- Case Study Vignettes – Confidentiality and Consent
- Case Study vignettes – Confidentiality
- Anger Management
- Case Study vignettes – the duty and boundaries of care
- Case study vignettes – Nurse Holding Powers
- A Baby Vignette
- Case Study vignette – Blood tests
- Case Study vignette – Complicated Concordance
- Quick mini-scenario
- Case Study Vignettes: Cigarette Rationing
- Case Study Vignette – Just for Socrates
- Case Study Vignette – Anorexia and Veganism
Mental health care most often becomes ethically clouded when it interacts with the law.
Jodie is a 19 year old female who is voluntarily admitted to the acute mental health unit following a suicide attempt whilst under the influence of alcohol. This is her first presentation to the service and you spend some time to get to know her the following day.
During the course of conversation Jodie tells you what caused her to act as she did.
“I was out with a group of my friends and I saw an old college professor who sexually assaulted me 2 years ago. I never reported it cos I thought nothing would be done and I’ve never told anyone else about it. I got really drunk and it played over in my head. I wanted to tell my friends but I couldn’t.”
“I didn’t realise it but I guess I’m not over it and I don’t want to carry on doing this to myself. What can I do?”
From a legal perspective, what obligations do you have as a nurse?
What processes are there to help Jodie decide whether to press charges and is it ethically right to use them?
How far can or should a nurse become involved in discussing this assault with Jodie?
I just sent a message through the ‘contact us’ type section that is really important to the site administrators (and has nothing to do with asking advice or anything like that!)
What happened to her was a Professional Sexual Exploitation. There is a really good website that helps people deal with it, and it’s really the only website that I’ve found. The link is http://www.advocateweb.org/hope2/index.php It really helped me to decide to report a psych hospital staff member that had been…inappropriate to say the least. It took me 4 years to report it and Adult Protective Services and the hospital eventually took me seriously and he was eventually terminated.
Anyway. Go as far as you feel comfortable discussing it with her. You can push her a little bit probably, but I wouldn’t do a whole lot. I *still* can’t really talk about what happened with me (in person, online is somewhat different) and another year has passed. The shame a person feels in this sort of situation is different than that of other victims. We let these people into our lives willingly, and then we let them control us after they hurt us…our fear of them keeps us from reporting – and then we have to fear that they’ll do it to someone else because we didn’t report. Obviously I’m speaking mostly from my experience and others I’ve read, and it’s really hard to know how extensive her relationship with the man was from the description you’ve given.
On a side note: even if the relationship had been consentual at some point (between any student and a prof – not talking about her here) it would have still been exploitation because of the exploiters power over the victim. It’s the same with doctors, lawyers, counselors, priests…etc. This happens way too often and it’s rarely reported to the proper authorities (licensing boards and/or law enforcement).
The first thing that comes to my mind is if this old college professor could potentially assault others – namely, there would be a duty to protect others from further harm. Especially as she was under 18 when it happened so there might be wider child protection issues. I know that if any professional becomes aware of any possible child protection concern there is a legal duty to report.
My inclination would be to avoid talking about the actual assault so as not to prejudice any potential police investigation – you could potentially mess up any kind of prosecution if you start to try and do any investigations yourself – I’d talk to her about alerting authorities for the sake of others who might be in a similar situation. And support her to do so – involving agencies if necessary.
just a couple of initial thoughts..
The nurse’s responsibility, legal and moral, is to Jodie and her wellbeing.
The nurse cannot make Jodie press charges, nor can she press charges on her behalf. The possibility of charges might be something the nurse could explore with Jodie.
The nurse would need to ensure she felt competent and capable of discussing this assault with Jodie, and dealing with any issues that might arise from such a conversation. Nothing worse than blithely ripping a scab off an old wound and being subsequently unable to deal with the resultant pain.
“How far can or should a nurse become involved in discussing this assault with Jodie?”
One of the worst things ever is finally working up the nerve to tell someone and reach out for help, and then to be greeted by a resounding wall of “DON’T DISCLOSE! I’m not qualified to go into this!”. I’ve experienced that (although not with a nurse). I would say that in the immediate instance, the nurse should listen to as much as Jodie wants to disclose. Whilst it may not be appropriate for her to advise or ‘discuss’, she can certainly actively listen.
Having said that, unless the nurse has other specialist training, she is probably not best placed to help Jodie come to terms with this, and so her role should be to discuss with Jodie the best options for what she could do next – whether that be the police, therapy, etc. It would certainly be a good idea to raise with Jodie that it would be best for her care if other members of the team were told about it, as they may be able to help (i.e. get a psychologist involved). Would also be a good idea to give her contact details for Victim Support or similar.
Essentially, now she’s been told, the nurse has a duty to Jodie’s welfare to help faciliate her moving forward. Gatekeeper, if you will.
If someone does persuade her to go to the authorities it is extremely important that no one makes her feel guilty for waiting so long to report what happened. The more time that passes after something like this, the harder it may be for the victim to talk about it.
Also, if she decides that she does not want to go forward with any sort of reporting and just wants to work through it, that decision needs to be supported! It is an extremely difficult decision to make and you know she had to have thought about this for a long time and wouldn’t take it lightly. She may not be in a space mentally where she could handle everything that comes from this. Because it has been so long, the police will most likely take her statement and unless she has some sort of evidence it’ll just get filed. Reporting to the university would probably get more results, especially if anyone has complained before.
Essentially, now she’s been told, the nurse has a duty to Jodie’s welfare to help faciliate her moving forward. Gatekeeper, if you will
I like the way you put that, i-t-m.
and beakie puts it professionally aptly:
The nurse’s responsibility, legal and moral, is to Jodie and her wellbeing.
Both these answers cover the main roles as I also view them.
But… just to stir the ethical-pot and perhaps further some ideas….
Who knows what really happened?
Nurses need to be very careful as to how far they delve into allegations of criminal behaviour – as cb puts it:My inclination would be to avoid talking about the actual assault so as not to prejudice any potential police investigation – you could potentially mess up any kind of prosecution if you start to try and do any investigations yourself
(this is different for nurses so charged with that responsibility – eg in the USA – SANE – sexual assault nurse examiners – who are specifically trained for that role and their evidence is admissible but there are significant protocols within the process).
Although it is good to believe patients are being genuine (or anyone really); nurses, doctors and other health ‘carers’ are also in a vulnerable position when patients confide in them – as they frequently do – as they only often get to hear the one side and are duty bound to accept the patient’s views and opinions on their experiences.
The nurse also has a duty to protect herself and also to not make judgment on the ‘accused’. Documentation should be clearly written so as to simply state the content of the disclosure and not to include any opinion or speculation.
My opinion is this: if mental health care is like normal health care, the nurse has no moral duty to do anything. I’m sure we all agree that it is not, and so questions like this arise. The answers to them are far from easy, and often impossible.
You think nurses in “normal” health care have no moral duty to do anything? Think again, Ted.
@ beakie
If a woman had broken her leg and said to the doctor “I didn’t realise it but I guess I’m not over it and I don’t want to carry on doing this to myself. What can I do?”, then the doctor might think it quite outside his duty to do anything about this disclosure. Indeed, why should he, *in his role as a doctor*, care? The nature of psychiatry makes personal problems a focus of attention, and so the difficulties that the post highlights arise. I’m not sure what I said is so strange. Perhaps you have different opinions on what moral duties medical/psychiatric nurses possess.
Nurses have no moral duty to do anything? My copy of the NMC Code of Professional Conduct says that’s total bollocks.
Plainly then as a mental health nurse if a patient of mine breaks his or her leg I have no moral duty to do anything …
Thanks Ted!
I meant aside from providing medical services in a generally respectable manner, obviously. (this should go without saying, but hey..)
I take it none of you disagree with the uncontroversial point I actually made. Let me put it differently. Medical nurses are duty bound to get involved in the problems their patients have with their bodies; psychiatric nurses are duty bound to get involved in the problems their patients have with their lives. This creates additional difficulties, as described in the thread.
There is another, related point here, which distinguishes medicine from psychiatry. Medical care was (and is, to some extent) essentially a private affair between doctor and patient. Hence both patient and doctor could refuse treatment. Psychiatric care is essentially a non-private affair between psychiatrist and patient. Just as the patient has trouble rejecting treatment, the psychiatrist has trouble refusing to treat the patient. Government involvement in medicine and psychiatry makes it more difficult for those who have different opinions on moral duty to practice the profession, by giving rise to situations where nurses have duties they consider either immoral or simply outside the realm of their job.
If I change my name, will you take me more seriously?
Even medical nurses should be paying attention to the holistic needs of their patients. People shouldn’t be sent away [with a broken leg] if they are, for example, homeless, or unable to look after themselves/requiring further care or support for whatever reason. Health care isn’t just about fixing something that’s physically or mentally wonky and moving them out. It’s rarely that simple.
Azulinebloo, I appreciate your sentiments, but feel it is important to emphasise that the job of the medical profession is to provide medical services. In a free market, there would be competition ensuring that the public received what they want, and undoubtedly some medical services would be combined with what you call holistic needs. I obviously have no problems with this, and applaud those who are genuinely concerned for the welfare of others. But to say that such acts are the moral *duty* of a medical nurse is a step too far, imo.
It is perhaps worth noting that once upon a time, private medicine provided a variety of free services to the homeless and otherwise disadvantaged. The move towards state medicine and state-regulated medical insurance made it much more difficult for these services to be offered, to the detriment of those who needed it most. In addition, state involvement drives up the cost of healthcare for all, and takes away the power of the patient to get the care they wish to receive.
“But to say that such acts are the moral *duty* of a medical nurse is a step too far, imo”
I completely disagree. It’s part of the job as well as a moral *duty* NMC CC.
I’m noticing a theme here!!
“I take it none of you disagree with the uncontroversial point I actually made. Let me put it differently. Medical nurses are duty bound to get involved in the problems their patients have with their bodies; psychiatric nurses are duty bound to get involved in the problems their patients have with their lives. This creates additional difficulties, as described in the thread.”
I disagree. All nurses are duty bound to see to the wellbeing of their patients. Be it physical, mental, societal or whatever.
In this case we are duty bound to support Jodie to make whatever decision she wants to make. Even a busy general nurse could make the time to put Jodie in touch with services that could help Jodie with this.
“But to say that such acts are the moral *duty* of a medical nurse is a step too far, imo.”
Not a step too far.
My opinion is this: if mental health care is like normal health care, the nurse has no moral duty to do anything. I’m sure we all agree that it is not, and so questions like this arise. The answers to them are far from easy, and often impossible.
My opinion is that you really are pig ignorant of nursing Ted. And every ensuing post has demonstrated this. You should go get an education on “what is nursing?” before you guess any more.
What *exactly* did you do for that one year in a mental health unit? I shudder myself to sleep at night thinking you were let loose anywhere.
If I change my name, will you take me more seriously?
I take you as being most serious – this is what scares me.
Ted, I suggest that before making any more pronouncements about what the moral duties of a nurse are, you actually take some time to *find out* what they are.
Your starting point should be the NMC Code of Professional Conduct, as this states our duties in black and white. You can read it online here:
http://nmc-uk.org/aArticle.aspx?ArticleID=3056
If a woman had broken her leg and said to the doctor “I didn’t realise it but I guess I’m not over it and I don’t want to carry on doing this to myself. What can I do?”, then the doctor might think it quite outside his duty to do anything about this disclosure.
That doctor would be completely wrong to think so.
Medical nurses are duty bound to get involved in the problems their patients have with their bodies; psychiatric nurses are duty bound to get involved in the problems their patients have with their lives.
The two do not separate themselves as easily as all that. Physical health problems can lead to problems with perception, emotion, cognition; problems in someone’s life can exacerbate their physical health problems; mental health problems can increase the risk of certain physical health problems; emotional wellbeing can impact on the progress of a physical illness.
And further to that beakie… we just don’t reduce patient’s to bio-psychological components anyhow. We care for a person – warts n all.
(tho usually we mental healthies refer the warts to the nurse practitioner in the GU clinic)
Getting back to the original post: My suggestion on the questions -
It is important to note that Jodie is now of legal adult age and no action can be performed on her behalf outside of an assessment deeming her to lack capacity. In this scenario it is unlikely her capacity is so impaired.
Her age at the time of the offence is only significant to the nature of any charges that may ensue and should not influence the here and now.
From a legal perspective, what obligations do you have as a nurse?
Jodie is reporting a crime and, although there is potential that she was taken advantage of, she is now out of that situation, of adult age and not at risk of further direct harm. This indicates that there is no immediate issues of vulnerability and the legal obligation starts and ends with the reporting and documentation of disclosures.
Clinically, there remains the need to address the effect of these reported events which have led to her being admitted to hospital.
What processes are there to help Jodie decide whether to press charges and is it ethically right to use them?
Reporting the crime is Jodie’s privilege and she should not be persuaded by the nurse in any way to report the crime. However, the nurse can empower Jodie by offering neutral advice such as Victims Support.
http://www.direct.gov.uk/en/Cr.....DG_4002679
If Jodie asks for advice in obtaining a legal representative then of course this can be supported by providing a telephone listing. A nurse should not directly recommend a solicitor or legal firm as this is promoting through your profession. Again, the aim is to ‘empower’ not to ‘lead’.
How far can or should a nurse become involved in discussing this assault with Jodie?
A nurse has a responsibility to holistically support the person but has to remember to remain within the confines of health care.
From a reporting perspective, the nurse needs to ensure documentation of the disclosures as described by Jodie and to avoid making reference to any opinion on the validity or nature of those comments.
The nurse should also refrain from engaging Jodie directly about the event (unless this is part of their role as in a Nurse Psychotherapist where boundaries are clearly identified by experienced staff and specific referral has been made to perform this task).
Should Jodie raise the matter, the nurse provides active listening, support and assessment of mental state. Jodie should be advised that the nurse can support her with the immediate feelings but again records any statement of facts without adding opinion or judgment.
Example of documentation might read:
“Jodie requested a quiet chat this evening. During the 1:1 time she was tearful and appeared agitated, clenching a tissue tightly in her hands.
She stated that on the evening of February 15th 2006 a man who she described as a former college professor had invited her to an extra tutorial to help her with her essay work. She described that she found him to be over-familiar and that his actions caused her to become fearful and to leave hurriedly. She stated recent events where she came across this man again whilst out socialising has caused her great difficulty and that her recent is directly related to this”
(You could describe the nature of any alleged assault if so disclosed – but in ad-verbatim reporting)
A bad example would be:
“Jodie requested a quiet chat this evening. During the 1:1 time she told me of some horrible things that her college professor did to her a couple of years ago and this is why she is suicidal. She was distressed to the point of crying all the time as she has been through a traumatic event and needs lots of support at the moment”
Remember – what you write in the reports may be subpoenaed and admitted as evidence. You may also be required to stand for cross examination in court on anything you write so don’t speculate or embellish on anything! You may do more harm than good.
I realise that this is a bit of a waste of space but I’d just like to thank Mr Ian. I’m finding reading this series of posts very useful.
I may even join in the discussion one day, when I’m a bit more confident.
I know I’m not commenting much (I start a lot of comments then confuse myself or can’t think of the right words) but I’m finding them useful too
Where is Ted? Has he backed off since he’s realised he might be wrong?!
I suspect not.
Probably despairing that the entire mental health system does not see the error of it’s ways.
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