• Thu. Nov 30th, 2023

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How may cultural and political ideals cause moral distress in acute psychiatry? A qualitative study | BMC Psychiatry

Through the individual interviews it became clear that the interviewees were preoccupied with the practical consequences of changes in the political, legal, and therapeutic ideals for the treatment of psychiatric patients, particularly the expectations concerning reduced use of restraints and coercion. This topic was expanded upon during the focus group sessions.

The interviewees found that the expectation to minimise the use of restraints or coercion came from politicians, the hospitals’ policy, and unit leadership, and from co-workers. Several of the interviewees found that this gradually made them more open to explore other solutions than restraining and coercive measures. Moreover, their threshold for administering physical restraining measures had become higher.

Even so, the interviewees offered rich descriptions of how these ideals and new legal guidelines also could cause moral distress. Four areas regarding this will be discussed: 1) Challenging behaviour and risk of violence; 2) Minimising the use of restraints and coercion created uncertainty; 3) Legal changes may frustrate treatment; and 4) Consequences for the nursing staff.

Challenging behaviour and risk of violence

An increasing number of patients have serious mental problems due to synthetic drug use. The nurses found that this, in combination with reduced number of beds in psychiatric units, had resulted in the patients currently admitted being more ill than, say, ten years ago. They experienced a greater tendency to physical violence, like scratching, kicking, blows and strangle-holds as well as serious verbal threats.

One of the nurses had had her ribs broken several times when trying to calm patients down. Patients spitting at the nurses and throwing object were not uncommon. Violent episodes had moreover resulted in broken curtains, pictures, and lamps on the wards. This development was described thus: “We endure more challenging situation for longer than we perhaps should sometimes, with unrest, threats and destruction lasting for a long, long time.”

The unpredictability and feelings of constantly «being on tenterhooks» were described as draining. Having potentially very violent patients moving freely among unsuspecting or anxious patients while they were waiting for transfer to a security unit was also seen as problematic. One of the nurses characterised the scenarios that could be played out on the ward as “limitless and surrealistic”.

Sometimes even co-patients were hurt. Patients had been beaten, threatened, and exposed to co-patients who were “in their face”. Once a patient pulled out another patient’s urine catheter. Afterwards the attacker calmly sat down although the injured man was bleeding profusely. Once a young female patient was attacked by a male patient. He forced her onto the floor and held her down. Later this same patient also managed to enter her room. “When people are howling in the corridors and the ward is in a chaos and alarms go off left and right, patients often want us to lock their door, but this we cannot do as we are responsible for them. But I do understand them …” an interviewee said. “Such conditions are unworthy”.

Unfortunate episodes created an apprehensive mood on the ward and were hard on vulnerable patients and made them retire to their rooms. This made it difficult for the nurses to offer the kind of therapeutic and beneficial environment they needed. Several interviewees described feelings of guilt when unable to safeguard patients who were mentally or physically attacked by co-patients. As a consequence, the nurses’ focus tended to shift from treatment and care to risk evaluation and safety.

Minimising the use of restraints and coercion created uncertainty

In spite of the patient population’s increasingly poor mental state the expectation to avoid restraints and coercive treatment was strong. It was strong “regardless of whether a hospital uses coercion a lot or sparingly. It is to be reduced”. Some held this to be a requirement coming from «the outside», without explaining this statement further. Others perceived the leadership and/or colleagues to be the source. However that may be, a dilemma arose when it came in conflict with safeguarding patients and staff. Many of the interviewees felt obliged to tolerate more challenging – even violent – behaviour then they previously had done. Restraints and coercion were no longer used until the risk of violence was imminent. Even so,

«It is difficult to know when we actually should use coercion. We try and try and try again all the measures at our disposal to avoid tight-holding or belts. When the patient in spite of this goes on and on and on … You get to a point when this is enough [has to be stopped]. But you don’t want to use coercion. Afterwards one may think what is right? What is wrong?».

Thus, where to draw the line for patients’ behaviour was seen as difficult:

«Where to draw the line? When does it become dangerous? When someone throws something in the wall? You never know if he’ll attack someone else next time. There is a lot of frustration that is not turned against us, but someone who is screaming and yelling and perhaps throws chairs around is rather threatening. These situations affect us …».

A nurse fresh out of college worried that other staff members’ expectations would make her «go too far» without elaborating this. Another found it difficult as «one does not know where one is supposed to draw the line as one handles things differently and have different limits». Sometimes the nurses wondered whether they or the patients were in control. Hindsight sometimes told them that they should have acted earlier to ensure everyone’s safety. Some interviewees said they rarely discussed how much threats and violence they were expected to tolerate and endure.

The interviewees held that they lacked the predictability and clear limits they needed to make patients and staff feel safe and secure. According to them, it was also a problem that the doctors tended to hesitate to prescribe restraining or coercive measures even when patients potentially could be violent. An interviewee said that she experienced “that one tries to avoid give the order, decisions that are seen as violating personal integrity, even when it could be a very helpful”. Some believed the reason for this could be that the doctors were expected to improve the statistics on the use of such measures and were worried about reactions from outside bodies like the Healthcare Complaints Commission if they did. This could lead to challenging and potentially dangerous situations for the nurses: «I have more than once experienced that the doctor on duty has ordered us to release a patient [from restraints] who still is in a drug induced psychosis and where nothing has changed during the last hour … still as aggressive toward us.»

The nurses tended to “go the extra mile and endure a lot, a lot … we also let co-patients endure a lot, really». Thus, the cost of limiting the use of restraints and coercion could limit the quality of patient care through letting innocent patients endure disturbances and violence on the ward, violence that could be aimed at them. This worried many of our interviewees.

The ideal of minimising the use of restraints and coercion seemed also to come from within. There seemed to be a general agreement among the interviewees that less use of such measures strengthened the patients’ dignity. One described the changes in this area of clinical practice as a relief. She regretted that she previously had taken part in restraining and coercive measures such as placing patients in belts over longer periods of time.

Even so, they all had experienced that restraints at times were necessary to stop patients from hurting themselves, other patients, or staff members. When unavoidable, such measures were described as care, although «these days this is a politically incorrect view». The current therapeutic ideal tended toward letting patients «run off steam» to avoid acting out and violence. Patients who were being very loud but not threatening, who talked directly to co-patients and generally occupied a lot of «space» could make co-patients feel insecure. “Whether we should accept such verbal acting out” caused a lot of discussion among the nurses. “The other patients hear this, too … there can be a lot of shouting, and several patients have said that this makes them anxious”. One of the nurses thought that as a patient “I would never have felt safe on a psychiatric ward”. Another held that being an acute psychiatric patient “is very terrible. To be locked in on an acute ward against one’s will and then having such experiences! It weighs very much on my mind afterwards.”

Having to prioritise threatening or very resource-intensive patients, left less time to follow up on other patients. Thus, the nurses found that the aim to reduce the use of restraints or coercion exposed some patients to greater risk of violence.

Ideals and legal changes may frustrate treatment

According to the interviewees, due to the new legislation’s strict criteria for involuntary hospital admission many patients who previously had been involuntarily admitted were now admitted on a voluntary basis. It was described as sad and frustrating to witness the gradual decline in patients who refused to receive help: “A great quandary which becomes more and more common, really, is concerning patients with mania who now tend to be admitted voluntarily, who perhaps are on the way “up” and very poorly.” This was experienced as a particularly difficult dilemma when it made children suffer because ill parents could not be retained on the ward against their will. “Some family members are desperate and don’t want their loved ones to be discharged, but there is no legal basis anymore on which to hold them the way we would have done a few years ago”. Untreated patients’ mental health may deteriorate to a point where their actions lead to «economic problems, poorer somatic health, and their messing up their lives quite severely before they are [involuntarily] admitted”.

Several interviewees said they often felt personally responsible for motivating patients to stay in hospital and accept treatment. However, when pressed for time their communication tended more towards persuasion or pressure than motivation: “How hard can you motivate someone to stay, voluntarily, without it becoming, how should I put it, a kind of concealed coercion?”.

Freer access to social medias through being allowed to keep their mobile phones on the ward made it possible for psychotic patients to socially disgrace themselves: “Our hands are tied until they have crossed the line, like when the patient has ruined a relationship, sent their employer nude pictures, for instance”. Such actions may be difficult for the family, too, particularly the patients’ children: “One thing is to disgrace oneself, but you have the family setting which may be totally on the breaking point”.

According to the new legislation longer observation time is required before a decision on involuntary administration of medication can be made. This could result in more use of restraints and coercion and longer hospital stays than necessary. One of the nurses said that her greatest moral challenge at work was to witness how obviously psychotic patients had to wait for days without medicines and adequate treatment. She felt that many of her colleagues agreed with her, but she was one of the very few who discussed this with the leadership.

The nurses worried that the legislation and the ideals concerning reduced use of restraints could affect the most vulnerable patients negatively. They wondered whether politicians ever discuss the needs of this particular group of psychiatric patients when they make decisions on restraining or coercive measures in psychiatric care. As one put it:

«They [the patients] are unable to take care of themselves and many have suffered many losses because of their illness; they have lost their house, their family, their jobs, and finally friends and family cannot take it anymore … I find that society does not take responsibility for the individual. [Politicians] hold that the individual may decide for themselves, basing their opinions on their own lives as resourceful people, and I find that I never would have liked to be treated like this. Would you have liked to lose everything, rejected, in the gutter?”

The interviewees missed a greater focus on the quality of treatment, on dignity and on care when restraining or coercive measures are unavoidable. This perspective seemed to be overshadowed by the seemingly sole focus on reduction of the use of such measures.

Consequences for the nursing staff

Although restraining or coercive measures at times were necessary, using them often left the nurses with a very unpleasant feeling: «In the morning [after having worked the weekend] you sit together with all the doctors and healthcare staff and have to defend the use of restraints. You feel defeated and perhaps a little ashamed for having had to use such measures». This in spite of having followed doctor’s orders and at the time assessed the measures used as unavoidable. Even though they were not directly criticised for having used restraints or coercion, the nurses could experience defeat and shame. While one claimed that he never had had such reactions, others held that such feelings were difficult to put into words and was something they had never reflected upon previously. One said that “it is the borderline between restraints/coercion, voluntariness, and participation which is so very difficult to contend with”.

Criticism of psychiatric care from various media, the descriptions of psychiatric units as torture chambers, and accusations of violation of human rights, were also experienced as difficult. The interviewees described feelings of isolation because society, family and friends were unable to appreciate what it is like to work on an acute psychiatric ward, the intense experiences, the dilemmas, and the fear. Some were upset by the seeming lack of appreciation among the national political leadership of the severity of the patients’ suffering and the massive challenges healthcarers faced on a daily basis on acute psychiatric wards. The nurses claimed that the groups of psychiatric patients that were discussed in various contexts were far less ill and more resourceful than the patients our interviewees cared for. As their patients were unable to take part in discussions in the media they were hardly ever recognised or heard.

Several of the nurses were furthermore upset by the lack of attention paid to violence from patients and how this also made healthcarers suffer. The interviewees expressed discomfort, guilt, bad conscience, and a feeling of inadequacy when unable to protect patients and staff during episodes of mental and/or physical violence. Such episodes «made the chest physically hurt». Overcrowded wards, inadequate resources and economic saving schemes worried the nurses as it threatened to frustrate their ability to maintain good quality care. Several found that a low staffing ratio led to more use of restraints and coercion. “With more staff we could have solved this differently. It is a perpetual problem”. Particularly on evening shifts and during the weekends, there could be low coverage of nurses and an extensive use of unqualified staff.

Time, competency, and experience were seen as decisive for being able to recognise signals in time to deescalate dangerous situations. However, this is «difficult when the unit is full to capacity». The ward’s architecture and size were also seen as a hindrance for less use of restraints or coercion: “As the rooms are small, they tend to be overcrowded”. All this could cause «growing qualms about being part of a system I do not find good enough». Reducing the use of restraining or coercive measures while saving on expenses was characterised as irreconcilable ideals. Some of the interviewees suffered from tension headaches, others found that exhaustion caused them to be irritable at home and in great need of rest and quiet.


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