Moral experiences of crisis management in a child mental health setting: A participatory hermeneutic ethnographic inquiry

The use of restraint and seclusion to manage crisis situations in mental health settings is being widely challenged, but is still common. The rates of restraint and seclusion episodes on child mental health units are of particular concern, as they have been reported to be significantly higher than on adult units. A growing body of literature has highlighted the misuse of these control measures and the serious harms that can result from these practices (e.g. traumatization, death of the child). The use of such measures poses ethical challenges to nurses and other staff members who aim to act in the best interests of children and ensure their safety, while promoting children's capacity to manage their behavior and recognize children's agency. This study sought to examine the institutional norms, structures, practices, and corresponding moral experiences of children, parents and staff members around crisis management and the related use of control measures in order to develop care approaches that promote an optimal reconciliation of ethical concerns in child mental health. A novel methodological framework drawing on Taylor's hermeneutic philosophy—participatory hermeneutic ethnography—was developed to conduct this study, which enabled an in-depth examination of the concept of children's agency. A five-month participatory hermeneutic ethnography was conducted in a Canadian child mental health setting providing care to children aged 6 to 12 years old. Data collection involved participant observation, interviews, and documentation review. An interpretive framework was used for data analysis. The results show how the strict structure in place both prevented and contributed to crisis situations. Children were expected to comply, conform and acquiesce with staff and were generally perceived as the objects of care; and not as active agents involved in care processes. Children perceived control measures as helpful in exceptional cases when there was an imminent risk to someone's safety, and largely disagreed with their use as a consequence for bad behavior. This perspective contrasted with most of the staff members who considered control measures contributed to help the child feel safe, learn the limits in the setting, and form a trusting relationship. Parents were not part of the everyday experiences in the setting, and were confident the staff would use control measures as a last resort. The results suggest that the prevalent view of the child shared by staff members as incomplete human becomings led to the adoption and legitimization of authoritative norms, structures and practices guided largely by a behavioral approach, which sometimes led to an increased use of control measures for reasons other than imminent harm. Children experienced these controlling practices as abusive and hindering the development of trusting relationships with the staff, which impeded the implementation of a more collaborative approach that staff members sought to put in place to prevent the use of control measures. Changes in conceptions of children from objects to agents by the staff and seeking a rapprochement with children, by getting to know what is meaningful to them and try to bridge these horizons, could help build more authentic trusting relationships that might be more conducive to the implementation of collaborative approaches.

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