We now introduce a case example to illustrate the commonalities of moral deliberation and responsive evaluation. In 1999 the ‘Quality of coercion in psychiatry’ project was started to develop and implement quality criteria concerning the use of coercion in Dutch psychiatry. The overall aim of the project was to improve the coercive practice in the mental health sector in the Netherlands. The project was funded by participating institutions, provinces and research funds. It consisted of three phases in which both moral deliberation and responsive evaluation were used. During the first phase (1999–2001) a discussion on coercion was set up in six mental healthcare institutions, and quality criteria were formulated. In the second phase (2002–2004) eleven institutions implemented the quality criteria nationwide. Responsive evaluation played a crucial role in these phases. In the current third phase (2006–2009) over 25 institutions developed projects to reduce the number of coercion events. Moral deliberation was systematically used as an intervention in one of the participating institutions.
Coercion is defined as forcing a client to (not) do something. There is no freedom to choose an alternative option . Examples are seclusion, enforced medication and fixation. In the Netherlands most clients in these situations will be secluded (70–80%). Forced interventions have an impact on the client’s wellbeing [12, 22], especially when they are not conducted in a careful, humane way. Many clients have witnessed feelings of powerlessness, fear and anger when undergoing forced interventions [12, 22]. Caregivers also experience intense feelings and emotions in the case of coercion and constraint. They have various, conflicting duties—for example respecting the autonomy of the client as well as protecting the safety of the group of clients and general order—and a forced intervention almost always implies that one of these duties cannot be fulfilled. Decisions with respect to these kind of moral dilemmas therefore tend to be ‘tragic’; none of the options is fully satisfying . This creates mixed feelings among caregivers, but they tend not to talk about these ambivalences in public.
Forced interventions are regulated by the Dutch Institutions Forced Admissions Act and legally only acceptable in situations of violence or uncontrolled behaviour. However, these interventions have become a structural part of the day-to-day care in Dutch mental health. Recently in the Netherlands caregivers, their professional organizations and national policymakers are beginning to acknowledge that there should be more reflection on the extent to which coercion might harm the well-being of clients . This awareness has been stimulated by recent, comparative studies on the use of seclusion in the European countries . These studies demonstrate that in Dutch mental institutions more clients are secluded than in other European countries.
Responsive Evaluation to Develop and Implement Quality Criteria (Phase 1 and 2)
Against this background, a Responsive Evaluation project was started to develop quality criteria concerning coercion. Although the aim was to reduce the amount of forced interventions, coercion was not completely rejected. Sometimes interventions are needed to protect the individual, others or the public order. The criteria focus on the ethical concern how to treat clients in a more humane way if coercion is inevitable and how to prevent coercion (as opposed to the legal question when to intervene).
The quality criteria were developed by researchers from Maastricht University in collaboration with clients, family members and various caregivers (nurses, psychiatrists, psychologists, vicars). Interviews, focus groups and dialogical meetings were organized in six participating mental institutions. This led to the formulation of eight quality criteria in which principles from ethics of care—responsibility, respect, openness and dialogue-were made relevant for coercion in psychiatry . An example of the quality criteria concerns communication. It says that caregivers should communicate with all participants, including the client and family, about the necessity and appropriateness of coercion. Communication also includes sharing information during incidents and listening seriously to clients. If a client does not cooperate or openly protests against coercion, caregivers should find out why he does not accept the restriction. Protest against coercion is a basic right of clients. When clients approve the measures taken, caregivers should check whether or not clients indeed accept them. So, in both cases—protest or approval—caregivers should look behind the response of the client, and start a dialogue to find out what the client needs. Initial protest may then develop into cooperation (and visa versa).
The second step was to implement these quality criteria among 11 psychiatric institutions. A steering and project group were formed. The steering committee was composed of representatives of the Board of Directors from the institutions and representatives of client and family interest groups. The project group consisted of project leaders in the eleven institutions. The implementation process was facilitated by means of responsive evaluation. In each of the institutions to foster dialogues between participants, and nationally aiming at a cross-institutional learning process between stakeholders (project leaders, caregivers, clients and family).
The cross-institutional evaluation was characterized by a phased and cyclical way of working. First of all in-depth interviews with project leaders, local evaluators, team leaders, nurses, psychiatrists and clients were organized to gain more insight in the experiences with the implementation and perceived changes in practice. The evaluator also attended the 2-month project group to monitor discussions and issues at stake. Internal dialogues were organized among stakeholders with the same interests. Project leaders were, for example, asked to respond to cases brought in by themselves. Most of these cases dealt with the process of implementation, such as managing resistance and gaining commitment among various stakeholders inside the hospital. The attendance of these meetings was good (at least ten of the eleven project leaders per meeting) and degree of engagement in conversations high. There was an open and respectful climate. Discussions in the group were very lively, constructive feedback was given, and creative solutions were brought to the fore. It was remarkable that during the conversations many aspects were encountered, like the relationship between caregivers and clients, but also the institutional, societal and political context and professionals codes and regulations. In an oral evaluation the project leaders reported that the collegial meetings kept them informed, inspired and empowered.
The learning process in the group of project leaders was intimately connected with and embedded in their practice. For example, participants discussed whether or not an institution should build extra seclusion rooms and a specialized unit for ‘difficult’ clients. In the case at hand, the Board of Directors wanted to build a specialised seclusion unit as part of a larger reorganization and building plan. In the discussion it soon became clear that the main purpose was to enhance the organizational efficiency. The project leader: ‘The management reasons: How should these bricks be piled and what is the most logical and cheap way to do that? There is not much talk about our vision on the quality of care.’ He felt that more seclusion rooms would not help to reduce the rate of seclusions. Participants recognized the case and brought several negative experiences with seclusion units to the fore; clients may experience it as a punishment to go to such a unit, the unit easily becomes a sort of internal police service within the organization and the availability of seclusion rooms will create a need. Participants also questioned the necessity of the reorganization: ‘For whom is this? It is certainly not in the interest of the staff and clients!’ They gave the advice to pay more attention to the means to prevent seclusion, such as creating ‘healing environments’ and enhancing the communication and interaction with clients. Some participants brought to the fore that a specialized intensive care unit that selects new, highly qualified staff members with special education and training would help to enhance the quality of care. However, this unit should then aim to reduce the amount of seclusions. The discussion helped the project leader in his negotiations with the Board. In the end, the Board decided to built four instead of the planned six seclusion rooms, legitimized by a substantial vision of care, in which attention was given to the prevention of coercion through the implementation of crisis intervention plans. The project leader considered the adjustments as an improvement, which were partly a result of the ongoing dialogues set in motion by the responsive evaluation.
During the process also deliberate attention was paid to the perspective of clients on coercion and client participation. The evaluation team reasoned that it might be difficult for clients to express their concerns in a mixed group of stakeholders within their own hospital and within the project group. They therefore organized internal dialogues among a homogeneous group of clients of the participating institutions selected by the evaluation team, which consisted of a client research partner and academic researcher. A core group of eight clients joined three meetings. From the onset the meetings were meaningful and respectful, according to the participants. In an oral evaluation at the end of three meetings participants said they valued the safe context and atmosphere. Participants felt they listened carefully to each other, valued the positive feedback and felt comfortable to share their personal experiences. Experiences illuminated that client participation in the local implementation projects was in most of the institutions a matter of individuals. Having ‘a say’ was often no more than responding to fixed plans. These participating individuals felt themselves not informed and supported by other clients. As a result they sometimes dropped out or got sick. Another issue was related to the financial compensation for the participation in the projects; individuals received nothing at all or a very small amount of money. They felt their experiential knowledge was not recognized.
Furthermore clients placed emphasis on the prevention of coercion by improving the liveability in the institutions, the contact and communication between all participants, the variety of treatments and the conditions for good care, such as the expertise and amount of staff. Talking to people, stimulation, motivation and adjustment of the environment should always be tried before the use of constraints and compulsion. Alternatives for coercion that were brought to the fore included the use of a time out or comfort room, taking a walk, the notion that one should not leave the client alone in a seclusion room and that interventions should be adjusted to the preferences of the individual client (some may favour forced medication above seclusion). The issues of the clients, as well as the issues of other stakeholders formed the basis for a document that was presented to the national steering committee. The discussion of the report was also part of the ongoing dialogues within and between various stakeholder groups.
In the presented responsive evaluation a broad array of ideas and stakeholder issues (safety, expertise, communication, conflicting duties, feelings and emotions, prevention and evaluation, conditions) emerged, and various approaches of and perspectives on reduction of coercion came to the fore. These varied from the substitution of interventions (replacing seclusion by forced medication) to the application of crisis plans and active use of the networks of the clients to prevent coercion. In the ongoing dialogues between stakeholders the rich plurality of perspectives and amount of issues have been structured. Developing a self-reflexive and critical attitude towards one’s practice, questioning taken-for-granted routines, talking about sensitive topics and opening up to voices usually not taken into account (client and family) were as important as the developed of new working routines and protocols. We recognized that participants learn the most when being confronted with new viewpoints.
Moral Deliberation as a Means to Foster Good Care Around Coercion (Phase 3)
During the third phase of the quality of coercion project, one institution specifically chose to use Moral Deliberation as a tool to improve care concerning coercion. It concerns a large mental health care institution in the east of the Netherlands (GGnet).  The institution played a central role in the whole project since its beginning in 1999. Initially GGnet focused on increasing the awareness, and the knowledge and the technical skills of professionals. Later the organization aimed at changing the attitude of professionals and clients with respect to coercion. Moral case deliberations (among other activities) were considered as the prime vehicle to realize these objectives [33, 34].
Within GGnet a moral deliberation group is responsible for these moral deliberations. This group consists of an academically based ethicist and five employees who had been trained in moral deliberation (a nurse practitioner, a sociologist/philosopher, two theologians, and a nursing teacher). A PhD student has been added to this group for 4 years in order to facilitate, monitor and study the implementation and the results of the moral deliberations. The implementation of moral deliberation project consists of several phases. After an investigation of the moral culture and ethics policy of the institution stakeholders shape a project plan. Then the moral deliberation group will start facilitating moral deliberations among teams. Next, a core group of experienced employees are trained as facilitator of a moral deliberation. Finally, the focus shifts to the implementation and structural attention for moral issues within in the institution. The current moral deliberation project within GGnet follows these steps.
Since the project has a specific normative aim, namely to decrease the amount of coercion events, we felt it was important to communicate the basic assumptions of dialogical ethics. A genuine dialogue is open and one should not start a moral deliberation session with stating that coercion is always morally wrong and that decreasing the amount of coercions is always morally better. What is morally good should get defined within concrete situations and by means of a dialogue.Footnote 2 Furthermore, it was made clear that dissents or minority positions should always be taken into consideration. Participants (the facilitator included) should get and pay respect for the moral positions expressed. Moral deliberation sessions should entail a ‘free moral space’ . The discussion of these assumptions helped to reduce the initial resistance of employees against moral deliberation (‘as if we are getting a moral teaching class with respect to coercion’).
The moral deliberation sessions took place on a regular basis, with good preparation. During the actual moral deliberation session, the facilitator introducesFootnote 3 the conversation method, explains the difference between dialogue and discussion/arguing, clarifies his own role (not acting as a consultant, not justifying thoughts and actions, not interfering with the content of the case),Footnote 4 and manages and clarifies the expectations of the participants with respect to the session. Then, the ‘owner’ of the moral question introduces his moral question. The facilitator refrains from arguing about or passing judgments on the moral question, but invites participants to help their colleague (owner) to formulate his moral question in a good way. Usually, participants find it difficult to postpone their initial judgments, and to start to sincerely ask open questions instead of giving or asking a kind of moral accountability or justification. Then, the other participants can start to formulate clarification questions which they need to get answered in order to construct a balanced moral judgment on the moral question at stake. When the clarification phase is finished, the participants can give their own moral judgment of the case, as if they were in the same situation as the owner of the case (i.e. they do not have to pass judgements on the owner of the case, but they have to present their own, reasoned moral position). This enumeration of different moral positions results in some parts that people seem to agree upon, and some parts that people seem to disagree upon. Disagreements are often the starting point for more detailed investigations regarding the arguments and pre-assumptions of the participants.
Dialogue is a basic requirement for true investigation in openness. As mentioned earlier, the anchor of moral wisdom within moral deliberation lies within the concrete case and the sincere (i.e. not hypothetical or imaginary) insights of participants. An example of the discussions in a moral deliberation session on coercion is the case concerning a young man who had been admitted to the ward since 5 days. On his fifth day, the nurse (presenting the case) came back from holidays. During that day she and her female colleague decided to put the man into the seclusion room in order to prevent aggressive escalations and to maintain the general safety on the ward. The nurse had a sincere concern with respect to the moral justification of her decision. At the end of the moral deliberation session (90 min) participants mentioned that they appreciated the fact that a colleague could openly doubt whether she did the right thing; they considered this as a professional attitude. Furthermore, they felt that the conversation method (i.e. the dialogue) caused enough security to examine each others presuppositions in more depth. They learned that the process of making a decision is much more complex and nuanced then often is suggested. They also realized that not the potential threat of the young man had been the decisive reason (often seen as an objective medical criterion for seclusion), but the lack of good communication with the young man, the risk estimation with respect of the female nurses during the evening shift, and the lack of any relationship with the young man because of the nurse’s holidays. They also acknowledged that it is difficult to find a factual proof, both positive and negative, for deciding whether the timing of a preventive seclusion is morally justified.
The Benefits of Both Approaches in Psychiatry
The input of practical experiences and interaction of all stakeholders during the process enhanced the knowledge about coercion. In the context of a safe environment of homogeneously composed groups participants responded to each other, asked questions, redefined problems, deliberated, revealed ‘blind spots’ and explored new dimensions and perspectives. Participants valued each other’s input, because it provided them with ‘eye openers’ and new insights. The dialogues not only inspired individuals, collectively participants developed a new line of thinking that has led to cultural shift in many institutions. This shift can be characterized as a transition from a control-oriented culture (with fixed problem definitions) to a negotiation culture with deliberate attention for the individual client, the family, prevention and structural evaluation of coercion . It may well be the case that the central role of dialogue in the moral case deliberations and responsive evaluation process finds its reflection in the shift towards a more reflective and deliberative culture. Likewise it may well be that the hermeneutic and constructivist epistemology of responsive evaluation indirectly and inherently has become integrated in the coercion practice. For example, seclusion is no longer seen as a causal and mechanical outcome of situation A, but caregivers have begun to realize that influencing situation A before it factually becomes situation A, is a process of negotiation, a construction that may well be reframed and redefined if they are willing to engage in dialogue. More fundamentally, the emerging dialogical attitude of caregivers and other stakeholders in itself already induced a reframing of the concept of coercion.