Jeanette Hewitt

Ethical Components of Researcher—Researched Relationships in Qualitative Interviewing

Qualitative interviews are widely and often uncritically adopted for health care research, with little justification of therapeutic value. Although they might provide valuable insights into the perspectives of participants, they represent only a version of reality, rather than “truth” per se. Qualitative research is vulnerable to bias through the attitudes and qualities of the researcher, social desirability factors, and conditions of worth. Exploitation, through role confusion, therapeutic misconception, and misrepresentation are particular risks for health care—related research. Ethical codes, biomedical principles and care philosophies provide little contextual guidance on the moral dilemmas encountered in the practice of research. If nurse researchers are to navigate the moral complexities of research relationships, then sensitivity to risk to participants must be of continual concern, from conception of the study to the reporting of outcomes. Examination of the self through critical reflection and supervision are therefore necessary components of ethical research.

‘You don't talk about the voices’: voice hearers and community mental health nurses talk about responding to voice hearing experiences

AIMS AND OBJECTIVES To explore service user and community mental health nurses views on responses to voice hearing experiences. BACKGROUND People who hear distressing auditory hallucinations (voices) are often in contact with mental health services. Nursing responses to this experience have been limited, although emerging evidence suggests some utilitarian alternative interventions, such as discussing the content and meaning of the voices. DESIGN Using exploratory interviews, this study investigated the response to voice hearing, with a purposive sample of community mental health nurses (n = 20) and service users (n = 20). This paper reports on a thematic content analysis of transcribed interviews, which highlighted differences in perspectives of voice hearers and the nurses supporting them. RESULTS Voice hearers reported that interventions from community mental health nurses were limited to reviews of medication, access to the psychiatrist and non-directive counselling. They identified alternative needs, which involved talking more about the content and meaning of their voices. Conversely, community mental health nurses regarded their responses to voice hearing as being considered, titrated and demonstrating an awareness of the personal contexts of service users. These responses were however restricted by their perception of skill limitations. CONCLUSIONS The contrasting views of nurses and users of services demonstrated in this study, reveal multiple social realities that represent a challenge to accepted professional responses in the provision of mental health care. RELEVANCE TO PRACTICE People who hear voices express an interest in more helpful responses from community mental health nurses. The findings of this study indicate that nurses must begin to orientate themselves towards a more critical practice stance that encompasses available knowledge on the voice hearing experience.

Why are people with mental illness excluded from the rational suicide debate

The topic of rational suicide is often approached with some trepidation by mental health professionals. Suicide prevention strategies are more likely to be seen as the domain of psychiatry and a wealth of psychiatric literature is devoted to identifying and managing suicide risk. Whether or not suicide can be deemed permissible is ostensibly linked to discussions of autonomy and mental capacity, and UK legislation directs that a patients wishes must be respected with regard to treatment refusal where decisional capacity is intact. In the context of the care and treatment of those with physical disorders, extreme and untreatable physical suffering is likely to be accepted as rational grounds for suicide, where the person possesses cognitive coherence and an ability to realistically appreciate the consequences of his or her actions. In the case of those with serious mental disorder, the grounds for accepting that suicide is rational are however less clear-cut. Serious mental illness is typically conceived of as a coercive pressure which prevents rational deliberation and as such, the suicides of those with serious mental illness are considered to be substantially non-voluntary acts arising from constitutive irrationality. Therefore, where an appropriate clinician judges that a person with serious mental disorder is non-autonomous, suicide prevention is likely to be thought legally and morally justified. There are arguably, two questionable assumptions in the position that psychiatry adopts: Firstly, that psychogenic pain is in some way less real than physical pain and secondly, that mental illness invariably means that a desire to die is irrational and inauthentic. If it can be shown that some people with serious mental illness can be rational with regard to suicide and that psychological pain is of equal significance as physical suffering, then it may be possible to conclude that some persons with serious mental illness should not by definition be excluded from the class of those for whom rational suicide may be a coherent choice.

Rational suicide: philosophical perspectives on schizophrenia.

Suicide prevention is a National Health Service priority in the United Kingdom. People with mental illness are seen to represent one of the most vulnerable groups for suicide and recent British Government policy has focused on prevention and management of perceived risk. This approach to suicide prevention is constructed under a biomedical model of psychiatry, which maintains that suicidal persons suffer from some form of disease or irrational drive towards self-destruction. Many react to the idea of self-inflicted death with instinctive revulsion, which has prevented serious discussion of the concept of rational suicide, particularly in relation to those with schizophrenia. The idea that there may be circumstances in which suicide can be viewed as rational is discussed within the biomedical approach to ethics and wider literature primarily in relation to physical disease, terminal states and chronic pain. It is not deemed a viable choice for those who are considered ‘non-autonomous’ due to the controlling forces of mental illness. I propose that suicide is not a consequence of mental illness per se, and that it may be seen as a rational response to a realistic perspective on the course and consequences of living with schizophrenia. The denial of dialogue about the validity of suicidal ideation for people with schizophrenia has led to negative consequences for people with serious mental illness in terms of justice and recognition of person-hood.

Redressing the balance in mental health nursing education: Arguments for a values-based approach

Evidence-based practice (EBP) has become a dominant epistemology in nursing education, and has devalued the complex interpersonal components of mental health nursing. A curriculum for mental health nursing, which values the personhood of service users, should focus on those processes that promote recovery within a therapeutic relationship committed to collaboration and respect for diversity. These relationships become possible where the preparation of mental health nurses for practice includes an examination of self in terms of beliefs and values and their consequences on others. The combination of action and reflection in praxis provides a means by which self-examination and professional obligation can be examined in order to construct a moral identity, which is responsive to the needs of people with mental health problems. Praxis is more than a means of reflecting on practice: it draws together skill, practice knowledge, attitudinal style, and moral reasoning. For this reason, ethical values have a vital role to play in the development of contemporary nursing praxis.

Investigating eating disorders in elite gymnasts: Conceptual, ethical and methodological issues

Abstract Elite gymnastics, and other sports where athletes and coaches are particularly concerned with aesthetic considerations, weight and shape, are fields within which the risk of eating disorders may be unusually high. Adolescent gymnasts, developing their own sense of self, at a time of life where body image concerns are common, often compete at the very top of the sport with a need to maintain a body shape and weight optimal for elite performance. Research into this field should address the range of sociological and ethical aspects of eating disorders in elite sport, their prevalence as well as the ethos of the sport itself. This paper addresses a range of conceptual, ethical and methodological issues relevant to conducting research in this sensitive yet important field.

Can supervising self-harm be part of ethical nursing practice?

It was reported in 2006 that a regime of ‘supervised self harm’ had been implemented at St George’s Hospital, Stafford. This involves patients with a history of self-harming behaviour being offered both emotional and practical support to enable them to do so. This support can extend to the provision of knives or razors to enable them to self-harm while they are being supervised by a nurse. This article discusses, and evaluates from an ethical perspective, three competing responses to self-harming behaviours: to prevent it; to allow it; and to make provision for supervised self-harm. It is argued that of these three options the prevention strategy is the least plausible. A tentative conclusion is offered in support of supervised self-harm.

Schizophrenia, mental capacity, and rational suicide

A diagnosis of schizophrenia is often taken to denote a state of global irrationality within the psychiatric paradigm, wherein psychotic phenomena are seen to equate with a lack of mental capacity. However, the little research that has been undertaken on mental capacity in psychiatric patients shows that people with schizophrenia are more likely to experience isolated, rather than constitutive, irrationality and are therefore not necessarily globally incapacitated. Rational suicide has not been accepted as a valid choice for people with schizophrenia due in part to a belief that characteristic irrationality prevents autonomous decision-making. Since people with schizophrenia are often seen to lack insight into the nature of their disorder, both psychiatric and ethical perspectives generally presume that suicidal acts result directly from mental illness itself and not from second-order desires. In this article, I challenge notions of global irrationality conferred by a diagnosis of schizophrenia and argue that, where delusional beliefs are unifocal, schizophrenia does not necessarily lead to a state of mental incapacity. I then attempt to show that people with schizophrenia can sometimes be rational with regard to suicide, where this decision stems from a realistic appraisal of psychological suffering.

Concepts, Models and Measurement of Continuity of Care in Mental Health Services: A Systematic Appraisal of the Literature

Accessible summary What is known on the subject?:Care continuity is considered to be a cornerstone of modern mental health care. As community mental health services have become increasingly fragmented and complex, the crucial criterion for best quality care has become the degree to which treatment delivered by separate services and professionals is continuous and well coordinated. However, clarification of the key elements of continuity has proved challenging and a consensus has not been reached.Recent research has shown significant levels of variation in the quality of care coordination across England and Wales, with potentially detrimental consequences for individuals. &NA; What this paper adds to existing knowledge?:Studies on care continuity identified in this review are grouped into three categories: studies defining concepts of care continuity, studies providing models of continuity and studies describing development of questionnaires about care continuity.There are many similarities and parallels between concepts of continuity described in the studies under review. Therefore, there is potential for developing a consensus on the nature of care continuity as a multidimensional concept. The priority placed upon the patients experience of care continuity is identified as a major focus in these studies. &NA; What are the implications for practice?:A consensus on the nature of care continuity would benefit both theory and practice in mental health nursing.It would provide a firmer foundation for new research seeking to improve continuity for people using services, and enable mental health nurses working as care coordinators to have a better understanding of the elements of their role that are most effective. Introduction: The increased complexity of community mental health services, and associated fragmentation of traditional dividing lines between services, has underscored the centrality of care continuity and coordination in modern mental health care. However, clarification of the key features of the care continuity concept has proved difficult and a consensus has not been reached. Aim/Question: This review draws together and critically examines latest evidence concerning concepts, models and scales based on a multidimensional understanding of care continuity. Method: Databases ASSIA, PubMed, MEDLINE and Cochrane were searched for papers dating from January 2005 to July 2016, of which 21 articles met the inclusion criteria. These were subjected to quality appraisal based on CASP and COSMIN checklists. Studies were grouped into three thematic categories describing concepts, models and scales of care continuity. Results/Discussion: Synthesis indicated correspondence between independent, multidimensional models of care continuity, providing greater clarity regarding the essential features of the concept. Association, although not causation, between care continuity factors and health outcomes is supported by current evidence. Implications for practice: Clarification of care continuity in mental health services may enable nurses working as care coordinators to develop a better understanding of key elements of their role, and provide guidance for future service development.

Mental Capacity of Adult Patients in Health Care

Mental capacity is a fundamental determinant of an individual’s ability to make autonomous decisions. Respect for autonomy is a legal and ethical requirement in health-care provision, which necessitates that a person’s autonomous wishes be respected and informed consent validly obtained before therapeutic intervention is carried out. In Britain and many other Western jurisdictions, mental capacity legislation has developed with the aim of providing a framework for J. Hewitt (*) Centre for Philosophy, Swansea University, Swansea, UK e-mail: j.l.hewitt@swan.ac.uk # Springer Science+Business Media Dordrecht 2015 T. Schramme, S. Edwards (eds.), Handbook of the Philosophy of Medicine, DOI 10.1007/978-94-017-8706-2_28-1 1 the assessment of mental capacity in health care, in a decision-specific context. Where a patient is judged to lack mental capacity with regard to a decision, the duty to respect autonomy is superseded by the duty to act beneficently and/or prevent harm which might otherwise occur due to the patient’s lack of capacity. Mental capacity legislation typically provides procedural criteria for assessing task-specific competence in terms of comprehension, appraisal, and communication. Procedural criteria do not however specify a threshold for competency assessment, or provide guidance on evaluation of irrational belief systems. Procedural assessment of mental capacity may therefore provide only a partial indication of a person’s autonomy, and further evidence in terms of instrumental rationality may be necessary to evaluation of capacity.