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In Sweden , this has among other things led to children having the right of secrecy in relation to their parents from the age of 15 [ 4 ].
At the same time as the rights of the young patient must be respected, the parents need both information and support to be able to assume their parental responsibility, something that psychiatric care has to balance in an ethically reasonable way [ 1 ]. There are also more stakeholders in relation to child and adolescent psychiatric care compared to the adult equivalent, such as schools and social services, something that creates more interfaces where conflicts of interest may emerge, since the primary concern of child and adolescent psychiatric care is the protection of the rights of the child [ 2 ].
According to Swedish legislation , this protection should be characterized by the young person participating in the care and decisions concerning its content. In an ideal situation, this participation can give the young person an understanding of the meaning of care [ 5 ].
Some of the problems or issues reported by nurses in geriatric care, acute medical care and school health were 1 that they often did not agree with the doctor on care measures [ 6 , 7 ], 2 , that demands from the organization, parents or relatives were not considered beneficial to the patient [ 6 , 8 ], 3 , that routine-centred care left little or no place to take account of the needs and wishes expressed by patients [ 6 ] and 4 that a strong group identity within the team where loyalty was expected was an obstacle to reporting incidents of neglect or abuse by colleagues [ 6 ].
Corresponding studies within adult psychiatric care have mostly focused on ethical issues defined by the researcher and how these were perceived by care staff in relation to coercive care, coercive measures and moral stress. We have not found any corresponding empirical studies in the field of child and adolescent psychiatric care. Nurses in adult psychiatric care often have a heavy work load; they have to administer coercive measures and often respond to violence from patients.
Some studies indicate that coercive measures nevertheless are rarely considered ethically problematic by nurses [ 9 , 10 ]. The heavy workload, however, creates emotional conflicts. Furthermore, loyalty within the team was strong and prevented independent decisions. It was important for the well-being of the nurses to find a solution to the ethical problems and when that was not possible they expressed feelings of guilt, frustration and powerlessness [ 12 ]. While there is some empirical research on ethics concerning the attitudes and approaches of staff in relation to adult patients, it is rare in child and adolescent psychiatric care.
In most cases, researchers have defined important issues, for instance coercive measures. In the present study, staff members described their view of the ethical landscape of professional care in everyday practice. The present study was carried out at six child and adolescent psychiatric wards in central Sweden, providing both voluntary and coercive care.
The clinics admitted children and adolescents under 18 years in need of psychiatric in-patient care from the surrounding catchment area. The patients were almost exclusively adolescents and the length of stay was usually around thirty days. Staff members on the wards who worked directly with the patients were invited to participate, regardless of occupational status. Approximately half of them were mental health care assistants.
Of the other half, the majority comprised registered nurses along with several doctors, psychologists, social workers and teachers. Almost all staff members had some form of health professional education. The decision to use anonymous diaries unfortunately precluded other relevant background data.
Approximately persons were employed on each ward. The number of people who handed in their diaries was The response frequency varied greatly between wards, ranging from 3 to 18 persons.
The staff members were asked to keep an ethical diary over the course of one week. The diary had eight pages, the first containing instructions and the following were blank, except for the name of the day. This method was selected in order to obtain statements freely provided by staff members, thus facilitating the discovery of experiences of the phenomenon in question that would otherwise have remained concealed if employing more structured methods.
In the brief instructions, the participants were asked to describe work situations and experiences that they considered to give rise to some form of ethical consideration. We also enquired about what thoughts these situations inspired in them. The actual formulations used in the instructions can be found in an Additional file 1.
Globalization, Knowledge and Society: Readings from International Sociology - Google 图书
In order to analyse the diaries we used qualitative content analysis [ 14 , 15 ], a method considered adequate for providing a qualitative description [ 16 ]. Every statement from the days that contained an ethical consideration or problem pertaining to psychiatric care or treatment was included in the analysis, which was conducted by three persons: VP, a social worker, KE, a pedagogue and IE, a child and adolescent psychiatrist. Our pre-understanding was derived from our review of the literature and our professional education and experience.
The first step of the analysis was to read through the statements several times in order to obtain an impression of the material as a whole.
During the readings, each statement was considered a meaning unit [ 17 ] in which we sought considerations or problems to be summarized into a condensed meaning unit. Thereafter , sub - themes and themes were created, the number of which was gradually reduced. When the interpretation of the whole material was completed, themes and sub-themes were chosen that provided a basis for a thick description [ 18 ] that best described the material as a whole [ 19 ]. The analysis involved a back and forth movement between the whole and parts of the text. In order to verify our interpretation , the material was rethematized on the basis of the sub - themes that had emerged and some adjustments were made to the final result.
An example of the thematization of a statement [ 17 ]. The formulation and interpretation of condensed meaning units were conducted independently by VP and KE. When formulating the themes, the material was split into two parts, one of which was dealt with by VP and the other by KE. We aimed to strive for ecological validity [ 20 ], which means that staff working within psychiatric care should be able to recognize their own situation in our results. In the course of our research, the results of the analysis were communicated to and discussed with staff from the participating clinics, as well as with staff from other clinics.
These discussions influenced the analysis, as they revealed which statements and interpretations were perceived as reasonable and could be said to reflect the experiences of the staff. Nine sub-themes and three themes emerged in the interpretation.
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Participants expressed an ideal of commitment and the will to act professionally. They wished to provide the best possible care for patients, dare to make priorities, have good communication with parents and involve them as a resource in relation to their children.
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They criticized colleagues who did not show commitment, were not objectively professional or expressed unacceptable values. The team should remain calm and show respect in meetings with angry, resentful or critical parents. Participants found it problematic that there were so many different views within child and adolescent psychiatric care. Commitment to work led to confirmation from both patients and their parents, which endowed the work with meaning. Our trade union strike, which resulted in no backup staff, doctors under stress, damned kids and the feeling of always being inadequate makes me want to stamp on the floor or just go home… but instead I remain friendly and clench my teeth… and repress my feelings, which is not a good thing.
Good ethics? The participants tried to find ways of showing patients respect in situations of ongoing observation or when coercive measures were employed. The participants endeavoured to find a strategy for collaboration and building alliances for good care with patients and their parents. Sometimes parents had their own difficulties and were unable to respond to the invitation, thus the team became very frustrated due to failure to create an alliance. The participants seldom perceived that prescribed coercive care or measures were ethically problematic.
Instead, ethical considerations were present at the borders of coercion , particularly in relation to pressure and restrictions applied towards patients, especially those admitted voluntarily.
Some coercive measures were also perceived as emotionally hard but ethically non-problematic. She exhibited acute anguish, wept and cried when given the gruel. However, I did not experience an ethical dilemma when forcing her. Several statements indicated an opinion among staff about the need for a professional distance to patients.
Some participants were more personal in their approach and critical of the idea of professional distance. We went there in order to provide support and advice to the son in the family who had been diagnosed with autism. The mother cried and told us that she could not make ends meet. Her debts amounted to 4, SEK.
She said that she just could not go on any longer. We, the staff, told her that we were unable to help her and were there for her son. We suggested that she contact our social worker who might be able to help her. Some parents have serious financial, social or psychological problems of their own. However, in such cases the needs of the patient comes first.
It can also happen that a team member chooses to prioritize patients instead of acting in accordance with organizational directives. There are also occasions when team members believe they must be loyal to their organization and team without necessarily giving lower priority to patients or parents, as when parents criticize colleagues. Belonging to the team was important and team members were expected to be loyal. The team members take care decisions on a continuous basis, thus many decisions were made when only a part of the team was present. Despite this, participants were nearly always loyal to decisions made by other team members, although they considered them to be wrong.
Some statements revealed that care staff dared to contradict the views of their manager or the doctor, but not those of their colleagues. The following day I had the feeling that the rest of the staff wanted this young person to be removed from the ward. During a subsequent conversation with the youth, he did not seem to understand what he was being accused of and even appeared sad , thus I found it difficult to remain firm.
But it was either that or giving in and arguing with the rest of the staff. It is always difficult being firm with someone who is already in an inferior position. The participants experienced inadequacy in relation to patients and many statements described the ineffectiveness of the organization. In one of the wards there was a conflict that created anxiety among the staff, thereby complicating coordination.
On another ward the team devoted an inordinate amount of time to planning and discussions, despite which the planning was inefficient, leading to delays and irritation among staff and patients. At many meetings with families, more than one member of the team was expected to be present and it was difficult to find a suitable time for all parties concerned. The participants described frustration at seeing the waiting list grow but being unable to help. Other departments of our clinic are overburdened with work.
Every day several staff members on the emergency ward have no patient-related work. Who says that we are not allowed to work and why? Is it the leadership team or part of it? I feel as if my professional competence is worthless. The leadership team makes everything so unwieldy and complicated. We are either too compliant or afraid of conflict. Several factors such as an increased number of patients and tasks, cutbacks or reorganizations cause stress. The participants described seriously ill patients who did not receive treatment, thus the ward became a terminus for the patient.
Some wards had limited resources.