Chapter 5: Psych - Ethical & Legal Considerations in Nursing PDF

The ANA, in cooperation with the American Psychiatric Nurses Association and the International Society of Psychiatric-Mental Health Nurses (2022), has published a scope and standards of practice manual specifically for psychiatric-mental health nursing. It maintains consistency with the ANA code of...

The ANA, in cooperation with the American Psychiatric Nurses Association and the International Society of Psychiatric-Mental Health Nurses (2022), has published a scope and standards of practice manual specifically for psychiatric-mental health nursing. It maintains consistency with the ANA code of ethics and applies those provisions to psychiatric-mental health nursing issues. Knowledge about the Code of Ethics for Nurses (ANA, 2015) and Psychiatric-Mental Health Nursing: Scope and Standards of Practice (ANA et al., 2022) is essential for guiding practice because they clarify the accepted expectations of the nurse in this field. Because legislation determines what is right or good within a society, legal issues pertaining to psychiatric-mental health nursing are also discussed in this chapter. Definitions are presented along with a description of the generally accepted and legal rights of psychiatric clients. Nursing competency and client care accountability are compromised when the nurse has inadequate knowledge about the laws that regulate the practice of nursing. Application of the legal and ethical concepts presented in this chapter promotes quality care in psychiatric-mental health nursing practice and promotes legal accountability. The right to practice nursing carries with it the responsibility to maintain a specific level of competency and to practice in accordance with certain ethical and legal standards of care. \*\*\*\*\*\*\*\*\*\*\*\*\*\*CORE CONCEPT Ethics is a branch of philosophy that deals with systematic approaches to distinguishing right from wrong behavior (Butts & Rich, 2019). Bioethics is the term applied to these principles when they refer to concepts within the scope of medicine, nursing, and allied health. Morals are fundamental standards of right and wrong that are learned and internalized (Catalano, 2020). Moral behavior is conduct that results from serious critical thinking about how individuals ought to treat others. Moral behavior reflects the way a person interprets basic respect for other people, such as the respect for autonomy, freedom, justice, honesty, and confidentiality. Values are personal beliefs about what is important and desirable (Butts & Rich, 2019). Values clarification is a process of self-exploration through which individuals identify and rank their personal values. This process increases awareness about why individuals behave in certain ways. Values clarification is important in nursing to increase understanding about why choices and decisions are made over others and how values affect nursing outcomes. Rights are expectations to which an individual is entitled either by established laws, policies, or ethical principles. A right is absolute when there is no restriction whatsoever on the individual's entitlement. A legal right is one on which the society has agreed and formalized into law. Both the National League for Nursing (NLN) and the American Hospital Association (AHA) have established guidelines of patients' rights. Although these are not considered legal documents, nurses and hospitals are responsible for upholding these rights of patients. \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*Ethical Considerations Theoretical Perspectives An ethical theory is a set of philosophical principles that can be used to guide how an individual makes decisions on ethical questions and issues. Several ethical theories are described here. \*\*\*\*\*\*\*\*\*\*\*\*\*Utilitarianism The basis of utilitarianism is the "greatest-happiness principle." This principle holds that actions are right to the degree that they tend to promote happiness and are wrong as they tend to produce the reverse of happiness. Thus, the good is happiness and the right is that which promotes the good. Conversely, the wrongness of an action is determined by its tendency to bring about unhappiness. An ethical decision based on the utilitarian view looks at the end results of the decision. Action is taken on the basis of the end results that will produce the most good (happiness) for the most people. \*\*\*\*\*\*\*\*\*\*\*\*\*Kantianism Named for philosopher Immanuel Kant, Kantianism is directly opposed to utilitarianism. Kant argued that it is not the consequences or end results that make an action right or wrong; rather, it is the principle or motivation on which the action is based that is the morally decisive factor. Kantianism suggests that our actions are bound by a sense of duty. This theory is often called deontology (from the Greek word deon, which means "that which is binding; duty"). Kantian-directed ethical decisions are made out of respect for moral law. For example, "I make this choice because it is morally right and my duty to do so" (not because of consideration for a possible outcome). \*\*\*\*\*\*\*\*\*\*\*Divine Command Ethics The divine command ethics approach to decision making is focused on that which is commanded by God. Many contemporary religions, including Judaism, Islam, and Christianity and numerous polytheistic religions, incorporate the importance of divine commands in ethical decision making (Rae, 2009). In Christian ethics, ethical decisions are based in the way of life and teachings of Jesus Christ. This ethical theory advances the importance of virtues such as love, forgiveness, and honesty and is associated with the principle "Do unto others as you would have them do unto you." In Judaism, the Ten Commandments, which focus on loving God and loving others, are considered divine commands. In Islam, the focus is on the moral principles and virtues elaborated in Islamic religious texts, including good character, kindness, charity, and forgiveness. \*\*\*\*\*\*\*\*\*\*\*\*Natural Law Theory Natural law theory is based on the writings of St. Thomas Aquinas. It advances the idea that decisions about right versus wrong are self-evident and determined by human nature. The theory espouses that, as rational human beings, we inherently know the difference between good and evil (believed to be the knowledge that is given to man from God), and this knowledge directs our decision making. \*\*\*\*\*\*\*\*\*\*\*\*Ethical Egoism Ethical egoism espouses that what is right and good is what is best for the individual making the decision. An individual's actions are determined by what is to their advantage. The action may not be best for anyone else involved, but consideration is only for the individual making the decision. Providing patient-centered care, an important health professions education competency identified in the IOM report (2013), speaks to some elements of ethical egoism. This competency promotes listening to and respecting the patient's values, preferences, and expressed needs in care management decisions. \*\*\*\*\*\*\*\*\*\*\*Ethical Dilemmas An ethical dilemma in nursing is a situation that requires the nurse to make a choice between two equally balanced alternatives (Catalano, 2020). Evidence exists to support both moral "rightness" and moral "wrongness" related to a certain action. The individual who must make the choice experiences conscious conflict regarding the decision. Not all ethical issues are dilemmas. An ethical dilemma arises when there is no clear reason to choose one action over another. Ethical dilemmas generally create a great deal of emotion. Often, the reasons supporting each side of the argument for action are logical and appropriate. The actions associated with both sides are desirable in some respects and undesirable in others. In most situations, taking no action is considered an action taken. For example, consider a patient who refuses to take a prescribed cardiac medication, claiming that they do not believe it is necessary. Although each patient has the right to refuse medication under ordinary circumstances, if the same patient is known to be depressed and suicidal, might they be intending self-harm by their refusal to take such a medication? And, if so, what is the best course of action? Many health-care settings have established guidelines for how to proceed should an ethical question or dilemma arise. Hospitals typically have a formal committee to explore and analyze ethical issues from several vantage points. Nurses can improve their critical thinking and clinical judgment skills by identifying such issues and seeking clarification through collaborative exploration with others and through ethics committee involvement. \*\*\*\*\*\*\*\*\*\*\*\*\*\*Ethical Principles Ethical principles are fundamental guidelines that influence decision making. The ethical principles of autonomy, beneficence, nonmaleficence, veracity, and justice are examples that are used frequently by health-care workers to assist with ethical decision making. \*\*\*\*\*\*\*\*\*\*Autonomy The principle of autonomy arises from the Kantian view of people as autonomous moral agents whose right to determine their destinies should always be respected. This view presumes that individuals are always capable of making independent choices. Health-care workers know this is not always the case. Children, comatose individuals, and some people with serious mental illness are incapable of making informed choices. In these instances, a representative of the individual is usually asked to intervene and give consent. However, health-care workers must ensure that respect for an individual's autonomy is not disregarded in favor of what another person may view as best for the client. \*\*\*\*\*\*\*\*\*\*\*\*\*Beneficence Beneficence refers to one's duty to benefit or promote the good of others. Health-care workers who act in their clients' interests are beneficent, provided their actions serve the individuals' best interests. In fact, some duties do take preference over other duties. For example, the duty to respect the autonomy of an individual may be overridden when that individual has been deemed harmful to self or others. "Doing good" for the patient should not be confused with "doing whatever the patient wants" (Indiana State Nurses Association \[ISNA\] Bulletin, 2013). Good care must include a holistic focus that considers the patient's beliefs, feelings, and wishes; the wishes of the family and significant others; and considerations about competent nursing care (Catalano, 2020). Despite these guidelines, it is not always clear which action is in the best interest of the client. When such dilemmas occur, nurses should reach out to available resources, such as an ethics committee or a supervisor, to build confidence that their decisions have explored various vantage points. Peplau (1991) recognized patient advocacy as an essential role for the psychiatric nurse. The term advocacy means acting in another's behalf as a supporter or defender. Being a patient advocate in psychiatric nursing means helping patients fulfill needs that, without assistance and because of their illness, may go unfulfilled. Individuals with mental illness are not always able to speak for themselves. Nurses serve in this manner to protect patients' rights and interests. Strategies include educating patients and their families about their legal rights, ensuring that patients have sufficient information to make informed decisions or to give informed consent, assisting patients to consider alternatives, and supporting them in the decisions they make. Additionally, nurses may act as advocates by speaking on behalf of individuals with mental illness to secure essential mental health services. \*\*\*\*\*\*\*\*\*\*\*\*Nonmaleficence Nonmaleficence is the requirement that health-care providers do no harm to their clients, either intentionally or unintentionally. Some philosophers suggest that this principle is more important than beneficence; that is, they support the notion that it is more important to avoid doing harm than it is to do good. In any event, ethical dilemmas arise when a conflict exists between an individual's rights and what is thought to best represent the welfare of the individual. An example of this conflict might occur when a psychiatric patient refuses antipsychotic medication (consistent with their rights), and the nurse must then decide how to maintain patient safety while psychotic symptoms continue. \*\*\*\*\*\*\*\*\*\*\*\*Justice The principle of justice has been referred to as the "justice as fairness" principle. It is sometimes called distributive justice, and its basic premise lies with the right of individuals to be treated equally and fairly regardless of race, gender, sexual orientation, marital status, medical diagnosis, social standing, economic level, or religious beliefs (Catalano, 2020). When applied to health care, the principle of justice suggests that all resources (including health-care services) ought to be distributed equally to all people. Thus, according to this principle, the vast disparity in the quality of care dispensed to the various socioeconomic classes within our society would be considered unjust. Retribution or restorative justice refers to the rules for responding when expectations for fairness are violated. Social justice assumes that rules for both distribution and rules for retribution should be fair and people should play by the rules (Maiese, 2017). It is important for nurses to recognize that in the latest revision of the Code of Ethics for Nurses (ANA, 2015), a new focus in one of the provisions states that nursing should integrate principles of social justice both in practice and in developing health policy. \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*Veracity The principle of veracity refers to one's duty to always be truthful. Catalano (2020) stated that veracity "requires the health-care provider to tell the truth and not intentionally deceive or mislead clients" (p. 128). There are times when limitations must be placed on this principle, such as when the truth would knowingly produce harm or interfere with the recovery process. Being honest is not always easy, but rarely is lying justified. Clients have the right to know about their diagnosis, treatment, and prognosis. \*\*\*\*\*\*\*\*\*\*\*\*A Model for Making Ethical Decisions The following steps may be used in making an ethical decision. These steps are consistent with the steps of the nursing process. 1.  Assessment: Gather the subjective and objective data about a situation. Consider personal values as well as values of others involved in the ethical dilemma. 2.  Problem identification: Identify the conflict between two or more alternative actions. 3.  Planning: a\. Explore the benefits and consequences of each alternative. b\. Consider principles of ethical theories. c\. Select an alternative. 4.  Implementation: Act on the decision made and communicate the decision to others. 5.  Evaluation: Evaluate outcomes. A schematic of this model is presented in Figure 5--1. A case study using this decision-making model is presented in Box 5--1. If the outcome is acceptable, action continues in the manner selected. If the outcome is unacceptable, benefits and consequences of the remaining alternatives are reexamined, and steps 3 through 7 in Box 5--1 are repeated. \*\*\*\*\*\*\*\*\*\*\*Ethical and Legal Issues in Psychiatric-Mental Health Nursing The Right to Treatment Anyone who is admitted to the hospital has the right to treatment. For example, a psychiatric patient cannot legally be hospitalized and then denied appropriate treatment. The American Hospital Association (AHA) has also identified the rights of hospitalized patients. The AHA patient bill of rights was originally written with an emphasis on protecting the patient from a breach of reasonable standards while hospitalized. These guidelines were revised in 2003 to create an emphasis on the importance of the collaborative relationship between the patient and the hospital health-care team. Titled The Patient Care Partnership, this document informs patients of their rights to high-quality care while hospitalized, to a clean and safe environment, to be involved in their own care, to have their privacy protected, to get help when leaving the hospital, and to get help with their billing claims (AHA, 2003). In 2010 federal law expanded patient rights to include insurability despite preexisting conditions. However, federal health-care law continues to be a debated issue and will no doubt continue to change depending on the prevailing political climate. Nurses practicing in hospital settings need to be aware of and adhere to legal statutes, accepted standards of practice, and organizational policies with regard to a patient's rights during hospital treatment. \*\*\*\*\*\*\*\*\*\*\*The Right to Refuse Treatment (Including Medication) Legally, patients have the right to refuse treatment unless immediate intervention is required to prevent death or serious harm to the patient or another person (Boland & Verduin, 2022). The U.S. Constitution and several of its amendments affirm this right (e.g., the First Amendment, which addresses the rights of speech, thought, and expression; the Eighth Amendment, which grants the right to freedom from cruel and unusual punishment; and the Fifth and Fourteenth Amendments, which grant due process of law and equal protection for all). In psychiatry, however, both ethical and legal issues must be considered. Sometimes patients are involuntarily hospitalized because they are at risk of harm to themselves or others and do not recognize the severity of their symptoms. To protect the patient's rights, specific legal criteria must be met to ensure that the involuntary hospitalization is justified. However, Saya and associates (2019) noted that the strictness of criteria for involuntarily hospitalization in the United States has made it harder to get treatment and has led to a criminalization of mental illness. Consequently, this population is detained in prisons in the United States more so than in any other country. \*\*\*\*\*\*\*\*\*\*\*\*\*The Right to the Least Restrictive Treatment Alternative The right to the least restrictive treatment alternative means that clients who can be adequately treated in an outpatient setting should not be hospitalized, and if they are hospitalized, they should not be sedated, restrained, or secluded unless less restrictive measures were unsuccessful. In other words, the client has a right to whatever level of treatment is effective and least restricts their freedom. The restrictiveness of psychiatric therapy can be described in the context of a continuum based on severity of illness. Clients may be treated on an outpatient basis, in day hospitals, or through voluntary or involuntary hospitalization. Symptoms may be treated with verbal rehabilitative techniques and move successively to behavioral techniques, chemical interventions, mechanical restraints, or electroconvulsive therapy. However, ethical issues arise in selecting the least restrictive means among involuntary chemical intervention, seclusion, and mechanical restraints. Boland and Verduin (2022) stated: Distinguishing among these interventions on the basis of restrictiveness proves to be a purely subjective exercise fraught with personal bias. Moreover, each of these three interventions is both more and less restrictive than each of the other two. Nevertheless, the effort should be made to think in terms of restrictiveness when deciding how to treat patients. (p. 841) Although the right to the least restrictive treatment may seem reasonable and expected, it is important to recognize that clients with mental illness have historically been hospitalized against their will simply because they had a mental illness. In the case of O'Connor v. Donaldson (1976), the Supreme Court ruled that harmless mentally ill individuals cannot be confined against their will if they are able to remain safe outside of a hospital setting. They must be considered dangerous to themselves or others or be so unable to care for themselves that their safety and survival are at risk. In 1981 the case of Roger v. Oken culminated in the ruling that all patients, even those involuntarily hospitalized, are competent to refuse treatment, but a legal guardian may authorize treatment (Boland & Verduin, 2022). These laws and policies have better attempted to protect the rights of clients with mental illness while still recognizing that, at times, an individual with acute mental illness may be unable to make decisions in the interest of their safety and survival. Ideally, it is hoped that a person recognizes their need for treatment and agrees voluntarily to be hospitalized if this measure is recommended by the health-care provider. The individual who is voluntarily hospitalized typically signs a consent to treatment upon admission, but it remains the person's right, as a voluntary patient, to revoke that consent and to be discharged from the hospital if they so choose. \*\*\*\*\*\*\*\*\*\*\*\*\*\*Legal Considerations The Patient Self-Determination Act, as part of the Omnibus Budget Reconciliation Act of 1990, went into effect on December 1, 1991. Cady (2010) stated: The Patient Self-determination Act requires healthcare facilities to provide clear written information for every patient concerning his/her legal rights to make healthcare decisions, including the right to accept or refuse treatment. (p. 118) \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*Nurse Practice Acts The legal parameters of professional and practical nursing are defined within each state by the state's nurse practice act. These documents are passed by the state legislature and are generally concerned with provisions such as the following:   The definition of important terms, including nursing itself and the various types of nurses   A statement of the education and other training or requirements for licensure and reciprocity   Broad statements that describe the scope of practice for various levels of nursing (advanced practice nurse \[APN\], registered nurse \[RN\], licensed practical nurse \[LPN\])   Conditions under which a nurse's license may be suspended or revoked and instructions for appeal   The general authority and powers of the state board of nursing Most nurse practice acts are general in their terminology and do not provide specific guidelines for practice. Nurses must understand the scope of practice protected by their license and should seek assistance from legal counsel if they are unsure about the proper interpretation of a nurse practice act. \*\*\*\*\*\*\*\*\*\*\*\*\*A person admitted to a program or facility for the purpose of receiving mental health services should be accorded the following: 1\. The right to appropriate treatment and related services in a setting and under conditions that are the most supportive of such person's personal liability and that restrict such liberty only to the extent necessary consistent with such person's treatment needs, applicable requirements of law, and applicable judicial orders. 2\. The right to an individualized, written treatment or service plan (such plan to be developed promptly after admission of such person), the right to treatment based on such plan, the right to periodic review and reassessment of treatment and related service needs, and the right to appropriate revision of such plan, including any revision necessary to provide a description of mental health services that may be needed after such person is discharged from such program or facility. 3\. The right to ongoing participation, in a manner appropriate to a person's capabilities, in the planning of mental health services to be provided (including the right to participate in the development and periodic revision of the plan). 4\. The right to be provided, in terms and language appropriate to a person's condition and ability to understand, a reasonable explanation of the person's general mental and physical (if appropriate) condition, the objectives of treatment, the nature and significant possible adverse effects of recommended treatment, the reasons a particular treatment is considered appropriate, the reasons access to certain visitors may not be appropriate, and any appropriate and available alternative treatments, services, and types of providers of mental health services. 5\. The right not to receive a mode or course of treatment in the absence of informed, voluntary, written consent to treatment except during an emergency situation or as permitted by law when the person is being treated as a result of a court order. 6\. The right not to participate in experimentation in the absence of informed, voluntary, written consent (includes human subject protection). 7\. The right to freedom from restraint or seclusion, other than as a mode or course of treatment or restraint or seclusion during an emergency situation with a written order by a responsible mental health professional. 8\. The right to a humane treatment environment that affords reasonable protection from harm and appropriate privacy with regard to personal needs. 9\. The right to access, on request, to such person's mental health-care records. 10\. The right, in the case of a person admitted on a residential or inpatient care basis, to converse with others privately, to have convenient and reasonable access to the telephone and mail, and to see visitors during regularly scheduled hours. (For treatment purposes, specific individuals may be excluded.) 11\. The right to be informed promptly and in writing at the time of admission of these rights. 12\. The right to assert grievances with respect to infringement of these rights. 13\. The right to exercise these rights without reprisal. 14\. The right of referral to other providers upon discharge. Adapted from the U.S. Code, Title 42, Section 10841, The Public Health and Welfare, 1991. \*\*\*\*\*\*\*\*\*Types of Law The two general categories of law that are of most concern to nurses are statutory law and common law. These laws are identified by their source or origin. \*\*\*\*\*\*\*\*\*Statutory Law A statutory law is a law that has been enacted by a legislative body, such as a county or city council, state legislature, or the U.S. Congress. An example of statutory law is a nurse practice act. \*\*\*\*\*\*\*\*\*\*\*Common Law A common law is derived from decisions made in previous cases. These laws apply to a body of principles that evolve from court decisions resolving various controversies. Because common law in the United States has been developed by individual states, the law on specific subjects may differ from state to state. An example of a common law might be how different states deal with a nurse's refusal to provide care for a specific client. \*\*\*\*\*\*\*\*\*\*\*Classifications Within Statutory and Common Law Broadly speaking, there are two kinds of unlawful acts: civil and criminal. Both statutory law and common law have civil and criminal components. Civil Law Civil law protects the private and property rights of individuals and businesses. Private individuals or groups may bring a legal action to court for breach of civil law. These legal actions are of two basic types: torts and contracts. \*\*\*\*\*\*\*\*\*Torts A tort is a violation of a civil law in which an individual has been wronged. In a tort action, one party asserts that wrongful conduct on the part of the other has caused harm and seeks compensation. A tort may be intentional or unintentional. Examples of unintentional torts are malpractice and negligence actions. An example of an intentional tort is the touching of another person without that person's consent. Intentional touching (e.g., a medical treatment) without the client's consent can result in a charge of battery, an intentional tort. \*\*\*\*\*\*\*\*\*\*\*Contracts In a contract action, one party asserts that the other party, in failing to fulfill an obligation, has breached the contract, and either compensation or performance of the obligation is sought as remedy. An example is an action by a mental health professional whose clinical privileges have been reduced or terminated in violation of an implied contract between the professional and a hospital. \*\*\*\*\*\*\*\*\*\*\*\*\*\*Criminal Law Criminal law provides protection from conduct deemed injurious to the public welfare. It provides for punishment of those found to have engaged in such conduct, which can range from community service and fines to imprisonment and death depending on the scope of the crime (Aiken, 2020). An example of a violation of criminal law is the theft of supplies or drugs by a hospital employee. Catalano (2020) noted, "The most common violation by nurses of the criminal law is failure to renew nursing licenses. In this situation, the nurse is practicing nursing without a license, which is a crime in all states" (p. 184). He adds that recent cases of intentional or unintentional death of clients and assisted suicide have also led to criminal charges against nurses. \*\*\*\*\*\*\*\*\*\*\*Legal Issues in Psychiatric-Mental Health Nursing Confidentiality and Right to Privacy The Fourth, Fifth, and Fourteenth Amendments to the U.S. Constitution protect an individual's right to privacy. Most states have statutes protecting the confidentiality of client records and communications. Nurses must recognize that the only individuals who have a right to observe a client or have access to medical information are those involved in the client's medical care. The client must provide written consent for health-care information to be shared with anyone outside the current treatment team. \*\*\*\*\*\*\*\*\*\*\*\*\*Health Insurance Portability and Accountability Act (HIPAA) Until 1996 client confidentiality in medical records was not protected by federal law. In August 1996 President Clinton signed the Health Insurance Portability and Accountability Act (HIPAA) into law. This federal privacy rule pertains to data that is called protected health information (PHI) and applies to most individuals and institutions involved in health care. PHI is defined as individually identifiable health information indicators that "relate to past, present, or future physical or mental health or condition of the individual, or the past, present, or future payment for the provision of health care to an individual and (1) that identifies the individual; or (2) with respect to which there is a reasonable basis to believe the information can be used to identify the individual" (U.S. Department of Health and Human Services, 2003). These specific identifiers are listed in Box 5--3. Under HIPAA, individuals have the rights to access their medical records, have corrections made to their medical records, and decide with whom their medical information may be shared. The actual document belongs to the facility or the therapist, but the information contained therein belongs to the client. The passage of HIPAA increased the level of control clients have over the information maintained in their medical records. Notice of privacy policies must be provided to clients upon entry into the health-care system. In 2013 HIPAA privacy and security rules were again expanded to afford more rights to patients concerning their medical information and to ensure greater security of a person's health information. For example, when patients are paying out of pocket for their care, they can tell a provider that they do not want treatment information shared with their health insurance plan (U.S. Department of Health & Human Services, 2013). Nurses in any practice setting need to be aware of HIPAA laws and any new legal provisions that will affect the conduct of their practice. Pertinent medical information may be released without consent in a life-threatening situation. If information is released in an emergency, the following information must be recorded in the client's record: date of disclosure, person to whom information was disclosed, reason for disclosure, reason written consent could not be obtained, and the specific information disclosed. Most states have statutes that pertain to the doctrine of privileged communication. Although the codes differ markedly from state to state, most grant certain professionals privileges under which they may refuse to reveal information about and communications with clients. In most states, the doctrine of privileged communication applies to psychiatrists and attorneys; in some instances, psychologists, clergy, and nurses are also included. In certain instances, nurses may be called on to testify in cases in which the medical record is used as evidence. In most states, the right to privacy of these records is exempted in civil or criminal proceedings. Therefore, it is important that nurses document with these possibilities in mind. Strict record-keeping using objective and nonjudgmental statements, care plans that are specific in their prescriptive interventions, and documentation that describes those interventions and their subsequent evaluation all serve the best interests of the client, the nurse, and the institution, should questions regarding care arise. Documentation often weighs heavily in malpractice case decisions. The right to confidentiality is a basic one, especially in psychiatry. Although societal attitudes are improving, individuals have experienced discrimination in the past for no other reason than having a history of mental illness. Nurses working in psychiatric-mental health nursing must guard the privacy of their patients with great diligence. \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*Exception: A Duty to Warn (Protection of a Third Party) There are exceptions to the laws of privacy and confidentiality. One of these exceptions stems from the 1974 case of Tarasoff v. Regents of the University of California. The incident from which this case evolved occurred in the late 1960s. A young man from Bengal, India (Mr. P.), who was a graduate student at the University of California (UC), Berkeley, fell in love with another university student (Ms. Tarasoff). Because she was not interested in an exclusive relationship with Mr. P., he became resentful and angry. He began to stalk her and record some of their conversations in an effort to determine why she did not love him. He soon became very depressed and neglected his health, appearance, and studies. Ms. Tarasoff spent the summer of 1969 in South America. During this time, Mr. P. entered therapy with a psychologist at UC. He confided in the psychologist that he intended to kill his former girlfriend (identifying Ms. Tarasoff by name) when she returned from vacation. The psychologist recommended civil commitment for Mr. P. and claimed that he had a diagnosis of acute and severe paranoid schizophrenia. Mr. P. was picked up by the campus police but released a short time later because he appeared rational and promised to stay away from Ms. Tarasoff. Neither Ms. Tarasoff nor her parents received any warning of Mr. P.'s stated intention to kill her. When Ms. Tarasoff returned to campus in October 1969, Mr. P. resumed his stalking behavior and eventually stabbed her to death. Ms. Tarasoff's parents sued the psychologist, several psychiatrists, and the university for failure to warn the family of the danger. The case was referred to the California Supreme Court, which ruled that a mental health professional has a duty not only to a client but also to individuals who are being threatened by that client. The Court stated: Once a therapist does in fact determine, or under applicable professional standards should have determined, that a patient poses a serious danger of violence to others, he bears a duty to exercise reasonable care to protect the foreseeable victim of that danger. Although the discharge of this duty of due care will necessarily vary with the facts of each case, in each instance the adequacy of the therapist's conduct must be measured against the traditional negligence standard of reasonable care under the circumstances. (Tarasoff v. Regents of University of California, 1974a) The defendants argued that warning the woman or her family would have breached professional ethics and violated the client's right to privacy. But the court ruled that "the confidential character of patient-psychotherapist communications must yield to the extent that disclosure is essential to avert danger to others. The protective privilege ends where the public peril begins" (Tarasoff v. Regents of University of California, 1974b). In 1976 the California Supreme Court expanded the original case ruling (now referred to as Tarasoff I). The second ruling (known as Tarasoff II) broadened the ruling of "duty to warn" to include "duty to protect." It stated that under certain circumstances, a therapist might be required to warn an individual, notify police, or take whatever steps are necessary to protect the intended victim from harm. This duty to protect can also apply to health-care providers who are required to protect patients who are vulnerable due to their inability to identify harmful situations (Guido, 2014). The Tarasoff rulings created a great deal of controversy in the psychiatric community regarding breach of confidentiality and the subsequent negative effect on the client-therapist relationship. However, most states now recognize that therapists have ethical and legal obligations to prevent their clients from harming themselves or others. Many states have passed their own variations on the original "protect and warn" legislation, but in most cases, courts have outlined the following guidelines for therapists to follow in determining their obligation to take protective measures: 1.  Assessment of a threat of violence by a client toward another individual 2.  Identification of the intended victim 3.  Ability to intervene in a feasible, meaningful way to protect the intended victim When these guidelines apply to a specific situation, it is reasonable for the therapist to notify the victim, law enforcement authorities, or relatives of the intended victim. They may also consider initiating voluntary or involuntary commitment of the client to prevent potential violence. \*\*\*\*\*\*\*\*\*\*\*\*\*Implications for Nursing Although the original decision in the Tarasoff ruling was directed toward psychotherapists, it has since been more broadly applied. Not all states identify RNs as having a duty to warn, but other statutes include a duty to warn for nurses at all levels, from LPNs to APNs. Four states currently have no duty to warn (Cottone, 2021). In 2018 New Jersey expanded its "duty to warn" law to require mental health professionals to notify local authorities whenever patients threaten harm to themselves or others (Sitrin, 2018). Although intended to promote greater gun safety by removing guns from people who are at risk of harming themselves or others with firearms, the law has far broader implications both professionally and politically. Even in states that do not recognize a duty to warn, practitioners still must decide about warning a potential victim and others. Every nurse, not just those practicing in psychiatric nursing, should be informed about the laws in their state regarding duty to warn. As Henderson (2015) noted, emergency nurses are often the front-line health-care workers and thus are in a position to identify persons at risk for violence and to protect the safety of the patient and others. In psychiatric-mental health nursing practice, if a client confides in the nurse about the potential for harm to an intended victim, it is the nurse's duty to report this information to the psychiatrist and to other team members. Reporting this information is not a breach of confidentiality. In such situations, the nurse may be considered negligent for failure to report. All members of the treatment team must be made aware of the potential danger that the client poses to self or others. Detailed written documentation of the situation is also required. \*\*\*\*\*\*\*\*\*\*\*\*Exception: Suspected Child or Elder Abuse The Federal Child Abuse Prevention and Treatment Act (CAPTA) requires each state to have provisions or procedures for requiring certain individuals to report known or suspected instances of child abuse and neglect (Child Welfare Information Gateway, 2019a). Many jurisdictions also have statutes requiring that suspected elder abuse or neglect be reported. At times, health-care professionals are worried that they may be liable for false allegations and therefore may be reluctant to report, but reporting statutes generally grant immunity to anyone making a good faith report about a reasonable suspicion. In fact, nearly every state and U.S. territory imposes penalties, from imposing fines to possible imprisonment, for mandatory reporters who fail to report suspected child abuse or neglect as required by law; in some jurisdictions, failure to report is identified as a felony (Child Welfare Information Gateway, 2019b). \*\*\*\*\*\*\*\*\*\*\*\*\*Implications for Nursing There is often an element of clinical judgment about whether a patient's communication raises a reasonable suspicion of abuse. For example, when a person is experiencing hallucinations or delusions, their perception about events may be distorted. The nurse has a responsibility to explore all patient perceptions of abuse or mistreatment and discuss these with other health-care team members to identify the most appropriate decision with consideration of all legal, ethical, and clinical factors. \*\*\*\*\*\*\*\*\*\*\*\*\*\*Informed Consent According to law, all individuals have the right to decide whether to accept or reject medical treatment. A health-care provider can be charged with assault and battery for providing life-sustaining treatment to a patient when the patient has not agreed to the treatment. The rationale for the doctrine of informed consent is the preservation and protection of individual autonomy in determining what will and will not happen to a person's body (Guido, 2014). Informed consent is permission granted by a patient to a physician to perform a therapeutic procedure. Before the procedure, the patient is presented with written information about the treatment and given adequate time to consider the benefits and risks of the procedure. Information should include treatment alternatives; why the physician believes this treatment is most appropriate; the possible outcomes, risks, and adverse effects; the possible outcome should the patient select another treatment alternative; and the possible outcome should the patient choose to decline all treatment. An example of a psychiatric treatment that requires informed consent is electroconvulsive therapy. Under some conditions, treatment may be performed without obtaining informed consent from the patient. A patient's refusal to accept treatment may be challenged under the following circumstances (Guido, 2014): 1.  When a patient is mentally incompetent to make a decision and treatment is necessary to preserve life or avoid serious harm 2.  When refusing treatment endangers the life or health of another 3.  During an emergency in which a patient is in no condition to exercise judgment 4.  When the patient is a child (consent is obtained from parent or surrogate) 5.  In the case of therapeutic privilege, information about a treatment may be withheld if the physician can show that full disclosure would a\. hinder or complicate necessary treatment, b\. cause severe psychological harm, or c\. be so upsetting as to render a rational decision by the patient impossible. Although most patients in psychiatric-mental health facilities are competent and capable of giving informed consent, those with severe psychiatric illness may not possess the cognitive ability to do so. If an individual has been legally determined to be mentally incompetent, consent is obtained from the legal guardian. Difficulty arises when no legal determination has been made, but the individual's current mental state prohibits informed decision making (e.g., a person who is psychotic, unconscious, or inebriated). In these instances, informed consent is usually obtained from the individual's nearest relative, or if none exist and time permits, the physician may ask the court to appoint a conservator or guardian. When time does not permit court intervention, permission may be sought from the hospital administrator. A patient or guardian always has the right to withdraw consent after it has been given. When this occurs, the physician should inform (or reinform) the patient about the consequences of refusing treatment. If treatment has already been initiated, the physician should terminate treatment in a way least likely to cause injury to the patient and inform the patient or guardian of the risks associated with interrupted treatment (Guido, 2014). The staff nurse's role in obtaining informed consent is usually defined by agency policy. A nurse may sign the consent form as a witness for the patient's signature. However, legal liability for informed consent lies with the physician. The nurse acts as a patient advocate, ensuring that the following three major elements of informed consent have been addressed: 1.  Knowledge: The patient has received adequate information on which to base their decision. 2.  Competency: The patient's cognition is not impaired to an extent that would interfere with decision making, or they have a legal representative. 3.  Free will: The patient has given consent voluntarily without pressure or coercion from others. \*\*\*\*\*\*\*\*\*\*\*Restraints and Seclusion An individual's privacy and personal security are protected by the Patient Self-Determination Act of 1991. This legislation includes a set of patient rights, including an individual's right to freedom from restraint or seclusion except in an emergency. The use of seclusion and restraint as therapeutic interventions for psychiatric patients is controversial, and many efforts have been made through federal and state regulations and through standards set forth by accrediting bodies to minimize or eliminate their use. In addition, there is an element of moral decision making when any kind of treatment is coerced, as is often the case with seclusion and restraint. Landeweer and associates (2011) pointed out that although coercion may sometimes be necessary, it can be detrimental to the patient, as it may produce trauma and mistrust. One advantage of using a forum such as a hospital-based ethics committee to guide moral decision making is that by exploring issues such as the use of seclusion and restraint with a diverse group of people who have different vantage points, alternative treatments can be identified and explored. Because injuries and deaths have been associated with restraint and seclusion, this treatment requires careful attention whenever it is deemed necessary. Further, because laws, regulations, accreditation standards, and hospital policies are frequently revised, anyone practicing in inpatient psychiatric settings must remain well informed in each of these areas. In psychiatry, the term restraints generally refers to a set of leather straps used to restrain the extremities of an individual whose behavior poses an immediate risk to the physical safety and psychological well-being of themselves and others. It is important to note that the currently accepted definition of restraint refers not only to leather restraints but also to any manual method or medication used to restrict a person's freedom of movement. Restraints are never to be used as punishment or for the convenience of staff. Other measures to decrease agitation, such as "talking down" (verbal intervention) and chemical restraints (tranquilizing medication), are usually tried first. If these interventions are ineffective, mechanical restraints may be instituted (although some controversy exists as to whether chemical restraints are indeed less restrictive than mechanical restraints). Seclusion is another type of physical restraint in which the client is confined alone in a room from which they are unable to leave. The room is usually minimally furnished with items to promote the client's comfort and safety. Because seclusion and restraint are both considered high-risk interventions, institutions, health-care accrediting bodies (such as The Joint Commission), and state mental health departments define specific expectations for their use. These standards typically include requirements for staff training and competency in the use of seclusion or restraint; expectations that these interventions will be used only as a last resort and for the shortest amount of time necessary; and what kinds of assessment and intervention are required before, during, and after the individual is secluded or restrained. The laws, regulations, accreditation standards, and hospital policies related to restraint and seclusion share a common priority of maintaining patient safety for a procedure that has the potential to incur injury or death. The importance of close and careful monitoring cannot be overstated. False imprisonment is the deliberate and unauthorized confinement of a competent person with the intent to prevent them from leaving the hospital; this includes use of threats or medications that interfere with the patient's ability to leave the facility (Aiken, 2020). Health-care workers may be charged with false imprisonment for restraining or secluding---against the wishes of the client---anyone admitted to the hospital voluntarily. Should a voluntarily admitted client decompensate to a level that restraint or seclusion for protection of self or others is necessary, court intervention to determine competency and involuntary commitment is required to preserve the client's rights to privacy and freedom. \*\*\*\*\*\*\*\*\*\*\*Hospitalization Voluntary Admissions Although the vast majority of mental health services are provided on a voluntary basis (Substance Abuse and Mental Health Services Administration \[SAMHSA\], 2019), much of voluntary treatment occurs in settings other than inpatient hospitalization. This has been influenced by the availability of a greater number of outpatient treatment options including partial hospitalization, intensive outpatient programs, and other specialized treatment programs. To be admitted voluntarily, an individual makes direct application to the institution for services and may stay as long as treatment is deemed necessary. The person may sign out of the hospital at any time unless the health-care professional determines that they may be harmful to self or others after a mental status examination and recommends that admission status be changed from voluntary to involuntary. Even when admission is considered voluntary, it is important to ensure that the individual comprehends the meaning of their actions, has not been coerced in any manner, and is willing to proceed with admission. \*\*\*\*\*\*\*\*\*\*\*\*\*\*Involuntary Commitment Although the term involuntary hospitalization is preferred by some over the term involuntary commitment or civil commitment, this process needs to be conducted with respect to state and federal law. Because involuntary hospitalization results in substantial restrictions of the rights of an individual, the admission process is subject to the guarantee of the Fourteenth Amendment to the U.S. Constitution that provides citizens protection against loss of liberty and ensures due process rights. Involuntary hospitalizations may be made for various reasons. Most states commonly cite the following criteria:   The person is imminently dangerous to themselves (i.e., suicidal intent).   The person is a danger to others (i.e., physically aggressive, violent, or homicidal).   The person is unable to take care of basic personal needs (the "gravely disabled"). Under the Fourth Amendment, individuals are protected from unlawful searches and seizures without probable cause. Therefore the person recommending involuntary hospitalization must show probable cause why the client should be hospitalized against their wishes; that is, the person must show that there is cause to believe that the client would be dangerous to self or others, is mentally ill and in need of treatment, or is gravely disabled. \*\*\*\*\*\*\*\*\*\*\*\*\*Emergency Commitments Emergency commitments are sought when an individual manifests behavior that is clearly and imminently dangerous to self or others. These admissions are usually instigated by relatives or friends of the individual or by police officers, the court, or health-care professionals. Emergency commitments are time-limited, and a court hearing for the individual is scheduled, usually within 72 hours. At that time, the court may decide that the individual may be discharged or, if deemed necessary and voluntary admission is refused by the person, an additional period of involuntary hospitalization may be ordered. In most instances, another hearing is scheduled for a specified time (usually in 7 to 21 days). \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*The Mentally Ill Person in Need of Treatment A second type of involuntary commitment is for the observation and treatment of mentally ill people in need of treatment. These commitments typically last longer than emergency commitments. Most states have established definitions of what constitutes "mentally ill" for purposes of state involuntary admission statutes. Some examples include individuals who, because of severe mental illness, are   Unable to make informed decisions concerning treatment   Likely to cause harm to self or others   Unable to fulfill basic personal needs necessary for health and safety In determining whether commitment is required, the court looks for substantial evidence of abnormal conduct---evidence that cannot be explained by a physical cause. There must be "clear and convincing evidence" as well as probable cause to substantiate the need for involuntary hospitalization to ensure that an individual's constitutional rights are protected. As mentioned earlier, the U.S. Supreme Court, in O'Connor v. Donaldson, held that the existence of mental illness alone does not justify involuntary hospitalization. State standards require a specific effect or consequence caused by mental illness that involves danger or an inability to care for one's own needs. These individuals are entitled to court hearings with representation, at which time determination of commitment and length of stay are considered. Legislative statutes governing involuntary commitments vary among states. \*\*\*\*\*\*\*\*\*\*\*\*Involuntary Outpatient Commitment Involuntary outpatient commitment (IOC) is a court-ordered mechanism used to compel a person with mental illness to submit to treatment on an outpatient basis. As these laws have evolved, they have taken a more "preventive approach." In this scenario a person with mental illness who is not currently dangerous, and therefore not legally committable to a hospital, could be ordered to community treatment on the basis of a complex clinical assessment and prediction about the future. Examples of eligibility criteria (SAMHSA, 2019) include those outlined in North Carolina's state statutes:   The person must have a mental illness.   The person is capable of surviving safely in the community with available supervision from family, friends, or others.   Based on the person's psychiatric history, the person is in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness.   The person's current mental status or the nature of their illness limits or negates their ability to make an informed decision to seek voluntary admission or comply with recommended treatment. Most states have already enacted IOC legislation or currently have agenda resolutions that pertain to this topic. Most commonly, clients who are committed into the IOC programs are those with severe and persistent mental illness such as schizophrenia. The rationale behind the legislation is to improve preventive care and reduce the number of readmissions and lengths of hospital stays for these clients. The need for this type of legislation arose after it was recognized that patients with schizophrenia who did not meet criteria for involuntary hospital treatment were, in some cases, ultimately dangerous to themselves or others. In New York, public attention to this need arose after a man with schizophrenia who had stopped taking his medication pushed a young woman into the path of a subway train. He would not have met the criteria for involuntary hospitalization until he was deemed dangerous to others, but advocates for this legislation argued that there should be provisions to prevent violence rather than waiting until it happens. The subsequent law governing IOC in New York became known as Kendra's law for the woman who was pushed to her death. Opponents of this legislation fear that it may violate the individual rights of psychiatric clients without significant improvement in outcomes. Although many states have enacted similar laws, New York's Kendra's law adds a stricter stipulation that the person must have been hospitalized at least twice within the prior 3 years as a result of noncompliance with treatment, or have committed, attempted, or threatened an act of violence or self-harm within the prior 2 years, and they would benefit from this type of treatment. Research has attempted to evaluate whether IOC improves care, reduces lengths of stay in the hospital, and reduces episodes of violence. Some studies have shown positive outcomes with IOC, including a decrease in hospital readmissions (Swartz et al., 2017; Swartz & Swanson, 2008). However, a Cochrane literature review (Kisely et al., 2017) concluded that compulsory community treatment resulted in no significant differences in service use, social functioning, mental state, or quality of life, although those in mandated outpatient treatment were less likely to be victims of crimes. The issues around whether IOC will improve treatment compliance and enhance quality of life in the community for individuals with severe and persistent mental illness will continue to be a focus of study and debate. \*\*\*\*\*\*\*\*\*\*\*The Gravely Disabled Client Many states have statutes that specifically define the "gravely disabled" individual. For those that do not use this label, the description of the individual who is unable to take care of basic personal needs because of mental illness is very similar. Gravely disabled is generally defined as a condition in which an individual, as a result of mental illness, is in danger of serious physical harm resulting from an inability to provide for basic needs such as food, clothing, shelter, medical care, and personal safety. Inability to care for oneself cannot be established by showing that an individual lacks the resources to provide the necessities of life; rather, it is the inability to make use of available resources. Should it be determined that an individual is gravely disabled, a guardian, conservator, or committee will be appointed by the court to ensure the management of the person and their estate. Legal restoration of competency requires another court hearing to reverse the previous ruling. The individual whose competency is being determined has the right to be represented by an attorney. It is an ethical and legal duty to ensure that whenever coercive treatments are used, including involuntary hospitalizations, seclusion and restraint, IOCs, mandated medication, and even prison commitments, the least restrictive intervention must first be considered. Sashadahran and Saraceno (2017) identified a current global shift toward more coercive care similar to that which existed before the community mental health movement. They cite increasing numbers of involuntary hospitalizations and note that in the United States there are currently three times as many individuals with mental illness in prisons as there are in hospitals. In addition, sexual predator laws in the United States allow indefinite hospital stays for serious sex offenders beyond their prison sentence completion. The authors posit that when risk management supersedes the most appropriate level of care for treatment, stigmatization of this population may increase (Sashadahran & Saraceno, 2017). \*\*\*\*\*\*\*\*\*\*\*\*\*Nursing Liability Mental health practitioners---psychiatrists, psychologists, psychiatric nurses, and social workers---have a duty to provide appropriate care based on the standards of their professions and the standards set by law. The standards of care for psychiatric-mental health nursing are presented in Chapter 8, "The Nursing Process in Psychiatric-Mental Health Nursing." \*\*\*\*\*\*\*\*\*\*\*\*\*Malpractice and Negligence The terms malpractice and negligence are often used interchangeably. Negligence has been defined as failure to exercise the care toward others that a reasonable or prudent person would do in the circumstances or taking action that a reasonable person would not. Negligence is accidental as distinguished from "intentional torts" (assault or trespass, for example) or from crimes, but a crime can also constitute negligence, such as reckless driving (Hill & Hill, 2022). Any person may be negligent. In contrast, malpractice is a specialized form of negligence caused only by professionals. Malpractice may be defined as an act or continuing conduct of a professional that does not meet the standard of professional competence and results in provable damages to their patient. Such an error or omission may be through negligence, ignorance (when the professional should have known), or intentional wrongdoing (Hill & Hill, 2022). In the absence of state statutes, common law is the basis of liability for injuries to patients caused by acts of malpractice and negligence by individual practitioners. In other words, most decisions of negligence in the professional setting are based on legal precedent (decisions that have been made previously about similar cases) rather than on any specific action taken by the legislature. To summarize, when a breach of duty is characterized as malpractice, the action is weighed against the professional standard. When it is brought forth as negligence, the action is contrasted with what a reasonably prudent professional would have done in the same or similar circumstances. Austin (2011) cited the following basic elements of a nursing malpractice lawsuit: 1.  A duty to the patient existed, based on the recognized standard of care. 2.  A breach of duty occurred, meaning that the care rendered was not consistent with the recognized standard of care. 3.  The patient was injured. 4.  The injury was directly caused by the breach of a standard of care. For the client to prevail in a malpractice claim, each of these elements must be proven. Jury decisions are generally based on the testimony of expert witnesses because members of the jury are laypeople who cannot be expected to know what nursing interventions should have taken place. Without the testimony of expert witnesses, a favorable verdict usually goes to the defendant nurse. \*\*\*\*\*\*\*\*\*\*\*\*Types of Lawsuits That Occur in Psychiatric Nursing Most malpractice suits against nurses are civil actions, which means they are considered breach of conduct actions on the part of the professional from whom compensation is sought. The nurse in a psychiatric setting should be aware of the types of behavior that may result in malpractice charges. The hospitalized psychiatric patient has a basic right to confidentiality and privacy. A nurse may be charged with breach of confidentiality for revealing aspects about a patient's case or even for revealing that an individual has been hospitalized if the patient can show that making this information known resulted in harm. When shared information is detrimental to the client's or patient's reputation, the person sharing the information may be liable for defamation of character. When the information is in writing, the action is called libel. Oral defamation is called slander. Defamation of character involves communication that is malicious and false (Aiken, 2020). Occasionally, libel arises out of critical, judgmental statements written in a person's medical record. Nurses need to be very objective in their charting, backing up all statements with factual evidence. Invasion of privacy is a charge that may result when an individual is searched without probable cause. Many institutions conduct body searches on patients with mental illness as a routine intervention. In these cases, there should be a physician's order and written rationale showing probable cause for the intervention. Many institutions are re-examining their policies regarding this procedure. Assault is an act that results in a person's genuine fear and apprehension that they will be touched without consent. Battery is the nonconsensual touching of another person. These charges can result when a treatment is administered to an individual against their wishes and outside of an emergency situation. Harm or injury need not have occurred for these charges to be legitimate. For confining a patient against their wishes outside of an emergency situation, the nurse may be charged with false imprisonment. Examples of actions that may invoke these charges include locking an individual in a room, taking a person's clothes for purposes of detainment against their will, and restraining a competent voluntary individual who demands to be released. \*\*\*\*\*\*\*\*\*\*\*\*\*Avoiding Liability Aiken (2020) suggested the following proactive nursing actions to avoid nursing malpractice and the risk of lawsuits: 1.  Effective communication with patients and other caregivers. The SBAR (situation, background, assessment, and recommendations) model of reporting information has been identified as a useful tool for effective communication with caregivers. Establishing rapport with patients encourages open and honest communication. 2.  Accurate and complete documentation in the medical record. The electronic health record (EHR) has been identified as the best way to document and share this information. The use of best informatics sources is identified as an essential nursing competency in the Quality and Safety Education for Nurses standards (QSEN Institute, 2013). 3.  Complying with standards of care, including those established within the profession (such as ANA standards) and those identified by specific hospital policies. 4.  Rapport with and knowledge of the patient, which includes helping the patient become involved in their care as well as understanding and responding to aspects of care in which the patient is dissatisfied. 5.  Practicing within the nurse's level of competence and scope of practice, which includes not only adhering to professional standards (those of the ANA and state boards of nursing) but also keeping knowledge and nursing skills current through evidence-based literature, in-services, and continuing education. Some patients appear to be more "suit prone" than others. Suit-prone patients are often very critical, complaining, uncooperative, and even hostile. A natural staff response to these patients is to become defensive or withdrawn. Aiken (2020) recommended instead that it is important to be direct and engage the patient in problem-solving. No matter how high the nurse's technical competence and skill, their insensitivity to a patient's complaints and failure to meet the patent's emotional needs often influence whether or not a lawsuit is generated. A great deal depends on the psychosocial skills of the health-care professional.