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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.

Background Use of physical restraint is a common practice in mental healthcare, but is controversial due to risk of physical and psychological harm to patients and creating ethical dilemmas for care providers. Post-incident review (PIR), that involve patient and care providers after restraints, have been deployed to prevent harm and to reduce restraint use. However, this intervention has an unclear scientific knowledge base. Thus, the aim of this scoping review was to explore the current knowledge of PIR and to assess to what extent PIR can minimize restraint-related use and harm, support care providers in handling professional and ethical dilemmas, and improve the quality of care in mental healthcare. Methods Systematic searches in the MEDLINE, PsychInfo, Cinahl, Sociological Abstracts and Web of Science databases were carried out. The search terms were derived from the population, intervention and settings. Results Twelve studies were included, six quantitative, four qualitative and two mixed methods. The studies were from Sweden, United Kingdom, Canada and United States. The studies’ design and quality varied, and PIR s’ were conducted differently. Five studies explored PIR s’ as a separate intervention after restraint use, in the other studies, PIR s’ were described as one of several components in restraint reduction programs. Outcomes seemed promising, but no significant outcome were related to using PIR alone. Patients and care providers reported PIR to: 1) be an opportunity to review restraint events, they would not have had otherwise, and 2) promote patients’ personal recovery processes, and 3) stimulate professional reflection on organizational development and care. Conclusion Scientific literature directly addressing PIR s’ after restraint use is lacking. However, results indicate that PIR may contribute to more professional and ethical practice regarding restraint promotion and the way restraint is executed. The practice of PIR varied, so a specific manual cannot be recommended. More research on PIR use and consequences is needed, especially PIR’s potential to contribute to restraint prevention in mental healthcare.

BackgroundNorway has extensive and detailed legal requirements and guidelines concerning involvement of next of kin (NOK) during involuntary hospital treatment of seriously mentally ill patients. However, we have little knowledge about what happens in practice. This study explores NOK’s views and experiences of involvement during involuntary hospitalisation in Norway.MethodsWe performed qualitative interviews-focus groups and individual-with 36 adult NOK to adults and adolescents who had been involuntarily admitted once or several times. The semi-structured interview guide included questions on experiences with and views on involvement during serious mental illness and coercion.ResultsMost of the NOK were heavily involved in the patient’s life and illness. Their conceptions of involvement during mental illness and coercion, included many important aspects adding to the traditional focus on substitute decision-making. The overall impression was, with a few exceptions, that the NOK had experienced lack of involvement or had negative experiences as NOK in their encounters with the health services. Not being seen and acknowledged as important caregivers and co sufferers were experienced as offensive and could add to their feelings of guilt. Lack of involvement had as a consequence that vital patient information which the NOK possessed was not shared with the patient’s therapists.ConclusionsDespite public initiatives to improve the involvement of NOK, the NOK in our study felt neglected, unappreciated and dismissed. The paper discusses possible reasons for the gap between public policies and practice which deserve more attention: 1. A strong and not always correct focus on legal matters. 2. Little emphasis on the role of NOK in professional ethics. 3. The organisation of health services and resource constraints. 4. A conservative culture regarding the role of next of kin in mental health care. Acknowledging these reasons may be helpful to understand deficient involvement of the NOK in voluntary mental health services.Electronic supplementary materialThe online version of this article (doi:10.1186/s12910-016-0159-4) contains supplementary material, which is available to authorized users.

The study finds a need for more family-oriented perspectives in both mental healthcare practices and healthcare ethics.

Broader perspectives on coercion are required to comprehend its ethical challenges and derive possible solutions to these from a patient perspective.

Coercion in mental healthcare does not only affect the patient, but also the patient's families. Using data from interviews with 36 family members of adult and adolescent people with mental health problems and coercion experiences, the present narrative study explores family members' existential and moral dilemmas regarding coercion and the factors influencing these dilemmas. Four major themes are identified: the ambiguity of coercion; struggling to stay connected and establishing collaboration; worries and distress regarding compulsory care; and dilemmas regarding initiating coercion. Subsequently, coercion can reduce, but also add burden for the family by creating strains on family relations, dilemmas, (moral) distress, and retrospective regrets; this is reinforced by the lack of information or involvement and low-quality care. Subsequently, it is a moral obligation to develop more responsive health services and professionals who provide more guidance and balanced information to increase the possibilities for voluntary alternatives and informed decision making.

Aim: Many medical doctors work outside their countries of origin. Consequently, language barriers and cultural differences may result in miscommunication and tension in the workplace, leading to poor performance and quality of treatment, affecting patient safety. However, there is little information about how foreign doctors and their colleagues perceive their collaboration and handle situations that can affect the quality of health services.Methods: Individual, semi-structured in-depth interviews were conducted with two groups of informants 16 doctors who had recently started working in Norway, and 12 unrelated Norwegianborn healthcare providers who had extensive experience working with doctors from foreign countries. Interviews were analysed according to the systematic text condensation method.Results: The foreign doctors described themselves as newcomers and found it difficult to speak with colleagues about their shortcomings, as they wanted to be viewed as competent. The Norwegian colleagues reported that many new foreign doctors had demanding work schedules; therefore, they were reluctant to give them negative feedback. They also feared that foreign doctors would react negatively to criticism. All participants, both the new foreign doctors and colleagues, reported that they took responsibility for the prevention of misunderstandings and errors; nevertheless, they struggled to discuss such issues with each other. Conclusions:Silence was the coping strategy adopted by foreign doctors and native healthcare professionals when facing difficulties in their working relationships. In such situations, many foreign doctors are socialised into a new workplace in which uncertainty and shortcomings are not openly discussed. Effective leadership and procedures to facilitate communication may alleviate this area of concern.