Coercive Interventions Mental Health Assignment

Running head: MENTAL HEALTH
Mental health
Name of the student:
Name of the University:
Author’s note

1MENTAL HEALTH
The uses of restrictive and coercive interventions are common in mental health settings
and it mainly involves the use of authority to restrain a person’s autonomy and restrict adverse
behaviours in some way or the others (Brady et al., 2017). Due to the nature of coercive practices
and its role in infringing human and ethical rights, there are many controversies surrounding the
use of this intervention in mental health settings. One such coercive intervention is the use of
psychotropic medications to control behaviour and symptoms for people with mental illness
(Sheehan et al., 2015). The main purpose of this essay to review the controversy regarding the
use of psychotropic medications in mental health and interpret the advantages and limitations
associated with the use of sedative medications in patient. In addition to this, essay will present
findings about the challenges faced by registered nurse in administering such medications to
patients who have risk of self-harm and harm to others.
People diagnosed with mental illness often display challenging behaviours when
progressive deterioration of symptoms occur and the problematic behaviour may be such that it
may threaten the physical safety of the patient or individuals near to him (Brady et al., 2017).
Psychotropic medications like antipsychotic medications, anti-depressants and mood stabilisers
are often provided to such patients (Charlot, Sheehan & Hassiotis, 2019). These medications
should be given for challenging behaviours and such medications should be avoided unless the
patient’s behaviour is very serious and it has not been addressed by the use of other treatment
(Flood, 2018). However, review of research paper by Sheehan et al. (2015) revealed that
concerns has been expressed regarding the use of these drugs as it is overused in patients with
intellectual disability and patients with severe mental illness (SMI). Hjorth et al. (2014)
enlightened the controversy surrounding the use of these medications by stating that prescribing
of high doses of antipsychotic drug is common in clinical practice without the use of appropriate

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clinical guidelines. This is considered inappropriate because of negative physical health
implications on patient such as side-effects and dose related toxicity. For instance, weight gain
occurs due to the use of multiple psychotropic medications. In some patients with SMI, it may
also lead to serious side-effects such as tremor, sexual dysfunction, sedation, decreased physical
activity and adverse effects on heart (Moncrieff, Cohen & Porter, 2013). Thus, due to these
disadvantages associated with use of psychotropic medication, there is a strong movement to
control or eliminate practice altogether.
In an attempt to understand the controversy surrounding the use of psychotropic
medicines like sedatives, there is a new to review research literatures related to the impact of
such coercive interventions on consumers as well as health care professionals. Firstly, the essay
will look into aim or advantage of using psychotropic drugs like sedatives with patient and then
consider the challenges linked to the practice. According to Scheppke et al. (2014), staffs in
mental health setting are often confronted with violent and uncooperative patient. These groups
of patient mostly exhibit symptoms of aggressive behaviour and altered sensory behaviour. In
order to gain medical control over these patients, staffs often provide medications like
benzodiazepines and haloperidol which have sedative effects. However, the study reported some
challenges or problems associated with the use of these medications. For example, most of these
patients are given sedative medications in high doses leading to negative hemodynamic and
respiratory side-effects (Schepis et al., 2018). Moreover, Mantovani et al. (2010) reports frequent
use of rapid tranquilization as a type of pharmacological management of agitation in patient with
SMI. The purpose of this intervention is to reduce symptoms without prolonged sedation and
keeping the patient responsive too. However, apart from the advantages, the authors expressed
concern regarding the use of high potency antipsychotic medication. It linked use of these

3MENTAL HEALTH
medications with severe side-effects such as excessive sedation and impaired motor and
cognitive function and this is consistent with the study by (Goldberg & Ernst, 2018). This study
suggests why there is a controversy surrounding use of psychotropic medications. To reduce risk
of harm to patient, mental health professionals must be very careful regarding use of these
medications and even if there is a need to use the drug, it should be given in lowest possible
dose. Instead of completely relying on such pharmacological interventions, the professional
team should be proficient in showing behaviour to effectively manage violent patient and prevent
damage to property or any harm to other patients too (Heckemann et al., 2019).
The review of above literature gave idea about the benefits and harms associated with
psychotropic medications on patient. However, as dealing with violent patient is a professional
responsibility of medical staffs, finding out how use of sedative medication and deciding to use
these types of drug challenge staffs is an area that must be explored too. The main purpose of
psychotropic drug is to restrict violent patient by the use of pharmacological effects like
sedation. However, one of the major concerns for staffs related to deciding about the use of such
coercive practice is the high risk of ethical challenges with the practice (Goldberg & Wagner,
2019). Hem et al. (2018) has discussed about some of these challenges by conducting a
systematic review of literature. As per the ethical principal of beneficence, use of coercion is
justified to promote the best interest of patient. However, as majority of staffs use coercion
techniques without taking patient’s permission, patient autonomy is significantly challenged.
Thus, autonomy infringement during use of coercive practice like using sedative medication
leads to anxiety among staffs. This form of decision making challenge is high for those staffs
who have less experience compared to experienced staffs. Moral distress is a common
behavioural response for such staffs too. How to strike a balance between maleficence versus

4MENTAL HEALTH
beneficence is one of the major issues for mental health professionals. Haw & Wolstencroft
(2014) indicated that the time has come when staffs must look beyond use of psychotropic
medications and integrate other therapeutic technique to manage violent behaviour of patient
with SMI.
Apart from ethical decision making challenges for mental health professionals in use of
psychotropic medications, many staffs are emotionally and psychological drained when exposed
to violent patients and using sedative drugs in such patient (Dib et al., 2018). For example, an
empirical study by Joubert and Bhagwan (2018) gave insight into the challenging role of
psychiatric nurse at in-patient psychiatric facilities. They are faced with daunting and complex
challenges when trying to dispense psychotropic medication and communicating with mental
health consumers. The study by Joubert(2015) explored experience of nurses and the key
findings from this research was that 88.35% psychiatric nurses encountered patients who refused
medication and they experienced feelings of anger and frustration due to these challenges.
Because of constant exposure to such trauma, many psychiatric nurse experience burnout too.
When critically analyzing the above two papers, it can be said that nurse lack the skills and
competency to manage medications too. Thus, the study gave the implication that further
training initiative related can enhance competence and skills to better manage patients with
aggression. Moreover, as many staffs suffer serious injury while trying to administer medications
to violent patient, there is a need for organization wide policy to protect nurse in this situation
too.
There were many research papers that explored the challenges faced by nurse in the use
of coercive practice of psychotropic medication by looking at their lived experience. The study
by Cooper et al. (2019) mainly focussed on evaluating the challenges for mental health

5MENTAL HEALTH
professionals in reducing and stopping antipsychotic medications for patient. By conducting a
focused group interview with these professionals, the studying findings showed that all
participants accepted that use of psychotropic medication has several side-effects. They also had
the intention to reduce the disadvantage and its adverse effect on patient by lowering the dose of
the drug. However, majority of participants reported challenges in trying to reduce and
discontinue antipsychotic medications for these group. They experienced both organizational and
patient related barriers. For example, organizational barriers included lack of resources to
support the reduction process and support funding for alternative treatments and poor continuity
of care because of lack of time or knowledge to reduce use of these drugs effectively. The study
reported about knowledge barriers too such as lack of any proper guidelines on reducing use of
antipsychotic medication and uncertainty around which patient may be suitable for reduction.
This is a very significant study in the context of understanding challenges for professionals in
using and reducing psychotropic medication use. It gives the implication for policy makers and
health leaders to come up with proper clinical guidelines to manage conflicting demands from
patient as well as families.
The study by Ramezani et al. (2019) focused on the use of coercive measures like
medication, seclusion and restraint too and investigated about challenges for nurse in the
management of aggressive patient. The study identified three broad categories of challenges
which were categorized into organizational policy, insufficient job growth and deficiencies in
organizational culture. For the theme of organizational policy, common opinion of participants
was that staff shortage result in ignorance of patient need and more incidence of patient
aggression in the ward. Shortage of protective equipment was identified as a barrier for nurse
while giving medications or coming near to psychiatric patients which is supported by Slemon,

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Jenkins and Bungay (2017) too. Lack of skills and competence to manage such patients and little
support from managers was also expressed as some challenges in the process. Lack of
knowledge has prevented them from implementing suitable interventions. Deficiencies in
organizational culture were an important theme too as participants as nurses had to take quick
decisions in risky situations without any support from other team members. Thus, effective
training and giving nurse the authority to take decision were some practice implications of this
study. Based on the analysis of the challenges for nurse in using sedative medications, it can be
said that many new initiative should be taken by mental health service in Australia to empower
registered mental health nurse. For example, prioritizing training and development related to
handling of aggressive psychiatric patient is a necessary quality improvement strategy. These
training programs can work to address aspects that needs better attention such as stigma, safety
of patient, risk assessment, crisis and stress management (Joubert & Bhagwan, 2018).
To conclude, the essay discussed about the controversy surrounding use of psychotropic
medications and found many disadvantages associated with its use for patient as well as health
care staffs. Some of the advantages of using such coercive medications were that it resulted in
quick relief from aggressive symptoms and protecting the patient or staff from many harm.
However, the literature review on the topic revealed about many challenges too such as high rate
of adverse effects for patient, weight gain issues and ethical concerns due to conflict between
autonomy and beneficence. In context of nurse, some of the key challenges or barriers were lack
of proper guidelines on managing such patient and reducing use of psychiatric medication, lack
of safety culture and team work to manage the issue and lack of competence or knowledge to
deal with the situation. Thus, overall the essay gives many implications to change organizational

7MENTAL HEALTH
environment as well as training patterns so that psychiatric nurses are better positioned in
confidently dealing with aggressive patients.
References:
Brady, N. S., Spittal, M. J., Brophy, L. M., & Harvey, C. A. (2017). Patients’ experiences of
restrictive interventions in Australia: Findings from the 2010 Australian survey of
psychosis. Psychiatric Services, 68(9), 966-969.
Charlot, L., Sheehan, R., & Hassiotis, A. (2019). Use of Medications in the Treatment of
Aggressive Behavior. In Handbook of Intellectual Disabilities (pp. 661-681). Springer,
Cham.
Cooper, R. E., Hanratty, É., Morant, N., & Moncrieff, J. (2019). Mental health professionals’
views and experiences of antipsychotic reduction and discontinuation. PloS one, 14(6).
Dib, J. E., Adams, C. E., Kazour, F., Tahan, F., Haddad, G., Haddad, C., & Hallit, S. (2018).
Managing acutely aggressive or agitated people in a psychiatric setting: a survey in
Lebanon. Medical journal of the Islamic Republic of Iran, 32, 60.
Flood, B. (2018). De-prescribing of psychotropic medications in the adult population with
intellectual disabilities: A commentary. Pharmacy, 6(2), 28.
Goldberg, J. F., & Ernst, C. L. (2018). Managing the side effects of psychotropic medications.
American Psychiatric Pub.

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Goldberg, S. G., & Wagner, K. (2019). American Psychological Association practice guidelines
for psychopharmacology: Ethical practice considerations for psychologists involving
psychotropic use with children and adolescents. Journal of clinical psychology, 75(3),
344-363.
Haw, C., & Wolstencroft, L. (2014). A study of the use of sedative PRN medication in patients at
a secure hospital. The Journal of Forensic Psychiatry & Psychology, 25(3), 307-320.
Heckemann, B., Hahn, S., Halfens, R. J., Richter, D., & Schols, J. M. (2019). Patient and visitor
aggression in healthcare: A survey exploring organisational safety culture and team
efficacy. Journal of nursing management, 27(5), 1039-1046.
Hem, M. H., Gjerberg, E., Husum, T. L., & Pedersen, R. (2018). Ethical challenges when using
coercion in mental healthcare: a systematic literature review. Nursing Ethics, 25(1), 92-
110.
Hjorth, P., Kilian, R., Sørensen, H. Ø., Eriksen, S. E., Davidsen, A. S., Jensen, S. O. W., &
Munk-Jørgensen, P. (2015). Reducing psychotropic pharmacotherapy in patients with
severe mental illness: a cluster-randomized controlled intervention study. Therapeutic
advances in psychopharmacology, 5(2), 67-75.
Joubert, P. D. (2015). An investigation into the roles of registered nurses and psychiatric nurses
at in-patient psychiatric facilities and its implications for nursing education in KwaZulu-
Natal (Doctoral dissertation).

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Joubert, P. D., & Bhagwan, R. (2018). An empirical study of the challenging roles of psychiatric
nurses at in-patient psychiatric facilities and its implications for nursing
education. International journal of Africa nursing sciences, 9, 49-56.
Mantovani, C., Migon, M. N., Alheira, F. V., & Del-Ben, C. M. (2010). Managing agitated or
aggressive patients. Rev Bras Psiquiatr, 32(S2), S96-103.
Moncrieff, J., Cohen, D., & Porter, S. (2013). The psychoactive effects of psychiatric
medication: the elephant in the room. Journal of psychoactive drugs, 45(5), 409-415.
Ramezani, T., Gholamzadeh, S., Torabizadeh, C., Sharif, F., & Ahmadzadeh, L. (2017).
Challenges of nurses’ empowerment in the management of patient aggression: A
qualitative study. Iranian journal of nursing and midwifery research, 22(6), 442.
Schepis, T. S., Teter, C. J., Simoni-Wastila, L., & McCabe, S. E. (2018). Prescription
tranquilizer/sedative misuse prevalence and correlates across age cohorts in the
US. Addictive behaviors, 87, 24-32.
Scheppke, K. A., Braghiroli, J., Shalaby, M., & Chait, R. (2014). Prehospital use of im ketamine
for sedation of violent and agitated patients. Western journal of emergency
medicine, 15(7), 736.
Sheehan, R., Hassiotis, A., Walters, K., Osborn, D., Strydom, A., & Horsfall, L. (2015). Mental
illness, challenging behaviour, and psychotropic drug prescribing in people with
intellectual disability: UK population based cohort study. Bmj, 351, h4326.

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Slemon, A., Jenkins, E., & Bungay, V. (2017). Safety in psychiatric inpatient care: The impact of
risk management culture on mental health nursing practice. Nursing Inquiry, 24(4),
e12199.