ETHICAL AND LEGAL FOUNDATIONS OF PMHNP CARE PEER REVIEWS
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Introduction
According to the Centers for Disease Control and Prevention, child abuse and neglect encompass physical abuse, sexual abuse, emotional abuse, and neglect, and are health problems detrimental to the public (U.S. Department of Health and Human Services, n.d.a.). Child abuse and neglect includes individuals under the age of 18 who are abused by a parent, caregiver, or another person (teacher, church leader, coach, etc.) that results in harm, potential for harm, or threat of harm to a child (U.S. Department of Health and Human Services, n.d.a.). Elder abuse involves individuals over the age of 60 who are intentionally abused or abused due to the failure of another person or body of people to act in a situation that creates or harms an older adult (U.S. Department of Health and Human Services, n.d.b.). Elder abuse includes physical abuse, sexual abuse, emotional or psychological abuse, neglect, and financial abuse that occurs by the elder’s caregiver or by someone they trust (U.S. Department of Health and Human Services, n.d.b.). The purpose of this discussion is to briefly touch on child and elder abuse reporting, then locate and discuss four scholarly, professional, or legal resources related to child and elder abuse reporting in the Walden Library that address ethical and legal considerations related to child and elder abuse reporting, and explain how this information could apply in my future clinical practice, including specific implications for practice within the state of Florida.
Ethical Considerations Related to Child Abuse Reporting
In the first article I reviewed, Forsner et al. identified a gap in “incidences and frequency” pertaining to the number of child abuse cases reported and their research indicated that moral conflicts drove abuse underreporting (2021). The aim of this study was to better understand the experiences of school professionals and their ethical deliberations in reporting abuse and/or neglect to the Social Welfare Board, as they are required by law to do so (Forsner et al., 2021). Other studies cited in the article found that “emotional distress” and “compassion fatigue” were common occurrences experienced by professionals in child protection (Forsner et al., 2021). The article also cited a scholar, Megan-Jane Johnstone and pointed out that research on obstructions related to the mandatory reporting of child abuse, specifically ethical aspects, needs further research in order to create and devise reliable interventions (Forsner et al., 2021).
Overall, moral conflicts in the professionals working at the school ultimately inhibit, to an extent, the proper reporting of child abuse and/or neglect. The most prominent barrier to child neglect or abuse noted in this study was the fear of negative consequences for the child, followed by negative consequences for the school professionals (Forsner et al., 2021). The authors of this study found that professionals felt pressured to make the right decision for the child due to the child’s dependency on the decisions being made on their behalf (Forsner et al., 2021). The study participants were concerned that reporting child abuse or neglect to Social Services would hurt their relationship with the child and would make them possibly unable to help the child (Forsner et al., 2021). They also found that the school professionals’ relationship with the child’s parents and negative experiences with Social Services made school professionals unlikely to report child abuse and/or neglect (Forsner et al., 2021).
Ethical Considerations Related to Elder Abuse Reporting
In the second article I reviewed, Yip et al. interviewed 17 healthcare professionals in British Columbia with experience in authorizing emergency legislation in relation to abuse, neglect, and self-neglect, to gain a better understanding about circumstances that lead up to an emergency response, and how individual roles are carried out by these professionals in the reporting process (2022). In the BC, the Adult Guardianship Act (AGA) designates responsibility to the emergency medicine personnel to report the abuse and neglect of adults 19 years and older, and specifically designates agencies to intervene if the adult is suspected to be abused/neglected and/or if the adult is incapicated (Yip et al., 2022). The AGA gives certain agencies “the authority to enter an adult’s residence without a court order, remove the adult to a safe place, provide emergency health care if needed, and/or take any other emergency measure that is necessary to protect the adult from harm” (Yip et al., 2022). The authors of this article admit that there is little research that explores how medical professionals navigate the sestressful situations regarding decision-making in situations of abuse, neglect, and self-neglect (Yip et al., 2022). The aim of this article was to gain insight into the decision-making process of mandated reporters in emergency situations of abuse, neglect, and self-neglect (Yip et al., 2022).
The article found that these complex situations involving the mandated reporting of abuse, neglect, and self-neglect require careful consideration of the situation, the adult’s mental capacity, the medical personnel’s ethical values, and the legal criteria surrounding this time-bound critical scenario (Yip et al., 2022). The study found that a medical personnel’s ethical decision-making process can lead to over-protection or under-response based on the location of the older adult and their medical diagnosis (Yip et al., 2022). For example, indigenous clients and individuals with mental health or substance use issues experiencing abuse, neglect, and/or self-neglect went underreported (Yip et al., 2022). These stereotypes and preconceptions by the medical personnel based on location, race, socioeconomic status, age, and diagnosis ultimately shape decision-making and prove ethical implications to be present (Yip et al., 2022). In regards to self-neglect, the study proved that medical workers are under moral distress when challenged with respecting the older adult’s autonomy in comparison to their duty to treat (Yip et al., 2022). The ethical dilemmas presented in this article led the authors to suggest the development of guidelines to help navigate the grey areas in the decision-making process of medical professionals (Yip et al., 2022).
Legal Considerations Related to Child Abuse Reporting
The third article I reviewed authored by Zicherman and Chien, reviewed the ruling in the Supreme Court case State v. James-Buhl, 415 P.3d 234 (Wash. 2018), where a teacher, Tanya James-Buhl, was prosecuted for not reporting known child abuse or neglect (2019). The case read that Tanya James-Buhl failed to report inappropriate touching of her three minor daughters by her husband, the three children’s stepfather and that she failed to comply with a statute requiring professional school personnel to report actual or suspected child abuse or neglect (Zicherman and Chien, 2019). Tanya James-Buhl had never been a teacher to any of her daughters. One of the daughters told the pastor of her church that Mr. Hodges, her step-father, was inappropriately touching her and the pastor contacted Child Protective Services (Zicherman and Chien, 2019). After a police investigation, it was determined that all three daughters of Tanya James-Buhl were sexually abused in the family home (Zicherman and Chien, 2019). The Washington State Supreme Court ruled that Tanya James-Buhl was not subject to state-mandated reporting because her knowledge of the abuse was not connected with her professional role as a teacher (Zicherman and Chien, 2019).
The Washington State Supreme Court analyzed the current law at that time, Code § 26.44.030 (2018), and came to the conclusion that the mandatory reporting law upheld by psychiatrists, mental health practitioners, teachers, counselors, administrators, child care facility personnel, and school nurses, does not imply that the duty is “unlimited” because it specifically pertains to certain occupations as the general public (Zicherman and Chien, 2019). The ruling of this case provides psychiatrists, among other mental health professionals, the ability not to jeopardize the practitioner-client relationship by upholding mandatory reporting laws (Zicherman and Chien, 2019). This case shines a light on the idea that legal responsibility is not always the same as ethical responsibility and vice versa (Zicherman and Chien, 2019). In cases like this, the best interest of the child should always be the priority.
Legal Considerations Related to Elder Abuse Reporting
In the last article reviewed, Hernandez-Tejada et al. set out to research and compare the correlates of elder abuse such as health and mental health symptoms in terms of demographic factors such as age, race, ethnicity, sex, cohabitation status, employment status and to identify causal links of elder abuse in terms of disparities in outcomes across these demographic factors (2020). The sample included 183 participants reporting elder abuse as any emotional, physical, or sexual mistreatment since 60 years of age (Zicherman and Chien, 2019). Psychopathology was defined as the criteria are outlined in the DSM-5-TR for generalized anxiety disorder, major depression and post-traumatic stress disorder (Zicherman and Chien, 2019).
This study noted very few causal links of elder abuse with regard to self-reported psychopathology and/or health (Zicherman and Chien, 2019). Only low income per household was associated with increased psychopathology in the elder abuse victim population, and only low income per household and unemployment were associated with poor self-rated health (Zicherman and Chien, 2019).
Applications in Clinical Practice and Florida State Laws
As a future psychiatric mental health nurse practitioner, it is important that not only am I able to recognize signs of abuse and/or neglect in this vulnerable population, it is even more important that I recognize my ethical and legal duties in reporting such abuse and/or neglect. Ethically speaking, it is always a balance to recognize what is best for the individual versus what is legally responsible. It is always important to remain unbiased and not let race, socioeconomic status, sex, age, or physical location influence my sphere of decision-making. Per the last study, it is helpful to recognize low household income correlates with increased psychopathology and to screen clients appropriately in my future clinical practice. Finally, when in doubt, I would always confer with a trusted college or mentor to gain better insight into a situation.
Chapter 39 of the Florida Statues mandates that any individual who knows or suspects that a child has been abused, neglected, or abandoned by the person responsible for the child’s welfare, must report such findings to the Florida Abuse Hotline of the Department of Children and Families (Florida Department of Children and Families, 2013). Also, Florida Chapter 415 mandates reporting of a vulnerable adult defined as an individual over the age of 18 years whose ability to perform the normal activities of daily living or to provide for his/her own care or protection is compromised due to a disability, brain damage, or the susceptibilities of aging (Florida Department of Children and Families, 2013).
In the state of Florida, everyone shares a responsibility to report suspected abuse or neglect, but some occupations require mandatory reporting and are identified as “professionally mandated reporters” (Florida Department of Children and Families, 2013). Mental health providers that are state mandated reporters include any hospital personnel, any health professional, any institutional worker, any mental health professional or nurse, or social worker or professional child care worker (Florida Department of Children and Families, 2013). A Florida State professionally mandated reporter is required by law to report any child abuse or neglect and must provide the Abuse Hotline Counselor with their full name when making the report (Florida Department of Children and Families, 2013). The professionally mandated reporter’s name is entered into the report but will remain confidential (Florida Department of Children and Families, 2013). To reach the abuse hotline, dial 1-800-96-ABUSE, or (18009622873) (Florida Department of Children and Families, 2013).
References
Florida Department of Children and Families. (2013). Reporting abuse Of children and vulnerable adults. https://www.myflfamilies.com/
Forsner, M., Elvhage, G., Ewalds-Kvist, B. M., & Lützén, K. (2021). Moral challenges when suspecting abuse and neglect in school children: A mixed method study. Child & Adolescent Social Work Journal, 38(6), 599–610. https://doi.org/10.1007/s10560-020-00680-6
Hernandez-Tejada, M. A., Frook, G., Steedley, M., Watkins, J., & Acierno, R. (2020). Demographic-based risk of reporting psychopathology and poor health among mistreated older adults in the national elder mistreatment study wave II. Aging & Mental Health, 24(1), 22–26. https://doi.org/10.1080/13607863.2018.1509296
U.S. Department of Health and Human Services. (n.d.a.). Fast facts: Preventing child abuse and neglect. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html
U.S. Department of Health and Human Services. (n.d.b.). Fast facts: Preventing elder abuse. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html#:~:text=Elder%20abuse%20is%20an%20intentional,a%20person%20the%20elder%20trusts.
Yip, S. H., O’Connor, D., Shakeri Shemirani, F., Brown, A., & Hyman, J. (2022). Emergency assistance in situations of abuse, neglect, and self-neglect: Exploring the complexity and challenges. Journal of Elder Abuse & Neglect, 34(2), 124–151. https://doi.org/10.1080/08946566.2022.2070317
Zicherman, B., & Chien, J. (2019). Limits to mandatory child abuse reporting. Journal of the American Academy of Psychiatry and the Law, 47(3), 384–385.
Peer2
Informed Consent and Capacity in Psychiatric-Mental Health Practice
My chosen topic spans the critical ethical and legal dimensions surrounding informed consent and capacity when providing mental health interventions to children and adults. The articles selected for this topic chronicle historical milestones, emerging jurisprudence, plus new scientific advances expanding constructive engagement pathways for handling children and adults with mental health problems. The articles also advocate for formal policies guiding tiered capacity assessments using tools factoring evolving cognitive abilities and balancing rights with care needs.
Summary of Article on Ethical Considerations for Adults
The article by Ventura et al. (2021) conducts an extensive scoping literature review encompassing over 300 initial studies on the critical relationship linking nursing care, human rights, and ethical considerations, specifically within the sphere of mental healthcare delivery. By systematically consolidating, codifying, and analyzing prior academic work chronologically spanning over four decades using robust qualitative methods, the authors ultimately spotlight the indispensable custodial role undertaken by mental health nurses in tirelessly striving to architect caring interventions firmly grounded in both upholding patient dignity as well as clinical appropriateness. However, the thematic synthesis also reveals the constant tightrope walk and balancing act expected from this community of healing professionals who assume responsibility for continually judging situations along spectrums of risk versus rights, restrictive safeguards versus nurturing autonomy, and medical mandate versus moral agency - while combating stigma and its impacts on help-seeking behaviors. The solutions proffered center around proactive training plus institutional policy reforms that embed human rights understanding firmly within all aspects of psychiatric ecosystem functioning.
Summary of Article on Ethical Considerations for Children
The article by Söderberg et al. (2022) utilizes semi-structured interviews capturing granular experiential insights from a total of fifteen nurses and assistant nurses employed within a specialized psychiatric inpatient facility tailored exclusively for distressed children and adolescents. By probing study participants across numerous facets encompassing perceived roles, expectations, duties, strengths, weaknesses, and detailed reactions to a tailored vignette scenario depicting patient aggression, the authors spotlight the glaring gap separating espoused care ideals from ground realities shaped by resource constraints, unclear hierarchies, role ambiguities and pathways dependencies that collectively constrain the realization of recovery-promoting nursing practice. However, the findings do suggest faint signals highlighting person-centered care attempts and relationship-building efforts on the part of motivated individuals punching above their professional weight within complex multi-disciplinary environments suffering from medical model dominance. Hence, it becomes imperative for the whole ecosystem, spanning regulators, executives, and physician leaders, to actively acknowledge and formally elevate the entire specialized nursing function to attract, nurture, and retain talent capable of manifesting continuity of trust and care.
Summary of Article on Legal Considerations for Adults
Delving into the pressing requirements within graduate nursing education, the article by Mangano et al. (2020) analyzes self-reflective journals maintained by students enrolled in a post-master specialist certification program aimed at augmenting core psychiatric mental health competencies for established nurse practitioners seeking career transitions. By framing insights using the Dreyfus model encompassing skill progression from novice to expert, the study highlights prime knowledge and experience barriers related to collaborative decision-making dealing with treatment plans, pharmacological interventions, plus symptom monitoring - domains demanding a combination of therapeutic relationships grounded in empathy and ethos of service to offset the depersonalized interventionist tendencies prevalent within medicalized environments. Hence, robust mentoring partnerships blending both scientific grounding and wise coaching become pivotal for shaping the next generation of advanced nursing practice able to balance both the art and science of psychiatric care delivery at the community scale using risk-benefit evaluations spanning both sides of the therapeutic table.
Summary of Article on Legal Considerations for Children
Finally, this article by Reiss et al. (2019) executes an empirical evaluation leveraging longitudinal nationally representative survey datasets gathered from over two thousand children and adolescents monitored carefully across areas of socioeconomic positions, stressful life events, and detailed mental health diagnostics. By rigorously incorporating elements of bivariate inquiry, hierarchical modeling, plus multivariate sensitivity analyses, the study investigates intricate associations linking parental income levels, housing situations, educational qualifications, employment statuses, and other common markers used to encapsulate lifetime advantage levels passed down generations along with traumatic disruptions plus adversities documented over assessment years - in order to quantify consequent impacts on childhood psychosocial well-being. Among all factors assessed, low parental education emerges as the factor compounding absolute and relative vulnerabilities even after controlling for the severity of external shock events - thus underscoring the essential protective buffer conferred by knowledge and coping capacities within caregiving environments. Hence, from a public health perspective, policy priorities seeking to alleviate psychiatric risks facing disadvantaged youth should likely emphasize early parenting support.
Practical Implications
As a practicing psychiatric nurse serving vulnerable children and adolescents grappling with developmental crises against a complex societal landscape marked by increasing disconnectedness, inequality of access, and broken support systems across Minneapolis - the progressive statutes governing our state, emerging practice guidelines from specialty chapters, as well as rising community activism around promoting young persons' agency - all converge to impose outstanding moral obligations as well as practical imperatives to reimagine the format and spirit of truly informed participative care.
Specifically, within intake evaluations, crisis response protocols as well and longitudinal treatment planning procedures, it becomes imperative to budget dedicated slots, allowing clients space to describe motivations, goals, preferences, plus apprehensions without excessive interruptions - opening doors for collaborative inquiry and trust-building. When confronting scary psychotic specters or suicidal compulsions, the emphasis on minimum necessary interventions to assure the safety and engagement of substitute decision-makers in a light-touch manner while seeking the least restrictive resources follows directly from the principles. Formally assessing and clearly documenting consent capability matrices spanning multidimensional symptom insight, situational appreciation, rationing ability, plus communication avenue effectiveness provides structured mechanisms for periodic reviews examining trajectory progress to expand self-determined choice opportunities responsibly. From a custodial team perspective, dedicated peer recovery specialist partners with lived mental health challenges aid in tempering clinical overreach tendencies by enlightening the hidden strengths behind perceived deficits through positive counter-narratives centered upon dignity and hope.
On the policy front, firmly embedding elements of trauma-informed care, de-escalation preparedness, calm spaces, sensory modulation, plus positive behavior support within therapeutic milieus helps acknowledge that irrational moments likely reflect skills gaps rather than character flaws. Accordingly, responses start aligning to nurture capability building for both clients and caregivers. Lastly, the relentless quest to keep youth voices meaningfully elevated during each evolutionary epoch requires consumer councils, youth movements as well and school-linked early intervention vehicles to sustain the impetus for systems change - so the next generation of struggling teens have access to compassionate solidarity on arduous journeys towards actualized potential.
References
Mangano, E., Gonzalez, Y., & Kverno, K. S. (2020). Challenges faced by new psychiatric–mental health nurse practitioner prescribers. Journal of Psychosocial Nursing and Mental Health Services, 58(10), 7-11. https://www.ispn-psych.org/assets/challenges-faced-by-new-psychiatricmental-health-nurse-practitioner-prescribers.pdfLinks to an external site.
Reiss, F., Meyrose, A. K., Otto, C., Lampert, T., Klasen, F., & Ravens-Sieberer, U. (2019). Socioeconomic status, stressful life situations and mental health problems in children and adolescents: Results of the German BELLA cohort-study. PloS One, 14(3), e0213700. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0213700Links to an external site.
Söderberg, A., Ejneborn Looi, G. M., & Gabrielsson, S. (2022). Constrained nursing: Nurses' and assistant nurses' experiences working in a child and adolescent psychiatric ward. International Journal of Mental Health Nursing, 31(1), 189-198. https://onlinelibrary.wiley.com/doi/full/10.1111/inm.12949Links to an external site.
Ventura, C. A. A., Austin, W., Carrara, B. S., & de Brito, E. S. (2021). Nursing care in mental health: Human rights and ethical issues. Nursing Ethics, 28(4), 463-480. https://sci-hub.se/https://doi.org/10.1177/0969733020952102Links to an external site.
