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.
Similar content being viewed by others
Notes
The English name for “PET” is “mental health care, ethics and coercion”.
Some key informants held double positions.
Norwegian Social Science Data Service (NSD 2015), http://www.nsd.uib.no/personvern/en/notification_duty/meldeskjema?eng).
“Shielding” is the main kind of seclusion in Norway. It differs legally from isolation in that it requires the continuous presence of staff.
References
Abma, T., Widdershoven, G., & Frederiks, B. (2008). Dialogical nursing ethics: The quality of freedom restrictions. Nursing Ethics, 15(6), 789–802.
Austin, W. (2007). The ethics of everyday practice: Healthcare environments as moral communities. Advances in Nursing Science, 30(1), 81–88.
Dauwerse, L., Weidema, F., Abma, T., Molewijk, B., & Widdershoven, G. (2013). Implicit and explicit clinical ethics support in the Netherlands: A mixed methods overview study. HEC Forum. doi:10.1007/s10730-013-9224-2.
Deady, R., & McCarthy, J. (2010). A study of the situations, features, and coping mechanisms experienced by Irish psychiatric nurses experiencing moral distress. Perspectives in Psychiatric Care, 46(3), 209–220. doi:10.1111/j.1744-6163.2010.00260.x.
Fox, E., Bottrell, M. M., Berkowitz, K. A., Chanko, B. L., Foglia, M. B., & Pearlman, R. A. (2010). Integrated ethics: An innovative program to improve ethics quality in health care. Innovation Journal, 15(2), 1–36.
Gaskin, C. J., Elsom, S. J., & Happell, B. (2007). Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature. British Journal of Psychiatry, 191, 298–303. doi:10.1192/bjp.bp.106.034538.
Graneheim, U., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105–112. doi:10.1016/j.nedt.2003.10.001.
Happell, B., & Harrow, A. (2010). Nurses’ attitudes to the use of seclusion: A review of the literature. International Journal of Mental Health Nursing, 19(3), 162–168. doi:10.1111/j.1447-0349.2010.00669.x.
Hem, M. H., Pedersen, R., Norvoll, R., & Molewijk, B. (2015). Evaluating clinical ethics support in mental healthcare: A systematic literature review. Nursing Ethics, 22(4), 452–466. doi:10.1177/0969733014539783.
Ho, A., MacDonald, L. M.-H., & Unger, D. (2016). Preventive ethics through expanding education. HEC Forum, 28(1), 69–74. doi:10.1007/s10730-015-9273-9.
Hoyer, G. (2000). On the justification for civil commitment. Acta Psychiatrica Scandinavica, 101, 65–71. doi:10.1111/j.0902-4441.2000.007s020[dash]16.x.
Kallert, T. W., Mezzich, J. E., & Monahan, J. (2011). Coercive treatment in psychiatry: Clinical, legal and ethical aspects. Hoboken, NJ: Wiley.
Kvale, S., & Brinkmann, S. (2009). Interviews: Learning the craft of qualitative research interviewing. Los Angeles: Sage.
Landeweer, E. G., Abma, T. A., & Widdershoven, G. A. (2011). Moral margins concerning the use of coercion in psychiatry. Nursing Ethics, 18(3), 304–316. doi:10.1177/0969733011400301.
Laukkanen, L., Suhonen, R., & Leino-Kilpi, H. (2015). Solving work-related ethical problems: The activities of nurse managers. Nursing Ethics,. doi:10.1177/0969733015584966.
Lindemann, H., Verkerk, M., & Walker, M. U. (2009). Naturalized bioethics: Toward responsible knowing and practice. Cambridge: Cambridge University Press.
Molewijk, B., Widdershoven, G., Verkerk, M., & Milius, H. (2008). Implementing moral case deliberation in a psychiatric hospital: Process and outcome. Medicine, Health Care and Philosophy, 11(1), 43–56. doi:10.1007/s11019-007-9103-1.
Pauly, B. M., Varcoe, C., & Storch, J. (2012). Framing the issues: Moral distress in health care. HEC Forum, 24(1), 1–11. doi:10.1007/s10730-012-9176-y.
Pelto-Piri, V. (2015). Ethical considerations in psychiatric inpatient care: The ethical landscape in everyday practice as described by staff. Örebro: Örebro University.
Scanlan, J. N. (2010). Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: What we know so far a review of the literature. International Journal of Social Psychiatry, 56(4), 412–423. doi:10.1177/0020764009106630.
Schomberg, R. (2012). Prospects for technology assessment in a framework of responsible research and innovation. In M. Dusseldorp & R. Beecroft (Eds.), Technikfolgen abschätzen lehren: Bildungspotenziale transdisziplinärer methoden (pp. 39–61). Wiesbaden: VS Verlag für Sozialwissenschaften.
Smith, J. P., & Herber, O. R. (2015). Ethical issues experienced by mental health nurses in the administration of antipsychotic depot and long-acting intramuscular injections: A qualitative study. International Journal of Mental Health Nursing, 24(3), 222–230. doi:10.1111/inm.12105.
Steinert, T., & Lepping, P. (2011). Is it possible to define a best practice standard for coercive treatment in psychiatry? In T. Kallert, J. E. Mezzich, & J. Monahan (Eds.), Coercive treatment in psychiatry. Clinical, legal and ethical aspects (pp. 49–56). Hobroken: Wiley.
Vetlesen, A. J. (1994). Perception, empathy, and judgement: An inquiry into the preconditions of moral performance. University Park, PA: Pennsylvania State University Press.
Voskes, Y. (2014). No effects without ethics. Reduction of seclusion in psychiatry from a care ethics perspective. Amsterdam: Vrije Universiteit Amsterdam.
Walker, M. (1993). Keeping moral space open—new images of ethics consulting. Hastings Center Report, 23(2), 33–40.
Wertheimer, A. (1993). A philosophical examination of coercion for mental health issues. Behavioral Sciences and the Law, 11(3), 239–258.
Widdershoven, G., Abma, T., & Molewijk, B. (2009). Empirical ethics as dialogical practice. Bioethics, 23(4), 236–248. doi:10.1111/j.1467-8519.2009.01712.x.
Wojtowicz, B., Hagen, B., & Van Daalen-Smith, C. (2014). No place to turn: Nursing students’ experiences of moral distress in mental health settings. International Journal of Mental Health Nursing, 23(3), 257–264. doi:10.1111/inm.12043.
Acknowledgments
We thank the informants who have participated in this study; Associate Professor Nina Olsvold at Diakonova University College and anonymous reviewers for valuable advices; and the Norwegian Directorate of Health for financial support.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interests
There are no conflicts of interest regarding financial support or relationships.
Disclosure
The manuscript has not been published or submitted for publication elsewhere.
Rights and permissions
About this article
Cite this article
Norvoll, R., Hem, M.H. & Pedersen, R. The Role of Ethics in Reducing and Improving the Quality of Coercion in Mental Health Care. HEC Forum 29, 59–74 (2017). https://doi.org/10.1007/s10730-016-9312-1
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10730-016-9312-1