Defensive practive in mental health (New Zealand)
Journal of the New Zealand Medical Association
Defensive practice in mental health
Richard Mullen, Anita Admiraal, Judy Trevena
NZMJ 28 November 2008, Vol 121 No 1286; ISSN 1175 8716
This study aimed to assess the extent of defensive clinical practice by psychiatrists and psychiatric nurses in a New Zealand Mental Health Service.
Defensive practice occurs whenever a practitioner gives a higher priority to self- protection from blame than to the best interests of the patient.
Negative defensive practice (avoidance behaviour) consists of avoiding certain procedures, patients or clinical scenarios because of the perception of the hazard of liability. Negative defensive practice appears by definition to be adverse in its clinical impact. Both positive and negative defensive medical practice appear commonplace.
Mental health practice may raise particular pressures to practice defensively. Questions of diagnostic validity and reliability are such that the evidence base for mental health practice is less easily interpreted, so that clinical decisions are based more on the impression and opinion of individual clinicians than is the case in other areas of medicine.
Clinicians in mental health are under pressure to respond not just to the needs and preferences of
individual patients, but also to those of their families, and to wider societal concerns.
NZ studies of medical practitioners report high rates of defensive practice and concern regarding complaints. In NZ, mental health clinicians may feel vulnerable in relation to ambiguity regarding clinical accountability, and they have reported feeling forced to practice in a defensive manner by the impression that they are increasingly being held to account for inadequacies within the mental health sector as a whole.
The NZ Parliament has legislated for a Health and Disability Commissioner (HDC)— an independent agency designed to facilitate the rapid resolution of complaints about the quality of health care and disability services. Complaints are considered an opportunity to improve health services and they rarely end in the censure of a practitioner.
Overall, nurses perceived more practice as defensive than psychiatrists.
This study indicates that defensive practice is widely perceived to be commonplace in mental health practice.
Prominent advocates of evidence-based medicine also emphasise the need for individual clinicians to interpret the problems of the individual patient, using available evidence in a critical manner, generally in the context of a dialogue with the patient.
If a group of clinicians has defensive norms, practicing less defensively carries a greater risk as it violates rather than reflects those norms. It seems that it is not enough to make the right decision, or the best available decision, the decision must also look right to outsiders.
The Bolam principle will tend to make clinicians behave as they believe other clinicians behave. Thus, if excessively defensive practice is the norm, less defensive practice appears correspondingly maverick and hard to justify.
Complaints about practice are seen in the USA as an important means of improving health care quality.
There are two main reasons why defensive practice may be on the increase. Firstly, defensive practice may be an inevitable part of a risk-averse culture, increasingly a concern in New Zealand as elsewhere. Secondly, the proliferation of treatment protocols and guidelines may make practitioners reluctant to substitute their own judgement.
Claims that there is a climate of defensive practice may tend to be self-fulfilling. Nonetheless, attention to the matter is warranted.
Our results are similar to those of other NZ studies of defensive practice.