Beyond Event Counting: A Nurse Practitioner‐Led Transparency and Repair Framework for Reducing Coercion in Acute Child and Adolescent Psychiatry

Dear Editor,

We read with great interest the article by Henriksen et al. (2026), which provides a timely and clinically important account of how formal and informal coercion may be embedded in acute child and adolescent psychiatric care. We write this letter as a practice‐focused commentary on that article, rather than as a critique of individual clinicians or wards. Henriksen et al. show that coercion is not confined to registered events such as restraint, seclusion, forced medication, or nasogastric feeding. It may also occur through ordinary ward practices, including withholding information, using discharge or home leave as leverage, or invoking the possibility of formal coercion to secure compliance. For psychiatric nurses and nurse practitioners, this observation is especially relevant because many of these interactions occur during routine nursing care, family communication, and crisis management.

We would like to extend the authors' discussion by proposing that transparency should be treated as a measurable and supportive nursing intervention. This should not be understood as a checklist to police staff or assign blame. Informal coercion often emerges in situations marked by acuity, risk, uncertainty, staffing pressure, and ward culture. The purpose of measuring transparency is therefore to create a shared language for reflection, supervision, and quality improvement. Staff trust in non‐coercive approaches appears critical to avoiding a negative spiral of coercion (Moell et al. 2025). A brief team‐based transparency prompt could ask: What has the adolescent been told? What choices are genuine? What clinical limits must be explained honestly? What happens if treatment is refused? How can the adolescent disagree, complain, or request review? Such prompts should be used in huddles, supervision, or debriefing, not as a punitive audit of individual staff.

Second, coercion reduction should be understood as a nursing systems intervention. A ward may reduce seclusion or restraint while still exposing young people to pressure that is unclear, frightening, or experienced as unfair. Adolescents may evaluate containment measures differently from staff, and when containment cannot be avoided, developmentally appropriate information, explanation, and debriefing are essential (Hottinen et al. 2012; Yurtbasi et al. 2023). Adolescents' broader experiences of inpatient mental health care also show that the ward environment and interactions with staff and peers are central to whether admission feels therapeutic or alienating (Shin and Ahn 2023). System‐level approaches have reduced restraint and seclusion in child and adolescent inpatient settings through strength‐based care, structured quality improvement, decision algorithms, individualized behavioral plans, and post‐event debriefing (Eblin 2019; LeBel et al. 2004).

Third, the nurse practitioner role should be understood as an implementation role rather than a claim that one profession can reduce coercion alone. We use “nurse practitioner‐led” to describe settings in which advanced practice psychiatric nurses or nurse practitioners participate in assessment, psychoeducation, risk communication, family meetings, crisis planning, medication education, and quality‐improvement work. In this position, nurse practitioners can bridge bedside nursing observations, medical decision‐making, adolescent and family perspectives, and ward‐level governance. The framework should nevertheless remain team‐based. In systems without a formal nurse practitioner role, a clinical nurse specialist, senior psychiatric nurse, charge nurse, or interprofessional quality‐improvement lead could coordinate the same functions.

Fourth, the concept of repair should be incorporated into routine clinical practice. Young people with post‐traumatic stress disorder, borderline personality disorder, out‐of‐home care, or recurrent admissions may be at higher risk for seclusion or restraint and require individualized crisis plans and post‐coercion review (Czernin et al. 2024; Yurtbasi et al. 2021). In eating‐disorder care, nasogastric feeding may be medically necessary and can support weight restoration, but its acceptance may depend on multidisciplinary care, tailored psychoeducation, and attention to psychological discomfort (Amianto et al. 2026). These examples show that reducing coercion does not mean avoiding clinically necessary treatment; rather, it means explaining, negotiating, reviewing, and repairing the therapeutic relationship when an adolescent experiences treatment as pressure.

We therefore propose a nurse practitioner‐led transparency and repair framework for acute child and adolescent psychiatric wards. Its practical elements are: (1) admission‐based explanation of ward rules, rights, treatment options, and non‐negotiable safety limits; (2) documentation of the adolescent's preferences, objections, communication needs, and crisis triggers; (3) anticipatory crisis planning for patients at higher risk of restraint, seclusion, forced treatment, or coercion‐adjacent communication; (4) structured debriefing after coercive or coercion‐adjacent encounters, including what the adolescent understood, what staff intended, what harm may have occurred, and what can be repaired; (5) staff reflective review focused on skill‐building, emotional support, and trust in non‐coercive approaches; and (6) aggregate monthly review of both formal events and selected process indicators, such as whether explanations, choices, complaints pathways, and post‐event debriefings were documented. To avoid an accusatory frame, these reviews should be anonymized when possible, embedded in existing quality‐improvement structures, and co‐designed with staff, adolescents, and families.

Henriksen et al. (2026) have provided an important foundation for practice change. The next step is to move beyond event counting and test whether team‐based transparency, shared crisis planning, staff support, and structured repair can reduce not only coercive events, but also the less visible pressures that shape young people's trust in psychiatric care.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

AI‐Assisted Editorial Support Disclosure

OpenAI ChatGPT (GPT‐5.5 Pro) was used for language refinement, editorial drafting assistance, and revision drafting support for the manuscript title and Letter body, including improving grammar, clarity, structure, and wording. The authors provided the target article, reviewer comments, PubMed‐derived references, clinical interpretation, and final scientific judgment. The tool was not used to generate research data, conduct statistical analysis, create figures or tables, or independently formulate scientific conclusions. The authors reviewed, revised, and verified all AI‐assisted text, checked the accuracy and relevance of all citations and references, and take full responsibility for the final content of the manuscript.

Data Availability Statement

Data sharing is not applicable to this article as no data sets were generated or analyzed during the current study.