We interviewed 20 adolescents who were coercively placed in residential or psychiatric care. The aim was to explore their views on the way staff relate and perform their duties, favorable characteristics in staff, consequences of different treatment from staff and their safety experiences. Thematic analysis identified the following themes: Situational triggers of frustration; Care-based; rule-based; or passive-avoidant interaction styles toward adolescents and their responses; Adolescents' reflections about staff's interaction styles; and the Consequences on the unit atmosphere depending on different interaction styles toward the adolescents. Adolescents preferred staff who showed them respect and a clear wish to make life easier.

The starting point of this study was that aspects of ethics as well as safety should be taken into account in meetings with patients and clients. The purpose was to increase the understanding of how staff in inpatient and institutional settings relate to the perspectives of good care and safety simultaneously in daily meetings with young clients and patients, especially in aggressive situations. The participants were staff who worked with youngsters on a daily basis at two institutions run by the National Board of Institutional Care (SiS) and a child and adolescent psychiatric clinic. The research questions were: 1) Which values can be found in the staff’s narratives about meetings with youngsters?, 2) How do staff describe the sequence of events in incidents of violence at their workplace?, and 3) How do staff describe their work with prevention and management of violence? Data collection was done through individual interviews, focus group interviews and questionnaires based on the Critical Incident Technique method. Interviews were analyzed with qualitative content analysis. Three themes of staff values emerged in the analysis: 1) From rule to relationship, an experienced movement from a rule-based to a more individualized care, 2) Ways to manage power and responsibility, thoughts about structure and pedagogics, and 3) An institution with a conscious culture, the importance of belonging to a supportive team with common basic views and an open climate. The staff described various kinds of incidents of violence and some of these incidents had serious consequences like seclusion of youngsters and staff injuries causing need for medical care. A need for more education, improved routines and organizational support was expressed. The work to prevent violence included individually detecting risks and, if necessary, communicating with other staff members when assessing these risks. Threats were reported as common but hard to cope with when directed towards a specific staff member and his or her family. The staff stressed the need, after a serious incident, to process what happened with colleagues and youngsters concerned. The colleagues were seen as the most important support, and there were some descriptions of shortcomings in the follow-up routines of violent incidents.

This study presents a qualitative description of situations at work that staff members perceive as giving rise to ethical issues. All staff members working with patients across seven wards were given the opportunity to freely describe ethical considerations in an ethical diary over the course of one week. One hundred and five staff members kept a diary. The diaries were analysed with qualitative content analysis where four dominant themes emerged: good care, order and clarity, loyalty, and inadequacy. These results contain statements in which patients are respected and listened to, as well as statements that express a desire for relatively strict, routine-based care. Relatively few statements were of a reflective or discussing nature which highlights the need for clinical ethical support. There is a need of a visible and supportive leadership which encourages ethical reflection. Reflections on real cases could provide an opportunity to challenge existing practices and thereby promote ethical awareness.

Background

Psychiatric staff members have the power to decide the options that frame encounters with patients. Intentional as well as unintentional framing can have a crucial impact on patients’ opportunities to be heard and participate in the process. We identified three dominant ethical perspectives in the normative medical ethics literature concerning how doctors and other staff members should frame interactions in relation to patients; paternalism, autonomy and reciprocity. The aim of this study was to describe and analyse statements describing real work situations and ethical reflections made by staff members in relation to three central perspectives in medical ethics; paternalism, autonomy and reciprocity.

Methods

All staff members involved with patients in seven adult psychiatric and six child and adolescent psychiatric clinics were given the opportunity to freely describe ethical considerations in their work by keeping an ethical diary over the course of one week and 173 persons handed in their diaries. Qualitative theory-guided content analysis was used to provide a description of staff encounters with patients and in what way these encounters were consistent with, or contrary to, the three perspectives.

Results

The majority of the statements could be attributed to the perspective of paternalism and several to autonomy. Only a few statements could be attributed to reciprocity, most of which concerned staff members acting contrary to the perspective. The result is presented as three perspectives containing eight values.

• Paternalism; 1) promoting and restoring the health of the patient, 2) providing good care and 3) assuming responsibility.

• Autonomy; 1) respecting the patient’s right to self-determination and information, 2) respecting the patient’s integrity and 3) protecting human rights.

• Reciprocity; 1) involving patients in the planning and implementation of their care and 2) building trust between staff and patients.

Conclusions

Paternalism clearly appeared to be the dominant perspective among the participants, but there was also awareness of patients’ right to autonomy. Despite a normative trend towards reciprocity in psychiatry throughout the Western world, identifying it proved difficult in this study. This should be borne in mind by clinics when considering the need for ethical education, training and supervision.

BACKGROUND:

Although there has been some empirical research on ethics concerning the attitudes and approaches of staff in relation to adult patients, there is very little to be found on child and adolescent psychiatric care. In most cases researchers have defined which issues are important, for instance, coercive care. The aim of this study was to provide a qualitative description of situations and experiences that gave rise to ethical problems and considerations as reported by staff members on child and adolescent psychiatric wards, although they were not provided with a definition of the concept.

METHODS:

The study took place in six child and adolescent psychiatric wards in Sweden. All staff members involved with patients on these wards were invited to participate. The staff members were asked to keep an ethical diary over the course of one week, and data collection comprised the diaries handed in by 68 persons. Qualitative content analysis was used in order to analyse the diaries.

RESULTS:

In the analysis three themes emerged; 1) good care 2) loyalty and 3) powerlessness. The theme 'good care' contains statements about the ideal of commitment but also about problems living up to the ideal. Staff members emphasized the importance of involving patients and parents in the care, but also of the need for professional distance. Participants seldom perceived decisions about coercive measures as problematic, in contrast to those about pressure and restrictions, especially in the case of patients admitted for voluntary care. The theme 'loyalty' contains statements in which staff members perceived contradictory expectations from different interested parties, mainly parents but also their supervisor, doctors, colleagues and the social services. The theme 'powerlessness' contains statements about situations that create frustration, in which freedom of action is perceived as limited and can concern inadequacy in relation to patients and violations in the workplace.

CONCLUSIONS:

The ethical considerations described by child and adolescent psychiatric care staff are multifaceted and remarkably often concern problems of loyalty and organization. These problems frequently had a considerable influence on the care provided. It seems that staff members lack a language of ethics and require both an ethical education and a forum for discussion of ethical issues.