Violent encounters in psychiatric care: a phenomenological study of embodied caring knowledge

Caring Knowledge as a Strategy to Mitigate Violence against Nurses: A Discussion Paper

Violence against nurses is a disturbing trend in healthcare that has reached epidemic proportions globally. These violent incidents can result in physical and psychological injury, exacerbating already elevated levels of stress and burnout among nurses, further contributing to absenteeism, turnover, and intent to leave the profession. To ensure the physical and mental well-being of nurses and patients, attention to the development of strategies to reduce violence against nurses must be a priority. Caring knowledge-rooted in the philosophy of care-is a potential strategy for mitigating violence against nurses in healthcare settings. We present what caring knowledge is, analyze its barriers to implementation at the health system and education levels and explore potential solutions to navigate those barriers. We conclude how the application of models of caring knowledge to the nurse-patient relationship has the potential to generate improved patient safety and increased satisfaction for both nurses and patients.

Philosophical underpinnings of intersubjectivity and its significance to phenomenological research: A discussion paper

Intersubjectivity is the proposition that human experience occurs in a world of shared and embodied understandings, mediated by culture and language. Nursing is fundamentally relational, and nursing research stems from an exchange between participants and researchers and indeed around the transaction of the patient and the nurse in the intersubjective space of clinical settings. Through the philosophical standpoints of Husserl, Merleau-Ponty, Heidegger, and Gadamer we examine these differing philosophical constructs of intersubjectivity and the contribution of these positions to phenomenological nursing inquiry. Particular framings of intersubjectivity should influence the way researchers interact with their participants and data so that the chosen philosophy sits coherently within a research plan and methodology. This exploration of philosophical standpoints is extended through examples of, and reflections upon, the authors' experiences of intersubjectivity in our published phenomenological nursing studies and through dynamic interactions that characterise interpretive activities within a research team.

Heideggerian structures of Being-with in the nurse-patient relationship: modelling phenomenological analysis through qualitative meta-synthesis

Heideggerian philosophy is frequently chosen as a philosophical framing, and/or a hermeneutic analytical structure in qualitative nursing research. As Heideggerian philosophy is dense, there is merit in the development of scholarly resources that help to explain discrete Heideggerian concepts and to uncover their relevance to contemporary human experience. This paper uses a meta-synthesis methodology to pool and synthesise findings from 29 phenomenological research reports on Being-with in the nurse-patient relationship. We firstly considered and secured the most relevant Heideggerian elements to nurse-patient Being-with (Dasein-with, circumspection, solicitude, and discourse). Under these deductive codes, we then inductively developed sub-themes that seemed to explain the multifaceted nature of Being-with, through a secondary analysis and synthesis of published data from 417 patient, carer and nurse participants. Dasein-with was enhanced when nurses had first-hand experience with a phenomenon. Nurses moved between the inauthentic they-mode (task-orientated busyness, existential abandonment, rough handling and deficient modes of concern in potentially violent encounters), and the authentic self-mode (seeking connection [knowing], and openness [unknowing], which exposed their emotional vulnerability). Through circumspection (making room for, deseverance and directionality), technology and people were encountered environmentally feeding into nursing attention, assessment and communication. Nursing as a social arrangement (solicitude) was expressed through either leaping-in care (also perceived as 'power over') or leaping-ahead care (moving the patient towards independence). There was a place for both inauthentic (idle talk) and authentic discourse (including non-verbal and spiritual discourse) that nurses wove through the ontic everydayness of nursing tasks.

Violence committed against nursing staff by patients in psychiatric outpatient settings

Violence against nurses has increased particularly in psychiatric outpatient settings as psychiatric care shifts from being inpatient-based to being outpatient-based. Violence is a complex phenomenon that must be explored in different psychiatric nursing environments and settings. Violence in psychiatric outpatient settings should especially be explored as violence in this context has scarcely been examined. The aim of this systematic review was to elucidate violence committed against nursing staff by patients in adult psychiatric outpatient settings, based on reports from previous studies. A literature search was conducted in the CINAHL (EBSCO), Ovid MEDLINE, and PsycARTICLES (Ovid) databases. Fourteen studies emerged after the selection and quality assessment process. These studies indicated that violence in psychiatric outpatient settings is a multidimensional phenomenon comprising the reasons for, forms of, and consequences of violence. Reasons for violence could be related to the patient as well as to nursing staff. In psychiatric outpatient settings, verbal violence was the most common form of violence, and violence most frequently led to psychological consequences for nursing staff. The findings of this review highlight the importance of nursing staff developing skills and interventions for managing different kinds of violent situations. Given the multidimensional consequences of violence, attention must be given to the occupational well-being and coping ability of nursing staff at work. Furthermore, it would be worthwhile to compare cultural and intercountry differences of violent exposures in psychiatric outpatient settings.

Coping strategies of caregivers towards aggressive behaviors of persons with severe mental illness

Aggression is one of the chief determinants of caregiver burden in severe mental illnesses. Clinical and treatment implications of aggression in mental illness are predominantly studied in perspectives of mental health care professionals. Coping style of caregivers towards aggression of persons with mental illness is understudied. So we studied coping strategies used by caregivers of patients with severe mental illness towards aggressive behaviors of patients and relationship between aggressive behavior and coping strategies. We assessed two hundreds and seventy caregivers of patients with severe mental illness attending outpatient psychiatry department using Modified Overt Aggression Scale and the Ways of Coping Scale - revised. 95.6% of the caregivers perceived verbal aggression followed by aggression against property (67%), auto aggression (33.7%) and physical aggression (25.6%). The study revealed that adaptive coping strategies - planful problem solving and seeking social support were used by 40% each of caregivers to deal with aggressive behavior. Only 4.4% of caregivers resorted to escape avoidance which is maladaptive coping strategy. Though adaptive strategies were used by caregivers these were not used in appropriate situations. Physical aggression and aggression against property were not significantly associated with planful problem solving (r = 0.105; p = 0.08 and r = 0.110; p = 0.07 respectively). But verbal aggression, aggression against property and physical aggression were associated with escape avoidance (r = 0.152; p = 0.01 and r = 0.168; p = 0.01 and r = 0.23; p = <0.001 respectively). The study concluded that coping in caregivers of severe mental illness is maladaptive with respect to aggression. Coping skills training would play a major role to address this issue.

"Like Every Normal Person?!" The Paradoxical Effect of Aging With Schizophrenia

Studies on aging with schizophrenia have focused mainly on the adversities of aging with mental illness. The present study, however, examined the subjective experience of well-being among individuals with schizophrenia. Taking a phenomenological reflective life-world approach, in-depth, semistructured interviews with 18 aging individuals with schizophrenia were thematically analyzed. Four main themes emerged: (a) "I love the pills . . . they are very helpful": A balanced course of the illness as a basis for well-being in old age; (b) "I'm going to have my own exhibition at the museum": Self-fulfillment as promoting well-being; (c) "It's just like a family here": Experiencing a sense of belonging; and (d) "I live like everyone else": Aging as an opportunity for normalization. Alongside hardship, the participants perceived old age as a "window of opportunity," enabling the fulfillment of lifelong desires for a social life, acceptance, and a satisfying occupation. Implications regarding interventions with this unique population are discussed.

Enhancing the professional dignity of midwives: A phenomenological study

Background:

When midwives are not treated with respect and their professional competencies are not recognised, their professional dignity is violated.

Objective:

This study explored and described how the professional dignity of midwives in the selected hospital can be enhanced based on their experiences.

Research design:

A descriptive phenomenological research design was used with in-depth interviews conducted with 15 purposely selected midwives.

Ethical considerations:

The Faculty of Health Sciences Research Ethics Committee of the University of Pretoria approved the study. The research was conducted in an academic tertiary hospital with voluntary participants.

Findings:

To dignify midwives it is essential to enhance the following: ‘to acknowledge the capabilities of midwives’, ‘to appreciate interventions of midwives’, ‘to perceive midwives as equal health team members’, ‘to invest in midwives’, ‘to enhance collegiality’, ‘to be cared for by management’ and ‘to create conducive environments’.

Conclusion:

The professional dignity of midwives is determined by their own perspectives of the contribution that they make to the optimal care of patients, the respect that they get from others and the support that hospital management gives them. With support and care, midwives’ professional dignity is enhanced. Midwives will strive to render excellent services as well as increasing their commitment.

Exposed to an Accumulation of Burdensome Feelings: Mental Health Nurses' Vulnerability in Everyday Encounters With Seriously Ill Inpatients

Seriously mentally ill patients' unusual behavior is considered challenging in caring relationships, but we know little about how this affects mental health nurses' vulnerability. This article uses a phenomenological design inspired by Heidegger's philosophy with the results of fieldwork and reflection groups with 11 nurses on an acute ward. The nurses were exposed to an accumulation of negative emotions, caused by potentially or actually harmful scenarios that were more extreme than those in other nursing contexts. They protected themselves through limit-setting approaches, which conflicted with their standards of building trusting relationships with patients. The feeling of guilt might function as an appeal for authentic practice, but a change in practice requires the use of acknowledgment approaches and the systematic debriefing of accumulated burdensome feelings.

Pattern and Type of Aggressive Behavior in Patients with Severe Mental Illness as Perceived by the Caregivers and the Coping Strategies Used by Them in a Tertiary Care Hospital

Aggressive behavior by patients with severe mental illness is a major problem needing intervention. This descriptive cross sectional study examined the perception and coping strategies of caregivers with a sample of 100 toward aggressive behavior by patients with severe mental illness in the outpatient and inpatient unit of the department of psychiatry in a tertiary care hospital. The data were collected by a semistructured interview using Revised Overt Aggression Scale-modified, Aggressive Behavior and Intervention Checklist, Ways of Coping Checklist-Hindi Adaptation and Impact of Patient Aggression on Carers Scale-Adapted. The caregivers perceived aggression in varying extent from the patients. Majority used problem-focused coping to deal with aggressive behavior. Most of the caregivers perceived insisting to take medicines and talking about patient's illness as the triggers for aggressive behavior which was managed by talking to the patient calmly, lovingly and by leaving the patient alone. The findings strongly suggest aggressive behavior as a frequent problem faced by family members of patient with severe mental illness. Nursing interventions should focus on counseling and psycho education for empowering caregivers to utilize strategies to reduce occurrence of aggressive behavior from patient and ways to effectively cope with the situation.

Experiences of emotional abuse among women living with HIV and AIDS in Malawi

Our aim for this study was to describe emotional abuse as it is experienced by women living with HIV and AIDS in Malawi. The study was conducted in the Lilongwe district in Malawi and used a descriptive phenomenological approach. Twelve women from two public health care clinics under the Lilongwe District Health Office were interviewed. Violating experiences that scarred the personhood and inherent value of being human were found to be the essence of their emotional abuse. Their husbands, family, and community members were responsible for the humiliation, abandonment, and blaming that caused them to feel hopeless.

Giving voice to vulnerable people: the value of shadowing for phenomenological healthcare research

Phenomenological healthcare research should include the lived experiences of a broad group of healthcare users. In this paper it is shown how shadowing can give a voice to people in vulnerable situations who are often excluded from interview studies. Shadowing is an observational method in which the researcher observes an individual during a relatively long time. Central aspects of the method are the focus on meaning expressed by the whole body, and an extended stay of the researcher in the phenomenal event itself. Inherent in shadowing is a degree of ambivalence that both challenges the researcher and provides meaningful insights about the phenomenon. A case example of a phenomenological study on the experiences of elderly hospital patients is used to show what shadowing yields.

Aspects of care culture in municipal care for elderly people: a hermeneutic documentary analysis of reports of abuse

INTRODUCTION

Care culture is an important contextual factor in care practice. Care culture refers to a process of creating meaning out of tradition, horizon and bildung. The care culture is often taken into consideration in situations that go beyond the everyday routine, such as cases of abuse. In Sweden, health care professionals are obliged to document and report any suspected bad conditions. Although the reports have the potential to communicate underlying values and assumptions about the care culture, such studies have not been performed.

AIM

The aim of this study was to understand how elderly care abuse in institutions could be understood from a care culture perspective.

DESIGN AND METHODS

A hermeneutic documentary analysis was conducted on 269 incident reports concerning suspected mistreatment of the elderly in three municipalities in Sweden. The hermeneutic analysis followed a four-stage process: selecting and reading the text, setting out the context, closing the hermeneutic circle, and finally creating a conceptual bridge towards a critical understanding from a phenomenological lifeworld perspective.

FINDINGS

  The care of the elderly in the municipality was based on a social culture that placed residents' needs at the centre. Following routines were considered important in preventing mistreatment and were intended to ensure that all patients were treated fairly and equally. Care was described as task oriented and often lacking in interpersonal relations. From a phenomenological lifeworld perspective, it was interpreted that in the municipalities' care of the elderly, there was a focus on elderly people's freedom at the expense of the vulnerability aspects of well-being.

CONCLUSION

Raising awareness of the care culture underlying abuse could help to improve understanding of care practice. Change may be only possible when reflected on the existing perspectives underpinning the care culture, and integrate them into a broader framework for caring.

Swedish registered psychiatric nurses' descriptions of presence when caring for women with post-partum psychosis: an interview study

The concept of nursing presence has been widely used in nursing and is a significant component of nursing practice. In order to increase our understanding of nursing presence, it needs to be studied in different contexts. In this study, a secondary analysis of interviews with 10 registered psychiatric nurses (RPN) in Sweden was conducted to explore nurses' descriptions of presence when caring for women with post-partum psychosis (PPP). Based on the research question: 'How do RPN describe nursing presence in the context of caring for women with PPP?' content analysis was used to analyze the data. Three categories emerged: the use of presence to protect, the use of presence to facilitate recovery, and the use of presence for learning. The findings underscore the importance of recognizing nursing presence as a strategy to improve psychiatric nursing for the benefit of the woman and her child, and as an important part of psychiatric nursing when providing compassionate and effective nursing care to this population.

Lifeworld-led healthcare is more than patient-led care: an existential view of well-being

In this paper we offer an appreciation and critique of patient-led care as expressed in current policy and practice. We argue that current patient-led approaches hinder a focus on a deeper understanding of what patient-led care could be. Our critique focuses on how the consumerist/citizenship emphasis in current patient-led care obscures attention from a more fundamental challenge to conceptualise an alternative philosophically informed framework from where care can be led. We thus present an alternative interpretation of patient-led care that we call 'lifeworld-led care', and argue that such lifeworld-led care is more than the general understanding of patient-led care. Although the philosophical roots of our alternative conceptualisation are not new, we believe that it is timely to re-consider some of the implications of these perspectives within current discourses of patient-centred policies and practice. The conceptualisation of lifeworld-led care that we develop includes an articulation of three dimensions: a philosophy of the person, a view of well-being and not just illness, and a philosophy of care that is consistent with this. We conclude that the existential view of well-being that we offer is pivotal to lifeworld-led care in that it provides a direction for care and practice that is intrinsically and positively health focused in its broadest and most substantial sense.

A review of ecological factors affecting inpatient psychiatric unit violence: implications for relational and unit cultural improvements

This review examines the research on ecologic factors that may contribute to or lessen the likelihood of inpatient unit violence. Understanding these factors can provide psychiatric inpatient unit staff with valuable therapeutic relational and cultural strategies to decrease violence. International and US studies from OVID Medline, CINAHL, and PsycInfo that evaluated aggression and violence on psychiatric inpatient units between 1983 and 2008 were included in this review. The review revealed that violence results from the complex interactions among the patient, staff, and culture of the specific unit. Inpatient psychiatric staff can decrease the potential for violence by using therapeutic relationship strategies such as using good communication skills, advocating for clients, being available, having strong clinical assessment skills, providing patient education, and collaborating with patients in treatment planning. Cultural improvements include providing meaningful patient activities and appropriate levels of stimulation and unit staffing.

Female caregivers' experiences of exposure to violence in nursing homes

Although earlier studies have examined caregivers' experiences of exposure to violence, few have investigated female caregivers working in nursing homes with a specific focus on experiences throughout the entire scenario of a violent situation. This study illuminates female caregivers' experiences of being exposed to violence in nursing homes. Twenty caregivers working in three nursing homes located in northern Sweden were asked to narrate about a situation in which they had been exposed to violence. Their narratives were analysed by using qualitative content analysis. We found that the caregivers had preconceived ideas about violent behaviour, that they experienced a loss of control over the situation, and that they then strove to regain control. Experiences such as these may influence caregivers' interactions with residents who display violent behaviour. As a result of violent interactions, caregivers may distance themselves from the residents, an attitude that may decrease the quality of care. There is a risk that violence in nursing homes is accepted and normalized as a part of the job and hence persists.

A survey of workplace violence across 65 U.S. emergency departments

OBJECTIVES

Workplace violence is a concerning issue. Healthcare workers represent a significant portion of the victims, especially those who work in the emergency department (ED). The objective of this study was to examine ED workplace violence and staff perceptions of physical safety.

METHODS

Data were obtained from the National Emergency Department Safety Study (NEDSS), which surveyed staff across 69 U.S. EDs including physicians, residents, nurses, nurse practitioners, and physician assistants. The authors also conducted surveys of key informants (one from each site) including ED chairs, medical directors, nurse managers, and administrators. The main outcome measures included physical attacks against staff, frequency of guns or knives in the ED, and staff perceptions of physical safety.

RESULTS

A total of 5,695 staff surveys were distributed, and 3,518 surveys from 65 sites were included in the final analysis. One-fourth of surveyed ED staff reported feeling safe sometimes, rarely, or never. Key informants at the sampled EDs reported a total of 3,461 physical attacks (median of 11 attacks per ED) over the 5-year period. Key informants at 20% of EDs reported that guns or knives were brought to the ED on a daily or weekly basis. In multivariate analysis, nurses were less likely to feel safe "most of the time" or "always" when compared to other surveyed staff.

CONCLUSIONS

This study showed that violence and weapons in the ED are common, and nurses were less likely to feel safe than other ED staff.

Strategies in caring for women with postpartum psychosis ? an interview study with psychiatric nurses

AIM AND OBJECTIVE

The aim of this study was to explore strategies in caring for women with postpartum psychosis used by nurses.

BACKGROUND

The most serious type of psychiatric illness in connection with childbirth is postpartum psychosis. Nearly two in 1000 newly delivered women are stricken by postpartum psychosis. Most of these patients need psychiatric care to recover. While earlier studies point to the need for psychiatric care, knowledge of specific nursing strategies in caring for postpartum psychosis patients remains limited.

METHODS

Interviews with 10 experienced psychiatric nurses were carried out, transcribed verbatim and an inductive content analysis was made.

RESULT

The main strategies for care found in this study were: (i) To create a patient-nurse relationship and (ii) To apply nursing therapeutic interventions. Presence, continuity and nurse-patient partnership contributed to create a relationship and incorporate the rest of the care team. To satisfy the patients' basic needs and feeling of security was the foundation of the nursing therapeutic interventions. Confirmation and giving hope were also used as nursing therapeutics as well as information to the patient and her relatives about her illness.

CONCLUSION

The conclusion of the study is that strategies used by nurses are a combination of general and psychiatric nursing approaches but the specificity in caring knowledge for caring patients with postpartum psychosis requires further development.

RELEVANCE TO CLINICAL PRACTICE

The result of the study indicates that it is important to organize patient care for postpartum psychosis with continuity and consistency and to support the nurse to create a relationship and therapeutic intervention with the patient. The present study shows the importance of further developing specific nursing theories that can be applied when caring for patients with postpartum psychosis. It also shows the need for further pedagogical education for mental health nurses.

Encounters in a locked psychiatric ward environment

This focused ethnographic study aims at describing encounters in the healthcare environment on a locked psychiatric ward. It was carried out in Sweden on an acute psychiatric ward for patients with affective and eating disorders. Data were collected through participant observations and informal interviews, and analysed by qualitative content analysis. The result shows that the healthcare environment on this locked psychiatric ward offered a space for encounters between people, in a continuum from professional care to private meetings and social events. It included joy and friendship as well as unintentional insights into other patients' suffering. The characteristics of the encounters formed three themes: the caring relationship, the uncaring relationship and the unrecognized relationship. The caring and the uncaring relationship concerned relationships between staff and patients or their next of kin. These revealed contrasting qualities such as respect and flexibility as well as lack of respect and mistrust. The unrecognized relationship theme visualized the patients' relationships with each other and included both supportive and intrusive elements that were probably significant for the outcome of care. The unrecognized relationship contributes with new knowledge about conditions for patients in inpatient care, and indicates that the patients' relationships with each other merit greater attention.

Lifeworld-led healthcare: revisiting a humanising philosophy that integrates emerging trends

In this paper, we describe the value and philosophy of lifeworld-led care. Our purpose is to give a philosophically coherent foundation for lifeworld-led care and its core value as a humanising force that moderates technological progress. We begin by indicating the timeliness of these concerns within the current context of citizen-oriented, participative approaches to healthcare. We believe that this context is in need of a deepening philosophy if it is not to succumb to the discourses of mere consumerism. We thus revisit the potential of Husserl's notion of the lifeworld and how lifeworld-led care could provide important ideas and values that are central to the humanisation of healthcare practice. This framework provides a synthesis of the main arguments of the paper and is finally expressed in a model of lifeworld-led care that includes its core value, core perspectives, relevant indicative methodologies and main benefits. The model is offered as a potentially broad-based approach for integrating many existing practices and trends. In the spirit of Husserl's interest in both commonality and variation, we highlight the central, less contestable foundations of lifeworld-led care, without constraining the possible varieties of confluent practices.

Patients longing for authentic personal care: a phenomenological study of violent encounters in psychiatric settings

This article focuses on patients' violence against caregivers. Several studies show that violence and threats within the health care setting are an increasing problem. Encounters that become violent have been the issue of many debates but the phenomenon is still not fully understood. It is important to understand the course of events in violent encounters, both for the sake of the patients and the caregivers' well-being. The aim of this study was to describe the essence of violent encounters, as experienced by nine patients within psychiatric care. Guided by a phenomenological method, data were analyzed within a reflective life-world approach. The findings explicate violent encounters characterized by a tension between "authentic personal" and "detached impersonal" caring. "Authentic personal" patients are encountered in an undisguised, straightforward, and open way, and they sense unrestricted respect that caregivers would show another human being. In these encounters violence does not develop well. However, in caring that is "detached impersonal," the encounters are experienced by the patients as uncontrolled and insecure. These encounters are full of risks and potential violence.

Clinician perceptions of personal safety and confidence to manage inpatient aggression in a forensic psychiatric setting

Inpatient mental health clinicians need to feel safe in the workplace. They also require confidence in their ability to work with aggressive patients, allowing the provision of therapeutic care while protecting themselves and other patients from psychological and physical harm. The authors initiated this study with the predetermined belief that a comprehensive and integrated organizational approach to inpatient aggression was required to support clinicians and that this approach increased confidence and staff perceptions of personal safety. To assess perceptions of personal safety and confidence, clinicians in a forensic psychiatric hospital were surveyed using an adapted version of the Confidence in Coping With Patient Aggression Instrument. In this study clinicians reported the hospital as safe. They reported confidence in their work with aggressive patients. The factors that most impacted on clinicians' confidence to manage aggression were colleagues' knowledge, experience and skill, management of aggression training, use of prevention and intervention strategies, teamwork and the staff profile. These results are considered with reference to an expanding literature on inpatient aggression. It is concluded that organizational resources, policies and frameworks support clinician perceptions of safety and confidence to manage inpatient aggression. However, how these are valued by clinicians and translated into practice at unit level needs ongoing attention.

Concept analysis: aggression

The concept of aggression is important to nursing because further knowledge of aggression can help generate a better theoretical model to drive more effective intervention and prevention approaches. This paper outlines a conceptual analysis of aggression. First, the different forms of aggression are reviewed, including the clinical classification and the stimulus-based classification. Then the manifestations and measurement of aggression are described. Finally, the causes and consequences of aggression are outlined. It is argued that a better understanding of aggression and the causal factors underlying it are essential for learning how to prevent negative aggression in the future.