VULNERABLE POPULATIONS AND THE ROLE OF THE FORENSIC NURSE
Melanie S. Lint
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Identify certain populations as being legally classified as vulnerable
2. Describe the role of nurses in working with these populations
3. Demonstrate understanding of the challenges experienced by vulnerable populations related to care access and provision
4. Explain the specialty practice of forensic nursing
5. Informed consent
VULNERABLE POPULATIONS are those groups typically defined by race/ethnicity, socioeconomic status, geography (urban or rural), gender, age, disability status, and risk status related to sex and gender. These populations are highly visible throughout society and include, but are not limited to, children, elderly, minority groups, those with intellectual disabilities, the homeless, and those who are incarcerated. The demographics of these populations, highlighted in Box 26-1, are constantly changing and it is difficult to determine at any point in time which group consists of the largest numbers. For example, the numbers of homeless individuals actually may be higher than that for minority groups, but due to lack of reporting about the homeless population, minority groups may be identified as being larger. Regardless of the numbers, vulnerable populations experience DISPARITY, or lack of equality, when it comes to health and health care.
According to Healthy People 2020, the term disparities often refers to racial or ethnic disparities. However, disparities can result from additional conditions such as age; socioeconomic status; geographic location; cognitive, sensory, or physical disability; religion; mental health; sexual identity; and gender. According to the U.S. Department of Health and Human Services (DHHS; 2010), “if a health outcome is seen in a greater or lesser extent between populations, there is disparity.”
Vulnerable populations and health disparities were addressed in the plan for transforming the mental health care system by the President’s New Freedom Commission on Mental Health (2003). One of the major goals identified was to eliminate disparities in mental health care. Specifically, the report identified concerns about the involvement of people with mental disorders in the criminal justice system and about the homelessness among those with mental disorders as national priorities (McNeil, Binder, & Robinson, 2005). In addition, various governmental agencies such as the Office of Minority & Health Disparities (OMHD), Substance Abuse and Mental Health Services Administration (SAMHSA), Institute of Medicine (IOM), the Surgeon General’s National Prevention Strategy, and the Centers for Disease Control and Prevention (CDC) are working to eliminate health disparities for vulnerable populations in the hopes of reducing the impact of these disparities on the overall health of the U.S. population. The National Alliance for the Mentally Ill (NAMI) also helps to advocate for elimination of barriers to mental health treatment for vulnerable populations.
BOX 26-1: SELECTED VULNERABLE POPULATIONS
• Minority groups
• Individuals with intellectual disabilities
• Homeless individuals
• Individuals who are incarcerated
All nurses, in all areas of practice and all settings, are ethically bound to provide care to patients regardless of their level of functioning, age, race, medical or mental health diagnoses, or economic status in life. When working with vulnerable populations, the nurse plays a major role in advocating for vulnerable patients because they may be unable to do so themselves. When the patient can do for himself or herself, the nurse allows him or her to do so. When the patient has physical or mental limitations, the nurse helps the patient with what he or she needs and assumes the responsibility to protect those who cannot protect themselves.
Psychiatric-mental health nurses (PMHNs), at the basic or advanced practice level, frequently interact with patients belonging to vulnerable population groups. One example of an advanced practice role in working with a vulnerable population is that of the forensic nurse. The forensic nurse most commonly works with individuals involved with the criminal justice system and with their families.
This chapter describes the vulnerable populations most often encountered by PMHNs. It addresses the major mental health issues commonly involved and the nurse’s role when working with each of these populations. This chapter also explores the specialty practice of forensic nursing, describing the requirements for practice and the forensic nurse’s roles and functions.
When working with vulnerable populations, nurses function as advocates for those populations and work to ensure the safety of all involved.
CHILDREN AND MENTAL HEALTH AND ILLNESS
Children are vulnerable because they often are not old enough to advocate for themselves. In some cases, they may grow up in foster care settings without one or both biological parents able to care and advocate for them. They may be born to homeless parents or live with parents who become homeless due to illness, loss of jobs, or loss of housing. Mental health care services may be inadequate and/or inaccessible for lower income families or those who lack any income. Children may not receive mental health services due to the stigma of mental illness. Sometimes, youth are not diagnosed and treated for mental health issues until they enter the criminal justice system. In addition, many states have a shortage of psychiatrists and advanced practice PMHNs who specialize in treatment of children and adolescents. Often their mental health concerns go untreated. Unfortunately, psychiatric conditions can become chronic and recur if they go untreated.
Attention deficit hyperactivity disorder (ADHD) is a disorder that often comes to mind when thinking about mental health issues in children. However, children also suffer from anxiety disorders, depression, conduct disorders, and intellectual and developmental disabilities. Children are also victims of physical, emotional, and sexual abuse. Adolescents are increasingly more likely to become involved with substance use and abuse.
Nurse’s Role When Working With Children
The nurse works to gather information about the child, the child’s family, and his or her functioning ability in school if the child is old enough for school. In addition, the nurse gathers information about the child’s social relationships. For example, how does the child get along with his or her peers? Is the child’s behavior appropriate for his chronological and developmental age? Does the child shrink, retreat, or appear frightened when adults approach? Also, information about the child’s growth and development is important. Has the child reached his or her appropriate milestones? Has the child shown any regression in development? For example, a child who was previously toilet-trained begins wetting the bed. This information may provide clues to possible abuse. School nurses as well as teachers are excellent resources because they are often in a position to observe a child’s functioning in school and with their peers. If abuse is suspected, nurses are ethically and legally bound to report suspected child abuse. (See Chapters 21 and 22 for an in-depth discussion of mental health issues related to children and adolescents.)
AGING INDIVIDUALS AND MENTAL HEALTH AND ILLNESS
Another vulnerable population that nurses in all areas of practice will encounter is the elderly. People aged 65 years and older are at the highest risk of completed suicide. In 2002, older adults accounted for 25% of completed suicides, yet they only accounted for 12% of the U.S. population. White men older than 85 years have an especially high rate of suicide (59 per 100,000; Ellson, 2007). Older Asian American women have the highest suicide rate among all women older than 65 years in the United States (Office of Minority Health, DHHS). The possible risk factors for higher suicide rates in later life include: older age; male gender; living alone; mental illness; access to firearms; social isolation; loneliness; depression; recently widowed, divorced, or separated; multiple chronic illnesses; alcohol or substance abuse; hoarding of medications; need for multiple medications; and feelings of hopelessness and worthlessness (Ellson, 2007). In addition, older adults are more vulnerable to abuse because of social isolation and mental impairment such as dementia or Alzheimer’s disease. Elder abuse can affect people of all ethnic backgrounds and social status and affect both men and women. Family members are more often the abusers than any other group. Spouses and adult children are the most common abusers of family members. Elder abuse is a family issue. (See Chapter 23 for an in-depth discussion of issues related to the elderly; Chapter 24 for additional information on elder abuse; and Chapter 16 for an in-depth discussion of cognitive disorders such as dementia of the Alzheimer’s type.)
Nurse’s Role When Working With the Elderly
The role of the nurse when working with the elderly is diverse. It may involve helping to improve the patient’s overall health and mental health well-being. Activities may include conducting depression screening or screening for dementia and for suicide risk at a nearby senior center or assisted living community, possibly in conjunction with other screening programs, such as hypertension and diabetes screening. Nurses visiting elderly patients in the home assess for depression and suicidal thoughts. They can also teach patients and families about the signs and symptoms that need to be identified. This is important as “older adults with depression have a high suicide attempt and success rate” (Shawler, 2010). PMHNs might be involved in individual, group, and family therapies to assist patients who are struggling with symptoms of anxiety and/or depression. They may help patients set up weekly medication boxes to ensure that they are more likely to remember to take their medications.
The PMHN also is ever vigilant in assessing for possible abuse. If abuse is suspected, laws in most states require health care providers to report suspected abuse or neglect to appropriate law enforcement agencies and adult protective services. (See Chapter 24 for more information about the nurse’s role in elder abuse.)
Specialized educational opportunities are available for registered nurses who provide direct care to vulnerable older adults in various settings. One course developed by the International Association of Forensic Nurses (IAFN) provides nurses with the essential knowledge and skills for responding appropriately to elder mistreatment. More information for those interested can be obtained from the IAFN website, www.iafn.org.
Populations at the opposite ends of the age spectrum, that is, children and the elderly, are considered vulnerable.
MINORITY GROUPS AND MENTAL HEALTH AND ILLNESS
Racial and ethnic minority groups are identified based on federal categories. These categories include: African Americans (Blacks), American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and White Americans (Whites). Hispanic American (Latino) is an ethnicity and may apply to a person of any race.
According to the report Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General, minorities have less access to and availability of mental health services (DHHS, 1999). In addition, minorities in treatment often receive a poorer quality of mental health care. For example, errors in diagnoses are made more often for African Americans than Whites for certain disorders such as schizophrenia and mood disorders. Moreover, minorities are underrepresented in mental health research.
The African American Community Mental Health Fact Sheet published by the NAMI (www.nami.org) states that “African Americans in the United States are less likely to receive diagnoses and treatments for their mental illnesses than Caucasian Americans.” Reasons cited for this disparity include stigma and misunderstanding about mental illness in the African American community; cultural biases against health care and mental health care professionals by African Americans; reliance on family, religious, and social communities for social support rather than health care professionals; and lack of health insurance for both medical and mental health care in this population.
The NAMI (2004) also cites that some mental illnesses are more prevalent in the African American population when compared with other cultures in the United States. For example, in a study investigating suicide rates over a 15-year period, the rate of suicide among African Americans was dramatically increased when compared with that of White Americans for the same age group. The suicide rate increased 233% for African Americans (NAMI, 2004). The study also showed that African Americans somaticize or manifest physical illness related to mental health problems more often than White Americans. Moreover, some studies suggest that African Americans metabolize medications more slowly than White Americans but they often receive higher doses of psychotropic medications, which may result in an increase in side effects and a decrease in medication compliance (NAMI, 2004). Genetic variation, exposure to different diets and environments, and other medications in use contribute to ethnic differences in metabolism of psychotropic medications and the effects of drugs on target organs (Flaskerud, 2000).
Data for other minority groups also reveal disparities. For example, American Indian/Alaska Natives are five times more likely to die of alcohol-related causes than Whites. The suicide rate in this population is 50% higher than the national rate. The availability of mental health services is severely limited by the rural, isolated location of many of these communities.
Nearly half of Asian Americans and Pacific Islanders have problems with availability of mental health services because of limited English proficiency and lack of providers with appropriate language skills. Refugees from Southeast Asian countries are at risk for posttraumatic stress disorder (PTSD) as a result of trauma and terror preceding their immigration to the United States. Because of the difference in their rates of drug metabolism, some Asian Americans and Pacific Islanders may require lower doses of certain drugs than those prescribed for Whites.
Moreover, Hispanic American youth are at a significantly higher risk for poor mental health than White youth by virtue of higher rates of depressive and anxiety symptoms, as well as higher rates of suicidal ideation and suicide attempts (DHHS, 1999).
Access to and availability of mental health services are limited for many minority groups.
Nurse’s Role When Working With Minority Groups
One of the recommendations of the President’s New Freedom Commission on Mental Health is to help provide better access to mental health services for members of minority groups and people in rural areas and to provide culturally competent care (President’s New Freedom Commission on Mental Health, 2003). When working with members of minority groups, the nurse must be sensitive to the traditions and customs of people of that minority group, especially related to health care in general as well as mental health care. According to Hill (2006), cultural differences between the professional nurse and their patients increase the complexity of providing care within the health care environment. Thus, to improve the health status of ethnic minority populations, nurses must first reflect on their own beliefs and values to assist them to respect the individuality of their patients and to provide culturally competent care (Hill, 2006).
INDIVIDUALS WITH INTELLECTUAL DISABILITIES AND MENTAL HEALTH AND ILLNESS
INTELLECTUAL DISABILITY, formerly known as mental retardation, is a term used when a person’s ability to learn at an expected level and function in daily life are limited. It is classified in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association [APA], 2013), with specific criteria.
Intellectual disabilities are caused by a problem that begins prior to birth up until the child turns 18. The cause is unknown in many children. However, intellectual disabilities may result from injury, disease, or a problem in the brain. Examples of common causes of intellectual disability include Down’s syndrome, fetal alcohol syndrome, genetic conditions, and infections that happen before birth (CDC, 2005). The level of intellectual disability can vary greatly from a problem that is very severe to one that is slight. Individuals may have trouble taking care of themselves and letting others know their wants and needs. Sometimes the disabilities coexist with physical illnesses as well.
Intellectual disabilities are a type of DEVELOPMENTAL DISABILITY, a diverse group of severe chronic conditions that are due to physical and/or mental impairments. Individuals with developmental disabilities have problems with major activities of daily living such as mobility, learning, language, self-help, and independent living. These disabilities begin at any time, from development through 22 years of age. They often last a lifetime (CDC, 2004).
Nurse’s Role When Working With Individuals With Intellectual Disabilities
Nurses may provide care for children or adults with developmental and intellectual disabilities in settings such as group homes, adult care homes, home health care, hospitals, sheltered workshops, or jails or prisons, among other places. Some individuals have triple diagnoses of serious mental illness, substance abuse, and intellectual disabilities. It is essential for nurses to help protect the rights of these vulnerable individuals who may easily be victimized by others.
Individuals with intellectual disabilities vary in their functional ability. Regardless of the severity of the disability, the nurse advocates for the individual and works to protect the rights of the individual.
THE HOMELESS AND MENTAL HEALTH AND ILLNESS
A HOMELESS PERSON, first identified by Public Law 100–77 (more commonly known as the “McKinney Act”), is described as one who lacks a fixed, regular, and adequate nighttime residence; that is, a supervised publicly or privately operated shelter, a temporary residence for individuals intended to be institutionalized, or a public or private place not ordinarily used as a regular sleeping accommodation for human beings (National Coalition for Homeless Veterans, 2009). The numbers on the homeless are staggering. Box 26-2 highlights some of the general statistics.
The correlation between homelessness and mental health problems is significant. Approximately 22% of the American population suffers from mental illness. A small percentage of the 44 million people who have a serious mental illness are homeless at any given point in time (National Coalition for the Homeless, 2009a). Additionally, an average of 16% of the single adult homeless population suffers from some form of severe and persistent mental illness.