Moral Deliberation in Psychiatric Nursing Practice

Initiating and maintaining clinical ethics support in psychiatry. Ten tasks and challenges – And how to meet them

Initiating clinical ethics support in psychiatry (CESiP) and maintaining its continuity appear to be easy. This is contradicted by the observed delay or lack of CESiP, e.g. ethics consultation. On the basis of a published literature search and the discussion of practical experiences over 2.5 years 10 tasks and relating challenges of initiating and maintaining CESiP are formulated and illustrated by examples. Referral to experiences is grounded on the systematic documentation of ca. 100 CESiP activities. The tasks and challenges illustrate how CESiP was initiated and maintained in child and adolescent, adult and forensic psychiatry. Each example is followed by a “rule of thumb” that was found useful in our centre. Discussion: Suggestions I–III are of organisational nature, IV–X have explicit ethical content concerning the ethos or professionalism of the ethics consultant and CES practice. Their realisation requires a minimum of stability of CESiP and considerable consultancy experience.

Managers' views on and experiences with moral case deliberation in nursing teams

AIMS

Providing management insights regarding moral case deliberation (MCD) from the experiential perspective of nursing managers.

BACKGROUND

MCD concerns systematic group-wise reflection on ethical issues. Attention to implementing MCD in health care is increasing, and managers' experiences regarding facilitating MCD's implementation have not yet been studied.

METHOD

As part of an empirical qualitative study on implementing MCD in mental health care, a responsive evaluation design was used. Using former research findings (iterative procedures), a managers' focus group was organised.

RESULTS

Managers appreciated MCD, fostering nurses' empowerment and critical reflection - according to managers, professional core competences. Managers found MCD a challenging intervention, resulting in dilemmas due to MCD's confidential and egalitarian nature. Managers value MCD's process-related outcomes, yet these are difficult to control/regulate.

CONCLUSIONS

MCD urges managers to reflect on their role and (hierarchical) position both within MCD and in the nursing team.

IMPLICATIONS FOR NURSING MANAGEMENT

MCD is in line with transformative and participatory management, fostering dialogical interaction between management and nursing team.

Evaluation and perceived results of moral case deliberation

Background:

Moral case deliberation is increasingly becoming part of various Dutch healthcare organizations. Although some evaluation studies of moral case deliberation have been carried out, research into the results of moral case deliberation within aged care is scarce.

Research questions:

How did participants evaluate moral case deliberation? What has moral case deliberation brought to them? What has moral case deliberation contributed to care practice? Should moral case deliberation be further implemented and, if so, how?

Research design:

Quantitative analysis of a questionnaire study among participants of moral case deliberation, both caregivers and team leaders. Qualitative analysis of written answers to open questions, interview study and focus group meetings among caregivers and team leaders.

Participants and research context:

Caregivers and team leaders in a large organization for aged care in the Netherlands. A total of 61 moral case deliberation sessions, carried out on 16 care locations belonging to the organization, were evaluated and perceived results were assessed.

Ethical considerations:

Participants gave informed consent and anonymity was guaranteed. In the Netherlands, the law does not prescribe independent ethical review by an Institutional Review Board for this kind of research among healthcare professionals.

Findings:

Moral case deliberation was evaluated positively by the participants. Content and atmosphere of moral case deliberation received high scores, while organizational issues regarding the moral case deliberation sessions scored lower and merit further attention. Respondents indicated that moral case deliberation has the potential to contribute to care practice as relationships among team members improve, more openness is experienced and more understanding for different perspectives is fostered. If moral case deliberation is to be successfully implemented, top-down approaches should go hand in hand with bottom-up approaches.

Conclusion:

The relevance of moral case deliberation for care practice received wide acknowledgement from the respondents. It can contribute to the team’s cohesion as mutual understanding for one another’s views is fostered. If implemented well, moral case deliberation has the potential to improve care, according to the respondents.

Nurses’ attitudes toward ethical issues in psychiatric inpatient settings

Background:

Nursing is an occupation that deals with humans and relies upon human relationships. Nursing care, which is an important component of these relationships, involves protection, forbearance, attention, and worry.

Objectives:

The aim of this study is to evaluate the ethical beliefs of psychiatric nurses and ethical problems encountered.

Research Design:

The study design was descriptive and cross-sectional.

Research context:

Methods comprised of a questionnaire administered to psychiatric nurses (n = 202) from five psychiatric hospitals in Istanbul, Turkey, instruction in psychiatric nursing ethics, discussion of reported ethical problems by nursing focus groups, and analysis of questionnaires and reports by academicians with clinical experience.

Participants:

Participants consist of the nurses who volunteered to take part in the study from the five psychiatric hospitals (n = 202), which were selected with cluster sampling method.

Ethical considerations:

Written informed consent of each participant was taken prior to the study.

Findings:

The results indicated that nurses needed additional education in psychiatric ethics. Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. Ethical code or nursing care -related problems included (a) neglect, (b) rude/careless behavior, (c) disrespect of patient rights and human dignity, (d) bystander apathy, (e) lack of proper communication, (f) stigmatization, (g) authoritarian attitude/intimidation, (h) physical interventions during restraint, (i) manipulation by reactive emotions, (j) not asking for permission, (k) disrespect of privacy, (l) dishonesty or lack of clarity, (m) exposure to unhealthy physical conditions, and (n) violation of confidence.

Discussion:

The results indicate that ethical codes of nursing in psychiatric inpatient units are inadequate and standards of care are poor.

Conclusion:

In order to address those issues, large-scale research needs to be conducted in psychiatric nursing with a focus on case studies and criteria for evaluation of service, and competency and responsibility needs to be established in psychiatric nursing education and practice.

Stimulating client involvement and client-provider dialog through participatory video: deliberations on long-term care in a psychiatric hospital

OBJECTIVE

Recent trends in health care indicate a shift toward client-centered care and an emphasis on dialog between clients and providers. The aim of this study is to assess the role of video-mediated moral deliberation in stimulating dialog between clients and providers.

METHODS

A participatory video project carried out in a long-term care facility of a psychiatric hospital was investigated as a case study. Data were collected through interviews, a focus group and a dialog session with providers, clients, managers and a family member.

RESULTS

Data analysis produced four themes: (1) the video elicits discussion by affecting viewers; (2) the video raises awareness and discussion of clients' needs and desires; (3) the video and discussion give a voice to clients; and (4) the video and discussions draw attention to client-provider relations.

CONCLUSION

The study shows that video-mediated moral deliberation can be a useful tool for starting dialog between clients and care providers. It can also contribute to changes in care provision by acting as a catalyst.

PRACTICE IMPLICATIONS

This study provides an example of how video-mediated moral deliberation can be applied in the context of psychiatric care. Opportunities regarding the usefulness of video-mediated moral deliberation include training purposes and education.

Aims and harvest of moral case deliberation

Deliberative ways of dealing with ethical issues in health care are expanding. Moral case deliberation is an example, providing group-wise, structured reflection on dilemmas from practice. Although moral case deliberation is well described in literature, aims and results of moral case deliberation sessions are unknown. This research shows (a) why managers introduce moral case deliberation and (b) what moral case deliberation participants experience as moral case deliberation results. A responsive evaluation was conducted, explicating moral case deliberation experiences by analysing aims (N = 78) and harvest (N = 255). A naturalistic data collection included interviews with managers and evaluation questionnaires of moral case deliberation participants (nurses). From the analysis, moral case deliberation appeals for cooperation, team bonding, critical attitude towards routines and nurses' empowerment. Differences are that managers aim to foster identity of the nursing profession, whereas nurses emphasize learning processes and understanding perspectives. We conclude that moral case deliberation influences team cooperation that cannot be controlled with traditional management tools, but requires time and dialogue. Exchanging aims and harvest between manager and team could result in co-creating (moral) practice in which improvements for daily cooperation result from bringing together perspectives of managers and team members.

Ethical problems experienced by psychiatric nurses in Korea

This study aimed to explore the ethical problems experienced by psychiatric nurses in a clinical setting. Data were collected using semistructured interviews with a purposive sample of 12 female psychiatric nurses from 3 psychiatric facilities in Korea. A thematic content analysis was used to identify ethical problems. The study illustrated 5 categories of ethical problems: moral unpreparedness and blindness, moral numbness, moral complacency, moral conflict, and moral stress. This study provides a theoretical basis of psychiatric ethical problems for developing ethical guidelines that will enable psychiatric nurses to make decisions reasonably and behave ethically in their workplace.

Enacting ethics: bottom-up involvement in implementing moral case deliberation

In moral case deliberation (MCD), healthcare professionals meet to reflect upon their moral questions supported by a structured conversation method and non-directive conversation facilitator. An increasing number of Dutch healthcare institutions work with MCD to (1) deal with moral questions, (2) improve reflection skills, interdisciplinary cooperation and decision-making, and (3) develop policy. Despite positive evaluations of MCD, organization and implementation of MCD appears difficult, depending on individuals or external experts. Studies on MCD implementation processes have not yet been published. The aim of this study is to describe MCD implementation processes from the perspective of nurses who co-organize MCD meetings, so called ‘local coordinators’. Various qualitative methods were used within the framework of a responsive evaluation research design. The results demonstrate that local coordinators work hard on the pragmatic implementation of MCD. They do not emphasize the ethical and normative underpinnings of MCD, but create organizational conditions to foster a learning process, engagement and continuity. Local coordinators indicate MCD needs firm back-up from management regulations. These pragmatic action-oriented implementation strategies are as important as ideological reasons for MCD implementation. Advocates of clinical ethics support should pro-actively facilitate these strategies for both practical and ethical reasons.

Organizing moral case deliberation Experiences in two Dutch nursing homes

Moral case deliberation (MCD) is a specific form of clinical ethics, aiming to stimulate ethical reflection in daily practice in order to improve the quality of care. This article focuses on the implementation of MCD in nursing homes and the questions how and where to organize MCD. The purpose of this study was to evaluate one way of organizing MCD in two Dutch nursing homes. In both of these nursing homes the MCD groups had a heterogeneous composition and were organized apart from existing institutional communication structures. As part of a naturalistic evaluation, systematic observations, interviews and focus groups were completed. The findings indicate that the heterogeneous composition and MCD meetings separate from existing structures have benefits. However, the participants also reported negative experiences. This gives rise to the question whether a mixed MCD group which meets separately is an effective way to embed MCD as an instrument for reflection on moral issues in daily practice. We conclude that there is no single answer to that question. In the end, the two implementation strategies (i.e. within existing communication structures and a mixed MCD group) can be complementary to each other.

Moral margins concerning the use of coercion in psychiatry

In the closed wards of mental health institutions, moral decisions are made concerning the use of forced seclusion. In this article we focus on how these moral decisions are made and can be improved. We present a case study concerning moral deliberations on the use of seclusion and its prevention among nurses of a closed mental health ward. Moral psychology provides an explanation of how moral judgments are developed through processes of interaction. We will make use of the Social Intuitionist Model of Jonathan Haidt that emphasizes the role of emotions, intuitions and the social context in moral judgments and reasoning. We argue that this model can help to explain social dynamics in the context of enforced seclusion. In the discussion we explore how moral psychology can be complemented with the normative perspective of dialogical ethics to develop strategies for improving psychiatric practices. We conclude that social processes play an important role in moral deliberations and that moral development can be fostered by bringing in new perspectives in the dialogue. Moral case deliberation provides a practical tool to systematically organize moral reflections among nurses on the work floor.

Attitudes to the use of seclusion: has contemporary mental health policy made a difference?

BACKGROUND

The use of seclusion in mental health services is controversial, and recent Government policy has identified the reduction and, if possible, elimination of seclusion as a national safety priority. As the professional group most likely to initiate seclusion, the attitudes of nurses will influence the extent to which policy translates to practice.

DESIGN

The Survey of Nurses' Attitudes to Seclusion Survey was completed by nurses (n = 123) from eight mental health services from Queensland, Australia.

METHODS

Data were analysed using SPSS to provide descriptive statistics for nurses' attitudes according to the scale. Correlation analysis was used to examine associations between demographic variables and attitudes towards seclusion.

RESULTS

Participants recognised the negative impact of seclusion on consumers; however, they continue to support its use, particularly in cases of threatened or actual violence to staff and other consumers. The impact of seclusion room on consumers was viewed as significant and yet most participants did not recommend changes other than painting the room for a calming effect. Demographic factors had limited impact on attitudes.

CONCLUSIONS

The continued support of the use of seclusion despite acknowledgement of its detrimental effects appears to reflect a lack of alternative approaches to the management of consumer behaviours such as violence and aggression.

RELEVANCE TO CLINICAL PRACTICE

While nurses continue to view seclusion as a necessary intervention, the success of strategies aimed at reducing its use will be limited. The implementation and evaluation of alternative approaches to the care of consumers is necessary to reduce reliance and seclusion and introduce changes to practice.

The essence of psychiatric nursing: redefining nurses' identity through moral dialogue about reducing the use of coercion and restraint

In this article, we focus on core values of psychiatric nurses in relation to coercion and constraint. We analyze changes that took place in a project aiming at reducing coercion at a closed inpatient ward of a psychiatric hospital. Using the philosophy of Hans-Georg Gadamer and Margaret Urban Walker, we analyze both the process of moral changes through dialogue and the outcome in terms of new identities and moral responsibilities. We conclude that the project stimulated nurses to redefine their roles and develop a deeper intersubjective understanding of core values of their profession.

Nurses' attitudes to the use of seclusion: a review of the literature

Seclusion is now widely recognized as a coercive strategy with negative consequences for the consumers and staff involved. Nevertheless, this intervention continues to be used frequently in mental health services internationally. Due to their direct care role, nurses are commonly involved in the initiation or management of seclusion. Understanding nurses' attitudes to seclusion is therefore essential for the success of any attempts to reduce its use. A review of the literature was conducted using the search terms 'patient', 'seclusion', 'attitudes', 'nurses' and 'containment'. Twenty-eight articles which met the inclusion criteria were identified. Analysis of these articles identified six main themes: a necessary intervention; workplace culture; staff composition and experience; conflict; ethical considerations; and consumer characteristics. An overview of the literature is presented according to these main themes. The research suggests that most nurses support the continued use of seclusion as a strategy for the management of violence and aggression. A deeper understanding of the factors that influence attitudes is necessary if seclusion rates are to be effectively reduced.

Autonomous decision making and moral capacities

This article examines how people with type 2 diabetes perceive autonomous decision making and which moral capacities they consider important in diabetes nurses' support of autonomous decision making. Fifteen older adults with type 2 diabetes were interviewed in a nurse-led unit. First, the data were analysed using the grounded theory method. The participants described a variety of decision-making processes in the nurse and family care-giver context. Later, descriptions of the decision-making processes were analysed using hermeneutic text interpretation. We suggest first- and second-order moral capacities that nurses specializing in diabetes need to promote the autonomous decision making of their patients. We recommend nurses to engage in ongoing, interactive reflective practice to further develop these moral capacities.

Dialogical Nursing Ethics: the Quality of Freedom Restrictions

This article deals with the question of how ethicists respond to practical moral problems emerging in health care practices. Do they remain distanced, taking on the role of an expert, or do they become engaged with nurses and other participants in practice and jointly develop contextualized insights about good care? A basic assumption of dialogical ethics entails that the definition of good care and what it means to be a good nurse is a collaborative product of ongoing dialogues among various stakeholders engaged in the practice. This article discusses the value of a dialogical approach to ethics by drawing on the work of various nursing scholars. We present a case example concerning the quality of freedom restrictions for intellectually disabled people. Issues for discussion include the role and required competences of the ethicist and dealing with asymmetrical relationships between stakeholders.

Implementing moral case deliberation in a psychiatric hospital: process and outcome

BACKGROUND

Clinical moral case deliberation consists of the systematic reflection on a concrete moral case by health care professionals. This paper presents the study of a 4-year moral deliberation project.

OBJECTIVES

The objectives of this paper are to: (a) describe the practice and the theoretical background of moral deliberation, (b) describe the moral deliberation project, (c) present the outcomes of the evaluation of the moral case deliberation sessions, and (d) present the implementation process.

METHODS

The implementation process is both monitored and supported by an interactive responsive evaluation design with: (a) in-depth interviews, (b) Maastricht evaluation questionnaires, (c) evaluation survey, and (d) ethnographic participant observation. In accordance with the theory of responsive evaluation, researchers acted both as evaluators and moderators (i.e. ethicists).

RESULTS

Both qualitative and quantitative results showed that the moral case deliberations, the role of the ethics facilitator, and the train-the-facilitator program were regarded as useful and were evaluated as (very) positive. Health care professionals reported that they improved their moral competencies (i.e. knowledge, attitude and skills). However, the new trained facilitators lacked a clear organisational structure and felt overburdened with the implementation process. The paper ends with both practical and research suggestions for future moral deliberation projects.