Moral Experiences of Crisis Management in a Child Mental Health Setting: A Participatory Hermeneutic Ethnographic Study.

Restraints and seclusion are routinely used in child mental health settings for conflict and crisis management, but raise significant ethical concerns. Using a participatory hermeneutic ethnographic framework, we studied conflict and crisis management in a child mental health setting offering care to children aged 6-12 years old in Quebec, Canada. The use of this framework allowed for an in-depth examination of the local imaginaries, of what is morally meaningful to the people in the setting, in addition to institutional norms, structures and practices. Data collection involved participant observation, interviews, and documentation review, with an interpretive framework for data analysis. We argue that the prevalent view of children shared by staff members as "incomplete human becomings" led to the adoption and legitimization of authoritative norms, structures and practices guided largely by a behavioral approach, which sometimes led to an increased use of control measures for reasons other than imminent harm. Children experienced these controlling practices as abusive and hindering the development of trusting relationships, which impeded the implementation of more collaborative approaches staff members sought to put in place to prevent the use of control measures. Study results are discussed in light of conceptions of children as moral agents.

Ethical challenges of seclusion in psychiatric inpatient wards: a qualitative study of the experiences of Norwegian mental health professionals.

BACKGROUND: Seclusion is an invasive clinical intervention used in inpatient psychiatric wards as a continuation of milieu therapy with vast behavioural implications that raise many ethical challenges. Seclusion is in Norway defined as an intervention used to contain the patient, accompanied by staff, in a single room, a separate unit, or an area inside the ward. Isolation is defined as the short-term confinement of a patient behind a locked or closed door with no staff present. Few studies examine how staff experiences the ethical challenges they encounter during seclusion. By making these challenges explicit and reflecting upon them, we may be able to provide better care to patients. The aim of this study is to examine how clinical staff in psychiatric inpatient wards describes and assess the ethical challenges of seclusion. METHODS: This study was based on 149 detailed written descriptions of episodes of seclusion from 57 psychiatric wards. A descriptive and exploratory approach was used. Data were analysed using qualitative content analysis. RESULTS: The main finding is that the relationship between treatment and control during seclusion presents several ethical challenges. This is reflected in the balance between the staff's sincere desire to provide good treatment and the patients' behaviour that makes control necessary. Particularly, the findings show how taking control of the patient can be ethically challenging and burdensome and that working under such conditions may result in psychosocial strain on the staff. The findings are discussed according to four core ethical principles: autonomy, beneficence, non-maleficence, and justice. CONCLUSION: Ethical challenges seem to be at the core of the seclusion practice. Systematic ethical reflections are one way to process the ethical challenges that staff encounters. More knowledge is needed concerning the ethical dimensions of seclusion and alternatives to seclusion, including what ethical consequences the psychosocial stress of working with seclusion have for staff.

Hospital ethics reflection groups: a learning and development resource for clinical practice.

BACKGROUND: An ethics reflection group (ERG) is one of a number of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the significance of ERGs in psychiatric and general hospital departments in Denmark. METHODS: This is a qualitative action research study, including systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Short written descriptions of the ethical challenges presented in the ERGs also informed the analysis of significance. RESULTS: A recurring ethical challenge for clinicians, in a total of 63 cases described and assessed in 3 ethical reflection groups, is to strike a balance between respect for patient autonomy, paternalistic responsibility, professional responsibilities and institutional values. Both in psychiatric and general hospital departments, the study participants report a positive impact of ERG, which can be divided into three categories: 1) Significance for patients, 2) Significance for clinicians, and 3) Significance for ward managers. In wards characterized by short-time patient admissions, the cases assessed were retrospective and the beneficiaries of improved dialogue mainly future patients rather than the patients discussed in the specific ethical challenge presented. In wards with longer admissions, the patients concerned also benefitted from the dialogue in the ERG. CONCLUSION: This study indicates a positive significance and impact of ERGs; constituting an interdisciplinary learning resource for clinicians, creating significance for themselves, the ward managers and the organization. By introducing specific examples, this study indicates that ERGs have significance for the patients discussed in the specific ethical challenge, but mostly indirectly through learning among clinicians and development of clinical practice. More research is needed to further investigate the impact of ERGs seen from the perspectives of patients and relatives.

[Preventing violence during hospitalisations in psychiatry]. / Prévenir les moments de violence lors des hospitalisations en psychiatrie.

Over recent years, the psychiatric sector has endeavoured to develop community-based care. Paradoxically, the number of compulsory hospitalisations is increasing. At the same time, the legal framework is evolving and measures relating to the deprivation of liberty in the context of psychiatric care have given rise to extensive guidelines. The work of the French National Health Authority represents, in this context, a certain continuity, with regard to the legal, ethical and social discussions around restriction of liberty practices within psychiatric units. The main focus is on the prevention and management of violent outbursts.

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 meaning of smoking for patients with mental disorder.

When patients smoke cigarettes in psychiatric services, it brings to the forefront current ethical and political dilemmas. This study aims to explore the meaning attributed to smoking by mental health patients who smoke and who are hospitalized in a psychiatric ward of a general hospital. This qualitative descriptive study was conducted with 96 smokers who were hospitalized in a psychiatric ward in Brazil. Semi-structured interviews, test of nicotine dependence, and content thematic analysis were carried out. The results show that tobacco has an important role in the lives of psychiatric patients. The meanings they attribute to tobacco use are related to overcoming difficulties that are consequential of mental disorders and of side effects caused by their treatments.

A guest in the house: nursing instructors' experiences of the moral distress felt by students during inpatient psychiatric clinical rotations.

Significant research has been done on the impact of moral distress among nurses, particularly in acute and intensive care settings. However, little research to date has investigated the experiences that nursing students have with moral distress. Additionally, there is a dearth of research on the role of nursing instructors' perceptions of their responsibilities to their students when encountering morally distressing situations. This manuscript describes a qualitative study conducted with eight mental health nursing instructors who acknowledged a responsibility for helping students deal with moral distress and ethical issues, but who also struggled with ways to do so. Additionally, instructors expressed frustration with their "guest" status on inpatient psychiatric units and their powerlessness to effect moral change in a medical model of psychiatric care.

El equipo de salud en la apreciación de un grupo de alumnos de 5to. año de medicina / The Health Team Estimation of a 5th Year Medicine Group of Students

Con el propósito de determinar el reconocimiento de quienes integran el equipo de salud institucional y la significación de su trato amable y respetuoso para lograr la satisfacción interpersonal de paciente y familiares, los autores utilizaron dos encuentas auto aplicadas y basadas respectivamente en selección de respuestas y escala termómetro, a un grupo de estudiantes de medicina sudamericanos del 5to año, durante la primera actividad docente de la asignatura Psiquiatría. en el Hospital Psiquiátrico de la Habana Dr. Eduardo Ordaz. Los resultados evidenciaron una importante tendencia a excluir conceptualmente del equipo al personal auxiliar y administrativo. Por otra parte, una vez informados al respecto mediante los perfiles incluidos en la segunda encuesta, las apreciaciones sobre el significado del desempeño interpersonal resultaron inferiores a las conferidas a profesionales y técnicos. Los autores destacan la importancia del buen trato de todos los integrantes del equipo, tanto en sus perfiles profesionales y técnicos como en los auxiliares y administrativos y que dichas actitudes positivas, conscientes y planificadas, junto al cumplimiento idóneo de sus diferentes contenidos de trabajo constituyen la esencia del éxito de los colectivos morales determinantes fundamentales de la satisfacción interpersonal y técnica de los pacientes y sus familiares. Hacen igualmente énfasis en que al igual que existen los efectos placebo en la relación médico paciente positiva, el desempeño integral adecuado del colectivo de trabajadores de un centro de salud, establece la relación usuario-institución positiva, cuyas potencialidades placebo resultan también trascendentes(AU)

With the purpose of determing the acknowledgment of the students from the institutional health team and the meaning of their polite and respectable treat to achieve the interpersonal satisfaction of patients and relatives, the authors used two self applied questioaires respectively based on the selection of answers and themomether scale to a group of 5th year Medicine students from South America, during the first Psychiatry teaching activity at the Psychiatry Hospital of Havana Comander Dr. Eduardo Bernabé Ordaz Ducungé. The results show an impotant tendency to exclude on the base of concept the auxiliary and managment personnel. In the other hand, once they were informed fom it through the profiles included in the second questionaire, the perception about the meaning of the personal improvement were inferior in relation to the ones given to professionals and technicians.The authors standout the importance of the polite treat of all the members of the team either in their professional and tecnchian or auxialiry and managment profiles; and tht these positive and planned attitudes that together with the fulfilment of the work constitue the esence of the success of the ethic work groups which are fundamental on the interpersonal and tecnical satisfaction of the patients and relatives. The authors also standout the placebo effects in the positive relationship doctor- patient, the adequate integral improvement of work team of a health center, setting a positive institution –client relationship , which powerful placebo effectsare also extraortdinary(AU)

[Autonomy, care and justice: ethical aspects of the psychiatric treatment of adolescents]. / Autonomie, Fürsorge und Gerechtigkeit1.

What is the right and good action in dealing with young patients in child and adolescent psychiatry? To answer this question, we have to consider professional standards, legal rules, and ethical reflections. With reference to the latter, four bioethical principles were proposed by Beauchamp and Childress to identify and to deal with ethical problems and conflicts. On the basis of this scheme we reflect on the legal aspects and discuss the following topics: (1) self-determination of adolescents concerning their own psychiatric treatment, (2) conflicts between autonomy and care, which occur relatively often, whenever restrictions to personal liberty are indicated, and (3) admission of adolescents in adult psychiatric wards. The bioethical principles facilitate a reliable decision-making process in individual cases. The standards of right and good action have to be implemented in the field of distributive justice. We find evidence that prioritization decisions for inpatient admission are already established in German child and adolescent psychiatry.

Trauma informed care on an inpatient pediatric psychiatric unit and the emergence of ethical dilemmas as nurses evolved their practice.

Two case studies are presented reflecting the ethical dilemmas experienced by nurses who were striving to improve their practice in the provision of patient care. The cases are described in the context of finding alternatives to cohesive interventions such as chemical restraints and physical restraints. A summary of the literature on ethical dilemmas that was relevant to the issues arising in these cases is included. Discussion of the use of the American Nursing Association's (ANA, 2001 ) Nursing Code of Ethics with Interpretive Statements is highlighted for its relevance and support of the nurses experiencing the ethical dilemmas.

Constant Observation in the general hospital: a review.

The role of Constant Observation (COb) in the general hospital is addressed. The difficulties of managing acute psychological disturbance in the general hospital are described. Concerns about confused behavior and suicidal risk appear to be the most common reasons for ordering COb. Organic brain syndrome is the most common diagnosis made in patients receiving COb. Medico-legal, ethical and therapeutic aspects of COb are noted. To our knowledge there is no research evidence that COb significantly decreases the rate of suicide in the general hospital. It appears that the role of COb is enshrined in the general hospital as a result of medico-legal process in addition to its therapeutic role. Further research in this area is needed.

[Clinical ethics in psychiatry: the experience at Douglas Hospital]. / Ethique clinique en psychiatrie: l'expérience de l'Hôpital Douglas.

The authors present a brief overview of the clinical ethics committee within their mental health university institute as well as its evolving mandates over the past few decades. The main functions include case consultation, input on elaboration of institutional policy, and staff education as well as public information on issues of ethics and mental illness. With examples and questions brought to the committee's attention, the authors demonstrate how these functions are intertwined. The authors conclude that ethical questioning helps examine clinical practices and serves ultimately in guiding towards best practices in mental health.

Noncredible psychiatric and cognitive symptoms in a workers' compensation "stress" claim sample.

Information is lacking regarding the prevalence of fraudulent psychiatric and cognitive symptoms in the "stress" claim workers' compensation population. Using various validity indices (Negative Impression Scale, the Malingering Index, and the Rogers Discriminant Function) of the Personality Assessment Inventory (PAI), between 9 and 29% of 233 workers' compensation "stress" claim litigants were identified as exhibiting noncredible psychiatric symptoms. In addition, 15% of the subjects were determined to have noncredible cognitive symptoms on the Dot Counting Test, although only 8% displayed suspect effort on the 15-Item Memorization Test, with 5% of subjects failing both cognitive effort tests. The percentage of positive identifications on both a PAI and cognitive credibility index ranged from only 2 to 4%. Further, correlations between PAI validity indices and cognitive effort scales were nonexistent to modest, indicating that the psychiatric and cognitive credibility indices are measuring different aspects of noncredible symptom production. It was predicted that the PAI profiles of the participants displaying suspect cognitive symptoms would be elevated on the Somatic Concerns, Antisocial, and/or Borderline scales; however, elevations (relative to subjects with credible cognitive performance) were instead noted on the Somatic Concerns, Depression, Anxiety, Anxiety-Related Disorders, and Schizophrenia scales.

Advocacy in practice: the experiences of independent advocates on UK mental health wards.

Independent advocacy in mental health has become increasingly valued in the UK although little work has examined the day-to-day experiences of advocates themselves. This article reports on a small-scale exploratory qualitative study of practising advocates' experiences of their work in acute and continuing care wards. The project results from collaboration between members of the UK Advocacy Network and the Department of Mental Health and Learning Disability at the University of Sheffield. Although the findings will be of interest to any professional allied to these areas they are particularly relevant to mental health nurses wishing to increase their knowledge of advocacy and gain a fresh perspective on inpatient care. The findings reveal difficulties inherent in advocacy practice as well as the nature and importance of good working relationships between advocates and clinicians. Despite acknowledging such relationships frequently exist, advocates can still encounter ignorance of their role and opposition to their presence. The clearest implication of the findings is the need for greater training of nurses and other clinicians in the role of the advocate.

Ethical aspects when treating traumatized refugee children and their families.

Basic ethical principles are worth analysing step by step when dealing with refugee children and their families. Three issues where potential ethical conflicts might arise for healthcare professionals in treating refugees with different cultural background are pointed out--traumatic life events, hierarchy and repatriation. An ethical analysis of the decision to admit a traumatized teenage refugee to a psychiatric ward is discussed with respect for the ethical principles autonomy, non-maleficence, beneficence and justice. There are both gains and losses, which are valued differently depending on the actors involved.