What are the key considerations for nursing care in mental health, particularly in regards to respecting patients' human rights and addressing ethical issues across diverse demographics, including adolescents and geriatric individuals?

Nursing Care in Mental Health: Human Rights and Ethical Issues

Core Ethical Principles

Mental health nursing must prioritize patient autonomy and dignity above all else, with persons in mental health settings primarily viewed as people who need to lead their lives in the most autonomous and pleasant way possible, rather than as subjects requiring institutional control. 1

The foundational framework for ethical mental health nursing care rests on seven overarching principles:

• Autonomy as the primary goal: Regulations and institutional organization must reflect the goal of autonomous living rather than interfere with it, including respecting resident choice in daily activities such as time to rise, whether to be alone or with others, and participation in decision-making. 1

• Quality of life as inseparable from quality of care: High-quality mental health care is only possible where overall care is of high quality, requiring institutional commitment at all administrative and medical leadership levels. 1

• Treatment must follow assessment: The tendency to overemphasize assessment while neglecting treatment implementation must change, as assessment without intervention violates the ethical duty to provide care. 1

• Trusting relationships over institutional control: The nursing culture must foster trusting relationships that build community, support residents' contributions to life around them, and acknowledge resident choice. 1

Critical Human Rights Considerations

Psychiatric medications must never be used as "chemical restraints" to control behavior, and clear distinction must be made between appropriate treatment of identified psychiatric symptoms versus restraining residents' activity. 1

Key human rights protections include:

• Voluntary consent and legal capacity: Psychiatric patients are vulnerable, and their participation in care decisions involves ethical dilemmas regarding voluntary consent, legal capacity to consent, freedom of choice, and sufficient comprehension. 2

• Protection from paternalistic practices: Mental health nurses frequently engage in acts of paternalism with common justifications for those acts, creating moral conflict between professional duties and patient autonomy. 3

• Adequate staffing as a human rights issue: Adequate staffing is essential to providing good mental health care, facilitating strengthened staff-resident relationships through permanent assignments and enabling closer observation of resident preferences. 1

Common Ethical Violations in Practice

Research reveals systematic ethical problems in psychiatric nursing that directly impact patient rights:

• Neglect and rude/careless behavior: Leading to disrespect of patient rights and human dignity. 4

• Bystander apathy: Failure to intervene when witnessing unethical treatment of patients. 4

• Authoritarian attitudes and intimidation: Using power dynamics to control rather than support patients. 4

• Violation of privacy and confidentiality: Disrespect of privacy, dishonesty or lack of clarity, and violation of confidence. 4

• Physical interventions during restraint: Inappropriate use of physical force without proper justification or documentation. 4

• Stigmatization: Perpetuating negative stereotypes about mental illness that violate human dignity. 3, 4

Specific Considerations Across Demographics

Geriatric Populations

For elderly patients with mental health needs, a lower starting dose of psychiatric medications (0.5 mg twice daily) is mandatory, reflecting decreased pharmacokinetic clearance and greater frequency of comorbidities. 5

• Depression affects 25-48% of hospitalized elderly patients, representing significantly higher rates than community settings and requiring systematic screening with validated instruments. 6

• Elderly patients exhibit greater tendency to orthostatic hypotension, requiring monitoring of orthostatic vital signs and careful titration to minimize risk. 5

• Patients with Parkinson's Disease or Lewy Body Dementia experience increased sensitivity to antipsychotics, manifesting as confusion, postural instability with frequent falls, and extrapyramidal symptoms. 5

• Unrecognized pain is common in dementia and manifests as increased behavioral symptoms or apparent psychiatric deterioration, requiring comprehensive pain assessment. 7

Adolescent Populations

For adolescents with mental health conditions, initial dosing must start at 0.5 mg once daily with careful titration, as somnolence is the most commonly observed adverse reaction and higher doses are associated with more adverse events without additional benefit. 5

• More than half of individuals who develop dementia had depression or irritability symptoms prior to cognitive impairment, making distinction between primary depression and early cognitive decline challenging in all age groups. 7, 6

• Long-term effects on growth and sexual maturation have not been fully evaluated in children and adolescents receiving antipsychotic medications, requiring ongoing monitoring. 5

Practical Framework for Ethical Decision-Making

When Considering Involuntary Treatment

Nurses must differentiate between rights-based approaches (emphasizing autonomy and legal protections) and relational ethical approaches (emphasizing therapeutic relationships and care), as 55.4% of nurses confuse these two frameworks. 8

The decision algorithm should follow:

1. Assess immediate safety risk: Is there imminent danger to self or others that cannot be managed through less restrictive means?

2. Evaluate decision-making capacity: Does the patient have sufficient knowledge, comprehension, and legal capacity to consent? 2

3. Explore less restrictive alternatives: Have all non-coercive interventions been attempted, including environmental modifications, reorientation strategies, and therapeutic communication? 6

4. Document medical necessity: Is there an identified psychiatric symptom requiring treatment, rather than behavioral control? 1

5. Ensure proper legal framework: Does the intervention comply with applicable mental health legislation regarding involuntary detention and treatment? 9

Environmental and Cultural Modifications

A homelike physical environment with spontaneity generated by children, pets, and plants is a necessary ingredient of high quality of life and success in managing behavioral symptoms. 1

Specific interventions include:

• Multi-component non-pharmacological interventions should be implemented immediately for all patients, including reorientation strategies, environmental modifications, and continuity of care. 6

• Permanent staff assignments to facilitate strengthened relationships and enable nursing assistants to participate meaningfully in interdisciplinary care planning. 1

• Individual and family psychosocial screening as part of routine care, addressing caregiver understanding of the link between medical illness and behavioral symptoms. 6

Critical Pitfalls to Avoid

Never add anticholinergic medications to treat any symptoms in elderly patients with mental illness, as these worsen confusion and cognitive function. 6

Additional critical errors include:

• Misinterpreting new-onset depression as purely psychiatric when it may represent early dementia, particularly in older adults. 7, 6

• Using antipsychotics or benzodiazepines for routine delirium treatment, particularly for hypoactive delirium, as these are contraindicated. 6

• Failing to screen for dehydration and malnutrition as common precipitating factors for delirium and behavioral changes. 6

• Neglecting to reassess mental status regularly (every 6 months minimum for stable patients, more frequently during acute illness) as new behaviors emerge. 6

• Insufficient personnel, excessive workload, and lack of supervision leading to unethical behaviors that violate patient rights. 4

Educational and Systemic Requirements

Nurses with bachelor's degrees differentiate significantly better between rights-based and relational ethical approaches than nurses without degrees, indicating the critical importance of formal education in psychiatric nursing ethics. 8

System-level requirements include:

• Formal agreements with consulting mental health providers for training, consultation, and treatment services should be a required component of care. 1

• Expanded Medicare-covered services to ensure adequate payment for training of nursing home staff, administrative consultation, record review, and supervision of care. 1

• Mental health indicators collected and reported as part of quality improvement profiles, including proportion of residents with depressive symptoms receiving treatment. 1

• Training frontline staff in behavioral assessment and interventions, which is associated with enhanced staff satisfaction and retention beyond better health care outcomes. 1