethics to every case is extremely important in mental health nursing and psychiatry. Crucially, not all patients undergoing mental health care may be able to care for themselves or be expected to make beneficial decisions.

Some research argues that patients in psychiatry may lose a ‘sense of self’, therefore losing autonomy and directing life-changing decision-making to the nurses and other carers in charge of their cases. It’s argued that mental health care is a journey toward rebuilding such autonomy.

However, nurses need to refer to their codes of ethics and practice without any form of powers of attorney in place (or other legal document). In some cases, patients may be able to make small decisions regarding their routines and treatment but might not be in a position to look at the ‘bigger picture’.

Where the issue of autonomy and self-governance becomes trickier, however, is when patients begin to regain control of their mental faculties. Where do the lines start and end? When should nurses stop making overarching decisions for their patients and start to give back control?

The answer to this is just as complex as you would expect. Essentially, it’s a matter of each case being unique, and nurses making daily decisions on whether their patients are considered fit and well enough to become autonomous once more.

In any case, it’s important for nurses working in mental health and/or psychiatry to carefully consider when to exercise their powers as caregivers and whether doing so will be in the patient’s best interests. Failing to balance these ethics properly could unintentionally cause harm to mental health patients.

When first studying mental health nursing – for example, via online PMHNP programs such as those supported by Marymount University – students soon find that ethics are core points for discussion. Marymount, in fact, openly discusses some of the most complex impacts of mental health nursing early on. It’s important, after all, for prospective nurses to understand ethical impacts as soon as possible!

Ethical considerations for mental health nurses

The ethical challenges facing mental health nurses daily are always likely to change. Therefore, while the following considerations are important, they might not always apply from patient to patient.

Taking into account the idea of self-governance and autonomy as discussed above, here are the key ethical points that mental health nurses need to remember when treating psychiatric patients.

Awareness of vulnerability

Mental health conditions are frequently ‘invisible’, which means that it’s highly unethical for nurses and caregivers to assume the severity of patients’ cases at face value. Even if a patient is high functioning on the surface, they might not show problems with dissociative identity, for example, until much later.

Therefore, it’s safe and recommended to assume that all mental health patients are vulnerable until thorough testing states otherwise. Even if a patient shows exceptional progress through treatment courses, nurses should always assume that they are at risk of relapsing or worsening through inappropriate care.

Nurses and caregivers should therefore also avoid exploiting potential vulnerabilities at all costs. For example, this might include overstepping relationship boundaries between carers and patients.

What’s more, patients should always have the right to receive treatment and care without fear of abuse or neglect. Any nurse or psychiatrist caring for mental health patients should be vigilant for any potential signs of abuse and report them as soon as possible.

It’s ethically sound for nurses and caregivers to ensure that patients receive the best possible care in the absolute safest environment. As mental health patients should always receive treatment as vulnerable individuals, this ethical position should be immovable.

Dignity

Despite mental health patients’ ability to show autonomy and self-governance, all patients deserve dignity. While they might not understand their current circumstances, this does not mean that standards should slip.

All psychiatrists should therefore recognize that mental health patients have human rights as defined within law. This stretches as far as non-maleficence and the agreement that patients should never receive unfair treatment due to racism, sexism, anti-religious sentiment or otherwise.

Again, even if a patient cannot communicate their rights and understand their treatments, nurses should consider how they might feel if they had full autonomy. As per general nursing ethics and codes, patients in psychiatry should expect fair treatment without fear of harm or loss of dignity.

This also means that nurses and psychiatrists should ensure that their patients receive dignified care from others in their department. Nurses should also consider the beliefs and wants of their patients – regardless of their condition or religious affiliation – and act on them wherever possible.

All patients require humanity and dignity in any medical care they receive. Mental health patients might feel especially scared that they cannot communicate their needs effectively enough with nurses and caregivers.

Therefore, it’s the responsibility of those caregivers to honor their patients’ wishes. Otherwise, they will cross ethical boundaries that further harm patients’ wellbeing and family relationships.

There’s a difficult balance to strike when it comes to negotiating with families. Some patient families may insist that they ‘know best’. However, nurses must consider the initial requests made by patients and make ethical decisions that they feel are appropriate.

Consent

Regardless of a patient’s condition and the severity of their case, a nurse or psychiatrist should always ask for consent before treatments take place. While treatments should, in theory, provide positive outcomes, caregivers should always consider their patients’ immediate needs and beliefs before starting them.

This can be a difficult stage to overcome if a patient cannot provide consent or knowledge of care for whatever given reason. Therefore, nurses should always look for assent where possible and to consider parental consent if a patient is younger than 18 years old. Regarding powers of attorney, nurses should also lean toward the law rather than gut instinct.

In the event of a patient being of sound enough mind to understand the treatments and give consent, nurses should always provide complete details of what to expect. It’s unethical to withhold details from either patients who can consent or those who do so on their behalf.

What’s more, psychiatrists and nurses should also consider their patients’ emotional intelligence and maturity. Can they feasibly process the information you need to share with them, and is it ethical to do so?

Confidentiality

As per human rights, all patients and their families should hold the right to confidential treatment. Unless it is professionally required for specialists to offer further advice, psychiatric treatments should remain private between patients and caregivers.

Many people find mental health difficulties highly embarrassing, and some patients may worry that ‘news’ of their psychiatric treatment could damage their careers and social standing.

Again, if a patient is unable to consent fully to some practices and does not have complete autonomy, this doesn’t mean that their rights to confidentiality are waivable. Communication between patients and carers should always be transparent. There should also be an understanding of privacy.

That said, nurses and psychiatrists should always act in the best interests of their patients’ health. If they feel, for example, that their lives are at risk if external specialists aren’t involved, then an ethical boundary may need to be crossed.

In line with obtaining consent, nurses should make it clear to patients and families that in some cases, data may need to be shared. This is, of course, to ensure that the patients get the help they need.

Maintaining confidentiality otherwise is extremely important. Some people may not feel comfortable trusting psychiatric nurses with their cases and therefore withdraw from treatment.

Confidentiality remains a highly complex area of ethics in nursing, not just mental health. Therefore, it’s wise to consider each case on its own merits.

Integrity

When treating mental health patients, it’s also important for caregivers and nurses to uphold the integrity of their establishments. That means that whenever they make decisions during care, they do so on behalf of the hospital or clinic in question.

Therefore, it’s even more important for nurses in mental health care to consider if their values align with their clinic’s. In cases where ethical lines blur and it’s difficult to obtain consent, for example, seeking advice from other team members is likely worthwhile.

At the same time, nurses and psychiatrists should always support others they work with in mental health care. This means providing additional ethical support, helping them make difficult decisions, referring to case precedents, and even communicating with patients.

The integrity of a hospital or clinic is important. It’s a place of trust and care for thousands of people at a time. Therefore, if any of its integrity is chipped away because of improper ethics, such a reputation can be hard to rebuild.

Therefore, all nurses should practice mental health care with a team mentality – and consider, as per their usual code of ethics, that the individual’s work always impacts that of the broader team.

Reducing stigma

Overall, working with a strong ethical code and mindset in psychiatry is important for upholding mental health care as a legitimate source of treatment.

For all that we are now more aware of different mental health concerns than ever, there is still some stigma surrounding it and the people who suffer. Therefore, it’s the job of nurses working in psychiatry to ensure that their treatments are helpful, carefully considered, and that patient human rights are protected.

The fact is that no one wants to visit a hospital with mental health problems. However, many patients are resistant to receiving care, period. They might feel embarrassed that they cannot easily overcome such issues on their own or that their careers might suffer as a result.

Beyond this, statistics show that around 40% of people in the US do not have access to mental health care should they need it. The work of mental health nurses has never been more important or in more demand.

Mental health nurses and those working in psychiatry owe it to their profession – and the people who need their help – to uphold exceptional care standards.

Every case holds ethical questions

Above all, nurses heading into mental health should remember that every case poses new ethical queries. Some are more complex than others. However, caregivers should always be ready to ask themselves some objectively difficult questions!

One of the key skills that all successful nurses should demonstrate is the ability to think critically and always in a patient’s best interests. Doing so in mental health cases is complex because of condition visibility, but this doesn’t mean that their needs are any less important.

When learning to become a mental health nurse, or to specialize in psychiatry, ethics will form the backbone of your study. Without ethics in psychiatry, patient outcomes and clinic integrity will always suffer. Before making any decisions in mental health care, always consider the needs of the patient, regardless of their ability to communicate.

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