Rule-breaking by psychiatric inpatients is introduced as a common problem, but, surprisingly, how staff respond to such behaviour has attracted little specific literature. It is a subject that raises complex and difficult questions of ethics, law and clinical practice. A sample of psychiatric nursing staff (574), from low-, medium- and maximum-security settings, took part in a decision-making exercise, designed to examine attitudes towards, and concepts of, patients' rule-breaking. Subjects viewed a short video-tape of fictional disturbed patient behaviour and their responses were elicited by a semi-structured questionnaire. They were shown one of a number of possible scenarios, with controlled variables including the fictional patient's gender and racial origin, the diagnosis, any past history of violence and the nature of the incident. Moral judgement emerged as a central theme. A theoretical model is proposed, in which the response to patient misdemeanour involves three inseparable components: containment of the unsafe; treatment of underlying pathology; and moral censure. It is concluded that clinical policies and guidelines must recognize the influence of moral judgement and introduce systems that ensure the reasonableness of those judgements, through education, staff support, supervision and mechanisms of appeal.
- moral judgement