SIB7012-A – Business Ethics and Sustainability
Final Assignment
OPTION 1 – ETHICAL ISSUE
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by
Name: [Student Name]
UB No.: [Student Number]
Date: [Date completed]
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Contents
1
Organisational Issue Background 4
History ofPsychiatric Care in the UK 4
Scenario 5
Stakeholders 5
Stakeholder Interests and Salience 5
The Stakeholder Salience model 5
Analysis of Issue – Practitioners’ Ethics of Duty Obligations 6
Analysis of Issue – Patient’s Human Rights 7
Management Analysis 9
Management’s Decision 9
Recommendations 10
Summary and Conclusion 10
REFERENCES 11
APPENDCES 15
Appendix A – Organisational Background 15
Period 15
Event 15
27
High/Medium 27
Low/Unknown 27
High/Medium 27
Low/Unknown 27
Appendix B – Background to the Issue 27
Coercion in Psychiatry Treatment 29
Appendix c – Monthly journal 29
Organisational Issue Background
History ofPsychiatric Care in the UK
Following centuries of unregulated community care of people with mental illnesses, madhouses and mental asylums/institutions were introduced as means for regulating care provision. Effective psychiatric medication was then developed in the late 1950s, prompting the closure of institutions and the introduction of a new psychiatric care approach called ‘Care in the Community’ whereby the treatment and support of patient with improved symptoms was transferred to outpatient clinics in the community.
Detention and Forced Medical Treatment in NHS Hospitals
This ‘Care in the Community’ approach existed simultaneously with the inpatient care approach designed for detaining treatment-resistant and/or dangerous patients who potentially committed crimes and harmedothers in the community. This triggered the introduction of the Mental Health Act (MHA) in 1959 (REF??). The MHA empowered professionals to force patients to take medication against their will, for reasons of protecting the safety of other people.The NHS, which had been formed in 1948, established specialist psychiatric hospitals to enforce patient detention under the MHA.
Patients detained under the MHA in NHS hospitals were deemed to lack capacity and were resultantly medicated forcibly and/or coercively, against their will. Guidance for addressing ensuing capacity issues in psychiatrywas later provided bythe UK government and the NHS inthe Mental Capacity Act (MCA) of 2005. This later informed creation of the Deprivation of Liberty Safeguards (DoLS) of 2009 statute (Ministry of Justice, 2008).
Scenario
The writer works in a National Health Service (NHS) psychiatric hospital where he witnessed a patient being admitted for treatment of psychotic symptoms that included threats to harm and kill other people. He refused psychotropic medication for fear of adverse side effects. He also rationally and truthfully said he had joined a new religious faith that forbade him to take mind-altering substances. Nevertheless, psychiatry practitioners told him that he was a danger to other people whom professionals had a statutory duty to protect. The patient was threatened with compulsory detention in the hospital under the MHA if he continued to refuse medication. The patient then complied and took the medication against his will. Please refer to Appendix A for a comprehensive version of this scenario.
Stakeholders
Stakeholder Interests and Salience
The Stakeholder Salience model
Table 2 contains comprehensive details of salience assessment and prioritisation of the NHS hospital’s stakeholders done using the Stakeholder Salience Model.
According to the assessment, the least important stakeholders for the NHS hospital are:
• Religious organisations
• Public and neighbours
• Non-governmental organisations
These are ‘latent’ stakeholders because they satisfy only one of the three relationship attributes. They are ignored as stakeholders by management, and their effort to influence changes disregarding by management, with no adverse effects on the organisation.
However, since Competitors and academic institutions satisfy two relational attributes, they occupy the ‘expectant’ stakeholders group and are moderate in importance.
Finally, the following stakeholders are the most important:
• Patients
• Employees
• Suppliers
• Management
• Government
• Regulators
The ‘high salience’ group status of the above stakeholders is based on satisfying all three attributes of the Stakeholder Salience Model, which enables them to influence the organisation in definitive ways.
Source: StakeholderSalience https://www.stakeholdermap.com/stakeholder-analysis/stakeholder-salience.html#mitchell
Ethical Problems Around CoercingPatients to Accept Psychiatric Medication
Analysis of Issue – Practitioners’ Ethics of Duty Obligations
The symptoms of serious mental disorder can impair the capacity of people to decide autonomously about taking psychotropic medication, which may cause them to refuse treatment (Sjostrand and Helgesson, 2008). However, when psychotic patients refuse medication, they may pose serious danger to themselves and/or other people around them.
When the dangerously mentally ill patient cited in this report refused psychotropic medication, the psychiatry professionals used a threat to influence him to comply against his will, for reasons of protecting the public. In doing so, the practitioners’ actions were consistent with the ethical principle of utilitarianism, which prioritises doing well for many people over doing well for just one individual in all situations (Poulsen, 2009). Thus, the coercive treatment of the patient is justified under utilitarianism theory since it allows professionals to do good for many people comprising the society, by using coercive treatment to reduce the dangerousness of the patient (Hiday et al 2015).
The Royal College of Psychiatrists ((RCP) 2014) and the Nursing And Midwifery Council ((NMC) 2015) codes of ethics and conduct also place rigid accountability obligations on psychiatry professionals to always safeguard and protect patients and other people from harm.These obligations force a duty of care for the public on professionals, making it paramount for their performance of duty to always seek to protect the public with no excerptions.Non-compliance renders them incompetent and liable for disciplinary action.Essentially therefore, failing to treat a psychotic person after respecting their choice to refuse medication breaches professionals’ ethics of duty around legal responsibility to protect others (Sjostrand and Helgesson, 2008).This means that the practitioners’ obligations of duty of care to society justified the coercive treatment of the patient’s after his refusal of medication.
Treating the patient was based on legal and ethical statutes, which makes it formal coercion that is therefore legal and ethical. This justifies the action of the professionals in question, and substantiates the legality and ethical correctness of treating their patient coercively (Peay and Eastman, 2006).
Analysis of Issue – Patient’s Human Rights
Hem et al (2016) insist that regardless of any prevailing capacity deficits caused by serious mental disorder, influencing and/or forcing another person to accept medical treatment constitutes coercion, which breaches their autonomy. Mendez (2013) further asserts that coercive medicinal treatment of psychiatric patients ‘is tantamount to torture’, a view which validates that, regardless of intensity of potential risk or dangerousness, patients’ freedom and liberty are severely restricted when they are coercively medicated. This means that coercive medication constitutes direct violation of the patient’s human rights.
The Convention for Human Rights (hereby referred to as the convention) dictates that ‘people should not be treated coercively in the interest of others’ (Heginbotham, 1987). The convention observes that the coercive and involuntary treatment of persons with serious mental disorders is justified only when serious harm is likely to happen to the affected individual themselves if treatment is not provided. It also clearly specifies that coercive treatment of a psychiatric patient must strictly be exercised only to protect the safety of the patient, and not anyone else.
However according to Sjostrand and Helgesson (2008), coercively medicating a dangerously mentally ill patient may uphold their individual interests and safety since it avoids potential retaliation from other people they may harm, which may harm them in return. For such a perspective to be valid however, it must be the person’s illness that is targeted for treatment, and not the dangerousness of his actions (Sjostrand and Helgesson (2008). The requirement to target the illness and not the dangerousness invalidates the validity of coercively medicating the patient discussed in this report since the professionals clearly identified the dangerousness of his actions as reason for treating him coercively.
Based on the need touphold the human rights of the patient, the coercive treatment of the psychiatric professionals can therefore be argued to be unethical and illegal.This follows it being clear that practitioners forcefully treated him for reasons of treating the dangerousness caused by prevailing mental disorder and protecting others, and not for treating his illness or upholding only his interests.
Strengths and Weaknesses
Coercively treating the patient safeguards the welfare and safety of members of society and renderspractitioners competent and responsible. However, treating another person for the benefit of others and not themselvesinfringes on their Human Rights, which risks criminal litigation (Galligan, 2006).
On the other hand, upholding the Human Rights of the individual patient over the safety needs of the public respects the autonomyof patients’and places favourable ethical status on the organisation. Nevertheless, allowing a single dangerously mental ill individual to refuse treatment and endanger society breaches mental health law and places the public in danger (Hiday et al, 2005).
Management Analysis
Management’s Decision
The management decided that it despite the existence of the law that allows the forcible administration of psychiatric treatment to both capable and incapable persons in article 3 of the constitution (Richardson, 1993), it stands guided by article 8 of the same constitution which dictates that all human beings have a right to private life as well as family life (Wilkinson,2002). This was in accordance to the case of pretty V UK (2002); an appeal to reverse forcible treatment which was granted based on article 8 of the constitution. This is further enhanced in article 8(1) provisions IV of MHA 2001 where a court ruled that every adult has rights and cannot be treated against their consent (pretty, 2001).
The organisation was therefore liable to article 8 and 8(1) of the constitution by acting unethically. The patient after being forced to take the medication suffered injuries such as increased violence (Lind, and Tyler, 2005)
Recommendations
1. The organization should look into improving the social welfare of the patients through developing a code of ethics to guide its employees on ethical practice.
2. The organization should use its managers as role models in developing a culture of ethics in its management for all the employees to emulate.
3. Disciplinary action should be taken against those employees who act unethically in their areas of practice despite having completed ethical training.
4. A deeper interpretation of the law is important because in as much as one section or article may permit certain actions, the same law may disregard such actions under certain circumstances. For example article 8 permits forcible treatment while article 8(1) goes against the same under certain circumstances for example due to the right to privacy.
Summary and Conclusion
Coercion to forcefully treat and detain patients with psychotic problems is allowed through the ECHR. Those who might not be aware of being detained are protected by the European human rights act which is aimed at safeguarding these groups of people. Emphasis is placed on strictly relying on the recommended medical procedures for the treatment of such persons. This can be concluded that the law does not fully cater for the rights of the patients in line with forceful treatment or coercion. Before a case is treated as coercion, it will have gone to extreme extends before action is taken. The social needs of the patients are not met as much emphasis is placed on the protection of the patient safety and health and not the common problems of suicide or death. There is simply too much practice of coercion permitted by the current European law on persons with psychiatric problems.
REFERENCES
1. Bartlett, P. and Sandland, R., 2007. Mental health law: policy and practice. Oxford University Press.
2. Bartlett, P., Lewis, O. and Thorold, O., 2007. Mental disability and the European convention on human rights (Vol. 90). Martinus Nijhoff Publishers.
3. Bayles, M.E., 2012. Procedural justice: Allocating to individuals(Vol. 10). Springer Science & Business Media.
4. Eastman, N. and Peay, J. eds., 1999. Law without enforcement: Integrating mental health and justice. Hart Publishing.
5. Galligan, D.J., 2006. Due process and fair procedures: a study of administrative procedures.
6. Heginbotham, C., 2003. BeanPhilip, Mental Disorder and Legal Control, Cambridge University Press, Cambridge, 1986. 207 pp.£ 27.50. Journal of Social Policy, 16(4), pp.584-586.
7. Hiday, V.A., Swartz, M.S., Swanson, J. and Wagner, H.R., 1997. Patient perceptions of coercion in mental hospital admission. International journal of law and psychiatry, 20(2), pp.227-241.
8. Hiday, V.A., Swartz, M.S., Swanson, J. and Wagner, H.R., 2005. Patient perceptions of coercion in mental hospital admission. International journal of law and psychiatry, 20(2), pp.227-241.
9. Lind, E.A. and Tyler, T.R., 2005. The social psychology of procedural justice. Springer Science & Business Media.
10. McKenna, B.G., Simpson, A.I., Coverdale, J.H. and Laidlaw, T.M., 2001. An analysis of procedural justice during psychiatric hospital admission. International journal of law and psychiatry, 24(6), pp.573-581.
11. Ministry of Justice. (2008). Deprivation of liberty safeguards: Mental capacity act 2005 : Code of practice to supplement the main mental capacity act 2005 code of practice : Issued by the lord chancellor on 26 august 2008 in accordance with sections 42 and 43 of the act. (). London: TSO.
12. Mitchell, R.K., Agle, B.R. and Wood, D.J., 2007. Toward a theory of stakeholder identification and salience: Defining the principle of who and what really counts. Academy of management review, 22(4), pp.853-886.
13. NURSING AND MIDWIFERY COUNCIL (NMC), 2015. The code: professional standards of practice and behaviour for nurses and midwives. London: NMC
14. Peay, J. and Eastman, N., 2006. Law without enforcement: Theory and practice (pp. 1-38). Hart Publishing.
15. Poulsen, H.D., 2009. Perceived coercion among committed, detained, and voluntary patients. International Journal of Law and Psychiatry, 22(2), pp.167-175.
16. Richardson, G., 1993. Law, process and custody: Prisoners and patients.
17. Royal College of Psychiatrists (2014) CR 186: Good psychiatric practice: code of ethics. (Online) Available from: http://www.rcpsych.ac.uk/files/pdfversion/ CR186.pdf (Accessed: 20 Sept 2017)
18. Szmukler, G. and Holloway, F., 1998. Mental health legislation is now a harmful anachronism. PSYCHIATRIC BULLETIN-ROYAL COLLEGE OF PSYCHIATRISTS, 22, pp.662-665.
19. Szmukler, G. and Holloway, F., 2000. Reform of the mental health act.
20. Zigmond, A. and Holland, A.J., 2000. Unethical mental health law; history repeats itself. February 2000 J. Mental Health L., p.50.
Case examples
21. Pretty v UK (2002) 35 EHRR 1
22. R (Wilkinson) v Broadmoor Special Hospital Authority (2001) EWCA Civ 1545
APPENDCES
Appendix A – Organisational Background
Traditionally and until the 18th century, psychiatric care was provided in the community without government support. This was replaced by madhouses between the industrial revolution and the 1930/40s. The madhouse approach collapsed and was followed by mental asylums in the 1940s and 1950s. Since there was no effective psychiatric medication up to this period, patients’ symptoms stayed constant, resulting in patients never getting discharged, and the institutions getting overcrowded as a result.
Table 1 Psychiatric care
The following constitutes a timeline for the provision of psychiatric care in the UK:
Period Event
Up to the 18th century Mentally ill people cared for by families, relatives and friends in the community with no help from the government
Industrial Revolution Madhouses established for containing and detaining people with psychiatric illnesses, marking the start of institutionalisation
Late 1930s –Late 1940s Approach of using madhouses fails
1940s and 1950s County asylums established to replace madhouses
1948 The National Health Service formed
1959 The first Mental Health Act introduced
Late 1950s –Late 1970s
Banning of admitting and detaining people in institutions begins
1983 ‘Care in the Community’ approach to mental health care introduced
Late 1980s Asylums and mental institutions abolished and their closure begins
1983 Mental Health Act modified
1983 – 1985 4000 second opinions conducted
1987 – 1988 Around 19000 people compulsorily detained in psychiatric hospitals
1999 – 2000 50000 people compulsorily detained in psychiatric hospitals
2005 2005: Mental Capacity Act introduced
2008 – 2010 18000 second opinions conducted, with 5000 recorded as ‘Refusing Treatment’
2009 Deprivation of Liberty Safeguards (DoLS) introduced
2009 – 2010 4000 Community Treatment Orders enforced
2010 – Current NHS successfully implementing Care in the Community and care in Inpatient facilitiessimultaneously
In the UK, the period up to the 18th century comprised family members caring for mentally ill relatives and friends in the community on informal basis. Formal structures only emerged during the industrial revolution when madhouses were established as part of an institutional approach. This approach failed, and was replaced in the late 1940s to early 1950s by publicly owned county asylums, which rapidly became overcrowded and underfunded. However advances in psychiatric medication that occurred in the late 1950s facilitated the development of effective psychotropic medication, which made it possible for people with mental illnesses to no longer be admitted into institutions but rather, receive treatment and support in the community through outpatient clinics. The National Health Service formed in 1948 also established hospitals for detaining patients who posed a danger to communities due to challenging symptoms.
Changes in mental health legislation were introduced gradually between the late 1950 and the late 1970s. Theseinitiated and supported the banning of admitting people into asylums, eventually leading to the abolition and closure of asylums and mental institutions in the late 1980s. The UK government had in 1983, introduced the ‘Care in The Community’ approach to mental health care, whereby NHS health teams and local authority social services coordinated mental patient care delivery by providing housing, occupational support, medical treatment, and therapeutic input to support successful reintegration and participation in the community. Thus, the Care in the Community approach also accommodated mentally disordered offenders being treated in the company of their families in the community, a situation thathas sometimes resulted in violent crimes being committed by mental patients against members of the public in the community. Essentially, over the 1987/88 period, around 19000 people were compulsorily detained in mental health hospitals, a number which increased to 50000 within the twelve years that followed (Zigmond, 2011). Also, 4000 community treatment orders were enforced in the 2009/10 period alone.
By the year 2000, 50000 patients were compulsorily detained in NHS hospitals under the MHA, facing forced or coercive treatment with medication against their will. However, to safeguard patients against potential erroneous compulsion and/or unjustified force of patients to comply with medication/treatment, the statutory second opinion system was introduced. 18000 such second opinions were conducted between 2008 and 2010, having increased from 4000 between 1983 and 1985. Of the 18000 second opinions in the 2008/10 period however, 5000 were recorded as refusing medication (Bartlett and Sandland, 2007)
As time progressed, additional statutory frameworks were introduced, which supported the MHA and the MCA. This enhanced the effectiveness and applicability of efforts in eliminating the unethical and/or coercive medicating of mentally ill people by psychiatry practitioners in the NHS and in private organisations. The Deprivation of Liberties (DOLs), introduced in 2005 — is an example of such — (Ministry of Justice, 2008) DOLs stipulates the mandatory requirements and actions to ensure when having to legally deprive the liberty of another person in the UK. and the current period when specially trained professionals provide the care of persons with mental illnesses in specialist hospitals. The pathway to the current system involved a period between the 18th and 19th centuries. This happened prior to the development of effective medication, and treatment of mental illness was ineffective, making it impossible to discharge people from institutions and asylums. Psychiatric medication was then developed in the late 1950s, making it possible for symptoms to be treated successfully, with patients being discharged for treatment in their homes in the community. Legislation was developed by the government to regulate psychiatry. In the institutions, patients were physically and psychologically abused, as well as forced to comply with treatment.
Researchers like — argued and proved that most practice prevailing and accepted in mental institutions at the time was abusive and unethical, which caused the government to abolish mental institutions in the period between 1948 and 1989. Also, in order to further eliminate the unethical practices in psychiatry and protect psychiatric patients, the UK Government also introduced the first Mental Health Act (MHA) (Bartlett, Lewis, and Thorold, 2007) in the year 2005. The Mental Capacity Act (MCA) was also introduced in 2008 to ensure that persons with impaired capacity due to mental health illness were protected from abuse and exploitation
Each of the thousands of compulsorily detained individuals receives forced or coercedtreatment, regardless of any objections they may have. However, to mitigate erroneous compulsion of patients to comply with treatment unnecessarily, statutory second opinions are used. 4000 second opinions were conducted between 1983 and 1985, and 18000 between 2008 and 2010. Of the 18000 second opinions, 5000 were recorded as refusing medication.
Generally, when the NHS was founded in 1948, psychiatric patients were cared for through detention in mental institutions, and forced to take medication even against their will.
With continuing evidence of abusive treatment and violation of the rights of mental patients by psychiatry practitioners due to unclear guidance around the capacity of mentally ill people to make own decisions and thus exercise autonomy during periods of distress, the UK government and the NHS produced revised versions of the MHA and developed and introduced new legislation called the Mental Capacity Act (REF??). As time progressed, additional statutory frameworks were introduced, which supported the MHA and the MCA. This enhanced the effectiveness and applicability of efforts in eliminating the unethical treatment of mentally ill people by psychiatry practitioners in the NHS and in private organisations. The Deprivation of Liberties (DOLs), introduced in 2007— is an example of such — (Heginbotham, 2003). DOLs stipulate the mandatory requirements and actions to ensure when having to legally deprive the liberty of another person in the UK.
By the year 2000, 50000 patients were compulsorily detained in NHS hospitals under the MHA, facing forced or coercivetreatment with medication against their will. However, to safeguard patient’s against potential erroneous compulsion and/or unjustified force of patients to comply with medication/treatment, the statutory second opinion system was introduced. 18000 such second opinions were conducted between 2008 and 2010, having increased from 4000 between 1983 and 1985. Of the 18000 second opinions in the 2008/10 period however, 5000 were recorded as refusing medication.
Stakeholders
Mitchel (2007) defines a stakeholder as any party or person with an interest in something.
The NHS is one of the largest public sector organisations in the world (REF??). It comprises a various stakeholders concerned with the care of psychiatric patients in its hospitals. The NHS’ mental hospital stakeholders are identified and their respective levels of importance is assessed using three key relationship attributes aligned with the Stakeholder Salience Model by Mitchell et al (1997). The findings are presented in Table 2 below.
The Stakeholder Salience Model is argued by Mitchel et al (2007) to be effective for use in identifying stakeholders, define their interests and determining their levels of importance. The model considers three key relational attributes namely power, legitimacy, and urgency for analysing and assessing given stakeholders to highlight their interests and reasons for relevance.
According to (Mitchell, Agle, and Wood, 2007), analysis using Stakeholder Salience Model exposes the behaviour of given stakeholders to justify the level of importance that they are worth.
Table 2: Salience Model
Stakeholder
Interest
Salience Assessment Reasons
Power Legitimacy Urgency
Employees
• Doctors
• Nurses
• Carers • Salary
• job security / satisfaction High High High • Powerful legal support
• Possess specialist skills
Competitors
• Private Psychiatric Hospitals
• • Dominating the market over the NHS High Low High • Competes for market share
• Can act deceptively and/or selfishly
Suppliers
• Drug Manufacturers
• Health / Medical Employment Agencies • Long-term supply contracts
• Sales and Profit High High High
• Provides vital and irreplaceable specialist inputs
Psychiatric Patients • Treatment and/or symptom management / support High High High • Absence of patients invalidates existence of organisation
Members of the public, and neighbours
• Family Members
• Friends
• Relatives
• Neighbours • Safety of the public and of neighbourhoods
• Good quality of life for all community members
• Impact of potential danger and abuse on community Low Low High • Can lobby for change, sometimes for reasons that appear unjustified to management
• May make selfish demands on organisation
Management
• NHS Corporate Managers
• Hospital Managers and Administrators • Salary
• Directs activities of organisation
• Sustainability and continuance of NHS mental health services High High High • Possess expert skills
• Exercise direct control of organisation
The UK Government
• Policy Makers
• Local Councils
• Social Services • Ensures justice and legality in psychiatric care provision
• Provision of social security and housing High High High • Sets laws
• Provide fundingand essential social support
Academic institutions
• Universities
• Other Tertiary Education Providers • Conducts research for knowledge generation and care improvement
• Trains psychiatrists and nurses High High Low • Consulted and deferred to by management
• Can not force organisation to change
• Exposes need for immediate change through research, thus placing demands on management
Not-for-Profit Organisations
• Non-governmental Organisations
• Charities • Advocacy and Lobbying
• Awareness campaigning and research Low Low High • Lobbies for immediate change
• Actions may be selfish or intentionally damaging
• Places demands on management by using research for exposing need for immediate change
Regulators and Professional Associations
• Care Quality Commission (CQC)
• Nursing and Midwifery Council (NMC)
• Royal College of Psychiatrists • Ensure safety and ethical practice by setting standards High High High • Enforces rules and imposes sanctions for non-compliance
Religious and/or Minority Organisations • Supporting and advocating for rights of people with mental illness Low High Low • Unable to force immediate attention to issues
• Low pressure for management to engage with this group, however, engaging them may improve organisational image
Stakeholder mapping of NHS mental health stakeholders
Stakeholder Mapping Grid
http://www1.worldbank.org/publicsector/anticorrupt/PoliticalEconomy/PDFversion.pdf
Table 3: Stakeholder Mapping Grid
Level of Importance Stakeholder Class Stakeholder Type
Latent Stakeholders
Low Importance
Dormant Religious Organisations
Public & Neighbours
Non-governmental Organisations
Discretionary
Demanding
Expectant Stakeholders
Moderate Importance
Active, Rather than passive
Dominant Competitors
Academic Institutions
Dangerous
Dependent
High Salience Stakeholders
High Importance
Definitive Patients
Employees
Suppliers
Management
Government
Regulators
Adapted from: Stakeholder Salience: https://www.stakeholdermap.com/stakeholder-analysis/stakeholder-salience.html#mitchell
Using the Salience Model in table 2 above, the following — classification of stakeholder importance can be achieved:
Table Posit that having only one of the three relationship attributes constitute ‘latent’ stakeholders makes stakeholders as latent, and of lowest importance to the organisation. Management may ignore them as stakeholders; disregard pressure from them, with no adverse effects on the organisation. The latent stakeholder group for the NHS psychiatric hospital are:
• Religious organisations
• Public and neighbours
• Non-governmental organisations
However, stakeholders satisfying two relational attributes comprise the ‘expectant’ stakeholders group, which is moderate in importance. Competitors and academic institutions are the two stakeholder groups occupying this category for the NHS hospital in question. This stakeholder group is active and not passive, ‘expects something’ from the firm, and require engaging with at higher levels.
Satisfying of all three attributes of the Stakeholder Salience Model places stakeholders in the final classification called the ‘high salience’ group. This group commands high importance to the organisation by influencing it in definitive ways. Their absence or pressure for action or change can threaten with closure. For the NHS psychiatric hospital under consideration, this group comprises:
• Patients
• Employees
• Suppliers
• Management
• Government
• Regulators
Table 4:
High/Medium Low/Unknown
High/Medium
Low/Unknown
Adapted from: http://www.click4it.org/index.php/Stakeholder_Analysis
Appendix B – Background to the Issue
Scenario
Whilst working as a mental health nurse (psychiatric nurse), the writer witnessed a psychotic patient being admitted into hospital after being brought in by his family members. He was hearing voices in his head and responding in a dangerous manner, making threats to harm others and attempting to physically assault staff and family. He was also verbalising threats to kill others, but did not threatento harm himself at any point.
The patient had previously been admitted into the current hospital several times before being treated to stabilise his symptoms. This led to his discharge back to live with his family in the community and be treated under Community Treatment Orders. During his treatment at home, the patient had a repeated pattern of believing that he was healed, and then refusing medication from the community psychiatric team members for fear of adverse side effects. However, even the slightest stoppage of treatment caused him to relapse and require readmission into hospital for treatment. In hospital, he was sometimes treated under mental health detention, which he disliked as he felt that it restricted his freedom to live his life the way he wanted.
The patient had historically responded positively to medication within a short period of admission into hospital, regardless of the length of time he would have missed his treatment and medication. On the occasion in question, the patient was offered medication that was proven to best treat his psychosis, based on his history. He refused to take the medication, insisting that he feared its side effects, and a religion that he had recently joined also forbade him to take mind-altering substances like drugs and medication. He said he was convinced that God was going to heal his psychosis at the right time and therefore, psychiatric professionals should never medicate him again. The family members in attendance confirmed that the patient was telling the truth about having recently joined a new religion that shared the beliefs that he was expressing.
Staff and hospital managers then told the patient that if he did not take the medication voluntarily, he would be detained under section on the MHA (1983). He was told that this way, he would be treated compulsorily, which would potentially delay his discharge back to live with his family again. He was told that by sectioning him and forcing treatment on him, professionals would be protecting his family and other members of his community from the potential harm that he was presenting due to psychosis. The patient then accepted the medication. He however kept protesting and accusing the hospital of disregarding his religion and denying him the exercising of his right to live as he chose without interference. He also said that the hospital and the psychiatrists were exposing him to adverse side effects of medication, which compromised his physical health to a high extent.
Coercion in Psychiatry Treatment
Coercion can be defined as the act of using force or threats to persuade someone to something (Poulsen, 1999).
Coercion can either be formal if exercised within regulations of the MHA, or informal if exercised through interventions that lie outside the boundaries of formal coercion (Valenti et al, 2015). The coercion that occurred in the situation informing this report was outside the coverage of the MHA, and therefore informal in nature. Valenti et al (2015) outlines that informal coercion would involve persuading, interpersonal leveraging, inducing, or threatening someone as means for influencing their acceptance of medicinal treatment.
Appendix c – Monthly journal
The table below shows a monthly journal of crucial readings for psychiatrists, psychologists and other stakeholders.
Table 5
Audience Relevant service areas Coverage of human rights
Service managers NHS Right to life
Right to liberty and security
Right to a fair trial
Freedom from torture and inhuman or degrading treatment
Respect for your private and family life, home and correspondence
Adapted from: http://bjp.rcpsych.org/content/182/2/91.full
