Ethical Dilemmas in coercive psychiatric care in sweden as experienced by frontline-workers in their work with adult patients

Abstract: Abstract Background: The use of coercion is an essential part of psychiatry despite occurrence of harm to patients and psychiatric staff. Contrasting to a global trend to reduce coercion, the number of coercive admissions and coercive treatment in Swedish psychiatry remains stable. Previous research identified frontline-workers to be especially likely to experience ethical dilemmas in their work with coerced patients. The literature identified for this study explored links between ethical judgement and the use of coercion. Research indicates that ethical dilemmas can lead to moral distress, inconsistency in practice and overuse of coercion. The literature identified for this study indicates that eEthical reasoning deliberations in contrast can mitigate moral distress can improve both the well-being and job satisfaction of psychiatric staff as well asand can  to decrease the usage of coercion without detrimental effects to frequency of violence or  treatment outcome. Research question: Which underlying conditions, context, values, power differences and ethical frameworks are involved in the experience of an ethical dilemma in psychiatric care for coerced patients? Data collection and analysis: Therefore, the current study seeks to identify ethical dilemmas as experienced by frontline workers to investigate situations and conditions that cause ethical dilemmas and analyze ethical reasoning. Seven interviews with frontline-workers (nurses, caretakers) from two different institutions were conducted. andData analyzedanalysis utilizedsing discourse analysis, following suggestions from Siegfried Jägers dispositive analysis that is based on Foucault’s discourse theory.  Results: Participants describe ethical dilemmas as a reoccurring phenomenon that is part of their daily work. The structural context from which they arise was described with naming impersonal and unchangeable factors such as legislation and hierarchy or a risk-avoidance paradigm. Diametrically dilemmas themselves were experienced within social interaction and characterised by personal values, emotions and empathy. The patient’s best, patient autonomy, patient autonomy, the responsibility to provide care to people in need were identified as main values. Descriptions of ethical dilemmas were shaped by ambiguity, but the justification of coercion was presented with a high degree of certainty. Discourses that were drawn upon were medical and philosophical discourse as well as inter-discourse. The critical interpretation of these findings on the background of previous research led to the identification of problematic aspects within psychiatry and consequently suggestions for improvement.suggestions Tof ethical deliberation as tool to detect, reflect upon and resolve ethical dilemmas with the aim to strengthen staff rights as well as patients’ rights, ethical reasoning methods should be taught and staff should get the possibility to discuss ethical dilemmas. Ethical deliberation should be aimed to improve psychiatric practice and patient rights. The responsibility of psychiatry for patients with capacity that are suicidal or aggressive must be debated. The psychiatrist role in assessment of dangerousness of patients must be debated on the background of an increasing trend towards risk avoidance. Patients’ possibility to appeal erroneous decisions about coercion must be strengthen, since the current system rarely leads to consequences despite a frequent erroneous decision. decrease coercion by abolishing arbitrariness of ethical reasoning. However, changes to dissolve sources of power differences would need changes of legislation and organization of psychiatry.