This chapter will explore mental health nursing within an ethics context. It will tease out the ethics of mental health nursing practice, presenting common ethical challenges mental health nurses face on a daily basis, providing a case-study example which will highlight potential solutions to those challenges.

On a daily basis mental health nurses make clinical decisions. These decisions have an ethical dimension, however this ethical dimension is not always acknowledged (Smith 2012). It does not necessarily follow that this lack of acknowledgement means mental health nurses are not ethical practitioners; clearly their practice will be framed by ethical rules and frameworks (Nursing and Midwifery Council (NMC) 2015). It is more the case that ethical reasoning and clinical decision-making have become so entwined it is hard to distinguish the difference, if indeed there is a difference. The competent mental health nurse will be adept at top-down ethical reasoning, using rules and frameworks, however to be expert they will need also to be bottom-up ethical reasoners (Smith 2012; Cohen 2004). In addition, mental health nursing practice has a unique aspect compared to other nursing fields of practice. In this field of practice it is the case that,

…. a fully conscious adult patient of normal intelligence may be treated without consent, not for the protection of others (though this is also possible) but in their own interests (Fulford 2009, p. 62)

Being able to control people who have been diagnosed with a mental health condition is nothing new. Indeed there is an historical context for such intervention which this chapter will explore. Restricting services users’¹ freedoms can be morally distressing, even where it is justified and especially where situations do not always have clear outcomes (De Veer et al. 2013). In the case-study part of the chapter we will consider how in these difficult circumstances mental health nurses can restrict service user freedoms beneficently and sensitively.

Over 30 years ago the main ward door on an acute mental health ward in the English health system was not routinely locked. Fast forward to the twenty first century and these doors are now routinely locked. The practice of locking the main ward door is not in itself unusual. What is unusual is that they are kept locked all the time, which in some ways can be seen as a return to the restrictive practices of the past (Ashmore 2008). Keeping the door unlocked was a key component in the process of creating a therapeutic environment (Ashmore 2008). Bowers et al. (2010) describe a journey of ‘door locking where in the 1960s and 1970s it was unusual to permanently lock the main ward door. By 2010 42% of ward doors were permanently locked. In 2015 the Care Quality Commission (CQC) reported that ‘86% of wards (1,109) had locked doors’ (p. 34) Care Quality Commission (CQC) (2015).

Locking doors certainly creates a potential ethical tension between keeping mental health service users’ safe, protecting the vulnerable, and eroding freedoms and being paternalistic (Bowers et al. 2010). At this juncture it would be useful to consider within an historical context why society has this imperative. Morse (1977) makes the following observation;

For hundreds of years, the Anglo-American legal system has been developing special rules for dealing with problems caused by the inherently perplexing phenomenon of mentally disordered behavior (Morse 1977, p. 529)

In madness: a brief history (2002) Roy Porter describes madness as being potentially as old as mankind. Porter (2002) supports this view by citing the ancient art of trepanning, where holes were drilled into a person’s skulls to allow ‘devils’ to escape. At this time madness was viewed as a punishment, where the gods would smite people with madness for committing a perceived wrong (Porter 2002). In early Christian times madness could be good or bad. It was good in the case of saintly visions. Inevitably it was only bad, satanic possession that needed to be dealt with and exorcised (Porter 2002). Around the Enlightenment (1620s–1780s) madness was starting to be viewed by some as a nervous system defect. This was the start of viewing madness as a medical condition. During this period locking up people who were viewed as mad would only happen if their family or the local community could not take care of them, and sometimes if they were viewed as being dangerous (Porter 2002). According to Porter (2002) in England only 5000 people out of a population of 10 million were held in asylums in 1800. At this time the medical discipline of psychiatry started to form, with the requirement that asylums were licensed and that they had a medical presence.

The standards of care in these facilities varied greatly irrespective of whether they were funded privately or by charitable donations. Physical punishment was not uncommon however some asylums offered rest and recuperation (Porter 2002). The legal system started to create special rules for people who were not necessarily committing crime, but whose behaviour was pejoratively viewed as not being the norm (Morse 1977). Demonstrating ‘abnormal’ behaviour in itself was not an issue; it only became an issue to control when the person was also viewed as not being socially responsible (Morse 1977). Creating special rules to manage what we would now view as mental distress was the start of society perceiving mental health conditions as a risk (Morse 1977). Society wanting to control behaviour that is perceived as a risk is nothing new. Throughout history political philosophers have explored this issue however they have always paid scant attention to risky behaviour arising from a person’s mental distress (Wolff 2006).

Over time, as societal norms and rules developed, people on a day by day basis were expected to abide and sign-up to these rules – even if this was a tacit process. The aim of these rules was to prevent people engaging in destructive behaviours including self-destructive behaviours (Wolff 2006). By abiding by these rules a person was given certain freedoms. If they broke these rules, such as committing a crime, these freedoms could be taken away as a form of punishment (Wolff 2006). This position does not consider rule-breaking behaviour where a person may break the rules due to a mental disorder. Where it is briefly considered, the general view is that people with a mental disorder who break the rules should not be punished they should be protected, even if this process restricts freedoms and in effect looks like a form of punishment (Wolff 2006).

In the early days of the asylums nursing as a profession did not exist, neither did psychiatry as a medical discipline. It is only since the 1930s that mental health nursing started to become recognised as a future field of nursing practice (Nolan 1993). Mental health nursing within a UK context has always been closely aligned with the medical discipline of psychiatry; as this discipline started to form in the 1800s mental health nursing practice also stated to take shape (Porter 2002; Nolan 1993). It is important to recognise mental health nurses have not always been called mental health nurses, throughout the ages they have had different titles such as keeper and attendant (Nolan 1993).

The role of the keeper started to emerge during the 1800s with the emergence of the asylums. The job of the keeper was to look after the institution, control the ‘inmates’, and where required be a servant to the doctor who was in charge of the asylum (Nolan 1993). As the asylums became more numerous and at the same time started to focus on the treatment of mental distress, the keeper role started to transform into the role of attendant (Nolan 1993). At this time there was the belief that mental health conditions should and could be treated and possibly ‘cured’ (Porter 2002). The role of the attendant was to assist in the delivery of these cures, which included anything from good basic care, exercise, and good nutrition, to activities such as fettering (tying people down), and blood-letting (Porter 2002; Nolan 1993). Similar to be the keeper role attendants tended to be un-trained, however this changed in 1889 where attendants were required to attend a national training course. From 1923 female attendants started to be called nurses, and male attendants began to gain this title from 1926 (Nolan 1993).

With the change of title from attendant to nurse there was a greater emphasis on the delivery of good basic care. More technical elements of care were in their infancy (Nolan 1993). Over time the notion of healing and curing within mental health care, started to incorporate psychiatric medication and talking therapies as important elements. Observation and control of people incarcerated in asylums were also important, however they became less explicit and more implicit as treatments such as fettering started to disappear (Nolan 1993; Roberts 2005). Treating mental distress in this way was continuing to be influenced by the medicalisation of madness; involving describing different forms of mental distress and developing different forms of treatments (Porter 2002). With the promise of treatment came the promise that irrationality could be controlled. At the forefront of controlling irrationality was the mental health nurse (Roberts 2005). Fast forward to the present day the challenge, for the contemporary mental health nurse, is to know how to wield this power to control in a way that acknowledges their societal responsibilities, while at the same time respecting the rights of the individuals they are required to control.

Having the power to control and being expected to control people with mental health conditions has been shaped by the historical development of mental health nursing practice; it has also been shaped by the media and by public perceptions (Smith 2012). Over recent years the media have covered high profile incidents of people with mental health conditions in a way that portrays people with mental health conditions as being more risky than so called ‘normal people’ (Wood et al. 2014; Johnson 2013). In addition, mental health services are usually portrayed as failing. This tends to be based on the view that they did not control the individual and in turn prevent the incident from happening (Wood et al. 2014; Johnson 2013). Driven by this societal expectation that people with mental health conditions should be controlled, mental health legislation has also been applied in a more controlling manner such as the increase in compulsory admissions to mental health services (Robert 2005; Johnson 2013).

Of course contemporary mental health nursing has moved away from the brutalities of the past in the way that people with mental health conditions were confined, conformed, and treated (Nolan 1993; Roberts 2005). The emphasis of contemporary mental health nursing practice is to be evidence-based and to be ethical, which includes abiding by the nursing profession’s ethical rules (Smith 2012; NMC 2015). That does not mean that interventions which confine and conform do not take place or that some treatments are not controversial, such as electroconvulsive treatment (ECT). However, if these practices are used in an unethical way mental health nurses are held to account (NMC 2015). It is important to recognise that these practices have an explicit and an implicit dimension. Explicit interventions include the use of mental health law, physical restraint, environmental control such as seclusion and locking wards, and the use of medication (Roberts 2005). Implicit interventions are more subtle; they are day to day interventions which the nurse may not recognise as having a controlling element. These include such interventions as observing and monitoring the service user, making clinical judgements and recording them, assessing including the assessment of risk, psycho-social interventions, and reviewing a service user’s care (Roberts 2005). The impact of both explicit and implicit interventions is that the service user knows they are being monitored. They know that if they do not conform and exhibit ‘normal behaviours’ their freedoms could be restricted. They also know they have to demonstrate conformity; in other words they have to control themselves (Roberts 2005).

Explicit interventions can be viewed as directly coercive, overtly restricting a service user’s freedoms, whereas implicit interventions allow an element of choice. However, the service user is being pressured to behave in ways that the mental health nurse and society expects them to behave (Smith, 2012; Roberts 2005). Having this sanctioned power to coerce and apply pressure emanates from a service user being labelled as having a mental health condition. Irrespective of the heated debates surrounding the use of these labels the outcome is the same. The mental health nurse has the power to control the individual with a diagnosed mental health condition (Roberts 2005). A check and balance to the use of this power is that the mental health nurse will follow the rules, including legislation, polices, and professional codes (Smith 2012). The challenge with a rules-based approach is that it is more suited to making clinical decisions when a situation is not complex; when there is plenty of time to make the decision and the outcome is relatively certain (Smith 2012). The reality of everyday clinical practice is that this is not usually the case. Certainty of outcome, for example, can be a luxury rather than a given. Irrespective of this uncertainty the mental health nurse will still have to make decisions which have to be justified; this may include providing evidence of the right motives and/or the right outcomes (NMC 2015).