Psychiatric Mental Health, part 2: Informed Consent, Ethical Principles
by Cathy Parkes July 22, 2021 Updated: December 29, 2021 10 min read
In this video, Cathy teaches the concepts of informed consent and nursing ethical principles as they pertain to the mental healthcare setting. Both of these concepts are covered in your Fundamentals of Nursing material, but it's important to know and consider them from the mental healthcare perspective as well, because in this setting you will be presented with some unique challenges
This series follows along with our Psychiatric Mental Health Nursing Flashcards which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Informed consent is the patient's voluntary decision to undergo a procedure or intervention
Informed consent is something that you will need to know about in your Fundamentals of Nursing course, which is why we cover it in our Fundamentals of Nursing Flashcards as well as in our Fundamentals series article on Informed Consent and the Right to Refuse. But, informed consent is also important to consider from the psychiatric mental health perspective.
Some of the mental health disorders and conditions that you will learn about throughout your Psychiatric Mental Health studies, like schizophrenia, could make a patient not competent to give informed consent.
When obtaining informed consent, the provider's role is to explain the nature of the procedure, risks and benefits of the procedure, alternatives to the procedure, as well as any risks and benefits of those alternatives. The provider will also assess the patient's understanding of the information.
If a patient has questions about the procedure even after they have already given consent, the provider must be contacted to answer those questions. As a nurse, you can reinforce the provider's teaching, but you would not be the one to answer questions about the procedure for the purposes of informed consent.
When obtaining informed consent, the nurse's role is to sign the informed consent form as a witness, confirm that the patient received and understands the procedure information, ensure the patient is competent and gave consent voluntarily.
All elements of informed consent must be documented on a form or in the patient's medical record.
Who can give informed consent in the mental health setting?
Patients under the influence of drugs or alcohol, or patients with dementia, delirium, or schizophrenia may NOT be competent to provide consent.
Schizophrenia, as well as the difference between dementia and delirium, are covered in the disorders section of our Psychiatric Mental Health Nursing Flashcards. These flashcards are purpose-built to help you learn and retain key points about these disorders for your mental health classes and exams.
As a general rule, a patient needs to be 18 years old or older to give informed consent, however, many states give minors the right to consent to treatment if they are emancipated, married, in the military, or require substance abuse or mental health treatment. Since mental health treatment is one of these exceptions in many states, you will likely encounter more minors who have given informed consent when you are learning or working in a mental health/psychiatric setting or unit.
Even after consent has been obtained, the patient has the right to change their mind and decline treatment.
Nursing ethical principles
Having ethical principles in nursing help guide us to choose and differentiate between right and wrong, or behavior that's correct and incorrect.
The ethical principles underlying good nursing practice are foundational knowledge that will support your whole nursing education and nursing career, which is why it's usually covered in your Fundamentals of Nursing or intro nursing classes (and why we cover it in our Fundamentals of Nursing Flashcards as well as in our Fundamentals series article on The Nursing Profession and Ethics). But, ethical principles are also very important to consider from the psychiatric mental health perspective. Why? Because you might encounter more stressful or ethically unclear situations in the mental health setting.
The principles we've summarized here are Autonomy, Beneficence, Nonmaleficence, Justice, Fidelity, Advocacy, and Veracity.
Autonomy as a nursing principle is your patient's right to make their own healthcare decisions. This is the principle underlying informed consent, the right to refuse, the patient self-determination act, and many more.
For example, in the psychiatric mental health setting, you would practice autonomy by respecting a patient's right to refuse their medication.
Beneficence as a nursing principle means to promote good. You can easily decode this term if you know that the prefix bene- means good (it's the same root as Bueno in spanish, Bien in French, and the word beneficial!).
We created our Medical Terminology flashcards to make breaking down words into their parts easy, so you never have to be confused by an unfamiliar word on an exam!
For example, in the psychiatric mental health setting, in practicing beneficence you might provide a quiet space and remain with an anxious patient.
Nonmaleficence as a nursing principle means to avoid causing harm.
For example, you perform multiple checks when giving a medication to avoid medication errors.
Justice as a nursing principle means to treat your patients fairly and equally—distributing your care equitably among assigned patients.
This might sound pretty straightforward. But in the psychiatric mental health setting, you might have a patient with a particular personality disorder or behavioral abnormality. As Cathy notes in this video, it's possible that it could get under your skin or cause you distress, and it may feel difficult to spend the time you need to with that patient. But as a nurse, you should recognize your own feelings regarding that patient, and in the end, you do need to distribute care equitably, despite those challenges.
In the video where Cathy teaches the concepts of Nurse/Client Relationship and Therapeutic Communication from our flashcards, she provides an example of swapping care of a particular patient with her colleague who was having a difficult time with a patient because of a countertransference situation. Cathy and her colleague working together were able to ensure that patience received just care in that situation that was difficult for the nurse.
Fidelity as a nursing principle means to be faithful and loyal; to keep promises you have made to your patients.
Advocacy as a nursing principle means to promote and protect the patient's rights, health and safety. This is something you will do all the time as a nurse. You are next to the patient, caring for the patient, and know the patient better than anyone else on the healthcare team. You will do this on a regular basis every shift that you work!
For example, if you see something concerning or an alarming condition come up with your patient, you would reach out to the provider and get that patient the help they need.
Veracity as a nursing principle simply means to tell the truth. You should be honest with patients about, for example, possible side effects of a medication.
As another example, the nursing communication technique of presenting reality is a way that we practice veracity. In the mental healthcare setting, if you had a patient who says that they're hearing voices, you would acknowledge that they are hearing voices, but you don't want to validate that there are voices.
If a patient asks if a procedure will be painful, and you know that it is, you would not lie and say that it is not.
Hi, I'm Cathy with Level Up RN, and in this video, I am going to talk about informed consent as well as nursing ethical principles.
So informed consent is a patient's voluntary decision to undergo a procedure or intervention.
And when we have informed consent, there are certain things the provider needs to do, and then there are certain things that are the responsibility of the nurse.
So the provider needs to explain the nature of the procedure to the patient, explain the risks and benefits of the procedure to the patient, provide alternative solutions to whatever problem exists, and explain the risks and benefits of those alternatives.
The provider needs to make sure the patient fully understands the information and answer any questions that they have.
As the nurse, you are not explaining the procedure or the risks and benefits.
What you are responsible for doing is signing the consent form as a witness and making sure the patient received all of that information from the provider and make sure the patient is competent to provide consent and gave their consent voluntarily.
So let's talk about what it means to be competent to give consent. In general, you have to be over 18 and not impaired in some way. So patients who are under the influence of drugs and alcohol, patients who are schizophrenic and may be having hallucinations, and patients with dementia. Those patients may not be able to provide informed consent.
Also, there are some exceptions to that over 18 rule. So if there are minors who are emancipated, in the military, or married, they actually may be able to provide informed consent.
Also, minors who are seeking mental health services may be able to do so without parental consent in most states.
So, if as a nurse, when you come to have the patient sign their informed consent form, and you are signing as a witness, if the patient decides, "You know. I have some more questions about this procedure," it is not your responsibility to answer those questions about the procedure.
You need to call the provider up, have them come back or call the patient to answer those questions.
Once the patient has signed that consent form, they have the right to change their mind prior to the procedure if they want to, because that is their right, like we discussed in the last video.
They have the right to refuse treatment at any time, even if they already signed that consent form.
Alright. Let's now do a review of our nursing ethical principles. I know a lot of you have probably already heard about these principles in your fundamentals class, but I feel like it's worth a quick review here as we apply those principles to a mental healthcare setting.
So our first principle is autonomy. We need to respect a patient's right to autonomy, so they need to be able to make their own healthcare decisions, and they have a right to refuse a medication or any type of procedure.
Then we have beneficence, which is to promote good. So we want to help our patient and assist them in a therapeutic way.
Then we have nonmaleficence. That means we want to avoid causing harm to the patient.
That's why we check our medications three different times, so we do not perform a medication error and harm the patient.
Then we have justice, which means to treat fairly and equally. So we want to distribute our care amongst our patients in an equitable way, which sounds straightforward and easy on the surface, but if you have a patient who has a certain personality disorder or something else going on, and it's kind of getting under your skin or triggering you in some way, it can sometimes be difficult to spend the time you need to with that patient.
But as a nurse, you just need to kind of recognize your own feelings regarding that patient. And in the end, you do need to distribute your care equitably, despite those challenges.
Then we have fidelity, which is being faithful or loyal to your patient, keeping your promises.
And then we have advocacy. Advocacy is something that you will do all the time as a nurse. So, as a nurse, we are next to the patient and caring for the patient. We know that patient more so than anyone else on the healthcare team.
So if we see a concerning thing or an alarming condition come up with the patient, we need to reach out to the provider and get that patient the help they need.
So I do this on a regular basis every single shift that I work at the hospital, and you will too as well when you become a nurse.
Okay. And then veracity is our last ethical principle. That means to tell the truth. So, when you're giving a patient, for example, their bipolar meds or their medications for schizophrenia, a lot of those medications have some really bad side effects and a lot of side effects. And you need to really be honest with the patient about those side effects. In addition to explaining the benefits of the medication. But you don't really want to blindside the patient with all these crazy side effects. You really need to let them know up-front, so.
And just another silly example here. My mom when I was young, I needed my tonsils out when I was six. And she told me, "Oh, it's going to be fun. We're going to go to the hospital. You're going to have this little procedure and then you're going to get all the ice cream you want. It's going to be amazing." So I'm going to the hospital, looking forward to my ice cream, and of course, I wake up from my surgery in excruciating pain, and I'm throwing up from the anesthesia, and I definitely don't want ice cream.
And my mom's an amazing person, so I'm not trying to trash on my mom here, but she did not exercise veracity prior to my tonsil surgery.
So I'm a big proponent of making sure you're being honest with your patient.
When I go into my patient's room to do a wound VAC dressing change at the hospital and they ask me, "Is this going to hurt?" And I'm like, "Yeah, it's going to be uncomfortable. We're going to get you pain meds. I'm going to go slow. I'm going to be careful. We'll get through it, but it is not going to be comfortable."
I really just need to tell them up front. And then you need to be honest with your patients as well.
Okay, quiz time. I have three questions for you guys this time. Let's say, as the nurse, you are going into your patient's room and you need them to sign the informed consent form. And when you go in there the patient has more questions about the procedure they're supposed to have.
What do you do?
The answer is... you call the provider and you get the provider to come back or call the patient and answer all of those questions. You do not answer those questions as the nurse.
Okay, second question. A patient with schizophrenia who is having command hallucinations is competent to provide consent, true or false?
The answer is... false. If a patient is having those command hallucinations, it's really going to impair their ability to make decisions such as consenting to a procedure.
Third question. Respecting a patient's right to refuse their medication is an example of what nursing ethical principle?
The answer is...autonomy. So how'd you guys do? If you missed one or more of those you may want to go back and watch the video or review the information on our flashcards.
So I will see you at the next video. Thank you so much for watching!
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