Nursing Ethics Question!

[Nugget]

Hello! I have not visited this forum in awhile, and I have missed it!

I live in Canada, and have a ethical dilemma/question:

I work for an assertive community treatment team (outpatient/community psychiatry). We currently have a patient who has not been medicated for 2 years (as they refuse any and all medication), and has gradually worsened since then; However, at this point, is still considered capable to make treatment decisions.

My dilemma is this: One of the social worker's on the team approached me and asked how I would feel giving our patient money in exchange for allowing me to give them an antipsychotic injection. I told her that I felt it was unethical to essentially bribe a patient to take an injection, and that I would not feel comfortable participating in this.

Well, she consulted with our psychiatrist and our psych resident and our resident went out with the social worker and gave this patient $20 in exchange for receiving the IM (typically it is only nurses who give IM's on the team, we are just lucky to have a resident right now who is very hands-on!).

So now I feel I have been forced into this difficult situation where I do not feel comfortable bribing our patients, but this patient's IM has been restarted and the only way they would accept it is by me giving them $ (which, I should mention, this patient will end up spending on crack).

My question is: Can anyone link me to some standard of practice, or nursing regulation that will help support my standpoint when I am sure to get blow back from my co-ordinator/other team members? I couldn't find anything in the CNO standards, and would appreciate some guidance!

Cheers,

Michelle

[Sour Lemon]

I don't know the answer to your question, but it sounds like an interesting problem. We bribe psych patients to take their medication all the time, but usually with cigarettes. I've never heard of a cash exchange.

[Penelope_Pitstop, BSN, RN]

I was an ACT nurse very recently in my career. I, too, had a patient who clearly needed to be medicated due to psychotic symptoms but was with capacity in terms of decision-making. What we did was slightly different. She had been bugging her case manager to take her shopping for sneakers (the patient had the money but we were her payee and needed to approve any special request checks out of her account) so her case manager said, "well, I'll take you into the office, the nurse will give you your shot, then we'll go get your sneakers." It was the only way she would accept the shot. We were bribing? Yes, but it was with her own money.

In your case, I would tell the resident that he or she had to finish what was started, and that you are not on board with this at all. If the injection begins to work after a few doses, the patient may very well come around and realize the improvement in quality of life.

ACT is not for those who can't think outside of the box.

[offlabel]

What happens when the patient demands money for his not committing suicide? They've potentially created a worse situation. Very sloppy thinking.

[elkpark]

Perhaps you're not finding anything in the CNO literature to support your position because this actually is "a thing." Lots of programs have used monetary incentives (paying people) to get people to do various desired health-related behaviors. It's not considered automatically unethical.

"The use of monetary incentives to change health behavior is not uncommon. Incentives are used to enhance health behaviors for reducing adverse outcomes in myriad populations. Incentives to encourage drug users' participation and retention in research studies, as well as in vaccination programs, vaccine clinical trials and drug abuse treatment programs is also common (e.g. [2-5]). The use of incentives in these contexts has undergone ethical scrutiny ..."

THE SCIENTIFIC AND ETHICAL RATIONALE FOR USING INCENTIVES TO PROMOTE CONTRACEPTIVE USE AMONG DRUG-ABUSING WOMEN - HEIL - 212 - Addiction - Wiley Online Library

Other references:

Incentives to promote family planning

The Effect of Monetary Incentives and Peer Support Groups on Repeat Adolescent Pregnancies A Randomized Trial of the Dollar-a-Day Program | JAMA | The JAMA Network

[Scottishtape]

Perhaps you're not finding anything in the CNO literature to support your position because this actually is "a thing." Lots of programs have used monetary incentives (paying people) to get people to do various desired health-related behaviors. It's not considered automatically unethical.

"The use of monetary incentives to change health behavior is not uncommon. Incentives are used to enhance health behaviors for reducing adverse outcomes in myriad populations. Incentives to encourage drug users' participation and retention in research studies, as well as in vaccination programs, vaccine clinical trials and drug abuse treatment programs is also common (e.g. [2-5]). The use of incentives in these contexts has undergone ethical scrutiny ..."

THE SCIENTIFIC AND ETHICAL RATIONALE FOR USING INCENTIVES TO PROMOTE CONTRACEPTIVE USE AMONG DRUG-ABUSING WOMEN - HEIL - 212 - Addiction - Wiley Online Library

Other references:

Incentives to promote family planning

The Effect of Monetary Incentives and Peer Support Groups on Repeat Adolescent Pregnancies A Randomized Trial of the Dollar-a-Day Program | JAMA | The JAMA Network

This is very interesting. My first instinct screamed, "No!", but after reading these, I can see how it can go either way.

Great thread, OP.

[Penelope_Pitstop, BSN, RN]

This is very interesting. My first instinct screamed, "No!", but after reading these, I can see how it can go either way.

When I worked in acute care (ten years) I would have thought anything of this nature was most definitely unethical; however, that all changed in a community mental health setting, let me tell ya. It truly is a different world.

[SouthpawRN]

Interesting dilemma, can you call your BON and ask them, pretty sure they would be the "official" resource. People get paid to participate in medical research studies and drug trials all the time. I have been on the receiving end of those. Even in my statistics class we got extra credit for participating in some online research questionnaires for ongoing studies, I even won a $100 Amazon gift card and got a few Starbucks gift cards too.

I guess the idea of nonmalficence comes in (bet you didn't think you would hear that word again after graduating nursing school, heh) So do no harm? Also we are advocates for our patients but must respect their autonomy. So are we violating their autonomy by bribing them?

[elkpark]

So are we violating their autonomy by bribing them?

Are our employers violating our autonomy by paying us to come to work?

[SouthpawRN]

Are our employers violating our autonomy by paying us to come to work?

I don't have an answer for that. hence the question mark at the end of my sentence?

ANA Code of Ethics is Page 8 Code of Ethics for Nurses With Interpretive Statements

(View Only for Members and Non-Members)

[MunoRN, RN]

I was an ACT nurse very recently in my career. I, too, had a patient who clearly needed to be medicated due to psychotic symptoms but was with capacity in terms of decision-making. What we did was slightly different. She had been bugging her case manager to take her shopping for sneakers (the patient had the money but we were her payee and needed to approve any special request checks out of her account) so her case manager said, "well, I'll take you into the office, the nurse will give you your shot, then we'll go get your sneakers." It was the only way she would accept the shot. We were bribing? Yes, but it was with her own money.

In your case, I would tell the resident that he or she had to finish what was started, and that you are not on board with this at all. If the injection begins to work after a few doses, the patient may very well come around and realize the improvement in quality of life.

ACT is not for those who can't think outside of the box.

I would actually think it makes it far worse, not better, that it's her own money.

The basic premise of offering someone some sort of benefit, monetary or otherwise, for complying with a course of treatment is that otherwise they might cost the system a lot of money, so if they can reduce those costs to the system through compliance then they've earned a portion of the money that is saved.

Withholding someone's own money from them (money that is already there's) unless they are compliant would seem to be pretty straightforward financial abuse.

[Penelope_Pitstop, BSN, RN]

I would actually think it makes it far worse, not better, that it's her own money.

The basic premise of offering someone some sort of benefit, monetary or otherwise, for complying with a course of treatment is that otherwise they might cost the system a lot of money, so if they can reduce those costs to the system through compliance then they've earned a portion of the money that is saved.

Withholding someone's own money from them (money that is already there's) unless they are compliant would seem to be pretty straightforward financial abuse.

The clients for whom we were payee had at one point been deemed without capacity to make financial decisions on their own behalf (as decreed by a psychiatrist and approved legally) or decided that they needed our assistance and signed over their financial rights. Although our clientele mostly was with capacity during my tenure, we remained their respective payee. This meant that their benefit payout went to us, not them. I think any additional income went to them (not many worked).

Being their payee included a budget, which was approved by a case manager, psychiatrist and the client. Weekly checks were handed out based on said budget and special requests were also possible. However, there were stipulations within the special check request. Receipts must be turned in, the nature of the request must be in writing prior to the check being cut, and money must be available that also allowed for the aforementioned budget to continue.

This particular client never gave us receipts and was in danger of losing her special request privilege (a privilege she had agreed to). So this was, in fact, a special privilege that the case manager had to have okay'd by finance. It's not much difference than an advance on allowance or dipping into savings that weren't previously agreed upon for that purpose.