Challenges Faced By Psychiatric Nurses In Maintaining Patient’s Autonomy: A Literature Review

Ethical Issues Faced By Psychiatric Nurse

Method

What is the frequency of ethical issues faced by Psychiatric Nurse in relation to Patient autonomy?

Mental health nursing is a key domain, where nurses deal with different kinds of patients, experiencing psychological issues. For instance, the nurses need to have enough skills, knowledge and patience to deal with these kinds of patients and provide adequate care to them. In this context, the nurses may undergo several challenges while dealing with such patients. In several cases, the patients become violent and it becomes tough for the nurses to deal with these kinds of patients, making the patients satisfied with the services and providing them maximum quality of services (Fortinash and Worret 2014). Another challenge is that since mental illness impairs the capacity of reasoning and making choices, responding to the needs of patient without violating the principle of autonomy becomes a difficult task for nurses. According to the NMBA standards of nursing practices, nurses are required to provide safe and responsive care to patient in accordance with relevant policies, standards and legislation (Nursing and Midwifery Board of Australia – Registered nurse standards for practice 2017). For psychiatric nurse also, taking decision in the best interest of patient becomes necessary. However, according to ethical practice, respecting patient’s autonomy is important. However, mental health nurse are often confronted with the issue of taking decisions on behalf of patient in emergencies. This leads to ethical conflict issues (Puthran et al. 2013). There is a need to analyse nurse experience of conflict in relation to violating patient’s autonomy during care. Hence, in order to adapt appropriate model to solve the nursing issues in psychiatric practice, the purpose of this literature review is to evaluate the psychiatric nurse perspective of violating patient’s autonomy during emergencies. Appropriate literature search will be done, followed by the review of these literatures, in order to find what is already known about the topic and what areas are left to be explored.

Search strategy

In order to search relevant literatures for the current study, several authentic search engines has been explored, including Pubmed, Chocrane library, Medline, Google scholar and CDU library. The search date was filtered between the year 2008 to 2017. Other inclusion criteria for taking literatures include they must be peer reviewed journal articles and all of the articles must dealing with challenges faced by nurse due to violation of patient’s autonomy only. Article based on other challenges related to clinical issue were excluded. The primary search term included ‘psychiatric or mental health nurse’, ‘psychiatric nurse and violation of patient’s autonomy’, ‘perception of nurse related to challenges in patient’s autonomy’ and other relevant term.

Literature Review:

Literature analysis method

All the article were analysed and selected by reviewing the title and abstract first. This was done to ensure that all articles were selected according to the inclusion criteria. The final selection of article was done based on removing duplicates and selecting final articles based on extensive reading of the entire articles. The data collected were analysed by the approach of thematic analysis to categories the nurse perception about violating patient’s autonomy into different themes.

The review of literature related to perception of psychiatric nurse towards violation of patient’s autonomy gave rise to the following theme:

Violation in autonomy of psychiatry patients due to inappropriate nurse attitude and complexity of psychiatric nursing:

In acute inpatient and emergency settings, the psychiatric nursing staffs’ faces several difficult challenges, which they need to deal critically; especially while dealing with dangerous and aggressive patients. According to the ethical codes of nurses, nurses are liable to provide adequate freedom, respect and positive regards towards the patients. However, in some cases, patients become so aggressive or violent that he nurses need to restrict their autonomy or hinder their human rights in the care setting.

 The review of the study by Eren (2014)  evaluated the nurse’s attitude towards ethical issues in psychiatric inpatient setting. The cross sectional interview with 202 psychiatric nurse in five psychiatric hospitals in Istanbul revealed different ethical code related problem faced by nurse. The study showed that conflict between nurse and patient occurred because of inappropriate attitude of nurse. For example nurses were found to be disrespectful towards patient’s right of autonomy and they were often found to neglect patient’s interest in time of emergencies. The main factors leading to frequent ethical problem for nurse was poor nurse-patient ratio, work overload, neglect, careless behaviour, lack of knowledge regarding nursing ethics and communications skills and inability to cope with the complexity of psychiatric nursing. Hence, until the knowledge of nurse regarding nursing is their attitude towards coping with psychiatric nurse is improved, they cannot solve ethical challenges related to maintaining patient’s autonomy during care. The structure of care for psychiatric patient in hospital setting is also a reason for such issues and forced hospitalization and isolation increases the ethical dilemmas by violating the patient autonomy and privacy rights.

Therefore, Eren (2014) was successful in demonstrating the key reasons, which lead to ethical dilemmas for nurse in the area of, maintain patient’s autonomy. The only gap in the study was that data collection by convenience sampling limited the validity of the result. However, the research also pointed out to future research with the question of how nurse can acknowledge ethical issues in daily life and what education may reduce unethical behaviour and nurse-patient conflict in psychiatric setting.

Another research study was based on the assumption that respect for patients autonomy is dependent on the ability to handle mentally ill patient, appropriate attitude and knowledge about subjective feeling of patient. With this assumption, Puthran et al. (2013) investigated about the experience of psychiatric nurse in violating patient’s autonomy with regard to decision making. Past studies have reported that psychiatric nurse plays an important role in addressing patient’s need and their wish for autonomy. The psychiatric nurse’s strategy of manipulation and persuasion supports them to justify the action of violating patient’s autonomy. The main intention of violating patient’s autonomy is to protect patients form making harmful decisions (Smith and Herber 2015). Some studies has also reported that legal status of patients and poor collaboration between the health care team responsible for particular patient’s treatment also results in violation of autonomy and ethical conflict in psychiatric setting (Lawn et al. 2015).

Puthran et al. (2013) analysed the psychiatric nurse’s perception of autonomy of mentally ill patients by cross sectional interview with nurse in Mangalore. It was based on use of closed ended questionnaire with Likert scale. The assessment of perceoption was done with 5 point likert scale and grade of poor, moderate, good and excellent for specified percentage. Therefore, the main perceptions that were evaluated on likert scale included perception of autonomy, maintaining confidentiality, preventing harm to patients and complying with research ethics and professionalism. The overall perception of autonomy was good for all nurses. The main limitation of the study is that only close ended questionnaire was used which only gave an idea of level of perception and there was lack of detail regarding the challenges in relation to each perception. Use of open ended questions would have strengthened the validity of the study. The conclusion from the study is that perception of autonomy is not dependent on demographic variable, instead this can be strengthended by developing a trusting relationship with mentally ill patient. Hence, nurses need to adapt strategies to justify their control in decision making for patient based on certain emergency situation. The moral obligations make it difficult for patient to balance clinical responsiveness and commit to rules and regulations while proving treatment to mentally ill patient.

Antipsychotic long acting injections (LAI) is often prescribed to patient with mental health problems. The main advantage of administering antipsychotic LAI is that it facilates consistent drug delivery without risk of overdose. Mentally ill patients are often non-adherent with medications too and LAI improves medication adherence too (Westaway et al 2016). Mental health nurse working in inpatient setting is mostly responsible for administering antipsychotic LAI to patients. However, this medication is associated with serious side effects and nurses are often attacked for ethical misconduct as they their role is complicated by the need to balance care and professional and ethical obligations in care. Therefore, the nursing action of injecting LAI without patient’s consent in often regarded as hostile, restrictive and coercive approach too care. Nurses are sometimes correct in their action of restraining and detaining patients due to their role of keeping patients safe and secure (Gray, 2015).

Smith and Herber, (2015) further explored in depth about the level of challenges faced by mental health in administering antipsychotic depot and LAI. The phenomenological research approach was used to conduct the study with qualified mental health nurses who had at least 6 months experience in administering LAI. The semi-structured interview with participants gave rise to the themes of lack of alternative, safety, feeling uncomfortable and issues in maintain therapeutic relationship. Each of the theme were analysed in depth. The nurse found delivering the LAI a challenging task because they could not address the ethical issues involved in it as there was no alternative way to help patient. Many nurses also has safety concerns for patients as they were not sure whether LAI would do more harm or good to patient. Secondly, they also reported that ethical challenges like giving injection without prior consent from patient came in the way of their duty of maintaining therapeutic relationship with patient. They found it difficult to balance the role of a therapeutic nurse and the obligation to provide LAI to mentally ill patients. Hence, they were bounded to violate patient’s autonomy because of the need to protect other patients from harm. The key strength of the study is that the research has effectively illustrated the ethical issue of violating patient’s autonomy while administering antipsychotic LAI. The gap in the study is that frequencies of ethical issues could not be calculated by qualitative research method and mixed method study would have given this information. The main implications of the study for psychiatric nursing is that nurse must be given a mechanism to justify their action of violating patient’s autonomy and addressing ethical issues in care.

Reviewing the available literatures related to the research topic, it has been revealed that there are several issues or challenges faced by the mental health nurses. Inappropriate attitude of nurse such as neglect, lack of knowledge aboit nursing ethic and lack of coping skill for handling the complexity of psychiatric nursing were found as a factor in providing negative experience to nurses (Eren 2014). The review of literature also pointed out to the organizational constraint of maintaining safety of patient as reason for negative experience and distress in psychiatric nurses. In the ethical issue of administering LAI without patient’s content, it was found that nurses had little choice because they had no other alternative and they were bounded by the directives of the organization. Hence, it can be said that both personal inefficiency and organizational obligation resulted in patient-nurse conflict issue due to violation of patient autonomy. The gap in the current study is that some only evaluated the perception of nurse on Likert scale and other study only evaluated detailed experience of patient. Hence, there is a need for research methods which would specify both the frequence of ethical issues as well as the experience of nurse in such situation.

• What is the frequency of ethical issues faced by psychiatric nurse in relation to patient autonomy?
• What are the perception of nurse regarding challenges in maintain patient autonomy in emergency situations?

Conclusion

In conclusion, it can be interpreted that nurses in mental health care domain are facing several challenges in balancing patient’s right to autonomy and maintaining ethical and professional obligation in care. The literature review has revealed that issues arise not only because of lack of nurse’s knowledge and skills in dealing with the complexity of psychiatric nursing, instead organizational obligations also plays a role in such issues.  There is a need for in-depth study regarding the frequency of issues and perception of nurse so that specific mechanism can be developed by which nurses could report about the challenges and justify their actions in psychiatric setting.

Reference List

Eren, N., 2014, ‘Nurses’ attitudes toward ethical issues in psychiatric inpatient settings’, Nursing ethics, 21(3), pp.359-373.

Fortinash, K.M. & Worret, P.A.H., 2014, ‘Psychiatric Mental Health Nursing-E-Book’, Elsevier Health Sciences.

Gray, R., 2015, ‘Cash, choice, antipsychotic medication and the mental health nurse’, Journal of psychiatric and mental health nursing, 22(2), pp.149-153.

Lawn, S., Delany, T., Pulvirenti, M., Smith, A. & McMillan, J., 2015, ‘A qualitative study examining the presence and consequences of moral framings in patients’ and mental health workers’ experiences of community treatment orders’, BMC psychiatry, 15(1), p.274.

Nursing and Midwifery Board of Australia – Registered nurse standards for practice. 2017, ‘Nursingmidwiferyboard.gov.au.’, Retrieved 31 August 2017, from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx

Puthran, S., Vaswani, V., Jain, A. & Kakunje, A., 2013, ‘Perception about autonomy of patients having psychiatric disorder/illness by psychiatry nursing Staff’, Age, 21, p.30.

Smith, J.P. & Herber, O.R., 2015, ‘Ethical issues experienced by mental health nurses in the administration of antipsychotic depot and long?acting intramuscular injections: A qualitative study’, International journal of mental health nursing, 24(3), pp.222-230.

Westaway, K., Sluggett, J.K., Alderman, C., Procter, N. & Roughead, E., 2016, ‘Prevalence of multiple antipsychotic use and associated adverse effects in Australians with mental illness’, International journal of evidence-based healthcare, 14(Medication Safety Issue: 3), pp.104-112.