The health-care environment on a locked psychiatric ward: an ethnographic study

"Too soft for real psychiatry"? Gendered boundary-making between coercion and dialog in Italian wards

Psychiatric practice has always entailed a coercive dimension, visible not only in its formal expressions (e.g. compulsory treatment) but in many informal and implicit forms. In fact, contemporary psychiatric practices are characterized by an interplay of coercion and dialog to be interpreted not as binary categories but as extremes of a spectrum. Within this perspective, it becomes crucial to draw boundaries attributing meaning to professional identities and practices in psychiatric work. This is particularly relevant in acute wards: to explore this issue, we selected two cases according to a most-different-cases design, one ward with a mechanical-restraint approach compared to one with no-mechanical-restraint. We argue that gender, mobilized to performatively draw distinctions and hierarchies in order to define and justify different approaches to psychiatric crises along the continuum between coercion and dialog, is a key dimension in the boundary-making process. The analysis identifies two main dimensions of drawing gendered boundaries: inter-gender boundaries (overlapping the binary distinction between masculinity and femininity with a more coercive or relational-dialogic approach to crisis) and intra-gender boundaries (distinguishing and ranking of different masculinities and femininities), associating a less coercive orientation with a devirilized masculinity.

Therapeutic Landscapes and Psychiatric Care Facilities: A Qualitative Meta-Analysis

The environment in healthcare facilities can influence health and recovery of service users and furthermore contribute to healthy workplaces for staff. The concept of therapeutic landscapes seems to be a promising approach in this context. The aim of this qualitative meta-analysis is to review the effects of therapeutic landscapes for different stakeholders in psychiatric care facilities. A systematic literature search was conducted in the four data bases PubMed, PsycInfo, CINAHL, and Web of Science. Thirteen predominately qualitative studies were included in this qualitative meta-analysis. The methodological quality of these qualitative studies was assessed, using an adapted version of the Journal Article Reporting Standards for Qualitative Research, and a thematic analysis was conducted. The results were categorised into the three main themes of the physical (built and natural), social, and symbolic dimensions of the therapeutic landscape. Given the heterogeneity of the summarised data and an overall methodological quality of the included studies that can be rated as medium, the results should be interpreted with caution. Current findings are based almost exclusively on qualitative studies. Therefore, there is a need for quantitative study designs that investigate the relationship between specific environmental elements and mental health outcomes for different stakeholders in psychiatric facilities.

Agression en milieu psychiatrique fermé : identification des déclencheurs qui précèdent les agressions contre les intervenants

Cette étude vise l’identification des déclencheurs qui précèdent les agressions survenues dans un hôpital psychiatrique fermé. Une analyse de contenu de 140 rapports d’incident visant l’identification du déclencheur qui précédait immédiatement les événements d’agression survenus entre 2012 et 2017 a été effectuée. Avec un accord interjuge de 0,87, les résultats concordent avec ceux retrouvés dans des études précédentes. Plus de 37 % des agressions surviennent à la suite d’une intervention verbale d’un intervenant, alors qu’un peu plus de 54 % ont lieu à la suite d’un contact physique entre un intervenant et un patient. Moins de 9 % des agressions subies par le personnel sont liées à des événements où il a été impossible d’observer un déclencheur. Ces résultats sont discutés dans le cadre d’une approche interactionnelle sur l’agression en psychiatrie légale et ils permettent de proposer des pistes pour réduire le risque d’agression.

Recovery-oriented practice: Participant observations of the interactions between patients and health professionals in mental health inpatient settings

Despite an increasing attention towards recovery orientation in the mental health services, the provision of recovery-oriented practice is challenged in the inpatient wards. Moreover, the existing research within this area is modest and we currently have limited knowledge of how recovery-oriented practice is integrated into inpatient settings. A cornerstone of recovery-oriented practice is the collaboration, patient involvement, and choices, particularly when deciding and planning treatment options. Thus, this ethnographic study aimed to explore how recovery-oriented practice is reflected in the interactions between patients and health professionals around treatment in two mental health inpatient wards in Denmark. Participant observations were conducted in two mental health inpatient wards from November 2014 to January 2015. The Recovery Self-Assessment scale inspired the observation guide and the initial data analysis. Field notes were analysed deductively and inductively using qualitative content analysis. One theme with four subthemes emerged showing that interactions were characterized by an 'as-if collaboration' where 'negotiating on limited grounds' was an important feature of interactions, in which health professionals seemed to have superiority, acting on behalf of 'competing demands'. Patients had to navigate in a field of 'inconsistent guidance and postponed decisions' and faced tendencies of 'control and condescending communication'. The results suggest that recovery oriented values such as equal collaboration, choice and patients' personal preferences are reflected rhetorically in the interactions between patients and health professionals. However, they are negotiated within organizational logics and often overruled by competing demands.

Nurses experiences of delivering care in acute inpatient mental health settings: A narrative synthesis of the literature

Inpatient psychiatric care requires a balance between working with consumers' priorities and goals, managing expectations of the community, legal, professional and service responsibilities. In order to improve service delivery within acute mental health units, it is important to understand the constraints and facilitating factors for good care. We conducted a systematic narrative synthesis, where findings of qualitative studies are synthesised to generate new insights. 21 articles were identified. Our results show that personal qualities, professional skills as well as environmental factors all influence the ability to provide recovery focused care. Three overarching themes which either facilitated or hindered were identified. These included: (i) Complexity of the nursing role (clinical care; practical and emotional support: advocacy and education; enforcing aspects of the Mental Health Act. and, maintaining ward safety); (ii) Constraining factors (operational barriers; change in patient characteristic; and competing understandings of care); and (iii) Facilitating factors (ward factors; nursing tools; nurse characteristics; approach to people; approach to work and ability to self-care). We suggest that the therapeutic use of self is central to the provision of recovery oriented care. However person-centred practice can be fragile and fluid and a compassionate system of support is needed to enable an understanding of context and self. It is critical to have a work environment which fosters hope and optimism and is supportive of autonomy, ensures workload balance, and is safe.

Stressed spaces: mental health and architecture

OBJECTIVE

To present a comprehensive review of the research literature on the effects of the architectural designs of mental health facilities on the users.

BACKGROUND

Using a team of cross-disciplinary researchers, this review builds upon previous reviews on general and geriatric healthcare design in order to focus on research undertaken for mental health care facility design.

METHODS

Sources were gathered in 2010 and 2011. In 2010 a broad search was undertaken across health and architecture; in 2011, using keywords and 13 databases, researchers conducted a systematic search of peer reviewed literature addressing mental health care and architectural design published between 2005 to 2012, as well as a systematic search for academic theses for the period 2000 to 2012. Recurrent themes and subthemes were identified and numerical data that emerged from quantitative studies was tabulated.

RESULTS

Key themes that emerged were nursing stations, light, therapeutic milieu, security, privacy, designing for the adolescent, forensic facilities, interior detail, patients' rooms, art, dementia, model of care, gardens, post-occupancy evaluation, and user engagement in design process. Of the 165 articles (including conference proceedings, books, and theses), 25 contained numerical data from empirical studies and 7 were review articles.

CONCLUSIONS

Based on the review results, especially the growing evidence of the benefits of therapeutic design on patient and staff well-being and client length of stay, additional research questions are suggested concerning optimal design considerations, designs to be avoided, and the involvement of major stakeholders in the design process.

KEYWORDS

Evidence-based design, hospital, interdisciplinary, literature review, post-occupancy.

An Interpretation of Nurse-Patient Relationships in Inpatient Psychiatry: Understanding the Mindful Approach

Nurses who work in acute inpatient psychiatry, where lengths of stay are increasingly shortened, struggle to establish therapeutic nurse–patient relationships. The purpose of this inquiry was to illuminate the nature of relationships between inpatient psychiatric mental health (PMH) nurses and their patients. The author used semistructured interviews and nonparticipant observation in an interpretive phenomenological inquiry. The data consisted of texts that were transcribed from narratives and observations. The meanings that were generated led to the uncovering of patterns of commonality, or themes. Of the themes uncovered, the theme of mindful approach highlighted PMH nurses as engaging with patients in distress, strategically creating encounters to establish a basis for ongoing therapeutic work. The PMH nurse–patient relationship in acute inpatient psychiatry continues to be under pressure, but nurses still carefully construct relational approaches in response to patient distress, and patients in these settings experience these approaches as meaningful to their recovery.

Women's Experiences of Being in an Acute Psychiatric Unit: An Occupational Perspective

Introduction:

The need to address gender sensitivity and implement strategies to improve the treatment of women within inpatient mental health facilities has gained international recognition. Ascertaining service users' perspectives is a critical prerequisite to ensure that potential strategies are appropriate. This study aimed to identify factors influencing the occupational engagement of women service users in an acute inpatient mental health unit in Melbourne, Australia.

Method:

In this phenomenological study, five women were interviewed about their experiences of occupational engagement. Data were analysed according to Colaizzi's (1978) procedure, to generate an ‘essence statement’. Fieldnotes were kept and an audit trail of the analysis process was recorded.

Findings:

Three main themes emerged: (1) Living in hospital is difficult; (2) What we need from staff; and (3) More meaningful things to do, please.

Conclusion:

Study findings highlight a need for more empathetic communication with staff, more effective use of the physical environment to enable improved perceptions of safety, and more meaningful occupational opportunities.

The development of recovery competencies for in-patient mental health providers working with people with serious mental illness

Delivering recovery-oriented services is particularly challenging in in-patient settings. The purpose of this study was to identify the most salient recovery competencies required of in-patient providers. Established methods for the development of competencies were used. Data collection included interviews with multiple stakeholders and a literature review. Data analysis focused on understanding how characteristics of the in-patient context influence recovery-enabling service delivery and the competencies associated with addressing these issues. Eight core competencies with four to ten sub-competencies were identified based on a tension-practice-consequence model. The competency framework can serve as a tool for tailoring workforce education.

The experience of working on a locked acute psychiatric ward

This study's aim was to elucidate health-care staff experience of working on a locked acute psychiatric ward. In many countries changes in health care has contributed to fewer beds available in inpatient care, and a concentration of patients with severe psychiatric conditions. This implies a changing work environment in acute psychiatric care. Qualitative interviews with health-care staff (n= 10) were carried out on a ward for patients with affective disorder and eating disorder in a Swedish hospital. Qualitative content analysis was used. Four themes were identified from the data: 'undergoing changes in care delivery', 'feeling a need for security and control', 'managing the demands at work' and 'feeling a sense of responsibility'. This study adds to earlier research into how a sense of responsibility can place a significant burden on health-care staff working on a locked psychiatric ward and also contribute to increased control of patients. This study also shows that relationships and power structures among health-care staff need to be addressed when organizational changes are made in care delivery. Further research is needed to reach a comprehensive understanding of care on locked acute psychiatric wards, including a development of nursing and medicine as knowledge domains in one common context.

"They can do whatever they want": Meanings of receiving psychiatric care based on a common staff approach

This study deepens our understanding of how patients, when cared for in a psychiatric ward, experience situations that involve being handled according to a common staff approach. Interviews with nine former psychiatric in-patients were analyzed using a phenomenological-hermeneutic method to illuminate the lived experience of receiving care based on a common staff approach. The results revealed several meanings: discovering that you are as subjected to a common staff approach, becoming aware that no one cares, becoming aware that your freedom is restricted, being afflicted, becoming aware that a common staff approach is not applied by all staff, and feeling safe because someone else is responsible. The comprehensive understanding was that the patient's understanding of being cared for according to a common staff approach was to be seen and treated in accordance with others' beliefs and valuations, not in line with the patients' own self-image, while experiencing feelings of affliction.

Ethnographic research into nursing in acute adult mental health units: a review

Acute inpatient mental health units are busy and sometimes chaotic settings, with high bed occupancy rates. These settings include acutely unwell patients, busy staff, and a milieu characterised by unpredictable interactions and events. This paper is a report of a literature review conducted to identify, analyse, and synthesize ethnographic research in adult acute inpatient mental health units. Several electronic databases were searched using relevant keywords to identify studies published from 1990-present. Additional searches were conducted using reference lists. Ethnographic studies published in English were included if they investigated acute inpatient care in adult settings. Papers were excluded if the unit under study was not exclusively for patients in the acute phase of their mental illness, or where the original study was not fully ethnographic. Ten research studies meeting our criteria were found (21 papers). Findings were grouped into the following overarching categories: (1) Micro-skills; (2) Collectivity; (3) Pragmatism; and (4) Reframing of nursing activities. The results of this ethnographic review reveal the complexity, patient-orientation, and productivity of some nursing interventions that may not have been observed or understood without the use of this research method. Additional quality research should focus on redefining clinical priorities and philosophies to ensure everyday care is aligned constructively with the expectations of stakeholders and is consistent with policy and the realities of the organisational setting. We have more to learn from each other with regard to the effective nursing care of inpatients who are acutely disturbed.

Understanding the milieu experiences of patients on an acute inpatient psychiatric unit

The role of inpatient mental health units is changing. Increasingly, people with acute and severe mental illness are admitted for short periods of intense treatment and are discharged quickly to community-based care. Reduction in average lengths of stay for psychiatric inpatients has been accompanied by a marginalization of the concept of therapeutic milieu in the mental health discourse. This phenomenological inquiry focuses on understanding the life-world of six people with acute psychiatric illness who were hospitalized on an acute inpatient psychiatric unit. Working together, a team of four, including mental health clinicians and consumers, developed and implemented this interpretive study using the phenomenology of Heidegger and Taylor. The principle investigator conducted the interviews, and the research team engaged in a complex interpretive process, reviewing narrative accounts, exploring personal meanings and key themes, and reconstructing shared meaning as lived and shared by participants. In this report, the authors describe patient experiences of a rule-bound, controlling, and sometimes oppressive milieu while highlighting patient experiences of healing and health as lived within that same milieu. The authors describe patients' embodied, dialectical, and often paradoxical experiences of fear and affirmation, alienation and connection, and abandonment and healing. The authors share selected narrative accounts to generate new understanding of patient experiences and suggest that the inpatient psychiatric milieu remains an important but often neglected component of psychiatric treatment.

The bulldozer and the ballet dancer: aspects of nurses' caring approaches in acute psychiatric intensive care

Demanding conditions in acute psychiatric wards inhibit provision of safe, therapeutic care and leave nurses torn between humanistic ideals and the harsh reality of their daily work. The aim of this study was to describe nurses' caring approaches within this context. Data were collected from interviews with nurses working in acute psychiatric intensive care. Data were analysed using qualitative analysis, based on interpretive description. Results revealed a caring-approach continuum on which two approaches formed the main themes: the bulldozer and the ballet dancer. The bulldozer approach functioned as a shield of power that protected the ward from chaos. The ballet dancer approach functioned as a means of initiating relationships with patients. When examining the data from a theoretical perspective of caring and uncaring encounters in nursing, the ballet dancer approach was consistent with a caring approach, while the bulldozer approach was more complex and somewhat aligned with uncaring approaches. Conclusions drawn from the study are that although the bulldozer approach involves a risk for uncaring and harming actions, it also brings a potential for caring. This potential needs to be further explored and nurses should be encouraged to reflect on how they integrate paternalistic nursing styles with person-centred care.

The meaning of care on a locked acute psychiatric ward: Patients' experiences

BACKGROUND

The deinstitutionalization of psychiatric care has led to a concentration of patients to fewer wards. This leads to difficulties in separating voluntarily and involuntarily admitted patients, and there is a risk that the interest in safeguarding patients' autonomy will decrease.

AIMS

The aim of this study was to elucidate the meaning care has to patients on a locked acute psychiatric ward. The study was performed on a ward for patients with affective and eating disorders who were admitted both voluntarily and involuntarily.

METHODS

Interviews were conducted and analysed using qualitative content analysis.

RESULTS

The results show that to the patients, care had contradictory qualities some alleviated their suffering while others contributed to stress. The alleviation from suffering originated from the experiences of strengthened integrity and self-determination, from being supported, and having a place of refuge on the ward. In contrast to this, there were experiences of being dependent and trapped because of lack of influence and choice, and being controlled.

CONCLUSIONS

In conclusion, this qualitative study shows that to the patients, care can mean being disciplined in a way that risks undermining the alleviation of suffering that care can provide. It is thus important to be observant when it comes to manifestations of control in care. The study also shows that the support of fellow patients has a value as a complement to the care given by staff members and next of kin, something that needs to be further investigated.

Creating Trust in an Acute Psychiatric Ward

The ideal of trust pervades nursing. This article uses empirical material from acute psychiatry that reveals that it is distrust rather than trust that is prevalent in this field. Our data analyses show how distrust is expressed in the therapeutic environment and in the relationship between nurse and patient. We point out how trust can nonetheless be created in an environment that is characterized by distrust. Both trust and distrust are exposed as `fragile' phenomena that can easily `tip over' towards their opposites. Trust is not something that nurses possess or are given; it is rather something that they earn and have to work hard to achieve. Regarding themselves as potential causes of distrust and active wielders of power can contribute to nurses developing a more realistic view of their practice. Assuming a realistic middle-way perspective can help to manoeuvre between the extremities of excellence and resignation, which in turn can lead to processes that create trust between psychotic patients and nurses.