W1: Intro to Mental Health, Legalities, and Ethics.

Prep for Practicum

• Check DC Connect for orientation information and location
• Professionalism is expected at all times
• Review the practicum guide for professional dress requirements
• Ontario Shores students only need to bring their original CPIC's to orientation
• Complete all orientation information and bring copies of ALL tests to submit - without those there is no ID or keys and there will be no access to units

Housekeeping

• Review the course outline and week-to-week schedule
• Review DC Connect

Reaching the Professor

• Email: [email protected]
• Office hours are by appointment only

Definitions of Mental Health

• World Health Organization: Mental health is not merely the absence of disease, but a state of well-being where the individual realizes abilities, copes with normal life stresses, works productively, and contributes to their community
• Public Health Agency of Canada: Mental health is the capacity to feel, think, and act in ways that improve the ability to enjoy life and face challenges, and is a sense of emotional and spiritual well-being respecting culture, equity, social justice, interconnections, and personal dignity.

Influences on Mental Health

• Resilience allows adaptation to life circumstances
• Culture establishes acceptable cultural norms
• Nature vs. Nurture involves inherited biology versus childhood nurturing
• Social Influences include societal focus, neuroscience, political strategy, social change, social determinants of health and social media

Mental Health Continuum Model

• The model classifies mental health into four stages: healthy, reacting, injured, and ill.
• Healthy: Normal mood fluctuations, calm, good humor, performs well, mentally in control, normal sleep, few difficulties sleeping, physically well, good energy, socially active, limited alcohol/gambling
• Reacting: Irritable/impatient, nervous, sad, sarcasm, procrastinates, forgetful, intrusive thoughts, nightmares, muscle tension, low energy, decreased socializing, controlled regular alcohol/gambling
• Injured: Anger, anxiety, hopeless, negative attitude, bad performance, decisions, restless sleep, nightmares, aches, fatigue, avoidance, withdrawal, hard to control drinking/gambling
• Ill: Aggression, panic attacks, suicidal thoughts, over insubordination, cannot controll performance/behaviour, cannot fall/stay asleep, sleeps too much/little, physical illness, constant fatigue, doesnt answer calls/go out, addiction, other addictions

Mental Health Nursing Roles

• Helping the person to prevent or recover from illness
• Preventing further decompensation and enabling resiliency and empowerment.
• Specializing in working with all ages
• Work settings include homes, community nursing/public health, community healthcare centres, hospitals, street, academic institutions, telemedicine, and forensics/corrections

Legalities and Ethics

• Legalities include Legislation, Mental Health Act (MHA), Client Rights under the Law, MHA forms, Brian's Law and Community Treatment Orders (CTO) & Formal Advocacy regarding Consent and Capacity issues
• Ethics: CNO values client well-being and choice, privacy, respect for life, maintaining commitments and fairness

Mental Health Act (MHA)

• Sets out criteria for voluntary, informal, and involuntary admissions to psychiatric facilities
• Includes the maintenance of psychiatric outpatients under Community Treatment Orders (CTO)
• Requires assessing the capacity of psychiatric patients to manage property following admission
• Protects the rights of psychiatric patients by requiring formal rights advice in certain circumstances
• Provides for the review of informal/involuntary admissions, managing property and CTOs before the Consent and Capacity Board

Patient Definition Under the Mental Health Act:

• Voluntary patient: Agreed to be admitted for care and observation
• Informal patient: Admitted based on a substitute decision maker's consent under the HCCA
• Involuntary patient: Assessed by a psychiatrist and meets the criteria in section 20 of the MHA via Form 3 or 4
• Patients admitted under court order (Form 6 or 8), according to sections 21 to 25 of the MHA are Forensic Patients

Patient Rights Under the Law

• Patients have the right to treatment, to refuse treatment, and to have authorized treatment
• Patients have the right to confidentiality, protection from harm, and least restrictive care
• They have the right to confidentiality, duty to warn, protect and report abuse
• They can consent to competency, advance directives, community treatment orders and can be admitted involuntarily under certain criteria

Form 1

• Mandatory psychiatric assessment application by a physician
• Initiated by any physician who has seen the client within the last 7 days
• It requires the physician to believe the client meets specific tests related to past/present and future harm to self/others
• Involves Box A for serious harm tests and Box B for persons incapable of consenting to treatment and meet specific criteria
• Used as a means to access further psychiatric assessment for a max of 72H, no rights advice is given until assessed
• Form 42 is a notice indicating their rights

Form 2

• Order for the examination, and requires information from family or friends concerned about the psychiatric status of an individual
• Signed and issued by a Justice of the Peace to police, allowing them to take the individual to a facility for examination by a physician
• Part A conditions: threatening to harm or acting violently, or demonstrating lack of competence to care for self
• Part B conditions: If the patient previously received Tx for a serious, reoccurring mental health disorder; if untreated will result in substantial harm to self or others or substantial deterioration, if the patient has shown previous clinical improvement when treated, suffering from the same disorder in which they previously received treatment for, incapable to consent to treatment, with substitue decision maker consent obtained

Form 3

• Certificate of involuntary admission valid for 14 calendar days, including the day it was signed
• A Form 30 notice must be given and a rights advisor must be notified
• The rights advisor meets with the patient to explain significance of certificate and right to review by CCB
• Box A notes risk of serious harm to self, others, impairment
• Box B states incapable with SDM consent, previously received Tx for mental Illness, left untreated will result in serious harm, clinical improvement from Tx, suffering from the same mental illness, and likely to result in self harm or deterioration

Form 4

• Certificate of Renewal completed before lapse of Form 3
• First renewal: One month, including the day signed
• Second renewal: Two months, including the day signed
• Third & Subsequent Renewals: Three months, including the day signed
• Mandatory Consent and Capacity Board (CCB) hearing every 4th renewal whether or not patient wishes to dispute status
• If expired they gain voluntary status

Commuity Treatment Order (CTO)

• Treatment of people with mental health conditions and have experienced multiple hospitalizations
• Came in effect in Dec 2010 to deal with "revolving door" situations, facilitating community supervision for those with 2+ admissions to facilities
• Cumulative 30-day period during the prior three years as the baseline reference
• Goal: Transition patients out of hospitals to community treatment and monitoring that is less restrictive, but can take action to detain of they are a threat
• Bill 68(Brian's Law)

Consent and Capacity

• Treatment: Anything done for a therapeutic, preventive, palliative, diagnostic, cosmetic, or health-related purpose, including a treatment course, plan, or community plan
• Capability: A person is capable of making a decision about relevant information and understanding consequences
• A capable decision involves understanding info about the proposed treatment and reasonably forseeing consequences

Substitute Decision Maker

• A substitute decision maker is consulted if the patient lacks decision making capacity.
• Legal Heirarchy: Legal Guardian -> Attorney for personal care -> Representative appointed by CCB -> Spouse/partner -> Child/Parent/CAS -> Parent with right of access -> Brother/Sister -> Other Relative -> Public Guardian & Trustee

Consent and Capacity Board (CCB)

• The Consent and Capacity Board (CCB) is an independent provincial tribunal that deals with fair and accessible adjudication of consent and capacity issues and balancing rights for the public safety
• Adjudicate matters of capacity, consent, civil committal and substitute decision making

Principles of Bioethics

• Autonomy: Respecting the rights of others to make their own decisions.
• Nonmaleficence: Doing no wrong to a patient.
• Beneficence: The duty to promote good.
• Justice: The duty to distribute resources or care equally.
• Principle of impossibility: Rights or obligations that cannot be met in the circumstances are no longer obligations
• Fidelity: Maintaining loyalty & commitment.

Ethical Dilemma vs Distress

• Ethical Dilemma: One has an obligation to act but needs to choose between 2 incompatible alternatives
• Ethical Distress: Unable to act on moral choices due to restraints, potentially causes burnout, and causes a host of physical and sleep issues

CNO Step of Ethical Decision Making

• Assess: Recognizing the values present to help recognize ethics
• Plan: Weighing your options against healthcare and reformulate
• Implement: Carrying on the actions you decided for your ethical problem

Mental Status Assessment (MSA)

• An MSA is performed to evaluate a person's current cognitive and emotional functioning as part of a complete and holistic assessment
• It involves observations throughout structured interviews, direct questioning, and subjective data
• Method for determining changes in behaviour
• Requires knowing client’s educational and cultural background
• See the full description on Week 1 DC Connect
• It covers Appearance, Speech, Emotion (mood & affect), Perception, Thought process & content, Insight/judgment and Cognition

MSA: Appearance & Findings

• Clean, appropriate clothes for fit, age, situation, and religion
• Normal variations include trendy, gothic or eccentric
• Abnormal findings include dirty clothes, inappropriate dress, malodorousness
• Grooming/Hygiene: Findings should be neat and clean, with makeup in moderation (though hair would still follow colour trends)

Safety Guidelines

• Never walk down hallways or corridors alone; staff should be present
• Tell staff where you are going if out in the milieu
• Never be alone with a patient in a room
• Position yourself closest to the exit when possible (in activity rooms or bedroom)
• If a situation or patient is escalating, report immediately to staff
• Do not participate in code whites – observe from a distance only
• Review restraint policy at institution
• Students should not be caring for a patient in restraints

Code White

• An emergency requiring extra support from nurses, allied staff and security
• It is called when de-escalation methods have failed or in rapidly changing dangerous situations
• A psychiatrist/MD to respond to order STAT meds if clinically indicated
• Overhead alert to call for staff to needed to regain control
• Includes Code white kits & Documentation
• Could result from violent outbursts

Transference

• Past feelings, issues, and transferred into current relationships, and situations
• Nurses may be potential a potential target for these feelings and unknowingly remind the client of someone from their past

Counter-Transference

• Reverse occurs when unresolved conflicts from nurses present counter transference, and may be completely unware of the situation

Empathy

• Respond accurately to client feelings, emotions and moods
• Use the right family of emotions, distinguish between expressed vs discussed feelings, read non-verbal behaviour clues and name with care
• Use variety of support, and adjust emphasize feelings to adjust appropriate

Empathy Formula

• You feel .... (name the emotion expressed by the client) because ..... (name the thoughts, experiences, and behaviors the client has mentioned)

Nursing: Putting it All Together

• Use the nursing process
• Pay attention to the ADL’s
• Use yourself as a therapeutic agent
• Foster hope, resiliency and recovery
• Participate appropriately in group activities
• Be active in the milieu
• Document interactions and care Prevention and Crisis intervention ONLY if appropriate
• Provide discharge teaching and health promotion