Perkins D V, Hudson B L, Gray D M, Stewart M
Department of Psychological Science, Ball State University, Muncie, IN 47306, USA.
Psychiatr Serv. 1998 Oct;49(10):1317-22. doi: 10.1176/ps.49.10.1317.
Community-based treatment of persons with serious mental illness requires providers to become involved in clients' personal lives to a greater degree than does hospital-based treatment. The study examined attendant ethical dilemmas, especially for staff who lack professional training or work in rural communities.
A total of 95 staff members from five community mental health centers read 14 vignettes describing ambiguous ethical dilemmas involving professional role boundaries or client confidentiality. Twenty-seven staff members were from rural agencies, and 68 from urban-suburban agencies; 60 were direct care staff, and 35 were supervisory. Participants were asked to make and justify a more conservative or a less conservative decision in response to each dilemma.
Years of experience as a mental health provider and previous ethics training correlated positively with staff having experienced more situations similar to those in the vignettes; however, these variables were not related to the decision made or the type of ethical justification for it. When the analysis controlled for experience and previous ethics training, staff made fewer conservative decisions in boundary dilemmas than in confidentiality dilemmas. Compared with nonrural providers, rural providers had experienced more boundary dilemmas and made fewer conservative decisions in response to them.
Boundary problems occur frequently in community-based services, especially in rural settings, and may or may not be handled conservatively. With the expansion of case management and other in vivo services, better understanding of ethical risks and informal practices will help improve services and provide appropriate training and supervision of staff.
与基于医院的治疗相比，对严重精神疾病患者进行社区治疗要求服务提供者更大程度地介入患者的个人生活。本研究调查了随之而来的伦理困境，特别是针对缺乏专业培训或在农村社区工作的工作人员。
来自五个社区心理健康中心的95名工作人员阅读了14个描述模糊伦理困境的 vignette，这些困境涉及专业角色界限或患者保密问题。27名工作人员来自农村机构，68名来自城市-郊区机构；60名是直接护理人员，35名是管理人员。要求参与者针对每个困境做出并说明一个更保守或不太保守的决定。
作为心理健康服务提供者的年限和之前的伦理培训与工作人员经历过更多与 vignette 中类似情况呈正相关；然而，这些变量与所做的决定或其伦理依据的类型无关。在分析中控制了经验和之前的伦理培训后，工作人员在界限困境中做出的保守决定比在保密困境中少。与非农村服务提供者相比，农村服务提供者经历过更多的界限困境，并且对此做出的保守决定更少。
界限问题在基于社区的服务中经常出现，尤其是在农村地区，并且可能以保守或不保守的方式处理。随着个案管理和其他现场服务的扩展，更好地理解伦理风险和非正式做法将有助于改善服务，并为工作人员提供适当的培训和监督。
