The ethics of involuntary procedures.

If a psychiatric nurse is a patient advocate, as the American Nurses Association Code of Ethics (ANA, 2000) requires, when may she place a patient on an involuntary hold? When is the nurse justified in medicating a psychotic patient against his or her will? When does the nurse declare the situation calls for the "last resort" (ANA, 1999) and place a threatening patient in seclusion and/or restraints? The answer to these questions is, "It depends." Every time a psychiatric nurse implements an involuntary procedure, that nurse makes an ethical decision. Psychiatric nurses make such decisions daily when caring for the seriously mentally ill. Very few psychiatric nurses, however, have articulated how they go about making such decisions. Nurses have little guidance in determining ethical choices in situations where involuntary procedures may be required. Nursing choices are constrained by law and hospital policy, but there are tremendous gray areas where the rules are unclear. The Standards of Psychiatric-Mental Health Clinical Practice (ANA, 1994) and the ANA Code of Ethics (2000) call for advocacy, least restrictive measures, avoidance of coercion, and respecting the patients' decisions as appropriate. There is no statement on how to determine appropriateness. What do psychiatric nurses believe to be appropriate? Fisher's (1989) research indicates that in dealing with danger, appropriate action is defined by a collective social process. She found that nurses negotiate with their colleagues to determine when to apply involuntary procedures, rather than relying only on patient indicators. Her qualitative research revealed that nurses develop an operational philosophy about intervening involuntarily that is derived primarily from experience and minimally from formal education. The context of the decision is very important, as is the nurse's belief in the necessity of the involuntary procedure. For a novice, there are virtually no guidelines other than the legal parameters defined by the states and the federal government. With the exception of testimony regarding seclusion and restraint (ANA, 1999), few nurses have been visibly active in current legislative debates on commitment law. Since psychiatric nurses have the primary responsibility for implementing involuntary procedures (actually placing the patients in the locked unit, giving the forced medications, and applying restraints), they should be actively participating in the debate. Where is their voice? To find out, I interviewed four California nurses for their perspectives on involuntary procedures and the proposed changes. In this group of experienced psychiatric nurses, there was a real ambivalence about changing the law. None of them was following the progress of the legislation, and all said the existing law already was subject to abuse. All were concerned that making it easier to treat patients against their will might not be in patients' best interest. In general, their ideas reflected doubt that changing the law would benefit the patients. Perhaps nurses are not raising their voices because they are not convinced change is indicated. The absence of a nursing voice, however, is a strong message that nurses don't care enough to take a stand and fight for the existing criteria to be maintained, or to advocate for a more beneficial solution to be found. …