Mental health of the substance abuse
THE PURPOSE OF this ethnographic study was to examine psychiatric community health nurse (CHN) practices and practice issues that are influenced by an ethic of care. Psychiatric CHN interventions that support patient dignity, self-esteem and autonomy, which are often underrecognized and undervalued are described. One of the most significant insights revealed in this study, is the discovery of issues nurses face when they engage in caring acts, but confront obstacles in practice. Specifically, the negative impact of the strict regulatory mechanisms imposed by third-party insurance payers, in particular HMOs, are implicated as obstacles that create ethical conflict for psychiatric CHNs.
Nurses share an ethical commitment to the provision of care designed to meet the needs of special populations. Skills requiring critical thinking, ethical decision making, conflict resolution, and the ability to advocate for compromised populations have become important for nurses, especially those engaged in more autonomous roles, such as community health nursing. Many CHNs do not recognize the existence of ethical dilemmas in practice (Berger et al 1992; Chubon 1994; Duncan 1992; Haddad 1992 and Kristoff et al 1994), but still engage in actions that have relevance to ethical issues.
A nurse may struggle internally when witnessing conditions and obstacles in which a patient under her or his care, is seemingly or realistically the victim. Resultant choices and actions show ethical principles when they originate from a motivation to provide good care to a patient (beneficence), use funds and services in fair ways (justice), involve advocacy for the rights of the individual (autonomy), and protect the patient’s right to privacy (confidentiality). Nurses do experience internal conflict when they feel that a situation is beyond their abilities to treat but seems wrong and unfair. It is important to ask when this happens and who acknowledges this experience. Nurses themselves may not classify these experiences of conflict as ethical dilemmas, but rather identify them as “problems to be solved, or frustrations to be worked through” (Chubon, 1994, p. 16). This ethnographic study of psychiatric CHN practice documents various experiences, behaviors, and perspectives connected with the concepts of ethics and care in this realm of practice.
The experience of facing ethically laden issues in community health nursing is not uncommon. An ethical conflict is identified as “a situation that arises that leaves the provider with a sense of internal discomfort, involves competing moral claims, and forces a choice between two or more equally unsatisfactory alternatives” (Sellin, 1999, p. 4). Saveman, Hallberg, and Norberg (1996) suggested that nurses need education and support to help them confront ethical dilemmas in home care situations and that skills development in reflection and decision making have not been adequately addressed for practitioners of community health nursing. Time restraints or personal values may effect a nurse’s decision to further consider an issue, or they may cause the nurse to avoid the reflection process entirely.
Dunbar (2000) and Utterback (2001) spoke to the financial challenges home care agencies now face with the implementation of the standardized data collection tool called the Outcome and Assessment Information Set (OASIS), and the prospective payment system (PPS). The burden of accurate documentation of patient needs on which third-party reimbursement and the financial solvency of the agency depends, rests on the shoulders of the CHN. Psychiatric nursing interventions that are often aspects of therapeutic communication skills are barely assessed using the OASIS assessment and are almost never recognized as valuable enough to receive third-party reimbursement. This inequality between reimbursement for medical versus psychiatric conditions makes it far less profitable to provide nursing services to psychiatric patients, and places psychiatric CHNs in a position where their skills are undervalued and the amount of care that they are financially allowed to provide to psychiatric patients is very limited. This creates an ethical dilemma for psychiatric CHNs, who are concerned with the quality of care that psychiatric patients receive and are aware that the nature of the therapeutic relationship they provide can make a considerable difference for the psychiatric patient at home, but is generally not profitable for agencies to provide.
This ethnographic study of psychiatric CHN practice contains observations of situations in practice that provide evidence of nursing behaviors associated with a commitment to therapeutic nursing interventions and problem solving of many kinds. Studies by Aroskar (1989) and Duncan (1992) speak to some of the issues nurses practicing in community settings recognize as problematic, but they do not focus on psychiatric nurses and they do not use participant observation or interviews. One ethnographic study (Krassy, 1995) describes a Community Home Health Agency, but no ethnographic studies of Psychiatric Community Health Nursing were located in the literature. Chubon (1994) conducted an ethnographic study about homecare nurses’ experiences with AIDS patients and uncovered several ethical issues that could be applied to patients with mental illness. She pointed out that in an effort to do good, it is possible to create a blindness to the existence of conflict. The nurse may not want to experience feelings of inadequacy, which can result in a glossing over of conflict and a narrow vision of what beneficence can mean in any specific situation.
Sellin (1999) identified client autonomy, competence, and safety as the principle situational themes related to ethical dilemmas in psychiatric home care settings. She emphasized the importance of the nurse/client relationship as a valuable strategy for the prevention of full-blown ethical conflicts and of its value in promoting patient autonomy and medication compliance at home.
Tags: Health substance