Correlates of psychiatric staff's attitude toward coercion and their sociodemographic characteristics.

BACKGROUND: A deeper understanding of the nurses' characteristics that influence their positive attitudes toward coercion is necessary if coercive measures rates are to be effectively reduced. AIM: To identify the difference in psychiatric staff attitudes toward coercive measures in relation to their sociodemographic characteristics. SETTING: The study conducted at the National Center for Mental Health, which is regulated under the authority of the Jordanian Ministry of Health. PARTICIPANTS: A total of 85 psychiatric staff recruited from the National Center for Mental Health. METHODS: A cross-sectional, descriptive, correlational design was used. Data were collected using a self-administered questionnaire, which consisted of 15 items that focused on assessing a staff's attitude toward coercion. RESULTS: The relationship between clinical unit and attitude toward coercion was significant (r = -.30; P = .006). Similarly, the correlations between gender-based units and attitudes toward coercion were significant (r = -.38; P = .002). Another significant correlation was revealed with different years of experience (r = .22; P = .04). CONCLUSION: The more years of experience in the field of psychiatric nursing the more positive attitude toward coercion. Moreover, working with male psychiatric patients and in acute psychiatric units increase the risk of coercive measures use.

Moral distress in acute psychiatric nursing: Multifaceted dilemmas and demands.

BACKGROUND: In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored. RESEARCH DESIGN: A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke's six analytic phases were used. ETHICAL CONSIDERATIONS: Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary. FINDINGS: Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally 'flat', cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness. CONCLUSION: Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients' suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves.

Disclosure of confidential information by mental health nurses, of patients they assess to be a risk of harm to self or others: An integrative review.

There is a duty of confidentiality on the part of mental health nurses when they handle confidential patient information. Nonetheless, it may be necessary to disclose confidential information of a patient if the patient is assessed as being a risk to self or others, to protect the patient or others from harm. However, disclosing information inappropriately may constitute a breach of confidentiality. There is a paucity of information on how mental health nurses understand the rules of confidentiality when deciding to withhold or disclose confidential information in these circumstances. An integrative review of the literature was undertaken to explore the disclosure of confidential information by mental health nurses when they assess a patient as being a risk of harm. The findings indicate the rules of confidentiality are not well understood, or are not adhered to by mental health nurses. Risk assessments were found to underpin deliberations to withhold or disclose confidential information of a patient, despite risk being difficult to predict with any certainty. For risk assessment, mental health nurses were noted to prefer their unstructured clinical judgement over actuarial methods; and defer to their clinical intuition over scores of a structured risk assessment instrument, when making structured clinical judgement-backed decisions in this area of their practice. Gaps in the literature that may be addressed by future empirical research were revealed during this integrative review.

Convergence and divergence: An analysis of mechanical restraints.

BACKGROUND: Psychiatric nurses are regularly confronted with the uses and effects of control interventions such as mechanical restraints. Although there are evident tensions in the literature regarding the use of mechanical restraints, very little research has focused on the lived and embodied experience of their use, whether from the patient's perspective or the perspective of nursing staff responsible for their application. RESEARCH AIMS: (1) to gain access to the bodily phenomenon of being placed in mechanical restraints; (2) to give voice to the intimate experiential understanding of this experience; and (3) through phenomenological interpretation, to understand the subjective processes and meaning-making of this experience. RESEARCH DESIGN: For this research, we adopted a distinctly ethics-oriented application of the methodology known as interpretative phenomenological analysis, that is, the interpretive dimension of the research focused on ethical practice in mental healthcare - one that is informed by experiential accounts of the lived body. PARTICIPANTS AND RESEARCH CONTEXT: A total of 40 in-depth semi-structured, nondirected interviews with both nurses (n = 21) and patients (n = 19) we conducted to meet the aims of this article. Participants were recruited from an inpatient psychiatric unit of a Canadian general hospital. ETHICAL CONSIDERATIONS: The research received research ethics board clearance from both the hospital where the study took place and the University of Ottawa. FINDINGS: The comparative analysis is presented under the following headings: (1) context of care, (2) meaning of quality of care, (3) emotional reactions and nurse-patient relationship, (4) meeting the needs and (5) need for alternatives. DISCUSSION/CONCLUSIONS: The research findings are discussed in light of current literature and implications for practice.

Textbook descriptions of people with psychosis - some ethical aspects.

BACKGROUND: Textbooks are central for the education of professionals in the health field and a resource for practitioners already in the field. OBJECTIVES: This article focuses on how 12 textbooks in psychiatric nursing and psychiatry, published in Norway between 1877 and 2012, describe and present people with psychosis. RESEARCH DESIGN: We used qualitative content analysis. ETHICAL CONSIDERATIONS: The topic is published textbooks, made available to be read by students, teachers and professionals, and no ethical approval was required. FINDINGS: The analysis shows that all 12 textbooks describe and present people who are considered as psychotic from a 'perspective from above'. In this perspective, the readers are learning about psychosis in the professional's language and from the author's viewpoint. Most often the textbooks communicate a universal image of people with psychosis, a description that fits with the diagnostic criteria. The analysis also shows that two textbooks in psychiatric nursing combined this perspective with a 'perspective from within'. Here, the readers are learning about psychosis from the patients' own viewpoint. The authors communicate a personal, psychotic universe that differs from various people, even if they have the same diagnosis, and the descriptions are focusing on the patient as a whole person. DISCUSSION AND CONCLUSION: Drawing partly on Rita Charon's writings about narrative knowledge in the health field, and partly on insights from Martha Nussbaum and her concept of narrative imagination, we argue that mental health professionals need to learn about, understand and fathom what patients go through by reading, listening to and acknowledging the patients' own stories and experiences. Cultivating the capacity for empathy and compassion are at the very heart of moral performance in the mental health field. A valuable moral resource in that regard is leading textbooks and how they describe and present people with severe mental illness.

Moral mindfulness: The ethical concerns of healthcare professionals working in a psychiatric intensive care unit.

Healthcare professionals working on inpatient wards face the externalizing or challenging behaviour of the patients who are admitted. Ethical values and principles in psychiatric nursing have been reported to be important when approaching patients during the most acute phase of deterioration in their mental health. Hence, the aim of this study was to discover and describe staff members' ethical and moral concerns about their work as healthcare professionals in a psychiatric intensive care unit. The study has a qualitative descriptive design and makes use of Framework Analysis. Registered nurses and psychiatric aides in a psychiatric intensive care unit in Sweden were observed during ethical reflection meetings. Four to six staff attended the 90-min meetings. The data comprise observations from six meetings, which provided 94 pages of text. The results demonstrate that the work was described as being both motivating and exhausting. The staff faced ethical concerns in their daily work, as patients often demonstrated challenging behaviours. Three themes were identified as follows: (i) concerns about the staff impacting on patients' experience of care, (ii) concerns about establishing a safe working environment, and (iii) concerns about becoming unprofessional due to expectations and a high workload. Ethical concerns included simultaneously taking into account both the patients' dignity and safety aspects, while also being exposed to high workloads. These elements of work are theorized as influencing complex psychiatric nursing. If we are to bring these influential factors to light in the workplace, advanced nursing practice must be grounded in moral mindfulness.

[The reception, a prerequisite of the encounter: a political question]. / L'accueil, condition sine qua non de la rencontre : une question politique.

The reception of a patient in psychiatry is a stage which consists of more than a single initial contact between a person suffering psychologically and a caregiver. This time can open the way to an encounter, without which a care relationship cannot be established. The reception as a paradigm of psychiatric care questions the concept of this care, at a time when caregivers cannot avoid the question of their political engagement.

Patients' moral views on coercion in mental healthcare.

BACKGROUND: Coercion in mental healthcare has led to ethical debate on its nature and use. However, few studies have explicitly explored patients' moral evaluations of coercion. AIM: The purpose of this study is to increase understanding of patients' moral views and considerations regarding coercion. RESEARCH DESIGN: Semi-structured focus-group and individual interviews were conducted and data were analysed through a thematic content analysis. Participants and research context: A total of 24 adult participants with various mental health problems and experiences with coercion were interviewed in 2012-2013 in three regions of Norway. Ethical considerations: Ethical approval and permissions were obtained according to required procedures. Informed consent and confidentiality were also secured. FINDINGS: Ethical considerations regarding coercion included seven main themes: the need for alternative perspectives and solutions, the existence of a danger or harm to oneself or others, the problem of paternalism, the problem of discrimination and stigma, the need for proportionality, the importance of the content and consequences of coercion and concerns about way that coercion is carried out in practice. DISCUSSION: The participants' views and considerations are in line with previous research and reflect the range of normative arguments commonly encountered in ethical and legal debates. The study accentuates the significance of institutional factors and alternative voluntary treatment opportunities, as well as the legal and ethical principles of proportionality and purposefulness, in moral evaluations of coercion. CONCLUSION: Broader perspectives on coercion are required to comprehend its ethical challenges and derive possible solutions to these from a patient perspective.

Ethical challenges when using coercion in mental healthcare: A systematic literature review.

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.

Factors Relating to Self-Efficacy Among Psychiatric Nurses.

This study aimed to clarify the factors related to self-efficacy experienced by psychiatric nurses. Analysis of qualitative descriptive data from a free self-description questionnaire administered to 16 psychiatric nurses working in psychiatric hospitals revealed 24 codes across the following 8 categories as factors that increase self-efficacy: A1. possibility of practical use in nursing, A2. nursing judgment, A3. improvement of psychiatric symptoms, A4. the patients presenting a positive attitude, A5. building a relationship of trust with the patients, A6. building a relationship of trust with other nurses, A7. work progressing according to plan and A8. team medical practice. Twenty-five codes across the following 10 categories were identified as factors that decrease self-efficacy: B1. lack of communication, B2. uncertainty in caregiving, B3. recurrence of psychiatric symptoms, B4. feeling overpowered by a patient, B5. sense of being too busy to work adequately, B6. difficulty in bringing about self-improvement, B7. sense of loss regarding one's role as a nurse, B8. lack of physical strength, B9. mechanical performance of nursing and B10. fluctuating view of nursing due to mistakes. These factors require intervention for psychiatric nurses' self-efficacy.

Medidas coercitivas desde el punto de vista psicológico del paciente / Coercive measures from patients' psychological point of view

Introducción: se han hallado dos herramientas de evaluación fiables y válidas que miden las repercusiones psíquicas que las técnicas coercitivas tienen sobre los pacientes mentales. La existencia de estas herramientas habilita la continuidad en la investigación sobre la temática. Objetivo: revisar las preferencias de los pacientes de las instituciones de salud ante las distintas medidas coercitivas. Métodos: se realizó una búsqueda bibliográfica sistemática en bases de datos digitales y otras fuentes. Se realizó revisión por pares de los trabajos, utilizando como criterio temático de inclusión, la pertinencia en los temas a tratar. Tras el examen del resumen, cuerpo y conclusiones, se seleccionaron aquellos cuyo contenido se refería a: (1) las vivencias de los pacientes y personal cuando se aplicaban las medidas coercitivas; (2) preferencias de los pacientes sobre estas; (3) medidas preventivas; y (4) cuidados necesarios. Desarrollo: Los estudios revisados apuntan al peligro ético que desarrolla el uso o la mala aplicación de estos protocolos coercitivos. Se debe tener en cuenta que la integridad física del personal sanitario también corre peligro en el tratamiento de pacientes psiquiátricos. En esta disyuntiva entre preservación de la dignidad del paciente y seguridad del personal, han sido propuestas diversas medidas tanto accesorias/compensatorias como sustitutivas de estas técnicas perjudiciales para la salud mental de los pacientes. Conclusiones: La comunicación entre el personal que implementa estas medidas y el paciente que las recibe, es esencial para una buena alianza terapéutica y el correcto desarrollo del tratamiento(AU)

Introduction: Two reliable and valid assessment tools have been found that measure the psychic impact of coercive techniques on mental patients. The existence of these tools enables continuity in research on the subject. Objective: This paper reviews the preferences of the patients of the health institutions about different coercive measures. Methods: A systematic bibliographic search was carried out in digital databases and other sources. Peer review of the works was carried out, using as a thematic criterion of inclusion, the relevance in the topics to be treated. After examining the summary, body and conclusions, those whose content referred to were selected: (1) the experiences of the patients and staff when the coercive measures were applied; (2) patients' preferences about these; (3) preventive measures; and (4) necessary care.. Body: The studies reviewed point to the ethical danger that leads to the use or misapplication of these coercive protocols. It should be taken into account that the physical integrity of health personnel is also at risk in the treatment of psychiatric patients. In this dilemma between the preservation of the patient's dignity and the safety of the personnel, various measures have been proposed, both ancillary and compensatory, as well as substitute for these techniques that are detrimental to the mental health of patients. The purpose of these measures is to avoid the use of these coercive techniques. Conclusion: communication between the personnel implementing these measures and the patient receiving them is essential for a good therapeutic alliance and the correct development of the treatment(AU)

Using Participatory Action Research to Develop a Working Model That Enhances Psychiatric Nurses' Professionalism: The Architecture of Stability.

Ward rules in psychiatric care aim to promote safety for both patients and staff. Simultaneously, ward rules are associated with increased patient violence, leading to neither a safe work environment nor a safe caring environment. Although ward rules are routinely used, few studies have explicitly accounted for their impact. To describe the process of a team development project considering ward rule issues, and to develop a working model to empower staff in their daily in-patient psychiatric nursing practices. The design of this study is explorative and descriptive. Participatory action research methodology was applied to understand ward rules. Data consists of audio-recorded group discussions, observations and field notes, together creating a data set of 556 text pages. More than 100 specific ward rules were identified. In this process, the word rules was relinquished in favor of adopting the term principles, since rules are inconsistent with a caring ideology. A linguistic transition led to the development of a framework embracing the (1) Principle of Safety, (2) Principle of Structure and (3) Principle of Interplay. The principles were linked to normative guidelines and applied ethical theories: deontology, consequentialism and ethics of care. The work model reminded staff about the principles, empowered their professional decision-making, decreased collegial conflicts because of increased acceptance for individual decisions, and, in general, improved well-being at work. Furthermore, the work model also empowered staff to find support for their decisions based on principles that are grounded in the ethics of totality.

Managing Professional and Nurse-Patient Relationship Boundaries in Mental Health.

Caring nurse-patient relationships in mental health settings are key components in helping patients recover. These professional relationships provide a safe, trustworthy, reliable, and secure foundation for therapeutic interactions; however, nurses face challenges in setting and maintaining relationship boundaries. Although patients ask for special privileges, romantic interactions, and social media befriending, or offer expensive gifts, nurses must recognize that these boundary violations may erode trust and harm patients. These violations may also trigger discipline for nurses. Professional relationship guidelines must be applied with thoughtful consideration, and nurses must monitor their emotions and reactions in these relationships. The current article is a sharing of personal experiences about boundaries augmented by evidence in the literature, and focuses on managing potential boundary violations (i.e., social media, sexuality, over-involvement, and gift giving) in mental health settings. [Journal of Psychosocial Nursing and Mental Health Services, 55(1), 45-51.].

Responses and Results to Ethical Problems by Psychiatric Nurses in Japan.

The aim of this study was to investigate the responses of Japanese psychiatric nurses to ethical problems, and the results of those issues. The participants were 130 nurses who worked in psychiatry wards in a hospital. The nurses answered the question "how did you respond when you faced an ethical problem and what results did you get?" in free description. Seven categories were selected qualitatively from their responses: "Lack of action and no change," "Experiencing problems and feeling gloomy," "Pointing out misconduct and being hurt," "Consultation among staff and resolution or not," "Consultation with physicians and getting positive or negative responses," and "Searching for and providing evidence-based care," and "Thinking for themselves." The facts that some nurses do not cope with ethical problems and some face moral distress without knowing what to do suggest that "improvement of moral efficacy to cope with ethical problems", "proposing resolution methods", and "organizational ethics support" may be useful.

Ethically Relevant Differences in Advance Directives for Psychiatric and End-of-Life Care.

BACKGROUND: Psychiatric advance directives (PADs) represent a shift from more coercive to more recovery-oriented care and hold the promise of empowering patients while helping fill the gap in treatment of non-dangerous patients lacking decision-making capacity. Advance directives for end-of-life and psychiatric care share an underlying rationale of extending respect for patient autonomy and preventing the harm of unwanted treatment for patients lacking the decision-making capacity to participate meaningfully in planning their care. OBJECTIVE: Ethically relevant differences in applying advance directives to end-of-life and psychiatric care are discussed. DESIGN: These differences fall into three categories: (1) patient factors, including decision-making capacity, ability to communicate, and prior experience; (2) decisional factors, including expected outcome and the nature of the decisions; and (3) historical-legal precedent. RESULTS: Specific recommendations are offered. CONCLUSIONS: Clinicians need to appreciate the ethical implications of these differences to effectively invoke PADs or assist patients in creating PADs.

Caught between compassion and control: exploring the challenges associated with inpatient adolescent mental healthcare in an independent hospital.

AIM: To extend our understanding of how healthcare assistants construct and manage demanding situations in a secure mental health setting and to explore the effects on their health and well-being, to provide recommendations for enhanced support. BACKGROUND: Contemporary literature acknowledges high rates of occupational stress and burnout among healthcare assistants, suggesting the context in which they work places them at elevated risk of physical harm and psychological distress. Yet, there is a deficit of qualitative research exploring the experiences of healthcare assistants in adolescent inpatient facilities. DESIGN: An exploratory multi-method qualitative approach was used to collect data about the challenges faced by healthcare assistants working on secure adolescent mental health wards in an independent hospital during 2014. METHOD: Fifteen sets of data were collected. Ten participants completed diary entries and five participants were also interviewed allowing for triangulation. Data were analysed using Interpretive Phenomenological Analysis. FINDINGS: The findings illustrated how inpatient mental healthcare is a unique and distinctive area of nursing, where disturbing behaviour is often normalized and detached from the outside world. Healthcare assistants often experienced tension between their personal moral code which orientate them towards empathy and support and the emotional detachment and control expected by the organization, contributing to burnout and moral distress. CONCLUSIONS: This study yielded insights into mental health nursing and specifically the phenomenon of moral distress. Given the ever-increasing demand for healthcare professionals, the effects of moral distress on both the lives of healthcare assistants and patient care, merits further study.