There are a number of critical considerations for Registered Psychiatric Nurses in independent practice. Registered Psychiatric Nurses in independent practice are strongly encouraged to explore these considerations in the independence practice context and to develop a plan to address them. Registered Psychiatric Nurses in independent practice are also encouraged to keep a record of this plan.

Accountability

The Registered Psychiatric Nurse in independent practice demonstrates accountability to the client, the public and the professional regulatory body by:

• recognizing personal and professional boundaries and limitations
• making appropriate referrals
• seeking out appropriate personal and professional resources
• assuming responsibility for continually maintaining and upgrading skills and education in clinical areas of focus
• applying the concepts of accountability, responsibility, and continuing competence
• knowing professional issues in psychiatric nursing practice
• knowing and applying the Standards of Psychiatric Nursing Practice and professional Code of Ethics
• identifying and incorporating best practices
• being aware of the requirements for a business including financial management of business records, taxes, Workers Compensation Board requirements, labor codes and professional and general insurance requirements as well as business license requirements and business and residential zoning laws.

Informed Consent

The Registered Psychiatric Nurse in independent practice demonstrates knowledge and understanding that the issues of competency, capacity and consent arise in numerous contexts including, but not limited to:

• consent and competency/capacity to consent to admission/entry to a hospital/facility, agency/service or psychiatric nursing care, treatment, psychiatric nursing interventions, tests and procedures, research, and release of information

The Registered Psychiatric Nurse in independent practice demonstrates an understanding that the legal principles governing competence/capacity to consent vary depending on the context:

• age of consent identified under federal and provincial/territorial legislation
• client’s ability to understand the nature of the treatment or procedure, the benefits, and risks
• client’s intellectual capacity to understand what is proposed
• client’s cognitive capacity to understand and comprehend what is being proposed
• client’s mental status

The Registered Psychiatric Nurse in independent practice demonstrates knowledge of and effective application of the principles of consent as it applies to psychiatric nursing practice including, but not limited to:

• implicit or explicit consent
• consent is considered valid only when given “voluntarily” (client’s decision is the product of the conscious mind) and not coerced in any way
• consent is considered to be valid only if the client is competent
• consent of next-of-kin is only relevant if the client is not capable of consenting and if the next-of-kin is duly appointed as the substitute decision-maker
• consent is to be obtained in advance of the initiation of any test, procedure, or psychiatric nursing intervention
• consent must relate to specific treatment or psychiatric nursing intervention(s) undertaken
• record keeping, reporting and other disclosures of information
• full and frank disclosure of the nature of the intervention(s), the risks, and alternatives
• the scope of consent
• emergency treatment under provincial or federal law, imminent and serious risk to self or imminent and serious risk to others

Informed consent must be obtained at the beginning of the professional relationship. If the conditions that the client imposes would render the intervention(s) futile or harmful, the Registered Psychiatric Nurse in independent practice should withdraw from the relationship.

The Registered Psychiatric Nurse must clearly identify processes to be followed to address issues of consent.

Confidentiality

Written client authorization is required prior to the releasing or obtaining of information about that client to or from anyone, including referring agencies or individuals.

Professionally acquired information must be treated as confidential communication. The obligation of confidentiality begins in any situation in which there would be a reasonable expectation of privacy.

The Registered Psychiatric Nurse in independent practice demonstrates knowledge and application of confidentiality principles in the therapeutic relationship and manages and stores all information about clients in ways that maintain confidentiality.

The Registered Psychiatric Nurse in independent practice is familiar with the legal and ethical guidelines concerning confidentiality and demonstrates knowledge and ability to define those circumstances where confidentiality can be breached. These include:

• imminent or serious risk to self
• imminent or serious risk to others
• imminent risk for substantial mental or physical deterioration
• court subpoena or when required by law
• where the Registered Psychiatric Nurse is a defendant in a civil, criminal, or disciplinary action arising from the professional relationship
• where there is informed consent previously obtained in writing; and then, such information may only be revealed in accordance with the terms of the consent

Conflict of Interest

The Registered Psychiatric Nurse in independent practice adheres to all ethical principles and abides by the Code of Ethics. Conflict of Interest issues include, but are not limited to:

• directly or indirectly recruiting clients from one’s employer
• providing services to a client personally known to the Registered Psychiatric Nurse on a social basis
• providing services to a minor unless parental consent is formally obtained
• recognition of conflict-of-interest situations

The Registered Psychiatric Nurse in independent practice is advised to seek professional assistance and/or consultation with the provincial regulatory body if it is unclear whether or not a specific situation constitutes a conflict of interest.

The Registered Psychiatric Nurse who maintains employment as an employee and also holds an independent practice must be aware of employer policy on conflict of interest and be aware that the employer’s insurance will only cover employment activities within the employment setting and the RPN must hold appropriate insurances for the self-employed portion of their practice.

Malpractice Liability Insurance

The Registered Psychiatric Nurse in independent practice must have adequate professional liability and business insurance coverage. Proof of insurance is required. Registered Psychiatric Nurses in independent practice are encouraged to contact their provincial regulatory body to determine which insurance documentation must be submitted and when.

Documentation and Records

The responsibility rests with the Registered Psychiatric Nurse in independent practice to become familiar with the issues surrounding ownership and access to health records and requirements arising through provincial and federal information management and privacy legislation.

Records refer to documentation kept about clients, whether on paper, on computer, or by any other means and include appropriate storage, retention, and authorized release of client information.

It is recommended that the documentation include:

• a general client information form
• a voluntary consent form signed and dated by the client or by a duly appointed substitute decision-maker
• a contract signed and dated by both the independent practitioner and the client
• documentation of services provided, and any organizational/operational policies used in practice
• times and dates of contacts with clients
• referral forms for consultation with other professionals in situations requiring additional expertise
• a signed release of information in the event of referral to other health care professionals or agencies

At all times, the client files (electronic or hard copy) and pertinent documentation must be properly secured and maintained to ensure client confidentiality. The files and documentation will be maintained in accordance with privacy legislation in each provincial jurisdiction. Registered Psychiatric Nurses in independent practice are encouraged to familiarize themselves with all pieces of legislation that address access, use, disclosure, and storage of personal health information.

The Registered Psychiatric Nurse in independent practice is required to keep accurate and adequate records. Failure to do so could be considered to be professional misconduct.

Continuous Quality Improvement

The Registered Psychiatric Nurse in independent practice must be personally and professionally responsible for all clinical and business aspects of the service. These aspects include, but are not limited to:

• scheduling of clients
• purchasing of equipment and supplies
• residential zoning bylaws (if planning service from own home)
• developing referral sources
• maintaining client records
• paying bills and taxes
• collecting fees
• writing reports
• maintaining appropriate insurance both business and professional
• keeping accurate records
• nature and scope of the service
• service location
• mutual expectations between the client and the Registered Psychiatric Nurse
• education and experience, diplomas, certificates, and other relevant documents available for inspection upon request
• contractual agreements with established agencies for third party reimbursement

The Registered Psychiatric Nurse in independent practice ensures mechanisms to evaluate psychiatric nursing practice and services.

The Registered Psychiatric Nurse in independent practice ensures that any advertising will provide accurate and factual information and will not exaggerate the benefits of the services provided, mislead the public, or detract from the public image of the psychiatric nursing profession.

The Registered Psychiatric Nurse in independent practice may not use the logo of the regulatory body or make any other representation which would imply speaking on behalf of or in any way representing the regulatory body.

The Registered Psychiatric Nurse in independent practice must recognize the need for referrals and consultation with other professionals or resources in situations requiring additional expertise.

The Registered Psychiatric Nurse in independent practice must meet the continuing competence requirements in their province of practice.

Termination of Practice

The Registered Psychiatric Nurse in independent practice must have a plan for the termination of practice as it relates to:

• clients of the service
• referral sources
• professional colleagues
• transfer of clients
• transfer of client files when appropriate written permission has been obtained from the client
• maintaining or destroying client files in a confidential manner in accordance with provincial legislation
• arrange for a transfer of client files to a trustee under provincial legislation
• closure of business accounts and payment of fees
• catastrophic events such as death or unforeseen circumstance