Ethical challenges for nurses delivering coercive interventions in community mental health settings: A scoping review.

The number of Australians subject to coercive interventions in community mental health services continues to increase. This is in the context of a growing awareness of the harms from coercion, increasing concerns about potential breaches of human rights and an ongoing uncertainty regarding the clinical benefits of community treatment orders, the primary instrument of legislated coercion in community mental health services. Nurses in community mental health services are on the frontline with regard to coercion. They police the requirements of the community treatment order, administer medication to people in community settings without their consent and facilitate re-hospitalisation if indicated. Coercive practice contradicts the person-centred, recovery-oriented and trauma-informed care principles that inform contemporary mental health nursing. This contradiction may generate ethical challenges for nurses and result in ethical distress. The aim of this scoping review was to map the research literature on how nurses in community mental health settings recognise and manage the harm associated with the administration of coercive interventions and consider the ethical challenges that may arise within this practice. The search strategy yielded 562 studies with author consensus determining a total of three articles as meeting the inclusion criteria. The resulting literature identified three themes: (1) maintaining the therapeutic relationship, (2) promoting autonomy and (3) using subtle forms of control. This review demonstrated that there is minimal research that has considered the ethical challenges related to the use of coercion by nurses in community mental health settings.

A guide to community mental health law for district nurses: the right to aftercare.

District nurses frequently provide physical care and treatment to patients in their own homes and care homes who have previously been detained under the Mental Health Act 1983 for the treatment of a mental illness. Such patients are commonly subject to community provisions of the Mental Health Act 1983 and it is important that districts nurses are aware of the implications of these provisions on the patients care and support. In this article the author considers a detained mental health patient's right to aftercare under the Mental Health Act 1983, section 117.

Human resources and models of mental healthcare integration into primary and community care in India: Case studies of 72 programmes.

BACKGROUND: Given the scarcity of specialist mental healthcare in India, diverse community mental healthcare models have evolved. This study explores and compares Indian models of mental healthcare delivered by primary-level workers (PHW), and health workers' roles within these. We aim to describe current service delivery to identify feasible and acceptable models with potential for scaling up. METHODS: Seventy two programmes (governmental and non-governmental) across 12 states were visited. 246 PHWs, coordinators, leaders, specialists and other staff were interviewed to understand the programme structure, the model of mental health delivery and health workers' roles. Data were analysed using framework analysis. RESULTS: Programmes were categorised using an existing framework of collaborative and non-collaborative models of primary mental healthcare. A new model was identified: the specialist community model, whereby PHWs are trained within specialist programmes to provide community support and treatment for those with severe mental disorders. Most collaborative and specialist community models used lay health workers rather than doctors. Both these models used care managers. PHWs and care managers received support often through multiple specialist and non-specialist organisations from voluntary and government sectors. Many projects still use a simple yet ineffective model of training without supervision (training and identification/referral models). DISCUSSION AND CONCLUSION: Indian models differ significantly to those in high-income countries-there are less professional PHWs used across all models. There is also intensive specialist involvement particularly in the community outreach and collaborative care models. Excessive reliance on specialists inhibits their scalability, though they may be useful in targeted interventions for severe mental disorders. We propose a revised framework of models based on our findings. The current priorities are to evaluate the comparative effectiveness, cost-effectiveness and scalability of these models in resource-limited settings both in India and in other low- and middle- income countries.

"Restricted Community Members": Research Protections and Opportunities for Individuals Committed to Assisted Outpatient Treatment.

Several forms of mandated community treatment exist in the United States. One mechanism, assisted outpatient treatment (AOT), has become both more common and more controversial in recent years. The status of individuals committed to AOT remains unclear within regulatory guidelines aimed at protecting research participants. Should individuals on AOT be considered psychiatric inpatients, prisoners, community members, or something else? The authors argue that persons on AOT inhabit a gray area wherein they should be given some of the ethical protections afforded to involuntary inpatients and prisoners, but they should also enjoy freedoms as members of the community. The authors' term for this population is "restricted community members." The need to protect individuals in this population from potentially coercive forces of AOT while also offering them the opportunity to participate in research is especially acute in areas of research where the need is great: serious mental illness and substance use disorders.

A qualitative study examining the presence and consequences of moral framings in patients' and mental health workers' experiences of community treatment orders.

BACKGROUND: Mental health recovery involves acknowledging the importance of building the person's capacity for agency. This might be particularly important for patients on community treatment orders (CTOs - which involve enforced treatment for their mental illness), given limited international evidence for their effectiveness and underlying concerns about the use of coercion by workers and systems of care towards this population of people with mental illness. METHODS: This study sought to understand how the meaning of CTOs is constructed and experienced, from the perspective of patients on CTOs and workers directly administering CTOs. Qualitative interviews were conducted with South Australian community mental health patients (n = 8) and mental health workers (n = 10) in 2013-14. During thematic analysis of data, assisted by NVIVO software, the researchers were struck by the language used by both groups of participants and so undertook an examination of the moral framings apparent within the data. RESULTS: Moral framing was apparent in participants' constructions and evaluations of the CTO experience as positive, negative or justifiable. Most patient participants appeared to use moral framing to: try to understand why they were placed on a CTO; make sense of the experience of being on a CTO; and convey the lessons they have learnt. Worker participants appeared to use moral framing to justify the imposition of care. Empathy was part of this, as was patients' positive right to services and treatment, which they believed would only occur for these patients via a CTO. Workers positioned themselves as trying to put themselves in the patients' shoes as a way of acting virtuously towards them, softening the coercive stick approach. Four themes were identified: explicit moral framing; best interests of the patient; lessons learned by the patient; and, empathy. CONCLUSIONS: Experiences of CTOs are multi-layered, and depend critically upon empathy and reflection on the relationship between what is done and how it is done. This includes explicit examination of the moral framing present in everyday interactions between mental health workers and their patients in order to overcome the paradox of the moral grey zone between caring and controlling. It suggests a need for workers to receive ongoing empathy training.

Moral decision-making among assertive community treatment (ACT) case managers: a focus group study.

The context of care in assertive community treatment (ACT) can be precarious and generate ethical issues involving the principles of autonomy and paternalism. This focus group study examined case managers' situated accounts of moral reasoning. Our findings show how they expressed strong moral obligation towards helping the clients. Their moral reasoning reflected a paternalistic position where, on different occasions, the potential benefits of their interventions would be prioritised at the expense of protecting the clients' personal autonomy. The case managers' reasoning emphasised situational awareness, but there was a risk of supporting paternalistic interventions and denying the clients' right to autonomy.

'When coercion moves into your home'--a qualitative study of patient experiences with outpatient commitment in Norway.

The use of coercion on people with mental health problems is a serious intervention, and a reduction in its use is a declared goal in mental healthcare. Yet, many countries have introduced expanded powers of coercion in recent years, including outpatient commitment (OC). However, the evidence of the effectiveness of OC is inconclusive, and little is known about how patients experience OC schemes. The objective of this qualitative study was to explore (i) patients' experiences with OC, and (ii) how routines in care and health services affect patients' everyday living. The data were collected in 2011-2012 and included 11 qualitative in-depth interviews with patients subject to OC. The study used a narrative approach to interviews and a thematic narrative analysis. Participants generally complied with the OC requirements because of the clear and secure framework of OC, and also because they believed that the alternative would be involuntary hospitalisation. No one reported physical force, but coercion was experienced as limitation of freedom of action through excessive control and little patient influence or participation in their own treatment. Factors affecting patients' freedom of action under OC should be taken into account when the imposition of an OC order is considered.

The use of leverage in community mental health: ethical guidance for practitioners.

BACKGROUND: Leverage is a particular type of treatment pressure that is used within community mental health services to increase patients' adherence to treatment. Because leverage involves practitioners making proposals that attempt to influence patients' behaviours and choices, the use of leverage raises ethical issues. AIM: To provide guidance that can assist practitioners in making judgements about whether it is ethically acceptable to use leverage in a particular clinical context. METHOD: Methods of ethical analysis. RESULTS: Four ethical duties relevant to making such judgements are outlined. These four duties are (1) benefitting the individual patient, (2) benefitting other individuals, (3) treating patients fairly and (4) respecting patients' autonomy. The practical requirements that follow from each of these duties are considered in detail. It is argued that practitioners should determine whether the use of leverage will mean that care is provided in ways that are consistent with the requirements of these four duties, regardless of whether the patient accepts or rejects the terms of the proposal made. CONCLUSION: Particular attention must be paid to determine how the requirements of the four duties should be applied in each specific treatment scenario, and in making careful judgements when these duties pull in opposing directions.

[Involuntary treatment of mental patients in the community: legal and ethical dilemmas].

This article focuses on the measure of involuntary treatment of mental patients in the community, not only with regard to human rights and more specifically those of persons with mental disorders, but also with regard to ethics and deontology in mental healthcare delivery service. In this light, the important role of informed consent in psychiatry with regard to the psychiatric act is examined. Informed consent of mental patients in treatment when they are in need of voluntary or involuntary hospitalization is further examined, while emphasis is being put on the case of involuntary treatment. The Convention for Human Rights and Biomedicine (Convention of Οviedo), the European Convention of Human Rights, other documents of International Organizations (UN) and specialized national legislation (A. 2071/1992, Chapter vi, Greek law) constitute basic reference and interpretation points. The examination of consent and the demarcation of the exceptions are important issues that need to be approached. More particularly, our interest lies with the article 7 of the Convention for Human Rights and Biomedicine, which specifically refers to the protection of person who suffers from a mental disorder. The opinion that informed consent in psychiatric treatment and involuntary treatment are concepts and processes which are distinct but not always mutually exclusive is enhanced. In any case, involuntary treatment causes major dilemmas as far as informed consent in the psychiatric act is concerned, as it raises issues that affect the autonomy of the person. Today, however, there are many factors which influence public politics towards the adoption of the measure of involuntary treatment within the community. How is it that this paradoxical link is legitimized and justified: involuntary treatment and community? The enactment of the above mentioned measure in many European and North American countries has created new paths in the practice of contemporary psychiatry. Nonetheless, it continues to divide the psychiatric and legal word for it causes intense questioning from a legal, ethical, deontological and clinical aspect, as it offends fundamental rights of the individual. In a legal civilization, in which the principle of informed consent or refusal constitutes a basic rule of the lawfulness of the medical and psychiatric act, any divergence from this rule has consequences for the patients and affects a well-tempered therapeutic treatment. The above mentioned measure could be counterbalanced by the legal regulation of advance directives and the provision for the appointment of a proxy person by the mental patient.

Opening the gift: social inclusion, professional codes and gift-giving in long-term mental healthcare.

Deinstitutionalisation has not only made the social inclusion of clients a key objective in long-term mental healthcare, it may also affect the role of the care professional. This article investigates whether the social inclusion objective clashes with other long-standing professional values, specifically when clients give gifts to care professionals. In making a typology of gifts, we compare the literature on gift-giving with professional codes for gifts and relate both to the objective of social inclusion of clients. Our typology draws on an analysis of ethnographic fieldwork carried out in 2007/2008 at a Dutch mental healthcare centre. We identify four types of gifts for professionals in long-term mental healthcare, each relating individually to professional codes and the objective of social inclusion of clients. Only the 'personal gift' directly supports social inclusion, by fostering personal relationships between professionals and clients. Acceptance of this type of gift is advocated only for long-term care professionals. We suggest that professional codes need to consider this typology of gifts, and we advocate promoting reflexivity as a means of accounting for professional behaviour in deinstitutionalised care settings.

Arranged matches and mental illness: therapists' dilemmas.

Traditional societies place especial value on marriage and having children, and marriages are often arranged. A series of situations and dilemmas associated with arranged matches and their consequences are described in the course of mental health work with ultra-orthodox Jewish people with severe mental illness. Issues of confidentiality may arise with parents and matchmakers; on the other hand, respectful cooperation with religious authorities, counselors in the community, and family members is important. Information on genetic counseling, contraception, medication during pregnancy, and breastfeeding are considered and interact with communal structures and practices. There is a need for close support and evaluation during the process of marriage, childbearing, and parenthood.

Out of sight, out of mind: making involuntary community treatment visible in the mental health system.

Most specialised mental health services in Australia are delivered in community settings and one in six services comprise involuntary treatment. Despite a growing demand for community treatment orders (CTOs) worldwide - and comparatively high rates of use in Australia - the clinical, legal and ethical aspects of CTOs remain contentious. This article examines federal, state and territory mental health policy documents and discovers little reference to CTOs. The "invisibility" of CTOs in mental health policy raises questions about the transparency and accountability of the mental health system, and about whether this policy silence ultimately entrenches the marginalisation of, and discrimination against, people living with mental illness.

Recognition as a valued human being: perspectives of mental health service users.

The acknowledgement of basic human vulnerability in relationships between mental health service users and professionals working in community-based mental health services (in Norway) was a starting point. The purpose was to explore how users of these services describe and make sense of their meetings with other people. The research is collaborative, with researcher and person with experienced-based knowledge cooperating through the research process. Data is derived from 19 interviews with 11 people who depend on mental health services for assistance at least three times a week. Data is analysed according to the Interpretative Phenomenological Analysis (IPA). Results confirm that reciprocity is fundamental for relationships, and that recognizing the individual entails personal involvement. The participants describe a struggle, and recognizing this struggle may help the professional to achieve a deeper understanding of the individual.

Threats and offers in community mental healthcare.

Making threats and offers to patients is a strategy used in community mental healthcare to increase treatment adherence. In this paper, an ethical analysis of these types of proposal is presented. It is argued (1) that the primary ethical consideration is to identify the professional duties of care held by those working in community mental health because the nature of these duties will enable a threat to be differentiated from an offer, (2) that threatening to act in a way that would equate with a failure to uphold the requirements of these duties is wrong, irrespective of the benefit accrued through treatment adherence and (3) that making offers to patients raises a number of secondary ethical considerations that need to be judged on their own merit in the context of individual patient care. The paper concludes by considering the implications of these arguments, setting out a pathway designed to assist community mental healthcare practitioners to determine whether making a specific proposal to a patient is right or wrong.

Percepción, actitudes y necesidades de los profesionales de atención primaria con relación al paciente con demencia / Perception, attitudes and needs of Primary Care professionals as regards the patient with dementia

ObjetivoConocer la percepción, las actitudes y las necesidades expresadas por los profesionales de atención primaria de nuestro medio, con relación al diagnóstico y el seguimiento de los pacientes con trastornos cognitivos.DiseñoEstudio transversal en 26 Áreas Básicas de Salud (ABS) de Girona.EmplazamientoABS de la Región Sanitaria de Girona.ParticipantesMédicos y diplomados en enfermería (DUE).MedicionesCuestionario autoadministrado por los propios profesionales en el contexto de las reuniones periódicas de los equipos.ResultadosRespondieron la encuesta 218 profesionales (108 médicos y 110 diplomados de enfermería [DUE]) de 19 ABS (73% del total). El 98,6% de los participantes creyó necesario realizar formación en demencias pero el 49,1% de médicos y el 74,5% de DUE refirió no haber realizado nunca formación específica o no en los últimos 5 años. El 88,7% de los médicos refiere no realizar el diagnóstico de demencia de forma habitual y solamente en el 25,5% de los casos se efectúa en las fases leves de demencia. Las principales barreras referidas por los médicos para el diagnóstico de demencia fueron la poca confianza en el diagnóstico (32,6%) y la falta de tiempo en la consulta (31,4%). El 87% de los médicos refirió dificultades en el seguimiento y control de estos enfermos.ConclusionesEste estudio aporta información útil para los agentes implicados en la atención a la demencia. Identifica aspectos de formación prioritarios y las barreras y dificultades para el diagnóstico, tratamiento y seguimiento de estos enfermos en el ámbito de la atención primaria(AU)

ObjectiveTo find out the perception, attitudes and needs expressed by primary care professionals in the Girona (Spain) health area as regards the diagnosis and monitoring of patients with cognitive disorders.DesignCross sectional study conducted in 26 primary healthcare areas (ABS) in Girona.SettingPrimary healthcare areas (ABS) in Girona.ParticipantsPhysicians and primary nursing care (PNC).Main measuramentsSelf-administered questionnaire by the professionals in the centres. In the context of regular meetings of the teams.ResultsA total 218 practitioners from 19 ABS (73% of total) responded to the questionnaire (108 physicians and 110 primary nursing care-PNC-). Almost all (98.6%) of participants thought they needed training in dementia, but 49.1% of physicians and 74.5% of PNC mentioned never having any specific training or not in the last 5 years. A total of 88.7% of doctors do not make a diagnosis of dementia on a regular basis, and only in 25.5% of cases do they make one in the mild stages of dementia. The main barriers reported by physicians in the diagnosis of dementia were the lack of confidence in diagnosis (32.6%) and lack of consultation time (31.4%). The great majority (87%) of physicians mentioned difficulties in monitoring and control of these patients.ConclusionsThis study provides useful information for those involved in the care of dementia. It identifies priority training issues, and barriers and difficulties in the diagnosis, treatment and monitoring of these patients in the field of primary care(AU)

Components of cultural competence in three mental health programs.

OBJECTIVE: The aim of this study was to identify components of cultural competence in mental health programs developed for cultural groups by community and mental health professionals from these groups. METHODS: Three programs were studied: a prevention program primarily serving African-American and Afro-Caribbean youth, a Latino adult acute inpatient unit, and a Chinese day treatment program in a community-based agency. Nine study-trained field researchers used a semistructured instrument that captures program genealogy, structure, processes, and cultural infusion. Program cultural elements were identified from field notes and from individual and group interviews of consumers and staff (N=104). A research-group consensus process with feedback from program staff was used to group elements by shared characteristics into the program components of cultural competence. RESULTS: Components included communication competencies (with use of colloquialisms and accepted forms of address); staff in culturally acceptable roles; culturally framed trust building (such as pairing youths with mentors), stigma reduction, friendly milieus (such as serving culturally familiar foods and playing music popular with the culture), and services; and peer, family, and community involvement (including use of peer counselors and mentors, hosting parent weekends, and linking clients with senior center and community services). CONCLUSIONS: Incorporating these components into any program in which underserved cultural populations are seen is recommended for improving cultural competence.

Sexuality and consumers of mental health services: the impact of gender and boundary issues.

The importance of sexuality to humanity is clearly acknowledged. However, for consumers of mental health services, it tends to be a neglected topic. Although nurses are at the forefront of mental health service delivery, evidence suggests they are reluctant to include sexuality as part of their care. This article describes the findings from a qualitative exploratory research project that examined mental health nurses' attitudes to discussing sexuality with consumers. Fourteen mental health nurses from a service in Queensland participated in this study. Data analysis revealed two main themes: the impact of gender, and professional boundary issues. In terms of gender, participants referred to the impact of sexual dysfunction experienced by young adult male consumers. For female consumers the discussion centred on vulnerability to sexual exploitation and the need to exercise protective measures to ensure safety. Participants indicated concerns about being professionally compromised when discussing sexuality with consumers of the opposite sex. These findings highlight the need for further exploration of mental health nurses' attitudes towards discussing sexuality with consumers as part of their practice.

Periculosidade versus cidadania: os sentidos da atenção à crise nas práticas discursivas dos profissionais de um Centro de Atenção Psicossocial / Periculosity and citizenship: the meanings of attention to the crisis in the discursive practices of the Psychosocial Healthcare Centers professionals

A crise, considerada a expressão da doença psíquica, refere-se a situações em que, no curso do desenvolvimento de vida, ocorrem vivências conflitivas que geram rupturas com a realidade socialmente aceita e com os laços afetivos que sustentam a pessoa. Esta pesquisa objetiva conhecer os sentidos presentes nas práticas discursivas dos profissionais acerca da atenção à crise nos Centros de Atenção Psicossocial (CAPS). Caracteriza-se por uma abordagem qualitativa que utiliza a perspectiva teórica do Construcionismo Social. Os dados utilizados fazem parte do banco de dados da pesquisa Avaliação dos Centros de Atenção Psicossocial da Região Sul do Brasil (CAPSUL). No presente estudo, analisamos 27 entrevistas realizadas com profissionais do Centro de Atenção Psicossocial de Alegrete e três diários de campo com o registro de 390 horas de observação. A análise dos dados identificou sentidos - periculosidade e cidadania - que foram discutidos na busca de compreender sua influência na construção de práticas de atenção à crise.

The crisis, considered the expression of mental illness, refers to situations in which, during the development of life, there are conflicting experiences that generate ruptures with the socially accepted reality and the emotional ties that sustain the person. This study aims at getting to know the meanings present in the discursive practices of professionals concerning the attention to the crisis in the Psychosocial Healthcare Centers (CAPS). It is characterized by a qualitative approach that uses the theoretical perspective of social constructionism. The data used are part of the database research Evaluation of Psychosocial Healthcare Centers in Southern part of Brazil - CAPSUL. In this study, 27 interviews with professionals from the Psychosocial Healthcare Center of Alegrete city and three field diaries with the record of 390 observation hours were analyzed. Data analysis identified the meanings - periculosity and citizenship - which were discussed in an attempt to understand their influence on the construction of attention practices to the crisis.