FAQs and frequent concerns
This is the next in a series of posts and documents on this developing theme and has been written by Mick Mckeown and Jonathan Gadsby. Tomorrow, we are presenting our recent paper (behind paywall – sorry, not much we can do about that here) at the Critical Voices Network Ireland 2021 conference and hope to gain a further sense of what people make of the idea.
Following is a list of frequently asked questions or concerns that nurses and others may have to the idea of conscientious objection from forced pharmaceutical interventions. In each case we offer some responses. Our responses are not intended to dismiss these concerns out of hand – in many cases we recognise that they are motivated from the same kinds of care and commitment to service-users and colleagues that motivates us, too. Yet it is also true that we cannot see that any of these questions deal a decisive blow to the need for this new right.
- Will nurses be asked at their job interview if they are a ‘conscientious objector’? If not directly, perhaps they will be asked questions that try to reveal if they are likely to refuse to give forced pharmaceutical interventions and the answer may go against them?
We think that this would be a real risk if the idea of conscientious objection were to be considered an identity (‘I am a conscientious objector’) rather than a case-by-case decision. However, we feel there are a number of reasons to suggest that it should only be afforded as a right on the basis of a case-by-case decision. That being the case, the only answer any nurse could be required to give to the question of whether they would object to enforced pharmaceutical interventions is that they would look forward to weighing up the decision to enforce pharmacy carefully, with colleagues. It would be up to the managers to show that they are able to uphold all of the rights of their staff.
The following three FAQs share many features and will be addressed together:
2. What will it be like for service-users to know that some of the team agree with what is happening to them and others object? This will cause terrible upset and division, won’t it? Some nurses will be seen as heroes and some as villains?
3. Who would be brave enough? Surely this would be career suicide? Won’t the rest of the nursing team hate the nurse who does this?
4. This right will be invoked when a restraint team is trying to work out how to give an enforced pharmaceutical intervention to someone who is objecting – loudly and emotively – and then one of the nurses will back out of the situation, claiming that they ‘conscientiously object’ to it, and this will cause chaos and a dangerous situation for everyone concerned, including the service-user. Such a nurse will end up being despised. The right will not protect nurses from traumatic experiences, it will create new ones.
These extremely important questions very strongly imply the need for a feature that might not be immediately obvious; while the right is certainly an individual right based on individual matters of conscience, it requires a team of nurses for it to be expressed and upheld. In this regard, the right is not especially different from other rights. The presence of the right would create the necessity for enhanced team discussion and decision making to become a new norm. It is crucial that this right be seen in the context that it is a team of nurses who create the space for a person to exercise their conscience. It would be expected that the supportive discussion would be of a proactive nature, behind closed doors, and its details not revealed or discussed with service users. It may be that some nurses will consider that their conscience has been satisfied with this new level of conversation and, indeed, some who still wish to raise objections may subsequently choose to participate in the team action of enforcing pharmaceutical intervention because they know that they have been listened to, they have witnessed a higher level of discussion than might otherwise have taken place and they therefore feel they can submit to the team’s decision without personal moral injury. Others may feel differently, of course.
In short, the right is not envisaged as something that a nurse would exercise during an urgent scene in which they are being asked to help and they suddenly refuse. Instead, the existence of the right would demand close team discussion and decision-making.
A new right to conscientiously object from enforced pharmaceutical intervention would require new managerial training. Managers (and indeed, all professionals) have a responsibility to create spaces and a dialogue that upholds the existing rights and protected characteristics that their staff already have and this new right would require careful consideration. The emergency scenario described above would have dreadful consequences for the whole team and the service-user and is clearly unacceptable. There are many arising issues from it, but especially it is a failure of leadership.
Additionally, it is important to note that we are not asking for the right to abstain from physical restraint of service-users. A nurse could never exercise this right in order to stand back from assisting with the physical restraint of a service user deployed in order to manage an unsafe situation.
5. Why stop with forced pharmaceutical interventions? If you are so against coercion, why not other forms of control and even the Mental Health Act itself?!
It seems very likely that there are times when removing the control a person has of their own body, in a practiced, safe way with a team of trained nurses is essential for their and others’ safety. We have maintained throughout that this request for a new right of conscientious objection is fuelled by several factors, one being a serious evidential concern about the drugs used in mental health services and a lack of leadership on this issue within nursing and other health professions. It is not merely a libertarian impulse! Nurses who are troubled by any form of coercion will continue to have difficulties that this right does not attempt to address; this right is not the right to abstain from all forms of coercion within mental health services.
6. This only really applies to acute settings. If the nurse has a problem with forced pharmaceutical interventions, perhaps they should just leave and get a community job?
There are several reasons why this sentiment, which in fact is very often what happens in real life, is inadequate. Firstly, the nurse ‘escaping’ to the community has not actually left this situation behind; they may have responsibilities for service-users detained under CTO and these service-users may be readmitted and they will need to be part of that decision-making. If the community nurse feels that they are making decisions that will lead to the same outcome but performed by other nurses, they will still be caught in intolerable issues of conscience. Secondly, the effect of such an unwritten policy is to remove nurses with issues of conscience from the ward environment, further impoverishing the discussions that might take place and creating or maintain a split between community and ward nurses, in which care, continuity of care, reputations and team working will all potentially suffer. Finally, we see this right as applicable to community-given pharmaceutical interventions as there conversations to be had about Community Treatment Orders and the threat of force in regards to pharmaceutical interventions.
7. Nursing is supposed to be an evidenced-based profession. If the nurse does not like taking part in an evidenced-based intervention, perhaps they are not fit to be a nurse?
No, this is a misunderstanding about the meshed nature of evidence and values in mental health, seen at every level, from concepts of illness and wellness through to choices about service provision, policy and individual nursing interventions. Evidence cannot be used to resolve this issue of conscience because many sets of values that pervade mental health services (and are present in wider scholarship and within the population) can be convincingly ‘evidenced’, but not in ways that provide any kind of final answer, a ‘best and only practice’ for mental health nurses.
8. Surely the problem here is to do with service-user rights, not nurses’ rights? Wouldn’t it be a better initiative to get nurses to spend more time ensuring the rights of service-users rather than claiming new ones for themselves?
This seems like a very important argument and we agree that if all nurses were highly conscious of service-user rights the service would be greatly improved. However, there is a non-sequitur in this argument; it does not follow that a greater emphasis on a nursing right will be to the detriment of a focus on service-user rights. In fact, one could easily imagine that they would be mutually reinforcing. We see nurses and service-users as often caught in the same issues of institutional power and institutional cultures. However, there are issues of employment law and within our NMC code of conduct that are troubled by not affording nurses this right, and that is what we seek to address.
9. Have you consulted service-users about this? Shouldn’t they be asked?
It is difficult to imagine that service-users would object to a nursing right that leads to a greater need for careful consideration of enforced-pharmaceutical interventions. However, this issue has been approached as an ‘in house’ concern within mental health nursing. The reason is that we maintain that it is a logical and perhaps inevitable consequence of our degree-level education and NMC-backed growth into a profession in our own right. We are increasingly asking for and being given responsibilities as autonomous practitioners and held accountable as individuals. It therefore follows that we are required to be critical thinkers, a phrase used by the NMC as a key purpose of our education. It is engagement with the mental health services as a critical thinker that has led many nurses to literature such as that of Joanna Moncrieff, Robert Whitaker and many others, including alternative therapeutic approaches to issues formerly considered to be the sole territory of biomedicine, such as ‘psychosis’. There is therefore a potential for moral injury caused by current practices that nurses need to address within our profession. To insist that only service-user rights should drive our practice might imply (once again) that nurses must simply do what others want of them, unquestioningly. As it is a right for nurses which is called for, we feel it is important that nurses take a lead in making the case for this and lead any necessary campaign or debate. Critical and supportive contributions from constituencies/perspectives other than nurses are welcome, but not necessarily required.
10. Some patients end up very glad that they were given medication, even if at the time they refused it. How do you answer that?
Perhaps, although this might sometimes be something said more by nurses – a ‘mythologised future gratitude’ than is actually the case. It is important to note that the provision we are asking for would be a for a case-by-case basis, not a blanket position on the use of enforced pharmaceutical interventions that might be the opposite of critical thought. A nurse might object to enforced pharmaceutical interventions only once in their whole career – or not at all. However, even if rarely used, the right itself has the potential to change the discourse about the use of enforced pharmaceutical interventions for the whole profession. If the results of enforced pharmaceutical interventions ‘speak for themselves’ then yes, this right is unnecessary and will not be used. Experience suggests otherwise to us – as does a lot of very challenging longitudinal data on recovery rates and a growing understanding of the serious health concerns that go with longer term use of psychotropic drugs.
11. Every job has aspects that people do not like very much. Are there not times when a nurse just has to do what they are told for the smooth operation of the service and being part of a team?
There certainly are times like that and very often good nursing work is in the context of team work. However, there is huge difference between being asked to tidy the clinic room, attend a difficult meeting or work on a bank holiday and enforcing a pharmaceutical intervention, something that occupies a very unusual alteration of value-norms that run across every field of nursing. Also, there are times when the experiences of nurses move beyond being of a role which contains good aspects and less enjoyable ones to being a role that is expected to do all the aspects of mental health services that are often mandated by other professions but that they themselves never have to enact; this issue of forced pharmacy could be considered a paradigmatic example.
The following two questions will be treated together:
12. What is the point of having a forensic mental health service if those patients are not being treated for their mental health problems?
13. When a person is detained under MHA Section 3 it is for treatment. If they are not being given that treatment it makes a mockery of their detention, surely?
Both of these questions get to the very heart of a contradiction that nurses and other mental health professionals currently work under; in order to detain under the MHA, one must detain ‘for treatment’. But what is ‘treatment’ when the efficacy and morality of psychiatric medications has been troubled? This is one of the key reasons why in this document and others we have written ‘enforced pharmaceutical interventions’ and not the phrase that is most commonly used, ‘forced treatment’. So, yes, both of these questions are right. If ‘treatment’ means pharmacy and if pharmacy is not clearly treatment in an uncontested way, then there is a grave problem. However, it is exactly this kind of problem that this right would help not only to highlight but to create further ways to resolve. Many nurses already view themselves as having much to offer in terms of creating a therapeutic alliance and would see that as already moving beyond the narrow view of ‘treatment’ given in the Mental Health Act; by this we show that we already view that ‘treatment’ means more than pharmacy.
14. Wouldn’t this cause terrible clashes between doctors and nurses? The medics would say the patient needs their medication and the nurses would have to explain why they had not given it. The medical team would be hugely insulted and make strong demands. This would be intimidating and it could easily lead to grievance issues and legal challenges.
This is a very important point but it does hide over-simplicities. One is that this is not a doctors versus nurses debate. One author that has been mentioned several times is Joanna Moncrieff, whose notion of ‘disease centred vs drug centred’ seems to provide a very welcome sense that one can be evidenced, critical, aware of the contested nature of pharmaceutical interventions, concerned about the impact of the use of enforcing them, and still be a prescribing, practicing consultant psychiatrist. The issues raised are as much ‘in house’ for doctors as they are interdisciplinary. Also, when this issue is presented as a nursing right of conscience and not merely an intellectual disagreement, we believe that it should draw medical colleagues into more holistic discussions about the impact and morality of enforced pharmacy and that these are to everyone’s advantage. Handled well, it could promote new forms of interdisciplinary respect and understanding, rather than damaged relationships, and perhaps be an opportunity to move beyond unhelpful binaries that already cause divisions.
15. There are already lots of systems in place for nurses’ views to be heard on this. In a functioning MDT nurses take part in ward-rounds and if they have something to say they are listened to. Also, nurses write reports for MHA Tribunals and these are also taken into account. Is there really a need for a separate right of conscientious objection?
The infrequency of Tribunals means that they could never be enough to protect nurses with a conscientious objection from potential moral injury and so we do not see that they are likely to be the main focal point for this potential new right. However, ward-rounds are one such place and it might be that a clinical unit or Trust would identify the need for new skills and perhaps even new personnel to create or oversee spaces for nurses’ rights to be considered and upheld. However, we suspect that to properly uphold the rights of individual nurses and to be empowering to them as a group, the focus will be the inter-shift nursing handover, with views taken forward to the ward round as a set of nursing team concerns.
16. Health is bio, psycho and social. The medication is there to address the ‘bio’ bit, and other interventions – and whole other professions – exist to address the psycho and social parts. Probably most nurses would prefer to sit and talk with a patient about their problems rather than inject them against their will, but we need a holistic healthcare in which all members play their part.
17. Health is bio, psycho and social. In practice, you often need to give someone a ‘bio’ intervention in order to settle things down enough to be able to talk, think about problems and make other plans. This is true across all kinds of health care settings.
Much scholarship exists that suggests that pharmaceutical interventions in mental health services, far from ‘looking after the bio bit’, are causing a multitude of physical health problems. This will be the cause of some of the aspects of conscience that this potential new right could address. However, more than this, the purposes of ‘biopsychosocial’ has not been furthered by viewing it as a means to divide labour and create discrete disciplines. Furthermore, mental health nursing identity is not captured by the biomedical and never has been; this cannot be thought of as mental health nursing ‘straying out of its lane’. We are (and aspire to be) a profession of health-promotors and, yes, health is irreducibly biopsychosocial. Neither is this something special for mental health nurses; nurses from all fields of nursing also demand the right to view health in this way.
This potential right does not arm nurses to object from all biomedical approaches or from psychiatric pharmacy per se. Much of the debate about it so far seems to surround acute settings, but we suspect that there will be as much discussion about community-given ‘depots’ (long-acting injected pharmaceutical interventions, usually prescribed for years or many years) as there will be about ‘rapid tranquilisation’ or other acute use during the first weeks a person is in hospital. Although the ‘depot’, given quietly in a clinic or the person’s home, does not have the same appearance of being ‘enforced’ it is very often in a context in which refusal is understood to lead straight to re-hospitalisation and the threat of force.
18. Most nurses are not prescribers. If the doctors say medication should be given, what right has a nurse to claim that they know better?
When it comes to making decisions about medication, nurses should certainly not claim to be more expert than their medical colleagues, although every nurse will witness poor prescribing during their carer. However, this question, while having the appearance of a sensible argument, actually gives a false impression of the current reality; a nurse is responsible for the pharmaceutical interventions they administer, even in instances that it is incorrectly prescribed. They need to know what doses are safe, recommended and even to have an eye to polypharmacy; nurses are held accountable for errors made. Not only this, but nurses are a crucial interface between service-user and prescriber, with many conversations about pharmaceutical interventions taking place between nurse and service-user only. Nurses routinely need to explain to service-users the reasoning behind prescriber decisions. Nurses routinely explore service-user experience of pharmaceutical interventions and convey it back to the prescriber. In all of these interactions, a conscientious nurse, educated to degree level, tasked by their Code of Conduct to prevent harm and raise concerns about harm and to openly discuss benefits and costs of taking pharmaceutical interventions with service-users is already required to think in ways that mean they cannot have a policy of ‘just do what the doctor says’.
19. If patients are left ‘unmedicated’ they will suffer. Can that be right?
Once again, this question implies a simplicity that is simply not reality. People in distress suffer. Medicalisation provides certain kinds of relief and certain kinds of new problems; freedoms and traps. Pharmaceutical interventions may decrease suffering and increase it, sometimes simultaneously, sometimes short-term gain becomes long-term disaster. The word ‘unmedicated’ assumes far too much about the nature of distress or the ability of drugs to relieve it. It also obscures the need for a full range of bio, psycho and social approaches to distress.
20. If patients are left ‘unmedicated’ they will present a higher risk profile to themselves and others on the ward. How will the objecting nurse feel when there is an assault or suicide and others in the MDT feel it is because the patient should have had a pharmaceutical intervention sooner?
This question is a development of the preceding one. The best way to answer it seems to be that it already takes place, in questions about whether, and to what extent, prescribed drugs (or their absence) played a role in risk-related events and so it could not be argued that this kind of issue is somehow created by giving nurses more rights. Indeed, it is hoped that the proposed right in question will ensure better conversations about pharmaceutical interventions and more team cohesion surrounding more considered decisions. If that does happen, then this right will go a little distance towards making the nurse described in the question feel better, perhaps much better, knowing that, should unfortunate risk-related events occur, at least the team made the most careful decisions they could.
21. What about Health Care Assistants? Many are trained to take a role in forced pharmaceutical interventions. Will they also be allowed to conscientiously object?
This is a very difficult question. We cannot ignore the fact that Health Care Assistants are part of the nursing team more than they are part of any other, that they may have training and a role with enforced pharmaceutical interventions, that they may be very experienced, know service-users well, and that there is no reason to exclude them from having issues of conscience about it. However, our claim is that this issue of conscience is inevitable for some nurses when required by their degree education to become critical thinkers, having learned about the contested nature of the drugs used in Mental Health Services, required to uphold a Code of Conduct that includes raising concerns about issues of harm and to openly discuss interventions with service-users. That being the case it would be difficult to then say that the right should be inclusive of Health Care Assistants. At present we see this as a matter for the NMC to resolve. All of the above elements mean that we feel clear that Health Care Assistants should be included in team discussion about forced pharmaceutical interventions and we anticipate that many will do so invaluably. However, we currently see this as a right that should be afforded to registered nurses.
22. How can a ward function with current staffing levels if more patients are left ‘unmedicated’? Would this all lead to unintended consequences like more locked doors and more use of seclusion? Seclusion can also be pretty traumatic for patients, are you going to be proposing a right to conscientious objection from using seclusion next?
This is really two separate questions. The first, about staffing, could be said to betray an underlying assumption that psychiatric drugs are required to make the management of wards easier rather than being a targeted treatment for mental illness, although more charitable interpretations are possible. If more staffing is required because nurses are given rights, then we believe that more staffing is required. However, we do not think that this is the inevitable result of affording this new right of conscientious objection, especially in that we suspect that the lack of this right (and the lack of leadership and quality discussion that upholding this right would require) is a reason for nurses to leave the profession, currently.
The second question, about seclusion, is important. It might be that there is a greater use of seclusion as a result of affording this right. However, it might not be. As stated above, we suspect that this right will affect ‘rapid tranquillization’ rather less than it affects decisions about long-term use of ‘depot’ neuroleptics and, also as stated, this right does not give nurses permission to avoid restraint situations in instances when they are about direct risk to service-users and staff. Yet it may be that, within the context of a better set of discussions about the ethics and effectiveness of drugs, nurses will be empowered and encouraged to practice a greater range of interventions, including better interpersonal work with ‘psychosis’ (such as voice-hearing work or the Open Dialogue Approach, about which scholarship is growing all the time).
23. This seems like nurses with degrees getting somewhat above themselves. There are reasons why the service works the way it does, even if at first forced pharmaceutical interventions can seem a bit shocking.
There will be people who take this kind of functionalist view of services and they are forgetting that nurses are given responsibility for their actions, held accountable as professionals, under a Code of Conduct. If they want people who are employed just to do what they are told, smoothly implementing policies without question, they do not want a 21st Century nurse educated in the UK. Secondly, nurses are often told what they should study, think and feel, by doctors, practice managers, commissioners, even psychologists. None of those people ever have to pin a person to the floor and pull their trousers down; they are welcome to have opinions, as are we. Within our profession, given the complex nature of mental health services, some nurses rise to become senior nurses and managers (and teachers) who impress due to their ability to efficiently perpetuate the cultures and practices of mental health services rather than on their skills as critical thinkers. Therefore we fully anticipate that some nurses will dismiss this attempt to claim a new right as being about ‘academic’ nurses who do not remember the ‘reality’ of ‘nursing on the ground’.
24. There are so many challenges facing mental health services in 2021. Why agitate for this kind of change right now?
If something is deemed a right it does not need to fit in with a timetable or be convenient. We also contend that some of the challenges facing our profession are rooted in this complex set of issues and the lack of leadership and lack of quality discussion. We also see this issue as highly topical; current aspirations for more recovery oriented services and coproduction are undermined by a proliferation of restrictive practices and especially forced pharmacological treatment, which breaches trust and damages relationships. The existence of the proposed right in a context of receptive services staffed by critically thinking nurses might just enable a more genuine commitment to recovery and coproduction.