NURS2930 Week 2 Slides PDF

Chapter 7 & 8 Ethical Responsibilities, Legal Obligations & Cultural Considerations for Psychiatric Mental Health Nursing Practice Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.  Plan Part 1: Ethical Responsibilities & Legal Obligatio...

Chapter 7 & 8 Ethical Responsibilities, Legal Obligations & Cultural Considerations for Psychiatric Mental Health Nursing Practice Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.  Plan Part 1: Ethical Responsibilities & Legal Obligations Part 2: Culture, Race, Ethnicity, and the Social Determinants of Health Copyright © 2014 Elsevier Canada, a division of Reed El 2 sevier Canada, Ltd. All rights reserved.  CNO Practice Standards ETHICS: Each nurse understands, upholds and promotes the values and beliefs described in CNO’s Ethics Practice Standard. RELATIONSHIPS – THERAPEUTIC & PROFESSIONAL: Each nurse establishes and maintains respectful, collaborative, therapeutic and professional relationships Copyright © 2014 Elsevier Canada, a division of Reed El 3 sevier Canada, Ltd. All rights reserved. Copyright © 2014 Elsevier Canada, a division of Reed El 4 sevier Canada, Ltd. All rights reserved.  Ethical Concepts Ethics: The expression of values that guide practice Deontology: System of ethics with the central concepts of reason and duty Bioethics: Used in relation to balancing fundamental ethical principles in clinical situations Copyright © 2019 Elsevier Canada, a division of Reed 5 Elsevier Canada, Ltd.  Six Principles of Bioethics Match the term to the definition A. Maintaining loyalty and 1. Autonomy commitment B. The duty to distribute resources 2. Nonmaleficence or care equally 3. Beneficence C. Respecting the rights of others to make their own decisions 4. Justice D. Doing no wrong to a patient 5. Principle of E. That rights or obligations that impossibility cannot be met in the circumstances are no longer obligations 6. Fidelity Copyright © 2019 Elsevier Canada, a division of Reed F. The duty to promote good 6 Elsevier Canada, Ltd. Consequentialist Ethical Theory Based on the belief that every person in society has the right to be happy We have an obligation to make sure happiness results from our actions Bringing about the greatest good with the least harm for the greatest number of people (utilitarianism) Also called thehe principle of utility Copyright © 2014 Elsevier Canada, a division of Reed El 7 sevier Canada, Ltd. All rights reserved. Virtue Ethics Aristotle- virtuous people would make decisions that would maximize their own & others’ well-being Good people will make good decisions Virtues are attitudes, dispositions, or character traits (e.g. honesty, courage, compassion, generosity, fidelity, integrity, fairness, self-control) Most valued virtues in healthcare are compassion & care Virtues, fostered through learning, practice, & self- discipline, enable us to use these attitudes & traits to guide decisions Copyright © 2014 Elsevier Canada, a division of Reed El 8 sevier Canada, Ltd. All rights reserved.  Relational Ethics Relational Ethics: developing ethical theory that requires nurses to appreciate the context in which an ethical issue arises Mutual respect Engagement Embodied knowledge Interdependent environment Uncertainty and vulnerability Therapeutic Nurse-Client relationship is a key element of the nursing process 9 Therapeutic Nurse-Client Relationship 5 components of a nurse-client relationship: trust, respect, professional intimacy, empathy and power Trust – connection; integral to care Respect – recognising the dignity, worth and uniqueness of every individual, regardless of socio-economic status, personal attributes and the nature of the health problem Professional intimacy - physical activities or non-physical that creates closeness, such as bathing or access to the client’s personal information Empathy - expression of understanding, validating and resonating with the client Power – professional and positional power over patients 10  Ethical Dilemma Occurs when a choice must be made between two mutually exclusive courses of action, each of which has favourable & unfavourable consequences How we respond is based partly on our own morals (beliefs of right & wrong) and values Whenever one’s own value system is challenged, increased stress results Moral distress- nurses know, or believe they know, the right thing to do, but for various reasons, can’t or won’t take the right action Moral uncertainty- when a nurse feels indecision or a lack of clarity, or doesn’t even know what the moral problem is, but feels uneasy & uncomfortable Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. All rights reserved. 11 Ethical Dilemmas in Mental Health Ethical dilemma: a situation in which ethical principles conflict or there is no one clear course of action Many dilemmas in mental health involve the client’s right to self-determination and independence (autonomy) and concern for the “public good” (utilitarianism) The CNO Code of Conduct for Nurses is a guide to ethical behaviour for nurses https://www.cno.org/globalass ets/docs/prac/49040_code-of-c onduct.pdf 12  Ethical decision-making includes: Ethica Gathering information l Clarifying values Identifying options Decisi Identifying legal on- considerations and practical restraints Makin Building consensus for g the decision reached Reviewing and analyzing the decision 13 Copyright © 2014 Elsevier Canada, a division of Reed El 14 sevier Canada, Ltd. All rights reserved.  15 Talk to colleagues or seek professional supervision Spend time thinking about Self- ethical issues and determine what your values and beliefs Awaren are regarding situations before they occur ess Be willing to discuss ethical concerns with colleagues or Issues managers ** Remember confidentiality ** Mental Health Legislation Historically, in Canada, mental health legislation was developed to protect members of the public from so-called mentally deranged or dangerous people Legislation ensured that these people were isolated from the public Did not protect their rights as people and Canadian citizens New legislation “offers an important mechanism to ensure adequate and appropriate care and treatment, protection of human rights of people with mental disorders and promotion of the mental Copyright © 2014 Elsevierhealth ofof Reed Canada, a division sevier Canada, Ltd. All rights reserved. populations” El (WHO, 16  Mental Health Legislation International/National—The domain of international human rights and declarations, and the protection of these covenants Provincial/territorial—Provinces and territories each establish mental health legislation. Distinctions exist with regard to involuntary admission criteria, the right to refuse treatment, and who has the authority to authorize treatment. Refer to the specific provincial or territorial act governing practice in your jurisdiction. Copyright © 2019 Elsevier Canada, a division of Reed 17 Elsevier Canada, Ltd.  Patients’ Rights Under the Law Right to treatment Right to refuse treatment Authorization of treatment Consent Competency Advance directives Involuntary admission criteria Community treatment orders Copyright © 2019 Elsevier Canada, a division of Reed 18 Elsevier Canada, Ltd.  Voluntary Admission Mental health clients retain all civil rights afforded to all people This includes the right to refuse treatment and Rights of discharge themselves Clients Have right to refuse treatment, receive mail, refuse visitors; EXCEPT: if suicidal – cannot have belts, shoelaces, etc; making threatening phone calls – only have supervised phone 19 calls  Clients hospitalized voluntarily have the right to request discharge at any time and must be released unless they represent a danger to themselves or others; if such a danger is present, then Release commitment proceedings must From the be instituted to keep them in the hospital Hospital Communities have a right to be protected against dangerous people. Clients who are no longer dangerous must be discharged from the hospital 20 Rights of Clients Involuntary Admission Under the order of someone else Persons detained in this way lose only the right to freedom; all other rights are intact (they cannot discharge themselves) Persons held without their consent must present an imminent danger to themselves or others; this must be proven at a hearing if the person is to be committed Provincial mental health legislation permits authorized authorities (i.e. police) to bring the individual in for examination and treatment without their consent. 21 Patients’ Rights Under the Law (Cont.) Least restrictive care Seclusion Restraints Confidentiality Duty to warn Duty to protect Reporting of abuse Confidentiality of communicable diseases Confidentiality after death Protection of patients Copyright © 2019 Elsevier Canada, a division of Reed 22 Elsevier Canada, Ltd. Least Restrictive Environment Treatment must be provided in the least restrictive environment appropriate to meet the client’s needs This philosophy is central to the deinstitutionalization of large hospitals and the move to community-based care and services Human or Mechanical restraint or seclusion in a locked room can be used only when the person is imminently aggressive or threatening to harm himself 23 Least Restrictive Environment (cont’d) Restraint and seclusion, if used, must be in place for the shortest time necessary Many regulations govern the monitoring of clients in seclusion or restraint for their safety 24  Specific Mental Health and Addictions Legislation Health Care Consent Act Mental Health Act Substitute Decisions Act Community Treatment Orders Personal Health Information Protection Act Part XX.I of the Criminal Code of Canada Medical assistance in dying Copyright © 2014 Elsevier Canada, a division of Reed El 25 sevier Canada, Ltd. All rights reserved.  Health Care Consent Act (HCCA) Applies to all aspects of health care (both medical and psychiatric) and provides rules for obtaining informed, voluntary consent for treatment, and involvement from substitute decision makers. Outlines rules for determining capacity in three key areas: treatment decisions; admission to care facilities; and personal assistance services https://ontario.cmha.ca/provincial-policy/criminal-justice/mental-health-and-addictions-legislation/#:~:text=The%2 0Ontario%20Mental%20Health%20Act,around%20assessment%2C%20care%20and%20treatment. https://www.oha.com/Legislative%20and%20Legal%20Issues%20Documents1/OHA_Mental%20Health%20and%20the%20Law% 20Toolkit%20-%20Revised%20(2016).pdf Copyright © 2014 Elsevier Canada, a division of Reed El 26 sevier Canada, Ltd. All rights reserved.  Case Study Elsevier Canada, Ltd. Copyright © 2019 Elsevier Canada, a division of Reed A 27-year-old male is court committed by his parents to your unit with a diagnosis of paranoid schizophrenia. He lashes out at staff when they attempt to give him his medications. He states, “You are trying to poison me.” His family asks if you can “force” him to take his medications. How would you respond to this family? 27  Mental Health Act (MHA) The MHA’s main purpose is to regulate the involuntary admission and treatment of people in psychiatric facilities and in out-patient settings under Community Treatment Orders (CTOs) This act in Ontario allows physicians to assess ( Form 1) and to detain (Form 3, Form 4) patients for set periods of time. The Health Care Consent Act and Mental Health Act also allows for the involuntary treatment of patients if they are incapable (Form 33). Patients have the right to appeal to the Consent and Capacity Board to assess their capacity to make their own health care decisions https://ontario.cmha.ca/provincial-policy/criminal-justice/mental-health-and-addictions-legislation/#:~:text=The%20Ontario%20Mental%20Health%20Act,around%20ass essment%2C%20care%20and%20treatment. 28  Mental Health Act (MHA) A Form 1 (Application by Physician for Psychiatric Assessment) allows a physician to detain a patient for a psychiatric assessment Lasts up to 72 hours at a Schedule 1 Facility Criteria for Form 1 (at least one): Harm to self Harm to others Physical impairment PLUS, evidence of a mental disorder A Form 42 (Notice to Person) is always given to a patient to notify them that they are under a Form 1 Copyright © 2014 Elsevier Canada, a division of Reed El 29 sevier Canada, Ltd. All rights reserved.  Mental Health Act (MHA) A Form 2, (Order For Examination), is a form that any member of the public (or family member) can fill out when they are concerned about the mental well-being of an individual A Justice of the Peace is required to initiate the process, and the member of the public must contact them to issue the Form 2 Form 2 does not allow hospital detention Form 2 is to allow the police to apprehend and bring the person to a physician for examination. The purpose of the examination is for the physician to decide whether to sign a Form 1 for further assessment Copyright © 2014 Elsevier Canada, a division of Reed El 30 sevier Canada, Ltd. All rights reserved.  Mental Health Act (MHA) A Form 3 (Certificate of Involuntary Admission) is for a patient who meets criteria for an involuntary admission Lasts 2 weeks It must be a different MD who signs the Form 1 and Form 3 Form 3 Only Allows for Detention, Not Treatment Copyright © 2014 Elsevier Canada, a division of Reed El 31 sevier Canada, Ltd. All rights reserved.  Mental Health Act (MHA) A Form 4 (Certificate of Renewal) is issued when a patient continues to meet criteria for an involuntary admission after a Form 3 expires Copyright © 2014 Elsevier Canada, a division of Reed El 32 sevier Canada, Ltd. All rights reserved.  Mental Health Act (MHA) A Form 33 is a form given to a patient anytime a physician deems them incapable to consent to treatment, manage their own property, and/or manage the collection/release/use of their health information Treatment incapacity A substitute decision maker (SDM) must be found immediately If unable, a Public Guardian and Trustee will take over decision-making If a patient declines to appeal the finding, or if they do not appeal their finding of incapacity within 48 hours, then a physician can begin treating the patient Copyright © 2014 Elsevier Canada, a division of Reed El 33 sevier Canada, Ltd. All rights reserved.  Mental Health Act (MHA) In the province of Ontario, the Consent and Capacity Board (CCB) is an independent, government review panel that holds hearings to determine whether a patient meets the criteria for incapacity to treatment and/or involuntary hospitalization The CCB is independent of the physician and the hospital and is a quasi-judicial body The board is made up of physicians, psychiatrists, nurse practitioners, lawyers, and public members Copyright © 2014 Elsevier Canada, a division of Reed El 34 sevier Canada, Ltd. All rights reserved. Community Treatment Orders “Legal mechanisms by which individuals with mental illness and a history of non-compliance can be mandated against their will to undergo psychiatric treatment in an outpatient setting” (Snow & Austin, 2009) CTOs came into effect in Ontario on December 1, 2000, as part of the amendments to the MHA designed to deal with the “revolving door” patient. 35  Community Treatment Orders Introduced to facilitate the supervision of treatment in the community of persons who had experienced two or more admissions to a psychiatric facility or for a cumulative period of 30 days during the prior three- year period. As set out in the legislation itself, the purpose of CTOs is to get patients out of hospital and into the community where they may be provided with community-based treatment or care and supervision that is less restrictive than being detained in a psychiatric facility. The legislation goes on to provide that CTOs are directed at developing a comprehensive community treatment plan for the person who, “as a result of his or her serious mental disorder” experiences the following pattern Community Treatment Orders The person is admitted to a psychiatric facility where his or her condition is usually stabilized; after being released from the facility, the person often stops the treatment or care and supervision; the person’s condition changes and as a result the person must be re-admitted to a psychiatric facility There are many rules and procedures  Substitute Decisions Act (SDA) Decision making around property or finances, and decisions about personal care Explanation and rules about power of attorney and the role of the Office of the Public Guardian and Trustee https://ontario.cmha.ca/provincial-policy/criminal-justice/mental-health-and-addictions-legislation/#:~:text=The%20Ontario%20Mental%20Health%2 38 0Act,around%20assessment%2C%20care%20and%20treatment.  Personal Health Information Protection Act (PHIPA) Governs the collection, use, and disclosure of personal health information The nurse is the health information custodian and must understand the Circle of Care MHA can take precedence over the terms of PHIPA, i.e., involuntary assessment or disclosure of PHI Copyright © 2014 Elsevier Canada, a division of Reed El 39 sevier Canada, Ltd. All rights reserved.  Part XX.I of the Criminal Code of Canada A section of the Criminal Code which addresses the criminal liability of accused persons affected by a “mental disorder” in the commission of a criminal offence. Describes a court’s powers to order assessments and make determinations regarding fitness to stand trial and rendering a verdict of “not criminally responsible” (NCR). It also prescribes the composition and powers of Review Boards (the ORB in Ontario) 40 https://ontario.cmha.ca/provincial-policy/criminal-justice/mental-health-and-addictions legislation/#:~:text=The%20Ontario%20Mental%20Health%20Act,ar ound%20assessment%2C%20care%20and%20treatment. Tort: A Wrongful Act That Results in Injury, Loss, or Damage Unintentional Torts Negligence: harm caused by failure to do what is reasonable and prudent Malpractice: breach of duty directly causes injury or loss to the client Intentional Torts Assault: causes person to fear being touched in an offensive manner Battery: harmful or unwanted actual contact False imprisonment: unjustifiable detention 41 Prevention of Liability Nurses can minimize the risk of lawsuits through safe, competent nursing care and descriptive, accurate documentation 42  Medical Assistance in Dying (MAID) Bill C-14 was passed into law in Canada in June 2016 Created because of a Supreme Court decision in Carter v. Canada in 2015 (previous ruling in 1993 was denied) Bill C-14 amended to C-7 on March 17, 2021, which is more inclusive (except mental illness) Mental illness was to be included on March 17, 2023 (extended to March 2024 & then March 17, 2027) Copyright © 2014 Elsevier Canada, a division of Reed El 43 sevier Canada, Ltd. All rights reserved.  MAID Eligibility Criteria Request MAID voluntarily (self-request only) 18 years of age or older Capacity to make health care decisions Must provide informed consent Eligible for publicly funded health care services in Canada Copyright © 2014 Elsevier Canada, a division of Reed El 44 sevier Canada, Ltd. All rights reserved.  MAID Eligibility Criteria continued Diagnosed with a "grievous and irremediable medical condition," where a person must meet all of the following criteria: serious and incurable illness, disease or disability advanced state of irreversible decline in capability, experiencing enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable Mental Illness as sole underlying medical condition is excluded until March 2027 Copyright © 2014 Elsevier Canada, a division of Reed El 45 sevier Canada, Ltd. All rights reserved.  Question Do you think people should have the right to die by MAID if their sole diagnosis is mental illness? Copyright © 2014 Elsevier Canada, a division of Reed El 46 sevier Canada, Ltd. All rights reserved.  Medical Assistance in Dying (MAID) The law no longer requires a person’s natural death to be reasonably foreseeable Safeguards for persons whose natural death IS reasonably foreseeable: request for MAID must be made in writing two independent doctors or nurse practitioners must provide an assessment the person must be informed that they can withdraw their request at any time the person must be given an opportunity to withdraw consent and must expressly confirm their consent immediately before receiving MAID (however final consent can be waived) Copyright © 2014 Elsevier Canada, a division of Reed El sevier Canada, Ltd. All rights reserved. 47  Medical Assistance in Dying (MAID) Safeguards for persons whose natural death IS NOT reasonably foreseeable: same as previous slide PLUS, the person must be informed of available and appropriate means to relieve their suffering the person and the practitioners must have discussed reasonable and available means to relieve the person’s suffering, and agree that the person has seriously considered those means the eligibility assessments must take at least 90 days, but this period can be shortened if the person is about to lose the capacity to make health care decisions immediately before MAID is provided, the request can be withdrawn, and the person must give consent Copyright © 2014 Elsevier Canada, a division of Reed El 48 sevier Canada, Ltd. All rights reserved.  Medical Assistance in Dying (MAID) Final consent can now be waived immediately before receiving MAID for patients whose natural death IS reasonably foreseeable, where: the person has been assessed and approved to receive MAID the person is at risk of losing decision-making capacity before their preferred date to receive MAID, and has been informed of that risk the person arranges in writing with their practitioner to waive final consent ** “Audrey’s Amendment”** https://www.youtube.com/watch?v=XwRRKq29ts w Copyright © 2014 Elsevier Canada, a division of Reed El 49 sevier Canada, Ltd. All rights reserved.  Medical Assistance in Dying (MAID) How does death occur? Either a physician or nurse practitioner will administer the medication usually IV OR The patient can self-administer the medication orally RNs and RPNs do not prescribe, dispense, compound, prepare or administer any medications associated with MAID Copyright © 2014 Elsevier Canada, a division of Reed El 50 sevier Canada, Ltd. All rights reserved.  Medical Assistance in Dying (MAID) Where does death occur? In a setting of the patient’s choice (except institutions who don’t allow it) MAiDHouse; only one location in Toronto currently https://globalnews.ca/news/8431294/suicide-pods -sarco-legalized-switzerland/ Copyright © 2014 Elsevier Canada, a division of Reed El 51 sevier Canada, Ltd. All rights reserved.  Medical Assistance in Dying (MAID) Can healthcare personnel refuse to participate in MAID? Yes, healthcare personnel including nurses do not have to participate in the care of a patient undergoing MAID (conscientious objection) Can someone who dies of MAID be an organ donor? Yes, but the death may need to occur in the hospital Copyright © 2014 Elsevier Canada, a division of Reed El 52 sevier Canada, Ltd. All rights reserved. MAID Statistics Copyright © 2014 Elsevier Canada, a division of Reed El 53 sevier Canada, Ltd. All rights reserved. MAID Statistics Copyright © 2014 Elsevier Canada, a division of Reed El 54 sevier Canada, Ltd. All rights reserved. MAID Statistics Copyright © 2014 Elsevier Canada, a division of Reed El 55 sevier Canada, Ltd. All rights reserved. MAID Statistics Copyright © 2014 Elsevier Canada, a division of Reed El 56 sevier Canada, Ltd. All rights reserved.  Question Which individual with mental illness may need involuntary hospitalization? A. A person with alcoholism who has been sober for 6 months but begins drinking again B. An individual with schizophrenia who stops taking prescribed antipsychotic drugs C. An individual with bipolar disorder, manic phase, who has not eaten in 4 days D. Someone who repeatedly phones a national TV broadcasting service with news tips Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 57  Part 2: Culture, Race, Ethnicity, and the Social Determinants of Health Culture Cultural norms Ethnic groups World View Cultural Safety Colonization Social determinants of health Trauma-informed practice Copyright © 2014 Elsevier Canada, a division of Reed El 58 sevier Canada, Ltd. All rights reserved. Copyright © 2014 Elsevier Canada, a division of Reed El 59 sevier Canada, Ltd. All rights reserved. Cultural Views and Contexts Impacting Mental Health Care  Western Tradition  Eastern Tradition  Medicine Wheel Copyright © 2019 Elsevier Canada, a division of Reed 60 Elsevier Canada, Ltd.  Culture, Mental Health, and Mental Illness Stereotyping The generalized conscious or unconscious conceptualization of a group of people that does not allow for individual differences within the group E.g. people with a mental health illness are violent Enculturation Transmission of culture Children learn from parents which behaviours, beliefs, values, & actions are “right” and which are “wrong” Culture outlines its acceptable range of options Deviance from cultural expectations is problematic & may be labelled “illness” Copyright © 2019 Elsevier Canada, a division of Reed 61 Elsevier Canada, Ltd. The Cultural Landscape of Canada Indigenous Peoples Multicultural Contexts -Immigration policies -Ethnocentrism -Colonization -Refugees in Canada Copyright © 2014 Elsevier Canada, a division of Reed El 62 sevier Canada, Ltd. All rights reserved.  Culture, Mental Health, and Mental Illness Ethnocentrism Perception that one’s own values, beliefs, and behaviours are superior to other cultures Acculturation Learning and adopting the beliefs, values and practices of their new cultural setting Assimilation Acculturation makes dominant culture more natural than the ones they learned in their homeland Cultural imposition Forced assimilation of the dominant culture’s values, beliefs, and behaviours Copyright © 2019 Elsevier Canada, a division of Reed 63 Elsevier Canada, Ltd.  Mental Health Concerns of Indigenous Peoples Intergenerational trauma Hopelessness and suicide Family violence, family separation, and community violence Substance use Needs for culturally relevant and appropriate services Copyright © 2019 Elsevier Canada, a division of Reed El 64 sevier Canada, Ltd.  Intergenerational Trauma Since first contact between the Indigenous peoples of Canada and dominant immigrant settler nations, Indigenous communities were displaced and disconnected from their traditional ways Government policies and legislation led to forced cultural genocide and attempts at assimilation Indian Act: Rather than remaining self-sufficient, “the Indian” became subjects of Canada considered inferior to their non-Indigenous counterparts and monitored by a system of constant surveillance The experience of colonization in Canada created a legacy of historical social and political injustices characterized by cultural oppression, displacement from traditional lands, incarceration of children in government-run Indian Residential Schools (IRSs), and removal of children by child welfare authorities These experiences have resulted in intergenerational loss of traditional family values, leading to a breakdown of the nuclear family and community structures and, therefore, to social and economic challenges These traumatic experiences reverberate in subsequent generations as close-knit community networks cope with layers of psychic pain and disruptions in the social fabric This legacy of colonization contributes to the elevated rates of 65 alcoholism, suicide, domestic violence, and community demoralization, Hopelessness & Suicide Suicide and self-inflicted injuries are the leading causes of death for First Nations youth and adults up to 44 years of age. Approximately 55% of all Indigenous people are under 25 years of age. Suicide rates for Inuit youth are among the highest in the world, at 11 times the national average Between December 12, 2015, and March 16, 2016, six people, most of them youth, died by suicide in Pimicikamak Cree Nation. Dozens of others in this community of approximately 6 000 made attempts following these deaths, with more than 150 students—in a school of about 1 200— placed on a suicide watch list. During this time, band leaders declared a state of emergency, catapulting the crisis into the headlines and highlighting what the top Indigenous chief in Canada has deemed a national suicide epidemic that reaches well beyond Pimicikamak The community of Attawapiskat in Northern Ontario reported a further 11 deaths by suicide in July 2016. Children as young as 10 years old reportedly died by suicide 66 Family Violence, Family Separation, Community Violence High rates of family violence, sexual abuse, incarceration, and emotional distress underscore the significance of historical trauma on the current mental health and societal problems facing many Indigenous peoples. The multiple traumas and revictimization that many Indigenous people endure are linked to complex trauma responses, which require strong, culturally sensitive intervention programs. The intergenerational trauma is further exacerbated by family disunity as children are placed in the care of child welfare agencies. Mistrust and fear of these authorities resonates from the 1960s, when large numbers of children of Indigenous ancestry were removed from their families and placed for adoption (60’s Swoop). While Indigenous children continue to be over-represented in the child welfare system, women experience disproportionately higher levels of violence in terms of both incidence and severity and are disproportionately represented in the number of missing and murdered women across Canada. Relationship and community violence experienced among Indigenous communities has not been met with a thorough response by policing and legal systems. In 2016, a long-awaited inquiry into the root causes of the disproportionate rates of violent crime against Indigenous women and girls was initiated 67 Substance Use Although high proportions of mental health problems exist, most visible among them substance use issues Mental health services are underused by Indigenous populations. Substance use disorders have reached epidemic proportions in many areas, and many Indigenous women become street involved in either sex or the drug trade As an integral part of the healing process, the National Native Alcohol and Drug Abuse Program (NNADAP) provides Indigenous-specific programs and inpatient, outpatient, and residential treatment for addictions. It provides direction and identifies opportunities to ensure that individuals, families, and communities have access to appropriate, culturally relevant services. There are approximately 53 Indigenous addiction treatment centres across the country that are not only used by Indigenous people but also open to other funding agencies. Barriers to access and cumbersome referral processes that require many pages of information and consents often hinder recovery. Like other specialist services, wait lists as long as 6 months and limited local detoxification resources continue to challenge many health authorities. Copyright © 2014 Elsevier Canada, a division of Reed El 68 sevier Canada, Ltd. All rights reserved. Culturally Relevant & Appropriate Services While general psychiatric treatment focuses on individuals, the problems affecting the mental health of many Indigenous people involve problems relating with others, including family members, social networks, their communities, and governmental structures Addressing trauma and resulting mental health and substance use problems can often be greatly feared and avoided, leading to secrecy and further embedding experiences of shame and stifling recovery Consideration of the impact of the collective identity and political situations of Indigenous peoples is crucial for promoting healing Communities with higher levels of knowledge about traditional languages and in which Indigenous languages were widely spoken were among those that reported more than 50% fewer suicides than those that had lost their languages. Need to address Social Determinants of Health Copyright © 2014 Elsevier Canada, a division of Reed El 69 sevier Canada, Ltd. All rights reserved.  Question When was the last residential school closed in Canada and where? Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. All rights reserved. 70  Answer Closed in 1996 Saskatchewan Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. All rights reserved. 71  Mental Health Concerns of Refugees Post-traumatic stress Adjustment disorders Depression Suspiciousness and distrust of authorities Needs for culturally relevant and appropriate services (including for those without dominant language skills, or for English or French as an additional language) Copyright © 2019 Elsevier Canada, a division of Reed El 72 sevier Canada, Ltd.  Barriers and Facilitators to Mental Health Care in a Multicultural Context Stigma and discrimination Communication barriers Misdiagnosis Cultural concepts of distress Genetic variations in pharmacodynamics Copyright © 2019 Elsevier Canada, a division of Reed 73 Elsevier Canada, Ltd.  Cultural Competence for Psychiatric Mental Health Nurses Five constructs 1. Culturalawareness 2. Cultural knowledge 3. Cultural encounters 4. Cultural skill 5. Cultural desire Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 74 Cultural Competence for Psychiatric Mental Health Nurses (Cont.) 1. Cultural awareness Culture of the patient, nurse, and setting Examine beliefs, values, and practices of own culture Recognize that during a cultural encounter, three cultures are intersecting Copyright © 2019 Elsevier Canada, a division of Reed 75 Elsevier Canada, Ltd. Cultural Competence for Psychiatric Mental Health Nurses (Cont.) 2. Cultural knowledge Learn by attending cultural events and programs Forge friendships with diverse cultural groups Learn by studying Learning cultural differences helps nurses Establish rapport Ask culturally relevant questions Identify cultural variables to be considered Copyright © 2019 Elsevier Canada, a division of Reed 76 Elsevier Canada, Ltd. Cultural Competence for Psychiatric Mental Health Nurses (Cont.) 3. Cultural encounters Deter nurses from stereotyping Help nurses gain confidence in cross-cultural interactions Help nurses avoid or reduce cultural pain Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 77  Cultural Competence for Psychiatric Mental Health Nurses (Cont.) 4. Cultural skill Ability to perform a cultural assessment in a sensitive way with cultural humility Skill of deep reflection Use professional medical interpreter to ensure meaningful communication Use culturally sensitive assessment tools Goal A mutually agreeable therapeutic plan Culturally acceptable Capable of producing positive outcomes Copyright © 2019 Elsevier Canada, a division of Reed 78 Elsevier Canada, Ltd. Cultural Competence for Psychiatric Mental Health Nurses (Cont.) 5. Cultural desire Genuine concern for a patient’s welfare Willingness to listen until the patient’s viewpoint is understood Patience, consideration, and empathy Copyright © 2019 Elsevier Canada, a division of Reed 79 Elsevier Canada, Ltd.  Case Study Elsevier Canada, Ltd. Copyright © 2019 Elsevier Canada, a division of Reed Ms. B is admitted to your unit. In your assessment you identify some cultural patterns that may support or interfere with her health and recovery process. What can you do? 80  Questions?? Copyright © 2014 Elsevier Canada, a division of Reed El 81 sevier Canada, Ltd. All rights reserved.  Chapter 29 Recovery, Survivorship, and Public Mental Health Approaches Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 82 Serious Mental Illness (SMI) In Canada, no uniform definition for SMI SMI usually refers to: Schizophrenia Mood disorders Other psychotic disorders SMI is a significant health care challenge and is the leading cause of disability in Canada After the age of 40, one in two Canadians will have had, or have, a mental illness 83 Serious Mental Illness (SMI) Patients at risk for multiple physical, emotional, and social problems more likely to be victims of crime, be mentally ill, have under-treated or untreated physical illnesses, die prematurely, be homeless, be incarcerated, be unemployed or under employed, engage in binge substance abuse, live in poverty, and report lower quality of life and social satisfaction Commonalities with chronic physical illness 84 Older Adults with SMI Before deinstitutionalization, psychiatric hospitals were long-term residences Patients became dependent on services and structure and were unable to function independently Vignette – Marian Copyright © 2019 Elsevier Canada, a division of Reed El 85 sevier Canada, Ltd. Marian At the age of 19, Marian was admitted to a facility that cares for people with serious mental illnesses. She is now 79, and with the exception of living in a group home for 2 years in her thirties, she has been an inpatient at the SMI facility. Marian's symptoms have been stable, and the treatment team discusses discharge with her. She accepts their recommendation that she no longer needs inpatient treatment. She is discharged to a community supportive-living home. At her new home, she spends long periods sitting in front of the living room window. Marian does not ask to go out into the garden she watches for so many hours. Indeed, she rarely asks for anything, including snacks or recreational activities. The caregivers work with Marian for several months to help her to recognize her needs of the moment and then to articulate or act on them. There is a major celebration on the day she walks into the kitchen and makes a peanut butter sandwich of her own volition. Some of the dependency caused by the institutionalization is being positively altered. Copyright © 2014 Elsevier Canada, a division of Reed El 86 sevier Canada, Ltd. All rights reserved. Young Adults with SMI Limited experience with formal treatment contributes to a cycle of treatment, brief recovery, and relapse contributes to some patients not truly believing that a SMI problem exists.  additional problems, such as increased frequency of relapse, legal difficulties, homelessness, substance abuse, and unemployment Vignette – Christopher Copyright © 2019 Elsevier Canada, a division of Reed El 87 sevier Canada, Ltd. Christopher After graduating from high school, Christopher enlists in the armed forces and serves for 5 years. Afterward, he settles in Nova Scotia and takes a job in a security firm. In his first psychotic break, Christopher becomes paranoid and threatening at work and is hospitalized briefly. Upon discharge, Christopher refuses aftercare and will not take medication. He quits his job and moves to another city. For the next 15 years, Christopher works intermittently, is homeless off and on, and drinks heavily whenever he has money. He is hospitalized only when his behaviour is threatening to others. He consistently resists aftercare recommendations, showing no insight into his illness. One day, Christopher simply disappears. Copyright © 2014 Elsevier Canada, a division of Reed El 88 sevier Canada, Ltd. All rights reserved. Issues Confronting Those With SMI Establishing a meaningful life can be difficult Comorbid conditions Physical disorders and dying prematurely Depression and suicide more people with SMI engage in self-harming behaviours than suicide Substance abuse much higher risk for substance abuse both a mental disorder and a substance use disorder is said to have a concurrent disorder Copyright © 2019 Elsevier Canada, a division of Reed El 89 sevier Canada, Ltd. Issues Confronting Those With SMI (Cont.) Social problems Stigma Isolation and loneliness Victimization Economic challenges Unemployment and poverty Housing instability Caregiver burden Copyright © 2019 Elsevier Canada, a division of Reed El 90 sevier Canada, Ltd. Issues Confronting Those With SMI (Cont.) Treatment issues Inadequate treatment response and nonadherence Poor insight, possibly related to anosognosia (inability to recognize one’s deficits- frontal, temporal, parietal damage such as stroke or dementia) Medication adverse effects (see Box 29 – 1 page 638) Residual symptoms Relapse, chronicity, and loss Copyright © 2019 Elsevier Canada, a division of Reed El 91 sevier Canada, Ltd. Issues Confronting Those With SMI (Cont.) Involuntary treatment Community treatment orders (CTOs) Criminal offences and incarceration Police and corrections treatment of persons with recurrent or persistent mental illness Copyright © 2019 Elsevier Canada, a division of Reed El 92 sevier Canada, Ltd. Resources for Persons With Recurrent Persistent Mental Illness Comprehensive community treatment Overall goal is to improve the patient's ability to function independently in the community Community services and programs  Psychiatric or medical-somatic services Substance abuse treatment and support  Case management  Medication monitoring  Assertive community treatment (ACT) Copyright © 2019 Elsevier Canada, a division of Reed El 93 sevier Canada, Ltd. Evidence-Informed Treatment Approaches Assertive community treatment (ACT) Cognitive behavioural therapy (CBT) Cognitive enhancement therapy (CET) Family support and partnership Social skills training Supportive psychotherapy Vocational rehabilitation and related services Copyright © 2019 Elsevier Canada, a division of Reed El 94 sevier Canada, Ltd. Interventions Empowering, whole-person approaches Motivational interviewing Emphasizing quality-of-life issues Developing and maintaining relationships Supportive psychotherapy Reality checking for psychosis Activities that increase skill and comfort with socialization Education and support groups for patients and families Harm reduction and abstinence for comorbid substance use Copyright © 2019 Elsevier Canada, a division of Reed El 95 sevier Canada, Ltd. Rehabilitation Versus Recovery Rehabilitation focuses on: managing patients’ deficits helping patients learn to live with their illness Recovery focuses on: achieving goals of patients’ choosing and highest quality of life possible leading increasingly productive and meaningful lives emphasis is on the person and the future rather than on the illness and the present Copyright © 2019 Elsevier Canada, a division of Reed El 96 sevier Canada, Ltd. Recovery Definition: a process in which people with mental health problems and illnesses are empowered and supported to engage actively in their own journey of well-being According to the College of Family Physicians of Canada (2018): It is “a personal and self-determined journey toward well-being, with every person having their own set of unique experiences and needs. Recovery journeys build on individual, family, cultural, and community strengths, and are supported by many types of services and treatments” (p. 3) Recovery An active process unique to each individual Broader than clinical recovery About having a satisfying and hopeful life Focus on the person’s strengths, resources, and rights Shaped by culturally safe and competent practices Requires a less medically centred approach and a wider perspective on what constitutes positive outcomes Recovery-Oriented Practice Is “helping patients reach optimal mental health is about more than reducing or managing symptoms. It is about supporting patients to live satisfying, hopeful, and contributing lives, even when there are ongoing limitations caused by MH&A issues” ( Canadian College of Family Physicians, 2018, p. 3 ) Dimensions of Recovery- Oriented Practice ( Canadian Colleg e of Family Physi cians, 2018, p. 4 ) A patient with schizophrenia does not feel that he needs medication because “there is nothing wrong with me.” This response is most likely an example of: a. Denial b. Projection c. Anosognosia d. Paranoid ideation Copyright © 2019 Elsevier Canada, a division of Reed El 101 sevier Canada, Ltd.