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!
Specializes in LTC, assisted living, med-surg, psych.
Are our employers violating our autonomy by paying us to come to work?
Bingo! I was getting all set to say how unethical I thought it was to bribe patients into doing what we wanted them to do, and then Elkpark comes up with this brilliant answer. I totally agree, BTW.
Thats a tricky question but perhaps there is a way forward. Has the team involved the family in the decision making process? As a mental health nurse and a mother I have no problem with the process and probably would be providing the $20 dollars myself. When I was a case manager on an ACT team in Montreal I took a consumer out for a coffee because he came to my office having shaved, showered and had wore clean clothes.
I can remember paying my daughter to practice the piano, but she ended up quitting anyways but that is another story.
Specializes in Medsurg/ICU, Mental Health, Home Health.
Has the team involved the family in the decision making process?
I can't speak for the OP, but I know that family involvement, period, depends on the client culture, so to speak. I worked on three different teams through two agencies and on my original team, I would say less than a quarter of clients had regular family involvement. Several had none. Then again, this was an ACT population that was either A) formerly a long-term resident in a state psych facility or B) if younger, dual diagnosis and/or a serious legal history...any of the above can lead to family estrangement.
I may be speaking out of turn, but I know that involving the family could often be impossible for us. We were the support system....although the clients within that agency had a strong sense of community among themselves. The other agency didn't have that and tended toward a population less likely to have been institutionalized for sometimes decades. Interesting how much difference when technically the same population was served (same admission standards and same geographical area covered).
It's nice to encounter other ACT folks. It's so difficult to explain what we do. (Did, in my case).
It's a great idea for that one client. But she's going to mention it to a friend, and they'll tell two friends, and they'll tell two friends, and so on, and so on... How are you going to handle everyone else that wants money for taking their meds? What else will she want money for? The whole program could snowball.
People with psychotic illnesses and concurrent substance abuse are at high risk for self harm which can result in chronic disability and the cost of a lifetime of health care for a person living with chronic disability is millions of dollars. If $20.00 a month motivates a person to receive treatment for their psychotic disorder and prevents self harm, then it's money worth spending. Although the patient may be initially motivated by the money, the hope is that they will 'feel better' as their intrusive thoughts are decreased by the medication and 'feeling better' will motivate them to continue taking their medication.
If you see if happening I would report it, as well as chart what I saw. I would keep extremely careful notes on this situation because it stinks to high heaven. In the meantime look for a new job whaere they don't ask you to do illegal things to get all the boxes ticked.
If you see if happening I would report it, as well as chart what I saw. I would keep extremely careful notes on this situation because it stinks to high heaven. In the meantime look for a new job whaere they don't ask you to do illegal things to get all the boxes ticked.
I agree that thorough and complete documentation is always appropriate in healthcare settings of all kinds; however, what do you see in the OP's scenario that you consider "illegal"? Even the OP is asking about ethical concerns, not legal concerns.
Specializes in Hospital medicine; NP precepting; staff education.
Most behavior modification plans I've encountered have a form of positive reinforcement. The item or "carrot" is agreed upon by the interdisciplinary team and put into writing for consistency and documentation.
Specializes in Medsurg/ICU, Mental Health, Home Health.
In the meantime look for a new job whaere they don't ask you to do illegal things to get all the boxes ticked.
Getting all of the boxes ticked?
Let me reiterate what others (and I) have already said...
the purpose of an ACT team is to keep those at greatest risk for institutionalization living as independently as possible in the community.
Many, many of the clients rely on long-term depot injections of anti-psychotics to keep them out of harm's way. Without the medication, these individuals are not capable of living independently due to the nature of their illness. Their quality of life is poor, their self-care likewise and judgement altered. They may make decisions that, if medicated, would not have been made. However, it's very difficult to commit these individuals - they would have to be deemed a danger to themselves or others.
Trust me, there's nothing about ticking boxes. It's about keeping people out of the hospital, out of prison, alive and accounted for. There are no nurse managers looking over your shoulder at all times and no one is getting in trouble or being chided because a client refuses medications. It is a social work-based module that utilizes nurses in a different way than even an inpatient psych unit.
Furthermore, the psych resident concocted this idea. He or she is not, just as in the hospital, the supervisor of any nurses. The agency isn't asking for anything shady to be done. The resident took it upon herself or himself to do this. And it wasn't for any compensation on the resident's part. Reimbursement is based on maintaining standards for therapeutic contact as defined in the agency's contract with the government.
ACT is rough. While some ACT nurses do usually see clientele in an office, it's encouraged that most encounters are at a client's residence if not in the community. It's a nursing job that is not comparable to any other.
I understand your concern for the OP's employment, but it's really hard to look at this and compare it to a situation that would arise in a hospital.
I'm getting a blank page on page 8 of the Code of Ethics on your link. What concerns about the OP's scenario do you think are addressed by the ANA Code of Ethics?
I will just add that, had the RN done this (pay the client to take the shot) independently, autonomously, without discussing this with the rest of the treatment team, I would have significant concerns about the situation. But this is an intervention that was decided on and endorsed by the rest of the treatment team. I agree that, if the OP is uncomfortable with the situation, she should address her/his concerns with the rest of the treatment team. However, it is also true that there is a sizeable body of literature available on the ethics and efficacy of the use of incentives in healthcare.
(And are you really unsure about whether getting paid for our work is a violation of our autonomy? :))
Where does the funding come from? The only issue I see is if the funding comes from the patient's own money supply period Then it could be that you would holding his own money from him if he doesn't comply.
If Community or government funds are used you have a situation where fellow patient might say "Hey where's my money for taking my meds??"
I've seen situations where a provider puts himself in the position of Good Samaritan and provides some special service but then when that person leaves, the subsequent staff gets the deal with the tantrum when the patient doesn't get it.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
This is the most interesting thread I've ever seen on Allnurses.
I think what we are missing in the conversation, is that the OP says that she is almost certain that the patient would spend the money on crack. Given that, there is another ethical layer to the story.
I suppose that problem could be bypassed if the patient was agreeable to a different type of incentive. But if he isn't, then there's little difference between saying "You can have 20 bucks if you take your injection" and "You can smoke crack if you take your injection."
Still not sure whether or not incentives are ethical even without the crack problem, but I think it's a pressing issue in this particular case.
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VivaLasViejas, ASN, RN
22 Articles; 9,996 Posts
Bingo! I was getting all set to say how unethical I thought it was to bribe patients into doing what we wanted them to do, and then Elkpark comes up with this brilliant answer. I totally agree, BTW.