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!
I have worked in the trenches of lock down units and out patient treatment for the mentally challenged for years before crossing over to hospice. If these people were like everyone else we wouldn't neet psychiatry. We use bribes from the minute they wake up until their head hits the pillow. "If you eat all your food we can play a game," "If you swallow all your medicine I'll say you're a good person," "Your favorite nurse will give you your meds," "You can smoke a cigaretter if you etc... Almost sounds like child rearing...
The IDT team knows what they're doing legally.
Most of these people don't have family; that's why the state has control of their money as their guardians (in America).
This person is troubled and probably doesn't have any friends ether. Possibly a support group at your unit; if they attend, or do they just have an appointment with the doc? The medications are life saving for those who need them. The frame of mind with many of these people is that we are trying to poison them somehow.
This can be conscious or unconscious and that's one of the many reason needed meds are refused.
I don't think this patient is of a mindset to go out tomorrow on a loud speaker and tell the world how to get $20 if you're under mental health care. I've seen this approach many times. Sometimes with cash, candy, toys, words of encouragement, something withheld, etc...
God help this person and hopefully the medication works. Many times the meds have to be tweaked so there's another rub. This population is very different than any of the other nursing specialties. You could sit and talk with someone all day and if you didn't know your stuff you would have no idea what you're dealing with. Most do want to help themselves, but once some of them start feeling better from medication, they stop taking it...most common scenario for admitting someone against their will (involuntary admit).
As a psych RN you don't seem to have an understanding of the various techiques that need to be used for psych patients for their safety/well being. Sometimes the person just needs an excuse/reason to make it ok to take their meds.
Many of you who answered the OP have probably never worked long term in a real psych ward...or perhaps you're all seasoned psych nurses: we are a special breed.
Are our employers violating our autonomy by paying us to come to work?
I get some of the rationale for this, but this example is hardly valid. There is no equivalency there at all. At the outset, the employer employee relationship is based on two rational entities coming into a voluntary agreement with each other. The patient to caregiver relationship just can't be reduced to cash exchanges for service.
That is degrading to patients and their care givers and really demonstrates the perils of going down this rabbit hole.
As their appointed financial power of attorney it's not legal to withhold their funds unless they do something for you, this is actually felony extortion despite the legal right to manage their funds. A financial POA can only ensure that the person is spending their money appropriately, and shoes would be an appropriate purchase, 300 pairs that aren't even their size would not be.
Not doubting for a minute that this is true and appropriate. But there is no obligation for that staff to actually accompany or see to the transportation to the mall or wherever to by her shoes.
Those of you who support this, are you nuts??? What part of this is unethical don't you get? All the excuses!. To the person who said "We get bribed to go to work" (seriously?) I teach nursing ethics and what is described here is unethical. Period. What happens when the budget is tightened and the bribe money runs out? What happens when the patient leaves your environment and becomes part of an environment where monetary bribery is not an option? You get them to comply only while they're in your "care". As long as you can afford the bribe they'll take the treatment. Is that nursing? If you think so then those of us in nursing education have failed you and I'm sorry.
Those of you who support this, are you nuts??? What part of this is unethical don't you get? All the excuses!. To the person who said "We get bribed to go to work" (seriously?) I teach nursing ethics and what is described here is unethical. Period. What happens when the budget is tightened and the bribe money runs out? What happens when the patient leaves your environment and becomes part of an environment where monetary bribery is not an option? You get them to comply only while they're in your "care". As long as you can afford the bribe they'll take the treatment. Is that nursing? If you think so then those of us in nursing education have failed you and I'm sorry.
As a nursing educator, would you care to state an actual logical rationale for your determination this is unethical? Or is the extent of your response to call people expressing an opinion other than yours names? If insulting and browbeating people with specious arguments is your idea of presenting an opposing argument, then you've failed the nursing education profession. And I don't think you're sorry at all.
Hmm I too am a nurse educator, have been practicing mental health nursing since 1974, have attended the best universities both in Canada and in Australia but I respectfully disagree with your opinion. Deontological ethics is not about sticking to some didactic rules which dictate what one should or shouldn't do. It is about an enlightened , collegial discussion with others about values and principles. Thats what I was taught and what I teach and I hope that I make the world a better place as a result. The decision as to what is best for the consumer is made in this manner , of course involving the family, consumer/ patient/ client and the treating team.
It is perfectly within your rights to think I am not "sorry at all", but I can tell you I really am. Additionally, just as everyone has a right to a difference of opinion, I have that right as well. I do not agree that monetary bribery is a viable nursing approach. As nurses, we are to be the patient advocate first. I would like someone to explain how monetary bribery, which is at best a temporary or situational solution, solves a problem like medication adherence. How is bribery putting the patient in the position to achieve a permanent positive outcome if keeping them compliant depends on a bribe?
My question was, and still is, what happens when the bribe stops?
If receiving the money was the patient motivator, why should the patient comply once that is taken away? What happened to educating the patient/family as to the importance of medication adherence? Teaching the patient and having them learn the rationale for taking a medication is more likely to lead to positive clinical outcomes than paying the patient $20 to take a pill.
It is perfectly within your rights to think I am not "sorry at all", but I can tell you I really am. Additionally, just as everyone has a right to a difference of opinion, I have that right as well. I do not agree that monetary bribery is a viable nursing approach. As nurses, we are to be the patient advocate first. I would like someone to explain how monetary bribery, which is at best a temporary or situational solution, solves a problem like medication adherence. How is bribery putting the patient in the position to achieve a permanent positive outcome if keeping them compliant depends on a bribe?
My question was, and still is, what happens when the bribe stops?
If receiving the money was the patient motivator, why should the patient comply once that is taken away? What happened to educating the patient/family as to the importance of medication adherence? Teaching the patient and having them learn the rationale for taking a medication is more likely to lead to positive clinical outcomes than paying the patient $20 to take a pill.
You are certainly welcome to have a different opinion; just be clear, with yourself as well as the rest of us, that what you are stating is your opinion on the question. Your initial post above stated that you are right (that the incentive is inherently unethical) and the rest of us are wrong. "Nuts," even.
I've also taught ethics as a nursing faculty member, in more than one nursing program, and I've worked in psychiatric nursing for decades. Ethics in healthcare is about a lot more than "'A' is bad, 'B' is good." It's about examining a particular situation/dilemma from the perspective of all the fundamental ethical principles. As Katillac already requested, please explain your rationale for why using a monetary incentive in this situation is "unethical." Which ethical principles are violated, and how? The concerns and objections that you raise are practical concerns, not ethical ones.
Also, please explain how offering a monetary incentive to persuade an independent psychiatric client who has been determined to have the capacity to make her/his treatment decisions, and who has the freedom to remain in or leave treatment, to take medication s/he doesn't want to take is ethically different from our employers paying us to come to work. (I don't know about you, but I would just as soon have stayed at home and stayed in bed this morning -- getting up and coming to work was certainly not my first choice of how to spend the day, and if my employer weren't "bribing" me to be here, I wouldn't be here.
What happened to educating the patient/family as to the importance of medication adherence
Those of you who support this, are you nuts??? What part of this is unethical don't you get?
Generally ad hominem statements are not effective discussion tools........
I've never been a psych nurse and hadn't even heard of assertive community treatment before this thread, but honest question...
First of all, I'm going on the assumption that the client's mental illness is quite severe if they're requiring this type of treatment -- which is specialized and finite. By "finite" I mean that there are only so many staff members on the team, and only so many hours in a week. I can't imagine that one whose depression is well controlled with their SSRI and psych appointments qualifying for a program like this.
So, is it better for that client to refuse meds, only to have their illness escalate to the point of being a danger to self/others? And then being admitted, court getting involved, client deemed incompetent, and then lose their ability to choose/meds forcibly given?
This way, the pt is still making his own decision -- even if an incentive is involved. Once the client is stabilized on their meds, they can THEN be more effectively taught about adherence, and be more able to self-reflect on their quality of life medicated vs unmedicated.
tyvin, BSN, RN
1,620 Posts
I have worked in the trenches of lock down units and out patient treatment for the mentally challenged for years before crossing over to hospice. If these people were like everyone else we wouldn't neet psychiatry. We use bribes from the minute they wake up until their head hits the pillow. "If you eat all your food we can play a game," "If you swallow all your medicine I'll say you're a good person," "Your favorite nurse will give you your meds," "You can smoke a cigaretter if you etc... Almost sounds like child rearing...
The IDT team knows what they're doing legally.
Most of these people don't have family; that's why the state has control of their money as their guardians (in America).
This person is troubled and probably doesn't have any friends ether. Possibly a support group at your unit; if they attend, or do they just have an appointment with the doc? The medications are life saving for those who need them. The frame of mind with many of these people is that we are trying to poison them somehow.
This can be conscious or unconscious and that's one of the many reason needed meds are refused.
I don't think this patient is of a mindset to go out tomorrow on a loud speaker and tell the world how to get $20 if you're under mental health care. I've seen this approach many times. Sometimes with cash, candy, toys, words of encouragement, something withheld, etc...
God help this person and hopefully the medication works. Many times the meds have to be tweaked so there's another rub. This population is very different than any of the other nursing specialties. You could sit and talk with someone all day and if you didn't know your stuff you would have no idea what you're dealing with. Most do want to help themselves, but once some of them start feeling better from medication, they stop taking it...most common scenario for admitting someone against their will (involuntary admit).
As a psych RN you don't seem to have an understanding of the various techiques that need to be used for psych patients for their safety/well being. Sometimes the person just needs an excuse/reason to make it ok to take their meds.
Many of you who answered the OP have probably never worked long term in a real psych ward...or perhaps you're all seasoned psych nurses: we are a special breed.