The role of online ethics consultation on mental health

Abstract

Background

Nurses experience moral distress when they cannot do what they believe is right or when they must do what they believe is wrong. Given the limited mechanisms for managing ethical issues for nurses in Japan, an Online Ethics Consultation on mental health (OEC) was established open to anyone seeking anonymous consultation on mental health practice.

Research objective

To report the establishment of the Online Ethics Consultation and describe and evaluate its effectiveness.

Ethical considerations

The research was conducted in accordance with the Declaration of Helsinki.

Research design

This evaluation describes the outcomes of 5 years of operation of the Online Ethics Consultation on mental health in Japan

Participants

The Online Ethics Consultation received 12 emails requesting consultation. Consultees included mental health nurses, psychiatrists, and service users.

Findings

The most common questions directed to the service were about seclusion and physical restraint. Response time from receipt of email to sending a reply was between 1 and 14 days. Despite the disappointing number of consultations, feedback has been positive.

Discussion

The Online Ethics Consultation was established to assist morally sensitive nurses in resolving their ethical problems through provision of unbiased and encouraging advice. Mental health care in Japan has been less than ideal: long-term social hospitalization, seclusion, and restraint are common practices that often lead to moral distress in nurses and the questions received reflected this. The head of the Online Ethics Consultation sent a supportive, facilitative response summarizing the opinions of several consultants.

Conclusion

This study provides key information for the establishment of an online ethics resource the adoption of which has the potential to improve the experience of nurses, allied health and clients of mental health services. This paper has implications for services concerned with improving patient care, managing nurses’ moral distress, building ethics into decision-making.

Keywords

Clinical ethics ethics consultation mental health/psychiatry moral distress nursing ethics

Introduction

Nursing has been viewed as “a self-defining moral practice focused on caring”¹ and as “a moral endeavor.”² Nurses confront difficult ethical situations in their practice,³ which can lead to moral distress. Since moral distress was first referred to by Jameton,⁴ it has been recognized as common among nurses in every field of the healthcare system, and it is likely to be experienced at some point in their careers.⁵ Varcoe et al.⁶ redefined it as “the experience of being seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards.”

The most common triggers of moral distress are said to be staff shortages, unsafe care, poor team communication, economic constraints, increasing clinical acuity, and a drive for efficiency.^7
–9 When nurses cannot take the right course of action, they experience moral distress.¹⁰ Barriers preventing nurses from taking action are both internal, such as lack of confidence, and external, such as lack of time, lack of administrative support, power imbalance, institutional policy, or legal limitations.¹¹ Lack of power or decision-making authority, and lack of respect for the nurse’s role in decision-making have also been implicated.¹²

Few studies have explored the causes of moral distress in mental health settings, but this issue is attracting increasing concern in mental health nursing practice.¹³ Mental health nurses are reported to experience moral distress in situations such as being unable to respond to their patients’ needs, having no time to deliver respectful care,¹⁴ dealing with insufficient information given to patients about their medications,¹⁵ and being called on to seclude or restrain a patient.¹⁶ People with mental health disorders are vulnerable to violations of their human rights, and these violations can lead to moral distress in nurses.

Moral distress is said to produce a range of strong, negative feelings, such as anger, frustration, and guilt, with ongoing moral distress detrimental to nurses’ personal or professional well-being.¹⁷ Nurses experiencing moral distress are likely to stop trying to think for themselves about what to do or what should be done in nursing, which can lead to burnout.¹⁸ A study by Christrodoulou-Fella et al.¹³ revealed that one in four nurses reported wanting to quit, and that 15% of the nurses had resigned a position in the past due to moral distress.¹⁹

Rationale for starting the project

Notwithstanding the negative effects of moral distress, it may also have positive aspects. It can be a driving force motivating nurses to become moral agents.²⁰ In addition, it has been shown that nurses who are more morally sensitive experience moral distress more intensely.²¹ Strategies should be taken to prevent morally sensitive nurses from becoming burned out and leaving their jobs.

In Japan, many mental health nurses are aware of ethical problems, and experience moral distress in clinical settings,²¹ which have a number of potentially distressed aspects. Psychiatrists in many mental health hospitals in Japan serve as head of the clinical team and often own the hospitals. Therefore, nurses may hesitate to voice concerns about ethical problems because they realize that they have little power to make decisions, have little confidence to act, and may therefore experience despair and hurt feelings.²² Mental health nurses in Japan have been shown to have low professional efficacy,¹⁸ which renders them unable to change their situations or resolve the moral problems they face.

Nurses who can solve ethical problems and improve the situations surrounding these ethical problems might acquire the confidence to continue their efforts. Nurses who have someone with whom to consult, discuss issues, and from whom they receive help with problem-solving might be more likely to deal more effectively with ethical problems. Even if a problem remains unresolved, simply talking about the experience is a primary way to work through moral distress.²³ and Christrodoulou-Fella et al.¹³ highlighted the need to develop and implement supportive interventions for vulnerable groups of mental health nurses.

In many Western countries, one key mechanism for dealing with problems of clinical ethics in health care is ethics consultation offered by clinical ethics committees²⁴ or ethics consultants. Although hospitals with clinical ethics committees have been increasing in Japan since 2002 when the Japan Council for Quality Health Care established a clinical ethics consultation system as a quality indicator,²⁵ ethics committees remain the venue where doctors discuss moral dilemmas. Other ways of ensuring ethical practices include clinical supervision which provides nurses with a confidential venue to explore values and ethics individually or in groups and has been shown to alleviate ethical conflicts that are a source of stress.²⁶

However, Japan has no such system in place. Although case conferences and case reviews are the most common venue for discussing ethical problems arising from patient management, it is difficult for younger or less experienced nurses to question senior medical/nursing colleagues or established hospital policy. As a result, mental health nurses in Japan lack access to effective systems for dealing with ethical problems, especially those causing moral distress.

Given this situation, it was decided to establish an ethics consultation system on mental health that would be available to any mental health nurse working anywhere who desires consultation, useful support, and encouragement with the safeguard of anonymity without fear of repercussions from his or her workplace. In other countries where nurses have access to an ethics consultation system within their own facilities, an online system is unnecessary. Thus, the Online Ethics Consultation on mental health (OEC) system is unique. Even in Japan there is no such system.

Mental health nursing in the Japanese context

Global standards recommend transition away from reliance on inpatient care toward community care,²⁷ but care in Japan is largely custodial and mental health hospitals have an extremely long length of stay compared with comparable member countries in the Organisation for Economic Co-operation and Development (OECD).²⁸ Certain aspects of mental health care in Japan are less than ideal, which can cause moral distress in mental health clinicians. This section focuses on two major problems in Japanese mental health care: long-term social hospitalization and physical restraint.

Many patients remain in hospitals longer than necessary,²⁹ a situation labeled “long-term social hospitalization,” which is one of the most distressing ethical issues for Japanese mental health nurses^.18,30 In 2017, only 38% of inpatients with mental disorder in Japan were hospitalized for less than a year, whereas 29% were hospitalized between 1 and 5 years, 14% between 5 and 10 years, and 19% for more than 10 years; 10% of the inpatients (25,932 people) were hospitalized for more than 20 years.³¹

Unfortunately, seclusion and restraint are not rare in Japan, with little legislation covering this coercive aspect of care. In 2017, 12,817 inpatients were secluded, and 12,528 were physically restrained.³¹ The number of patients physically restrained in mental health hospitals in 2013 more than doubled compared to a decade earlier³² and is steadily rising.^31,33 This contrasts with other countries such as Australia where rates are far lower and continue to decline.³⁴ In a survey involving 11 mental health hospitals in Japan, the average period of seclusion was 46.8 days (longest period, 1799 days)³⁵ and the average period of physical restraint was 96.2 days (longest period, 1096 days).³⁵ The average period of restraint in Japan was far longer than in other countries in 2009: 48.7 h in Switzerland, 9.6 h in Finland and Germany, and 4 h in California.³³ In addition, 35.9% of new inpatients in Japan were secluded.³⁶

Physical restraint, the intervention of last resort, has been criticized internationally as inhumane, cruel, and potentially dangerous.³⁷ In 2017, a 27-year-old English teacher from New Zealand was found in a state of cardiopulmonary arrest 10 days after admission to a mental health hospital in Japan. He died 7 days later. During his hospital stay, he was restrained by strapping him to his bed at the waist, wrists, and legs even though he had calmed down and was compliant with treatment.³⁸ This situation is likely widespread.

There are several reasons why long-term inpatients are not discharged to community care and why physical restraint has been so pervasive. One is lack of staff. According to Japan’s medical service law, the minimum required number of medical doctors, including psychiatrists, per inpatient in mental health hospitals is one-third that required in general hospitals, and the number of nurses per inpatient in mental health hospitals is two-thirds that in general hospitals. Staff numbers need to be increased, especially at night, because some medical workers restrain or isolate patients to prioritize their safety at night when fewer workers are present.³²

Another reason lies in the medical payment system. Hospitals in Japan are paid per occupied bed day. Furthermore, approximately 90% of mental health hospitals are private, most of which are for-profit. This profit orientation might lead to conditions such as insufficient staff and hospitalizing patients with less need for care for prolonged periods. This situation creates moral distress for clinicians.¹⁸

Aims

The Online Ethics Consultation was established to help mental health nurses make ethical decision on their conflicts, encourage them to pursue what they think is right, alleviate their moral distress, and improve quality of care.

The aim of this article was to report the establishment of the Online Ethics Consultation and describe how it functions.

Framework of the Online Ethics Consultation

The Online Ethics Consultation is maintained solely by volunteers, and consultation is provided free of charge. After building the Online Ethics Consultation website, it was promoted through announcements and distribution of flyers at seminars and conferences on mental health.

There are 14 Online Ethics Consultation consultants: 5 mental health nurses, 3 psychiatrists, 2 psychosocial workers, 2 lawyers, and 2 ethicists. Among them, eight consultants are university academics, and two work in clinical settings. All are volunteers, and consultation is free of charge.

Anyone can access the Online Ethics Consultation website (http://www.konan-wu.ac.jp/∼rinriconsul/) to ask a question or can solicit help by clicking the “for people seeking consultation” button, which brings us a consultation form. Once a consultee completes the form and clicks the confirmation button, the form is transmitted to the head of the consultation team. The team head then forwards the email to various consultants with expertise in a range of different professions to obtain their opinions. The consultants send their opinions, advice, and/or suggestions back to the team head, who summarizes the opinions in a document. Once the consultants approve the document, the team head sends it to the consultee. This process takes 1 to 14 days.

The consultation form requests essential information in addition to the consultee’s initial question. Consultees must provide a nickname (or pseudonym), a requested deadline (as soon as possible, within 2–3 weeks, or in no hurry), and an email address. The form also contains optional items such as consultee’s profession (nurse, psychosocial worker, psychiatrist, occupational therapist, physical therapist, nurse assistant, other medical staff, service user, family member, or others), preferred consultant (nurse, psychiatrist, lawyer, psychosocial worker), and telephone number. Consultees are not required to divulge their proper names or facility names to protect their identity and privacy.

Online Ethics Consultation responses are intended to be respectful, supportive, encouraging, and empathetic because the consultees might be morally distressed. Consultees are facilitated and empowered to independently solve their problems by considering several options presented by the consultants and examples of similar situations and how these were resolved.

The website provides other information, including description of the Online Ethics Consultation process: how the Online Ethics Consultation can address concerns and what responses consultees can expect. Other information includes what the Online Ethics Consultation cannot do, such as direct intervention with clients, hospitals, managers, or colleagues, and involvement in lawsuits or other legal procedures. There is information about ethical issues likely to occur in mental health settings and legalities related to seclusion and restraint. There are information and examples of previous consultations (only those with consultees’ consent), which comprise simplified and anonymized questions and responses.

How the Online Ethics Consultation worked

For 5 years from June 2014, the Online Ethics Consultation received a total of 14 emails requesting consultation. We excluded two emails that fell outside the scope of the project (e.g. requesting that consultants become a member of the ethics committee at the consultee’s hospital) (Table 1).

Table 1.

Users, content, and response times of Online Ethics Consultation.

	Professional background	Content of consultation	Response time (days)
1	Psychiatrist	Seclusion	1
2	Psychiatrist	Seclusion	14
3	Nurse	Seclusion and restraint	5
4	Service user	Patient–-psychiatrist relationship	2
5	Nurse	Restricted telephone use	9
6	Nurse	Seclusion	4
7	Service user	Maltreatment	5
8	Service user	Patient–psychologist relationship	3
9	Nurse	Seclusion in a general ward	3
10	Family member	Seclusion	1
11	Service user	Involuntary hospitalization	3
12	Psychiatrist	Nurses’ moral attitude	10

Consultees

Consultees were nurses (4), psychiatrists (3), service users (4), and a patient’s family member (1). Although the Online Ethics Consultation’s main target was mental health nurses, only 4 (33.3%) of 12 emails came from nurses. Most of the consultees explained that they found the Online Ethics Consultation during an online search.

The rate of psychiatrists among consultees was unexpectedly high (25%). We found that psychiatrists as well as nurses struggle with ethical issues and lack a venue in which to discuss these issues. Psychiatrists hold ultimate responsibility and accountability for decision-making in clinical care, which brings with it concerns about ethical issues such as seclusion and restraint.

The rate of service users was also higher than expected. Although service users should consult with the medical doctor managing their care, those who contacted the Online Ethics Consultation had little trust (confidence) in their psychiatrists or psychologists. They explained that they had no clinicians with whom to consult and were desperate to find someone. Even though consultation for service users and their family members was not part of the Online Ethics Consultation’s stated purpose, provision of objective advice delivered with empathy appeared to fulfill a need.

Content of consultation

The most frequent question was about restriction of patient activities, especially seclusion and physical restraint (by six consultees). Consultees asked about the legality of restraining a mental health patient in a seclusion room: the seclusion of a mental health patient with influenza who would not stay in his or her room; whether it was permissible to seclude a patient with an eating disorder to restrict exercise; the rights of secluded patients to communicate with people outside the hospital by telephone or letter; and whether it was permissible to seclude a mental health patient with leukemia who was unable to stay calm. Most of the consultations on seclusion and restraint came from clinicians.

Two consultations concerned perceived unethical attitudes of colleagues. Two service user consultations involved involuntary hospitalization and alleged maltreatment. The remaining two service user issues pertained to therapy and relationships between patients and medical staff.

Some consultations appeared to be moral dilemmas, such as the seclusion of a patient with influenza where the purpose of the seclusion was to prevent the spread of the virus. Two nurse consultees expressed moral distress. One felt it was wrong for nurses to take custody of the telephone cards paid for by the patients, and another wanted to know what to do about patients believed to be illegally secluded in the institution where the consultee worked.

Responses from the Online Ethics Consultation

Our responses always began with an acknowledgment of the consultees’ distress and expressed appreciation for the consultees’ courage in contacting the Online Ethics Consultation. In cases regarding the legality of particular practices, we provided direct factual advice. Even with straightforward legal matters, we addressed ethical aspects and gave advice about whom to involve in the case to improve patient care.

No emails were ignored. Even when content was irrelevant to ethics consultation, our responses explained the Online Ethics Consultation’s purpose. Some service users’ cases were considered outside the scope of the Online Ethics Consultation (e.g. patient–psychiatrist relationships), but we responded to those cases anyway because we felt it was important to acknowledge the consultees.

One of the advantages of the Online Ethics Consultation was its written format, which ensured that responses were carefully considered to avoid offense and checked for accuracy. The consultee received a coherent reply that summarized the advice received of various consultants rather than receiving separate consultant opinions. Finally, input from several consultants from different professional backgrounds minimized the likelihood of bias.

Response time from receipt of email to sending a reply was 1–5 days in “as soon as possible” cases, 9–10 days in “within 2–3 weeks” cases, and 14 days in “in no hurry” cases. These are satisfactory response times considering that the Online Ethics Consultation process involves collecting consultants’ opinions, summarizing them, and obtaining the consultants’ approval.

In some cases, the team head needed to gather more detailed information from the consultees before requesting input from the consultants. Five consultees sent additional questions or comment. However, the format of the Online Ethics Consultation precluded clarification of details through face-to-face communication, which can convey nonverbal information, which is a disadvantage.

Feedback from the consultees

Several consultees sent emails expressing their gratitude and satisfaction with the Online Ethics Consultation responses. They said that the consultation was helpful and the response time was rapid. The Online Ethics Consultation did not receive any email expressing a negative reaction. However, the Online Ethics Consultation’s effectiveness in alleviating nurses’ moral distress has not been assessed, although it is likely that nurse consultees benefited from the combined effect of writing down their problems and receiving empathetic timely responses.

The number of consultations was fewer than expected. It is highly unlikely that clinicians or service users have little need to consult on the ethical issues they face. However, mental health nurses and other clinicians might not conceptualize the problems they face as ethical ones, or understand or trust the process of ethical consultation. For those seeking help online, the Online Ethics Consultation website list of “ethical issues likely to occur in mental health settings” and “past examples of our consultation” might provide the answers. It is also likely that most nurses are unaware of the Online Ethics Consultation, and so it needs to be more widely publicized.

Ethical considerations

This project obtained an ethical approval from Sonoda Women’s University. Informed consent was not obtained, as the consultation was done anonymously. This article contains no information that would identify the consultees.

Conclusion

Moral distress has many negative effects on nurses, with the more morally sensitive nurses more likely to feel morally distressed. The Online Ethics Consultation was established to assist morally sensitive nurses in resolving their ethical problems through provision of unbiased, supportive, and encouraging advice. This article has implications for services concerned with improving patient care, managing nurses’ moral distress, building ethics into decision-making, and providing a forum for discussion about ethical issues.

Footnotes

Acknowledgements

The authors thank all the consultants of the Online Ethics Consultation. Without their contribution, the Online Ethics Consultation could not work.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Japanese governmental fund, JSPS KAKENHI Grant Number JP25463597.

ORCID iD

Kayoko Ohnishi

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