Subtle coercion in psychiatric practice.

Making nursing decision for patients who cannot communicate their own wishes and needs is a common problem in psychiatric and mental health nursing. The aim of this article is to present the findings of a qualitative study focused on situations in which patients do not cooperate with a nursing decision about what should be done for them. The design of the study utilized some steps associated with the grounded theory method. Data were collected from unstructured interviews with 10 British nurses with long experience in psychiatric nursing. By implementing the strategy of constant comparative analysis of the transcribed interviews, it was found that nurses use different types of subtle coercion in order to achieve their own goals for the patient. These goals were justified as being in the best interest of the patient. The main components of subtle coercion are part of a process consisting of: assessing a patient's competency for self-choice; acting strategically; modifying the principle af autonomy; justifying strategies; and reflecting ethically on the action taken. The study indicates that further empirical investigation of clinical situations involving subtle coercion is required. Particular attention should be paid to organizational factors and how these contribute to the use of subtle coercion. A specific question that needs to be theoretically and empirically explored is, can coercion be justified as 'ethically right' in some situations but not in others?