Coercion in mental health care gives rise to many ethical challenges. Many countries have recently implemented state policy programs or development projects aiming to reduce coercive practices and improve their quality. Few studies have explored the possible role of ethics in such initiatives. This study adds to this subject by exploring health professionals’ descriptions of their ethical challenges and strategies in everyday life to ensure morally justified coercion and best practices. Seven semi-structured telephone interviews were carried out in 2012 with (...) key informants in charge of central development projects and quality-assurance work in mental health services in Norway. No facilities used formal clinical ethics support. However, the informants described five areas in which ethics was of importance: moral concerns as implicit parts of local quality improvement initiatives; moral uneasiness and idealism as a motivational source of change; creating a normative basis for development work; value-based leadership; and increased staff reflexivity on coercive practices. The study shows that coercion entails both individual and institutional ethical aspects. Thus, various kinds of moral deliberation and ethics support could contribute to addressing coercion challenges by offering more systematic ways of dealing with moral concerns. However, more strategic use of implicit and institutional ethics is also needed. (shrink)

Background: Moral case deliberation is increasingly becoming part of various Dutch healthcare organizations. Although some evaluation studies of moral case deliberation have been carried out, research into the results of moral case deliberation within aged care is scarce. Research questions: How did participants evaluate moral case deliberation? What has moral case deliberation brought to them? What has moral case deliberation contributed to care practice? Should moral case deliberation be further implemented and, if so, how? Research design: Quantitative analysis of a (...) questionnaire study among participants of moral case deliberation, both caregivers and team leaders. Qualitative analysis of written answers to open questions, interview study and focus group meetings among caregivers and team leaders. Participants and research context: Caregivers and team leaders in a large organization for aged care in the Netherlands. A total of 61 moral case deliberation sessions, carried out on 16 care locations belonging to the organization, were evaluated and perceived results were assessed. Ethical considerations: Participants gave informed consent and anonymity was guaranteed. In the Netherlands, the law does not prescribe independent ethical review by an Institutional Review Board for this kind of research among healthcare professionals. Findings: Moral case deliberation was evaluated positively by the participants. Content and atmosphere of moral case deliberation received high scores, while organizational issues regarding the moral case deliberation sessions scored lower and merit further attention. Respondents indicated that moral case deliberation has the potential to contribute to care practice as relationships among team members improve, more openness is experienced and more understanding for different perspectives is fostered. If moral case deliberation is to be successfully implemented, top-down approaches should go hand in hand with bottom-up approaches. Conclusion: The relevance of moral case deliberation for care practice received wide acknowledgement from the respondents. It can contribute to the team’s cohesion as mutual understanding for one another’s views is fostered. If implemented well, moral case deliberation has the potential to improve care, according to the respondents. (shrink)

Background: To better understand the kinds of ethical challenges that emerge when using coercion in mental healthcare, and the importance of these ethical challenges, this article presents a systematic review of scientific literature. Methods: A systematic search in the databases MEDLINE, PsychInfo, Cinahl, Sociological Abstracts and Web of Knowledge was carried out. The search terms derived from the population, intervention, comparison/setting and outcome. A total of 22 studies were included. Ethical considerations: The review is conducted according to the Vancouver Protocol. (...) Results: There are few studies that study ethical challenges when using coercion in an explicit way. However, promoting the patient’s best interest is the most important justification for coercion. Patient autonomy is a fundamental challenge facing any use of coercion, and some kind of autonomy infringement is a key aspect of the concept of coercion. The concepts of coercion and autonomy and the relations between them are very complex. When coercion is used, a primary ethical challenge is to assess the balance between promoting good (beneficence) and inflicting harm (maleficence). In the included studies, findings explicitly related to justice are few. Some studies focus on moral distress experienced by the healthcare professionals using coercion. Conclusion: There is a lack of literature explicitly addressing ethical challenges related to the use of coercion in mental healthcare. It is essential for healthcare personnel to develop a strong awareness of which ethical challenges they face in connection with the use of coercion, as well as challenges related to justice. How to address ethical challenges in ways that prevent illegitimate paternalism and strengthen beneficent treatment and care and trust in connection with the use of coercion is a ‘clinical must’. By developing a more refined and rich language describing ethical challenges, clinicians may be better equipped to prevent coercion and the accompanying moral distress. (shrink)

Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder, and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient’s autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical (...) practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient’s and the therapist’s perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist’s approach, who used motivational interventions with a view to appealing to the patient’s responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions. (shrink)

In this article, an intervention aimed at improving quality of care to prevent seclusion in psychiatry by focusing on the first five minutes at admission is analyzed from a care ethics perspective. Two cases are presented from an evaluation study in a psychiatric hospital. In both cases, the nurses follow the intervention protocol, but the outcome is different. In the first case, the patient ends up in the seclusion room. In the second case, this does not happen. Analyzing the cases (...) from a care ethics perspective, we conclude that applying the intervention in the right way implies more than following the steps laid down in the protocol. It requires a new way of thinking and acting, resulting in new relationships between nurses and patients. Care ethics theory can help clarify what good care is actually about and keep in mind what is needed to apply the intervention. Thus, care ethics theory can be highly practical and helpful in changing and improving healthcare practice. (shrink)

A systematic literature review on evaluation of clinical ethics support services in mental healthcare is presented and discussed. The focus was on (a) forms of clinical ethics support services, (b) evaluation of clinical ethics support services, (c) contexts and participants and (d) results. Five studies were included. The ethics support activities described were moral case deliberations and ethics rounds. Different qualitative and quantitative research methods were utilized. The results show that (a) participants felt that they gained an increased insight into (...) moral issues through systematic reflection; (b) there was improved cooperation among multidisciplinary team members; (c) it was uncertain whether clinical ethics support services led to better patient care; (d) the issue of patient and client participation is complex; and (e) the implementation process is challenging. Clinical ethics support services have mainly been studied through the experiences of the participating facilitators and healthcare professionals. Hence, there is limited knowledge of whether and how various types of clinical ethics support services influence the quality of care and how patients and relatives may evaluate clinical ethics support services. Based on the six excluded ‘grey zone articles’, in which there was an implicit focus on ethics reflection, other ways of working with ethical reflection in practice are discussed. Implementing and evaluating clinical ethics support services as approaches to clinical ethics support that are more integrated into the development of good practice are in focus. In order to meet some of the shortcomings of the field of clinical ethics support services, a research project that aims to strengthen ethics support in the mental health services, including patients’ and caregivers’ views on ethical challenges, is presented. (shrink)

In recent years, the attention on the use of coercion in mental health care has increased. The use of coercion is common and controversial, and involves many complex ethical challenges. The research question in this study was: What kind of ethical challenges related to the use of coercion do health care practitioners face in their daily clinical work?

Background Coercion can cause harm to both the patient and the patient’s family. Few studies have examined how the coercive treatment of a close relative might affect young next-of-kin. Research questions We aimed to investigate the views and experiences of health professionals being responsible for supporting young next-of-kin to patients in mental health care (children-responsible staff) in relation to the needs of these young next-of-kin in coercive situations and to identify ethical challenges. Research design We conducted a qualitative study based (...) on semistructured, focus group interviews and an individual interview. Participants and research context We held three focus group interviews with six to seven children-responsible staff in each group (a total of 20 participants) and one individual interview with a family therapist. The participants were recruited from three hospital trusts in the eastern part of Norway. Ethical considerations The study was approved by the National Data Protection Official for Research and based on informed consent and confidentiality. Findings Coercion was not a theme among the participants in relation to their work with young next-of-kin, and there was much uncertainty related to whether these young people need special support to deal with the coercive treatment of their close relative. Despite the uncertainty, the study indicated a need for more information and emotional support among the youth. Discussion Few studies have addressed the potential impact of coercive treatment of a close family member on young next-of-kin. The findings were consistent with existing research but highlighted disagreement and uncertainty among the children-responsible staff about to what extent the young next-of-kin should visit and whether they should enter the ward unit or not. We identified ethical challenges for the children-responsible staff related to the principle of not inflicting harm ( nonmaleficence). Conclusion From the perspective of children-responsible staff, it appears that the coercive treatment of a close family member entails a need for extra support of young relatives both in relation to information and the facilitation of visits, but more systematic knowledge about these issues is needed. (shrink)

Background: Young next of kin to patients with mental health problems are faced with many challenges. It is important to focus on the special needs of children and adolescents as next of kin to ensure their welfare and prevent harm. Research questions: We aimed to investigate young next of kin’s need for information and involvement, to examine the ways they cope with situations involving coercion related to the treatment of their relative, and to identify ethical challenges. Research design: We conducted (...) a qualitative study based on semi-structured, individual interviews. Participants and research context: Seven young next of kin aged 14–22 years participated in the study. The informants were recruited from a regional hospital trust in Norway. Ethical considerations: The study was approved by the National Data Protection Official for Research and based upon informed consent and confidentiality. Findings: The adolescents wanted more information and described a need for increased interaction with their sick relative at the hospital. They struggled to keep their relationship with their relative intact, and they described communication problems in the family. Coercive treatment was perceived in a negative way. Discussion: The study finds that there are ethical challenges at stake for young next of kin and their families other than those that are often emphasized by traditional healthcare, which often focuses on the individual patient’s rights. These challenges are related to the young next of kin’s needs for interconnectedness and for the preservation of relationships as well as challenges related to family communication and the need for information. Conclusion: The study finds a need for more family-oriented perspectives in both mental healthcare practices and healthcare ethics. (shrink)

Background Seven wards from three Norwegian mental health care institutions participated in a study in which regular ethics reflection groups focusing on coercion had been implemented and evaluated (2011–2015). This article presents (1) a thematic overview of the ethical challenges identified based on a systematic qualitative analyses of 161 ethics reflection groups and (2) some general observations on these ethical challenges. Results The ethical challenges are divided into four main thematic categories: (1) formal coercion, (2) informal coercion, (3) uncertainty related (...) to the Norwegian legislation on coercion and (4) professional role and identity. Some ethical challenges did not fit into these categories. Only 36% of the ethical challenges were related to the use of formal coercion or the interpretation of the health law. Conclusion Even within coercion regulated by law, weighing different moral values remains important to reflect upon the appropriateness of the possible use of coercion. (shrink)

Background: In spite of a national strategy for reducing coercion in the mental health services, Norway still has a high rate of involuntary treatment compared to other European countries. It is therefore crucial to study various parties involved in involuntary treatment in order to reduce coercion. Research question: How do patients and staff in a Norwegian locked psychiatric ward experience coercion? Research design: Participant observation and interviews. Participants: A total of 12 patients and 22 employees participated in this study. Ethical (...) considerations: This study is accepted by the National Committee for Medical Health Research Ethics. Findings: The participants experienced coercion in different ways. Patients often felt inferior, while many of the staff felt guilty for violating patients’ dignity, although they ascribed responsibility for their actions to the “system.” The main themes are (1) corrections and house rules, (2) coercion is perceived as necessary, (3) the significance of material surroundings, and (4) being treated as a human being. Discussion: The discussion draws upon the concepts of vulnerability, guilty conscience, and ethical sensitivity, related to the staffs’ divergent views on coercion. Conclusion: Especially among staff, there are divergent views of coercion. Professionals being physically and emotionally close to the patient are more likely to understand him or her as a unique person with individual needs. If patients are kept at a distance, professionals as a group change to understand patients as members of a group with common needs and common restrictions. (shrink)