Background: Professionals within the mental health services face many ethical dilemmas and challenging situations regarding the use of coercion. The purpose of this study was to evaluate the significance of participating in systematic ethics reflection groups focusing on ethical challenges related to coercion. Methods: In 2013 and 2014, 20 focus group interviews with 127 participants were conducted. The interviews were tape recorded and transcribed verbatim. The analysis is inspired by the concept of ‘bricolage’ which means our approach was inductive. Results: Most participants report positive experiences with participating in ethics reflection groups: A systematic and well-structured approach to discuss ethical challenges, increased consciousness of formal and informal coercion, a possibility to challenge problematic concepts, attitudes and practices, improved professional competence and confidence, greater trust within the team, more constructive disagreement and room for internal critique, less judgmental reactions and more reasoned approaches, and identification of potential for improvement and alternative courses of action. On several wards, the participation of psychiatrists and psychologists in the reflection groups was missing. The impact of the perceived lack of safety in reflection groups should not be underestimated. Sometimes the method for ethics reflection was utilised in a rigid way. Direct involvement of patients and family was missing. Conclusion: This focus group study indicates the potential of ethics reflection groups to create a moral space in the workplace that promotes critical, reflective and collaborative moral deliberations. Future research, with other designs and methodologies, is needed to further investigate the impact of ethics reflection groups on improving health care practices. Keywords: Coercion, Ethics reflection groups, Focus group study, Health care professionals, Mental health care Background Some studies refer to ‘large-scale’ and ‘small-scale’ Ethical challenges in mental health care ethical challenges . A large-scale ethical challenge Professionals within the mental health services face may be a question concerning whether to put a patient many ethical dilemmas and challenging situations. Prior- in belts (‘coercion’) while a small-scale ethical chal- itising between patients, cooperation between patients lenge may be about whether to reject the patient’sques- and family as well as the use of coercion are important tions about being allowed to call their parents or not examples. An ethical challenge occurs where there is (‘persuasion’ or ‘leverage’) [ibid.]. Some distinguish be- doubt, uncertainty or disagreement about what is mor- tween the terms ‘challenge’ and ‘dilemma’ and by that ally good or right [1–3]. indicate that a dilemma involves facing a situation where there is no good solution, but where you have to make a choice, typically between two alternatives. We * Correspondence: email@example.com Centre for Medical Ethics, Institute of Health and Society, Faculty of prefer to use these terms interchangeably since an eth- Medicine, University of Oslo, P.O.Box 1130, Blindern, NO-0318 Oslo, Norway ical challenge could mean that all solutions have serious VID Specialized University, Faculty of Health Studies, Box 184, Vinderen, downsides. NO-0319 Oslo, Norway Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hem et al. BMC Medical Ethics (2018) 19:54 Page 2 of 14 The use of coercion in mental health care them - for example how to balance autonomy with ben- Over the last years, the use of coercion in mental health eficence  - within the mental health services than in services has received increasing attention. Coercion other parts of the health care system [16–18]. It is a raises some of the most difficult ethical issues . By co- paradox since law and practice in mental health services ercion we refer to both formal, informal  and per- raises many complex ethical challenges (1–6) and prob- ceived coercion [8, 9], and between there are many grey ably have the potential to undermine the right to free- areas. ‘Formal coercion’ is formally regulated, decided dom to a greater extent than what is found in any other and documented, while ‘informal coercion’ includes all part of civil society and legislation . forms of coercion and use of power, control or manipu- In a systematic literature review on the evaluation of lation without any formal decision or documentation. clinical ethics support in mental healthcare, the results ‘Perceived coercion’ may overlap with both formal and showed that (a) participants reported that they gained an informal coercion, and is defined by the individual’s sub- increased insight into moral issues through systematic re- jective experience of being forced or not. flection; (b) there was improved cooperation among The use of coercion threatens patients’ autonomy. Co- multidisciplinary team members; (c) participants were un- ercion can cause psychological and physical harm, and it certain whether clinical ethics support led to better patient also threatens health professionals’ perception of what care; (d) the issue of patient and client participation is good care and treatment is. Most often, it is used to help complex; and (e) the implementation process is challen- the patient. However, it may also be used to protect ging. Clinical ethics support services have mainly been others or even be misused by professionals. Therefore, studied through the experiences of the participating facili- the use of coercion, is a complicated moral enterprise. tators and healthcare professionals. Consequently, there is Szmukler and Appelbaum  have developed a hier- a lack of knowledge of whether and how various types of archy of pressure that is common in clinical practice, clinical ethics support services influence the quality of where the lowest level is persuasion (‘persuasion’). The care and how patients and relatives may evaluate clinical next steps are influence (‘leverage’), request (‘induce- ethics support services. Based on six ‘grey zone articles’,in ments’), and finally threats (‘threats’) that end with the which there was an implicit focus on ethics reflection, use of coercion, including physical force [ibid.]. The other ways of working with ethical reflection in practice terms ‘coercion context’  and ‘coercive shadow’  are discussed. Implementing and evaluating clinical ethics show how the coercive dynamics are expressed in differ- support services as approaches to clinical ethics support ent ways in mental health care. that are more integrated into the development of good Norvoll and Pedersen [12, 13] show how the ‘coercive practice was stressed . shaping’ of mental health care is expressed in hierarchies In a focus group study from municipal health and care and communication patterns, the use of house rules, and services where the aim of the study was to examine what a paternalistic culture where patients feel the lack of free- issues the employees discussed in ethics reflection dom and powerlessness. The experience of losing one’s groups (ERG), whether the ethics initiative has had an freedom is a core element of coercion. Patients may feel impact on the quality of the services and work environ- small, exposed and vulnerable, which may cause them to ment, and if so, what kind of impact, and the extent to have difficulty communicating their own needs and de- which it had contributed to increased competence in sires to staff. The patients’ counter-power strategies can be ethics. Results show that employees of the municipal passive in terms of withdrawal and an attempt to escape health and care services experience many complex tasks or evade contact. Counter-power can also take the form of requiring professional skills, but also situations that re- active resistance, which in turn can cause the patient to be quire expertise in ethics and health law. Situations in- interpreted as ill or lacking insight into his/her own ill- volving conflicting value judgments appear to be ness. Being coerced may be experienced as an existential particularly demanding, and the informants presented event or even dehumanising, since it may influence how situations that challenged them in several ways. The the patients perceive themselves and may give rise to a most common topics were the use of coercion, inter- feeling of losing one’sself [ibid.]. action with relatives, and decisions about treatment in- tensity. The study shows that employees in municipal Clinical ethics support related to the use of coercion in health and care services find that the ethics initiative has mental health care been an important contribution to quality and compe- Over the last decades, health care ethics, laws and pol- tence, handling ethical challenges in a better way . icies have given higher priority to patient autonomy, and In two surveys where municipal contact persons for the attempts to reduce coercion and to use coercion in a Norwegian ethics project and ethics facilitators participated, better way . However, there has been less systematic around half of the respondents found the ethics project to attention to ethical challenges and how to deal with have been highly significant for daily professional practice. Hem et al. BMC Medical Ethics (2018) 19:54 Page 3 of 14 Outcomes include better handling of ethical challenges, ‘community health services’ (general practitioners, emer- better employee cooperation, better service quality, and bet- gency rooms and homecare). Formal coercion mainly ter relations to patients and next of kin. Factors associated takes place within specialised health services, though com- with significance of the activities were sufficient support munity health services may request involuntary hospital- from stakeholders, sufficient available time, and ethics facil- isation. The quality of the public health services in itators having sufficient knowledge and skills in ethics and Norway is generally high and used by all social classes. Pri- access to supervision. The authors conclude that there is a vate for-profit mental health services are relatively limited. need to create regional or national structures for follow-up The PET-project is inspired by discourse/dialogical ethics and develop more comprehensive ethics training for ethics  and addresses the ethical challenges related to coer- facilitators . cion and involvement from all stakeholders’ perspectives. Sometimes it is obvious which actions and measures However, the project is not about ethical analysis of coer- are necessary in order to deal with ethical challenges in cion as such. Ethics reflection groups were offered to em- a good way. Other times it is not clear what the best ap- ployees in order to share their experiences related to the proach or solution is. Situations can be complex and use of coercion and to better deal with ethical challenges confusing, which may make it difficult to put into words related to coercion [2, 3, 16, 25, 26]. what is at stake . Systematic ethics reflection can help This article presents how the participants in the ethics health professionals develop an ethical language covering reflection groups evaluate – for good and bad – the sig- the challenges they face. Research shows that reflecting nificance of these ethics reflection groups. on the challenges faced in daily work, both individually and in the team, may help health professionals to be- Methods come more conscious of their own understanding, their Our main research question was: attitudes and actions . Ethics reflection can contribute - What kind of significance did participating in sys- to learning, which means finding new solutions, devel- tematic ethics reflection groups – focusing on ethical oping a better practice and learning how to work better challenging coercion and involvement of patient and together . Reflection is arguably an essential feature family - have to mental health care professionals? of all professional development and professional compe- In addition, we had questions concerning the imple- tence [22–24]. Research suggests that ethical reflection mentation and organisation of the ethics reflection groups can help raise awareness about proper use of co- groups as well as the training of the facilitators. We will ercion, alternatives to coercion and better handling of publish a separate article based on the findings from this ethical challenges [25–28]. part of the study. One of several aims of the sub-project was to establish Presentation of the PET-project ethics reflection groups in mental health care as well as One important exception regarding commitment to sys- evaluating the process. Therefore, regularly occurring ethics tematic ethics work in order to better deal with the ethical reflection groups at seven departments within three hos- challenges related to coercion within mental health care is pital trusts in the southeastern part of Norway were estab- the Norwegian research- and development project called lished. The participating departments reflect the variety of PET (the English name for ‘PET’ is ‘Mental health care, mental health services: acute, rehabilitation, forensic, ado- ethics and coercion’) – running from 2011 to 2016 - lescent, geriatric and outpatient services. The wards estab- which was inspired by Dutch initiatives [1, 25–28]and lished and conducted ethics reflection groups for two years similar initiatives in other parts of Norwegian health care. (2012–2014). All ethics reflection groups were held within The study included four sub studies: a) systematic litera- the same wards, and within those wards, all (except in one ture reviews on evaluation of ethics support in mental unit) ethics reflection groups were held across units. The health care  and ethical challenges related to coercion Centre for Medical Ethics (CME) supported this initiative , b) interviewing patients, children and next of kin of by training 21 ethics facilitators who were to lead the patients about coercion and involvement [12–14, 30], groups. Within each ward, one person coordinated the c) the implementation and evaluation of ethics reflection organisation of the ethics reflection groups. Each ethics re- groups  and d) a national survey among mental health flection group was held once or twice a month. A multidis- care staff and patients on coercion . This article pre- ciplinary group of health care professionals (i.e nurses, sents evaluation findings from part c. socio-therapists, psychologists, psychiatrists, doctors, qual- The PET-project is part of the National Strategy for In- ity management staff, team leaders, managers) participated creased Voluntariness in Mental Health Care (2012– voluntarily in the groups. Participants were encouraged to 2015). Mental health care in Norway is publicly funded bring up their own ethical challenges in connection with and organised as ‘specialised health services’– that is, hos- the use of coercion. Based on information from 186 facilita- pital trusts (hospitals and outpatient clinics) – and as tor reports, the ethics reflection groups lasted between 50 Hem et al. BMC Medical Ethics (2018) 19:54 Page 4 of 14 and 90 min, and the mean and the median numbers of possible to accomplish (due to people being busy on the people who participated in the reflection groups was re- ward, off duty, on sick leave or on holidays). spectively 9,39 and 9,0. The groups were usually facilitated Focus group interviews are usually conducted by a mod- by two facilitators. A stepwise ethics reflection model - the erator who will safeguard that all voices are heard, that the CME-model - was utilised in the deliberations: 1. What is dialogue is based on the subject that is in focus, and that the ethical question? 2. What are the facts? 3. Who are the the group’s experiences are expressed through the conver- stakeholders and what are their views? 4. Which values are sation [34–40]. We chose to have two moderators (first at stake? 5. Which principles/guidelines/laws are at stake? and second author), and we supplemented each other with 6. Which alternatives for action exist? 7. Conclusion. questions. Furthermore, since moderators must also be at- Furthermore, implementation and follow-up was secured tentive to the group dynamics [35, 40], we were conscious from CME (teaching, supervision, network meetings), as about creating an accepting atmosphere so that the partic- well as research on several areas (ethical challenges, team ipants would feel free to talk . We followed up with work, coercion, inclusion of patients and network, ethics questions for elaboration. reflection groups) utilising a broad range of research We explicitly invited more and less experienced ethics methods (questionnaires, focus group interviews, facilitator reflection group participants. We also invited participants forms). More details about the organisation, implementa- who were positive as well as critical towards ethics reflec- tion and functioning of the ethics reflection groups, as well tion groups. In the beginning of the focus group inter- as the training of the facilitators, will be presented in an- views, we explicitly stated that we would like them to other paper . share both positive and critical experiences with the ethics reflection groups. In addition, we explicitly instructed the Focus group interviews participants not to focus on consensus but learn from dif- The rationale for conducting focus group interviews was ferent perspectives on the subject (as usually happens that we wanted to talk to a large multidisciplinary group within ethics reflection groups). Furthermore, we wanted of health care professionals in order to cover as wide a to include people from the management in the focus range of experiences with ethics reflection groups as groups, since we assumed that they would offer nuanced possible. In addition, our aim was to learn about the and more distanced views on positive as well as negative interpersonal dynamics and culture while health care experiences with the ethics reflection groups. professionals talked about doing systematic ethics reflec- The interviews were tape recorded and transcribed tion [34–40]. Consequently, in 2013 (after one year of verbatim, and consist of 200 pages (2013) + 195 pages running ethics reflection groups), we performed 13 focus (2014), in total 395 pages. group interviews; seven focus groups with 53 clinicians and six focus groups with 32 members of the manage- Data analysis ment. In 2014 (after two year of running ethics reflection The analysis is inspired by the concept of ‘bricolage’ groups), we conducted seven focus group interviews [41, 42], which means we have moved freely back with a total of 42 participants (combining clinicians and and forth in the data material. Our approach was in- management). In total, we conducted 20 focus group in- ductive [42, 43]. First, all five authors did a naïve terviews with 127 participants (some participants took reading of all the transcripts in order to obtain a part both years). The reason for the high numbers was first and overall impression of the data material. that we wanted to have a good view of the experiences Each one of us, independently, made a rough outline with the ethics reflection groups for each ward. In of what we found interesting and important. This addition, the focus group interviews functioned as a way formed the basis of our first discussions. We pro- of staying in touch with the seven wards and facilitating ceeded by starting to make categories based on our their implementation process (i.e. the focus group inter- impression of the material and agreeing on the main views did not only function as data-collection). Further- findings. This led to the initial structuring of the more, the planned focus group interviews created an material by themes. We made an overview of de- opportunity for the participants to reflect together on scriptions involving experiences with ethics reflection the implementation of the ethics reflection groups groups, which formed the central meaning units. (which most teams otherwise would not have planned The empirical material was reread several times in by themselves). The focus group participants were not order to validate the main categories which are de- the same as the ethics reflection group participants. We scribed in the results section of this paper: their ex- asked the local coordinators of the ethics reflection periences with systematic reflection on ethical groups to take responsibility for organising the focus challenges, increased awareness of the use of coer- group interviews. They put together participants for the cion, improved interdisciplinary cooperation, and focus group interviews based on what was practically lack of involvement of patient and family. Hem et al. BMC Medical Ethics (2018) 19:54 Page 5 of 14 We have discussed with each other by sharing our Experiences from systematic reflection on ethical thoughts and impressions, and we have basically agreed on challenges the interpretation of the findings. This means that we have The structured model for reflection is helpful exploited the fact that we are five researchers with both Most of the participants value the systematic way of deal- similar and dissimilar theoretical and empirical interests; as ing with ethical challenges (the CME-model for ethics re- a whole we possess comprehensive knowledge of doing sys- flection), and appreciated the CME-model which was used tematic ethics reflection in health care, as well as extensive in the reflection groups. In some places, the systematic ap- experience utilising qualitative research methods. Likewise, proach to ethical challenges has become part of the ‘cul- we have presented preliminary findings to health care pro- ture’, meaning that they try to or prefer to approach fessionals and researchers, which contributed elaborations, various (ethical) challenges in a more systematic way. This amplifications and clarifications of the results. Through this means that they recognise the ethical challenges and speak work we have aimed at meeting both primary (credibility, about them in a structured way, which they did not do be- authenticity, criticality, and integrity) and secondary (expli- fore they implemented ethics reflection groups. The citness, vividness, creativity, thoroughness, congruence, and CME-model is fixed, and serves as a guide for how to sensitivity) criteria of validity . move ahead with the reflection. It safeguards a systematic and well-structured approach to talk about ethical chal- Ethical considerations lenges, which again allows space for everybody participat- The work was undertaken conforming to the provi- ing in the group. The dialogue between the participants sions of the Declaration of Helsinki , which allows for multiple perspectives on the ethical challenge. means that basic ethical principles for research ethics Furthermore, the attention to values and norms in the such as informed consent, the right to privacy, re- CME-model, and the invitation to the participants to spect for personal integrity and dignity [41, 45]were present their viewpoints, contributes to the understanding followed. To protect the patients’ privacy, we asked of those who think differently, for instance regarding the participants in advance to mask characteristics that use of coercion. Also, the focus on various alternatives for may contribute to recognition. All participants gave dealing with the ethical challenges has been evaluated informed consent after having received written and positively by most of the participants. However, the model oral information about the project. The information in itself does not guarantee a successful reflection group. contained, among other things: the aims and topics of It is important to use the model in the right way, and the focus group interviews, the confidentiality of the people may think differently about what the right use of data, the way we will store the data and use the ana- the model is. For example, it seems to be important that lysis for scientific papers and presentations, and the the use of the model does not become too rigid. On one possibility to withdraw from the focus group study at of the participating wards, they found that an inflexible any moment without giving any reason. During the use of the model hampered the natural flow of the reflec- transcription process, we have also been mindful to tion process: participants sometimes could not contribute change the names of people, institutions, and places, to the reflection because the facilitator said they had not as well as considering all information with regard to yet arrived at this point in the reflection model. Hence, the risk of identification of individuals. they found that the facilitator managed the model in a lin- ear way. Another participant mentioned that the facilitator Results had too much focus on where to put the points for reflec- In the PET-project, we have studied what kind of ethical tion in the model, leading to more attention on how to challenges the professionals report that they struggle with operate the model than on the content of the case. in their daily practice. They experience ethical challenges in Most participants describe that they have moved from areas like the use of formal as well as informal coercion, having ‘opinions’ or emotional reactions concerning the that they feel insecure about the legal framework for coer- situation at hand, towards being able to provide reasons cion, their identity and professional role, that they experi- and work analytically with the ethical challenges they ence organisational difficulties and lack of resources, and face. This ‘move’ increases their consciousness and it the abuse of power and lack of professional competence safeguards a more structured approach to morally de- among some colleagues [46, 47]. The professionals experi- manding situations. One said: ence challenges, which seem to occur across various wards and services, as well as challenges that are context specific I find that our way of talking with each other is . The present study shows that systematic ethics reflec- different from when we have meetings where we tion makes a difference for the professionals’ perception of discuss patient treatment. People are calmer … people and dealing with ethical challenges related to coercion in are not so emotional. I think we share difficult issues several ways. in a different way in those meetings. Hem et al. BMC Medical Ethics (2018) 19:54 Page 6 of 14 The step in the model dealing with ‘alternative course of Moreover, reflecting on ethical challenges together, action’ is helpful since it illuminates that there are several they report, has led them to greater tolerance for differ- options or ways to proceed in a certain situation. Several ent opinions than before, which again creates a stronger participants said that using the model can be helpful in dis- ability to be self-critical. They have gained a broader per- cussions about subjects other than coercion as well, and spective, they think their attitudes have changed and that they had used the model in other meetings discussing they see the value in illuminating different opinions, or patient treatment. One said it this way: IfindthatI am utilising each other’s perspectives and competence. aware of the different stages of the model, I am conscious of them, and they pop up in other situations, as well. Dealing with emotions in ethics reflection Health care professionals are often an affected party in clinical situations, and there is room for sharing this (re- Professional development and better quality of treatment ferring to ‘affected parties’ in the reflection model). They Regarding ethics reflection, somesaytheythink themost tell us that they receive help in sorting through difficult important thing is to be ‘in process,’ which means the adop- feelings, and they acknowledge that everybody has a lot tion of an attitude where sharing different opinions and to learn. They say that the CME-model is a support viewpoints among colleagues is a value in itself. They ac- when it comes to adopting a critical/analytical stance to- knowledgethattheyare nowabletoreflect more than be- wards their emotions. They think that staying focused fore; some said they used to act in a more reactive manner on the solutions in a situation (“How are we going to before they started with the ethics reflection groups. Their deal with this dilemma?”) helps them to not be over- enhanced ability to reflect makes them feel more secure as whelmed by their feelings. professionals. One said: They feel that connecting emotions to the values at stake is a different way of framing and containing emo- The first step towards change is through tions, which they appreciated. acknowledging the use of coercion as an integrated part of a culture which is accustomed to setting limits People can express their emotions, but it is different, for others. Through ethics reflection groups, our the dialogue is framed in a way so that they do not language is challenged concerning what we are accuse their colleagues or get overwhelmed by their actually doing. Our concepts and the way we use feelings. We can talk about emotions, reflect, and them are being questioned. connect them to values. Many participants report that the deliberations in the re- Furthermore, some said that reflections focusing flection groups have helped them to develop a language de- only on emotions were of lesser quality. Several of scribing the ethical challenges they face. Participating in the participants on this ward were critical of ethics such deliberations makes health professionals more experi- reflection groups because they felt they needed theor- enced in identifying ethical challenges. One participant etically informed discussions on ethical challenges, used the word character formation, feeling that the deliber- and not reflection on clinical cases and emotions con- ations they have in the ethics reflection groups create pro- nected to working with them. They thought that as fessional development among colleagues over time. This clinicians they would profit from gaining more know- participant indicates that some think their attitudes are ledge about normative theories. In addition, some changing from being rigid and inflexible to becoming more participants on another ward - after having partici- open and letting themselves to a lesser extent be governed pated in ethics reflection groups - found that they be- by formal rules or old habits. The participants say that they came anxious about making mistakes in the treatment have developed an increased awareness about the fact that of the patients. Hence, they could recognise that they there is not always one solution or one concrete answer in had a tendency before to act in situations, instead of a situation. They report that they have developed a space sometimes stepping back and reflecting critically on for reflection where it is possible to ask questions like: what would be the best way to approach the situ- What could I have done differently? Consequently, they are ation. Acting without reflecting could for instance – more than before - able to see alternatives. Furthermore, lead to unethical behaviour, like putting the patient in several of them say It is important to reflect on how exercis- belts. However, being afraid of behaving in an uneth- ing coercion is affecting me. They find they have developed ical manner could result in interfering too late, e.g. in a stronger competency to make more correct decisions, one crisis situation, the patient could lose control and which again is increasing their professional competence act out. After one such incident, they needed to work and confidence and the quality of treatment. Keeping up on how to balance between interfering and not inter- reflecting creates better treatment, one participant said. fering, and search for alternative ways of interfering. Hem et al. BMC Medical Ethics (2018) 19:54 Page 7 of 14 Increased awareness of the use of coercion conscious or subconscious attempt to make the differing The participants talk about having developed a critical at- situations of patients and professionals utterly visible. titude to, and an increased awareness, about their use of coercion. They say they are now reflecting and asking Even if you do not think about it, there is a tendency more questions about their own practice. Their thinking is in our attitude that “I have and you have not, I can more focused so that the use of coercion does not become leave at 3 pm., you have to stay. I go to the mountains a routine. Ethics reflection contributes to the health care on Friday, you get pizza or porridge tomorrow”. professionals’ staying on top of the situations, meaning that they are proactive, which they say is an indicator of In other words, the critical view in the reflection groups, good quality. Consequently, they are able to raise new and including the topic of everyday activities, made visible self-critical questions like What are we actually doing? aspects they did not think about because they belonged to the everyday routines of the ward. The more extreme cases - connected to formal use of coercion - are more defined and Increased awareness of the use of informal coercion clear, which the everyday challenges are not, they contend. Increased awareness also resulted in acknowledging that the use of coercion is located on a continuum: on the Cooperation rather than coercion one side of the continuum there is the use of power and Participants say they are changing their perspective by informal coercion (often invisible or subtle, like using starting to ask themselves why coercion is necessary. They manipulation or pressure) and on the other side you find tell us that sometimes – after having had ethics reflection formal coercion (often visible and concrete, like using - there was no need for coercion any longer. Furthermore, belts or forced medication). Taking part in ethics reflec- they think that systematic ethics reflection is informative tion groups has resulted in the health care professionals for clinical practice in the way that it fosters cooperation becoming conscious of the power they possess, and their with the patient: they now more systematically initiate dia- use of informal coercion. They ask themselves questions logues with the patient, for instance about how he or she about “how they coerce” like: experienced coercion and informing the patient about their own views and reasons. Sometimes, the results from How do we welcome a patient? How do we approach systematic ethics reflection were written in the patient’s patient and family when they show up at the acute chart, which led to a change in their approach towards the unit in a crisis? How do we care for them? Do we patient, or the coercion that is being used, or the way the offer something to drink? Are we nice, and do we coercion is being executed. Participants from one ward inform them about the reason why we have to go told us that one of their male patients was severely and re- through the patient’s luggage? peatedly degrading female staff members: Along these lines, realising there is an effect on the The patient, who was very hostile towards the female ‘small-scale’ phenomena, they also contend that they staff, treated them in a disgusting way. He really have developed increased focus on “more correct” use of crossed the line. The female staff kept him at four coercion and alternatives to coercion: What kind of limi- arm’s length. Through ethical reflection, however, they tations should we put on this patient in this situation? managed to change their attitude towards him. They For how long should she be ‘shielded’? How long should decided to start being nice to him. They said to the patient be allowed to be outside the ward? They themselves: “Whatever you feel now, approach him in focus critically on their daily routines: We have discus- a friendly way.” The result was that the patient also sions about how long people should be allowed to stay in changed his way of being towards the staff. bed; where, when should we interfere, what do we do? When the staff perceived this patient as disrespectful to- Awareness of the terms ‘us’ and ‘them’ wards them, it is easy to imagine that they would be un- On some wards, there had been a tendency to draw a friendly and possibly be more inclined to use informal or strict line between “us” and “them” (i.e. us as profes- formal coercion in their interaction with him. One can as- sionals and them as patients). The participants described sume how such a way of interacting could develop into a an increased awareness concerning the potential nega- ‘coercive relationship’ rather than a cooperative one. tive effects of this kind of categorisation, and about what Several participants felt that the ethics reflection groups you are talking about when the patients are present. One contributed to a better understanding of the perspectives example was to share with colleagues what you are going of the patient and the relatives. The deliberation method to do the coming weekend or during holidays, some- used in the ethics reflection groups encourages the profes- thing that can be seen as innocent small-talk or as a sionals to identify all stakeholders and examine their Hem et al. BMC Medical Ethics (2018) 19:54 Page 8 of 14 views, i.e. both the professionals, patients and the family. contributes to teambuilding and a broader foundation for Furthermore, the topic of many dilemmas was how to in- cooperation. By creating common perspectives, which is volve the patient and/or the family and prevent coercion. demanding because they came from different backgrounds One person said: The patients and family members are de- and different professional cultures, they became closer as scribed in a very respectful way in the reflection groups. I colleagues. It was a way of creating trust in the team, and think this leads to better involvement of patient and family hence they became more effective as a team, enabling in our clinical work. Some participants were unsure about them to offer better treatment to the patient. this possible effect, since they had attempted to involve Having reflection groups across wards, which most of the patient and family before they started to run ethics re- the participating units had, meant they got views from flection groups. outside, creating new perspectives. Learning from each other is like seeing the elephant from different angles, Improved interdisciplinary cooperation one participant said. By this, they also learn about the Reflecting together different cultures existing on different wards and depart- In general, many participants appreciate the fact that the ments. In addition, they say it is important to arrange reflection groups created an explicit and structured area group reflection after a difficult incident, also to talk for reflection, both among their colleagues and among about disagreement that might have occurred. However, various professional disciplines. In addition, some partic- showing feelings in reflection groups normally requires ipants state that for them the reflection groups are the that one feels safe with the colleagues, some point out. only democratic arena at the workplace. Taking part in Not knowing each other and having large groups can the ethics reflection groups removes the hierarchies be- compromise feelings of safety, which may have an im- tween professionals due to the focus on everybody’s own pact on the quality of the ethics reflection. Some em- ethical reflections. More in general, many participants ployees at one unit felt criticised and misunderstood by highlighted the values that were practiced within the colleagues from another unit, and they ended up defend- ethics reflection groups: equality, respect, active listen- ing themselves. They also tell us that they were frus- ing, taking the perspective of the other, and speaking trated because they spent a lot of time explaining freely without being personally criticised. They acknow- challenges in their work, since the other participants did ledge that through the ethics reflection groups they rea- not know the details of their work situation. They felt lised they were not alone in experiencing an ethical that defending and explaining took time and energy challenge. Creating a culture where difficult dilemmas away from concentrating on deliberating on the ethical are deliberated among various disciplines is of great challenge they were facing. The employees on that unit value, leading to a collective basis for decision-making. needed to find a way of doing ethics reflection that felt This often led to the shared understanding that The con- constructive and not destructive, which meant that they clusion is owned by everybody. gave up having ethics reflection together with another On one ward, several participants claimed they did not unit. They created two subgroups. profit from ethics reflection groups since they thought On several wards, the participation of psychiatrists and their discussions about ethical challenges already were psychologists was missing. Several participants said that on a high level. This was in contrast to the level of the psychiatrists and psychologists – because they have the deliberations in the ethics reflection groups, as they ex- final decision-making responsibility in patient treatment perienced it. They thought that the exchanges were - contribute with a different perspective than the nursing emotionally laden at the expense of the health care pro- staff, who participate the most in the groups. Many said fessionals’ cognitive capabilities. Sometimes, the cases this is a problem, due to the need to develop a greater presented were on the extreme side and not really rele- understanding of each other’s perspectives. On a couple vant, they wanted more focus on everyday problems. On of wards, they had, for that reason, decided to make it this ward, there were several psychologists being trained obligatory for the professionals who have formal respon- as clinical experts, and they felt their needs for supervi- sibility for the patient’s treatment or care to take part in sion and reflection were well taken care of in the pro- the ethics reflection groups. This resulted in greater grams they were enrolled in. safety for everybody in establishing a common ground for patient treatment. Building a professional culture Several participants reported on the fact that some of By elaborating on dilemmas and by challenging people’s the professionals attending the reflection groups did not basic assumptions, systematic ethics reflection is a way to actively take part in the discussions. They were perceived build a professional culture. One person was explicit, say- as passive and just listening. Therefore, in those refec- ing that they wanted to create a culture where we talk tion groups, it was often the same people initiating dis- about challenges as a team. Learning from each other cussions, i.e. they presented questions and topics and Hem et al. BMC Medical Ethics (2018) 19:54 Page 9 of 14 followed up in the deliberations during the group ses- Strengths and limitations sion. Hence, the professionals in such groups were not Those participants in the focus group interviews who had able to profit from each other’s competence as much as been actively engaged in the discussions in the ethics reflec- they would like to or could have done. Consequently, ac- tion groups reported that they had positive experiences. cording to these participants, the fostering of a profes- However, there were also employees who had not partici- sional culture was compromised. pated in ethics reflection groups or participated only once or a few times. Although these participants lacked extensive Lack of direct involvement of patient and family experience with the ethics reflection groups and its signifi- Even though the health care professionals perceived cance, we think the varied experiences and levels of experi- that the inclusion of the patient and the family’sper- ence are important when wanting to explore the possible spectives was improved in clinical work following the significance of ethics reflection groups. implementation of the ethics reflection groups, the One strength of this study is that it provides many pos- patient and the relatives were not physically present sible reasons why ethics reflection groups are regarded as in the deliberations in the groups. Generally, the par- positive or not. In this article, we have relied on only one ticipants did not talk much about involving the pa- source of data, namely two rounds of focus group inter- tient and family directly in the ethics reflection views. However, we have also evaluated the usefulness and groups and no one reported having tried to invite outcomes of ethics reflection groups via various validated them to the groups. and self-developed questionnaires. Preliminary analysis from these other studies, which will be published later , Discussion corroborates with most of the findings of this study. If we This focus group study shows how mental health had done extensive observational studies in addition, our care practitioners describe their experiences from data would possibly be even more differentiated for in- two years of ethics reflection groups. In summary, stance regarding the use of informal coercion and the con- most of the participants report positive experiences. tribution of ethics reflection groups to improved team The positive effects of the groups include: A system- cooperation. However, we think that the focus group dis- atic and well-structured approach to discussing eth- cussions stimulated critical exchanges between the partici- ical challenges, a space where all professionals can pants. We triedtoinvitethose whoweremore critical, as participate, multiple perspectives, improved profes- well, but they were clearly in the minority in the focus sional competence and confidence, consciousness of groups. The major strengths of this study is that it includes formal and informal coercion, constructive disagree- many participants, different types of wards, two series of in- ment, truly learning from each other, creating trust terviews after one and two years of the intervention, the in the team, better understanding of those who think use of multiple methods, and that the findings are consist- differently, a challenge to paternalistic and coercive ent across the interviews and methods used. This study concepts, attitudes and practices, less judgmental supports the claim that group reflection can be beneficial and emotional reactions, acknowledging and dealing through exposing people to different points of view but it more constructively with the stakeholders’ emotions, also offers more detail about how it does this in the specific more analytic and reasoned approaches, room for in- context of mental health care and through the specific ternal critique and identifying potential for improve- framing of ethics reflection groups. ment and better alternative course of action. The Finally, we as interviewers also did the training and rep- deliberations and methods used in ethics reflection resented the group of researchers involved in the interven- groups are also reported to influence the clinical tion study, which may have created bias by influencing the work in general, e.g. better interdisciplinary cooper- group discussions, and our interpretation of the results ation and inclusion of patients’ and relatives’ per- (e.g. by being less critical even though we explicitly asked spectives. However, participants also had critical for critical evaluations of the ethics reflection groups as remarks regarding ethics reflection groups, i.e. lack well). On the one hand, we believe that this is part of a of flexibility in the way the reflection model was complex real-world research environment, but, on the used, too much or too little emphasis on emotions, other hand, we might not have sufficiently acknowledged not sufficient focus on normative theories in the the importance of stepping back from investment in the deliberations, insufficient interdisciplinary compos- process as advocates for it. However, implementation re- ition of the groups, and lack of direct involvement search can be considered a “hybrid construction” since it of patients and family. is useful for the construction of knowledge, as well as hav- In the following discussion, we will first present some ing a normative agenda: helping wards with implementing strengths and limitations of our study, and then we will ethics reflection groups and improving coercion practices. discuss some of the main results. This requires balancing several competing positions. Hem et al. BMC Medical Ethics (2018) 19:54 Page 10 of 14 Improved quality of the use of coercion through dealing or cooperation across the wards is required. However, this better with ethical challenges related to the use of pluralism in perspectives may also represent a huge poten- coercion tial for mutual learning and quality improvement if dis- The participants in this study report that the ethics reflec- agreement and alternative solutions are identified and tion group may have contributed to the reduction of the dealt with constructively [23, 48, 49]. useofcoercivemeasuresonthe onehandand animprove- Another possible contribution to the improvement of the ment of the use of coercive measures on the other hand. quality of coercion relates to taking into account the per- The participants also reported some examples in which the spectives of the patients and next-of-kin when coercion is impact had been experienced after the actual deliberation at stake. Research has shown that patients and next-of-kin and the concrete dilemmas dealt with in the groups. regard the use of coercion – in particular the use of infor- In the ethics reflection groups, the professionals mal coercion - as problematic, and they find it important to reflected upon ethical challenges related to the use of co- be involved in the decision-making processes to a greater ercion. ‘Coercion’ was broadly defined: we asked them to extent than is the case today [12, 13, 50]. The fact that include formal, informal and perceived coercion. We did health professionals - through systematic ethics reflection – this on purpose, since the literature [7–9] and our own re- are encouraged to identify and describe the view of all search indicate that coercion in mental health care is a stakeholders may represent a small but important step in complicated ‘moral enterprise’, encompassing both ‘big services where this is often not done. It may also be one moral dilemmas’ (e.g. forced medication or physical re- important strategy in creating a culture that is less ‘coercive’ straints) and ‘small everyday moral issues’ (e.g. related to and more inclusive. According to Kierkegaard , it is eas- asymmetric relationships, pressure, communication and ier to help in a good way if health professionals understand cooperation) [3, 16, 29]. Furthermore, they were asked to theperspective of thepersontheywanttohelp. Similarly, use a systematic approach (the CME-model). the Norwegian philosopher Vetlesen contendsthat The health professionals participating in this study report moral judgment and helping action is only possible if we that they have developed an increased awareness of the way understand what is at stake for the other. This may sound they exercise coercion – not limited to the cases deliberated like self-evident or superfluous insights. However, inter- in the groups. They relate this change broadly to the ‘coer- views with patients and relatives on coercion and involve- cive culture’ -or ‘coercion context’  - within which they ment indicate that these ‘basics’ are often missing in mental operate. The participants also strongly underscored the im- health care, when the patient is severely ill [12, 13, 50]. portance of reflecting on informal coercion. Many talked Even though participants clearly reported that ethics about how they and their colleagues – during the two-year reflection groups contributed to changing their attitudes project period - developed an increased awareness of eth- and ways of thinking about coercion, we should be ical challenges related to informal use of coercion. They cautious regarding the causal relationship between re- had been able to develop both an awareness regarding flection groups or moral case deliberation and the im- recognising ethical challenges, and a moral language with provement of quality of care (e.g. through reduction of which they could make the previously implicit ethical chal- the use of coercive measures). Two international studies lenges more explicit. This is promising “since many of the have reported positive results due to case discussion, most frequently experienced ethical challenges are not clinical case review or facilitated deliberation. Donat  given much notice in traditional medical and health science found that there was a reduction of use of seclusion and ethics and are not even regarded as ethics by many” [2, restraint after the use of clinical case reviews and identi- 104]. Ethics reflection groups seem to have the potential a) fying critical cases. Furthermore, Gaskin et al.  found to analyse and challenge habitual ways of thinking, talking, that staff integration, treatment plans and treating pa- acting and reacting, b) to identify challenges and potential tients as active participants improved through meetings for improvement, new and better solutions, and c) contrib- being conducted with an outside facilitator to analyse uting to changing and improving certain routines and ways the root causes of ward issues and to produce possible of thinking, without causing insurmountable resistance. solutions. Yet, despite these findings, the lack of causal Systematic ethics reflection is not a top-down enterprise relationship between (any) interventions and the reduc- in which the health professionals are told that they should tion of coercion, has been stressed recently when look- think and act in a certain way. Rather, it is a bottom-up ing at the use of appropriate research designs. Van de approach to change through professional growth, internal Sande et al.  describes a Cochrane review  cover- deliberations, and interprofessional learning which is ing 2155 citations which found no randomised con- regarded as a safe, respectful and inspiring start towards trolled study investigating the effects of interventions improvement [48, 49]. Health care professionals generally aiming at reducing seclusion. Likewise, a more recent re- bring with them diverse expertise and experiences. This view by Stewart et al.  could not identify well de- may be a big challenge when interdisciplinary teamwork signed studies in this domain since 2000. Hem et al. BMC Medical Ethics (2018) 19:54 Page 11 of 14 Critique and safety – A delicate balance Creating safety and at the same time stimulating crit- Safety is an important requirement in order to create an ical reflection remains an ongoing tender balance, atmosphere in which one dares to reflect on challenges though, and here is where the facilitator has a vital role regarding coercion. Furthermore, being willing to look at in manoeuvring between safety and critical exploration, your way of exercising informal coercion – which we realising that without feeling sufficiently safe, people have seen has been important for the participants in this may restrict themselves in opening up and in scrutinis- study – might be threatening since it may be connected ing how they feel, think and act. In the latter case, facili- to the way you use your personality as a professional tators should be aware of this tension between freedom . Reflecting on ethical issues inherently involves ask- of speech and critical questioning, and at the same time ing (self)critical questions. For some, this can be threat- not making the participants feel insecure. This requires ening while for others it does not cause such feelings. not only skills and tact from the facilitator, but in the Generally, participants in an ethics reflection group need long run, also from every team member. to feel safe enough in order to (among other things) re- How to raise critical questions in a constructive way, veal that one does not know what the right thing to do without undermining safety and curiosity in the groups, is, to share emotions, and to disagree with others. Such is an important area for further research. a process of moral change through dialogue is described by Landeweer et al. . The role of emotions in ethics reflection groups We found that not knowing each other and/or large eth- The CME-model used in this project does not put spe- ics reflection groups (e.g. 18 participants) might com- cial emphasis on emotions. Moral deliberation in many promise the feeling of safety, especially where the groups forms – including the CME-model – could be criticised consist of people from different units with the same ward. for focusing only on rational arguments and for being As we have described, some health care professionals from too cognitivist. Thus we were surprised that so many of one ward tended to feel criticised by the questioning of the participants appreciated the way emotions – some- participants from other wards. The reason for some par- times strong emotions – were taken care of and framed ticipants feeling criticised and consequently withdrawing within the CME-model, despite the model’s rather ra- from cross-ward groups might be that those participants tional framework. It appears to be common – and were feeling especially vulnerable and insecure (maybe re- regarded as necessary - to share emotions among col- gardless of the ethics reflection groups). Another way of leagues when working with people with mental health understanding this is that the content of the questions, or problems, and many professionals have been trained the way the questions were asked, was too critical and specifically to handle their own and the patient’s emo- maybe too provocative for these participants. Most likely, tions in clinical work. For example, within psycho- it is a combination of the two. dynamic approaches to clinical work, it is emphasised It is important that the group atmosphere is charac- that professionals’ emotions may carry valuable informa- terised by mutual respect, openness and good will. How- tion concerning what is at stake for the patient and for ever, what is enough respect, openness and good will the professionals (transference and countertransference cannot be defined in advance; we probably need a flex- ), and that a general key to high quality treatment ible approach responding to what is happening and what (across many different types of therapeutic approaches) people experience. We do not want to say that one is that the professionals are able to develop trusting and should not be critical, but it is important to balance this safe relationships with the patient and the family. Fur- against the need for safety, so that the participants per- thermore, the professionals’ ability to emotionally ceive the ethics reflection groups as something positive, self-regulate is by many regarded as one of the most im- adding value and quality to their way of performing their portant and basic requirements . job. One could, for instance, be open and curious when According to this kind of approach – if emotional re- asking questions rather than being judgmental or con- actions are not handled in a competent way in the pro- fronting. On the other hand, a professional should aim fessional team – there is the danger of displaying for willingness to be self-critical, receiving challenging negative reactions and distance to the patient. Thus, be- questions, and learning from colleagues. Mann et al.  ing reactive - meaning acting on one’s emotions rather suggest that group reflection (“shared reflection”)can be than acknowledging emotions and reflecting on their beneficial through exposing people to different points of meaning - may have adverse effects in clinical work. view. Discussing the question whether reflective practice Framing one’s emotions within a structured model in can be taught and learned, they say: “The factors [that systematic ethics reflection – through describing the ‘in- contribute to] … appear to be a facilitating context, a volved’ or ‘affected’ parties and their views, interests and safe atmosphere, mentorship and supervision, peer sup- experiences - appears to be a possible way of dealing port and time to reflect” [ibid., 614]. more constructively and analytically with emotions. The Hem et al. BMC Medical Ethics (2018) 19:54 Page 12 of 14 fact that the participants were so content with this way the other group, they started from the beginning with an of working with emotions, might indicate that they rea- equal mix of members from the client council, the family lised that their emotions were treated more respectfully council and the team of healthcare professionals. The sec- when included in a structured and thorough deliberation ond group evaluated client participation more positively. where many aspects of the ethical problem were in- However, the researchers conclude that client participation cluded. Furthermore, emotions are important for both ‘requires continuous reflection and alertness on relational detecting ethical challenges and reflecting upon what is dynamics and the quality of and conditions for dialogue. at stake in the situation . Hence, emotions are con- Patient and family participation puts the essentials of MCD nected to reasoning, and in that way, emotions serve the (i.e. dialogue) to the test’ [ibid., p. 207,16]. Therefore, work moral inquiry. They are not taken for granted, neither on how to systematically integrate patients and family in are they neglected, but are questioned in order to de- ethics reflection, in both dealing with ethical challenges and velop a better understanding of the moral issue at stake in the way coercion is being used, is an important task for [61, 62]. To train one’s sensitivity to ethically important future practice and research. moments in clinical work is termed ‘ethical mindfulness’ by Guillemin and Gillam [4, 58]. Conclusion In order to provide good treatment and care in the context Involving patient and family in ethics reflection groups of coercion, it is important that healthcare professionals Some participants seem to think that participating in the have continuous attention to what good treatment and care ethics reflection groups seem to improve patient and fam- is, and what it means to be a good professional and a good ily involvement in clinical work. However, the participants organisation. In conclusion, health care professionals in this tended to become rather vague when we asked about in- project are satisfied with systematic ethics reflection related volvement of patient and family in the ethics reflection to the use of coercion. According to the participants in the groups. Mostly, they were not yet prepared to involve present study, ethics reflection groups not only had positive them directly in the ethics reflection groups. However, effects on the dilemmas on coercion dealt with in the they said that the fact that the CME-model explicitly asks groups, but also on other aspects of their work, like team- about ‘involved parties’ was inspiring. Some said it urged work and multidisciplinary cooperation, awareness of infor- them to involve the perspectives of patient and family to a mal coercion, the coercive culture, attitudes towards the greater extent in their deliberations and in their clinical patient, and on patient and family involvement. Systematic work. Nevertheless, there may be a potential to make eth- ethics reflection made a difference for many participants in ics support even more democratic or inclusive, and to this project by helping them to develop a new language, learn more through involving the patient and family dir- which described more accurately the ethical challenges they ectly in the actual ethics reflection groups [49, 63, 64]. were facing. Furthermore, the employees helped each other There are different ways to include the patient and develop new perspectives and horisons related to the use of families. The most direct is to include patient and/or a coercion, good treatment and care, and good cooperation. family member in the group deliberations. Another way This study confirms the potential “of creating and facili- is to make sure that a professional or another represen- tating a moral space within the institution that encourages tative for the patient or family talk to them before and critical, reflective and collaborative moral thinking” (14), after the deliberation in the group, so that their views at the same time realising that “keeping moral space and experiences are described as well as possible, and open”,asWalker puts it, is an ongoing process re- that they get feedback. A third possibility is having a quiring a consistent and a long-term perspective. The representative from a patient or family organisation as a theoretical foundation of systematic ethics reflection – permanent member of the group. discourse ethics and hermeneutics – contributes to keep- There is sparse research on patient and family involve- ing the moral space open, and being sensitive to both the ment in clinical ethics support. In one study on Norwe- often implicit or hidden moral dimension of everyday gian ethics committees, the relatives were generally very work, and how presuppositions of what is taken for positive to being included in discussions . However, granted or seen as necessary or morally good can be this was a qualitative study from somatic health care, deconstructed and challenged, in order to stimulate free and deliberations in clinical ethics committees are not and critical thinking. the same as ethics reflections groups. The present study has shown that systematic ethics re- Another study evaluates patient- and client participation flection in the health services is a young discipline with in two different series of moral case deliberation (MCD) great potential. In the future, it will be important to de- . In one of the groups, patient participation was re- velop the work of systematic ethics reflection so that ex- quired by adding one member of the client council to an ploration of healthcare challenges includes all affected already existing MCD group of healthcare professionals. In parties, patients, relatives as well as employees. Hem et al. BMC Medical Ethics (2018) 19:54 Page 13 of 14 Abbreviations Received: 23 June 2017 Accepted: 24 May 2018 CME: Centre for Medical Ethics (University of Oslo); PET-project: the English name for ‘PET’ is ‘Mental health care, Ethics and Coercion’ References Acknowledgements 1. Landeweer E, Abma T, Widdershoven G. 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BMC Medical Ethics – Springer Journals
Published: Jun 5, 2018
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