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Ethical considerations in psychiatric inpatient care: The ethical landscape in everyday practice as described by staff
Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This thesis focuses mainly on the general ethical considerations of staff and not pre-defined specific ethical problems or dilemmas. The aims of this thesis were: first, to map ethical considerations as described by staff members in their everyday work in child and adolescent psychiatry as well as in adult psychiatry; second, from a normative ethical perspective, examine encounters between staff and patients; and third, to describe staff justification for decisions on coercive care in child and adolescent psychiatry. The material in the three first studies comprised ethical diaries written by staff in 13 inpatient clinics. The fourth study included all the medical records of patients who were admitted to coercive care during one year in child and adolescent psychiatry in Sweden.

In a final analysis, combining all the four studies, three staff ideals were identified: being a good carer, respecting the patient’s autonomy and integrity and having good relations with patients and relatives. Staff often felt that the only reasonable way in many situations was to act in a paternalistic way and take responsibility, but they considered it to be problematic.

Four main themes were identified as ethical considerations. These were the borders of coercion, the emphasis on order and clarity rather than a more reciprocal relationship with patients, a strong expectation of loyalty within the team, and feelings of powerlessness, mostly in relation to patients.

I have identified four challenges for inpatient psychiatry. First, formal and informal coercion in inpatient care raise ethical concerns that also can be emotionally difficult for staff. Second, the professional role and care needs to be redeveloped from providing routinised care to providing more individualised care. Third, staff often worry about how patients manage their life after discharge, indicating that patients need better support. Fourth, staff also need support; they often experience feelings of being alone with their thoughts about ethical difficulties at work. Future research could contribute in the mapping of ethical considerations, in helping to develop, implement and evaluate methods for managing these issues in psychiatric settings, and to develop the normative ethical language so that it is more relevant to the clinic reality.

Place, publisher, year, edition, pages
Örebro: Örebro university , 2015. , 97 p.
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 120
Keyword [en]
Staff, psychiatric care, diary method, qualitative content analysis, ethical issues, decision making, coercive care, adolescent
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
URN: urn:nbn:se:oru:diva-43270ISBN: 978-91-7529-069-0 (print)OAI: oai:DiVA.org:oru-43270DiVA: diva2:792455
Public defence
2015-05-08, Universitetssjukhuset, hörsal C3, Södra Grev Rosengatan, Örebro, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2015-03-04 Created: 2015-03-04 Last updated: 2017-10-17Bibliographically approved
List of papers
1. The ethical landscape of professional care in everyday practice as perceived by staff: a qualitative content analysis of ethical diaries written by staff in child and adolescent psychiatric in-patient care
Open this publication in new window or tab >>The ethical landscape of professional care in everyday practice as perceived by staff: a qualitative content analysis of ethical diaries written by staff in child and adolescent psychiatric in-patient care
2012 (English)In: Child and Adolescent Psychiatry and Mental Health, ISSN 1753-2000, E-ISSN 1753-2000, Vol. 6, no 1, 18- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Although there has been some empirical research on ethics concerning the attitudes and approaches of staff in relation to adult patients, there is very little to be found on child and adolescent psychiatric care. In most cases researchers have defined which issues are important, for instance, coercive care. The aim of this study was to provide a qualitative description of situations and experiences that gave rise to ethical problems and considerations as reported by staff members on child and adolescent psychiatric wards, although they were not provided with a definition of the concept.

METHODS: The study took place in six child and adolescent psychiatric wards in Sweden. All staff members involved with patients on these wards were invited to participate. The staff members were asked to keep an ethical diary over the course of one week, and data collection comprised the diaries handed in by 68 persons. Qualitative content analysis was used in order to analyse the diaries.

RESULTS: In the analysis three themes emerged; 1) good care 2) loyalty and 3) powerlessness. The theme 'good care' contains statements about the ideal of commitment but also about problems living up to the ideal. Staff members emphasized the importance of involving patients and parents in the care, but also of the need for professional distance. Participants seldom perceived decisions about coercive measures as problematic, in contrast to those about pressure and restrictions, especially in the case of patients admitted for voluntary care. The theme 'loyalty' contains statements in which staff members perceived contradictory expectations from different interested parties, mainly parents but also their supervisor, doctors, colleagues and the social services. The theme 'powerlessness' contains statements about situations that create frustration, in which freedom of action is perceived as limited and can concern inadequacy in relation to patients and violations in the workplace.

CONCLUSIONS: The ethical considerations described by child and adolescent psychiatric care staff are multifaceted and remarkably often concern problems of loyalty and organization. These problems frequently had a considerable influence on the care provided. It seems that staff members lack a language of ethics and require both an ethical education and a forum for discussion of ethical issues.

Place, publisher, year, edition, pages
London: BioMed Central, 2012
Keyword
Staff; Child and adolescent psychiatric care; Ethical considerations; Diary method; Qualitative content analysis; Ethical issues
National Category
Clinical Medicine
Research subject
Psychiatry
Identifiers
urn:nbn:se:oru:diva-43922 (URN)10.1186/1753-2000-6-18 (DOI)22568978 (PubMedID)2-s2.0-84863559486 (Scopus ID)
Available from: 2013-12-30 Created: 2015-03-27 Last updated: 2017-12-04Bibliographically approved
2. Staffs’ perceptions of the ethical landscape in psychiatric inpatient care: A qualitative content analysis of ethical diaries
Open this publication in new window or tab >>Staffs’ perceptions of the ethical landscape in psychiatric inpatient care: A qualitative content analysis of ethical diaries
2014 (English)In: Clinical Ethics, ISSN 1477-7509, E-ISSN 1758-101X, Vol. 9, no 1, 45-52 p.Article in journal (Refereed) Published
Abstract [en]

This study presents a qualitative description of situations at work that staff members perceive as giving rise to ethical issues. All staff members working with patients across seven wards were given the opportunity to freely describe ethical considerations in an ethical diary over the course of one week. One hundred and five staff members kept a diary. The diaries were analysed with qualitative content analysis where four dominant themes emerged: good care, order and clarity, loyalty, and inadequacy. These results contain statements in which patients are respected and listened to, as well as statements that express a desire for relatively strict, routine-based care. Relatively few statements were of a reflective or discussing nature which highlights the need for clinical ethical support. There is a need of a visible and supportive leadership which encourages ethical reflection. Reflections on real cases could provide an opportunity to challenge existing practices and thereby promote ethical awareness.

Place, publisher, year, edition, pages
London: Sage Publications, 2014
Keyword
Staff, psychiatric care, ethical considerations, diary method, qualitative content analysis
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:oru:diva-41937 (URN)10.1177/1477750914524069 (DOI)2-s2.0-84901407092 (Scopus ID)
Available from: 2015-01-16 Created: 2015-01-16 Last updated: 2017-10-18Bibliographically approved
3. Paternalism, autonomy and reciprocity: ethical perspectives in encounters with patients in psychiatric in-patient care.
Open this publication in new window or tab >>Paternalism, autonomy and reciprocity: ethical perspectives in encounters with patients in psychiatric in-patient care.
2013 (English)In: BMC Medical Ethics, ISSN 1472-6939, E-ISSN 1472-6939, Vol. 14, no 1, 49- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Psychiatric staff members have the power to decide the options that frame encounters with patients. Intentional as well as unintentional framing can have a crucial impact on patients' opportunities to be heard and participate in the process. We identified three dominant ethical perspectives in the normative medical ethics literature concerning how doctors and other staff members should frame interactions in relation to patients; paternalism, autonomy and reciprocity. The aim of this study was to describe and analyse statements describing real work situations and ethical reflections made by staff members in relation to three central perspectives in medical ethics; paternalism, autonomy and reciprocity.

METHODS: All staff members involved with patients in seven adult psychiatric and six child and adolescent psychiatric clinics were given the opportunity to freely describe ethical considerations in their work by keeping an ethical diary over the course of one week and 173 persons handed in their diaries. Qualitative theory-guided content analysis was used to provide a description of staff encounters with patients and in what way these encounters were consistent with, or contrary to, the three perspectives.

RESULTS: The majority of the statements could be attributed to the perspective of paternalism and several to autonomy. Only a few statements could be attributed to reciprocity, most of which concerned staff members acting contrary to the perspective. The result is presented as three perspectives containing eight values.Paternalism; 1) promoting and restoring the health of the patient, 2) providing good care and 3) assuming responsibility.Autonomy; 1) respecting the patient's right to self-determination and information, 2) respecting the patient's integrity and 3) protecting human rights.Reciprocity; 1) involving patients in the planning and implementation of their care and 2) building trust between staff and patients.

CONCLUSIONS: Paternalism clearly appeared to be the dominant perspective among the participants, but there was also awareness of patients' right to autonomy. Despite a normative trend towards reciprocity in psychiatry throughout the Western world, identifying it proved difficult in this study. This should be borne in mind by clinics when considering the need for ethical education, training and supervision.

Place, publisher, year, edition, pages
BioMed Central, 2013
Keyword
Staff; Psychiatric care; Paternalism; Autonomy; Reciprocity; Qualitative theory-guided content analysis; Diary method; Ethical considerations; Ethical issues
National Category
Bioethics Medical Ethics Social Sciences
Research subject
Psychiatry
Identifiers
urn:nbn:se:oru:diva-43921 (URN)10.1186/1472-6939-14-49 (DOI)000328501900001 ()24314345 (PubMedID)2-s2.0-84889026420 (Scopus ID)
Available from: 2013-12-30 Created: 2015-03-27 Last updated: 2017-12-04Bibliographically approved
4. Justifications for coercive care in child and adolescent psychiatry: A content analysis of medical documentation
Open this publication in new window or tab >>Justifications for coercive care in child and adolescent psychiatry: A content analysis of medical documentation
(English)Manuscript (preprint) (Other academic)
Keyword
Psychiatry, coercive care, medical records, decision making, ethics, adolescents
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:oru:diva-43925 (URN)
Available from: 2015-03-27 Created: 2015-03-27 Last updated: 2017-10-17Bibliographically approved

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