Nurses’ experiences of informal coercion on adult psychiatric wards

Abstract

Background: Informal coercion, that is, situations where caregivers use subtle coercive measures to impose their will on patients, is common in adult psychiatric inpatient care. It has been described as ‘a necessary evil’, confronting nurses with an ethical dilemma where they need to balance between a wish to do good, and the risk of violating patients’ dignity and autonomy. Aim: To describe nurses’ experiences of being involved in informal coercion in adult psychiatric inpatient care. Research design: The study has a qualitative, inductive design. Participants and research context: Semi-structured interviews with 10 Swedish psychiatric nurses were analysed with qualitative content analysis. Ethical considerations: The study was performed in accordance with the Declaration of Helsinki. In line with the Swedish Ethical Review Act, it was also subject to ethical procedures at the university. Findings: Four domains comprise informal coercion as a process over time. These domains contain 11 categories focusing on different experiences involved in the process: Striving to connect, involving others, adjusting to the caring culture, dealing with laws, justifying coercion, waiting for the patient, persuading the patient, negotiating with the patient, using professional power, scrutinizing one’s actions and learning together. Discussion: Informal coercion is associated with moral stress as nurses might find themselves torn between a wish to do good for the patient, general practices and ‘house rules’ in the caring culture. In addition, nurses need to be aware of the asymmetry of the caring relationship, in order to avoid compliance becoming a consequence of patients subordinating to nurse power, rather than a result of mutual understanding. Reflections are thus necessary through the process to promote mutual learning and to avoid violations of patients’ dignity and autonomy. Conclusion: If there is a need for coercion, that is, if the coercion is found to be an ‘unpleasant good’, rather than ‘necessary evil’ considering the consequences for the patient, it should be subject to reflecting and learning together with the patient.