A Practical Introduction to Mental Health Ethics

Grahame Smith

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781351743914
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

As a mental health nurse, possessing an ethical sensibility and developing ethical reasoning is vital. This book is a practical introduction to the skills and knowledge the mental health nurse is professionally required to develop in their journey towards effectively managing complex ethical decisions. Written with the training mental health nurse in mind, this book is a clear and concise guide on how to approach common, ethically-complex situations mental health nurses will eventually find themselves faced with. It includes textboxes which take the reader into a 'real world' scenario to help them explore the moral and ethical issues discussed throughout the chapter.

To ensure professional currency, the content of this book is mapped to the Nursing and Midwifery Council's pre-registration education standards of 2010, and uses a scenario-based approach in order to provide a pragmatic and robust resource.

A Practical Introduction to Mental Health Ethics is essential reading for pre-registration mental health nursing students, while also being of value to registered mental health nurses working in ethically challenged areas such as dementia care, psychiatric intensive care units.

1
CLINICAL DECISION-MAKING WITHIN AN ETHICAL CONTEXT

Background

The aim of this chapter is to explore the ethical dimension of the clinical decisions that mental health nurses make on a daily basis. Mental health nurses may not always recognise that the decisions they make have an ethical dimension. In other words, this dimension tends to be hidden (Smith 2012b). This does not mean mental health nurses are not ethical in their practice, however they may not fully recognise the context they practice within, where ‘a fully conscious adult patient of normal intelligence may be treated without consent, not for the protection of others (though this is also possible) but in their own interests’ (Fulford 2009: 62).

To act ethically the mental health nurse has to be aware of the context they practice within and they have to ethically reason in a way that is systematic and justifiable. By reasoning in this way the nurse will develop a justifiable position which considers the rules inherent within a situation such as the law, it will also pay attention to the facts and the values, and it will be embedded within a relevant ethical theory (Bloch and Green 2009; Barker 2011). These considerations among others will be developed in more detail as the book progresses. As a starting point lets us consider what ethics are, the historical nature of mental nursing practice, evidence-based practice, and the clinical decision-making process and its relationship to being ethical.

Ethics, ‘derived from the Greek ethikos, meaning “disposition”, has a philosophical home in the discourse of moral philosophy, the study of conduct with respect to whether an act is right or wrong, to the goodness and badness of the motives and ends of the act’ (Bloch and Green 2009: 3). Ethics or ethical theories are divided into normative theories, which focus on ‘what actions are right, what ought to be done, what motives are good, and what characteristics are virtuous’ (Smith 2012b: 144), and non-normative theories. The latter are descriptive, describing ethical beliefs, conduct, and how people ethically reason (Smith 2012b). This book will concentrate on ethical theories which are normative theories. The importance of understanding what constitutes being ethical is important for the mental health nurse as they will be expected to professionally act ethically and do the right thing (Smith 2012b; NMC 2015a).

On entering your new ward a service user pushes past you, shouting ‘I am one with the angels, you devils!’ He reaches the ward door and kicks it a few times. He then promptly turns around and goes back to his bed. The staff member at the door tells you not to worry as John knows the door is locked and he is not going anywhere. On reading John’s case notes you notice that John is well known to services and he has a diagnosis of schizophrenia. He was admitted to the ward after he stopped taking his medication; he then became aggressive towards his Mum. John would not restart his medication while at home, but he did agree to come into hospital. Once admitted John agreed to restart his medication. You decide to have a chat with John. On entering his room you notice that he has not washed for days. John will not fully engage with you; he just keeps repeating that he wants to go home. You ask one of the staff about John, and they mentioned that he sleeps all day, but there is nothing that can be done as this is his ‘human right’. When looking at John’s medication card you notice he misses most of the medication that is prescribed in the day.

The historical context

Mental health nursing as a specialist field of practice is a recent phenomenon and one that does not exist within a vacuum (Roberts 2005; Foucault 1961; Porter 2002; Nolan 1993). Mental health nursing in the UK has always been closely aligned with the medical discipline of psychiatry which has largely shaped how mental health nurses practice today (Nolan 1993; Zilboorg and Henry 1941; Fulford et al. 2006). The work of Nolan (1993) on the history and development of mental health nursing from the eighteenth century onwards provides a ‘template’ to better understand this alignment.

Mental health nurses have not always been called mental health nurses and even today there are two titles in common use: mental health nurse and psychiatric nurse. Currently the professionally registered title is ‘registered nurse – mental health’ (NMC 2010). Historically, mental health nurses have had a number of titles bestowed upon them from the title of keeper then to attendant and then finally to psychiatric nurse or mental health nurse (Nolan 1993: 6–7). All of these titles were used as common titles and with those titles came a variety of roles. The role of the keeper was to look after both the house and the mentally ill that resided within the house, whereas the role of the attendant was to look after the institution including controlling the ‘inmates’ and also to be a servant for the medical staff (ibid.). The role of the attendant was a direct historical development from the role of the keeper, however like the keeper, attendants were still un-trained and there was no common agreement of what a good attendant did besides looking after the institution, training would be given on an ad-hoc basis and dependent on the motivation of the medical superintendent (ibid.). The attendant was generally expected to be a rule keeper, an enforcer of the rules, a servant to the patients, a spiritual guide, and an intermediary between doctor and patient (ibid.: 53–54). Attendants like ‘keepers’ were also ‘prized’ for their abilities to do physical work such as cleaning and manual labour (ibid.: 48).

There was a shift to systematically training attendants this happened from 1889 where attendants were now required to attend a national training course and from 1923 female attendants started to be called nurses, however males were still called attendants until 1926 (ibid.). This change from the title of attendant to the title of nurse started to reflect the belief that the ‘embryonic’ mental health nurse should have a more caring role and, possibly as a consequence, deliver therapy (ibid.). An underpinning influence on the historical development of the mental health nurse role was the burgeoning belief that mental health problems should and could be treated and possibly ‘cured’ (Clarke 2008). Certainly the advent of the ‘mental asylum’ from the eighteenth century onwards came into being on the belief the ‘mad’ could be ‘cured’ with the right therapy (Jones 1996). At that time the attendant role was in the forefront of delivering this right therapy which was based on good basic care including exercise and good nutrition (ibid.). Over time elements such as ‘observation and control’ also became part of this therapy and finally during the embryonic development of the mental health nurse role further therapies started to emerge, such as psychiatric medication and psychological interventions (Nolan 1993; Shorter 1997).

This move towards therapy and treatment was ultimately influenced by the medicalisation of madness (Shorter 1997; Read 2004). Historically this medicalisation process meant that madness was described has having different forms, and over time, as psychiatry developed as a medical profession, different psychiatric disorders were identified, as were their accompanying treatments (Berrios 1996; Sims 2003; Oyebode 2008).

This process of describing and identifying psychiatric disorders and their accompanying treatments also led mental health nursing down a similar path in that mental health nursing delivered some of those treatments (Clarke 2008). By the twentieth century, with the discipline of psychiatry becoming truly medicalised and using scientific methods, mental health nursing also followed suit in using more scientific methods (Zilboorg and Henry 1941; Clarke 2008; Gournay 2009).

Contemporary mental health nursing has certainly moved from treating mental health service users in what in hindsight could be seen at times as a brutal and with immoral ways (Clarke 2008). Read (2004) highlights that mental health service users from the seventeenth century onwards were confined and made to conform, and such treatments as bloodletting and fettering were regularly used. Nowadays bloodletting as a mental health treatment would not be allowed; it is not evidence-based, and mental health service users also have rights which are enshrined within statutory law (Read 2004; Clarke 2008). It is important to note that confining and conforming still takes place through the use of implicit and explicit inter ventions (Coppock and Hopton 2000; Roberts 2005). Explicit interventions include the use of mental health law, restraint, seclusion, locked ward doors, and the administration of medicines (Roberts 2005). Whereas implicit interventions take more subtle forms such as controlling through levels of observation, record keeping, the assessment and care planning process, the delivery of care, and so on (Roberts 2005; Jones and Eales 2009).

Having power to use both implicit and explicit interventions stems from the use of the mental illness concept: even though the use of this concept is conceptually controversial, it does mean that once an individual is labelled mentally ill the mental health nurse may be sanctioned by society to control that individual (Roberts 2004, 2005). Partly this approach emanates from the view that an individual who is labelled mentally ill has an increased potential to exhibit diminished judgement and because of this they are then perceived to be more risky or dangerous than the ‘average person’ in society (Radden 2002; Smith 2012b). Let us return to the chapter scenario:

John has a diagnosis of schizophrenia. He is also presenting as a risk towards his mother when he is at home. While on the ward he does not appear to be a risk, and he is taking his medication; or is he? He is willing to stay on the ward by not actively trying to leave the ward; he bangs the ward door, realises it is locked and then returns to his bed. He sleeps all day; is this a problem? It is in terms of him not taking his medication. Is it a human right to sleep all day?

It appears that there are a number of areas of concern regarding John’s stay on the ward. What is also concerning is that the mental health nurses on the ward may be unaware of the duty of care they have towards John and implications of using sanctioned power such as a locked door. This lack of awareness may reflect the ‘lack of societal will to question the power that mental health services hold’ (Smith 2012b: 151), leading to some ethical issues being hidden away.

Evidence-based practice

There is a strong positivist or scientific influence prevalent within contemporary mental health nursing practice similar to the practice of psychiatry (Clarke 2008; Newell and Gournay 2009; DH 2006a, 2006b). This influence can not only be seen to be prevalent it also can be seen to dominant the way mental health practitioners construct their respective practice (DH 2006a, 2006b; NMC 2010). As an example mental health nurses will tend to empirically conceptualise the mental distress of a service user in terms of the service user’s diagnosis and subsequent symptomology; in addition clinical guidelines are likely to be catalogued under a diagnosis (Newell and Gournay 2009; Gournay 1995). Returning to the chapter scenario John has a diagnosis of schizophrenia; he has auditory hallucinations and delusions, however he is more than a diagnosis, like everyone else he has hopes and aspirations and should be treated in a person-centred way (Watkins 1998; Smith 2012a).

Evidence-based practice (EBP) is a dominant form of scientific knowledge within mental health nursing practice (Smith 2014). Using this type of knowledge requires the mental nurse to base and justify their clinical decision-making on the best evidence available (ibid.). To ensure the best evidence is available clinical guide lines will be a good source; these guidelines will use evidence which includes the testimonies of clinical experts to the systematic review of Randomised Control Trials (RCTs) (ibid.). The best type of evidence is RCT based evidence, this type of evidence is continually being updated, hence the changes in clinical guidelines (ibid.). On this basis when making clinical decisions (ibid.) mental health nurses should, where possible:

• identify the most appropriate literature;

• critically assess the evidence, considering whether it is reliable and/or valid;

• apply the chosen evidence; and

• evaluate the application of this evidence.

The process above is very similar to the activities of evidence-based medicine, however evidence-based mental health nursing should not neglect the importance of evidence gathered from the mental health nurse-service user relationship (Perraud et al. 2006). The scientific approach that underpins mental health practice also extends to the way information is collected about mental health service users. Psychiatrists primarily collect information through a psychiatric examination process, this process is standardised and the information accrued from this process is available to the multi-disciplinary team including the mental health nurse (Fulford et al. 2006; Smith 2014). The mental health nurse builds on this information through the use of assessment methods built on a psycho-social approach, which should be reliable and valid (Gournay 2009; Smith 2014).

A good example of the use of a scientific assessment approach within mental health nursing practice is the way mental health nurses currently assess clinical risk (Eales 2009; Rylance and Simpson 2012). To collect clinical risk information a mental health nurse will use an assessment tool which has been designed specifically to collect quantifiable information with the further intention of assisting in the predicting and subsequent management of clinical risk (Rylance and Simpson 2012; Welsh and Lyons 2001). One of the limitations with this approach to assessing risk is that according to Welsh and Lyons (2001: 302) a ‘tool developed for research purposes may not address practitioner needs’. Welsh and Lyons (ibid.: 302) provide an example in that ‘one off scoring systems’ do not and cannot ‘reflect the dynamic and often protracted nature of risk behaviour’.

It has to be acknowledged that just using assessment tools to assess risk is not in accordance with best practice (Rylance and Simpson 2012). The mental health nurses should be using a structured risk assessment approach...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Introduction
• 1 Clinical decision-making within an ethical context
• 2 The ethical self
• 3 Ethical reasoning: a pragmatic approach
• 4 Recognising ethical issues
• 5 Gathering Facts and Values
• 6 Ethical rules and frameworks
• 7 Ethical theories
• 8 Managing the outcome
• 9 Future development
• Conclusion
• References
• Index