Balancing Autonomy and Safety: A Comprehensive Review of Patient and Psychiatric Nurse Perspectives on Patient Rights in Mental Health Care

1. Introduction

Patient rights in psychiatric settings are crucial to maintaining the dignity and autonomy of individuals undergoing treatment. However, balancing patient rights with the need for safety and therapeutic intervention often presents ethical challenges (Ebrahimi & Salehi Dehno, 2018). These challenges can create a significant divide between the expectations of patients and healthcare providers, especially nurses, who are tasked with both ensuring patient safety and maintaining therapeutic relationships. Informed consent is one of the most debated issues within psychiatric care, with nurses often prioritizing safety over the autonomy of the patient (Roberts, 2020). Patients, however, express a desire for more involvement in decisions concerning their care, as well as a better understanding of their rights (Cutcliffe & Links, 2021). This divergence between patient and nurse views often leads to confusion and a sense of powerlessness among psychiatric patients, as well as ethical dilemmas for healthcare providers (Tsunematsu et al., 2021). Globally, mental health policies, such as the WHO QualityRights initiative, call for respect for human rights and the implementation of person-centered care (WHO, 2021). However, in practice, patients often report feeling disempowered or unaware of their rights (Chavez & Nunez, 2020).

In some cases, institutional policies and high workloads contribute to limited communication between staff and patients, reducing opportunities for dialogue about rights and choices. Additionally, cultural and systemic factors may further hinder patient autonomy, especially in countries where mental illness is highly stigmatized. Nurses often operate under pressure, having to balance therapeutic goals with legal responsibilities and risk management. The lack of training in ethical reasoning and rights-based care models contributes to inconsistent practices. This highlights the urgent need for reforms that reinforce rights awareness, therapeutic alliance, and ethical competency in psychiatric settings.

2. Methodology

This literature review follows the framework outlined by Cooper (2017), which includes defining the research problem, conducting a systematic literature search, evaluating the data, analyzing the results, and interpreting findings. Studies were selected based on the following inclusion criteria: published in English, between 2018 and 2021, and focused on psychiatric care and patient rights.

The electronic databases searched included PubMed, Scopus, and PsycINFO. Keywords used included: "patient rights," "psychiatric nursing," "patient autonomy," and "informed consent in psychiatry." The final selection included 10 peer-reviewed articles, among which 5 were highly cited and directly related to the study’s aim. Additional articles were obtained from the reference lists of included studies. To assess the quality of the studies, the CASP checklist was employed, ensuring the studies met rigorous standards for methodological quality. The data was then synthesized into three overarching themes: communication, participation in decision-making, and the use of restrictive measures in psychiatric care (Ebrahimi & Salehi Dehno, 2018; Roberts, 2020; WHO, 2021; Tsunematsu et al., 2021; Cutcliffe & Links, 2021). A narrative synthesis approach was used to integrate findings from both qualitative and quantitative studies. Duplicates were removed manually, and abstracts were screened independently by two reviewers. Any discrepancies in study selection were resolved through discussion and consensus. Ethical approval was not required for this review, as it did not involve human participants. The process adhered to PRISMA guidelines to ensure transparency and rigor in the selection and analysis of literature.

3. Results

a. Communication Barriers

One of the key barriers to the realization of patient rights in psychiatric settings is poor communication. Ebrahimi and Salehi Dehno (2018) found that a significant percentage of psychiatric patients (42%) did not fully comprehend the procedures or treatment they were undergoing, which can contribute to feelings of alienation. Nurses, due to time constraints and increased patient load, often do not engage in clear, open communication regarding patient rights (Roberts, 2020). Effective communication, as identified by Tsunematsu et al. (2021), is pivotal in making patients feel empowered and involved in their treatment. Moreover, Chavez and Nunez (2020) noted that there is a mismatch between the expectations of healthcare providers and patients when it comes to understanding informed consent. Patients often feel rushed or pressured into signing documents they do not fully understand, a situation exacerbated by the complexity of psychiatric diagnoses. Improving communication requires a cultural shift within psychiatric institutions, where patients are seen as active participants rather than passive recipients. Creating more time for patient interactions can enhance trust and reduce anxiety. Communication should be adapted to individual needs, including cognitive or language limitations. Institutions must prioritize training in therapeutic communication skills. Strengthening this aspect of care leads to more ethical and person-centered treatment environments.

b. Participation in Decision-Making

Another theme emerging from the literature is the involvement of patients in decision-making regarding their treatment plans. According to Cutcliffe and Links (2021), patients frequently report feeling excluded from decisions about their treatment, which can lead to mistrust and dissatisfaction with care. This finding is supported by Ebrahimi and Salehi Dehno (2018), who showed that patients who are not involved in their care are more likely to be non-compliant with treatment. Nurses, however, are often caught in the dilemma of whether to prioritize patient autonomy or ensure adherence to treatment plans, especially in cases where patients may not have the capacity to make informed decisions due to their psychiatric condition (Roberts, 2020).

Tsunematsu et al. (2021) highlight that in forensic psychiatric care, the notion of shared decision-making is less commonly practiced due to the coercive nature of the environment. The lack of shared decision-making negatively affects patients' satisfaction with care and undermines their sense of autonomy. Encouraging participation requires building mutual trust and giving patients space to express their preferences. This approach can foster a sense of agency and improve adherence to care plans. Even in cases where decision-making capacity is limited, collaborative strategies can still be applied. Respecting patients’ values and involving them where possible strengthens the therapeutic alliance. Shared decision-making should be viewed as a dynamic process tailored to the patient’s needs and evolving condition.

c. Use of Restrictive Measures

The third critical issue is the use of restrictive interventions such as involuntary medication or seclusion. According to Tsunematsu et al. (2021), the decision to implement coercive measures is often made based on clinical judgment and institutional policy rather than patient consent. This creates an ethical dilemma for nurses, who are required to balance patient autonomy with the safety needs of the institution. However, Cutcliffe and Links (2021) argue that the use of such measures is often justified by nurses as being in the best interest of the patient, even though it may violate basic human rights. Chavez and Nunez (2020) found that restrictive measures often lead to feelings of anger and distrust among patients, making it difficult for therapeutic relationships to thrive. Nurses themselves report experiencing moral distress when having to apply such measures, particularly when they feel that the treatment goes against their ethical beliefs (WHO, 2021). Minimizing the use of coercive interventions requires a shift toward de-escalation techniques and trauma-informed care. Facilities should implement clear guidelines and accountability measures to ensure restrictions are only used as a last resort. Promoting a culture of empathy and patient-centered care can significantly reduce reliance on such practices. Involving patients in post-incident reviews may also support emotional recovery and relationship repair. Ultimately, restrictive measures should be replaced where possible with approaches that prioritize dignity, trust, and recovery-oriented values.

4. Discussion

The findings of this review underscore the ethical complexities that arise in psychiatric care, particularly regarding communication, autonomy, and restrictive interventions. Nurses are often caught between adhering to institutional policies and respecting patient autonomy. The study by Ebrahimi and Salehi Dehno (2018) emphasized that while nurses view their actions as necessary to ensure patient safety, patients see them as violations of their rights. Furthermore, while the WHO’s QualityRights initiative (2021) advocates for the promotion of person-centered care, the evidence suggests that psychiatric institutions still struggle to fully implement these principles. The findings from Tsunematsu et al. (2021) and Chavez and Nunez (2020) demonstrate that the use of restrictive interventions often diminishes patients' sense of autonomy and worsens their mental health outcomes. Ultimately, there is a clear need for training that emphasizes patient rights and ethical decision-making. This can help nurses better navigate the complexities of psychiatric care, ensuring that both patient safety and autonomy are preserved. The moral distress reported by nurses when implementing restrictive measures suggests that institutional support for ethical reflection is essential (Cutcliffe & Links, 2021). Increased collaboration between staff and patients can foster a more balanced therapeutic environment. Organizations should evaluate their policies through a human rights lens to identify areas needing reform. Emphasizing empathy and cultural competence may also improve care quality and trust. Future studies should explore practical interventions that reduce coercion without compromising safety. A shift toward more inclusive and rights-oriented models of care is both necessary and overdue.

5. Conclusion

This review demonstrates the need for greater alignment between the rights of psychiatric patients and the ethical practices of healthcare providers. While nurses play a crucial role in safeguarding patient safety, there must be a stronger focus on communication, informed consent, and shared decision-making to empower patients. Moreover, restrictive measures should be used sparingly and only when absolutely necessary, ensuring that patient dignity and autonomy are not compromised.

6. Recommendations

• Implementing training programs focused on human rights and ethical decision-making for healthcare providers.
• Developing clear guidelines that promote shared decision-making and autonomy while safeguarding safety.
• Encouraging patient education on their rights to foster a greater sense of control and trust.
• Ensuring regular institutional reviews of practices involving restrictive interventions.