https://www.infirmiere-canadienne.com/blogs/ic-contenu/2026/04/13/soins-de-sante-mentale-involontaires
Moral and ethical complexities of involuntary treatment create significant challenges for nurses
By Angela Russolillo
April 13, 2026
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The knowledge, skills and evidence base for expanded nursing roles in the care of people with mental health and substance use disorders already exist. What’s missing is the political motivation to implement these changes and provide the necessary resources and support.
In the British Columbia (B.C.) mental health-care system, nurses occupy a complex position at the intersection of care delivery and policy implementation. Nurses are responsible for enacting care authorized through legislation, such as the Mental Health Act. While physicians initially determine when individuals require involuntary treatment, nurses carry out the practical aspects of these decisions by administering medications, implementing seclusion protocols, and applying physical restraints when clinically indicated.
This places nurses in a uniquely challenging position of balancing therapeutic relationships with legal requirements. While each Canadian province has unique mental health legislation, B.C. is one of a few provinces with plans to expand involuntary treatment facilities for people with co-occurring mental health and substance use disorders.
This article examines the role of nurses in the delivery of involuntary treatment in B.C., situates current policy developments within this context, and draws on B.C.’s experience to propose actionable recommendations to strengthen nurses’ role in mental health care delivery and policy development across Canada.
Nursing practice potentially in conflict with legal enforcement
The moral and ethical complexities of involuntary treatment create significant challenges for nursing practice. Despite nurses’ commitment to empathetic and person-centred care, the routine application of involuntary treatment can inadvertently perpetuate harmful stereotypes and traumatic experiences for patients. The combination of therapeutic care alongside legally coerced treatment can normalize practices that may conflict with nursing’s fundamental principles of autonomy and human rights when providing care to patients.
Perhaps most concerning is nurses’ notable absence from policy decisions that directly impact their practice. Recent proposed changes in B.C. — to expand involuntary treatment facilities in the province for people with co-occurring mental health and substance use issues — have far-reaching implications for care delivery (Office of the Premier, 2024). These changes will be implemented with minimal nursing input, despite nurses providing 24/7 care in designated facilities operating under the Mental Health Act. With approximately 75 such facilities in B.C., nurses play a crucial role in daily care delivery. The disconnect between policy development and direct-care creates significant challenges for implementation and potentially compromises care quality and health outcomes.
The current health human resource crisis adds another layer of complexity to this situation. British Columbia’s plans to expand involuntary treatment capacity to more than 400 beds, alongside new clinical guidelines encouraging broader application of the Mental Health Act (Ministry of Health, 2025), face a significant obstacle: there simply aren’t enough nurses to safely staff these facilities or provide safe and equitable care to the growing patient population.
Rising vacancies across the nursing sector are projected to increase over the next five years, with patient safety, care quality and health system sustainability at risk (Ahmed and Bourgeault, 2022). More specifically, there is a recognized shortage of care providers for individuals with mental health and substance use disorders, and an even greater shortage of those licensed to provide the full scope of mental health services, including assessment and ongoing treatment. Despite increasing rates of unregulated drug deaths, mental health and substance use hospitalizations, and related morbidity and mortality, B.C. has some of the poorest ratios of mental health providers in Canada (Canadian Institute for Health Information [CIHI], 2021; CIHI, 2023a, 2023b).
Enhancing access to care by removing barriers to practice
Rather than expanding involuntary treatment capacity in the province, governments and health leaders should be re-designing care to include optimizing and expanding nurses’ scope of practice to enhance access to voluntary mental health and substance use services. Nurses currently face several barriers that prevent them from working to their full scope. Increased patient workloads, staffing shortages and organizational limitations on practice all contribute to underuse of nursing expertise. In addition, a lack of professional development opportunities and access to speciality education limit nurses from developing advanced mental health and substance use disorder competencies. Coordinated policy approaches could address legitimate concerns about mental health and substance use treatment access while simultaneously expanding nurses’ authority to provide evidence-based interventions.
Nurses and nurse practitioners (NPs) play a pivotal role in increasing access to mental health care, yet their potential remains largely untapped. Unlike many other countries, Canada does not train psychiatric nurse practitioners, missing an opportunity to develop this specialized role that has proved vital in other health-care systems (Gallop, 2024; Meunch & Fraze, 2022).
While NPs in B.C. do have capacity to assess and treat psychiatric disorders, as well as provide initial certification under the Mental Health Act, they receive no formal advanced education or training in mental health. They rely on primary care training received during their graduate education, which is often equivalent to basic-level competencies. Nurse practitioners who want advanced mental health training must independently seek out professional development opportunities and this education is rarely acknowledged as part of their unique skill set.
Expanding the scopes of practice of registered nurses (RNs) and registered psychiatric nurses (RPNs), in addition to that of NPs, could significantly improve access to care. Building on B.C. nurses’ existing ability to prescribe opioid agonist therapy (OAT) through certified practice, expanding RN and RPN prescriptive authority for psychiatric medication prescribing would address one key component of comprehensive mental health care. This expansion would leverage nurses’ existing competencies while addressing critical service gaps and growing demand for mental health services.
Expanding scope of practice must be accompanied by appropriate compensation. Nurses are understandably reluctant to take on additional responsibilities and risks without corresponding increased wages. Unlike physicians who are funded on a fee-for-service model, nurses cannot receive compensation for psychotherapy, counselling or prescribing. Nurses are educated and trained to practise in community and acute care settings and are able to holistically screen for, manage and coordinate care, yet they remain underutilized. Recognition of the time, education and training required for expanded scope through appropriate compensation is essential for successful expansion and implementation.
Barriers are political, not practical
The barriers to implementing these changes are not practical — they are political. The knowledge, skills and evidence base for expanded nursing roles in the care of people with mental health and substance use disorders already exist. What’s missing is the political motivation to implement these changes and provide the necessary resources and support. Expanding nursing scope of practice requires strong government endorsement, which could be demonstrated through dedicated education funding streams, formal recognition of advanced nursing competencies that standardize practice across provinces, and the removal of regulatory barriers (Byres, 2018). Government leadership is essential to overcoming jurisdictional inconsistencies and ensuring that nurses can work to their full potential, particularly in underserved areas where expanded scope could significantly improve access to care and health outcomes (Byres, 2018).
There are several key opportunities that could help bridge the gap between policy and practice, and support improved access to mental health care:
- Include nurses in mental health policy development at all levels
- Invest in training programs for psychiatric nurse practitioners
- Expand prescribing authority for RNs and RPNs
- Develop compensation models for additional nursing responsibilities
Missed opportunity
The B.C. government’s plan to increase involuntary treatment capacity in the province represents a missed opportunity to redesign how we deliver mental health care. While involuntary treatment may be needed as a last resort in certain circumstances, there is a lack of evidence to support its effectiveness (Morris and Kleinman, 2023), particularly in the context of substance use (Bahji et al., 2023; Werb et al., 2016). In contrast, policy guidance and research consistently demonstrate that voluntary and person-centred approaches are associated with improved health outcomes and fewer harms (Kallert et al., 2008; Ludici et al., 2022; WHO, 2021).
We should be investing in voluntary services that respect patient autonomy while making optimal use of nursing and other allied health expertise (e.g., psychologists). For example, expanding community-based crisis response teams, implementing nurse-led outpatient programs for medication management, and improving access to psychotherapy could increase the reach of more collaborative care models. Unfortunately, these evidence-based approaches continue to be underfunded and overlooked in policy decisions despite links to reduced health care costs due to decreased need for acute care services and improved quality of life.
Bridging the gap between policy and practice
Nurses are vital to mental health care delivery, yet their voices are often missing from key policy decisions. By bridging this gap between policy and practice, we can develop more effective, humane approaches to mental health care that better serve both patients and practitioners. The path forward requires recognizing and optimizing nursing’s contribution to mental health and substance use care — not through expanded involuntary measures, but through enhanced scopes of practice and greater involvement in policy development. The barriers to this system transformation are not a question of capacity, but commitment.
Building a safe, sustainable and coordinated health system demands collaborative investment from government, clinicians and communities, with both immediate and long-term commitments to evidence-based public policy.
References
Ahmed, H., & Bourgeault, I. V. (2022). Sustaining nurses in Canada: A set of coordinated evidence-based solutions targeted to support the nursing workforce now and into the future. Canadian Federation of Nurses Unions. https://www.bcnu.org/news-and-events/update-magazine/2023/spring-2023/sustaining-nursing-in-canada
Bahji, A. , Leger, P. , Nidumolu, A. , Watts, B. , Dama, S. , Hamilton, A. & Tanguay, R. (2023). Effectiveness of Involuntary Treatment for Individuals With Substance Use Disorders: A Systematic Review. The Canadian Journal of Addiction, 14 (4), 6-18. doi: 10.1097/CXA.0000000000000188
Byres, D. (2018). Nursing Policy Secretariat: Priority Recommendations. British Columbia Ministry of Health. https://www.health.gov.bc.ca/library/publications/year/2018/nursing-policy-consulation-report-Jan24-2018.pdf
Canadian Institute for Health Information. (2021). A profile of selected mental health and substance use health care providers in Canada, 2021. https://www.cihi.ca/en/a-profile-of-selected-mental-health-and-substance-use-health-care-providers-in-canada-2021
Canadian Institute for Health Information. (2023a). Mental health and substance use disorder discharges. https://www.cihi.ca/en/indicators/mental-health-and-substance-use-disorder-discharges
Canadian Institute for Health Information. (2023b). Repeat hospital stays for mental health and substance use. https://www.cihi.ca/en/indicators/repeat-hospital-stays-for-mental-health-and-substance-use
Gallop, R. (2024). Advanced practice psychiatric nursing in Canada. International Society of Psychiatric Advance Practice Nurses. https://www.ispn-psych.org/what_canada
Iudici, A., Girolimetto, R., Bacioccola, E., Faccio, E., & Turchi, G. (2022). Implications of Involuntary Psychiatric Admission: Health, Social, and Clinical Effects on Patients. The Journal of nervous and mental disease, 210(4), 290–311. https://doi.org/10.1097/NMD.0000000000001448
Kallert, T. W., Glöckner, M., & Schützwohl, M. (2008). Involuntary vs. voluntary hospital admission: A systematic literature review on outcome diversity. European Archives of Psychiatry and Clinical Neuroscience, 258(4), 195-209. https://doi.org/10.1007/s00406-007-0777-4
Ministry of Health (MoH) (2025, March 12). B.C. improving care for people with mental-health, substance-use challenges. https://news.gov.bc.ca/releases/2025HLTH0015-000202
Morris, N. P., & Kleinman, R. A. (2023). Taking an evidence-based approach to involuntary psychiatric hospitalization. Psychiatric Services (Washington, D.C.), 74(4), 431-433. https://doi.org/10.1176/appi.ps.20220296
Muench, U., & Fraze, T. K. (2022). The future of behavioral health-harnessing the potential of psychiatric mental health nurse practitioners. JAMA Network Open, 5(7), Article e2224365. https://doi.org/10.1001/jamanetworkopen.2022.24365
Office of the Premier. (2024). Province launches secure care for people with brain injury, mental illness, severe addiction. https://news.gov.bc.ca/releases/2024PREM0043-001532#:~:text=The%20Province%20is%20also%20building,involuntary%20care%20under%20the%20act
Werb, D., Kamarulzaman, A., Meacham, M. C., Rafful, C., Fischer, B., Strathdee, S. A., & Wood, E. (2016). The effectiveness of compulsory drug treatment: A systematic review. The International journal on drug policy, 28, 1–9. https://doi.org/10.1016/j.drugpo.2015.12.005
World Health Organization (WHO) (2021, June 9). Guidance on community mental health services: Promoting person-centred and rights-based approaches. Geneva: WHO. https://iris.who.int/bitstream/handle/10665/341648/9789240025707-eng.pdf?sequence=1
Angela Russolillo, PhD, MSc, RPN, is an assistant professor in the School of Nursing at the University of British Columbia and a clinician scientist at St. Paul’s Hospital.
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