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With the evolution of psychiatric nursing as a profession, along with the development of practice based on theory, the role of client advocate has become increasingly important and complex for the professional psychiatric nurse.

This paper is a discussion of ethical and legal issues encountered by the professional psychiatric nurse when acting as an advocate for clients. This discussion includes an overview and definition of advocacy and ethics. This overview provides a framework for discussion of issues encountered by the psychiatric nurse when acting as an advocate for the client.

The next section provides a working definition of advocacy in the context of the nurse-client relationship.

To discuss ethical and legal issues that nurses may encounter when acting as an advocate for the client, a definition and understanding of advocacy is necessary.

According to Kohnke (cited in Leddy and Pepper, 1993 p. 438), advocacy in nursing is "the act of informing and supporting a person so that he can make the best decisions possible for himself". In a review of Kohnke's notion of advocacy, Johnstone notes "informing is supplying patients with the information they need in order to make informed decisions" (1995, p. 280). Johnstone also notes that "supporting consists of two roles notably an action role and a non-action role" (1995, p. 280). Johnstone describes the action role of support as "assuring patients that they have both the right and the responsibility to make their own self-determining choices; and, second, of reassuring patients that they do not have to give in to pressure from others to change [their] decisions if [they] do not choose to" (1995, pp. 280-281). In her description of the non-action role, Johnstone notes it demands "that the advocate refrains from subtly undermining a patient's decision - especially if it is a decision with which the advocate does not agree" (1995, p. 281). Leddy and Pepper note that Kohnke's definition of advocacy "serves the client in supportive ways, acts on behalf of the client and shares full or at least mutual responsibility in decision making with the client" (1993, p. 438).

In their discussion of the advocacy role, Leddy and Pepper (1993, pp. 439-441) indicate that an emphasis must be placed on mutuality in the nurse-client relationship, facilitation of client strengths, protection of the client in the health care delivery system and coordination of health services for the client.

In examining mutuality and the advocacy role, Leddy and Pepper note that "evidence is abundant that decisions made for persons by other persons without participation of those affected or those who have the expertise to make the most informed judgments are less likely to be understood or workable" (1993, p. 439). In their examination of the concept of mutuality in acting as a client advocate, Leddy and Pepper state "nurses have both the expertise in health and the ability to help people achieve health. Clients have the expertise in understanding and evaluating their situations; they have control of their lives and their health" (1993, p. 439). Leddy and Pepper conclude that "it is entirely appropriate that decisions affecting health be made by the client, with full informational support, empathy, and respect from the nurse" (1993, p. 439).

Facilitation of client strengths as noted by Leddy and Pepper is that the "advocate assumes that every client has strengths and that the nurse's job is to help the client to use those strengths to achieve the highest level of health possible" (1993, p. 440). According to Kohnke (cited in Leddy and Pepper, 1993 p. 440) "emphasis on facilitation in the advocacy process requires that the advocate take responsibility to make sure they (clients) have all the necessary information to make "informed decisions" and to support clients in the decisions they make".

In looking at the role of protector and advocacy, Leddy and Pepper believe that "the greatest need for the nurse to act as protector is the need to change a condition or situation in the health care delivery system in which either the client is given inadequate care or the environment poses some hazard" (1993, p. 440). This protective role described by Leddy and Pepper means "the nurse is obliged to monitor the quality of care and to be responsible for intervening when harmful behaviors are observed in any health care worker" (1993, p. 440). Mauksch and Miller (cited in Leddy and Pepper, 1993 p. 440) state "this does not mean that one acts as an adversary to a colleague, but rather that the client is protected and efforts are made to resolve the conflict resulting from the client's protection needs".

Leddy and Pepper indicate "the most widely accepted client advocate role is that of coordinator" (1993, p. 441). In their discussion of coordination, Leddy and Pepper state "it is usually acceptable for the nurse to articulate the relationships among the various health care workers caring for the client" (1993, p. 441). They indicate acceptability of the nurse for this role is because "the nurse is the one professional focusing on the client's whole response to his health situation, the nurse can use coordination to ensure that the client has access to all parts of the delivery system needed and that the various services are offered at an appropriate time, place, and cost for the client" (1993, p. 441).

Having presented a working definition and overview of advocacy, the next section provides a definition and overview of ethics.

According to Beauchamp and Childress (cited in Johnstone, 1995 p. 39) ethics is "designed to illuminate what we ought to do by asking us to consider and reconsider our ordinary actions, judgements and justifications". Johnstone adds that "ethics is not concerned with merely describing the world (although a description of the world would of course be helpful to its discourse), but rather in prescribing how it should be" (1995, p. 39). Johnstone in defining ethics states it is "a complex system of prescriptive principles of conduct which, when critically applied, override all other considerations that might have had some bearing on the choices made and the actions taken in a given situation" (1995, p. 40). Within this definition, Johnstone indicates "ethics in this sense is sometimes referred to as systematic ethics" (1995, p. 40).

To assist in developing an understanding of ethics, attention is required to what ethics is not. As noted by Johnstone (1995, p. 40) ethics are distinguished from legal law, a code of conduct or ethics, hospital etiquette, hospital policy, public opinion, following the orders of a superior, or a "gut response" on the supposed right or wrong of a given act. Johnstone indicates "if nurses fail to distinguish ethics from these, they not only risk failing to prevent moral errors and harms from occurring in health care domains, but may actually cause them to occur" (1995, pp. 40-41). Noting the importance of distinguishing these items from ethics necessitates a look at how they differ from ethical considerations.

In describing the difference between ethics and legal law Hart (cited in Johnstone, 1995 p. 42) states "law and ethics are quite separate action-guiding systems, and care must be taken to distinguish between them. Making this distinction may not only help to prevent moral errors, but may also enforce moral and intellectual honesty about the undesirability of morally iniquitous law". Johnstone provides the example that "if morality was not distinct from legal law we could not judge certain laws (e.g. Nazi laws) to be morally iniquitous" (1995, p. 42).

In an essay on ethics and codes of ethics, American nurse Lavinia Dock (cited in Johnstone, 1995, p. 45) reported "if we have ethics, we will not need a code. This code is to regulate those who have no ethics, and in proportion as ethical principles are made a part of our natures and lives, our codes and restrictions will shrivel away and die the death of inanition". Dock (as cited in Johnstone, 1995 p. 45) went on to explain that she was not "advocating the total rejection of rules and regulations of professional conduct - to the contrary, particularly since such rules and regulations, as given in a code, could serve as helpful mechanisms to prop up the steps of those who are young in self-government or feeble in self-control". Johnstone notes "the issue was not to call codes of rules and regulations ethics" (1995, p. 45). In light of this view of codes of ethics, Johnstone warns "nurses around the world would be well advised to be cautious in their use of formally stated and adopted codes of ethics, and to be especially vigilant not to fall prey to worshipping the code at the expense of being ethical" (1995, p. 46). Despite this view of codes of ethics Johnstone believes "codes of ethics have an important role to play in the broader schema of professional nursing ethics in so far as they can provide a public statement on the kinds of moral standards and values that patients and the broader community can expect nurses to uphold, and against which nurses can be held publicly accountable" (1995, p. 47).

A point for consideration when looking at codes of ethics as indicated by Johnstone is "codes of ethics have only prima facie moral authority (this is, they may be overridden by other and stronger moral considerations), and hence can only guide, not mandate, moral conduct in particular situations" (1995, p. 47). This is supported by the observations of Jones in that while "guidelines of ethical conduct may be laid down by RPNABC and RNABC but they are, unlike laws and regulations, unenforceable" (1998, p. 7-22).

According to Johnstone "nothing could be more different from ethics than etiquette" (1995, p. 48). Johnstone makes the distinction by noting "although both seek to guide behaviour and conduct, they do so in quite different ways and for quite different purposes" (1995, p. 48). Johnstone in her description of the differences notes "ethics speaks to morally significant rights and wrongs, with behaviour being guided by critically reflective moral principles which seek to maximise the interests of all people equally" (1995, p. 48). By contrast, Johnstone notes "etiquette, speaks more to maintaining style and decorum, with behaviour being guided by the unreflective and arbitrary dictates of custom and convention" (1995, p. 48).

Johnstone reports "like legal law and etiquette, institutional policy can be morally iniquitous and in application can seriously conflict with the demands of ethics" (1995, p. 50). Although it can be at odds with ethics, Johnstone notes "institutional or hospital policy plays an important practical role - it helps to coordinate the running of the system and to make institutional practices consistent and predictable" (1995, p. 50).

Johnstone reports "if ethics were merely a matter of public opinion or majority view, all we would have to do is conduct an opinion poll on a given practice or procedure" (1995, p. 53). Such public opinion polls as Johnstone notes "would suffice to confirm whether the practice or procedure in question was morally right or wrong" (1995, p. 53). As an example of public opinion being overwhelmingly unreliable, Johnstone cites "the example of the might is right formula witnessed the witch hunts of the fourteenth and seventeenth centuries and the legal execution of many women who were killed by live burnings at the stake for alleged witchcraft" (1995, p. 53).

In her discussion of modern western moral thinking, Johnstone states "moral thinking relies heavily on the notion of rationality, and in particular on rational persons autonomously and freely choosing the moral principles they are going to commit themselves to and are going to rely upon for guiding their moral actions and decisions" (1995, p. 54). By this account, Johnstone reports "it can be seen that following the moral commands or authority of another is quite incompatible with the notion of autonomous moral thinking and acting" (1995, p. 54). Barry (cited in Johnstone, 1995 pp. 54-55) notes that "a hierarchical system of authority may mean in practice that, because everyone is accountable for a given action, it is difficult or impossible to decide who is to be held ultimately accountable".

Johnstone indicates "a gut response thesis of ethics holds that, if a person feels good about a given act, the act in question is morally right. Conversely, if a person feels bad about a given act, the act is question is morally wrong" (1995, p. 56). In continuing the discussion of gut response ethics, Johnstone notes "this thesis is hardly tenable in a world comprised of diverse groups of people who have diverse preferences and feelings" (1995, p. 56). In considering whether gut responses have a place in ethics, Johnstone notes "it is not being suggested here that gut feelings have no role to play in ethics or ethical decision making. Rather, it is being claimed that they do not have an ultimate role to play" (1995, p. 56). Johnstone continues "at best the role of gut feelings is complementary to reasoned morality; at worst gut feelings alone may have no role at all" (1995, pp. 56-57).

Having provided an overview and definition of advocacy and ethics, the next section examines ethical and legal issues encountered by the professional psychiatric nurse when advocating for and on behalf of the client.

Ethical and legal issues arise from the nurse acting as client advocate when there are opposing interests amongst a variety of different people, agencies and institutions. This section examines ethical and legal issues related to the interests of the nurse, the client, the family constellation, society, and employing agencies. After the presentation of ethical and legal issues, a decision making model useful in dealing with ethical issues will be presented.

Assuming the role of advocate on behalf of a client can give rise to ethical and legal concerns related to differing moral values of the nurse and the client and the interaction of the nurse with other nurses and allied health professionals. In the case of differing moral values, the following example illustrates when the nurses and clients moral values may give rise to ethical concerns. A client with a well-documented history of alcohol and drug misuse and addiction is admitted to a facility. The nurse holds strong moral values related to the use of alcohol and drugs. When moral values of the nurse and the client are vastly incongruent, the possibility of non-therapeutic interactions between the nurse and the client are very real and possible. In such a situation, the nurse through self-awareness should recognize the impact of her moral beliefs and values on the relationship with the client. As Curtin and Flaherty note "if the differences between the patient and the professional are irreconcilable, the professional must withdraw from the care of the patient and refer him or her to someone who value system is in accord with the patient's" (1982, p. 91). The following is an illustration of ethical and legal issues related to other nurses and allied health professionals. A nurse witnesses another nurse or allied health professional physically strike a client or patient. Leddy and Pepper (1993) describe one ethical principle required of the nurse in acting as client advocate as being a protector. Leddy and Pepper note "the nurse is obliged to monitor the quality of care and to be responsible for intervening when harmful behaviors are observed in any health care worker" (1993, p. 440). This is congruent with the RPNABC code of ethics which notes "the Registered Psychiatric Nurse takes appropriate action when actions of any health team member are not in conformity with accepted standards of care" (1995, p. 35). A legal obligation also exists to report physical assault of any client by a nurse or other member of a care giving team.

In acting as an advocate for the client, nurses may find themselves in direct conflict with clients in relation to the clients rights. As Jones notes "never before in the history of psychiatric nursing has the nurse been confronted by so much legislation focused on the rights of the mentally ill" (1998, p. 7-2). These rights defined by Jones (1998, p. 7-2) include the right to informed consent, freedom of information, confidentiality, privacy, treatment and refusal of treatment.

In Canada, the model used for informed consent is referred to as a reasonable patient standard. As noted by Johnstone, the reasonable patient standard model of informed consent is set "by reference to hypothetical behaviour of adult, competent people in the sorts of situations which are presented to courts and other tribunals for decisions" (1995, p. 229). As Johnstone states "on the basis of this model, health care providers have a duty to disclose to a patient all the information necessary to making an intelligent and rational choice (including information pertaining to small material risks)" (1995, p. 229). For the purpose of illustration, I provide the following example commonly found in my work situation. A client has been prescribed Clozapine. As noted by the Canadian Pharmaceutical Association "agranulocytosis has been estimated to occur in association with Clozapine use at an incidence of approximately 1%" (1995, p. 274). The nurse has a legal duty to report to the client this 1% risk. Although the risk of agranulocytosis is small at only 1%, the risk is material in that as noted by the Canadian Pharmaceutical Association "fatalities occurring in association with Clozapine induced agranulocytosis have generally resulted from infections due to compromised immune systems" (1995, p. 274). With respect to ethical considerations, the nurse has a moral obligation to provide the client with all the necessary information so that the client can make a reasonable decision regarding the provision of health care they wish to receive. In light of this consideration, Kohnke (cited in Johnstone, 1995 p. 280) notes that the nurse must consider "whether they have the most up to date and relevant information to give to the patient (bearing in mind the ever present legal as well as moral dangers of giving incorrect information)". Although vaguely worded, with respect to informed consent and the ethical responsibility of the nurse, the RPNABC code of ethics states "the Registered Psychiatric Nurse is obligated to inform clients about their care and to ensure informed consent prior to providing care" (1995, p. 34).

In looking at issues of confidentiality and privacy, Jones notes "frequently the terms privacy and confidentiality are considered synonymous terms" (1998, p. 7-4). Jones indicates that this perception "is incorrect" (1998, p. 7-4). In separating privacy from confidentiality, Jones states "privacy refers to a client's right to have control over personal information whereas confidentiality refers to the obligation not to divulge anything said in a nurse-client relationship" (1998, p. 7-5). For the purpose of illustration, I provide the following example of confidentiality. A client reports that she is going to kill her husband, and the nurse has reason to believe this is true. The client forbids the nurse to inform others of her intentions. In this example, there are legal and ethical issues. Legally, in the province of British Columbia a duty exists to warn when others are threatened (Appendix A). Legally, the nurse must assess the potential for violence, discuss with the client your options as a professional (Appendix A) and discuss with the client their options (Appendix A). This legal requirement conflicts with general principles of ethics. Using Kohnke's notion of ethics as cited in Johnstone "it demands that the advocate refrains from subtly undermining a patient's decision - especially if it is a decision with which the advocate does not agree" (1995, p. 281). This duty to warn when others are threatened also contradicts The International Code of Medical Ethics. As Johnstone notes "confidentiality is held to be absolute by the International Code of Medical Ethics" (1995, p. 251). Interestingly, Johnstone Reports this absolute confidentiality is "not [held] by the ICN Code for Nurses" (1995, pp. 251-252). Johnstone indicates that this "immediately raises the prospect of moral disagreement between these two professional groups and the possibility of significant moral conflict" (1995, p. 252). The duty to warn is supported by Curtin and Flaherty in their discussion of the nurse-patient relationship in which they indicate "health professionals are human beings too and as such they have rights, values and principles" (1982, p. 90). In recognizing the rights of health professionals, Curtin and Flaherty state "they are not merely automatons programmed to carry out the wishes of others" (1982, p. 90). Curtin and Flaherty indicate "although the primary focus of ethical concern in any clinical decision ought to be the welfare of the individual and, although the patient has an integral if not central role is such decision making, the patient has no more right to coerce the professional than the professional has to coerce the patient" (1982, p. 91). One method available to the psychiatric nurse as noted by the duty to warn when others are threatened (Appendix A) is "to specify the limits of confidentiality, as early as possible, with all clients". Also noted in the duty to warn when others are threatened (Appendix A) is to "document this in the progress notes to demonstrate that this issue was discussed and the client was advised of the limitations of confidentiality". The duty to warn when others are threatened meets the ethical guidelines of the RPNABC. The RPNABC code of ethics states "the psychiatric nurse holds in confidence all information obtained in the nurse-client relationship and uses professional judgement in sharing information when this is in the best interest of the client and society" (1995, p. 34).

Using the distinction between privacy and confidentiality as provided by Jones (1998, p. 7-5), privacy relates to the clients control over personal information. This brings about the concern of releasing information about a client to another agency or facility. This is a situation that I encounter everyday in my current practice. As an intermediary between the hospital and community, we frequently get requests from the hospital to share information we have gathered pertaining to the client. While on the surface the sharing of such information appears to facilitate continuity of care, it can clearly violate clients' rights of privacy. Such situations give rise more to ethical than legal concerns. In discussing the issue of privacy, Jonestone indicates it is "connected with the principle of autonomy, which demands that people should be respected as autonomous chooser, and have the right to act on their choices provided these do not seriously impinge on the moral interests of others" (1995, p. 254). This means that if the information being kept secret doesn't result in stronger moral considerations, doesn't result in avoidable harms to innocent others and as long as the information doesn't seriously impinge on the moral interests of others, there is a moral obligation to keep the information private unless otherwise specifically directed by the client to divulge the information.

In society, confusion exists around the issue of the "right" to healthcare. Johnstone states "the right to health care (taken in its broadest sense and not to be confused with medical care) is complex and controversial" (1995, p. 213). In discussing the confusion, Johnstone notes "many philosophers' criticisms derive from their erroneously equating "health care" with medical care" (1995, p. 213). In delineating health care from medical care, Johnstone states "since medical care makes up only a small portion of overall health care, it is obviously not synonymous with health care" (1995, pp. 213-214).

For the purpose of this discussion, the right to treatment will encompass the broader meaning of health care. Jones notes "the right to treatment is a guaranteed right of the person" (1998, p. 7-9). Jones indicates this right to treatment should include "judgements as to the appropriateness of treatment, the client who is considered untreatable and the client who refuses treatment" (1998, p. 7-9). In a discussion of appropriateness of treatment, Jones reports "the decision about whether a treatment is justified must always pass the test of clinical judgement (nursing, medical or otherwise) that the chance of benefit outweighs the hazards" (1998, p. 7-19). Jones continues by noting that "if the chance of benefit is held to outweigh the risk of suffering (or loss from the morbidity and mortality of the treatment) the recommendation is that the treatment be given" (1998, p. 7-19).

With the current restructuring of the health care delivery system, in particular, mental health, territorial lines are being drawn for geographically designated health regions. This restructuring is referred to as New Directions in Health Care. In my practice, I have found that with the development of Regional Health Boards (RHB), the movement of psychiatric clients has been restricted. Clients are no longer being sent to where the best available services are located. Clients are now required to access services located within their specific health region. This has resulted in undue suffering of clients in that they are being prevented from accessing the best available services which often results in either inappropriate care or inadequate housing being provided. As an example of the crisis in the housing of persons with mental illness, Dewar notes "an estimate of the number of people who immediately require an apartment unit or subsidized apartment in 1996 was 120 individuals. In one year we see a 50% increase to 191, which will only continue to increase creating a greater crisis" (1998, p. 3). This example illustrates an ethical issue when acting as a client advocate. In their examination of the concept of mutuality in advocacy, Leddy and Pepper state "nurses have both the expertise in health and the ability to help people achieve health. Clients have the expertise in understanding and evaluating their situations; they have control of their lives and their health" (1993, p. 439). In defining ethics, Johnstone states "it is a complex system of prescriptive principles of conduct which, when critically applied, override all other considerations that might have had some bearing on the choices made and the actions taken in a given situation" (1995, p. 40). The ethical issue in this example is that clients are assumed to have control of their lives and their health. The nurse acting in an ethical or moral fashion would override all other considerations that have a bearing on choices and actions being taken in a particular situation. In this example, the client does not have control of their life and health. The needs of the client are being placed in a secondary position to the bureaucracy of the health care system. To act as an advocate, and adhere to ethical principles, the nurse should challenge these artificial boundaries. This goes directly to the right of the client to be autonomous, a fundamental aspect of the clients right to appropriate treatment, and to participate fully in the decision making process.

In my work setting, a voluntary emergency psychiatric care facility, all clients have the right to refuse treatment. This includes the right to leave the facility at any time. Equally, clients can be asked to leave our facility at any time. This raises both legal and ethical issues. We have a legal duty to ensure that clients within our care do not pose a threat or danger to themselves or to others. When a client outright refuses treatment, which usually means refusal of medication or refusal to be sent to other care facilities such as shelters, we balance the clients rights with our rights to not provide service. In exercising our rights to not provide service, we must ensure that the client is not suicidal or homicidal and that "adequate" accommodations are in place before discharging the client. When we have met the legal obligations of ensuring that the client is not suicidal or homicidal and that "adequate" housing is in place the client is then discharged from our care. This legal obligation includes the duty to warn when others are threatened with harm. Ensuring that the client is not a harm to himself or to others and ensuring that adequate housing is in place prior to discharging a client who is refusing treatment, ethical standards of the Registered Psychiatric Nursing Association (RPNABC) are being met and maintained. Within the code of ethics of the RPNABC it states the Registered Psychiatric Nurse is "guided by consideration for the dignity, rights and independence of all clients" (1995, p. 34). In allowing non-compliance, the client's autonomy or independence is being maintained, and the arrangement of housing before discharge meets the consideration of dignity requirement.

In looking at legal and ethical issues related to the family constellation, the following example is frequently encountered at my work site. A client comes into care and as the client and staff are working together towards the clients discharge, the family will express concern that the client is being discharged prematurely and are requesting information related to the treatment the client has received and how the clients condition has progressed from admission to the point of discharge. In some cases, family members get quite specific in their requests and ask us to reveal the contents of personal conversations that we have had with the client. In their book on nursing ethics, Curtin and Flaherty note "the nurse family relationship is more complex than the nurse-patient relationships because it requires human-to-human relationships with at least two members of a family and sometimes with many more" (1982, p. 114). In recognizing the complexities of this relationship, Curtin and Flaherty note "families are caught in the intricacies of a health problem that taxes their human relationships and coping capacities" (1982, pp. 120-121). The disclosing of information to family members related to the treatment of the client goes to the core of the ethical considerations of privacy and confidentiality of the client. The client has a reasonable expectation that information related to their treatment will be treated as private unless they have given specific instructions otherwise. There exists no legal obligation to provide such information to family members upon their request or demand. The only situation where information would be provided without the consent of the client is when a situation exists where harm might come to a family member. The issue of releasing information related to the clients treatment to family members also goes to the principles of ethical advocacy as outlined in Leddy and Pepper (1993, pp. 439-441). In particular the principle of mutuality in decision making in the context of the nurse-client relationship. In support of this notion, Beauchamp and Childress (cited in Johnstone, 1995 p. 253) indicate "if it were common practice to breach confidentiality, patients/clients would probably lose their trust and confidence in their attending health care professionals, and would probably refrain from divulging critical information to them". In outlining ethical conduct between the nurse and the client, the RPNABC states "the Registered Psychiatric Nurse holds in confidence all information obtained in the nurse-client relationship and uses professional judgement in sharing information when this is in the best interest of the client and society"(1995, p. 34).

As noted in Jones "despite recent developments, attitudes of the general public regarding the balance between clients rights and community safety remains tilted towards the latter" (1998, p. 7-13). If society is viewed from a systems perspective, service is being provided not only to the client before us, but to the larger community and society as a whole. In acting as a client advocate, in a societal context, the RPNABC code of ethics states "the Registered Psychiatric Nurse shares with other citizens the responsibility for initiating and supporting action to meet the mental health needs of individuals and groups within our society" (1995, p. 35). In terms of a community, which is part of the larger society, and within my present work setting, we have become a member and part of the community. We achieve this by holding an annual open house, attend local community meetings to hear and share concerns, supplies are purchased locally including contract services for equipment and extraordinary maintenance requirements and while attending community meetings efforts are made to work with other service organizations in meeting the needs of the community. Recently, our society applied to city hall for zoning variances and permits to construct a 20-unit apartment building adjacent to our present site. The apartment building would be for the exclusive use of persons identified with a mental illness living within our community. Our executive director outlined information and statistics related to the housing needs of our clients, spoke of how inadequate housing was creating increased use of emergency services including the emergency room of the hospital, and outlined the effect on the mental health of our clients created by living in substandard housing. In exchange for the land we sought from the city, we were required to sign over a separate piece of property to the Royal Columbian Hospital. During public hearings, the neighbors were pleased and applauded the construction of the apartment building. We were described as good neighbors who provide an invaluable service. Conversely, the community was angry that the hospital was being given additional land. The community opposed any further expansion of the hospital and many community members indicated that the hospital was not a good community member. Working with and having support from the community we are part of, allows us to provide services to meet the identified needs of the client and the community. In terms of the larger community, as Curtin and Flaherty note "nurses, who are the largest group of health care professionals, have the potential to influence very strongly the health care system, its practitioners, and its consumers" (1982, p. 75). In recognition of this influence, Curtin and Flaherty go on to state "each health professional and each patient must be given the right to hear a different drumbeat and to be accepted for what he is, regardless of his social values and capacity for achievement " (1982, p. 76). Curtin and Flaherty continue by stating "care is developed out of the patient's needs, health problems, the family and community and their resources, the character of the health care system, and the resources of the health care workers who are available" (1982, p. 76). Inherent in these statements is the nurses need to pursue advanced levels of education and to conduct relevant research to improve the ability of the client to meet their health needs and to meet the needs of the larger society. Using myself, enrollment and work in the advanced diploma program better prepares me to meet the increasing and changing needs of the client, the community and the larger society. Again, in terms of legal issues, the duty to warn when harm is threatened assists in meeting the needs of safety for the community and society.

Legal and ethical issues arising from employing agencies encompasses not only the agency but includes other health professionals including doctors. Legal and ethical issues with respect to employing agencies arise from agency policies and treatment plans of other health professionals that conflict with ethical and legal standards of the practice of nursing.

As noted earlier, Hospital etiquette and hospital policy is distinct from the discipline and application of ethics. Where hospital etiquette deals with decorum and hospital policy deals with coordination of running the system, ethics is concerned with the rightness or wrongness of a particular course of action.

A recent example of an ethical issue in my workplace, which resulted in conflicts between hospital or facility etiquette and hospital or facility policy, and superiors, is now presented. A client well known to our service was admitted to our facility, floridly psychotic, with difficulty in swallowing. A consulting psychiatric who deemed the client to be manifesting the swallowing difficulties as an attention seeking behaviour saw the client. Over a three-day period, the client lost seven pounds. This was reported to the consulting psychiatrist who recommended that the client be sent to the emergency room of the Royal Columbian Hospital. The hospital administered three litres of electrolyte fluid and returned the client to our facility. The client continued to have difficulty swallowing and over the next four days, the client lost fourteen pounds. It was noted that the client was making extraordinary efforts to take fluids, however, was unable to swallow. The nursing staff met with the executive director and reported that the client was well beyond our care capabilities and that the client should be admitted to the hospital. The executive director agreed but qualified her agreement in noting that collegial relationships with the psychiatrist must be maintained to ensure a collaborative approach to professional relationships was being maintained. The client was sent back to the hospital. The client's worker was informed of our decision. He responding by noting that despite the fourteen-pound weight loss the client looked well, the psychosis was subsiding and that the hospital would not admit for extended treatment as they were at overflow capacity. We expressed our disagreement with the workers observations noting that the client did not look well, the psychosis had not abated and that the inability to swallow fluids and food despite the psychiatrists opinion was not behavioural. The hospital again administered intravenous fluids and returned the client to our facility. The hospital noted that they concurred with the decision of the psychiatrist and believed that it was behavioural. This decision was discussed with the executive director and we expressed concerns that if the client was returned to us the most we could do was observe her inability to swallow and effectively we would be observing the client starve to death. The executive director instructed us to accept the client back for admission as she had been informed by the hospital that if we did not accept the client they were planning to discharge the client home. The executive director believed that the client could at least be observed in our facility, something that would not be possible if the client were sent home. The client was again presented to the psychiatrist. At this point, it was suggested that perhaps the client was experiencing a severe adverse reaction to the medication. The psychiatrist reminded us that he was the doctor and he stated clearly that he would not admit this patient to the hospital. In consultation with the executive director, the client was again transferred to the hospital. We informed the hospital that we would not take the client back into our care, she was well beyond our capabilities, and we felt that a serious medical condition was being overlooked. We contacted the client's general practitioner and he facilitated the admission to the hospital. It was discovered that the client indeed was experiencing a severe adverse reaction to the medication and subsequently a gastro tube was surgically placed in the client's abdomen to ensure that the client received adequate nourishment.

In this example, the issues were our inability to provide adequate medical care, disagreement with the opinion of a superior (the psychiatrist) and an attempt to care for the client is a less expensive setting to hospital. In providing care to this client, the nurses involved and the facility were in violation of the code of ethics as outlined by the RPNABC. In their code of ethics, the RPNABC states "the Registered Psychiatric Nurse provides competent care to clients based on the Standards of Practice and is accountable for outcomes of nursing actions" (1995, p. 35). As indicated in the RPNABC standards of practice, performance factor 5.6 includes "interventions to achieve expected physiological outcomes" (1995, p. 21). This standard in this situation was not being met. Further, the RPNABC code of ethics state "the Registered Psychiatric Nurse takes appropriate action when actions of any health team member are not in conformity with accepted standards of care" (1995, p. 35). By allowing the client to be repeatedly admitted to our facility despite our inability to provide adequate levels of care, this ethical standard was not being met. When the decision was made to involve the clients general practitioner, and to state that the client would not be for readmission until the swallowing difficulty had been resolved, we then met the requirements of ethical standards of practice as required by the RPNABC.

To make ethical decisions when acting as a client advocate, the use of a decision making model is helpful in determining how to make ethical decisions with respect to issues that arise in acting as an advocate for the client.

Johnstone in her book on bioethics describes a moral decision-making model. Johnstone indicates that "a moral problem can be approached by way of a five step process:

1. Assessing the situation;
2. Diagnosing or identifying the moral problem;
3. Setting moral goals and planning an appropriate moral course of action;
4. Implementing the moral plan of action;
5. Evaluating the moral outcomes of the action implemented" (1995, p. 183).

Use of a decision making model, in working through ethical issues, allows the nurse to consider all factors, when ethical dilemmas require decisions to be made that affect the client, the family, the nurse and the employing agency. This decision making model is consistent with the standards of practice as outlined by the RPNABC (1995) in that it involves aspects of the nursing process. Specifically, this model requires assessment, planning, and implementation of interventions and evaluation of the interventions that have been implemented.

Psychiatric nurses are in a unique position to act as client advocates. Our role as coordinators of health care services demands it. In fulfilling the role of client advocate, an integral part of being a professional psychiatric nurse, the importance of developing an understanding of the concept of advocacy, knowledge of ethics, and its principles, are crucial. An understanding of the concepts and principles of advocacy and ethics enhances my development of professionalism as a nurse and has broader implications for the advancement of the professional as a whole.

As a professional psychiatric nurse, I am confronted daily with a variety of ethical and legal issues, which require consideration in acting as a client advocate, as they undoubtedly will impact my practice and interactions with clients. Areas of ambiguity exist, require identification and careful consideration before reasonable and rational decisions are to be made. An understanding of the concepts and principles of advocacy and ethics allows me to strengthen the nurse-client relationship and to provide better service to those entrusted to my care.

REFERENCE

Canadian Pharmaceutical Association. (1995). Compendium of pharmaceuticals and specialties. Ottawa, Ontario Canada: Canadian Pharmaceutical Association.

Curtin, L., Flaherty, M. J. (1982). Nursing ethics theories and pragmatics. Bowie Maryland: Prentice Hall.

Dewar, C. (1997). Pioneer community living association annual general report. New Westminster, British Columbia: Pioneer Community Living Association.

Johnstone, M. J. (1995). Bioethics a nursing perspective. Australia: Harcourt Brace.

Jones, D. (1998). Adjunctive therapies: issues and interventions in psychiatric nursing practice (4^th ed.). New Westminster, British Columbia: Douglas College.

Leddy, S., and Pepper, J.M. (1993). Conceptual bases of professional nursing (3^rd ed.). Philadelphia, Pennsylvania: J. B. Lippincott.

Registered Psychiatric Nurses Association of British Columbia. (1995). Competencies expected of the beginning practitioner of psychiatric nursing standards of psychiatric nurses in british columbia code of ethics (revised). Coquitlam, British Columbia: Registered Psychiatric Nurses Association of British Columbia.

APPENDIX A

FRASER VALLEY/NORTH SHORE REGION

NEW WESTMINSTER MENTAL HEALTH CENTRE

PROTOCOL FOR MANAGING OUT OF CONTROL/THREATENING CLIENTS:

DUTY TO WARN WHEN OTHERS ARE THREATENED

You have a legal duty to warn if there is a reasonable possibility that your client may carry out a threat to harm someone. The principle involved is that your responsibility to protect others, from harm overrides your responsibility to maintain the confidentiality of the client/therapist relationship. In other words, the protection of the public takes precedence over the confidentiality of the therapist-client relationship in appropriate circumstances.

Given the appropriate circumstances, you will need to:

1. Assess the "potential for violence":

a. Arrange to have more contact with the client

b. Review history, consult with colleagues

a. Activate Caution Sheet, notify Director

2. Discuss with the client your options as a professional:

a. to make a no-homicide contract with them
b. to assist them to be hospitalized
a. to disclose to threatened party
d. to contact the police
3, Discuss with the client their options:
a. to make a no-homicide contract/decision
b. to admit themselves to the hospital
c. to be assessed by a psychiatrist for committal

If disclosure to the threatened party is made, only the necessary information needs to be given. Much of confidentiality can be maintained as long as the requirement to warn of possible harm is fulfilled.

You may want to inform the police. If you make a regular report the police will interview/interrogate the threatener. You can make a "for information only" report, only to make the police aware, and request them not to interrogate the threatener.

It is useful to specify the limits of confidentiality, as early as possible, with all clients. Document this in the progress notes to demonstrate that this Issue was discussed and the client was advised of the limitations of confidentiality.

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