Skip to main content

The Role of Ethics in Reducing and Improving the Quality of Coercion in Mental Health Care


Coercion in mental health care gives rise to many ethical challenges. Many countries have recently implemented state policy programs or development projects aiming to reduce coercive practices and improve their quality. Few studies have explored the possible role of ethics (i.e., ethical theory, moral deliberation and clinical ethics support) in such initiatives. This study adds to this subject by exploring health professionals’ descriptions of their ethical challenges and strategies in everyday life to ensure morally justified coercion and best practices. Seven semi-structured telephone interviews were carried out in 2012 with key informants in charge of central development projects and quality-assurance work in mental health services in Norway. No facilities used formal clinical ethics support. However, the informants described five areas in which ethics was of importance: moral concerns as implicit parts of local quality improvement initiatives; moral uneasiness and idealism as a motivational source of change; creating a normative basis for development work; value-based leadership; and increased staff reflexivity on coercive practices. The study shows that coercion entails both individual and institutional ethical aspects. Thus, various kinds of moral deliberation and ethics support could contribute to addressing coercion challenges by offering more systematic ways of dealing with moral concerns. However, more strategic use of implicit and institutional ethics is also needed.

This is a preview of subscription content, access via your institution.


  1. 1.

    The English name for “PET” is “mental health care, ethics and coercion”.

  2. 2.

    Some key informants held double positions.

  3. 3.

    Norwegian Social Science Data Service (NSD 2015),

  4. 4.

    “Shielding” is the main kind of seclusion in Norway. It differs legally from isolation in that it requires the continuous presence of staff.


  1. Abma, T., Widdershoven, G., & Frederiks, B. (2008). Dialogical nursing ethics: The quality of freedom restrictions. Nursing Ethics, 15(6), 789–802.

    Article  Google Scholar 

  2. Austin, W. (2007). The ethics of everyday practice: Healthcare environments as moral communities. Advances in Nursing Science, 30(1), 81–88.

    Article  Google Scholar 

  3. Dauwerse, L., Weidema, F., Abma, T., Molewijk, B., & Widdershoven, G. (2013). Implicit and explicit clinical ethics support in the Netherlands: A mixed methods overview study. HEC Forum. doi:10.1007/s10730-013-9224-2.

    Google Scholar 

  4. Deady, R., & McCarthy, J. (2010). A study of the situations, features, and coping mechanisms experienced by Irish psychiatric nurses experiencing moral distress. Perspectives in Psychiatric Care, 46(3), 209–220. doi:10.1111/j.1744-6163.2010.00260.x.

    Article  Google Scholar 

  5. Fox, E., Bottrell, M. M., Berkowitz, K. A., Chanko, B. L., Foglia, M. B., & Pearlman, R. A. (2010). Integrated ethics: An innovative program to improve ethics quality in health care. Innovation Journal, 15(2), 1–36.

    Google Scholar 

  6. Gaskin, C. J., Elsom, S. J., & Happell, B. (2007). Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature. British Journal of Psychiatry, 191, 298–303. doi:10.1192/bjp.bp.106.034538.

    Article  Google Scholar 

  7. Graneheim, U., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105–112. doi:10.1016/j.nedt.2003.10.001.

    Article  Google Scholar 

  8. Happell, B., & Harrow, A. (2010). Nurses’ attitudes to the use of seclusion: A review of the literature. International Journal of Mental Health Nursing, 19(3), 162–168. doi:10.1111/j.1447-0349.2010.00669.x.

    Article  Google Scholar 

  9. Hem, M. H., Pedersen, R., Norvoll, R., & Molewijk, B. (2015). Evaluating clinical ethics support in mental healthcare: A systematic literature review. Nursing Ethics, 22(4), 452–466. doi:10.1177/0969733014539783.

    Article  Google Scholar 

  10. Ho, A., MacDonald, L. M.-H., & Unger, D. (2016). Preventive ethics through expanding education. HEC Forum, 28(1), 69–74. doi:10.1007/s10730-015-9273-9.

    Article  Google Scholar 

  11. Hoyer, G. (2000). On the justification for civil commitment. Acta Psychiatrica Scandinavica, 101, 65–71. doi:10.1111/j.0902-4441.2000.007s020[dash]16.x.

    Article  Google Scholar 

  12. Kallert, T. W., Mezzich, J. E., & Monahan, J. (2011). Coercive treatment in psychiatry: Clinical, legal and ethical aspects. Hoboken, NJ: Wiley.

    Book  Google Scholar 

  13. Kvale, S., & Brinkmann, S. (2009). Interviews: Learning the craft of qualitative research interviewing. Los Angeles: Sage.

    Google Scholar 

  14. Landeweer, E. G., Abma, T. A., & Widdershoven, G. A. (2011). Moral margins concerning the use of coercion in psychiatry. Nursing Ethics, 18(3), 304–316. doi:10.1177/0969733011400301.

    Article  Google Scholar 

  15. Laukkanen, L., Suhonen, R., & Leino-Kilpi, H. (2015). Solving work-related ethical problems: The activities of nurse managers. Nursing Ethics,. doi:10.1177/0969733015584966.

    Google Scholar 

  16. Lindemann, H., Verkerk, M., & Walker, M. U. (2009). Naturalized bioethics: Toward responsible knowing and practice. Cambridge: Cambridge University Press.

    Google Scholar 

  17. Molewijk, B., Widdershoven, G., Verkerk, M., & Milius, H. (2008). Implementing moral case deliberation in a psychiatric hospital: Process and outcome. Medicine, Health Care and Philosophy, 11(1), 43–56. doi:10.1007/s11019-007-9103-1.

    Article  Google Scholar 

  18. Pauly, B. M., Varcoe, C., & Storch, J. (2012). Framing the issues: Moral distress in health care. HEC Forum, 24(1), 1–11. doi:10.1007/s10730-012-9176-y.

    Article  Google Scholar 

  19. Pelto-Piri, V. (2015). Ethical considerations in psychiatric inpatient care: The ethical landscape in everyday practice as described by staff. Örebro: Örebro University.

    Google Scholar 

  20. Scanlan, J. N. (2010). Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: What we know so far a review of the literature. International Journal of Social Psychiatry, 56(4), 412–423. doi:10.1177/0020764009106630.

    Article  Google Scholar 

  21. Schomberg, R. (2012). Prospects for technology assessment in a framework of responsible research and innovation. In M. Dusseldorp & R. Beecroft (Eds.), Technikfolgen abschätzen lehren: Bildungspotenziale transdisziplinärer methoden (pp. 39–61). Wiesbaden: VS Verlag für Sozialwissenschaften.

    Chapter  Google Scholar 

  22. 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), 222–230. doi:10.1111/inm.12105.

    Article  Google Scholar 

  23. Steinert, T., & Lepping, P. (2011). Is it possible to define a best practice standard for coercive treatment in psychiatry? In T. Kallert, J. E. Mezzich, & J. Monahan (Eds.), Coercive treatment in psychiatry. Clinical, legal and ethical aspects (pp. 49–56). Hobroken: Wiley.

    Chapter  Google Scholar 

  24. Vetlesen, A. J. (1994). Perception, empathy, and judgement: An inquiry into the preconditions of moral performance. University Park, PA: Pennsylvania State University Press.

    Google Scholar 

  25. Voskes, Y. (2014). No effects without ethics. Reduction of seclusion in psychiatry from a care ethics perspective. Amsterdam: Vrije Universiteit Amsterdam.

    Google Scholar 

  26. Walker, M. (1993). Keeping moral space open—new images of ethics consulting. Hastings Center Report, 23(2), 33–40.

    Article  Google Scholar 

  27. Wertheimer, A. (1993). A philosophical examination of coercion for mental health issues. Behavioral Sciences and the Law, 11(3), 239–258.

    Article  Google Scholar 

  28. Widdershoven, G., Abma, T., & Molewijk, B. (2009). Empirical ethics as dialogical practice. Bioethics, 23(4), 236–248. doi:10.1111/j.1467-8519.2009.01712.x.

    Article  Google Scholar 

  29. Wojtowicz, B., Hagen, B., & Van Daalen-Smith, C. (2014). No place to turn: Nursing students’ experiences of moral distress in mental health settings. International Journal of Mental Health Nursing, 23(3), 257–264. doi:10.1111/inm.12043.

    Article  Google Scholar 

Download references


We thank the informants who have participated in this study; Associate Professor Nina Olsvold at Diakonova University College and anonymous reviewers for valuable advices; and the Norwegian Directorate of Health for financial support.

Author information



Corresponding author

Correspondence to Reidun Norvoll.

Ethics declarations

Conflict of interests

There are no conflicts of interest regarding financial support or relationships.


The manuscript has not been published or submitted for publication elsewhere.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Norvoll, R., Hem, M.H. & Pedersen, R. The Role of Ethics in Reducing and Improving the Quality of Coercion in Mental Health Care. HEC Forum 29, 59–74 (2017).

Download citation


  • Coercion
  • Ethics
  • Clinical ethics support
  • Mental health policy
  • Quality improvement and research