The Role of Ethics in Reducing and Improving the Quality of Coercion in Mental Health Care

Abstract

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 (i.e., ethical theory, moral deliberation and clinical ethics support) 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.

Post-incident reviews—a gift to the Ward or just another procedure? Care providers’ experiences and considerations regarding post-incident reviews after restraint in mental health services. A qualitative study

“…This has prompted bans on all kinds of coercive measures [8]. In addition, ethical and professional imperatives urge developing reflexive practices aimed at limiting the use of coercion in morally justified cases and helping patients maintain hope and identity during crises, including the use of restraint [9,10]. Despite the promise of these S/R reduction programmes, most studies on them have been based on development work aimed at S/R reduction, not rigorous research, so it is difficult to assess how much the different interventions have individually contributed to these supposedly promising results [2,7,11].…”

“…However, the broader question of how PIRs relate to the wider context of the organisation and culture is poorly described, although non-punitive, supportive approaches are recommended [16][17][18]. Human care philosophies with supportive approaches for conducting PIRs may conflict with the traditional organisation and culture of psychiatric institutions, often historically characterised by bureaucratic, hierarchical structures with paternalistic cultures that include habitual coercive practices and allow patients' voices to have only marginal effects on services [10,19].…”

En studie av synet på etiske utfordringerrelatert til arbeid med bruk av tvang hos ansatte i psykiske helsetjenester

“…Vi vet for eksempel at etikk-refleksjonsgrupper -som nettopp har fokus på etiske utfordringer, uenighet og tvil -kan vaere et nyttig verktøy for å ta opp og bedre håndtere uenighet og til å identifisere nye løsninger (Hem, Molewijk & Pedersen, 2017). Etisk bevissthet og kompetanse kan både bidra til å identifisere problemene og til å håndtere utfordringene knyttet til tvangsbruk Norvoll, Hem & Pedersen, 2016).…”

Direct coercion – challenges for nursing practice

“…W Australii, Nowej Zelandii i Niemczech wprowadzane są specjalne procedury służące zmniejszeniu zakresu stosowania przymusu bezpośredniego w praktyce [17].…”