Coercive Treatment Research Articles

Is too much insight bad for you?

Insight in psychosis is associated with reduced psychotic symptom severity, less coercive treatment and better functioning. Controversially, it has been suggested that insight may lead to depression, higher suicide risk and worse self-perceived quality of life. Future clinical trials are warranted to address this 'insight paradox', particularly the direction of causality.

Nurses’ experience of nasogastric tube feeding under restraint for Anorexia Nervosa in a psychiatric hospital

BackgroundAnorexia nervosa is a complex mental disorder that has severe physical and psychological consequences, often requiring hospitalisation, and in the most severe cases, patients receive coercive treatment. Among the various nursing tasks associated with encountering these patients, the administration of nasogastric tube feeding under restraint stands out. It is crucial to recognise and address the unique practical and ethical challenges nurses face when caring for adults struggling with severe anorexia nervosa. The aim of the study was to gain a deeper understanding of registered nurses’ experience of nasogastric tube feeding under restraint in hospitalised patients with severe anorexia nervosa.MethodsA naturalistic design guided this study. Narrative interview data were analysed using reflexive thematic analysis. The participants were twelve registered nurses recruited from an inpatient ward for adult patients with an eating disorder in a Norwegian psychiatric hospital.ResultsThree main themes were developed: providing good nursing care during coercive treatment; having ethical concerns about nasogastric tube feeding under restraint when the patient reaches a body mass index that is not immediately life-threatening; and having concerns about involving personnel from another ward in the nasogastric tube feeding under restraint procedure.ConclusionsNurses find nasogastric tube feeding under restraint to be part of life-saving nursing for patients with severe anorexia nervosa. It raises ethical concerns, especially with patients with a body mass index that is no longer life-threatening. Our results demonstrate the vulnerability of nurses as well as the difficulties and ethical dilemmas of nursing during nasogastric tube feeding under restraint.

Mental healthcare in South Tyrol

Mental healthcare in South Tyrol, as everywhere in Italy, is still characterized by Law 180, which came into force in 1978 under the leadership of Franco Basaglia and Bruno Orsini. The Ministry of Health subsequently set atarget number of beds of 10/100,000 inhabitants. Unlike in other parts of Italy, private clinics play aminimal role in South Tyrol. The "Psychiatric Services" are part of the state healthcare system responsible for all citizens and are also responsible for compulsory outpatient care. According to the concept of community care, also due to the small number of inpatient beds, agreat deal of care is provided on an outpatient basis. Coercive measures can only be used in the case of an illness requiring urgent treatment that the patient refuses, without recourse to endangering circumstances (self-endangerment or danger to a third party). Inpatient hospitalization is only possible if treatment also takes place and the principle of "outpatient before inpatient" also applies in this context, i.e., coercive treatment can only take place as an inpatient if it cannot be carried out as an outpatient. Forensic psychiatry has very few places and mentally ill offenders are often in prison or occupy beds in general psychiatric wards. Compared to Germany there are fewer beds available but staffing levels are better, particularly for nursing. In relation to the number of inhabitants, compulsory treatment is more frequent than in Germany, whereas involuntary hospitalization and physical restraint are much rarer (only possible in Italy by court order).

Ethical concerns in caring for persons with anorexia nervosa: content analysis of a series of documentations from ethics consultations

BackgroundCaring for patients with anorexia nervosa (AN) is associated with high levels of moral distress among healthcare professionals. The main moral conflict has been posited to be between applying coercion to prevent serious complications such as premature death and accepting treatment refusals. However, empirical evidence on this topic is scarce.MethodsWe identified all 19 documentations of ethics consultations (ECs) in the context of AN from one clinical ethics support service in Switzerland. These documentations were coded with a sequential deductive-inductive approach and the code system was interpreted in a case-based manner. Here, we present findings on patient characteristics and ethical concerns.FindingsThe ECs typically concerned an intensely pretreated, extremely underweight AN patient endangering herself by refusing the proposed treatment. In addition to the justifiability of coercion, frequent ethical concerns were whether further coerced treatment aimed at weight gain would be ineffective or even harmful, evidencing uncertainty about beneficence and non-maleficence and a conflict between these principles. Discussed options included harm reduction (e.g. psychotherapy without weight gain requirements) and palliation (e.g. initiating end-of-life care), the appropriateness of which were ethical concerns in themselves. Overall, nine different types of conflicts between or uncertainties regarding ethical principles were identified with a median of eight per case.ConclusionsEthical concerns in caring for persons with AN are diverse and complex. To deal with uncertainty about and conflict between respect for autonomy, beneficence and non-maleficence, healthcare professionals consider non-curative approaches. However, currently, uncertainty around general justifiability, eligibility criteria, and concrete protocols hinders their adoption.

Ethical case discussions before compulsory medication in psychiatry

Ethical case discussions in psychiatric hospitals are particularly useful when amoral conflict between respect for the patient's autonomy and well-being becomes apparent when considering the legitimacy of coercive treatment. To date, there is hardly any data on the procedure and the results of such case discussions. We therefore present data from alarge psychiatric clinic. We retrospectively analyzed ethical case discussions prior to compulsory medication in aquantitative and qualitative manner. The study analyzed the protocols of all ethical case discussions over a2-year period. They used the method of principle-based ethical case discussion. The qualitative analysis of selected cases was supplemented by reference to case records. An advance care directive was not available in any of the cases, so that the presumed will was used generally to assess the autonomy perspective. It proved quite complex to address danger to third parties when assessing the beneficence and nonmaleficence perspective. In 5 out of 35 consultations, the compulsory medication was not recommended from an ethical perspective. Ethical case discussions enable aholistic individual examination of moral obligations. They contribute to well-founded decisions and can help to reduce the frequency of coercive medications, suggesting routine use of ethics counselling.

Views and experiences of involuntary civil commitment of people who use drugs in Massachusetts (Section 35)

BackgroundInvoluntary civil commitment (ICC) is a court-mandated process to place people who use drugs (PWUD) into substance use treatment. Research on ICC effectiveness is mixed, but suggests that coercive drug treatment like ICC is harmful and can produce a number of adverse outcomes. We qualitatively examined the experiences and outcomes of ICC among PWUD in Massachusetts. MethodsData for this analysis were collected between 2017 and 2023 as part of a mixed-methods study of Massachusetts residents who disclosed illicit drug use in the past 30-days. We examined the transcripts of 42 participants who completed in-depth interviews and self-reported ICC. Transcripts were coded and thematically analysed using inductive and deductive approaches to understand the diversity of ICC experiences. ResultsParticipants were predominantly male (57 %), white (71 %), age 31–40 (50 %), and stably housed (67 %). All participants experienced ICC at least once; half reported multiple ICCs. Participants highlighted perceptions of ICC for substance use treatment in Massachusetts. Themes surrounding ICC experience included: positive and negative treatment experience’s, strategies for evading ICC, disrupting access to medications for opioid use disorder (MOUD), and contributing to continued substance use and risk following release. ConclusionsPWUD experience farther-reaching health and social consequences beyond the immediate outcomes of an ICC. Findings suggest opportunities to amend ICC to facilitate more positive outcomes and experiences, such as providing sufficient access to MOUD and de-criminalizing the ICC processes. Policymakers, public health, and criminal justice professionals should consider possible unintended consequences of ICC on PWUD.

THE EXERCISE OF PUBLIC HEALTH POWERS IN MENTAL HEALTHCARE - THE IMPACT ON PUBLIC SAFETY

To ensure public safety, most European states have statutory powers enabling a range of compulsory interventions for persons with infectious diseases and mental disorders. The evidence of their meaningfulness in mental health patients is dubious, especially regarding their preventive effect on public safety. To reveal the mental health services' impact on violent offense commissions after discharge from involuntary inpatient care, a retrospective three-case series study was conducted. A scoping literature review was performed to construct the recommendations for practice improvement and further studies. Based on individual clinical expertise, the common issues in delivering involuntary mental healthcare in Latvia are described. To conclude, coercive psychiatric interventions shall be considered as a part of internal security and human rights protection and, therefore, shall be surveilled, in line with communicable diseases. Legal mechanisms (temporary protection against violence, coercive measures of a medical nature) are not effective against persons with severe mental illness and fail to prevent violent incidents. By the time being, during involuntary admission and treatment, the patient is subjected to various safety risks, that are inconsistent with the basic rights or best interests, and thus determines the state's obligation to promote voluntary treatment and provide the least restrictive approach.

Perceptions of Community Corrections and Treatment Experience: A Qualitative Study Among People With Incarceration Histories Receiving Outpatient Methadone Treatment.

Community correctional experiences among individuals receiving methadone treatment (MT) for opioid use disorder (OUD) are poorly understood. We qualitatively investigated perceptions of community corrections and treatment experiences among individuals with criminal-legal system experience currently receiving outpatient MT. From January to December 2017, we recruited 42 individuals with history of criminal-legal system involvement enrolled in outpatient MT at a low-barrier nonprofit organization operating multiple clinics in Connecticut. An experienced qualitative research team conducted one-to-one, in-person, semistructured interviews about incarceration and treatment experiences with individuals receiving MT. Participants completed a demographics survey. The interviews were audiorecorded, transcribed, de-identified, and independently coded using NVivo. Participants described the community corrections system as restrictive and abstinence-focused. Most participants described positive perceptions of and experiences with community corrections officers (CCOs), yet described negative perceptions of and experiences with the community corrections system overall. Participants perceived CCOs to have limited knowledge of OUD and MT. Participants described a range of CCO judgment toward their OUD, with some appearing understanding and nonjudgmental while others were perceived to have stigma and prejudice. Few participants noted assistance from CCOs with seeking MT or community-based substance use disorder care. Some participants desired improved treatment facilitation, but viewed forced or coercive treatment negatively. To our knowledge, this is the first qualitative study to examine community corrections experience among people receiving outpatient medication for OUD. While individuals receiving MT have negative experiences with the community corrections system, they perceive individual CCOs positively. Interventions addressing gaps in CCOs knowledge of OUD and MT are needed to optimize support for individuals on probation or parole with OUD. Provision of OUD treatment facilitation appears desirable to some individuals in community supervision.

Operator guidance systems in road construction: a technological mediation perspective

PurposeUsing real-time support systems may help operators in road construction to improve paving and compaction operations. Nowadays, these systems transform from descriptive to prescriptive systems. Prescriptive or operator guidance systems propose operators actionable compaction strategies and guidance, based on the data collected. It is investigated how these systems mediate the perceptions and actions of operators in road pavement practice.Design/methodology/approachA case study is conducted on the specific application of an operator guidance system in a road pavement project. In this case study, comprehensive information is presented regarding the process of converting input in the form of data from cameras and sensors into useful output. The ways in which the operator guidance systems translate data into actionable guidance for operators are analyzed from the technological mediation perspective.FindingsOperator guidance systems mediate actions of operators physically, cognitively and contextually. These different types of action mediation are related to preconditions for successful implementation and use of these systems. Coercive interventions only succeed if there is widespread agreement among the operators. Persuasive interventions are most effective when collective and individual interests align. Contextual influence relates to designs of the operator guidance systems that determine human-technology interactions when using them.Originality/valueThis is the first study that analyzes the functioning of an operator guidance system using the technological mediation approach. It adds a new perspective on the interaction between this system and its users in road pavement practice.

Physical Restraint Practices at the Emergency Department of a Mental Health Hospital.

Coercive treatments can lead to ethical, legal, and clinical concerns, especially in emergency settings. The indications and characteristics of patients for whom physical restraint is indicated should be well-evaluated in order to prevent unnecessary practices. The aim of this study was to comprehensively assess the physical restraint practices in psychiatric emergencies and clinical characteristics related to their use. All patients admitted to the emergency unit of a tertiary mental health hospital between June 1 and June 30, 2022, were included in the sample. Data were retrieved from the manual and electronic medical records. Age, gender, clinical settings, diagnosis, substance use, and other factors were categorized and analyzed, comparing physically restrained and not-restrained patients. Totally, 2051 patients were included in the study (1022 female and 1029 male). The mean age of the participants was 39.5 ± 14.8 years (female: 40.3 ± 14.8 male: 38.4 ± 14.7, P = .004). Seventy-two (3.51%) of the admitted patients were exposed to physical restraint and those had significantly lower number of applications in the past year (P = .020). The median restraint duration was 90 (60-150) minutes. Fifty-four (75.00%) of the physically restrained patients were male (P < .001), and they were significantly younger (mean age 34.5 ± 12.1 vs. 39.5 ± 14.9, P = .005). Clinical diagnoses of restrained patients were significantly different, in favor of psychosis. While 42 (58.33%) of the restrained patients were substance-negative, 15 (20.83%) were screened as positive for at least 1 substance (P < .001). Physically restrained patients differ from others with regard to age, gender, and number of previous applications. Fewer hospital applications in the past year were related to higher incidence of physical restraints.

Supportive Interventions of Chinese Police in Domestic Violence: Do Officer Knowledge and Training Matter?

Policing domestic violence (DV) poses significant challenges in China due to cultural, legal, and organizational complexities. Policing DV in China favors mediation over assertive interventions, complicating law enforcement's role. While previous research has focused on coercive interventions by Chinese police, there is limited information on non-coercive, supportive approaches. This study investigates the relationship between police officers' knowledge and training regarding the Anti-DV law and their willingness to provide supportive services to DV victims in China. It also considers various individual and organizational factors. The data used in this study are derived from the Policing DV in China project, with a sample of 1,353 respondents who had experience dealing with DV cases within the past 3 years. The study focuses on three dependent variables representing supportive approaches to DV cases: Referral, Counseling, and Protection orders. Independent variables include officers' knowledge of the Anti-DV law and agency training. Control variables include the use of body-worn cameras (BWC) and attitudes toward Violence Tolerance, Male Dominance, and Gender Equality. Additionally, demographic variables, working environment, length of service, and police rank are considered. The analytical approach involves a three-step strategy, incorporating descriptive, bivariate analyses, and regression analyses. The results are interpreted using odds ratios and average marginal effects, and statistical software such as SPSS by IBM and R by Open-Source Model is utilized for data analysis. Key findings indicate that more than half of the officers referred intimate partner violence survivors to shelters and assisted victims in filing protection orders. Counseling practices varied across provinces and between male and female officers. Agency training and the use of BWC were positively associated with non-coercive and supportive approaches, while knowledge of the DV Act, male dominance score, and gender equality score did not predict the use of such approaches. Demographic characteristics, including police rank, length of service, and province of employment, influenced the utilization of non-coercive and supportive approaches. This study examines the challenges faced by Chinese police officers when responding to DV cases and their willingness to provide supportive interventions. The study highlights the complexities surrounding the initiation of protection orders due to officers' legal knowledge and discretion. The study emphasizes the importance of police support in addressing DV in China and the role of agency training in promoting non-coercive responses. It highlights regional variations in police support and underscores the need for addressing disparities in service provision across different provinces.

Obstetric Violence in Italy: From Theoretical Premises to Court Judgments.

Historical mistreatment and violence directed toward women's bodies extend to the field of medicine, and obstetric and gynecological practices are not immune to such misconduct. Obstetric violence (OV) refers to actions involving disrespectful, abusive, or coercive treatment directed at pregnant and birthing women. This includes institutional and personal attitudes that lead to the violation of women's autonomy, human rights, and sexual and reproductive health. Despite various international legislative initiatives and recommendations from the World Health Organization (WHO) addressing disrespectful and abusive treatment, OV is still poorly known to Italian public opinion. This study aims to investigate whether the concept of OV has been conversely assimilated in judicial decisions. A retrospective analysis was conducted to scrutinize judgments in Italy until June 2023 related to OV. The Italian legal database 'De Jure Giuffrè', which collects sentences by various Courts, and the terms 'obstetric' and 'violence' as keywords were used for the research. The full-text revision of the results (n. 41 sentences) al-lowed the selection of 5 eligible contributions covering the following issues: Informed Consent, Kristeller maneuver, Vaginal Birth After Cesarean (VBAC), Acceleration of childbirth without indication, and Episiotomy. The analysis of individual judgments was complemented by an examination of the key issues involved. The reviewed judgments frequently seemed to be grounded in technical aspects and inclined towards a predominant evaluation of childbirth outcomes. However, some encouraging aspects emerged, particularly in terms of attention to the female body, acknowledgment of consequences within the intimate-relational dimension, and a commitment to the principle of self-determination through the provision of free and informed consent. Ensuring the psychophysical well-being of women and unborn children, fostering positive interactions between pregnant women and medical staff, and actively working to reduce the grounds for litigation are among actual emerging priorities in healthcare. In this sense, fundamental elements include the implementation of continuous staff training and education as well as a focus on promoting the self-determination of women, leveraging new technologies for this purpose, and ensuring legal protection of their rights.

Coercive Medication: Who, how, how Long? A Retrospective Chart Analysis in 6 Hospital Sites in Baden-Wuerttemberg

Evaluation of the practice of coercive treatment in Germany after the Constiutional Court's decision in 2011. The documented emergency treatments (N=86) and judicially approved compulsory treatments (N=62) in 2015 and 2016 at 6 hospital locations in Baden-Württemberg were retrospectively analysed. Patients had an average of 8 previous psychiatric hospitalisations with a cumulative duration of 645 days on average and 87% had a psychotic disorder. 34% received subsequent compulsory treatment within one year. The median duration of compulsory treatment was 15 days. 92% of the patients were taking an antipsychotic at discharge, 45% received further treatment in a day hospital or a psychiatric outpatient clinic. Coercive treatment affects a relatively small, chronically severely ill group of patients and is frequently recurrent among them. For considerable part, no consecutive treatment setting can be established after discharge.

Ethical challenges for nurses delivering coercive interventions in community mental health settings: A scoping review.

The number of Australians subject to coercive interventions in community mental health services continues to increase. This is in the context of a growing awareness of the harms from coercion, increasing concerns about potential breaches of human rights and an ongoing uncertainty regarding the clinical benefits of community treatment orders, the primary instrument of legislated coercion in community mental health services. Nurses in community mental health services are on the frontline with regard to coercion. They police the requirements of the community treatment order, administer medication to people in community settings without their consent and facilitate re-hospitalisation if indicated. Coercive practice contradicts the person-centred, recovery-oriented and trauma-informed care principles that inform contemporary mental health nursing. This contradiction may generate ethical challenges for nurses and result in ethical distress. The aim of this scoping review was to map the research literature on how nurses in community mental health settings recognise and manage the harm associated with the administration of coercive interventions and consider the ethical challenges that may arise within this practice. The search strategy yielded 562 studies with author consensus determining a total of three articles as meeting the inclusion criteria. The resulting literature identified three themes: (1) maintaining the therapeutic relationship, (2) promoting autonomy and (3) using subtle forms of control. This review demonstrated that there is minimal research that has considered the ethical challenges related to the use of coercion by nurses in community mental health settings.

Risk factors for coercion length at psychiatric hospitals in Israel: Relationship with staff.

Coercive interventions continue to be applied frequently in psychiatric care when patients are at imminent risk of harming themselves and/or others. The purpose of this study was to demonstrate the relationship between the length of coercion and a variety of factors, including the sociodemographic background of patients, their diagnoses and the characteristics of hospital staff. This is a one-year cross-sectional retrospective study, including records of 298 patients who underwent restraint and/or seclusion interventions in male acute, closed wards in two psychiatric hospitals in Israel. A higher proportion of academic nurses to nonacademic nurses on duty leads to a shorter coercion time (P < 0.000). The number of male staff on duty, without any relation to their level of education, also leads to the shortening of the coercion time. The presence of registered, academic female nurses, male staff on duty and the administration of medication before coercive measures can reduce the length of restriction.

A Scoping Review of Adult Inpatient Satisfaction with Mental Health Services.

Patient satisfaction with hospital services has been increasingly discussed as an important indicator of healthcare quality. It has been demonstrated that improving patient satisfaction is associated with better compliance with treatment plans and a decrease in patient complaints regarding doctors' and nurses' misconduct. This scoping review's objective is to investigate the pertinent literature on the experiences and satisfaction of patients with mental disorders receiving inpatient psychiatric care. Our goals are to highlight important ideas and explore the data that might serve as a guide to enhance the standard of treatment and patient satisfaction in acute mental health environments. This study is a scoping review that was designed in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) statement. A systematic search was conducted in the following databases: PubMed, MEDLINE, PsycINFO, CINAHL, and EMBASE. A comprehensive review was completed, including articles from January 2012 to June 2022. Qualitative and quantitative studies were included in this review based on our eligibility criteria, such as patient satisfaction as a primary outcome, adult psychiatric inpatients, and non-review studies published in the English language. Studies were considered ineligible if they included nonpsychiatric patients or patients with neurocognitive disorders, review studies, or study measure outcomes other than inpatient satisfaction. For the eligible studies, data extraction was conducted, information was summarized, and the findings were reported. A total of 31 studies representing almost all the world's continents were eligible for inclusion in this scoping review. Different assessment tools and instruments were used in the included studies to measure the level of patients' satisfaction. The majority of the studies either utilized a pre-existing or newly created inpatient satisfaction questionnaire that appeared to be reliable and of acceptable quality. This review has identified a variety of possible factors that affect patients' satisfaction and can be used as a guide for service improvement. More than half of the included studies revealed that the following factors were strongly recommended to enhance inpatient satisfaction with care: a clear discharge plan, less coercive treatment during the hospital stay, more individualized, higher quality information and teaching about the mental disorder to patients by staff, better therapeutic relationships with staff, and specific treatment components that patients enjoy, such as physical exercise sessions and music therapy. Patients also value staff who spend more time with them. The scope of patient satisfaction with inpatient mental health services is a growing source of concern. Patient satisfaction is associated with better adherence to treatment regimens and fewer complaints against health care professionals. This scoping review has identified several patient satisfaction research gaps as well as important determinants of satisfaction and how to measure and utilize patient satisfaction as a guide for service quality improvement. It would be useful for future research and reviews to consider broadening their scope to include the satisfaction of psychiatric patients with innovative services, like peer support groups and other technologically based interventions like text for support. Future research also could benefit from utilizing additional technological tools, such as electronic questionnaires.

Pursuing an overarching commodification script through country-specific interventions? The EU’s New Economic Governance prescriptions in healthcare (2009–2019)

Abstract After the 2008 financial crisis, the European Union (EU) introduced a New Economic Governance (NEG) regime, which enabled much more coercive interventions of EU executives in social policy areas hitherto shielded from them. This study assesses the policy orientation of their NEG prescriptions in healthcare for Germany, Ireland, Italy, and Romania from 2009 to 2019 and the potential for countervailing actions of labour movements. Acknowledging organized labour’s contribution to the making of decommodified healthcare systems after 1945, we ask if the NEG prescriptions were informed by an overarching healthcare commodification script, as this is a necessary (albeit not sufficient) condition for transnational counter-movements. Our analysis reveals that the country-specific NEG prescriptions of the European Commission and the Council followed an overarching commodification script, which especially targeted the countries that lagged behind in health service commodification. NEG thus represents a case of reversed differentiated integration, which provided both opportunities and challenges to transnational counter-movements.

Patients’ experiences with coercive mental health treatment in Flexible Assertive Community Treatment: a qualitative study

BackgroundFlexible Assertive Community Treatment (FACT) teams have been implemented in Norwegian health and social services over the last years, partly aiming to reduce coercive mental health treatment. We need knowledge about how service users experience coercion within the FACT context. The aim of this paper is to explore service user experiences of coercive mental health treatment in the context of FACT and other treatment contexts they have experienced. Are experiences of coercion different in FACT than in other treatment contexts? If this is the case, which elements of FACT lead to a different experience?MethodWithin a participatory approach, 24 qualitative interviews with service users in five different FACT teams were analyzed with thematic analysis.ResultsParticipants described negative experiences with formal and informal coercion. Three patterns of experiences with coercion in FACT were identified: FACT as clearly a change for the better, making the best of FACT, and finding that coercion is just as bad in FACT as it was before. Safety, improved quality of treatment, and increased participation were described as mechanisms that can prevent coercion.ConclusionResults from this study support the argument that coercion is at odds with human rights and therefore should be avoided as far as possible. Results suggest that elements of the FACT model may prevent the use of coercion by promoting safety, improved quality of treatment and increased participation.

COURT PRACTICE OF APPLICATION OF CRIMINAL LEGAL MEASURES FOR IMMEDIATE COMMITMENT OF A CRIMINAL OFFENSE

The article analyses the judicial practice of applying criminal-legal measures for the indirect execution of a criminal offense. It has been established that the courts take into account the fact of indirect execution of a criminal offense when characterizing the person of the culprit and determining his social danger, namely, appoint a more severe punishment from the list of alternatives or appoint a punishment above the lower limit. At the same time, the courts quite often exempt such persons from serving a probationary sentence. At the same time, general types of exemption from criminal liability are practically not applied. This is due to the fact that, in the vast majority, intentional acts are committed in this way - minor crimes, while the condition for applying many types of exemption from criminal liability is the commission of a careless minor criminal offense. Most often, the courts classify cases of the commission of a criminal offense by means of indirect execution using a minor under the relevant article of the Special Part of the Criminal Code of Ukraine and under Art. 304 of the Criminal Code of Ukraine as the involvement of minors in criminal and illegal activities. However, quite often it is also taken into account as a circumstance that aggravates the punishment, which is very controversial. In some cases, in the case of indirect execution of a criminal offense using a minor, the courts may consider this only as a circumstance that aggravates the punishment. In cases where a minor who is involved by a criminal in the performance of the objective side of the act understands the real nature of his actions, certain coercive measures of an educational nature can be applied to such a person. Such measures of a criminal legal nature, such as coercive measures of a medical nature, coercive treatment, or coercive measures of an educational nature in the case of indirect execution of a criminal offense do not have any differences from the general procedure for applying these measures to the guilty person.

Exploring use of coercion in the Norwegian ambulance service – a qualitative study

BackgroundHealthcare laws allow for exceptions from the consent requirement when patients are not competent to consent or pose a danger to themselves or others. In these cases, the use of coercion may be an alternative to voluntary health care. Ambulance personnel are regularly confronted with patients who need healthcare but refuse it and/or refuse to cooperate. This study aimed to explore ambulance personnel`s experience with use of coercion and factors influencing the use of coercion in the ambulance service in Norway.MethodWe conducted two focus group interviews with a total of eight informants, all ambulance personnel from a large Norwegian ambulance service. Digital recordings of the interviews were transcribed verbatim and analysed using systematic text condensation.ResultsThe informants` stories revealed several methods of coercion used by the ambulance personnel; physical coercion, pragmatic coercion, pharmacological coercion and coercion used to ensure the patient is secured during transportation. The main reasons for using coercion were preventing patients from harming themselves or others and to ensure that patients unable to consent receive healthcare considered necessary. Systemic factors as difficulty of applying the law to real-life situations, and organizational factors as fear of breaching guidelines, experienced lack of support from the management, fear of charges of misconduct, and lack of training in assessing patients´ competence to consent seem to influence ambulance personnels use of coercion.ConclusionEthical grey areas in clinical practice emphasize the need for clinical discretion. Despite the fact that regulatory provisions allow for exceptions from the requirement to obtain consent, transferring these regulations to real life prehospital settings can be difficult. Consequently, the decisions made by ambulance personnel in clinical situations are highly influenced by organizational ethos and guidelines. The informants describe the coercive interventions they have employed to manage patients who are deemed to require healthcare but refuse it and/or refuse to cooperate.