Good morning everyone and welcome back to BSN 620. This is week two. Today we're going to be talking about ethical responsibilities and the legal obligations for psychiatric mental health nursing. To start off today's conversation, I want to ask you a question and have you reflect on this. If involuntary admission protects someone from harm but removes their right to choose, is it an act of compassion or an act of control? So, take a moment to really think about this question and how you would address this. Since this is a recorded lecture, we can't have a discussion about it. So I'll just make some uh comments about um this debate here. Is it an act of compassion or an act of control? Since we are going to be talking about ethics today and as we're going to learn sometimes we don't know whether something is right or wrong and we need a lot more context and it really depends on the situation. So the reason that I wanted to ask this question is because it is important especially in psychiatric nursing because autonomy which is a client's right to choose is a core ethical principle in nursing. But in mental health care sometimes clients may be experiencing impaired judgment or they can be a risk to themselves or to others. And this really creates a tension between ethics where we want to respect individual choices as well as the law where we have a duty to care and a duty to protect. So thinking about this question about involuntary admission, protecting someone's um uh someone from harm but removing their right to choose. There are a variety of princip ethical principles that are at play here which we'll go over as well. But many of these you've been learning about since uh you first got into nursing. So autonomy is an ethical principle at play here. The right to self-determination, beneficence, which is uh acting in the client's best interest. And oftentimes as nurses working in mental hair mental health, we do get caught balancing the two. And on top of that, there is some legislation that we do have to be aware of as well with the Mental Health Act in Ontario. It allows involuntary admission, especially when someone is a risk to themselves or to others or they're unable to care for themselves because of their mental health issues. And then we have the healthc care consent act which actually emphasizes informed consent and capacity. So as mental health nurses we have to be able to understand both respecting rights and knowing when the law mandates intervention. So as you reflect back on this question that I've posed, sometimes there is no single right answer, right? like how do we know what to prioritize here? Do we respect the client's immediate wish or do we are we are we trying to prevent potential harm? Right? So sometimes there's no single right answer until we know more of the context. So as mental health nurses, we have to know that we are constantly going to be balancing ethics and the law. And the key takeaway really is is that ethical responsibilities and legal obligations do collide. And within our scope of nursing, especially in the psychiatric um field, we really have to practice critical thinking, compassion, and awareness of the legal framework that can help us guide uh these decisions that we're going to make. So, we'll start off by talking a little bit more about ethics. And as I mentioned, this should be a review, but um ethics, they essentially are the expression of values that do guide our practice. And every nurse will face dilemmas in which our values, our responsibilities, our obligations, they seem to conflict, in which there is no clear path to quote unquote doing right or determining what is the most fitting or the best solution here. So we have our ethics on one side which is once again the expression of values that really guide our practice and in contrast to this we have legislation which is the foundation of legal obligations. So mental health legislation is really designed to protect and provide safeguards and supervision to improve the lives and the mental well-being of the general community and citizens. Right. So this gen this legislation generally acknowledges the fundamental value of mental health and it aims to ensure that the rights of individuals are protected. So the image that we have here it really depicts a decision-making guide for um client care ethics. Right? So as nurses, first we need to know what our our values and our beliefs are and what we feel is our way of determining what is good versus um bad, what is right versus wrong. So when we are experiencing some sort of ethical dilemma, we can use a process where we are able to identify that problem. Then we are able to really describe what the ethical considerations are. Right? So what are the clinical issues here at play? What is the full context? What are some of the ethical principles that are involved such as autonomy, maleficence, beneficence, and so on and so forth? Right? Then once we've kind of weighed in on all of the the factors that are involved, the principles that are involved, we can hopefully choose a solution, right? We can make an informed decision. We can justify it. We have to consider all of the aspects, all of the individuals involved, all the relationships that are involved. We have to consider what the rules and the duties are, including what the law says. And then once we've made a decision, then we can actually put a plan into place to actually implement and evaluate. So, are there implications for the organization um when it comes to this decision that you've made? Um are there any moral distress concerns which we'll talk about? Um what is the evaluation plan and and how are we going to ensure that the client's best interests have been met in this situation? And to guide us with this decision-m process, there are a lot of ethical theories. And for the purpose of today's um lecture, we're going to be touching on a few of those um ethical theories. So those include um deontology, the consequentialist and the virtue theory as well as relational ethics which is something that is becoming an important foundation for nursing and nursing practice. So we'll start off with deontology. So with deontology, this is an ethical theory that uses rules to distinguish from right and wrong. So in mental health, deontology really emphasizes adherence to moral rules and duties such as respecting patient autonomy, respecting confidentiality regardless of the outcome. So in general a typical deontological um concept might be don't lie, don't steal, don't cheat, right? These are basic principles that we've all heard about, right? And these are rules that are telling you what is right from wrong. Don't lie because it's wrong. Don't steal because it's wrong. And don't cheat. So if you do those things then that is wrong and if you adhere to the rules then you are behaving in quote unquote the right manner. So if you think about deontology we're thinking about rules and duties that are helping us distinguish right from wrong. And of course, as we know, we do have the Canadian Nurses Association's uh code of ethics to guide our nursing practice. So, of course, we should review that as well. And when we're talking about deontology, there are u six basic principles that we're going to be learning about. And we'll start off with autonomy. So this is about respecting the rights of others to make their own decisions. So the client has the right to make their decisions about whether they want to get treatment or not, whether they want certain medication, whether they want a certain procedure. So in mental health, what happens if the client is unable to make that decision? Maybe they don't have the mental capacity because their illness and their symptoms are not allowing them to have clarity to fully understand the consequences. How do we balance autonomy in that situation? What if that client wants to refuse medication even though we know that taking their medication is going to be helpful and will hopefully potentially stabilize their symptoms but the client is unable to make that decision because of their illness. How do we balance autonomy? Next we have non-maleficence. This is doing no wrong to a client and this is of course um a very important aspect of nursing. So here you know avoiding harm by not trying to force treatment that could potentially cause side effects or trauma. This could be an example of malef of non-maleficence. Right. Next we have uh beneficence. This is the duty to promote good. So here we are trying to um act in a manner that is promoting the client's well-being and preventing um self harm for that client, preventing deterioration for that client. Justice is the duty to distribute resources or care equally. So here we want to ensure that um fair and equal access to treatment and safety measures are available to all the clients that we are working with. The principle of impossibility is that rights or obligations that cannot be met in the circumstances are no longer obligations. So here we're really trying to recognize that full that fully respecting autonomy may not be possible if the client lacks decision-making capacity due to for example acute psychosis. Right? So it's kind of going back to my point in number one. So we know that the client's autonomy is something that we definitely should consider. However, if this right that the client has to autonomy cannot be met because of these circumstances, it's impossible. Then in that moment, it is no longer considered an obligation. This is what deontology is telling us. Lastly, we have fidelity. So, this is maintaining loyalty and commitment, right? So, we're remaining loyal to the the client's uh trust while also upholding our professional and legal obligations. So now that we kind of understand what the six principles of bioeththics are in relation to deontology, want to start to think a little bit of how this might even pose a little bit of a dilemma when we're working in mental health. So from a deontological perspective, as nurses, we have a duty to respect autonomy, right? We have to respect the client's rights in order to make their own decisions. However, we also have a duty to protect the client and others from harm. And sometimes these duties can conflict. For example, if you honor autonomy, you may fail in beneficence, which is the duty to promote good. If you override autonomy, then you may violate the fidelity and non-maleficence. and so on and so forth. Right? So the mental health act in Ontario which is the law can allow treatment in certain involuntary contexts but the ethical tension remains because if we involuntarily admit someone then we're not adhering to the principles of autonomy. Maybe we're not adhering to the principles of uh non-maleficence. But if you look at it from another perspective, maybe we are adhering to the the principles of beneficence because we are promoting good especially if the client might be a harm to others. So we're promoting good by protecting others. So as you can see there are many situations where we bring in the principles of deontology that there's no right or wrong or it's rather it's difficult to distinguish between what is right and what is wrong and the tension persists from a deontological perspective as I mentioned we have a duty to respect autonomy me, but we also have a duty to protect from harm. So, start to think about this as we're talking about these client scenarios and even start to think about your own um examples when you're working with clients. It doesn't even have to be mental health, but if it is, um that's even great. Uh that's even better. But even start to think about your own practice. um if there have been situations where these principles that we just mentioned these six have uh collided. So next we have the consequentialist theory. So this is an action. This is when we're thinking about whether an action is morally right or wrong based on the consequences. So the name will also remind you the consequentialist theory, right? So the right action is the one that produces the greatest amount of good or the least amount of harm in any given situation. And one common uh and popular um consequentialist theory is utilitarianism. And this particularly exclusively appeals to outcomes or consequences in determining which choice to make. So with utilitarianism, it's saying that the moral of an action is determined by its overall benefit. And some critics do argue that this theory does fails to take into account how people are affected by actions. So here we're saying that whatever action we take, it's determined to be either right or wrong based on the consequences. But the consequences may not take into account how people are affected by those actions. So the way that consequentialist uh theories may apply to mental health. So in terms of a focus on outcomes, a mental health nurse that's using a consequentialist approach would consider the predicted future well-being of the client and others involved. Right? because we're trying to think about how can our actions produce the greatest amount of good and the least amount of harm. So, we have to be able to predict some sort of future outcome. But that can be really difficult, right? Like, how do we know what the future is really going to hold? Even though we might be able to make a list of pros and cons, you truly never know what's going to happen and how things are going to unfold. So, it's really difficult to be able to balance these interests, right? A decision might involve balancing a client's um interests with the broader interests of their family or their community and it can be difficult to calculate the expected value, right? So we have to be able to identify the potential actions and we have to be able to assign probabilities to the outcomes of each action and we have to be able to determine the value of each outcome. Right? So is it quality of life that we are valuing? Is it the reduction in distress that we're valuing? And how do we put some sort of worth on this value? and choosing the action with the greatest expected value. This can be considered subjective, right? What you value as a nurse may not hold the same meaning to that client that you're working with or to the family and the community that might be involved. So one such example is um if we're thinking about treatment selection, right? So if we're choosing between two therapies, a consequentialist would assess which one is more likely to lead to recovery, improved functioning, and overall satisfaction for that client, even if the treatment involves more effort or temporary discomfort. So once again, there's never a clear answer. It all depends on the situation and the parties involved. So some of these I've already mentioned um the focus on the outcome the challenges uh you know it can be difficult to determine what is good and what is best cuz it's subjective. Uh think about are we sacrificing the interests of a few individuals for the benefit of many. So similarly, if we're thinking about that involuntary admission piece, if a client is um a harm to self or harm to others and we involuntarily admit them to the hospital, we are not keeping their autonomy um at the forefront because we're involuntarily admitting them. However, are we then promoting good by protecting others? Are we choosing an option that is leading to the greatest amount of good and the least amount of harm? So, is it the greatest amount of good for the community that is protected against this person that is thinking of harming others? But what about the good of the client who does not want to be in the hospital and now we've involuntarily admitted them? And that part about the least amount of harm, if we were to leave this client out in the community and they have the potential to hurt others, what about that least amount of harm? So if we put them in an involuntary hold and place them in the hospital, then people don't get injured. So the least amount of people are injured or the least amount of harm is inflicted. But what about the harm that is placed on the client? because they don't want to be there. Start to think about those which one is right or wrong. So the next is virtue ethics. Many argue that the consequentialist um approach does not provide guidance on what ought to be done and that it's through the use of virtues and virtue ethics that decisions can actually be made. So virtues provide us with guidance on what we can actually do and what one ought to do in a certain situation. So with virtue ethics we are saying that good people make good decisions and virtues are actually able to enable us to be and to act in ways that develop ethical potential and ensure ethical outcomes. So unlike deontology and utilitarianism theories where we're using duties and obligations to guide decision-m, virtue theorists don't use duties and obligations to guide decision-m. The core idea of virtue ethics is that instead of focusing just on rules like deontology or just on outcomes like the consequentialist theory, we are asking what kind of person or what kind of nurse should I be? So in nursing this means acting from good character traits or good virtues such as compassion, honesty, courage. So courage could be, you know, standing up for our clients rights or their safety. Um honesty of course is about being truthful even when it can be difficult. Um another virtue is patience. So taking time with someone who is fearful or confused, excuse me. So in mental health, situations are often uncertain and complex as we've already kind of established. And virtue ethics can really help nurses rely on our professional character and our moral integrity to help guide our actions, not just policies or checklists. So when it comes to virtues, we're thinking about attitudes, our dispositions, our character traits such as the ones I've mentioned, right? Honesty, courage, compassion, uh generosity, fidelity, um fairness, integrity, so on and so forth. And this is what actually enables us to do the first point like the attitudes, dispositions, the character traits help us make these ethical decisions and the most prevalent and most valued virtue in healthcare is compassion and it's caring. So an example of virtue ethics is that we have a compassionate nurse who nurse who goes beyond following just the rules to provide empathetic and attentive care to their patients, their clients. And this demonstrates a character trait of compassion um rather than just being an obligation. Just because I'm a nurse, I have to be compassionate and caring, but I'm going above and beyond. Right? So that is showing that this is actually a virtue that I carry. So another example could include um an honest individual who always tells the truth because it's part of their character or a client who calmly uh sorry not a client uh a patient person who calmly listens to a long story. Um and you know this makes patience um a a natural response for them. And um when it comes to virtue ethics, it's really offering us a framework for addressing mental health challenges by focusing on our own ability to cultivate these character traits like gratitude and wisdom and resilience, right? in both ourselves as individuals as well as clinicians. And there can be of course some challenges with using uh virtue ethics as our guiding principle or theory rather because defining virtues is challenging. It's subjective. Um there can be cultural differences in what we consider uh you know to be virtuous. For example, um mental illness can even impact a client's capacity to be able to exercise their virtues. So even though there are a lot of um helpful traits with using virtue ethics um there are challenges as we've just mentioned um you know the strengths are that it's holistic it's client- centered um but one challenge as I've mentioned is that subjectivity piece right um there's also you know a lack of clear rules so if we have a high stakes situation um relying on personal characteristics, it may not be enough, right? Sometimes we need clear guidelines on how to proceed in a certain situation. Um, there might even be some moral distress that the nurses can experience, right? So, nurses may feel torn between their personal virtues and even institutional demands. Um, how do we how do we balance that? There might even be um a risk of paternalism. So if we're acting from the the um idea of um benevolence, this might lead a nurse to sometimes maybe override client autonomy because you feel that you know what is best and that can be really challenging with me in mental health nursing where insight can sometimes be variable a variable um response based on the client and their certain situation. So, think about the the pros and the cons of of virtue ethics as well. And when I was saying that there might even be cultural differences in defining virtues, um start to think about what I'm what I might mean in terms of that. What are some examples that you could even think about where um there might be cultural differences in defining virtues because it is very subjective. So uh some examples I can I can think about um if we think about the virtue of respect right in a lot of western cultures respect emphasizes individual autonomy but then we also have a lot of collectivist cultures like in some eastern traditions um even some indigenous cultures there's a lot of collectivist approaches. We might even emphasize group harmony or respect for elders. So how do we balance that? Which one is right? Which one is wrong? If we think about the virtue of um honesty, right? If we're thinking about western cultural perspectives, um, honesty is absolutely a must. But if we think about some other cultures, sometimes we have to protect the family honor or we have to save face. So we may not be as truthful. So does that mean that in that situation honesty is not being displayed or is it displayed in a different way that might differ from your understanding of what honesty is? Right? So I hope you kind of understand with some of these examples that it can be difficult to describe um what a virtue means for you versus what it means to a client. So being aware that there are um differences can be helpful when you are facing an ethical dilemma. So next we're going to talk a little bit about relational ethics. So with this we're saying that an actionbased sorry we're saying that um this is a theory that says that an action-based ethics requires nurses to appreciate the context in which ethical issues arise. So the core idea really with relational ethics is that ethics is not just about rules like it is with deontology and it's not just about outcomes like it is with the consequentialist theories. It's about the quality of relationships between nurses, clients, families and the healthcare team. So we have to understand the context and that it is dynamic and it is a fluid interaction. So the core question really is what action or decision is the most fitting. So if we're thinking about mental health nursing, relational ethics might mean building trust with clients who may feel powerless or stigmatized. It might mean considering the client's context, their culture, and their relationships, not just their diagnosis. It could even mean recognizing that how you care. So your tone, your um the manner in which you care. Um the relationship in which you care, this is just as important as what you do. So how you do it is just as important as what you are doing. So it's not just that you're completing a task, but how are you completing that task? Is it with compassion? Is it with care? And when it comes to relational ethics, there are five core elements. So the first is mutual respect. So here we're valuing the client's voice, their dignity, their culture. And of course, it has to go the other way as well. The client has to uh have mutual respect for us as well. There is engagement. So being present and genuinely listening. Embodied knowledge is using professional knowledge and lived personal experience and there is an interdependent environment. So recognizing that clients, families and providers are connected and uncertainty within relationship. So this is accepting that in complex situations there isn't always a right answer. So if we try to think about some examples of relational ethics in mental health nursing. So say there's a client that has paranoid delusions and they're suspicious of staff. How does the nurse navigate trust with a paranoid client? So, instead of enforcing rules rigidly, the nurse takes time to build trust with the client. They use consistency, transparency, um a non-judgmental process, um and being present with the client. So the ethical action here isn't just protecting safety, but it's about nurturing trust through that relationship. Another example could be there is a client on the unit that has depression and they are uh refusing their medication. So instead of forcing compliance, uh the nurse can engage in a dialogue with the client, explore their concerns, and co-create a care plan that really honors the client's choices and their voice. So here, you know, autonomy is seen within that relationship of the nurse and the client. It's not just an isolated right that the client is able to refuse medication. So, I'm going to respect that. But the nurse is actually taking time to build that relationship, to build that trust, to understand, you know, why the client is refusing medications, what their fears are, what their concerns are, and trying to work with that client to ensure that their autonomy is maintained, but also that their care needs are not compromised. So relational ethics are really about um relationships over rules or outcomes. There's mutual respect, trust, engagement and it it emerges in the interaction not just from rules or duties or principles. So now that we've kind of talked a little bit about um the different the main different theories um when it comes to um ethics, we're going to talk a little bit about um some other situations um some definitions that you might um encounter as well. So when we're talking about an ethical dilemma, the nurse is a moral agent, right? So they have the power and the capacity to direct their motives and their actions to some ethical end. So essentially doing what is good and right. And as you can see some from some of the examples I've given that this is not something that is black and white. Ethics can sometimes feel like a very gray area. So the nurse might experience something called moral distress. This is when you know the right thing to do but you feel unable to do it because of rules, laws or other barriers. Other barriers could even include um like workplace dynamics, organiz organizational policies, uh system shortcomings, gaps and whatnot. So you know the right thing but you're not able to do it because of other barriers. So you might experience moral distress. So an example could be um as a nurse you want to give a client more time and you want to be more compassionate but you feel pressured to rush due to a staffing shortage. Then we have moral uncertainty. This is when you are not sure what the right thing to do is in a particular situation. So you're uncertain. So an example is that you're unsure if respecting a client's refusal of medications is the best choice or if protecting them from harm is more ethical. So some of those principles that we already spoke about are coming to play. So you want to respect the client's autonomy, but if they don't take their medication, they're not going to be well. Their symptoms are going to continue progress. They might continue to be a harm to self or others or uh be unable to care for themselves. So you want to protect them from harm, but then you also want to maintain their autonomy. So you feel a moral uncertainty in this situation cuz you're not sure how to proceed. Then we have moral residue. So these are the lingering feelings that nurses can experience. Uh sorry, these are the lingering feelings that nurses um who are experiencing moral distress or moral uncertainty can feel. So they might feel guilt. They might feel regret. They might even feel like there is some sort of moral scar that's been left on them from not being able to act as you believed you should. So after you experience moral distress and moral uncertainty, you might feel moral residue. Those are those challenging feelings. So you might feel upset even months later about a time that you had to restrain a client for example like that feeling still sits with you. Maybe you feel guilty. Maybe you feel regret. So that's that residue that remains from acting within that ethical dilemma. Oh, sorry about that. Let's go back. Um the last one is a moral uh is a moral resilience. So this is the ability to recover, adapt and maintain integrity after facing moral challenges. So here we're really using reflection and peer support or other ethical resources to learn and bounce back after a difficult ethical situation. So typically there might even be some sort of team debrief if there is some sort of ethical dilemma that has happened on an inpatient unit even in the community so that you're able to actually recover and adapt and maintain integrity and see how certain things might change if we were to encounter this situation again in the future. So, next I have a little bit of a case study that you can take a little bit of time to um think through. So, there's a 27-year-old male that has been admitted involuntarily with a diagnosis of paranoid schizophrenia. He refuses to take his medication um which is an antisycchotic medication saying, "You're trying to poison me." His family asks the nurse if he can be forced to take the medication. So, now that we've spoken about deontology, the consequentialist theory, uh, virtue ethics, and even relational ethics, I want you to go through this scenario from each of those perspectives. You don't have to spend too much time on it, but now that you know a little bit about those theories, what would be the most ethical action for the nurse to take based on that theory? And what reasoning or principles from this theory support this decision? So once again, deontology is really duty based, right? We're focusing on duties such as um respecting autonomy versus protecting the client from harm. You know, we're considering principles like beneficence, non-maleficence, and even fidelity. With consequentialist theories, we're focusing on the outcomes, right? So, which action brings the greatest good or the least amount of harm? With virtue ethics, we're focusing on the nurse's character traits, such as compassion, courage, honesty, and how should a quote unquote good nurse behave in this situation. And relational ethics is about focusing on the relationship. So there's mutual respect, engagement, trust building, context, and we're trying to figure out and ask ourselves what action is the most fitting in this relationship at this moment. And that was a little bit of a review for you. Um, so if we are thinking about deontology based on this scenario, we're really focusing on what are my duties as a nurse. So there's a duty to respect autonomy but also a duty of beneficence which is promoting well-being of this client and non-maleficence which is doing no harm. So we may argue that balancing autonomy with protection under the mental health act is the right thing to do. But is it with consequentialist theories? the action um we're talking about sorry the focus we're talking about is that the action leads to the best overall outcome. So is giving medication to this client who is involuntarily admitted um is this the best action is we know that this may reduce symptoms and this may reduce the client's risk and it may benefit the client the family and even overall society but forced medication could harm trust and cause trauma. So here we're trying to really weigh the overall benefits versus the harm of forced treatment. If we're thinking about virtue ethics, we're thinking about what does a quote unquote good nurse do in this situation, right? So we have to be guided by certain principles. We're trying to really emphasize building trust and showing care and acting with integrity. But how do we build trust with a client that has paranoid schizophrenia and thinks that you're trying to poison them? So with virtue ethics, we're really trying to prioritize a relationship and the moral character when making this decision. And lastly, with uh relational ethics, the focus is what is most fitting in this relationship. So, we're trying to recognize that the client's fears are valid, and we're trying to seek to build relationships and trust before considering coercion. So, we have to balance um and emphasize dialogue and respect and relational trust. So hopefully that gives you a little bit of an understanding about how you can take one situation and look at it from different uh theories and it's still very difficult. It's still a gray area and what is right and what is wrong in these situations. It's it's really subjective sometimes, isn't it? So when we're talking about research ethics, um as I mentioned, we do have the Canadian Nurses Association, the CNA, the code of ethics. And this really outlines the ethical standards of practice um for nurses. And then um it sets out our actions and our ethical responsibilities. Then there's also the tri council policy statement um the ethical conduct for research involving humans and this is actually the cornerstone of ethical research um that involves human participants in Canada and it was essentially developed by um uh three federal research agencies and it outlines um three um core principles which are respect for persons concern for welfare and justice. So respect for persons is a principle that essentially recognizes the intrinsic value and autonomy of every individual. So when we're talking about respect for persons, we're really talking about informed consent, um autonomy, um respect for vulnerable populations, right? So, as a researcher, you have to ensure that a client um has all of the information that they are freely willing to participate in this research, right? Um, for example, if you're doing mental health research with someone that does have a diagnosis, say, um, well, it doesn't matter what the diagnosis is, but um, that they have to be willing, that they have to be able to fully understand the study and they're capable of giving informed consent, that there's no coercion. Um, concern for welfare. This is referring to protecting the well-being, the privacy, and the safety of participants that are included in your research. Right? So, we're really trying to minimize physical, psychological, uh, social risks. We're ensuring that the benefits of the research um, outweigh uh, the risks. We're trying to respect autonomy, uh, confidentiality, and privacy. and we're trying to provide access to the clients um to support if distress does occur because of the research. So for example, if you're doing a study on uh um trauma recovery and participants might become uh emotionally distressed, we have to as a researcher have some support protocols put into place, right? Maybe they need to be referred for counseling or maybe they can be referred to some other outpatient um supports. Uh we have to be able to monitor for signs of harm um and so on and so forth. Lastly is justice. So this principle is about uh demanding fairness and equity in research participation. So um here you know recruitment needs to be inclusive and and the selection needs to be fair of course as it relates to the research study power imbalances have to be acknowledged and and addressed. Um so you know for example if you're a researcher and if the research is being done in a low-income community for example of course we cannot you know exploit the people's vulnerability or offer coercive incentives right and it's important to know that these principles work together and they don't work um separately they they're not just there in isolation. So, you know, a truly ethical research study in mental health, it has to balance all three. We can't just follow rules, but we have to foster trust and safety and respect um in all aspects of the research process. So when it comes to mental health legislation, historically in Canada, mental health legislation was developed um to protect members of the public from the so-called, you know, mentally deranged and dangerous patients. and legislation ensured that these quote unquote dangerous individuals were isolated from the public rather than ensuring that the rights their rights as people and you know citizens were protected. So like I mentioned this is historically what had happened. Um however there is a shift and as we know clients um u and citizens we have a lot of rights that are protected under the law. So when it comes to the provinces and the territories, the provinces and the territories each establish their own mental health legislation. So there are differences across the country and there are distinctions that do exist regarding involuntary admission criteria, the right to refuse treatment and who has the authority to actually authorize that treatment. So, that's going to depend on where like which province you're working in. Um, but we'll talk about this in more of a general context. And in your textbook, there actually is a table that shows you um the specific criteria based on the jurisdiction that you're in. So, of course, we're going to be focusing on Ontario, which is why I've been mentioning the Mental Health Act in Ontario. So the mental health act um it covers governs psychiatric care in Ontario and it covers three types of admission. So we have voluntary, informal and involuntary admission. Then you have the healthc care consent act and this governs consent to treatment including ensuring capacity and the use of a substitute decision maker and it operates alongside the mental health act. Sorry, this a should have been a capital. So this is a little bit of a review from last week's um lecture cuz I did mention it there. But under the mental health act, clients um can be involuntarily admitted to the hospital. So the first pathway is the form one which is the application for psychiatric assessment. And this is a form that is completed by a physician if the doctor feels that the client is a risk to themselves, to others or unable to care for themselves. And if the doctor believes that one of these criteria has been met, it could of course be all three, it could be two, but definitely one of them is the minimum requirement. They can complete a form one which then authorizes the police to bring the person into a hospital for a psychiatric evaluation. So the client can be held for up to 72 hours for an assessment and observation. And during this time they are not able to leave until they have been cleared by the physician. Similarly, we have the form two which is an order for examination. Instead of being completed by a doctor, this is completed by a justice of the peace. So here we might have concerned family members, a friend, a community member that believes that their loved one may need psychiatric assessment, but they're not able to get them to go to a doctor, which could be because of their symptoms based on their illness. They don't feel that anything is wrong with them. They don't want to go to the doctor. They're refusing treatment. U maybe their symptoms are so psychotic that they don't trust the family member. Once again, one of those three criteria has to be met. Unable to care for themselves because of their mental illness, a risk to self, or a risk to others. So, you have to be able to present evidence to the justice of the peace. And if they feel that one of these three conditions has been met, once again, they can complete the form two, which authorizes the police to um apprehend the individual and take them to a doctor or a psychiatric facility, a hospital for an assessment. And then they are um um assessed um by uh the inpatient um the doctor and um then the doctor can decide okay does this client um need to be admitted for a longer stay or can they be discharged into the community with um some other supports in place? So, when it comes to police apprehension, if someone is an immediate danger to themselves or others or they're unable to care for themselves, such as physical impairment um that may occur, the police can bring the person to a psychiatrist for an assessment without a warrant. So in both the forms that I've mentioned um at the end of the 72 hours the physician has to decide like I mentioned is this client going to be released or discharged. Are they going to admit them voluntarily? So the client is agreeing okay yes I do need to stay I need to be stabilized I will agree to being admitted or are we going to admit them involuntarily. So at the end of those 72 hours, one of these three pathways has to be established. Is the client being discharged? Are they agreeing to stay? Or are we going to involuntarily admit them because they still are not well enough and we need to further um observe them and do an assessment and treat them. There are 10 basic principles when it comes to the mental health care law that we are going to kind of go over and essentially this was uh developed from a comparative analysis of national mental health laws in 45 countries by the world health organization. So it's the promotion of mental health and prevention of mental dis health disorders. There needs to be access to basic mental health care. Mental health assessments need to be done in accordance with internationally accepted principles. There needs to be a provision for the least restrictive type of mental health care. Self-determination is the person's um right to make decisions about their own mental health and treatment um as long as they had the capacity to do so. There has to be a right to be assisted in the exercise of self-determination. There has to be an availability of a review uh procedure. There has to be an automatic periodical review mechanism that is put into place. There needs to be a qualified decision maker such as the physician um that completes that form for example and the respect of the rule of law. So the respect for the rule of law essentially means that all actions by mental health professionals, institutions, uh government authorities, they must follow some sort of established law and legal processes that ensures that the client's rights are protected and that care is provided legally and fairly. So legal framework um governs care um through like mental health acts, through regulations, through policies that are set out on how assessments, admissions, uh treatment and involuntary interventions can be done. However, client rights still have to be protected within that. Right? So clients can't be treated arbitrarily. um you know their rights still need to be maintained, their rights to consent, to appeal, to challenge decisions. Um all of these are part of the client's rights. And the last part for the respect of the rule of law is that there needs to be accountability on the mental health professionals part, right? We have to be able to act within the law and we have to be held accountable if we don't act within the law. So as mentioned each province and territory they provide a regulatory framework for the governance for uh health professionals and this gives the professional bodies their mandates and their powers. So for um like I mentioned um with with nurses, we know you know we have the the CNO, the College of Nurses of Ontario. So they are the ones that are our our professional body. They're the ones that set out mandates and regulations. Um so registered nurses, um you know, even registered psychiatric nurses, um there's other healthcare professionals that have their own colleges as well. Um and this type of regulation also sets out um the the the reserves titles and the scopes of practice um for our professional um registrations. So this includes you know the scope of practice but also the restricted activities uh excuse me the standards of practice. So the regulatory bodies they establish um acceptable qualifications for entry to practice standards of care. Um you know nurses are held to a basic standard of care and um psychiatric clients also have a right to a basic standard of care as well. Um policies and procedures are also included as part of this as well as well as traditional practice knowledge. So guidelines for ensuring adherence to standards of care. So of course there are standards of practice that we can look to that we have to follow and sometimes students or even practicing nurses can encounter situations in which they suspect negligence on the part of a peer or a colleague. Right? And in most provinces or territories nurses do have a legal duty to report for example if there's a risk to harm. Right? So, it's important for us to be able to document the evidence clearly and accurately before we make a serious accusation against a peer. And of course, this can pose an ethical dilemma. Um, think about it, right? You're you're working inatient, out um outpatient, in the community, wherever, and you see something that your peer is doing, your colleague is doing that does not meet that standard of practice. Maybe there's some sort of negligence, some sort of irresponsibility. Um, there could even be an impairment on that peer's part, right? Maybe cognitively they're impaired. Sometimes there might be even a suspicion or even clear evidence that your colleague might be impaired or under the influence of certain substances and that poses an ethical dilemma for you. This is your colleague. This is your peer. You have trusted them. They're a professional. uh you might have a relationship with them but now maybe their practice is putting others at risk. How do you handle that situation? So that ethical dilemma arises, right? Um self-determination. So when when we talk about guardianship, this is really referring to a legal arrangement in which a court appoints someone such as a guardian to make decisions on behalf of a person who cannot make safe or informed decisions for themselves due to mental incapacity. So here it's called a SDM, a substitute decision maker. Um, of course there's a whole criteria on how you become a substitute decision maker, why someone might need one. And for the purpose of this course, we don't need to know those details, but you do need to know that sometimes when a client has a incapacitating mental health condition temporarily, they might not be able to make informed decisions. So they might be appointed an SDM. So, a family member or a loved one can become an STDM. And if a family member is unwilling to do so or they their the client does not have any family members, but they're still unable to make decisions for themselves, they can also have an SDM that is appointed to them from the consent and capacity board. Sorry, not the consent and capacity board. I meant the public guardian and trustee. If you don't um have family members available or willing to do so, the public guardian and trustee serves as your SDM, not the consent and capacity board. That's something else which we'll talk about in a second. So in terms of the client's um rights under the law um of course in Ontario the client does have um the right um to authorize treatment. So they are able to authorize um to either accept or refuse treatment if they are deemed capable of being able to make that decision. However, if a client is unable and they're incapable of making a decision about their treatment based on their mental health symptoms, then they can be assigned a SDM, a substitute decision maker. So, this could be a family member um or someone that has a power of attorney uh for personal care. um if they don't have a family member, like I said, they could be assigned one um um through the public guardian and trustee. Um and essentially, the SDM has the legal authority to provide um or refuse consent on this client's behalf. And of course, we also have the consent and capacity board. So they are the ones that are going to do um a full review to even determine whether this client, this person is actually incapable of making decisions or not. They do a full review cuz even as a doctor, nurse, healthcare professional working with a client, you don't know their full story, right? We only know a little bit, especially what is being presented to us. Um, but the consent and capacity board does a full thorough assessment to determine whether this person is in fact incapable of making decisions and needs an STM or they are in fact capable of making their own decisions. Um, the client also has autonomy, right? So, informed consent means that they're able to give permission for a health procedure. uh you know after they received all the necessary information so they can understand the benefits, the risks, the alternatives, the consequences um and an essential aspect of informed consent is that it has to occur without coercion. Right? So sometimes there can be implied consent um where you know permission is inferred based on a client's actions. So, for example, if you're a nurse, you need to go do blood work. Um, and the client is already seated. They see you come in with all your instruments and they roll up their sleeve for their injection or they roll up their sleeve and give you their arm for blood work. That's an example of implied consent, right? Um, which is a which a reasonable person would understand as agreement that yes, I'm here to give your injection or yes, I'm here to take your blood work and you've given me your arm. Competency is the capacity to understand the consequences of your decision. Right? So in psychiatric mental health um nursing it's important that we know that the presence of psychotic thinking does not mean that the client is mentally incompetent or they're incapable of understanding. Right? So just because someone has a mental illness, even if they have psychotic thinking, they can still be capable of making their own decisions, right? They can still provide or deny consent. So having a psychiatric disorder doesn't automatically mean a person lacks decision-making capacity. And that's something that we truly have to remember as mental health nurses. It's about that that you know that implicit bias that stigma that we might bring in when it comes to mental health patients. So although psychotic symptoms can temporarily affect these abilities to make a decision, many patients that have a mental health disorder, even if they have psychotic thinking, they can still retain their capacity and their decision-m ability. And sometimes it can improve with treatment. And even when you simplify that information for them, um the right to refuse treatment, um we've kind of mentioned that as well. Um so sometimes clients are deemed incapable of making decisions. They have an SDM. Um a whole process has to be done um to ensure that the client needs an SDM and they're actually incapable. And then that decision maker is the one that is um able to say, "Yes, this client needs that treatment. Then we also have something called community treatment orders also known as um CTO's. So CTO's are an alternative to a hospital admission and essentially a community treatment order is for individuals that have a serious mental illness who tend to discontinue treatment after being discharged from the hospital which then leads to relapse and readmission. So then the client might need something called a CTO.