The Ethical Problems Encountered in Psychiatric Nursing Practice with Dangerous Mentally Ill Persons

Article excerpt

Psychiatric nursing practice in acute inpatient and emergency settings requires that practitioners identify and manage dangerous patients. The analyses reported here are part of a broader study that sought to understand how psychiatric nurses define and manage the dangerous mentally ill. This paper identifies three ethical problems encountered in the day-to-day practices of psychiatric nurses, as they cared for and managed the dangerous mentally ill. The three ethical problems, balancing support for patient autonomy with the need to maintain unit control; balancing the need for distancing with the desire to establish therapeutic relationships; and balancing the desire to "do the right thing " with the need to get along with colleagues, have implications for psychiatric nursing practice and the institutional settings that treat the dangerous mentally ill. Additionally, this study provides direction for further inquiry into the actual ethical problems encountered in practice.

Dangerousness represents the single most significant criterion justifying both involuntary commitment of the mentally ill and emergency interventions within psychiatric treatment settings (Cocozza & Steadman, 1977; Monahan, 1984). Psychiatric nursing practice in acute inpatient and emergency settings requires that practitioners identify and manage dangerous patients. Historically, psychiatric nurses have assumed responsibility for creating and maintaining safe environments for patients and staff (Cahill, Stuart, Laraia, & Arana, 1991; Sclafani, 1986). This tradition, requiring that staff act quickly to predict and control potential violence, remains a significant component of contemporary nursing work in psychiatric emergency and inpatient settings (Anderson & Roper, 1991; Grey & Diers, 1992; Morrison, 1993). The increased public attention to the incidence of interpersonal violence in society (Rigdon, 1994), coupled with the evidence of escalating violence within hospitals (Davis, 1991; Snyder, 1994), magnifies the importance of understanding psychiatric nursing practice with the dangerous mentally ill.

While it is generally agreed that it is morally acceptable and professionally justifiable to restrict an individual's liberty when that person's liberty could cause harm to others, it is also recognized that interventions to control behavior in psychiatric settings require justification (Beauchamp & Childress, 1989; Davis & Aroskar, 1991; Gaylin, 1974; Kittrie, 1971; Sclafani, 1986). On first glance these responsibilities, actions, and justifications may seem rather straightforward but, in fact, there are genuine ethical problems associated with dangerousness and its management.

Before moving into a discussion of the ethical problems associated with dangerousness, it may be helpful to point out some of the problems with the terminology dangerous mentally ill, as it is generally recognized that dangerousness is an ambiguous term without an accepted meaning (Shah, 1977, 1978). Dangerousness refers to the prediction of future violence. In the case of this study, the prediction is being applied to mentally ill persons. This estimation of the potential that a person will do something in the future that is defined as dangerous is based on the perception that a person possessing certain characteristics or demonstrating certain behaviors has a higher probability of performing certain acts in the future than someone who doesn't have the characteristics or who doesn't engage in the behavior (Steadman, 1980). Brooks (1978) suggested that this lack of a shared meaning about what constitutes dangerousness results in practitioners providing their own personal subjective definitions. These subjective definitions have tended to reflect the individual idiosyncratic values of the clinicians and the various political pressures they experience. Among the public, this lack of clarity in terminology contributes to assumptions that most individuals who commit a violent act are mentally ill and that most mentally ill individuals are dangerous (Cocozza & Steadman, 1977). …