Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Effect of Complex Working Conditions on Nurses Who Exert Coercive Measures in Forensic Psychiatric Care

Niclas Gustafsson, RN, MScN; Martin Salzmann-Erikson, PhD, RN

Abstract

Nurses who exert coercive measures on patients within psychiatric care are emotionally affected. However, research on their working conditions and environment is limited. The purpose of the current study was to describe nurses' experiences and thoughts concerning the exertion of coercive measures in forensic psychiatric care. The investigation was a qualitative interview study using unstructured interviews; data were analyzed with inductive content analysis. Results described participants' thoughts and experiences of coercive measures from four main categories: (a) acting against the patients' will, (b) reasoning about ethical justifications, (c) feelings of compassion, and (d) the need for debriefing. The current study illuminates the working conditions of nurses who exert coercive measures in clinical practice with patients who have a long-term relationship with severe symptomatology. The findings are important to further discuss how nurses and leaders can promote a healthier working environment. [Journal of Psychosocial Nursing and Mental Health Services, 54(9), 37–43.]

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Abstract

Nurses who exert coercive measures on patients within psychiatric care are emotionally affected. However, research on their working conditions and environment is limited. The purpose of the current study was to describe nurses' experiences and thoughts concerning the exertion of coercive measures in forensic psychiatric care. The investigation was a qualitative interview study using unstructured interviews; data were analyzed with inductive content analysis. Results described participants' thoughts and experiences of coercive measures from four main categories: (a) acting against the patients' will, (b) reasoning about ethical justifications, (c) feelings of compassion, and (d) the need for debriefing. The current study illuminates the working conditions of nurses who exert coercive measures in clinical practice with patients who have a long-term relationship with severe symptomatology. The findings are important to further discuss how nurses and leaders can promote a healthier working environment. [Journal of Psychosocial Nursing and Mental Health Services, 54(9), 37–43.]

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Coercive measures are commonly practiced within acute psychiatric care, as well as in forensic psychiatric care settings, and emotionally affect patients and staff in their working environment (Chambers, Kantaris, Guise, & Välimäki, 2015; Hui, Middleton, & Völlm, 2013; Mah, Hirdes, Heckman, & Stolee, 2015). The current qualitative study investigated the working conditions of staff in forensic settings and their views on exerting coercive measures on patients.

A Review of the Literature

The most frequently used coercive measures are mechanical restraints, seclusion, and forced medication (Wallsten et al., 2013). Although coercive measures are legitimized, in accordance with the legislations of most countries, they are highly controversial. Hence, there is a growing trend in research to find alternative methods to eliminate, or at least decrease, their frequency of use (Boumans, Egger, Souren, & Hutschemaekers, 2014; D'Orio, Purselle, Stevens, & Garlow, 2004; Wale, Belkin, & Moon, 2011). Previous research has predominantly focused on the relationship between coercive measures and patient characteristics and the harm they pose to patients, and patients' experiences of being subjected to coercive measures (Beghi, Peroni, Gabola, Rossetti, & Cornaggia, 2013; Shahpesandy et al., 2015). The effects on staff associated with the psychological issues of exerting coercive measures have not been closely examined.

Ethical Dilemmas When Using Coercive Intervention

Some articles have addressed problems from the staff perspective in relation to working conditions. One phenomenological study of nurses' experiences of exerting physical restraint in an acute inpatient psychiatric setting demonstrated that they view coercive measures as being highly incorporated in the work, or “part of the job,” but also associated with uncomfortable feelings (Bigwood & Crowe, 2008). Kontio et al. (2010) reported that staff experienced ethical dilemmas when using coercive intervention, although patients were thought to be in need of coercive measures due to the risk of self-harm or harming others. Ethical dilemmas were also reported when intervening in aggressive behavior by using mechanical restraints because the staff questioning patients' actions wondered if other alternatives would have been possible (Kontio et al., 2010). Terkelsen and Larsen (2014) found that staff experiences were associated with moral difficulties in defending their use of coercive measures. Although nurses expressed negative associations regarding coercive measures, it has been reported in the literature that coercion is needed for the benefit and safety of other patients in the ward (Happell & Harrow, 2010; van Doeselaar, Sleegers, & Hutschemaekers, 2008).

The Therapeutic Relationship in Psychiatric Nursing

The therapeutic relationship between patients and nurses is considered fundamental in psychiatric nursing (Barker & Buchanan-Barker, 2010; Halldorsdottir, 2008; Peplau, 1991). Establishing alliances and trust is associated with important characteristics of nurses' skills, such as expressing empathy, warmth, and understanding, and paying attention to patients' needs (Johansson, 2009). In forensic settings, the therapeutic nurse–patient relationship is a key factor that can ward off violent situations, which is considered important as violence is a prominent reason for coercive measures (Gildberg et al., 2015; Maguire, Young, & Martin, 2012; Pulsford et al., 2013). However, as nurses have the dual roles of being the individual who cares and executes coercive measures, complexity arises.

A Need to Understand the Working Conditions of Staff

What is known about staff experiences of and thoughts about exerting coercive measures is largely based on empirical studies in psychiatric settings, in which short-term care is provided. However, the forensic psychiatric setting differs in two profoundly important aspects. First, patients who have been sentenced by a court to receive forensic psychiatric care do not have the right to choose their caregivers. Second, length of stay is often a duration of several years (Hörberg, 2008; Statens Offentliga Utredningar, 2006). Given the complexity and long-term nature of the nurse–patient relationship, further understanding is needed of the working conditions of staff in forensic settings and their views on exerting coercive measures on patients. Hence, the aim of the current study was to describe nurses' thoughts on and experiences of exerting coercive measures in forensic psychiatric care.

Method

A qualitative descriptive study design was used (Polit & Beck, 2010) to investigate nurses' thoughts on and experiences of exerting coercive measures at work. Qualitative in-depth interviews were conducted and then analyzed with inductive content analysis (Elo & Kyngäs, 2008).

Setting and Participants

Initially, the administrative chief at the psychiatric clinic was formally contacted via an information letter about the study. A meeting with the operations, section, and unit managers was then arranged to further inform about and discuss the study. After approval, the operations manager distributed an information letter to 25 nurses. Eight nurses met the inclusion criteria: experience working at least 1 year in forensic psychiatry and having participated in at least three situations involving coercive measures. All eight nurses gave consent to participate and included five women and three men, each of whom had more than 2 years of experience and six of whom had more than 10 years of experience. Participants' ages ranged from 32 to 55 (mean age = 44.5 years). No further details of participants' personal data were recorded.

Data Collection

Prior to data collection, one pilot interview was conducted, as suggested by Polit and Beck (2010). The pilot interview was not included in the data set. Interviews were conducted in an undisturbed room at the psychiatric clinic during nurses' ordinary working hours. Prior to the interview, the interviewer (N.G.) engaged in a short phase of small talk to establish a comfortable atmosphere and ensure participants were given the proper information about their participation and, in particular, the voluntary nature of this participation (Gorden, 1992). Open-ended interviews were used to collect data. Interviews were introduced with an open and broad prompt (“Please tell me about an occasion in which you have been involved in the use of coercive measures in inpatient psychiatric care.”), which encouraged participants to narrate their experiences. The interviewer then used active listening and prompts and questions, such as: “Please elaborate on that situation when you administrated an injection without the patient's consent a bit more”; “How does that situation make you feel?”; and “How was your relation to that patient afterward?” Participants led the conversation and were able to provide the most relevant information from their point of view (Bernard, 2002). Interview duration ranged from 14 to 48 minutes (mean = 31.5 minutes). All eight interviews were digitally recorded and transcribed verbatim.

Data Analysis

Data were analyzed by means of a qualitative inductive content analysis. The analysis procedure was followed as described by Elo and Kyngäs (2008). Both authors were involved in the analysis. During the preparation phase, data to be analyzed were chosen and it was decided that all of the interview transcripts should be used because no data were considered irrelevant. To become familiarized with the data, all transcripts were read repeatedly. During this phase, questions were asked and notes were taken regarding the data, such as “What is happening?”, “Where does this situation take place?”, and “What are the feelings nurses think of when they have exerted coercive measures?” During this familiarization phase, recurring themes, actions, and terms, as well as differences, were identified within the individual interviews and across the separate interviews. While reading, notes were written in the margins and analytical memos were made in a separate Microsoft Word® document.

In the next phase, the process of open coding was conducted throughout the transcripts, as subcategories were constructed. Open coding involved carefully dividing the transcripts into fragments and evaluating their content. With the support of the notes and analytical memos, text units (i.e., the smallest pieces of data) were chosen and written separately on Post-it® notes in accordance with how they related to subcategories. For example, “pity” became one subcategory and a text unit was added: “...it was physically a large amount of fluid that I had to inject into him and this makes your buttock hurt, so simply for that reason I felt sorry for him.” Subcategories were thereafter sorted into different piles in accordance with their similarities and differences, and main categories were constructed. Constructing main categories from subcategories was an abstracting process, in which more general descriptions were constructed. The abstraction process also involved frequent discussions among the researchers regarding the internal homogeneity and external heterogeneity of the main categories (Patton, 1990).

To ensure validity, an external colleague was asked to review drafts of the transcripts, analytical memos, and subcategories and categories, as suggested by Burnard (1991). At first, the original category analysis was too broad and general. In concordance with what Burnard (1991) describes as a funneling process, categories were distilled to a smaller number of categories. This review prompted revision of some of the preliminary main categories, as some were similar and thus merged. However, the review supported the constructed subcategories and main categories. After revisions, the validity check was performed to be “reasonably complete and accurate” (Burnard 1991, p. 465).

Ethical Considerations

The current study did not require ethical vetting according to Swedish national law, as it did not handle sensitive data or concern participants' health. However, the study followed the ethical principles of the Declaration of Helsinki. All participants were provided oral and written information about the study, including its purpose and confidentiality, as well as its voluntary nature, in terms of the right to refuse or withdraw at any time without further consequences.

Results

Results described participants' thoughts about and experiences of coercive measures from the perspectives of four main categories: (a) acting against the patients' will, (b) reasoning about ethical justifications, (c) feelings of compassion, and (d) the need for debriefing.

Acting Against the Patients' Will

Participants reported that they, in some sense, always acted against the patients' will because all patients had committed crimes and therefore had been sentenced to forensic psychiatric care. Participants asserted that acting against the patients' will was something that occurred continuously and on a long-term basis, as one expressed: “Basically, we are exerting coercion all the time, and it is not just a matter of physical restraints, injections, and syringes…all of their period of care is a kind of coercion.” In one sense, acting against the patients' will was considered as being part of the job. However, when narrating about these aspects, participants put the responsibility on patients, with one saying:

I still often think that they have shown that they are actually not really in a state to make all their decisions themselves. It has most often been very aggressive behavior that has led to where we are now. I have in fact thought about it sometimes from my own perspective. Would I want to be stopped if I were in this condition? The answer is always yes.

Acting against the patients' will was associated with consequences that negatively affected participants due to patients' responses. One participant told about a situation that occurred when he/she was going to administer an intramuscular injection against the patient's will. The patient used a calm voice and made threats toward the participant's family, emphasizing that he had the resources to make reality of the threats. This situation of acting against the patient's will affected the participant with a persistent feeling of unease. The threat transcended the role of being threatened as a professional nurse and affected the participant as a private individual.

However, being affected by conducting coercive measures was not only seen as something negative. One participant questioned the idea of becoming used to coercive measures and not being affected, as well as the consequences of such a change and fear of becoming desensitized over time:

Should you get used to carrying out coercive measures or whatever else it might be? Do you develop such a thick skin in this profession that you stop caring about the person, about the ethics of it all? I have gotten used to situations where we use physical restraint and injections. I can accept that this is the way it is, that it maybe has to be this way for patient's best, but should you get used to this?

Reasoning About Ethical Justifications

Participants were asked to narrate a specific situation in which they had exerted coercive measures. Several participants did not at first address a specific situation, but rather began with an exposition about how they, in principle, relate to and argue for the necessity of coercive measures, as exemplified by one participant:

...but he was so ill that it would have been unethical to let him continue suffering in that way. It would not have been possible to persuade him to start taking his medicines given the state that he was in.

Participants were seemingly used to discussing caring and ethical ideologies in relation to coercive measures. They reported that they occasionally, in their spare time, ended up in such situations with friends and had to defend their actions and roles in relation to being a part of a larger societal apparatus.

One participant discussed a dramatic event involving a recently detained patient who was severely aggressive and had been mechanically restrained and given forced medication. The following day, the patient was assessed as no longer being in need of compulsory treatment and was released from the hospital. That same afternoon, the participant encountered the patient by coincidence at a restaurant. This situation forced the participant to reflect on and review his/her role in the situation (i.e., to consider the ethical arguments involved). The participant concluded that the exertion of coercive measures was correct and needed in this specific situation because the alternative would have resulted in severe harm, and his/her view is conveyed as a conviction of having helped the patient:

No, I don't feel like a villain in this. I have been working for a long time and seen that patients feel better after receiving medication, or at least do not fight after receiving medication. It can seem to be brutal to give an injection to someone who absolutely does not want to receive one, who is prepared to fight to avoid having one, but it ends well for the patient.

The fact that the patients who are being cared for in forensic psychiatry have been found guilty of crimes was incorporated into participants' ways of reasoning the ethical aspects of the situation. Participants stressed that they have an awareness of patients' crimes and history when exerting coercive measures, but none expressed the opinion that the coercive measures are a type of punishment. One participant stated:

The patients are punished, there is no getting away from that. They are locked up because they did something. But I don't know if you can call the coercive measures themselves a punishment. There are murderers who have never been restrained.

Feelings of Compassion

Subjecting a patient to a coercive measure emotionally affected participants. They described their feelings of compassion for patients who experienced mental illness and were so ill that voluntary care was no longer an option. These feelings of compassion became even more palpable when they, as nurses, talked about implementing coercive measures. One participant said he/she felt compassion when administering an intramuscular injection against the patient's will because the patient was scared, which resulted in increased muscle tension and so increased physical pain while the injection was administered. Although compassion may occur in situations in which coercive measures are used, no participants thought that these coercive measures were applied wrongfully or punitively. One participant explained, “I haven't felt that this goes against my principles or values, but what does happen sometimes is that I feel sorry for the person concerned.” However, feelings of compassion differed regarding which patient was being subjected to coercive measures. Participants commented that patients with schizophrenia or psychosis, or who in some other sense were seen as being “obviously ill,” elicited greater feelings of compassion than those who only expressed aggressive behavior, with one noting:

Obviously, you feel sorry for the patients sometimes, particularly if they are psychotic and afraid. You feel more pity for the psychotic patients than for those who are just aggressive, speaking honestly. But I also know that neglecting to do what I do, whether it is a matter of a mechanical restraint or medicating someone, will not make things better.

Although it was reported that it was more difficult to feel compassion for aggressive patients, it was also stated that it is important to understand the origin of this aggressiveness, as it may be a manifestation of fear. Reflecting on underlying factors and the origin of aggressions helped provide participants with a deeper insight into patients' underlying problems, which resulted in feelings of compassion.

The Need for Debriefing

The last theme involved nurses' thoughts and experiences of their dual roles, in that they were partly the individual who exerted the coercive measure and partly the individual who would later care for the patient on a daily basis. A strategy to fuse these dual roles was to establish a communication forum between themselves as nurses and patients. Participants advocated for the use of debriefing sessions to maintain a continuing good relationship with patients. During debriefing sessions, it was possible to explain each other's view of the situation, as one participant explained:

Actually, I think that if someone has done something to a patient that might be experienced by the patient as an assault, then that person should afterwards, when things have calmed down, talk with the patient to make sure that the patient does not have any negative feelings, that the patient understands afterwards why what was done was done and that there was no bad intention.

Debriefing sessions were also reported to be a concrete way of moving on, as one participant mentioned, “Yesterday was yesterday and that's what happened then, and today is an entirely new day with entirely new opportunities and we start again on a new page.” There was also the matter of the time that had elapsed since the situation to the debriefing session. Too much time should not have passed, as it then negatively affected patients, acting as an unnecessary reminder of the event. There was not a consistent opinion among participants that it was necessary to have a debriefing session in all situations and with all patients; instead it was expressed as an individual judgement, with one participant noting, “I am rather in two minds about whether these should be held regularly, all the time. Sometimes it is not suitable, you just open up wounds, but sometimes they could be great.”

Debriefing sessions were sometimes considered structured meetings. One participant told of a violent and chaotic situation in which the patient was mechanically restrained and given forced medication, and no structured debriefing was conducted. However, several weeks later, the participant ended up in a spontaneous conversation with the patient, who was at that time no longer psychotic. The conversation took place on the patient's initiative and they discussed the incident. The participant recalled that the patient laughed when they talked about the situation and that the patient was at that time able to understand the situation. At the time, the patient had felt violated, but already a few days later his thoughts became clearer and he was ashamed.

Discussion

The current small-scale study had a limited number of participants and conclusions cannot be drawn for nurses outside the studied group. However, the findings provide some important insights and indicate the need for further exploration of these issues by means of more thorough study designs with larger data sets. A strength of this study is that the sample was restricted to nurses working in forensic psychiatric care settings, while including nurses that varied in gender and age. Another strength is the use of Elo and Kyngäs' (2008) structured method to categorize and analyze data.

The main findings demonstrated that nurses in forensic psychiatric care are affected by their working conditions, both as professionals and private individuals. Nurses were notably attentive to and reflective of the fact that they consistently acted against the patients' will and also had a reflective attitude regarding their role as being the ones who exert coercive measures. Acting against the patients' will caused the nurses to feel compassion, but at the same time was considered as being expected of a nurse in a forensic care setting. Acting against the patients' will also evoked a need to ethically justify their work by means of moral reasoning, both at work and outside work.

In general, psychiatric nursing entails establishing alliances and trustful relationships that will lead to a sense of interplay in the nurse– patient relationship and accomplish a positive change toward health and recovery (Barker & Buchanan-Barker, 2005; Shanley & Jubb-Shanley, 2007). The working conditions for staff in the forensic psychiatric setting were reported to be problematic, as staff hold the dual roles of being a caring nurse who should express warmth and compassion (Johansson, 2009), while at the same time being obligated to exert coercive measures on patients against their will. However, the current findings contradict those of a Finnish study, which reported that nurses did not find coercive measures to be problematic (Lind, Kaltiala-Heino, Suominen, Leino-Kilpi, & Välimäki, 2004). It can be argued that togetherness (Shanley & Jubb-Shanley, 2007) in the nurse–patient relationship cannot be established during the most critical situations (i.e., those in which coercive measures are exerted), which is similar to what was reported in the study by Kontio et al. (2010) about the need to make rapid decisions, without discussing alternatives, during critical and aggressive situations.

In the current study, staff thought that debriefing sessions were an important communication forum, as they made it possible to explain each other's views. Bonner, Lowe, Rawcliffe, and Wellman (2002) emphasized the importance of establishing policies for debriefing and involving staff and patients. Similar to findings from Larue, Piat, Racine, Ménard, and Goulet (2010), the current authors found that debriefing was not conducted routinely and, if debriefing is conducted, it should be done within a certain timeframe. This factor must be further elaborated to be able to answer the question of when is the “golden time.” The current authors argue for systematic post-incident debriefing sessions, as these will benefit the working conditions of nurses who participate in coercive measures. These sessions are especially important to reduce stress and in developing clinical practice (Sjöberg, Schönning, & Salzmann-Erikson, 2015).

Kontio et al. (2010) studied the moral reasoning of nurses in relation to coercive measures and reported that they justified their actions through concerns for the safety of other patients and need for a therapeutic atmosphere in the ward. The reason turbulent situations justified and necessitated the use of coercive measures was also found in other studies (Bigwood & Crowe, 2008; Happell & Harrow, 2010; van Doeselaar et al., 2008). The current authors found that exerting coercive measures in forensic care impacted staff emotionally, which has also been noted in previous studies (Bigwood & Crowe, 2008; Kontio et al., 2010; Terkelsen & Larsen, 2014). Being emotionally affected at work may result in stressful situations, in which it is not possible to control the workflow. Lützén, Cronqvist, Magnusson, and Andersson (2003) studied the phenomenon of moral stress among nurses and found three preconditions: nurses feeling moral sensitiveness to the patients' lack of autonomy and vulnerability, external factors that prevent nurses from acting in the best interests of the patients, and stress resulting from having no control over a situation.

In relation to the concept of moral stress, external concerns could not be identified. However, it was found that nurses felt compassion for patients while exerting coercive measures. Nurses viewed patients as vulnerable, especially in situations in which they expressed fear, and exerting coercive measures over a long period of time could risk moral stress. However, staff continuously reflected on and discussed ethical considerations in relation to their work and drew conclusions regarding their violation of the patients' integrity. This finding was considered a moral sensitivity. In contrast to the findings in the study by Terkelsen and Larsen (2014), in which staff used coping strategies and blamed the system, staff in the current study had a positive attitude and accepted moral stress because not accepting this would put them at risk of becoming desensitized to their actions.

Conclusion and Implications for Practice

The main goal of the current study was to describe nurses' thoughts on and experiences of exerting coercive measures in forensic psychiatric care. This study has shown that nurses in forensic psychiatric care are affected (as professionals and individuals) by their working conditions. One of the more significant findings is that nurses are constantly reflecting on their working conditions and duties, and their need to ethically justify their work. The results can be used by nurse practitioners and clinical managers to develop targeted interventions aimed at further discussing these issues in more structured forums. Clinical managers may arrange ethical discussion forums in forensic wards to address staff feelings.

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Authors

Mr. Gustafsson is Specialist Psychiatric Nurse, Ersta-Sköndal College University, Stockholm; and Dr. Salzmann-Erikson is Associate Professor, Faculty of Health and Occupational Studies, Department of Health and Caring Science, University of Gävle, Gävle, Sweden.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Martin Salzmann-Erikson, PhD, RN, Associate Professor, Faculty of Health and Occupational Studies, Department of Health and Caring Science, University of Gävle, SE-801 76 Gävle, Sweden; e-mail: martin.salzmann@hig.se.

Received: May 15, 2016
Accepted: July 08, 2016

10.3928/02793695-20160817-06

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