Justifying Coercion: Nurses' Experiences Medicating Involuntary Psychiatric Patients

Abstract

This grounded theory study delineates the process inpatient psychiatric nurses use to respond to the challenging nursing problem of medicating resistant involuntary patients. Since approximately one third of all admissions to psychiatric units in the United States are involuntary (Durham, 1996), caring for involuntary patients is a significant part of psychiatric nursing. Medication administration is a major treatment modality that is expected in caring effectively for psychiatric patients (American Psychiatric Association (APA), 1994; APA, 1997; Patel & Hardy, 2001). The process of getting the involuntary patient to accept medication is a major nursing function in a psychiatric unit that treats involuntary patients (Gutheil & Appelbaum, 2000; Susman, 1998). If the nurse is able to convince a patient to accept medication voluntarily, involuntary medication treatment can be avoided. If not, legal procedures will be initiated that may lead to the nurse administering medication without the consent of and/or over the protests of the mentally ill individual being treated. The need for psychiatric nurses to participate in forced involuntary medication constitutes a recurrent ethical problem in settings that accept involuntary patients. This study used grounded theory methodology to uncover the process of Justifying Coercion that participating California psychiatric nurses use to resolve this problem. The process consists of three stages: (a) Assessment of Need, (b) Interpersonal Negotiation, and if the negotiation reaches an impasse, (c) Justifying and Taking Coercive Action. There are two distinct “critical junctures,” Decision to Engage and Impasse, which define the transitions from one stage to the next. The process continues after each instance of forced medication with the goal of replacing coercion with voluntary acceptance of medication for subsequent doses. The nurses believe patient improvement will be the eventual outcome of the coercive action. This belief motivates their intensive efforts at negotiation and is one of the primary explanations for Justifying Coercion.