Skip to ContentGo to accessibility pageKeyboard shortcuts menu
OpenStax Logo
Psychiatric-Mental Health Nursing

10.2 Legal Issues Relating to Mental Health Nursing

Psychiatric-Mental Health Nursing10.2 Legal Issues Relating to Mental Health Nursing

Learning Objectives

By the end of this section, you will be able to:

  • Discuss the laws applicable to nursing practice
  • Explain the laws and rights protecting clients receiving health care
  • Understand nursing challenges to protecting these client rights
  • Describe the role of the nurse in forensic services

Nurses should understand and keep abreast of any legal issues that affect health care in order to protect their hard-earned licenses, jobs, institutions, and clients. Nursing practice changes frequently in terms of best practices and emerging evidence; it also changes as health care and technology innovations and political developments lead to new laws and ethical issues. Nurses are accountable to practice according to current laws and standards. Federal and state legislatures direct practice with laws relating to negligence or that require reporting child and elder abuse. Federal agencies, such as the Centers for Medicare and Medicaid Services, create regulations to supplement and detail compliance with the federal and state laws. These regulations cover topics like staff-to-client ratios, proper training, the use of seclusion and restraints, and much more. Moreover, state boards of nursing establish and maintain their own regulations governing the scope of nursing practice, including the requirements and limitations for nursing practice and licensure. The following sections describe the most significant legal topics that nurses may encounter while caring for clients. Knowledge and understanding of these concepts will help assist the nurse with decision-making and in providing better care.

Laws Applicable to Nursing

Nurses must follow federal and state laws, administrative regulations, institutional policies, and professional standards. In terms of federal and state laws, criminal law is a system of laws that punishes individuals who commit crimes. Conviction for a crime requires that the prosecution show evidence to prove that the defendant is guilty beyond a reasonable doubt. Civil law, on the other hand, focuses on the rights, responsibilities, and legal relationships between private citizens, and possibly involves compensation to an injured party. The evidentiary standard to prove wrongdoing in a civil case is lower than in a criminal case. Other standards nurses must follow include the state nurse practice acts, which set professional regulations for the scope of nursing practice, licensure requirements, and enforcement procedures within a given state.

Criminal Challenges

Nurses are not immune from criminal prosecution if they break the law. Nurses have been prosecuted for crimes, such as negligent homicide, insurance fraud, theft of narcotics, manslaughter, and falsifying medical records. There are many examples of nurses being charged with crimes. One example took place in November of 2021 and September of 2022 when a nurse in Pennsylvania took narcotics from clients and attempted to cover it up by tampering with records. She is now facing charges of theft of drugs and tampering of records (Oltmann, 2023). There are many other ways that nurses can face criminal charges for various crimes against their clients. It is the nurse’s responsibility to practice responsibly, ethically, morally, and with care to protect themselves and their clients.


One type of civil case nurses may encounter in practice is a tort, an act of commission or omission that gives rise to injury or harm to another and amounts to a civil wrong for which courts impose liability. Tort law exists to compensate clients injured by negligent practice, provide corrective judgment, and deter negligence. An intentional tort is a wrong that the defendant knew (or should have known) would be caused by their actions. Examples of intentional torts include assault, battery, false imprisonment, slander, and libel. An unintentional tort occurs when a defendant’s actions or inactions were reckless or unreasonably unsafe. Unintentional torts can result from acts of commission (i.e., doing something a reasonable nurse would not have done) or omission (i.e., failing to do something a reasonable nurse would do).

Assault and Battery

Assault and battery are intentional torts (not to be confused with the separate crimes of assault and battery). In a civil context, assault means intentionally putting another person in reasonable apprehension, that is fear, of imminent harmful or offensive contact. The intentional causation of harmful or offensive contact with another person without that person’s consent is called battery. Physical harm does not need to occur in order to be charged with assault or battery. In fact, assault does not even involve a physical touch, although battery does. Assault and battery often arise in health care in relation to a client’s right to refuse treatment. For example, a hospitalized client can refuse to take prescribed medication. If a nurse forcibly administers medication without that client’s consent, it could be ruled battery in a court of law. Keep in mind, however, that it may be justified to force administration of a medication based on a provider’s order in an emergency situation to prevent imminent harm.

False Imprisonment

Another intentional tort is false imprisonment, defined as an act of restraining another person and causing that person to be confined in a bounded area. This tort often comes up in the use of restraints or seclusion, which is one reason why nurses must be vigilant in following agency policy related to the use of physical restraints and seclusion and must carefully monitor clients who are restrained or secluded.

Restraints are devices used in health-care settings, when alternative, less restrictive interventions are not effective, to prevent clients from causing harm to themselves or others. A restraint restricts a client’s freedom of movement without the permission of the person. Seclusion, by contrast, is defined as the confinement of a client in a locked room or an area from which they cannot exit on their own. Seclusion should only be used to manage violent or destructive behavior. The chapter will revisit restraints and seclusion in more detail later.

Slander and Libel

Slander and libel are also intentional torts. Spoken defamation is called slander, and written defamation is called libel. Defamation of character occurs when an individual makes negative, malicious, and untrue remarks about another person to damage their reputation. Nurses must take care in their oral communication and documentation to avoid defaming clients or coworkers, or they risk a civil suit for damages. For example, if one nurse talked about a client to another nurse out loud saying, “Did you hear that this client did . . .” while knowing that it was untrue, it could be an example of slander. An example of libel is a nurse making an untrue social media post disparaging a client.


When one individual deceives another for personal gain, it is called fraud. It is an intentional tort and can be charged as a crime. A nurse may be charged with fraud for documenting interventions not performed (in order to secure payment for them) or for altering documentation to cover up an error. Fraud can result in civil and criminal charges, as well as suspension or revocation of a nurse’s license.

Negligence and Malpractice

Negligence and malpractice are unintentional torts and may be the area with which nurses are most familiar. The failure to exercise the ordinary care a reasonable person would use in similar circumstances is called negligence. For instance, a Wisconsin civil jury instruction states, “A person is not using ordinary care and is negligent, if the person, without intending to do harm, does something (or fails to do something) that a reasonable person would recognize as creating an unreasonable risk of injury or damage to a person or property” (Wisconsin Civil Jury Instructions Committee of the Wisconsin Judicial Conference, 2023). Negligence committed by a health professional with a license is called malpractice. When a nurse provides negligent care, it is an example of malpractice. The guidelines that create a baseline of appropriate (reasonable) professional conduct for nurses are the standards of care. For instance, a court will measure a nurse’s behavior against the standard of care to determine if the behavior was negligent. The standard of care is generally defined by what a reasonable nurse in a comparable situation, with similar circumstances, education, and training would do.

Medical errors, a potential type of negligence, are a problem in nursing often highlighted in the media. Nurses are humans and make mistakes. How nurses and administration handle those mistakes is often the difference between being negligent or not. Potential for error is one reason why a system of checks and balances is built into medicine administration, with EMR systems with scanning systems, pharmacy systems and pharmacists, and two nurse verification for dangerous drugs.

But errors do not stop with medication administration. All areas of nursing practice can lead to errors, from documentation to equipment injuries, client falls, infections, and others. Even with all of the protections put into place by law and policy, the human factor has its part and mistakes happen. For example, a nurse may grab the wrong antibiotic and skip steps due to being behind with their work and cause a reaction. A responsible nurse will then self-report the mistake as per facility policy and notify the client’s provider as soon as the error is noted so that any possible adverse effect can be mitigated as soon as possible. Taking responsibility for an error may be the one thing that prevents the revocation of a nurse’s license, though this is not guaranteed depending on the degree of the error and the level of adverse effect. If the error were to result in a client’s death, there may be consequences no matter how responsible the nurse has been to self-report.

The best way to avoid malpractice is to be vigilant and follow protocol. There are some areas of negligence or malpractice that are specific to mental health. For example, a client may express thoughts of suicidal ideation. If the nurse does not act on those expressions and place the safeguards as per policy and the client acts on those thoughts, the nurse is responsible for the negligent action of not acting and therefore causing harm when it could have been avoided. Not performing timely and appropriate assessment and evaluation can also be malpractice. For example, not assessing the client who is restrained or not assessing for possibility of self-harm are forms of malpractice.

In order to determine the amount of money owed a victim of malpractice, courts examine economic damages, which are actual and measurable costs, disability or disfigurement, physical impairment, loss of life, and others. Courts also take “pain and suffering” into consideration, which is a more nebulous concept that is more difficult to quantify. For that reason, currently twenty-nine states have implemented tort reform, placing a cap on “pain and suffering” dollar amounts. The damages awarded vary greatly based on many factors, including severity of injury, the state that the case is brought in, the severity of the negligence, and the named plaintiffs.

Real RN Stories

Nurse: RaDonda Vaught
Years in Practice: Two
Clinical Setting: Large university hospital
Geographic Location: Tennessee

In March 2022, nurse RaDonda Vaught was found guilty of criminally negligent homicide and gross neglect of an impaired adult. The client was a seventy-five-year-old woman who was recovering from a brain injury. She was to get a PET scan in the radiology department prior to being discharged. She was prescribed Versed, a sedative, to calm her. The nurse, Vaught, mistakenly gave the client vecuronium, which is a powerful paralytic. This led to total muscle paralysis, stopped her from being able to breathe, and caused her death. Vaught also failed to monitor the client after administering the vecuronium, so she did not catch her error in enough time to reverse the paralysis. Despite the fact that the nurse did take the correct steps to report her error, in the peer review process at her institution, she was fired. After a subsequent review from the state board of nursing, she lost her license. The district attorney charged her with a crime, and the case went to court. She was sentenced to three years of supervised probation. It was a very public court case, watched by health-care professionals all over the United States.

Duty to Warn and Protect

In addition to state and federal criminal and civil laws regarding nursing practice, nurses and other mental health professionals have a duty to warn and protect third parties when they may be in danger from a client. This duty falls outside of HIPAA regulations, meaning that it does not violate privacy and confidentiality provisions. This duty includes assessing and predicting the likelihood of a client’s threat of violence or harm toward another person or groups of people and taking action to protect the identified victims. Duty to warn entails notifying the threatened party and local authorities, such as police and the Department of Health and Human Services, of the threat so that they may put protections in place. The duty to protect is a little less formal than the duty to warn. It can include possible commitment, development of a “no-harm” contract, teaching or arranging for anger management, referring for medical evaluation, or increasing therapy sessions and/or telephone contact. The most common threats that trigger the duty to warn are injury and homicide, but it also has come up with regard to STIs, child abuse or neglect, incest, and battery.

Mandatory Reporting of Suspected Abuse or Neglect

Many states also require health professionals to report suspected neglect or abuse, called mandatory reporting. State laws vary, but they generally include a definition of reportable abuse, a list of professionals required to report abuse, and the government agency designated to receive and investigate the reports. Nurses and other health professionals are referred to as mandated reporters because they are required by state law to report suspected neglect or abuse of children, adults at risk, and older adults. Adults at risk are adults who have a physical or mental condition that impairs their ability to care for their own needs. This is also defined by state statute and will vary from state to state. Nurses need to know the law and their role in the reporting requirements for the population that they work with.

Nurse Practice Acts

The board of nursing is the state-specific licensing and regulatory body that enforces the state practice act and issues nursing licenses to qualified candidates. If nurses do not follow the standards and scope of practice set forth by the nurse practice act, they can have their nursing license revoked by that same board of nursing. Each state is different and has the power to create regulations to detail, implement, and enforce the more general state nurse practice act statutes, but regulations cannot violate the laws set forth by the state. Just like state laws cannot violate those laws set forth by the federal government. Each state’s nurse practice act also determines the disciplinary action for violating the act, such as a fine, reprimand, reeducation, or loss of nursing license. It is up to the nurse to know the specific state laws for the state or states in which they are licensed.

Nursing students are legally accountable for the quality of care they provide to clients just as nurses are accountable. Students are expected to recognize the limits of their knowledge and experience and appropriately alert individuals in authority regarding situations that are beyond their competency. A violation of the standards of practice constitutes unprofessional conduct and can result in the board of nursing denying a license to a nursing graduate.

The Laws and Rights Protecting Clients

There exist both state and federal laws and regulations to shield client rights. One example, in addition to HIPAA and the ACA mentioned earlier, includes the Patient Safety and Quality Improvement Act of 2005, which encourages reporting medical errors. A patient bill of rights lists the minimum standards for the ways that clients can expect to be treated by health-care professionals.

Patient’s Bill of Rights Overview

Client rights serve as a guideline for client and staff professional behavior. There are four fundamental client rights—the right to courtesy, the right to respect, the right to dignity, and the right to timely, responsive attention to client needs—but they have been elaborated upon and expanded over time and with changes in society and health care.

In 1973, the Patient’s Bill of Rights was first adopted by the American Hospital Association (AHA) to protect clients. Client rights were developed with the expectation that hospitals and health-care institutions would support these rights while delivering effective client care. Although not legally binding, the Patient’s Bill of Rights provides clients with goals and expectations on how they are to be treated during a hospital stay. The Patient’s Bill of Rights embraces key areas regarding client rights related to treatment decisions, respect and nondiscrimination, access to and confidentiality of medical records, refusal of treatment, and the least restrictive treatment. Clients with psychiatric-mental health disorders have the same rights as other persons.

The AHA Patient’s Bill of Rights title was replaced with the name Patient Care Partnership (PCP) in 2001 to promote the concept that health care is a partnership between a client and a provider. The PCP utilizes plain language to inform clients about what they should expect during a hospital stay regarding rights and responsibilities. The PCP states that any hospitalized client has the right to quality hospital care, such as a clean and safe environment, involvement in care planning and decision-making, protection of privacy, assistance when discharging or leaving the hospital, and assistance with billing claims (AHA, 2003).

Mental Health Bill of Rights

Psychiatric-mental health clients deserve to be treated with dignity and have the same rights and protections as other health-care clients. Historically, individuals with mental health conditions have endured abuse and discrimination. According to Mental Health America (MHA), “From leaving people to languish in overcrowded state hospitals to lobotomies and forced sterilization, the treatment of those with mental health conditions is a dark stain on our history as a nation,” (2023, para 2) The Mental Health Bill of Rights recognizes that psychiatric-mental health clients may be at increased risk for mistreatment and abuse. With that in mind, the Mental Health Bill of Rights includes liberty and autonomy, protection from seclusion and restraint, community inclusion, access to services, and privacy (MHA, 2023). Clients have the following rights:

  • the right to be informed promptly of their rights at the time of admission and periodically thereafter, in language and terms appropriate to such person’s condition and ability to understand
  • the right to assert grievances with respect to infringement of the rights, including the right to have such grievances considered in a fair, timely, and impartial grievance procedure provided for or by the program or facility
  • the right of access to any available rights protection service within a program, facility, or state mental health system designed to protect and advocate the rights of individuals with mental illness, and the right to a qualified advocate for the purpose of receiving assistance to understand, exercise, and protect the rights described in this section and in other provisions of law
  • the right to exercise one’s rights without reprisal, including reprisal in the form of denial of any appropriate, available treatment
  • the right to referral as appropriate to other providers of mental health services upon discharge (Conlon et al., 2019)

Client Right to Treatment

The right to mental health treatment includes two components: the right to appropriate treatment and the right to an individualized, written treatment or service plan. The right to appropriate treatment and related services means that treatment occurs in a setting and under conditions that support personal liberty and restrict such liberty only when necessary to comply with treatment needs, laws, and judicial orders. The right to an individualized, written treatment plan means that the provider develops it promptly after admission, that treatment is based on the plan, that the health-care team periodically reviews and reassesses the treatment plan, and that the team appropriately revises the plan (Pirotte, 2022). The health-care team will include the professionals involved with the care for the client, including doctors, nurses, and therapists, and generally includes the client and family being involved in decision-making with the nurse maintaining the role of client advocate at such meetings.

All clients have the right to participate in the planning of mental health services provided, including the development and periodic revision of the plan of care. They also have the right to be provided with a reasonable explanation for the treatment plan, in terms and language appropriate to their mental condition and general physical condition and ability to understand. The treatment plan should also outline the goals of treatment, the nature and significant possible adverse effects of recommended treatments, the rationale for why a particular treatment is considered appropriate, reasons why access to certain visitors may be restricted, and any appropriate and suitable substitute treatments, services, and types of providers of mental health services (Figure 10.3).

Treatment Plan with categories: Name, Type of Treatment plan, Area(s) of focus, Presenting problem, Treatment Goal #1/#2, Objectives for Goal #1/#2, Interventions, Plan, The client actively participated in developing this treatment plan.
Figure 10.3 This sample mental health treatment plan clearly states the treatment goals and measurable objectives. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Emergency Treatment

Emergency treatment is the client right to receive care in the event they are in a life-or-death situation that requires medical attention before providers can obtain consent. There are circumstances where a client is not able to knowingly understand and intelligently make a decision. There are many reasons that a person may not have capacity to make their own decisions, from trauma and medical reasons to mental health reasons, including dementia, psychosis, substance misuse and acute intoxication or overdose, mania, among others. In these cases, providers need to assess capacity, and if that person is deemed to lack capacity, the decisions for care usually can be made by a surrogate decision-maker, such as a spouse or an adult child. There are certain circumstances when emergency exceptions apply:

  • a life- or limb-threatening situation
  • the client is without capacity to make decisions
  • there is no surrogate decision-maker available
  • time is of the essence, for example imminent risk of harm
  • under the circumstances, a reasonable person would consent

Once the emergency has passed, providers can reassess capacity and if the client remains without capacity, the health-care team can connect with a surrogate decision-maker.

The client right to treatment also includes continuity of care. An example of continuity of care is following up with clients after discharge. Haggerty et al. (2003) identified three types of continuity: informational continuity, management continuity, and relational continuity. Informational continuity involves tailoring a client’s care based on their past events and personal circumstances. Management continuity involves reassessing the approach to ensure consistency in care as the client’s needs change. Relational continuity involves maintaining the therapeutic relationship between a client and their providers (Haggerty et al., 2003).

The Right to Be Treated Fairly and with Respect

Every individual has the right to be treated fairly and with dignity and respect, meaning that a client has the right to be free from any threats and violence, the right to treatment without discrimination, and the right to be treated equally, regardless of age, gender, race, ethnicity, color, or disability. For example, when a nurse requests permission to enter a client’s room or asks a client how they would like to be addressed, this communicates respect for the client as an individual. Respect also involves nurses introducing themselves to clients, specifying what they plan to do, and showing gratitude to clients who entrust them with their care (World Health Organization [WHO], 2023).

The Right to Obtain One’s Medical Record

The federal Health Insurance Portability and Accountability Act (HIPAA) of 1996, discussed earlier in the chapter, provides clients with a legal, enforceable right to see and receive copies upon request of their medical and other health records, including bills maintained by their health-care providers and health plans. A client can also request someone else’s medical records if given permission in writing to act as their representative in accessing records. Health-care providers are required to provide copies of medical records within thirty days of the written request (, n.d.).

The Right to Refuse Treatment

Clients have the right to refuse treatment in the absence of informed, voluntary, written consent, except during an emergency documented by written order of a responsible mental health professional or in the case of a client committed by a court to a treatment program or facility. Clients also have the right to refuse to participate in research without an informed, voluntary, or written consent, and the right to appropriate protections in connection with participation. There are certain circumstances where the client cannot consent (or refuse) for themselves, such as clients with advanced dementia or intellectual disability. In these cases, a surrogate decision-maker is put in place to consent or refuse treatment.

The Right to the Least Restrictive Treatment

As a corollary to the idea that all clients have the right to be treated humanely in an environment that offers privacy and protection from harm (, n.d.), all clients also have the right to the least restrictive treatment. As mentioned earlier, nurses play a crucial role in the implementation of restrictive practices, such as seclusion and restraint. Guidelines vary by state and facility, but all agree that seclusion and restraints should only be used as a last resort after the providers have exhausted all attempts and techniques to de-escalate a situation. De-escalation techniques that nurses may use include using simple, nonthreatening language, setting clear boundaries, decreasing environmental stimuli, and providing diversions. Another option could be to offer the client an antianxiety medication. If no less restrictive measures work to de-escalate a situation, individuals who are at risk for behaviors that may result in harm to self or others may require the use of restraints (physical, chemical, environmental).

In the event a client needs restraints, the nurse must follow the facility’s policies and procedures and secure a medical order. In an extreme emergency, such as when a serious threat of harm to the client or others exists and only after all alternative interventions were unsuccessful, a nurse can apply the restraints without a medical order for nonviolent restraints. The provider must put in place an order for the restraints as soon as possible after their application, however, and the provider or trained RN must complete an in-person assessment within one hour of initiation of restraints or seclusion and every twenty-four hours to renew the order. For violent or self-destructive restraints, which are used for an imminent physical risk of harm to self or others, the provider must evaluate the client in person prior to, during, and immediately after initiation of the restraint as well as place the order.

Federal regulations regarding seclusion and restraints require the client to be evaluated by an RN or provider within four hours for adults, two hours for children and adolescents between the ages of nine and seventeen, and one hour for children under nine years old (called the “4/2/1 rule”). A new order and a face-to-face evaluation are required every twenty-four hours by the provider if restraints are still required (Electronic Code of Federal Regulations, 2023). Federal regulations also prevent the health-care provider from writing PRN (as necessary) orders for restraints. This means that if a client is in restraints and then has them removed, and then later needs restraints reapplied, this requires a new order. The procedure must be followed each time restraints are applied.

Another consideration when using restraints involves required nursing care and documentation. A nurse must understand and follow agency policy, which should meet or exceed guidelines set by federal and state laws and regulations. For example, when a client is in restraints, the nurse must assess the client every fifteen minutes and check vital signs, provide range-of-motion exercises, check skin integrity under the restraints, and provide fluids and toileting every two hours. When documenting, the nurse must document the type of restraints, the reason for the restraints, how long the client is in restraints, the care offered and provided during restraint use, and times care is offered or provided. Documentation is part of the client record and is considered a legal document.

Clinical Safety and Procedures (QSEN)

Application of Restraints

Topic (QSEN) Nonbehavioral Restraints Violent or Self-Destructive Restraints
(Client-Centered Care)
  • Pulling at lines
  • Pulling at tubes
  • Removal of equipment
  • Removal of dressing
  • Inability to respond to direct requests or follow instructions
Used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the client, staff, or others.
(Teamwork and Collaboration)
Alternatives to restraints will be considered and/or attempted (and documented in the medical record) prior to the application of restraints.
Evaluation/ Order
A written order based on an examination of the client by the provider is entered into the medical record prior to initiation of restraints.* The physician/provider must evaluate the client prior to, during, or immediately after initiation of restraints.
The provider must:
  • document an evaluation of the client’s immediate situation
  • document an evaluation of the client’s reaction to the intervention
  • document an evaluation of the client’s medical and behavioral condition
  • determine whether the restraint should be continued
  • supply an order for the restraint
* NOTE: A qualified RN may apply restraints in response to an unanticipated event prior to a physician order. The provider who is primarily responsible for that client’s care must then be notified immediately and a provider order obtained.
PRN Orders Are Not Allowed
Provider Order
(Teamwork and Collaboration)
The use of restraints is based on a current assessment.
The qualified RN will:
  • notify the provider and obtain an order prior to application (unless emergent, in which case an order should be obtained during or immediately after initiating restraints)
  • notify and consult with the provider as soon as possible after restraints are initiated
  • document provider notification in the medical record
Time Duration/
Limits of Order
(Client-Centered Care)
The order for nonbehavioral restraints will last as long as the restraints are in place. A new order is required before restraints can be reapplied after being removed. Orders are time limited based on age:
  • up to four hours for clients ages eighteen and older
  • up to two hours for children ages nine to seventeen
  • up to one hour for children eight and under
and Continued
(Teamwork and Collaboration)
If a client is to be kept in a restraint, a certified registered nurse must assess the client at least once every shift to see if the restraint is still clinically warranted. The client is evaluated by a qualified RN or provider at least every:
  • four hours for adults eighteen and older
  • two hours for children and ages nine to seventeen
  • one hour for children under nine
The RN must notify the provider if continued use of restraints is required and a new order is entered by the provider. However, the provider must conduct a face-to-face evaluation no less than every twenty-four hours prior to renewing behavioral restraints. At that time, the provider shall reevaluate the efficacy of the client’s treatment plan and work with the client to identify ways to help him/her regain control.
Care of Client
The client will be observed at least every two hours (or more frequently based on assessed needs). Direct continuous observation is required (i.e., a sitter at bedside). In-person assessments must be documented every ten to fifteen minutes, with no time lapse of greater than fifteen minutes.
  • Monitoring of clients in restraints will be performed by a staff member who has completed the required restraint training and competency assessment.
  • Care is provided based on the assessed needs of the client. Care will include:
    - offering liquids and nutrition
    - toileting
    - temporary release that occurs for the purpose of caring for a client’s needs (for example, toileting, feeding, and range of motion)
    - other interventions as indicated by assessment findings
  • Clients transported off the unit must be assessed for needs by a qualified RN and be accompanied by an individual qualified to provide monitoring and care identified in the assessment.
  • Clients restrained with a lap or waist belt must have continuous observation.
Nonbehavioral Restraint Flowsheet (in EHR)
  • verification of restraint order
  • modification of the plan of care
  • individual client assessments and reassessments
  • clinical justification
  • intervention used (restraint type)
  • education
  • monitoring results
  • staff concerns regarding safety; risks to the client, staff, or others that necessitated the use of restraint (if applicable)
  • any injuries to the client
Violent or Self-Destructive Restraint Flowsheet (in EHR)
  • verification of restraint order
  • modification of the plan of care
  • provider Notification
  • individual client assessments and reassessments
  • clinical justification
  • intervention used (restraint type)
  • education
  • monitoring results
  • staff concerns regarding safety risks to the client, staff, or others that necessitated the use of restraint (if applicable)
  • any injuries to the client (if applicable)
  • application participants
(Client-Centered Care)
  • Obtain appropriate provider order.
  • Explain to the client and/or the client’s family (including significant other) the reason for the use of the restraint device.
  • Notification of family, if not present, is recommended (if appropriate).
  • Apply restraints in manner that avoids undue physical discomfort, harm, or pain.
    1. If a client is restrained in a supine position, the client’s head should be free to rotate from side-to-side and, when possible, the head of the bed should be elevated to prevent risk of aspiration.
    2. If a client is restrained in a prone position, the client’s airway must be unobstructed at all times and the expansion of the client’s lungs not restricted.
  • Ensure call light is readily accessible to any client without continuous observation.
  • Provide emotional/psychological support.
  • Explain and assist the client in meeting safety and/or behavior criteria for the discontinuation of restraints.
  • Maintain proper body alignment.
Individualize the client’s plan of care to include continuous regard for the client’s rights of privacy, dignity, and attention to safety and physical and psychological needs.
Removal (Client-Centered Care)
  • A restraint shall be discontinued or the level of restraint reduced by a qualified RN as warranted by client condition and by nursing reassessment findings at the earliest possible time, regardless of the expiration time of the written order.
  • A temporary release that occurs for the purpose of caring for a client’s needs (e.g., toileting, feeding, and range of motion) is not considered a discontinuation of the intervention.
  • Upon removal of restraints, nurses must document discontinuation of the restraint and complete the restraint order in the EMR.
Repeat Episode
A new provider order is needed if a client’s restraints are taken off and they return to exhibiting behavior that requires restraint.
Table 10.1 Restraints (123Helpme, n.d.)

The Right to Informed Consent

The communication between a client and a health-care provider that results in agreement and permission by the client for treatment or services is called informed consent. Every client has a right to understand and ask questions prior to consenting to treatment. Informed consent, generally governed by state law and regulation, is the fundamental right of an individual to fully understand their health-care decisions before making those decisions. Most states allow a client to sue for battery if providers do not obtain consent before providing medical treatment. Informed consent requires that the client must voluntarily provide consent, must be mentally capable to consent and of legal age (eighteen or older), and must be properly informed. Proper information generally includes the client understanding the provider’s explanation of the diagnosis, the reason for the treatment or procedure, chances of success, and available alternative treatments and their risks. The client also has the right to change their mind at any time.

More specifically, the five elements required for documentation of informed consent include (1) disclosure of the nature of the procedure, (2) competency and comprehension of risks and benefits, (3) reasonable alternatives and voluntariness, (4) competence and understanding of risks or benefits of alternatives, and (5) the client’s understanding of elements one through four as evidenced by the written consent (Shah et al., 2022). Disclosure is when a health-care provider offers information to clients about treatments or tests regarding the process, risks, and benefits, and allows a client to make informed decisions whether to undergo such treatments or tests. Client competency and comprehension mean that the client is able to and understands the risks and benefits. It includes having the knowledge and skills needed to understand risks and benefits and decide effectively. Reasonable alternatives refer to the provider fully explaining available alternatives so that the client knows the options. Voluntariness refers to clients giving their agreement free of any coercion or pressure. A written form that includes all of this information is the actual informed consent.

There are several exceptions to the requirements of informed consent. One exception is when a client is incapacitated, in which case the surrogate decision-maker provides the informed consent. Another exception is a life-threatening emergency where there is not enough time to obtain consent. The law assumes that an unconscious person would consent to emergency care if the client were conscious and able to consent. Likewise, “there is no duty to disclose if the patient is so upset or mentally unstable that the provider reasonably believes that disclosure would be detrimental to the patient’s well-being. The burden of proof is on the provider to prove this.” (, 2023, para 30). Another exception is when a client voluntarily waives or gives up the right to consent. In addition, a legally emancipated child may provide their own informed consent, although legislation regarding minors and informed consent may vary by state (Shah et al., 2022).

One point to keep in mind is that in order to give legitimate informed consent, a client must have capacity and be legally competent to do so. Legal competency is a determination made by a judge about a person’s legal ability or inability to make medical decisions, stand trial, or sign a contract, among other legal decisions. Capacity, by contrast, is assessed by a health-care provider and is a clinical opinion regarding a client’s ability to make health-care decisions. Capacity can be determined by a provider by performing a few structured assessments, including cognitive testing and a competency assessment. For those deemed not competent to give informed consent, a legal guardian or person with medical power of attorney can be authorized to offer the consent.

Psychosocial Considerations

Competency to Stand Trial and the Insanity Defense

Mental health clients have a right to a determination of whether or not they are competent to make decisions on their own behalf. This comes up in informed consent but also arises when these clients have encounters with the law. They have the right to an evaluation of their mental state before they endure a trial and to determine if they can be held legally accountable for a crime.

In cases where there are questions about an individual’s mental competency and/or ability to stand trial, for example, the court system may order that the offender be evaluated for their competency to stand trial. To be competent to stand trial, a person must be able to understand the character and consequences of the proceedings against them and able to properly assist in their defense. The evaluation is performed by a psychiatrist or psychologist certified in forensic psychology.

In another circumstance, when evaluating for an offender’s mental condition at the time of an alleged crime, the evaluator must examine the person and review records, both medical and psychological, to determine if the person’s mental state at the time of the crime met the requirements for a major mental disease or defect. They then have to give an opinion if that condition majorly impaired the offender’s ability to appreciate the wrongness of the criminal act that they are accused of, if the offender’s mental condition substantially impaired their capacity to behave within the requirements of the law, or both.

A person who has been found to be legally mentally incompetent when they committed a crime may be found “not guilty by reason of insanity.” Or the person may be found guilty but receive a lessor or different punishment due to their mental impairment. The defendant must prove to the court that they did not understand what they were doing, did not know right from wrong, acted on an uncontrollable impulse, or all of these factors.

The Right to Privacy and Confidentiality

Another client right, client confidentiality is the expectation that information shared with the health-care providers or organization will not be divulged. Closely connected, so discussed together here, the right to privacy refers to the belief that one’s personal information is protected from public access. As a client advocate, a nurse is responsible for protecting client confidentiality and privacy.

Cultural Context

Ethics in Using an Interpreter

Age and culture may affect the steps a nurse takes to ensuring client confidentiality. For example, a sensory deficit, such as hearing loss, or cultural differences, such as language barriers, may require an interpreter to be present when explaining and providing care. This may compromise client confidentiality.

The International Medical Interpreters Association created an interpreter Code of Ethics to help maintain standards of conduct. Some of the tenets included relate to maintaining confidentiality, accurately interpreting the client’s message in their preferred language, keeping their own opinions out of the interpretations, and engaging in client advocacy to ensure accurate communication of cultural differences or preferences (International Medical Interpreters Association, 2006).

All clients have the right to confidentiality and privacy. This includes respecting someone’s privacy and abstaining from sharing personal or potentially sensitive information about an individual, especially if that information was shared in confidence or during a professional relationship. In the psychiatric-mental health setting, there may be additional exceptions to disclosure of information. For example, if the client is a risk to self or others, or in situations to protect the client or others from harm, it may be necessary to disclose confidential information with the duty to inform.

On a residential or inpatient care basis, the right to privacy and confidentiality includes the right to speak with others in private, to view visitors during regularly planned hours, and to have fair and easy access to the phone and mail, except when a mental health professional determines that denial of access to a particular visitor is necessary for treatment purposes. The mental health professional may, for a specific, limited, and reasonable period, deny such access in writing and incorporate the order in the treatment plan. An order denying such access should include the reasons for such denial.

Only members of the health-care team who are involved in a client’s care have the right to access client information. The client must provide written consent for the information to be shared with anyone outside the treatment team. The Privacy Act of 1974 prohibits the disclosure of a client’s medical record without written consent of the individual unless the disclosure is based on one of twelve exceptions. Transfer of information must be done carefully and by facility procedure; inappropriate disclosure of information may constitute a breach of client confidentiality (Conlon et al., 2019). Client confidentiality is protected under the law and if that is breached without authorization, and causes harm to the client, then the client may have cause to take legal action against the responsible party or group. For example, suppose a parent of a minor client calls for information and the parent is not the legal guardian, if the parent is still given the information requested, this is a breach of confidentiality. Another breach of confidentiality takes place when a parent of an adult calls for an update on a client in a residential treatment facility and is given information without there being client authorization on file to provide that parent with that information.

Client Rights in Facilities

Clients with acute mental health symptoms, or those who are at risk for hurting themselves or others, may be hospitalized. They are often initially seen in the emergency department for emergency psychiatric care. Clients may seek voluntary admission, or in some situations, may be involuntarily admitted after referral for emergency evaluation by law enforcement, schools, friends, or family members. Incarceration facilities are other settings where a number of mental health clients reside. In all facilities, voluntary or not, these clients have specific rights under federal and state laws and regulations.

Caring for the Client in a Hospital Setting

Acute care psychiatric units in general hospitals are typically locked units on a separate floor of the hospital with the purpose of maintaining environmental safety for clients. State-operated psychiatric hospitals serve clients who have chronic serious mental illness. They also provide court-related care for criminal cases where the client was found “not guilty by reason of insanity.” This judgment means the client was deemed to be so mentally ill when they committed a crime that they cannot be held responsible for the act, but instead require treatment.


There are two types of commitment for care and treatment in inpatient or outpatient mental health facilities. Voluntary admission happens when a person agrees to treatment in a mental health facility and is not an immediate threat to themselves or others. They are admitted and are free to leave at any time. Involuntary commitment can also be either inpatient or outpatient, but the person is confined against their will. In an involuntary hold, a person may be held for up to seventy-two hours (may vary by state), but the client must be a danger to themselves or others. After the seventy-two hours, the case/situation must go to the court system to determine if the hold should continue.

The specifics of the laws as far as how long and the reasons for a person to be committed vary by state. In general, a person must be a danger to the public or themselves. There are several types of involuntary commitment. In an emergency hospitalization, the client is held for a limited time in response to a crisis situation. In an inpatient civil commitment, there is a longer-term hold while the courts determine if the client meets the criteria for continued commitment. The last option is outpatient civil commitment (available in all states except Maryland and Massachusetts) where the person may be required to participate in outpatient treatment.

With an involuntary commitment, the client is not permitted to check out of their own accord from a health-care facility. When a client leaves an inpatient facility without permission, including if they fail to return from an authorized leave, it is called absconding. This is a significant health and safety issue to the client, the facility, client families, and, potentially, the public. Good therapeutic communication between clients and clinical teams helps reduce the occurrence of absconding events. Absconding has been linked to an increased risk of self-harm and suicide (Verma et al., 2020).

Caring for the Client in a Punitive Setting

The United States has the largest number of people incarcerated in the world. Almost 870 out of every 100,000 people in the United States are in jail or prisons (Davis et al., 2018). This population has very high rates of psychiatric conditions, substance use disorders, as well as many other acute and chronic health conditions. These individuals require care by nurses. One of the largest roles of nurses in corrections facilities is advocacy. It can be a challenge for nurses in this setting to provide the care that is needed on limited budgets. Some of these people have very serious psychological issues or psychiatric illnesses that require monitored medication regimens. Others have substance misuse issues that are high risk for serious complications of withdrawal. The nurse must be prepared to screen and handle these clients as well as advocate for the care that is needed and may be lacking.

Nursing Challenges When Upholding Client Rights

There are many legal and ethical challenges in health care. Vigilantly keeping client confidentiality in a digital age is a challenge legally and ethically. From a mental health viewpoint, maintaining the client’s autonomy while ensuring their safety can be a challenge, especially when their competency or capacity is in question.

Clinical Judgment Measurement Model

Applying the CJMM to Legal Guidelines

Rachel is a psychiatric nurse working in an inpatient psychiatric unit. She is assigned to care for Walter, a thirty-five-year-old male with a history of schizophrenia who was admitted involuntarily due to paranoid delusions and aggressive behavior. Walter has a history of noncompliance with medication and has been refusing to take his antipsychotic medication during his current hospitalization. Rachel is responsible for ensuring Walter’s safety and providing therapeutic interventions to address his symptoms.

Using the Clinical Judgment Measurement Model, we can analyze Rachel’s clinical judgment in this scenario.

Recognize Cues Rachel recognizes the cues indicating Walter’s paranoid delusions and aggressive behavior, including his refusal to take medication, agitation, and verbal threats. She assesses his mental status and identifies potential risks to his safety and the safety of others on the unit.
Analyze Cues Rachel analyzes Walter’s behavior in the context of his psychiatric history and current symptoms. She considers the potential consequences of his noncompliance with medication, including worsening psychotic symptoms and the risk of harm to himself or others.
Prioritize Hypotheses Rachel prioritizes the need to address Walter’s noncompliance with medication and manage his paranoid delusions and aggressive behavior. She considers the underlying factors contributing to his refusal and develops a plan to engage him in treatment while ensuring safety.
Generate Solutions Rachel develops a therapeutic relationship with Walter, using communication techniques to build trust and rapport. She educates him about the importance of medication adherence and explores his concerns and fears related to taking medication. Rachel collaborates with the treatment team to explore alternative interventions, such as psychosocial interventions and medication adjustments, to address Walter’s symptoms effectively.
Take Action Rachel implements the plan of care, including ongoing monitoring of Walter’s mental status and behavior, therapeutic communication, and collaboration with the treatment team. She intervenes promptly to address any escalation of symptoms or safety concerns, ensuring a proactive approach to managing Walter’s care.
Evaluate Outcome Rachel evaluates the effectiveness of interventions by assessing Walter’s response to treatment, including changes in his symptoms, behavior, and medication adherence. She documents his progress and any modifications to the plan of care, collaborating with the treatment team to adjust interventions as needed.

In psychiatric-mental health nursing, several legal issues could arise in this case:

  • Involuntary hospitalization: Walter was admitted involuntarily due to his psychotic symptoms and risk of harm to himself or others. Rachel must ensure that Walter’s rights are protected and that all legal requirements for involuntary hospitalization are met, including proper documentation and adherence to due process.
  • Medication administration: Walter’s refusal to take medication raises legal and ethical considerations regarding his right to refuse treatment. Rachel must follow institutional policies and legal guidelines for managing medication refusal, including documenting Walter’s decision-making capacity and exploring less restrictive alternatives to involuntary medication administration.
  • Client safety: Rachel is responsible for ensuring Walter’s safety and the safety of others on the unit. She must take appropriate measures to prevent harm, including implementing de-escalation techniques, enlisting support from security or crisis intervention teams when necessary, and documenting any incidents or interventions related to safety concerns.
  • Confidentiality: Rachel must adhere to laws and regulations governing client confidentiality, including the Health Insurance Portability and Accountability Act (HIPAA). She must ensure that Walter’s personal health information is protected and shared only with authorized individuals involved in his care.

In this use of the CJMM, Rachel demonstrates effective clinical judgment in managing Walter’s symptoms of schizophrenia and addressing his refusal to take medication. However, she must also navigate legal issues related to involuntary hospitalization, medication administration, client safety, and confidentiality. By applying the Clinical Judgment Measurement Model and adhering to legal standards, psychiatric-mental health nurses like Rachel can provide high-quality care while protecting client rights and minimizing legal liability.

Challenges to Maintaining Confidentiality and Privileged Communication

All health-care providers have a critical responsibility to maintain the clients’ right to security, privacy, and protection of client health-care information. Nurses must be mindful all of the time and careful not to discuss clients in any setting where they can be overheard. Keeping laptops with any personal health information secure and protected is imperative. Dispose properly of any paper that has any identifying information. Maintaining confidentiality is challenging for all nurses in all areas. Discussing clients with other nurses who are not involved in their care to decompress, or to confer with a question can easily breach confidentiality. Avoid posting anything on social media related to a client. Leaving messages for clients on possibly unsecure voicemail or with another person is also inappropriate. Nurses must be aware of the surroundings when talking to a client to make sure that they cannot be overheard if asking about confidential information. In mental health, it is particularly easy to breach confidentiality, because talking is a large part of the treatment and the situations can be very personal.

Any communication taking place within a therapeutic relationship between a client and the provider or counselor, among others, is considered to be privileged communication. In some states, this confidentiality extends to nurse-client relationships as well. Conversations and relayed information should remain confidential unless the client reports a threat to themselves or others. Information that falls under the confidential umbrella cannot be the subject of testimony in any legal proceedings unless the client has waived the privilege. Parties who are considered to have privileged communication cannot be legally compelled to divulge anything that is discussed between the parties, with the exception of the duty to warn or in case of the client being a danger to themselves.

Challenges with Mandatory Reporting

Many states require health professionals to report suspected neglect or abuse. For example, in Wisconsin, suspected neglect or abuse is reported to Child Protective Services (CPS), Adult Protective Services, or law enforcement. Nurses should be aware of the county or state agencies to whom they should report suspected abuse. Reporting to authorities is not without its own set of difficulties. There can be issues with the reporter feeling guilt about reporting, worrying that they are sending a child or adult into a worse situation of the “system” rather than the known difficulties of the home. There is also the guilt of reporting if not absolutely sure that there is abuse. Even harder still, if the abuse is not reported and something happens, the nurse can be held liable for not reporting. There are also times when a nurse suspects abuse and they are not supported by the provider or their management staff; this is a difficult situation. Reporting sexual abuse can be very difficult when the client does not want to report it. If the nurse is in a mandatory reporting state, they do not have a choice but to report it because they can be held responsible for not reporting. This can be very difficult to explain to a client, particularly one already in distress or who has been convinced by their abuser that there will be consequences to telling. There is rarely an easy answer when it comes to abuse of any kind.

Challenges to Boundaries

Professional boundaries are very important for nurses to maintain particularly when working in mental health. It is not uncommon for those with mental health struggles to have difficulty setting their own boundaries, so it makes it even more important for the nurse to have firm boundaries. At the same time, the professional standing and access to private information that nurses possess creates a power imbalance between the nurse and the client. In order to maintain a client-centered relationship while being mindful of the power imbalance, nurses must make every effort to set and uphold clear boundaries. When the client’s needs and the nurse’s needs are not clear, it can create boundary conflicts, such as:

  • sexual misconduct
  • inappropriate touching of clients
  • romantic relationships with clients
  • violation of HIPAA privacy regulations
  • conflicts of interest
  • accepting and giving gifts
  • overinvolvement with clients
  • social media communication between nurses and clients

Priorities must start with client safety. A nurse should speak with a dependable supervisor or colleague if a health-care professional is acting in an unprofessional manner or if the nurse is unclear of how to interpret a particular circumstance. Nurses should promptly and completely document any such events. It is imperative that nurses adhere to professional standards in their practice. It is critical for nurses to possess expertise in defining and upholding professional limits.

Challenges When Treating Clients Who Have Committed Crimes

Working with clients who have committed crimes can be very challenging. When providing nursing care to incarcerated clients, for instance, nurses may encounter people who have perpetrated violent crimes, such as sexual abuse of minors. Maintaining professionalism is of primary importance, as is taking a step back to recognize and regulate emotions that may arise with the interaction.

Psychosocial Considerations

Mindfulness and Reflection for Self-Care and Awareness of the Nurse

There are several tools nurses can use to care for themselves when feeling morally ambivalent about treating clients who have committed crimes. One tool is journaling. Writing about an experience and their feelings about the experience in private and without judgment is a way to gather perspective, sort out emotions, and determine a path forward.

Another method nurses use is reflecting with colleagues and peers. By sharing potentially common experiences with others, it gives the nurse different viewpoints and unique takes on how different people handle similar situations. It broadens the nurse’s perspective and offers options the nurse may not have thought about previously.

A third tool practitioners use is reflecting in the moment. Slowing down, where possible, and taking a second to think and, importantly, listen before acting can make a difference in a nurse’s approach (Aussie Nurse, 2020).

Challenges Regarding Payment for Services in Mental Health Care

Payment is another legal/ethical consideration nurses face when treating clients who may or may not have insurance. Insurance is the primary way clients pay for mental health care, including private insurance, Medicaid, and Medicare. For those who do not have insurance or have insurance that does not cover mental health, paying for treatment may be very expensive. Nurses should familiarize themselves with the options in their communities. In many areas, there are free clinics, community mental health centers, local nonprofits, and local safety net health-care systems. Many of these options require applying for the services or working with the hospital for a payment plan. Many nonprofit hospitals have charity care to provide a certain amount of care for free or at a discount. Nonprofit hospitals that accept Medicare and Medicaid are required to offer a certain amount of charity care each year. Another set of options includes support groups and hotlines. Many mental health providers offer some pro bono services as well. All of these options can be found online, by calling nonemergency help lines, or through community social workers.

Keep in mind, however, that if a person has an emergency mental health condition or is determined to be dangerous to self or others, they cannot be turned away from an emergency room or transferred to another hospital; that is known as “dumping.” They must be stabilized or admitted and stabilized until the emergency medical condition no longer exists.

The Role of Health Insurance

Nurses should be aware of the critical role health insurance plays in treatment and in treatment decisions. Here is a brief summary of insurance options; veterans also may qualify for their own insurance arrangements.

  • Medicaid and Medicare cover mental health care for those who qualify.
  • Medicaid coverage is based on multiple factors, including income.
  • Medicare covers those over the age of sixty-five and those who are disabled and have received Social Security for at least two years.
  • Private insurance covered, at least in part, by an employer.
  • Insurance purchased through the private market, paid monthly. Private market plans may have high deductibles and high out-of-pocket visit costs.

Disability Benefits for Mental Health Clients

Mental and psychological disabilities are conditions that can qualify individuals for benefits from the Social Security Administration (SSA). To qualify for benefits, a client must have a formal diagnosis of a potentially disabling condition, one that will cause a disability for twelve months or longer. The SSA performs a detailed review to evaluate each disability application. Each illness that is eligible has a severity level requirement and the specific medical information needed to support the claim. For most mental illnesses, the client needs to demonstrate that they have been on medication for two years without their condition improving.

Forensic Services in Mental Health Nursing

Forensic psychiatric nursing is a developing specialty. These nurses play a key role in linking health care to the judicial system. Historically, forensic nurses worked with crime victims during examinations, preserving evidence and providing court testimony. Now, a forensic psychiatric nurse can provide a psychiatric evaluation intended for use by the judicial system. They also frequently connect offenders with medical and social services that are needed to assist with the offender’s rehabilitation. There is some crossover in roles with correction nurses who provide care in correctional institutions.


This book may not be used in the training of large language models or otherwise be ingested into large language models or generative AI offerings without OpenStax's permission.

Want to cite, share, or modify this book? This book uses the Creative Commons Attribution License and you must attribute OpenStax.

Attribution information
  • If you are redistributing all or part of this book in a print format, then you must include on every physical page the following attribution:
    Access for free at
  • If you are redistributing all or part of this book in a digital format, then you must include on every digital page view the following attribution:
    Access for free at
Citation information

© Jun 12, 2024 OpenStax. Textbook content produced by OpenStax is licensed under a Creative Commons Attribution License . The OpenStax name, OpenStax logo, OpenStax book covers, OpenStax CNX name, and OpenStax CNX logo are not subject to the Creative Commons license and may not be reproduced without the prior and express written consent of Rice University.