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DOKTORSAVHANDLING

Institutionen för hälsovetenskapAvdelningen för omvårdnad Omvårdnad som reflekterande praktik

Att se och använda alternativ till tvång i psykiatrisk vård

Git-Marie Ejneborn Looi

ISSN 1402-1544ISBN 978-91-7583-407-8 (tryckt)ISBN 978-91-7583-408-5 (pdf)

Luleå tekniska universitet 2015

Git-M

arie Ejneborn Looi O

mvårdnad som

reflekterande praktik Att se och använda alternativ till tvång i psykiatrisk vård

Omvårdnad som reflekterande praktik

Att se och använda alternativ till tvång i psykiatrisk vård

Git-Marie Ejneborn Looi

Avdelningen för omvårdnad

Institutionen för hälsovetenskap

Luleå tekniska universitet

Sverige

Luleå 2015

Tryck: Luleå tekniska universitet, Grafisk produktion 2015

ISSN 1402-1544 ISBN 978-91-7583-407-8 (tryckt)ISBN 978-91-7583-408-5 (pdf)

Luleå 2015

www.ltu.se

Omslagsbild: Bilden på omslaget föreställer en person som mot sin vilja iförts handskar och

hjälm för att hindras från att skada sig själv. Personer med självskadebeteende som vårdats i

slutenvårdspsykiatrin är kanske de med mest erfarenhet av vad som händer när vårdare inte

längre förmår se en lidande människas behov utan istället ser ett problem som ska hanteras.

Denna avhandling vill motverka sådan självpåtagen maktlöshet och ingjuta hopp hos personal i

psykiatrisk vård genom att visa att det i varje situation finns olika handlingsalternativ. Fotot är

hämtat från Åkerman, S. & Eriksson, T. (2011). Slutstation rättspsyk: om tvångsvårdade kvinnor

som inte dömts för brott. Stockholm: Natur & kultur. Publiceras med tillstånd från författarna.

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Där konsten tar slut tar våldet vid

Innehåll Abstrakt .............................................................................................................. 1

Delstudier ........................................................................................................... 5

Förord ................................................................................................................ 7

Inledning ............................................................................................................ 9

Bakgrund .......................................................................................................... 11

Tvång ........................................................................................................... 11

Alternativ till tvång ....................................................................................... 14

Självskadebeteende ........................................................................................ 14

Omvårdnadsprocessen ................................................................................... 16

Vetenskapsteoretiskt ramverk ............................................................................ 17

Pragmatism ................................................................................................... 17

Abduktion ................................................................................................ 19

Teori och praktik ...................................................................................... 20

Rational............................................................................................................ 23

Övergripande syfte............................................................................................ 25

Metod .............................................................................................................. 27

Delstudie I .................................................................................................... 27

Deltagare och datainsamling ...................................................................... 27

Analys ....................................................................................................... 29

Metodval och etiska överväganden ............................................................ 29

Delstudie II ................................................................................................... 31


Analys ....................................................................................................... 31


Delstudie III och IV ...................................................................................... 34


Analys delstudie III ................................................................................... 35

Analys delstudie IV ................................................................................... 36


Metasyntes .................................................................................................... 39

Resultat ............................................................................................................ 41

Sammanfattning av resultatet från delstudie I-IV ........................................... 41

Delstudie I ................................................................................................ 41

Delstudie II ............................................................................................... 42

Delstudie III.............................................................................................. 43

Delstudie IV ............................................................................................. 43

Omvårdnad som reflekterande praktik .......................................................... 44

Syntes ....................................................................................................... 44

Relation .................................................................................................... 46

Behov ....................................................................................................... 47

Åtgärd ....................................................................................................... 48

Diskussion och kliniska implikationer ............................................................... 51

Omvårdnadsplanering ............................................................................... 53

Reflektion ................................................................................................ 54

Interaktivt projekt ..................................................................................... 56

Slutsats .............................................................................................................. 59

Jag vill tacka… .................................................................................................. 61

Referenser ........................................................................................................ 63

Summary in English .......................................................................................... 77

Abstrakt Tvångsåtgärder som fastspänning och tvångsmedicinering är vanligt

förekommande inom den psykiatriska vården och motiveras ofta av personal med

att det saknas alternativ. Användandet av tvångsåtgärder tycks vara särskilt vanligt

när det gäller unga kvinnor med självskadebeteende. Dessa kan uppleva

tvångsåtgärder som bestraffning och som ett hinder för att söka vård. Relationen

mellan patient och vårdare har beskrivits som ett kraftfullt verktyg för att minska

användandet av tvångsåtgärder, men det saknas i stor utsträckning forskning om

tvångsvård som fokuserar på patienters perspektiv och alternativ till tvång.

Avhandlingens övergripande syfte har varit att få ökad kunskap och förståelse för

omvårdnad som process i psykiatrisk vård ur patienters, studenters och personals

perspektiv, med särskilt fokus på alternativ till tvång vid självskadebeteende.

Avhandlingen har en pragmatisk utgångspunkt där ambitionen har varit att

resultat ska kunna omsättas i konkreta handlingar. Delstudierna har en kvalitativ

ansats där datamaterial har analyserats med innehållsanalys. Data består av 19

skrivna berättelser från personer som vårdats för självskadebeteende och som har

erfarenhet av tvångåtgärder, 14 loggböcker skrivna av sjuksköterskestudenter

under deras verksamhetsförlagda utbildning inom psykiatrisk vård, samt

fokusgruppsintervjuer med totalt 26 skötare, sjuksköterskor, läkare och

enhetschefer med erfarenhet av att tvångsvårda patienter.

Av berättelserna framkom att personer som vårdats inom psykiatrisk vård hade en

önskan om att mötas av förståelse av personalen, att utveckla tillitsfulla och

ömsesidiga relationer med dem, och att få vård som grundades på vetenskapliga

metoder. Deras faktiska erfarenheter beskrev en vård som var oförutsägbar,

kontraproduktiv och byggd på misstro och distans. Studenterna beskrev i

loggböckerna vikten av att avsätta tid och engagemang för relationsskapande,

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något som beskrevs som en förutsättning för att kunna göra bedömningar och lära

sig förstå patientens individuella tecken på hälsa och ohälsa. De beskrev hur de

identifierade patienters abstrakta behov så som behov av trygghet, empowerment,

självkänsla och hopp. Med dessa som grund individanpassade de åtgärder och

förhållningssätt och synliggjorde samt tog tillvara patienternas förmågor. I

fokusgruppsintervjuerna framkom hur personal med utgångspunkt i utmanande

situationer i psykiatrisk slutenvård resonerade kring möjliga åtgärder med fokus

antingen på personalens behov, patientens upplevelse, att följa rutiner eller att

uppfostra patienter. Beroende på fokus skiljde sig förhållningssätt och utformning

av åtgärder markant åt. I fokusgruppsintervjuerna framkom även personalens syn

på samarbete utifrån olika professionella roller. Utmärkande var att skötarna, trots

att de hade lägst formell kompetens, var den yrkesgrupp med störst inflytande vid

beslut om tvångsåtgärder eftersom de arbetade närmast patienterna och därför

hade förstahandsinformation om dem.

Resultaten visade en stor överenstämmelse mellan patienters, studenters och

personals perspektiv. En metasyntes av de olika delstudiernas resultat beskriver

omvårdnad som en reflektiv praktik. Att vårdaren har förmågan att bygga upp en

tillitsfull relation till patienten är en förutsättning för en relevant bedömning.

Bedömningen innebär att patientens individuella behov och förmågor identifieras

och ligger till grund för val av åtgärd och förhållningsätt med målet att minska

lidande och öka välbefinnande. Vägen till åtgärden är inte statisk, till en början

kan åtgärder enbart ha ett relationskapande syfte, behov kan förändras, åtgärder

behöva modifieras liksom att tilliten i relationen kan påverkas av olika faktorer.

Detta innebär att vägen till åtgärden inte bör ses som ett linjärt förlopp utan bättre

förstås som en dynamisk process som förutsätter ett reflekterande förhållningssätt

med relationen som grund, med det övergripande målet att stärka patientens

förutsättningar till återhämtning och välbefinnande.

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Den övergripande slutsats som kan dras är att om vårdarna lyckas skapa en

ömsesidig, tillitsfull relation till patienten, kan förstå dennes utryckta behov och

outtalade tecken samt arbetar proaktivt, i samarbete med patienten, med åtgärder

och medvetna förhållningssätt, så finns sällan behov av tvångsåtgärder. För detta

krävs att vårdarna får stöd i att utveckla sin reflektiva förmåga och även i att få ta

eget ansvar för varje situation och därigenom bygga upp en tillit till sin egen

förmåga.

Nyckelord: Alternativ till tvångsåtgärder, omvårdnad, process, psykiatrisk vård,

självskadebeteende, pragmatism, kvalitativ innehållsanalys

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Delstudier Denna avhandling bygger på nedanstående artiklar vilka refereras till i texten med

dess romerska numrering.

I Looi, G. E., Engström, Å., & Sävenstedt, S. (2015). A self-destructive care:

Self-reports of people who experienced coercive measures and their

suggestions for alternatives. Issues in Mental Health Nursing, 36(2), 96-103.

doi:http://dx.doi.org/10.3109/01612840.2014.951134

II Looi, G. E., Sävenstedt, S., & Engström, Å. (accepted). Easy but not simple –

Nursing students’ descriptions of the process of care in a psychiatric context.

Issues in Mental Health Nursing.

III Looi, G. E., Gabrielsson, S., Sävenstedt, S., & Zingmark, K. (2014). Solving

the staff's problem or meeting the patients’ needs: Staff members’ reasoning

about choice of action in challenging situations in psychiatric inpatient care.

Issues in Mental Health Nursing, 35(6), 470-479.


IV Gabrielsson, S., Looi, G. E., Zingmark, K., & Sävenstedt, S. (2014).

Knowledge of the patient as decision-making power: Staff members'

perceptions of interprofessional collaboration in challenging situations in

psychiatric inpatient care. Scandinavian Journal of Caring Sciences, 28(4), 784-

792. doi:http://dx.doi.org/10.1111/scs.12111

Originalartiklar publiceras med tillstånd av tidskrifternas utgivare.

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Förord En morgon i mina yngre tonår vaknade jag med en stark känsla för att det var

inom psykiatrin jag i framtiden skulle arbeta. Att jag inte hade någon tidigare

erfarenhet inom området spelade ingen roll, jag var fast övertygad om vad som

var mitt blivande yrke. Några år senare, 1985, avslutade jag min skötarutbildning

och kommande år arbetade jag som stolt skötare inom olika områden av

psykiatrin.

Genom åren har jag mött många människor med psykisk ohälsa, och dessa möten

har fungerat som källor för såväl inspiration som kunskap. Jag har fått ta del av

människors livsberättelser och erfarenheter, vilket har gett mig ökad kunskap,

inblick och förståelse för deras behov och situation.

En tid som varit särskilt betydelsefull för min yrkesmässiga utveckling är mina år,

i början av 90-talet, då jag arbetade med personer som nyinsjuknat i psykos på ett

utrednings- och behandlingshem. Jag ingick i en personalgrupp som fick

förtroendet att både planera och bygga upp en helt ny typ av verksamhet som

hade ett uppdrag att utreda, behandla och vid behov även rehabilitera unga vuxna

med misstänkt psykossjukdom. Idag kan jag titta tillbaka och konstatera att vi

framförallt stöttade de unga vuxna i deras återhämtningsprocess. Något som

väckte reaktioner var att vi tidigt i planeringsprocessen fattade beslutet att

behandlingshemmet skulle bedrivas under frivilliga former, eftersträva så hög

patientdelaktighet som möjligt och att vi inte skulle ha tillgång till tvångsåtgärder.

Många olyckskorpar kraxade, men detta var ett upplägg som skulle visa sig

fungera mycket bra. Åren på behandlingshemmet blev bland de mest lärorika i

min yrkeskarriär, och jag arbetade på behandlingshemmet fram till dess en ny

ledning tillsattes.

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Jag valde då att gå vidare och skaffa mig nya erfarenheter från andra delar av

psykiatrin, och det var i samband med detta som jag började få inblick i de brister

som på många sätt påverkade den psykiatriska vården. Frustrationen jag kände

över den hopplöshet och maktlöshet som jag tyckte genomsyrade många

arbetsplatser inom psykiatrin, ledde till att jag bestämde mig för att öka mina

möjligheter att kunna påverka vårdkvaliteten i positiv riktning och jag utbildade

mig till specialistsjuksköterska i psykiatrisk vård. Som färdigutbildad

specialistsjuksköterska fick jag sedan chansen att under några år bedriva ett

utvecklingsprojekt på en akutpsykiatrisk avdelning, ett uppdrag som inspirerade

och övertygade mig på samma sätt som arbetet på behandlingshemmet hade gjort

15 år tidigare. Även här visade det sig att det med relativt små medel är möjligt

att bedriva psykiatrisk vård som bygger på ömsesidighet och samarbete mellan

patient och vårdare, och där tvångsåtgärder i de flesta fall går att undvika.

Mina positiva erfarenheter blev sedan min startpunkt när jag slutligen blev

antagen som doktorand med möjligheten att utforma mitt projekt. Tron på att

förändring är möjligt är min självklara drivkraft.

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Inledning Den här avhandlingen handlar om förståelse för omvårdnad som process i

psykiatrisk vård med ett särskilt fokus på alternativ till tvång. Tvång motiveras

ofta med att det är nödvändigt för patienten när vårdare inte ser några andra

alternativ (Muir-Cochrane, Baird & McCann, 2015). Studier som beskriver

upplevelsen av tvång från patientens perspektiv är relativt få och de som finns

visar att tvång ofta upplevs som en strategi för kontroll och övervakning istället

för att möta deras behov (Hörberg, Sjögren & Dahlberg, 2012; Meehan,

McIntosh & Bergen, 2006 ). Ett sätt att arbeta med omvårdnad som en process, i

den psykiatriska vården illustreras i följande fallbeskrivning. Den är hämtad från

en sjuksköterskestudents loggbok som hon skrev i samband med att hon gick en

verksamhetsförlagd kurs med placering på en sluten psykiatrisk avdelning.

Fallbeskrivning: Patienten är en medelåldersman som tvångsvårdats många gånger på

avdelningen på grund av paranoida vanföreställningar och då vid upprepade tillfällen blivit

lagd i bälte. Under rapporten framkommer att mannen uppträder aggressivt, sover inte,

vandrar runt i korridoren och vägrar att vistas på sitt enskilda patientrum. Studenten

försöker att finnas i närheten av mannen utan att tränga sig på och efter en stund ber

patienten studenten om hjälp med några praktiska göromål och på det sättet så påbörjas ett

relationsskapande. När mannen tar kontakt så förmedlar studenten att hon tar sig tid, är

närvarande, lyssnar och tar mannen på allvar. När studenten lyssnar till mannens

beskrivning av sin situation så framkommer det att han är rädd och tycker att det är

obehagligt att vara på rummet på grund av möblernas placering. Studenten frågar då hur

han skulle vilja ha det istället och hur det ser ut hemma hos honom. Han beskriver bland

annat att han vill ha uppsikt över dörren både när han sitter vid skrivbordet och när han

sover. Utifrån mannens beskrivning av sin situation bedömer studenten att han har behov

av sömn, trygghet, tillit och ökad empowerment.

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För att mannen ska känna sig trygg och kunna visats och kunna sova i sitt rum så väljer

studenten som en första åtgärd att tillsammans med patienten möblera om patientrummet.

Studenten har ett medvetet förhållningssätt där hon bekräftar mannen och uppmuntrar till

medbestämmande och delaktighet för att han ska känna att han har en viss makt och

kontroll över sin situation.

Studentens utvärdering, citat från loggboken: För mig kan man säga att denna åtgärd

var en lätt handling, men den inlevelse patienten hade visar att det var något som betydde

jättemycket för honom. Han fick ha kontrollen och bestämma och jag lyssnade på hans

önskemål och visade att det var viktigt det vi gjorde. Patienten sa att han kände sig mycket

tryggare inne på sitt rum och han fick mer ro att skriva och läsa. Jag och min handledare

kom fram till att han verkade både lugnare och gladare och på läkarronden idag fick jag

höra av överläkaren att denna patient är den sjukaste patient som de har.

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Bakgrund

Tvång

Under 2013 vårdades ca 12 500 patienter i Sverige under någon av de två

kompletterande psykiatriska tvångslagarna, lagen (SFS,1991:1129) om

rättspsykiatrisk vård [LRV] eller lagen (SFS, 1991:1128) om psykiatrisk

tvångsvård [LPT] (Socialstyrelsens statistikdatabas). Föreskrifterna i hälso- och

sjukvårdslagen (1982:763) gäller all psykiatrisk vård, tvångsvårdslagstiftningen är

enbart ett komplement. Enligt lagen ska tvångsvården syfta till att patienten

frivilligt ska kunna medverka till nödvändig vård och ta emot det stöd som han

eller hon behöver. För att tvångsvård ska vara aktuellt måste tre förutsättningar

vara uppfyllda: (1) patienten ska lida av en allvarlig psykisk störning, till exempel

psykos eller depression med suicidrisk; (2) patienten ska vara i

oundgängligt behov av psykiatrisk heldygnsvård; (3) patienten motsätter sig

vården eller det finns grundad anledning att anta att vården inte kan ges med

patientens samtycke (SFS, 1991:1128).

Fram till 1929 var tvångsvård den enda vårdform som erbjöds till personer med

psykiska funktionshinder (Björkman, 2001). Dagens tvångsvårdslagstiftning

tillkom 1992 och ersatte Lagen om sluten psykiatrisk vård i vissa fall [LSPV].

Syftet med den nya lagstiftningen, LPT, var att minska användandet av tvång och

att stärka patientens autonomi och rättsäkerhet, psykiatrisk vård skulle ges under

frivilliga former i så stor utsträckning som möjligt. Det primära

bedömningskriteriet skulle vara vårdbehovet, inte skyddet för omgivningen

(Socialstyrelsen 1991:9). Trots goda intentioner visar studier att den nya

lagstiftningen inte haft avsedd effekt. Patienterna upplevde inte någon ökad

autonomi, fler patienter hade utsatts för tvångsåtgärder (Wallsten & Kjellin, 2004;

Wallsten, Östman, Sjöberg & Kjellin, 2008) och många frivilligt vårdade

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patienter uppgav att de utsatts för tvångsåtgärder under vårdtiden (Kjellin et al.,

2004). Det framkommer även en stor diskrepans mellan dokumentation av

tvångsåtgärder och patienternas beskrivningar, i 42 procent av fallen där

patienterna uppgett att de utsatts för tvång fanns inte åtgärderna dokumenterade i

journalen (Wallsten, Kjellin & Sjöberg, 2008).

I denna avhandling definieras tvång utifrån patientens upplevelse. Tvångsåtgärder

får enligt lag (SFS, 1991:1128) endast användas om de står i rimlig proportion till

syftet med åtgärden och ska utövas så skonsamt som möjligt och med största

möjliga hänsyn till patienten. Tvångsåtgärder får endast användas om patienten

inte, genom en individuellt anpassad information, kan förmås att frivilligt

medverka till att ta emot vård (SFS, 1991:1128). Raboch et al. (2010) har

studerat tvångsåtgärder i tio Europiska länder och funnit att typ av åtgärd och

frekvens varierar stort. Diagnos och svåra symtom var faktorer som generellt gick

att koppla till användning av tvångåtgärder men Raboch et al. menar på att den

stora variationen mellan länderna kan bero på landets sociokulturella traditioner

och vårdkulturer. Som tidigare framkommit förekommer även en stor diskrepans

mellan vad vårdare och patient anser vara tvång och det juridiska tvånget

överensstämmer inte alltid med det upplevda.

Att vårda en person mot dennes vilja ställer särskilt höga krav på vårdgivaren och

patienten ska kunna erbjudas ett varierat och individanpassat vårdutbud

(Socialstyrelsen, 2009). Dock framkommer i socialstyrelsens inventering att den

vård som erbjuds är ensidig och den vanligaste åtgärden är medicinska insatser.

Rapporten visar vidare på att den psykiatriska tvångsvården behöver utvecklas för

att kunna erbjuda en vård av hög kvalitet. Föreslagna åtgärder är bland annat att

stärka personalens kompetens så att ett varierat och behovsanpassat vårdinnehåll

kan erbjudas (Socialstyrelsen, 2009).

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Patienter som tvångsvårdats beskriver dock en organisation som präglas av rigida

regelsystem där de kan bemötas av vårdare som har en arrogant attityd, uttalar

provocerande kommentarer och som har fokus på kontroll och övervakning

istället för vård (Hörberg et al., 2012; Meehan et al., 2006). Enligt Meehan et al.

så var medicineringssituationen den största utlösande faktorn för aggressivitet och

patienterna upplevde att syftet med medicineringen snarare handlade om

beteendekontroll och straff än behandling för deras sjukdom. Enligt en

forskningsöversikt (Jarrett, Bowers & Simpson, 2008) sker tvångsmedicinering

ofta slentrianmässigt och kan inte betraktas som en evidensbaserad

behandlingsmetod, då det råder brist på forskning inom området. I studierna

framkom inga beskrivningar av alternativ till tvång och endast ett fåtal artiklar

beskrev utlösande faktorer till tvångsåtgärden. Jarrett et al. anser bland annat att

personalens attityder, preventiva insatser och alternativ till tvångsåtgärder är

faktorer som bör undersökas vidare.

I en nyligt publicerad översiktsartikel om tvångsvård visar van den Hooff och

Goossensen (2014) att det genomgående starkaste önskemålet, från ett

patientperspektiv, var att personalen lyssnade och tog patienten på allvar, men

patienternas erfarenheter var ofta de motsatta. Ser man till den aktuella

forskningen inom området så är det fortfarande ett stort fokus på säkerhet/risk,

personal och organisatoriska faktorer (Bak et al., 2015; Björkdahl, Hansebo &

Palmstierna, 2013; Bowers et al., 2009; Bowers et al., 2015; De Benedictis et al.,

2011; Fluttert, van Meijel, Nijman, Bjørkly & Grypdonck, 2010 m.fl.) och

mindre fokus på patientens perspektiv och den flexibla och behovsanpassade

tvångsvården som socialstyrelsen efterlyser.

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Alternativ till tvång

Ett flertal studier visar på att sjuksköterskor kan se på tvångsåtgärder som en

självklar och nödvändig arbetsuppgift utan andra acceptabla alternativ (Haglund,

von Knorring & von Essen, 2003; Jarrett et al., 2008; Marangos-Frost & Wells,

2000; Muir-Cochrane et al., 2015; Olofsson, 2005; Olofsson, Gilje, Jacobson &

Norberg, 1998). Att utföra tvångsåtgärder innebär dock ofta en inre konflikt för

sjuksköterskor då de vill se sig själva och sina kollegor som goda vårdare medan

tvångsåtgärder inte ses som en del av den goda vården (Olofsson et al., 1998).

Det finns kliniska exempel som visar att det är möjligt att kraftigt reducera

behovet av tvångsåtgärder i psykiatrisk vård (Ashcraft & Anthony, 2008; Barker

& Buchanan-Barker, 2010; Barton, Johnson & Price, 2009; Georgieva, de Haan,

Smith & Mulder, 2010; Hejlskov Elvén & Abild, 2015 m.fl.). Gemensamma

faktorer som bidrog till ett minskat behov av tvångsåtgärder, utifrån exemplen

ovan, var att vårdarna aktivt eftersträvade en nära relation till patient och hade

fokus på hopp och empowerment istället för kontroll och korrigering. Detta

bekräftas även i intervjustudier som beskriver att relationen mellan patient och

vårdare är ett kraftfullt verktyg för att förhindra tvångsåtgärder (Haglund et al.,

2003; Olofsson & Norberg, 2001; Vuckovich, 2009 m.fl.). Andra studier lyfter

även upp ledarskapet och organisationens betydelse (Huckshorn, 2004),

vårdmiljön (Muir-Cochrane et al., 2015) samt personalutbildning och reducering

av avdelningsregler (Huckshorn, 2014).

Självskadebeteende

I Sverige är personer med självskadebeteende överrepresenterade i statistiken över

tvångsåtgärder (Holm, Björkdahl & Björkenstam, 2011). Det är inget klart

definierat begrepp och det saknas konsensus om vad som ska räknas som

självskadebeteende (Mangnall & Yurkovich, 2008). I denna avhandling har det

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varit upp till deltagaren själv att avgöra om de anser sig ha ett självskadebeteende,

då rekryteringen av dessa deltagare skett helt anonymt (delstudie I).

Självskadebeteende har beskrivits som en samsjuklighetsproblematik till andra

diagoser och även i vissa fall kopplats till barndomstrauman (Mangnall &

Yurkovich, 2008; McAllister, 2003). I den senaste versionen av diagnosmanualen

DSM-V har dock icke suicidalt självskadebeteende (non-suicidal self-injury

[NSSI]) för första gången kommit med som förslagen oberoende diagnos

(American Psychiatric Association, 2013).

I en nyutkommen rapport (SBU, 2015) framkommer att personer med

självskadebeteende utsätts för dömande attityder från vårdpersonal. De känner sig

även maktlösa och upplever att tvångsåtgärder kan förekomma i straffande syfte,

de negativa vårderfarenheterna bidrar till att de inte söker vård. McAllister (2003)

visar på att självskadandet kan ha många olika orsaker och fylla olika syften för

personen som skadar sig. McAllister drar då slutsaten att vårdarna måste vara

flexibla och kunna erbjuda olika individuella lösningar för att kunna bryta det

traditionellt negativa diskurserna som ofta förekommer i den psykiatriska vården.

En nyligt publicerad litteraturöversikt (Karman, Kool, Poslawsky & van Meijel,

2015) visar att personalens bemötande och attityder har stor påverkan på

patientens välbefinnande och upplevelser av vårdens kvalitet. Resultatet visar

även på att det är vanligt att sjuksköterskor har negativa attityder till personer

med självskadebeteende.

Patienter vill bemötas som kompetenta unika individer och kunna känna att

personalen ser deras individuella behov (Lindgren, Öster, Åström & Hällgren

Graneheim, 2011). Tofthagen, Talseth och Fagerström (2014) visar på att

sjuksköterskor kan främja patienternas välbefinnande genom att skapa

förutsättningar för en ömsesidig relation och initiera personcentrerade

interventioner. Lindgren och Hällgren Graneheim (2015) lyfter också vikten av

det genuina mötet som en förutsättning för patientens återhämtning men visar

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även på att arbetet med personer som skadar sig själva kan vara både utmanade

och oförutsägbart vilket innebär att vårdaren har behov av kunskap, stöd och av

att få tid för reflektion för att kunna göra ett bra arbete. Detta stöds även av

Karman et al. (2015) som dessutom betonar möjligheten att arbeta nära patienten

samt stöd från kollegor som viktigt faktorer för att kunna förändra

sjuksköterskornas negativa attityder till patienter med självskadebeteende.

Omvårdnadsprocessen

I detta avhandlingsarbete beskrivs omvårdnadsarbete utifrån the process of care (se

delstudie II) eller omvårdnad som process och består av de tre delarna relation och

relationsskapandet, behov och behovsbedömning och åtgärder och förhållningssätt.

Både patienter och sjuksköterskor beskriver att en personlig relation är grunden

för en vårdande allians (Halldorsdottir, 1996; Jormfeldt, Svedberg, & Arvidsson,

2003; Svedberg, Jormfeldt, & Arvidsson, 2003 m.fl.). Relationen stärker

förutsättningarna för att se patienten som en unik individ med unika behov,

vilket är en nödvändighet för att främja hälsoprocessen. Omvårdnadsåtgärder som

fokuserar på respekt, delaktighet och empowerment är betydelsefulla för

patienternas upplevelse av hälsa (Svedberg et al., 2003). Detta står dock i kontrast

till hur omvårdnadsprocessen traditionellt beskrivs, där vare sig relationens

betydelse eller relationsskapande faktorer är synliggjorda. Omvårdnadsprocessen

beskrivs som en problemlösningsmodell som startar med datainsamling och går

sedan vidare med planering, utförande av intervention och avslutas med

utvärdering (Yura & Walsh, 1988) och i vissa fall så läggs även

omvårdnadsdiagnostisering till processen (Carnevali, 1983; Gordon, 2002 m.fl).

Eriksson (2014) beskriver relationen mellan patient och vårdare som kärnan i

vårdprocessen. Dock synliggör inte heller Eriksson relationen utan processen inleds

med patientanalys, som till stor del påminner om omvårdnadensprocessens

beskrivning av datainsamlingen.

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Vetenskapsteoretiskt ramverk Min vetenskapsteoretiska utgångspunkt är pragmatismen, vilket innebär att jag

har haft ambitionen att omsätta delstudiernas resultat till praktiska handlingar. Det

innebär att mitt fokus inte i första hand varit att förstå hur en patient upplever

tvångsåtgärder utan att söka efter konkreta handlingsalternativ där patientens

behov kan mötas utan att tvång används. Ytterligare en viktig aspekt utifrån detta

handlingsperspektiv har för mig varit att försöka förstå vad vårdare grundar sina

val av handlingar på.

Min långa erfarenhet inom psykiatrin kan innebära en risk för att jag blivit

begränsad i min förmåga att se olika möjligheter (jmf Hellzén, Kristiansen &

Norbergh, 20031), och jag har därför strävat efter en att ha en bred ansats och

utgått ifrån flera perspektiv. Konkret har det inneburit att jag samlat kunskap och

erfarenheter från både patienter, studenter och personal. Detta har hjälpt mig att

se fler möjligheter och handlingsalternativ. Dessutom har jag haft förmånen att i

vissa delar ha ett nära samarbete med en annan doktorand, vilket har varit mycket

berikande och stimulerat till kritisk reflektion och nya infallsvinklar.

Pragmatism

Pragmatismen formulerades i slutet av 1800-talet av Charles S Peirce och

kännetecknas av att den värderar en metod eller teori enligt dess funktion,

tillämpning och användbarhet (Peirce, 1990). Det finns ett antal filosofer som

utgått från Peirces teorier, och jag har i denna avhandling främst använt Richard

Rorty och John Deweys tankar som grund för mina reflektioner. Dewey är

filosof och har producerat en mängd teorier inom olika områden så som

1 Hellzén et al. visar på att lång erfarenhet kan vara en belastning då känsligheten i relation till brukarna minskade och de med lång erfarenhet hade sämre attityd.

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pedagogik, moral, demokrati och socialpsykologi. I denna avhandling refereras till

delar av Deweys teorier utifrån professorerna i pedagogik John Hartman och Gert

Biestas bearbetningar och tolkningar av Deweys texter (Biesta, 2004; Hartman,

2003).

Denna avhandling har ett fokus på alternativ till tvång, det vill säga ett

handlingsperspektiv. Utgångspunkten har varit personers erfarenheter av

psykiatrisk vård, från olika perspektiv. Inom pragmatismen finns det inte någon

platonsk önskan om att urskilja skenet från verklighetens innersta natur eller en

tro på att tingen verkligen är på ett visst sätt utan det anses mer meningsfullt att

utgå från att det finns mer eller mindre användbara beskrivningar av världen

(Rorty, 2003). Dewey ställde sig kritiskt till det dualistiska tänkandet2 och

utarbetade en handlingsteori som utgår från våra erfarenheter. Han menar på, i

motsats till många andra filosofer, att vi alltid är i kontakt med världen (Biesta,

2004). Enligt pragmatismen så är det inte meningsfullt att beskriva kunskap som

ett sätt att representera verkligheten, då sanningssökandet inte fyller någon

funktion i sig, istället bör forskningen ses som ett sätt att använda verkligheten

(Rorty, 2003). Det innebär, enligt Rorty, att sökande efter kunskap inte är ett

mål i sig utan bara ett av många medel för strävan efter mänsklig lycka.

I delstudierna finns det beskrivningar från flera olika typer av verksamheter, vilket

kan anses vara ett problem om man söker efter homogenitet eller sanningar. I

denna avhandling har ambitionen varit att visa att det finns många olika val

snarare än att identifiera den ”perfekta” tvångsfria vården eller att fastslå att

tvångsåtgärder är förkastligt. Därför tänker jag att beskrivningar från olika

2 Biesta (2004) beskriver att dualismen särskiljer delar exempelvis kropps – själ, stimuli – respons etc. medan Dewey anser att vi bör se delarna som funktionella faktorer inom en konkret helhet, inte som existentiella olikheter som dualismen förespråkar. Jag tolkar det som att det centrala är faktorers ömsesidiga påverkan, det vill säga processen, och inte hur faktorer står i relation till varandra.

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kontexter kan berika datainsamlingen och öppna upp för fler alternativ till

tvångsåtgärder. Sammanfattningsvis så har jag inte haft ambitionen att identifiera

ett rätt eller fel sätt att handla utan visa på möjligheter att välja olika alternativ för

att skapa hopp och tillfredställelse i vården både för patienter och för vårdare.

Abduktion

I mina resonemang har jag utgått från abduktion som är den bevisföringsform

som pragmatismen grundar sig på. Abduktion kan enkelt förklaras som att

hypoteser formuleras utifrån den erfarenhet vi har, kreativa hypoteser. Hypoteserna

testas empiriskt för att eventuellt formulera en ny hypotes som prövas, detta

fortsätter till dess att vi kan anta att vi nått den bästa förklaringen, tills vidare

(Harman, 1965; Peirce, 1990). Abduktionen öppnar upp för och stimuleras av

skilda perspektiv, kreativitet och associationsrikedom (Svensson, 2002a). Enligt

Svensson (2002a) handlar abduktion om att pendla mellan del och helhet för att

få en fördjupad förståelse och ökad insikt så att en ny innebörd kan uppstå till det

som redan är känt. En kritik mot abduktionen har varit att den inte följer samma

traditionellt stringenta regelverk som de övriga bevisföringsformerna, det vill säga

induktion, deduktion och hypotetisk deduktion. Samtidigt anser Birkler (2008)

att styrkan med abduktionen istället är att den är mycket tillämpbar.

Abduktionen skiljer sig från induktion som är den traditionella

bevisföringsformen inom den kvalitativa omvårdnadsforskningen (Bergdahl &

Berterö, 2015). I ett induktivt förhållningssätt utgår forskaren från en öppen och

förutsättningslös utgångspunkt och går mot en generalisering (Kvale &

Brinkmann, 2014). I en strikt tillämpning innebär det att tidigare erfarenheter

och kunskaper sätts åt sidan och att forskaren strävar mot ett öppet

förhållningssätt till det fenomen som studeras. Ett exempel på kritik mot ett

induktivt förhållningssätt är Bergdahl och Berterö (2015) som är starkt kritiska till

hur dagens omvårdnadsforskning generellt ser ut där de anser att den är för

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ospecifik och allmän. De anser vidare att det är viktigt att inte bara generera

allmänna teorier utan även kritiskt granska och utveckla teorierna genom att

hypotestesta och se om de är praktiskt tillämpbara. Eriksson och Lindström

(1997) stödjer ett sådant resonemang och menar att ett abduktivt förhållningssätt

kan vara en konstruktiv väg för att utveckla och förnya arbetssätt inom vården.

För att omsätta det abduktiva resonemanget till mitt forskningsprojekt så utgick

jag från mina egna erfarenheter av att vårda vid tvångsvård och mina erfarenheter

av att använda andra alternativ än tvångsåtgärder. Dessutom studerade jag tidigare

forskning som beskriver olika erfarenheter av tvångsåtgärder och alternativ till

tvång. Dessa utgångspunkter fanns sedan med i planeringen och utformningen av

de delstudier och analyser som ingår i avhandlingen. I forskningsprojekt har jag

utgått ifrån två övergripande hypoteser: det finns alternativ till tvångsåtgärder och

personal vill använda alternativ om de kan. Då jag insåg att delstudiernas resultat hade

många gemensamma skärningspunkter så genomförde jag även en metasyntes (jmf

Walsh & Downe, 2005). Detta innebär att de fyra resultaten sammanfördes och

tolkades (Graneheim & Lundman, 2004) till ett sammantaget femte resultat (se

resultat) som förväntas ligga till grund för en konkret arbetsmodell.

Teori och praktik

Att överbrygga klyftan mellan teori och praktik och implementera nya teorier

och metoder inom vården är inte helt enkelt (jmf Gask & Coventry, 2012;

Maben, Latter & Clark, 2006; Thorne et al., 1998). Enligt Biesta, så anser Dewey

att kunskap alltid handlar om relationen mellan våra handlingar och dess

konsekvenser, det vill säga att vi får kunskap om världen via våra handlingar.

Dewey ser inte människan som åskådare av ett färdigt universum utan menar att

vi är deltagare i ett ständigt utvecklande av ett oavslutat universum. Han menar

vidare att det krävs en process där vi gör kunskap, ”kunskapande”, något som

enligt Dewey är nödvändigt för att att få insikt om kunskapen (Biesta, 2004).

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Hartman (2003) beskriver Deweys tankar som att tanke och handling inte kan

åtskiljas på samma sätt som att teori och praktik är varandras förutsättningar, utan

inbördes rangordning. Han anser vidare att reflektion måste ha förankring i

handling och praktiska handlingar genererar ingen erfarenhet utan reflektion.

Detta innebär att om tanke och handling är synkrona så finns ett etiskt krav på

människan att leva som man lär och i det ingår att reflektera över sina handlingar,

vilket Dewey benämner som intelligent action (Hartman, 2003).

Aktionsforskningen är en forskningsmetod som bygger på pragmatismen och

Deweys teorier har fått ligga till grund för bland annat beskrivningen av

begreppet outcome validity (workability). Outcome validity är ett kvalitetsmått och

handlar om att mäta om forskningen lett till några reella förändringar, det vill säga

löst problemet, vilket är ett viktigt mål inom metoden (Herr & Andersson, 2014).

Även om de forskningsmetoder som jag använt inte varit inom ramen för

aktionsforskning så finns det delar i metoden som jag har inspirerats av. Jag har

haft ambitionen att skriva artiklar som är vetenskapligt välgrundade och samtidigt

lättlästa och omsättningsbara för att de ska kunna användas i verksamheterna till

stöd för reella förändringar. Dessutom har jag valt att skriva kappan på svenska

och eftersträvat att ha ett mer direkt tilltal med förhoppningen att den ska bli

intressant för en bred läsargrupp. Som stöd i utormningen av kappan, förutom

den traditionella akademiska processen, så har jag haft en referensgrupp bestående

av patient- närstående - och personalrepresentanter som fått läsa och ge

synpunkter på framförallt språkbruk, begriplighet och omsättningsbarhet. Jag

tänker att denna process delvis skulle kunna svara upp mot det Herr och

Andersson (2014) beskriver som democratic validity där de förespråkar vikten av att

personerna som forskningen berör bör vara involverade utifrån ett etiskt och

socialt rättighetsperspektiv.

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Rational Utifrån litteratur och mina egna erfarenheter tycks det finnas alternativ till tvång

men tvångsåtgärder är fortfarande vanligt förekommande inom den psykiatriska

vården och dessa motiveras ofta av personal med att det saknas alternativ.

Omvårdnadsforskning beskriver betydelsen av relationer, hur bedömningar av

behov kan genomföras och interventioner som kan fungera som alternativ till

tvång.

I det forskningsprojekt som ligger till grund för denna avhandling har jag utgått

ifrån två övergripande hypoteser: det finns alternativ till tvångsåtgärder och personal

vill använda alternativ om de kan. Hypoteserna har funnits med som grundläggande

antagande i planeringen och genomförandet av alla studier.

Omvårdnad kan beskrivas som en process med tre tydligt avgränsade områden

som i sig är beroende av varandra: skapandet av en relation, identifiering av

behov, samt åtgärder och förhållningssätt. En genomgång av litteraturen visar att

det finns forskning om tvång i psykiatrisk vård som beskriver delarna i processen,

men begränsat med forskning kring hur delarna kan knytas ihop till en helhet.

Jag har haft ambitionen att ta steget från kunskap om delar av den komplexa

verklighet som påverkar vården av personer med psykisk ohälsa till praktiska

handlingar som kan användas i omvårdnadsarbetet. Det innebär att mitt fokus

inte i första hand varit att förstå hur en patient upplever tvångsåtgärder utan att

söka efter konkreta handlingsalternativ där patientens behov kan mötas utan att

tvång används. Ur ett handlingsperspektiv har det för mig också varit viktigt att

försöka förstå vad personalen grundar sina val av handlingar på.

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Jag hoppas att denna avhandling ska bidra till ny kunskap genom att synliggöra

och visa på hur de olika delarna, relation, behov och åtgärd, kan sättas ihop till en

helhet. På det sättet kan innehållet i omvårdnadsarbetet konkretiseras för både

personal och patienter vilket förhoppningsvis ger dem nya och bättre verktyg att

hantera en svår situation.

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Övergripande syfte Baserat på mina utgångspunkter och argumentationen i rationalen är därför det

övergripande syftet att få ökad kunskap och förståelse för omvårdnad som process

i psykiatrisk vård ur patienters, studenters och personals perspektiv, med särskilt

fokus på alternativ till tvång vid självskadebeteende.

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Metod Alla fyra delstudierna analyserades inom ramen för kvalitativ innehållsanalys men

tillvägagångssättet varierade beroende på typ av data (fokusgruppsintervjuer,

självskrivna patientskildringar och loggböcker). Innehållsanalys är en flexibel

metod som är användbar för att analysera olika typer av textmaterial (Graneheim

& Lundman, 2004). Enligt Krippendorff (2013) har en text flera olika meningar

då den kan läsas ur flera olika perspektiv beroende på vilken utgångspunkt och

erfarenhet forskaren har. Detta är förenligt med den abduktiva processen där

forskaren använder sin erfarenhet i analysen och pendlar mellan praktik och teori

(Krippendorff , 2013). Krippendorff anser vidare att en text inte har en

förutbestämd mening som ska identifieras utan betydelsen i texten arbetas

succesivt fram och synliggörs av forskaren under tolkningsprocessen. Med stöd av

innehållsanalysen så kan texter bearbetas på ett systematiskt sätt så att trovärdiga

slutsatser kan dras (Krippendorff, 2013). En sammanställning av delstudiernas

syften, deltagare, datainsamlings- samt analysmetod visas i Tabell 1.

Delstudie I

Deltagare och datainsamling

Potentiella deltagare kontaktades via sociala medier och brukarorganisationers

hemsidor. Via dessa kanaler gavs en kort information och en länk till en hemsida

där de potentiella deltagarna fick utförlig information om studien.

Inklusionskriterierna var att personen hade vårdats för ett självskadebeteende och

hade erfarenheter av tvångsåtgärder/av situationer där tvångsåtgärder kunnat

undvikas samt vara minst 18 år. På hemsidan fanns ett webbformulär, med

instruktionen ”skriv din berättelse här”, där deltagarna helt anonymt kunde

beskriva sina erfarenheter i fritext. Datainsamlingen pågick under ca tre månader

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Tabell 1. Sammanställning av delstudiernas (I-IV) syften, deltagare, datainsamlingsmetod och

analysmetod.

Studie Syfte Deltagare Datainsamling Dataanalys

I Beskriva vilka uppfattningar personer med självskadebeteende har om alternativ till tvång i förhållande till deras erfarenheter av psykiatrisk slutenvård

19 personer Skrivna berättelser inlämnade anonymt via hemsida

Kvalitativ innehållsanalys

II Undersöka omvårdnad som process genom att beskriva sjuksköterskestudenters resonemang och erfarenheter av relationsskapande, behovsbedömningar och val av åtgärder i psykiatrisk vård.

14 sjuksköterske-studenter

Skrivna webbaserade loggböcker

Kvalitativ innehållsanalys

III Beskriva personals resonemang kring val av åtgärder i utmanande situationer i psykiatrisk slutenvård

8 skötare 10 sjuk-sköterskor 4 enhetschefer 4 läkare

Fokusgruppsintervjuer Kvalitativ innehållsanalys

IV Beskriva personals uppfattningar av interprofessionellt samarbete i utmanande situationer i psykiatrisk slutenvård

8 skötare 10 sjuk-sköterskor 4 enhets-chefer 4 läkare

Fokusgruppsintervjuer Kvalitativ innehållsanalys

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och genererade nitton berättelser. Det fanns inga frågor om

bakgrundsinformation men i berättelserna framkom att bland deltagarna fanns

både kvinnor och män i varierande åldrar samt att vissa hade erfarenhet från

rättspsykiatrin. Flera av deltagarna beskrev även tidigare erfarenheter från vård

inom barnpsykiatrin.

Analys

Analysen inleddes med att alla berättelserna sattes ihop till en text och lästes för

att få en förståelse för innehållet. Efter att ha läst berättelserna upprepade gånger

så utvecklades en analysstrategi som innebar att texten delades upp i två olika

grupper. En grupp bestod av kondenserade meningsenheter som beskrev

generella erfarenheter vården och den andra gruppen bestod av beskrivningar av

erfarenheter av alternativ till tvångsåtgärder samt önskningar och förslag till

alternativ. Texten i respektive grupp lästes på nytt och tre innehållsområden (jmf

Graneheim & Lundman, 2004) identifierades. I nästa steg anlyserades texten

genom att först sortera in textenheterna under respektive innehållsområde och

sedan kategorisera dem i flera steg. Respektive grupp genererade tre

subkategorier som låg till grund för de tre slutkategorierna som beskriver

önskningar i förhållande till reella erfarenheter.

Metodval och etiska överväganden

Jag övervägde under lång tid om forskningsprojektet gynnades av att fokusera på

en speciell patientgrupp. Mitt dilemma handlade om hur jag trodde att

avhandlingen skulle uppfattas. Valet att fokusera på en patientgrupp kunde bidra

till att avhandlingen uppfattades fokusera på en patientgrupps problematik i stället

för alternativ till tvång, samtidigt kunde valet att ha fokus på en patientgrupp

synliggöra det jag ville säga på ett tydligare sätt. Till slut så bestämde jag mig för

att det kunde vara mer meningsfullt att utgå från personer med

självskadebeteende. Beslutet grundades dels utifrån min yrkesmässiga erfarenhet

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av att tvångsåtgärder sällan var nödvändigt för denna patientgrupp, men trots

detta användes frekvent. Samt att vid tidpunkten för revideringen av etikansökan

publicerades en artikel med aktuell statistik som visade på att tvångsåtgärder

ökade mest för gruppen unga kvinnor och att sjukhusvård efter självmordsförsök

eller avsiktlig självskada fördubblats för samma grupp under den senaste 15-års

perioden (Holm et al., 2011). Sammantaget kändes valet av grupp naturlig för att

företräda problematiken, så tanken är inte att arbetssättet är specifikt för just

denna patientgrupp, utan det var en grupp som var representativ utifrån syftet.

Att utsättas för tvångsåtgärder kan upplevas mycket traumatiskt och kan även

återuppväcka andra svåra minnen (Bonner, Lowe, Rawcliffe & Wellman, 2002).

Att berätta om dessa erfarenheter kan givetvis riskera att skapa ett ytterligare

lidande. Utifrån denna vetskap så övervägde jag studien och formen för

datainsamling noggrant. Kom dock fram till att det möjligen kan vara så att det

finns risk för att det blir en paternalistisk omtanke som innebär att personer som

har erfarenhet av att tvångvårdas inte alls kommer till tals. Det råder mycket stor

brist på studier som beskriver vårderfarenheter ur ett patientperspektiv men det

finns desto fler studier som beskriver personalens uppfattningar om och

erfarenheter av att vårda personer med självskadebeteende (James, Stewart &

Bowers, 2012). På hemsidan fanns information om studien och tydliga

uppmaningar om att inte delta i studien om personen trodde att deltagandet

kunde bidra till att de började må sämre. Jag hade kunnat välja att göra intervjuer

istället, för att kunna följa upp deltagarna på ett bättre sätt, men jag hade då missat

möjligheten till spridning av deltagare över hela landet. Genom den geografiska

spridningen så minskar risken för att berättelserna skulle vara beskrivningar från

samma enhet. Anonymiteten kan även skapa trygghet och bidra till mer

frispråkiga svar (O’Connor, Madge, Shaw & Wellens, 2008).

31

Delstudie II


Deltagarna i denna delstudie bestod av 14 före detta sjuksköterskestudenter som

under sin sjuksköterskeutbildning genomfört en fyra veckor lång kurs som var

verksamhetsförlagd inom olika typer av psykiatriska verksamheter. Kontinuerligt

under kursens gång skrev de loggbok där de beskrev sina reflektioner och sitt

arbete med en utvald patient. Urvalet skedde genom att loggböcker där studenter

fått betyget väl godkänd lästes i syfte att identifiera de studenter som lyckats

synnerligen väl med att skapa tillitsfulla relationer till utmanande patienter.

Ytterligare inklusionskriterium var att studenten arbetat självständigt och fått

sparsamt med feedback från läraren samt att läraren hade verifierat studentens

beskrivningar med handledare eller klinisk adjunkt.

Studenterna hade en studieuppgift i kursen som gick ut på att de skulle arbeta

med en patient över tid och med denne försöka skapa en tillitsfull relation,

identifiera behov och planera, utföra samt utvärdera de valda åtgärderna.

Fortlöpande skulle studenterna dokumentera sitt eget arbete i en webbaserad

loggbok, de skulle även genomgående reflektera över och argumentera för sina

bedömningar och val. De fick även vid några tillfällen feedback från lärare. Det

var enbart de själva och läraren som hade tillgång till loggboken. Studenterna var

inte medvetna om att deras texter skulle ingå i någon studie när de skrev

loggarna. De utvalda loggböckerna innehöll 5 000-15 000 ord vardera.

Analys

Analysen inleddes med att loggböckerna lästes igenom noggrant och texten

sorterades sedan in under tre innehållsområden (jmf Graneheim & Lundman,

2004), relation, behov och åtgärd, utifrån strukturen på studieuppgiften. Därefter

lästes texten inom respektive innehållsområde förutsättningslöst och analyserades

32

genom att meningsenheter identifierades som beskrev vad studenterna gör, hur

de gör det och med vilka argument/vilket syfte. Meningsenheterna

kategoriserades sedan i flera steg. Analysen resulterade i sex subkategorier och tre

huvudkategorier.


Utifrån det övergripande syftet med avhandlingen så har denna delstudie utgått

från hypotesen, om man inte har tillgång till tvångsåtgärder och får stöd i att reflektera så

blir man mer kreativ i sitt vårdande och hittar alternativa lösningar. I min roll som lärare

så har jag inspirerats av filosofen och pedagogen John Deweys syn på lärande,

vilket också har påverkat forskningsprojektet. Enligt Biesta (2004), anser Dewey

att kunskap alltid handlar om relationen mellan handlingar och dess

konsekvenser, det vill säga tanke och handling kan inte åtskiljas på samma sätt

som teori och praktik är varandras förutsättningar. Att använda studenternas

loggböcker kändes utifrån detta perspektiv helt självklart. Det fanns en stor väl

bearbetad kunskapskälla i deras texter där Deweys resonemang kring sambandet

mellan teori, praktik och reflektion, kunde tillämpas och där studenternas

erfarenheter kunde tillvaratas.

Lärarens feedback till studenterna kan ha påverkat innehållet i loggböckerna och

därmed resultatet. Jag har dock tagit hänsyn till detta i urvalet så enbart

loggböcker där det förekommit sparsamt med feedback valdes ut. Feedbacken

lämnades kvar i det första analyssteget för att medförfattarna skulle kunna göra en

bedömning av lärarens eventuella påverkan. Det fanns även risk för att

studenterna idealiserat sina egna insatser, då studenten är i beroendeställning och

ska bedömas och betygsättas. Läraren hade en kontinuerlig kontakt med

handledare och kliniska adjunkter som bekräftade studenternas beskrivningar och

det verkade främst föreligga en risk för att studenterna tonat ner sin egen

betydelse och insats.

33

Det kan även anses problematiskt att studenterna läste kurslitteratur och utförde

studieuppgifter parallellt med skrivandet i loggboken samt att analysen utgick från

en studieuppgift. Då innehållet i datamaterialet blev styrt mot vissa teorietiska

utgångspunkter och givna ramar. Det fanns dock även en öppen ansats senare i

analysprocessen när studenternas beskrivningar av deras arbete och individuella

val inom respektive innehållsområde analyserades. Detta tillvägagångssätt

överensstämer väl med den abduktiva ansatsen då det är möjligt att växla mellan

teori och empiri för att succesivt öka förståelsen (Peirce, 1990). Innehållsanalys

beskrivs som en flexibel metod som kan användas i syfte att ge förslag på

praktiska, utbildnings och forskningsmässiga implikationer (Krippendorf, 2013),

vilket stöds av det pragmatiska förhållningssättet.

Att analysera en skriven, processad och reflekterad text skiljer sig en del från att

analysera en fenomenologisk kvalitativ intervju (jmf Kvale & Brinkmann, 2014),

även den fenomenologiska synen på kunskap skiljer sig från den pragmatiska.

Ricoeurs kunskapssyn utgår från ett empiriskt-holistiskt paradigm och har därmed

ett induktivt förhållningssätt (Thompson, 1981). Ricoeur (1976) menar på att

text inte är tal och skillnaden består i att tal är spontant och en text är tillrättalagd.

Ricoeur anser vidare att en berättelse ska vara så fri som möjligt från

teoretiserande och reflekterande för att nå ett djup i intervjun. Jag anser att texten

i loggböckerna har en annan typ av djup, även om tolkningsgraden inte är lika

hög, tack vare att studenterna har haft möjlighet att pröva, reflektera och

ompröva under en längre tid. Studenternas texter är reflekterade i en process i

flera steg och även till viss del bearbetade och teoretiserad mot kurslitteratur och

vetenskapliga artiklar. Först därefter startar den vetenskapliga analysprocessen där

det krävs ytterligare bearbetning och reflektion för att sammanställa innehållet i

texterna och formulera ett trovärdigt resultat av hög kvalitet. Jag jämför och

34

finner stöd för min argumentation om processen utifrån Herr och Anderssons

(2014) resonemang beträffande process validity. Enligt Herr och Andersson är

processtänkandet inte enbart begränsat till metoden utan bör vara ett

genomgående kvalitetskriterium och poängterar att det är viktigt att

bearbetningen inte stannar på ett ytligt plan utan är reflekterad på flera nivåer.

Med hänsyn till studenternas ringa erfarenhet så kan det diskuteras om studenter

var det bästa valet av deltagare, utifrån syftet med studien. Valet av deltagare till

denna delstudie utgick främst från det övergripande syftet då studenter är den

enda kategori vårdare, i patientnära arbete, som inte har tillgång till

tvångsåtgärder och därmed varit nödgade att utveckla andra alternativ. Dessutom

valdes endast de studenter som, enligt min bedömning, lyckats ovanligt bra med

att skapa relationer till uttalat ”svåra” patienter. Utifrån detta resonemang anser

jag att deltagarna i studien var bäst lämpade för att besvara forskningsfrågan men

inte i första hand för att de var studenter.

Delstudie III och IV


Alla skötare och sjuksköterskor (ca 50 personer) som arbetade på en

akutpsykiatrisk avdelning samt samtliga läkare och enhetschefer (ca 10 personer),

med erfarenhet av tvångsvård, som arbetade inom verksamhetsområdet tillfrågdes

om deltagande i studierna. Tjugoåtta tackade ja och tjugosex deltog slutligen i

fokusgruppsintervjuerna. Deltagarna fördelades i sex grupper utifrån

yrkestillhörighet (skötare, sjuksköterskor, enhetschefer och läkare) och erfarenhet

(mer eller mindre än 5 års erfarenhet av arbete inom psykiatrisk vård).

Datainsamling genom fokusgruppintervjuer ger möjlighet att ta del av

resonemang om ett givet ämne och genom interaktionen i gruppen belysa

komplexa beteenden och motiv (Morgan, 1997). Intervjuerna fokuserade på

35

synen på begränsande åtgärder och utgick från en vinjett (se nedan). Intervjun

inleddes med en öppen fråga ”Vad händer sen?” som följdes upp av frågan ”Vad

gör du?” Även klargörande frågor ställdes samt uppmuntrande kommentarer för

att utveckla olika resonemang. Ett protokoll användes för att kontrollera och

säkerställa att alla grupper diskuterade de förvalda områdena (bältesläggning,

extravak, ansvar och professionella roller) utifrån syftet. Under intervjuerna

deltog en moderator som ledde intervjun och en observatör vars uppgift var att

säkerställa att alla områden bearbetats och följa upp eventuella ”trådar” som

intervjuaren missade samt sköta inspelningen. I de grupper där någon deltagare

var mindre aktiv bjöd moderatorn in deltagaren i samtalet genom att ställa någon

fråga direkt till personen.

Vinjett: På avdelningen vårdas sedan en vecka en ung kvinnlig patient. Hon har tidigare

vårdats inneliggande vid ett flertal tillfällen och vårdas nu enligt lagen om psykiatrisk

tvångsvård efter en paracetamolintox i oklart syfte. Vid upprepade tillfällen har begränsande

åtgärder vidtagits i samband med att hon skadat sig själv eller andra inne på avdelningen.

Hela personalgruppen (skötare, sjuksköterskor, läkare, enhetschef) sitter och dricker

morgonkaffe. Personalen ser från fikarummet hur patienten springer genom korridoren fram

till ett kvarglömt dricksglas. Hon plockar upp glaset och slänger det i golvet så att det går

sönder, plockar upp en stor glasskärva och börjar skära sig i djupt i armen samtidigt som

hon skriker: - Släpp ut mig!

Analys delstudie III

Analysen inleddes med att alla intervjuer lästes som en helhet och utifrån syftet så

formulerades tre frågor som stöd för att strukturera upp analysen. Den första

frågan var ”varför väljer deltagarna att göra som de gör?” och meningsenheter

som beskrev resonemang kring val av åtgärder sorterdes ut och fyra olika

skäl/anledningar till deras val identifierades. Meningsenheterna kondenserades

och deltagarnas resonemang runt dessa skäl/anledningar lästes på nytt och

36

tolkades sedan vidare tills fyra fokus som karaktäriserade deras resonemang kunde

formuleras. Den andra frågan ”Vilka olika åtgärder väljer deltagarna?” besvarades

genom att identifiera vilka typer av åtgärder som beskrevs i de befintliga

meningsenheterna, vilket resulterade i att åtta åtgärder identifierades. För att

identifiera hur deltagarna förhöll sig till patienten vid utförande av åtgärden

ställdes en tredje fråga ”Hur utfördes åtgärden?”. För att besvara den frågan

sammanfördes resonemangen om fokus med åtgärd, till exempel alla resonemang

som tolkats som rutinmässiga (fokus) och handlade om samtal (åtgärd) bildade en

grupp etcetera. Genom att sedan upprepade gånger läsa de olika resonemangen

som gick att koppla till respektive åtgärd så identifierades 26 olika förhållningssätt

som var karaktäristiska utifrån resonemangen och i förhållande till varje åtgärd.

Under hela processens gång så skedde omvärderingar och korrigeringar utifrån

diskussioner i forskargruppen. Avslutningsvis ställdes den övergripande frågan

”Hur kan deltagarnas resonemang om val av åtgärder beskrivas?” Den frågan

besvarades genom att hela texten lästes på nytt och ställdes i förhållande till

resultatet. Det tolkade svaret formulerades och bildade det övergripande temat.

Analys delstudie IV

Även i denna analys lästes den utskrivna intervjutexten som en helhet. Utifrån

syftet valdes meningsenheter ut, kondenserades och sorterades upp utifrån grupp

och profession. I ett första steg identifierades och formulerades föreställningar

kring yrkesspecifika förhållningssätt som framkommit om respektive

profession/yrkesgrupp. För att urskilja hur deltagarna ser på arbetet i teamet och

det gemensamma ansvaret bearbetades och tolkades meningsenheterna på nytt,

oberoende av yrkesgrupp, och fyra typer av förväntningar identifierades och

formulerades. I det tredje steget så sorterades de yrkesspecifika meningsenheterna

ut för att få svar på hur deltagarna såg på det yrkesspecifika ansvaret.

Avslutningsvis tolkades hela resultatet som en helhet och ett gemensamt tema

identifierades.

37


Tvångsåtgärder kan upplevas svåra att prata om då personal kan känna sig

ifrågasatta och sårbara när de ska beskriva arbetsuppgifter kopplade till tvång

(Olofsson, 2005). Lützén och Schreiber (1998) menar dock att fokusgrupper kan

vara att föredra när intervjuer ska genomföras inom psykiatrisk vård med

motiveringen att psykiatrisk omvårdnad är en kommunikativ och interagerande

verksamhet där personalen är van att diskutera vårdrelaterade frågor i formella

och informella grupper.

Uppgiften att vara moderator alternerades med en av medförfattarna 3. Vi

reflekterade över vem av oss som skulle vara lämpligast till att göra intervjuerna i

respektive grupp. Vi kom fram till att jag som varit skötare i många år skulle

ansvara för intervjuerna med skötarna. Jag hade även arbetat med några av dem

och hade då varit en ”insider” men i forskarrollen blev jag nu en ”outsider”.

Vilket kan jämföras med Herr och Anderssons (2014) resonemang kring

positionering utifrån etnicitet, kön, tidigare yrkesroll etcetera. Herr och

Andersson menar att positionering kan vara på olika nivåer. I detta fall så hade vi

en gemensam bakgrund utifrån både yrkesroll och i vissa fall personlig kännedom

så då kunde jag eventuellt ha en fördel och till viss del bli en insider. Vårt

resonemang utgick ifrån att de kanske kände en större tillit och trygghet till mig

då jag har varit ”en av dem”, jämfört med min kollega som de endast kände till i

yrkesrollen som sjuksköterska och forskare.

3 Deltstudierna III och IV genomfördes i samarbete med doktorand Sebastian Gabrielsson och finns även inkluderade i dennes avhandling "A moral endeavour in a demoralizing context: Psychiatric inpatient care from the perspective of professional caregivers".

38

När vi diskuterade val av moderator till läkargruppen så blev det istället en

genusfråga. Vårt resonemang utgick från att de flesta läkarna var män och att de

eventuellt skulle känna en större samhörighet (jmf Herr & Anderssons

resonemang ovan) och respekt för min kollega då han också var man. Möjligen

var detta resonemang bara ett uttryck för våra stereotypa fördomar, men så

resonerade vi. Gunnarsson (2007) hänvisar till Haavinds koncept om den relativa

underordningen av kvinnor och Gunnarsson menar att det är viktigt att reflektera

över och synliggöra makt (o)balanser under forskningsprocessens gång. I detta fall

så tänker jag att vi nyttjade eventuella fördelar med att min kollega var man för

att gynna vårt eget mål om att få så innehållsrika intervjuer som möjligt, utifrån

syftet i studien. Resterande grupper delades upp utifrån att modererandet skulle

fördelas jämt, det vill säga min kollega var moderator för sjuksköterskorna och jag

var moderator i fokusgruppsintervjun med enhetscheferna.

Vi upplevde inga svårigheter med att få deltagarna att diskutera men i vissa

grupper var det någon deltagare som var lite lågmäld. Vi hade kunnat få andra

typer av diskussioner om vi valt att ha yrkesmässigt blandade grupper, men ansåg

att det möjligen kändes tryggare att samtala om ansvar och roller inom sin egen

yrkeskår. Dessutom så kunde möjligen en chefs närvaro, i blandade grupper, ha

en hämmande inverkan (Morgan, 1997). Det var ett procentuellt större bortfall i

skötargruppen som var den största yrkeskategorin på avdelningen. En tänkbar

anledning kan vara att många av skötarna arbetade enbart nattskift och de hade

inte möjlighet att delta i intervjuerna under sin ordinarie arbetestid.

Vinjetten beskriver en situation där en person skadar sig själv men i övrigt finns

ingen djupare beskrivning av patientens problematik och diagnos, vilket var ett

medvetet val, då vi vill att fokus skulle vara på hur personal resonerar och agerar

utifrån en situation som kunde anses som utmanande.

39

Metasyntes I syfte att få ytterligare kunskap och förståelse för omvårdnad som process i

psykiatrisk vård genomfördes en metasyntes av delstudiernas resultat. Walsh och

Downe (2005) menar att i en metasyntes integreras resultat från ett antal olika,

men inbördes relaterade, kvalitativa studier i ett tolkande syfte.

Datamaterialet var förutbestämt och begränsat och metasyntesen genomfördes

med stöd av metoder beskrivna i kvalitativ innehållsanalys (Graneheim &

Lundman, 2004). Analysen utgick ifrån omvårdnad som process med tre tydligt

avgränsade områden, relation, behov, samt åtgärder och förhållningssätt och dessa

områden skapade strukturen för analysen. Analysprocessen inleddes med att

resultattexten från delstudierna I-IV lästes upprepade gånger och text som beskrev

relation och relationsskapandet, behov och bedömningar och åtgärd och

förhållningssätt identifierades och sorterades upp i tre grupper. Därefter

formulerades meningsenheter under respektive innehållsområde (jmf Graneheim

& Lundman, 2004) och liknande beskrivningar sammanställdes med utgångspunkt

i vad som minskar respektive ökar risken för tvångsåtgärder. Slutligen

identifierades nyckelord och meningar från respektive innehållsområde som

sammanställdes i en figur (figur 1) som ska symbolisera en dynamisk process och

visa på respektive områdes centrala innehåll. Resultatet presenteras utifrån

respektive innehållsområde (relation, behov, åtgärd). Hänvisning till respektive

delstudie finns angiven inom parentes med romerska siffror.

41

Resultat

Sammanfattning av resultatet från delstudie I-IV

Delstudie I

Resultatet bygger på beskrivningar från 19 personer med erfarenhet av att ha

vårdats på en psykiatrisk enhet för ett självskadebeteende. Analysen resulterade i

tre kategorier. Genomgående så fanns en stor diskrepans mellan deltagarnas

önskemål och deras reella erfarenheter. De beskrev en önskan om att vårdarna

skulle se och förstå deras behov och att de skulle blir bli sedda och lyssnade till.

Deras erfarenhet var dock att de ofta blev negligerade och kände då en stor

maktlöshet. När de kände sig övergivna av vårdarna så sökte de egna

copingstrategier för att hantera sin ångest vilket i sin tur ofta resulterade i

tvångsåtgärder. I de fall som vårdarna kunde tolka deras signaler och förstå

situationen utifrån deras perspektiv så gick det att hitta individuella lösningar för

att möta deras behov, och tvångsåtgärder var inte nödvändiga. Deltagarna

önskade också en ömsesidig relation med vårdarna men möttes ofta med misstro.

Deltagarna beskrev ifrågasättande distanserade vårdare som hotade med

tvångsåtgärder, vilket ledde till att vårdarna upplevdes som fienden. Vårdarnas

fokus var ofta på att minimera risker för självskada genom olika begränsningar

istället för att försöka bygga en tillitsfull relation som beskrevs som den viktigaste

faktorn för att öka välbefinnandet och minska risken för självskada. I den

avslutande kategorin beskrev deltagarna att de vill ha en professionell vård men

deras erfarenheter var att vården ofta var kontraproduktiv. Övervakning och

disciplinering i en rigid och kaotisk vårdmiljö var vanliga beskrivningar, vilket

medfört att många av deltagarna helt förlorat tilltron till vården. Deltagarna

beskrev att i en professionell vård ingick bland annat flexibla individuella

42

vårdplaner som upprättades i samarbete med patienten, vårdpersonal med rätt

kompetens och möjlighet att få prata med en läkare som känner patientenen.

Delstudie II

Resultatet i delstudie två utgick från 14 sjuksköterskestudenters loggböcker och

resulterade i tre kategorier som beskriver resonemang och utförande av

relationskapande, behovsbedömning och utförande av åtgärderer som

sammantaget bildar ”the process of care”. I första kategorin beskrivs vikten av att

ha tillit till den tillitsfulla relationen. Med tillitsfull avsågs att patienten kände sig

trygg i studentens sällskap och hade tillräcklig tillit för att kunna uttrycka sina

tankar och upplevelser om sin aktuella situation. Utan en tillitsfull relation så

menade studenterna på att det fanns en uppenbar risk för felbedömningar och att

behov förbisågs eller att patienten tillskrevs behov de inte hade. Tillgänglighet,

bekräftelse, genuint engagemang, respekt, samhörighet och ärlighet var faktorer

som ansågs viktiga för relationsskapandet. Hinder för relationskapandet kunde

vara fördomar om och etikettering av patienter men även patienternas symtom.

Behovsbedömningarna handlade framförallt om att ge röst åt de outtalade

behoven. Detta gjordes genom att studenterna var mycket receptiva för att

försöka förstå och tolka tecken hos patienter som inte hade förmågan att själva

uttrycka sina behov. De identifierad basala behov så som sömn och nutrition men

framförallt såg de mer abstrakta behov som hopp, stärkt självkänsla och

empowerment. Utförande av åtgärder handlade till stor del om att balansera

mellan ett utförande av åtgärden och ett medvetet förhållningssätt. Åtgärderna

syftade till att tillgodose individuella behov och ta tillvara patientens förmågor för

att främja en positiv återhämtningsprocess.

43

Delstudie III

Resultatet utgår från olika personalgruppers resonemang kring val av åtgärder vid

utmanande situationer. Utifrån resonemangen identifierades åtta olika val av

åtgärder: agera (akut), samtala, vara med, aktivera, bälteslägga, övervaka,

tvångsmedicinera samt utskrivning, som utfördes med fokus antingen på

personalens behov, patientens upplevelse, att följa rutiner eller att uppfostra

patienter. Beroende på fokus identifierades 26 olika förhållningsätt vid utförandet

av de olika åtgärderna. Som exempel kan nämnas att vid samtal som utgick från

fokus på patientens upplevelse så hade vårdarna ett förhållningssätt där de visade

på att de var intresserade av att lyssna och försöka förstå patientens situation och

behov. Vilket kan jämföras med ett uppfostringsfokus där samtalet istället var av

klargörande karaktär och vårdarna hade då ett förhållningsättet med fokus på att

patienten skulle förstå ”vad som gäller”. Det övergripande temat visar på

spänningen mellan att lösa personalens problem eller att tillgodose patientens

behov.

Delstudie IV

Resultatet bygger på samma fokusgruppsintervjuer som delstudie III men syftar

till att beskriva personalens syn på samarbete utifrån olika professionella roller.

Läkaren beskrivs som den distanserade beslutsfattaren, enhetscheferna som

misstänksamma övervakare, sjuksköterskorna som förmedlande dämpare och

skötarna som informerade utförare. De olika yrkesgrupperna beskriver att de har

gemenamma ansvarsområden men också ett yrkesspecifikt ansvar i samband med

utmanade situationer. Utmärkande var att skötarna, trots att de hade lägst formell

kompetens, var den yrkesgrupp med störst inflytande vid beslut om

tvångsåtgärder eftersom de arbetade närmast patienterna och därför hade

förstahandsinformation om dem.

44

Omvårdnad som reflekterande praktik

Resultatet som presenteras nedan är en tolkad sammanställning av delstudiernas

resultat utifrån delarna relation, behov och åtgärder, i omvårdnad som process. I

metasyntesen framkommer att reflektion verkar vara en avgörande faktor för

vilken typ av bedömningar och vilka val vårdare gör. Resultatet förstås och

omsätts i diskussionen utifrån bland annat Schöns (1983) teori om reflection-in-

action och reflection-on-action, vilket innebär att reflektion över handling bör ske

både i den aktuella situationen såväl som efter. Olika former av stöd till reflektion

bedöms vara ett meningsfullt verktyg i det arbetssätt som här benämns som

omvårdnad som reflekterande praktik. Resultatet inleds med en övergripande

beskrivning av syntesen med dess centrala innehåll om procesen, vilket också

illustreras med en figur (figur 1). Därefter beskrivs innehållet i varje del av

processen mera ingående.

Syntes

Tolkningen av de sammanvägda resultaten visar att varje del av processen bygger

på och är beroende av varandra. Att vårdaren har förmågan att bygga upp en

tillitsfull relation till patienten är en förutsättning för en relevant

behovsbedömning och identifiering av patientens förmågor. Bedömning av

individuella behov är i sin tur utgångspunkten för val av åtgärd och

förhållningsätt med målet att minska lidande och öka välbefinnande. Vägen till

åtgärden är i denna process dock inte statisk eller linjär, till en början kan

exempelvis åtgärder enbart ha ett relationskapande syfte, behov kan förändras,

åtgärder behöva modifieras liksom att tilliten i relationen kan påverkas av olika

faktorer. Detta innebär att vägen till åtgärden bör förstås som en dynamisk process

som förutsätter ett reflekterande förhållningssätt med relationen som grund, med

det övergripande målet att stärka patientens förutsättningar till återhämtning och

välbefinnande.

45

Relation

Tillit Ömsesidighet

Ärlighet Bekräftelse

Respekt

Behov

Lyssna och förstå Identifiera basala

och abstrakta behov

Åtgärd

Öka välbefinnande och minska lidande Tillvarata förmågor

och resurser Medvetet förhållnings-

sätt Flexibilitet

Figur 1. Översikt över resultatet av metasyntesen. Med utgångspunkt i en förstå-

else av omvårdnad som process beskrivs omvårdnad i psykiatrisk vård som en re-

flekterande praktik där de olika delarna i processen är beroende av och samspelar

med varandra.

46

Relation Resultaten visar på att tillit är grunden i relationsskapandet (I,II,III) och

förutsättningar för tillit skapas via ömsesidighet, ärlighet, bekräftelse samt att

lyssna och genuint försöka förstå patientens situation (I,II). Relationen anses

tillitsfull när patienten känner sig tillräcklig trygg i vårdarens4 sällskap så att denne

vågar uttrycka sina tankar och upplevelser om sin aktuella situation (II). En

tillitsfull och ömsesidig relation mellan patient och vårdare är den enskilt

viktigaste faktorn till att patienterna känner ökat välbefinnande under vårdtiden

(I) och en förutsättning för att kunna identifiera patientens behov och förmågor

(II). Om patienterna känner tillit till personalen så är tvångsåtgärder5 oftast

överflödiga (I,II,III). I vissa fall kan tvångsåtgärder accepteras av patienten om

syftet med åtgärden är välmotiverat och utförs av vårdare som patienten känner

tillit till (I). Om tvångsåtgärder utförs på ett empatiskt och respektfullt sätt, även

om åtgärden går emot mot patientens önskan, så behöver inte ingripandet

påverka relationen negativt (II,III) men det kan också i vissa situationer vara värt

att gå emot verksamhetens regler och rutiner för att undvika att skada en tillitsfull

relation till patienten (II,III). Svåra symtom hos patienter, som paranoida

vanföreställningar och djup melankoli, (II) samt vårdarnas distansering från och

fördomar om patienterna är faktorer som försvårar relationskapandet (I,II). När

patienten inte känner tillit till vårdarna drar sig patienten undan på avdelningen

och undviker att berätta om hur de mår (I,II) och kan sedan avstå från att söka

hjälp trots svårt lidande och akuta vårdbehov (I).

4 Med vårdare avses generellt de som arbetat med patienten (både professionella och studenter) när resultatet är professionsspecifikt så anges den yrkestitel som avses

5 Med tvångsåtgärd avses alla handlingar som går emot patientens önskningar och vilja

47

Behov

För att kunna göra en individuell bedömning av patientens behov krävs det att

vårdaren tar sig tid att lyssna till och försöka förstå det patienten vill berätta men

minst lika viktigt i bedömningen är att försöka identifiera behov som patienten

inte kan kommunicera verbalt. Dessa outtalade behov kan istället uttryckas via

individuella eller mer generella tecken och beteenden exempelvis självskada

(I,II,III). De flesta behoven är inte så påtagliga utan av mer abstrakt karaktär (II).

Att identifiera och ta tillvara patienternas förmågor och resurser är också

grundläggande i en individuell vårdplanering (I,II,III). Det är viktigt att utgå från

patientens perspektiv och att patienten ges möjlighet till aktivt deltagande vid

planeringen och utformningen av vården (I,II,III). När vårdarna är tillgängliga, lär

sig att tolka patientens tecken och tillsammans med patienten identifierar

individuella lösningar för att tillgodose både basala och abstrakta6 behov så kan

tvångsåtgärder undvikas eller avstyras (I,II,III). Bedömningar och ordinationer på

tvångsåtgärder som inte överensstämmer med patienternas behov och strider mot

patientens bästa kan ifrågasättas och även ignoreras (III,IV). Om patienten inte

känner tillit till vården och vårdarna och därför inte vågar uttrycka hur de mår så

är det inte heller möjligt att göra en individuell bedömning av patientens behov

(I,II).

Andra faktorer som försvårar bedömningen och ökar risken för tvångsåtgärder

kan vara att vårdarna inte lyssnar eller tror på patienten eller inte förstår vad

patientens beteende står för (I,II). Bedömningarnas kvalitet kan också påverkas av

personalbrist, överbeläggningar, hög personalomsättning (III), osäkra läkare (IV)

och slentrianmässigt tänkande, till exempel ”hopplösa patienter” (I,II,III).

Bedömningarna kan även ha sin utgångspunkt i föreställningen att patienten

simulerar eller inte förstår sitt eget bästa (I,III). Andra vanliga uppfattningar är att

6 Med abstrakta behov avses här patientens behov som inte är påtagliga (synliga) eller objektivt mätbara som till exempel hopp, självkänsla, empowerment och initiativförmåga

48

patienten bara vill ha uppmärksamhet, och därför inte ska få det, eller att

beteendet hör till sjukdomsbilden samt att fokus ligger på problem istället för

förmågor och möjligheter (II,III). Beslutsmakten är kopplad till skötarna som

arbetar närmast patienten (IV), i vissa fall sammanfaller det med en tillitsfull

relation vilket höjer kvaliteten på bedömningen men i andra fall baseras

bedömningarna enbart på distanserade observationer och tolkningar från

vårdarnas perspektiv (I,III,IV). När bedömningarna fallerar och patientens

individuella behov inte identifierades så känner sig patienten övergiven (I) och

upplever en känsla av hopp- och maktlöshet (I,II). För att klara av vården

använder/utvecklar patienten coping strategier som ur vårdarnas perspektiv ses

som destruktiva. Vårdarna förstår inte patientens tecken och bedömer då

beteendena som oacceptabla utspel (I,II,III), vilket i sin tur ofta leder till

tvångsåtgärder eller utskrivning (I,III).

Åtgärd

Valet av åtgärder7 bör präglas av öppenhet och flexibilitet samt utfromingen av

åtgärden av individanpassning och patientdelaktighet. De åtgärder som patienten

ska erbjudas under vårdtiden, om möjligt utifrån patientens egna förslag,

dokumenteras (I,II,III). Speciellt viktigt är det att formulera vilka åtgärder som

ska vidtas vid tecken på försämring för att kunna arbeta preventivt (I,II,III). En

åtgärd kan vara ett samtal eller en promenad (II,III) men också att läsa dikter,

jonglera, rensa avlopp eller möblera om patientsalar (II). Kvaliteten på utförandet

av varje åtgärd är beroende av vårdarens förhållningssätt. Förhållningsätt som

utgår från bedömningen av de individuella behoven och förmågorna kan vara

exempelvis stärkande, bekräftande, uppmuntrande, stödjande, lugnade, etcetera

(II, III). Om vårdaren har ett medvetet individuellt anpassat förhållningssätt med

7 Med åtgärd avses alla handlingar som utförts utifrån en bedömning av individuella behov med målet att lindra lidande och

öka välbefinnande.

49

hänsyn till patientens behov så ökar patientens förutsättningar att komma vidare i

sin återhämtningsprocess (I,II,III). Andra förhållningssätt som distansering och att

ignorera patientens behov skapar istället ett lidande hos patienten (I) även en

uppfostrande approach med fokus på kontroll, beteende korrigering och straff är

vanligt förkommande (I,II,III) vilket medför att patienten inte vågar berätta för

vårdarna hur de mår och förebyggande åtgärder kan därmed inte vidtas (I).

Extravak är en vanlig åtgärd som innebär en stor påfrestning för både patient och

vårdare (I,III). Extravak innebär också att en vårdare kan avsätta all sin tid till en

patient och har en unik möjlighet att tillgodose behov och stärka och stödja

patientens förutsättningar (II). Dock är uppfostrande och distanserad

förhållningssätt vanliga vid extravak (I,III) utifrån argumentet att det är viktigt att

patienter som vill ha uppmärksamhet inte ska få det (III).

Att läkaren kontinuerligt träffar patienten för utvärdering och samtal är en viktig

förutsättning för att patienten ska kunna vara delaktig i sin vård istället för att

skötare för patientens talan med läkaren (I, IV). En individuell vårdplan som

präglas av kontinuitet, förutsägbarhet, individanpassning och flexibilitet är ett

värdefullt verktyg för att minska risken för tvångsåtgärder medan generella regler i

verksamheten komplicerar arbetet (I,II,III). När vårdare använder förhållningssätt

och åtgärder som är stärkande och ger stöd till patienten så behöver sällan

tvångsåtgärder användas (I,II,III). Däremot är tvångsåtgärder frekvent

förekommande i situationer där patienter anses vara i behov av

beteendekorrigering och bestraffning eller är övergivna av vårdarna. Likaså finns

tillfällen då vårdarna provocerar fram situationer för att få en anledning att

använda tvångsåtgärder (I,III) liksom att det finns tillfällen där vårdarna går emot

kollegornas bedömning för att kunna utföra åtgärder för att tillgodose patientens

behov (I,II,III).

51

Diskussion och kliniska implikationer I litteraturgenomgången har jag hittat gott stöd för vikten av en god relation i

omvårdnadsarbetet (Cleary, Hunt, Horsfall & Deacon, 2012; Halldorsdottir,

2008; Shattell, 2004; Shattell, Starr, & Thomas, 2007; Zugai, Stein-Parbury, &

Roche, 2015 m.fl.) och en hel del erfarenheter och utvärderingar av olika

interventioner och arbetssätt, till exempel personcentrering i psykiatrisk vård

(Beckett et al., 2013; Gabrielsson, Sävenstedt & Zingmark, 2015; Jormfeldt,

Rask, Brunt, Bengtsson & Svedberg, 2012; Matthias, Salyers, Rollins & Frankel,

2012 m.fl.). Sedan hittade jag även ett starkt stöd för de delar av mitt resultat som

visar på att vården ofta inte fungerar på ett sådant sätt att en god relation med

patienten prioriteras (Enarsson, Sandman & Hellzén, 2011; Hörberg, Sjögren &

Dahlberg, 2012; Lindgren, Aminoff & Hällgren Graneheim, 2015; Lindström,

1995; Örmon, Torstensson-Levander, Sunnqvist, & Bahtsevani, 2014 m.fl.).

Dessutom beskriver vårdare olika svårigheter med att bedriva en god vård så som

tidsbrist, vårdkultur, regler samt avsaknad av stöd och ledning (Delaney &

Johnson, 2014; Enarsson, Sandman & Hellzén, 2008; Looi & Hellzén, 2006

m.fl.). Andra studier visar på att det finns svårigheter med att omsätta teorier till

praktisk handling (Carlyle, Crowe & Deering, 2012; Gask & Coventry, 2012;

Jormfeldt, Svedberg, Fridlund & Arvidsson, 2007; McCance, McCormack &

Dewing, 2011; O`Donovan, 2007 m.fl.). Sammanfattningsvis kan man med stöd

i litteraturen hävda att vi vet hur god omvårdnad inom den psykiatriska vården

borde vara men inte så mycket om dess konkreta innehåll och hur man gör för

att realisera kunskapen i praktiken (jmf Barker & Buchanan-Barker, 2011)8.

8 Barker och Buchanan-Barker anser att ”mental health nursing” fortfarande är en myt, då sjuksköterskor (även lärare och forskare inom området) tycker att ”mental health nursing” är bra och viktigt men få kan definiera och konkretisera vad som är syftet och innehållet i begreppet.

52

Min intention är att kunna ge ett bidrag till den senare delen genom att diskutera

mitt sammantagna resultat mot, enligt mig, för ändamålet relevanta teorier. Jag

har ambitionen att utifrån beskrivningen av omvårdnad som reflekterande praktik

formulera ett arbetssätt som ska vara lätt att implementera och tillämpa.

Arbetssättet ska förhoppningsvis kunna bidra till en minskat behov av

tvångsåtgärder och ökad kvalitet i vården samt erbjuda personal konkreta och

flexibla verktyg i det patientnära arbetet. Ett möjligt sätt för att utvärdera

arbetssättet, som även skulle kunna bidra till att överbrygga klyftan mellan teori

och praktik, kunde vara projekt som utgår från en interaktiv forskningsmetodik

som exempelvis aktionsforskning.

Jag anser att det finns en allvarlig missuppfattning i den psykiatriska vården idag.

När vi identifierar brister så ropar många efter mer rutiner och när misstag begåtts

så är det rutinerna som brustit, men en rutin blir aldrig bättre än det innehåll som

den vilar på. Patienter suiciderar inte mindre för att det görs suicidbedömningar

eller för att det skrivs vårdplaner om inte den enskilde vårdaren och

organisationen tar ett ansvar för innehållet i vården. Det framgick tydligt, ur alla

tre perspektiven, att användningen av tvångsåtgärder inte minskade när vårdarna

följde rutinerna utan tvärtom så var det när vårdarna lyckades förstå patientens

behov och hade frihet/mod att ”tänka utanför boxen” och hitta individuella

lösningar som tvångsåtgärder kunde undvikas. För att höja kvaliteten på vården

måste vårdarna erbjudas en möjlighet att ge god vård och för det krävs att

vårdarna har kunskap, självkännedom och framförallt mod att förändra. För att

uppnå detta krävs både personligt och organisatoriskt stöd och konkreta verktyg

som kan stödja personalen.

Resultatet i denna avhandling visar tydligt på att en ömsesidig och tillitsfull

relation mellan patient och vårdare är helt avgörande för vårdens kvalitet. Zugai

et al. (2015) översikt visar på att acceptans, ärlighet, respekt, förståelse och en icke

dömande attityd är exempel på faktorer som kan bidra till en god relation, vilket

53

överensstämmer väl med våra resultat. Zugai et al. menar vidare att reflektion,

kunskap och självkännedom är viktiga förutsättningar för att utveckla sin

relationsskapande förmåga (Zugai et al., 2015). För patienterna räcker det inte

med att ”bara” ha en tillitsfull relation till vårdaren utan det är också viktigt att

komma vidare och se deras behov och arbeta med konkreta åtgärder (Shattell et

al., 2007). Detta anser jag ger stöd för vikten av att se relationsskapandet som en

självklar och avgörande del i det konkreta omvårdnadsarbete men även att

relationen ingår i en större dynamisk individanpassad process som även omfattar

behovsbedömningar och åtgärder med målet att främja hälsa och välbefinnande

(jmf Svedberg, Jormfeldt, Fridlund & Arvidsson, 2004)9. Detta medför att

omvårdnadasarbetet blir ett komplext arbete som kräver kunskap men framförallt

flexibelitet och förståelse.

Omvårdnadsplanering

Resultatet i denna avhandling beskriver en översiktlig struktur för

omvårdnadsarbetet som betonar relationen, behov och åtgärder. Detta skiljer sig

från en vanligt använd modell där omvårdnadsprocessen beskrivs som en

problemlösningsmodell (Yura & Walsh, 1988) med fokus på datainsamling,

diagnostik och interventioner (Carnevali, 1983; Gordon, 2002).

En omvårdnadsplanering blir aldrig bättre än den bedömning den stödjer sig på

därför är det viktigt att bygga en god grund för bedömningen via en tillitsfull

relation. Vidare för att kunna göra en relevant vårdplan så ska en aktiv

patientdelaktighet eftersträvas för att skapa en atmosfär som stimulerar till

ömsesidigt kunskapsutbyte i samarbetet mot det gemensamma övergripande målet

om återhämtning. Relationsskapandet bör tydligt lyftas fram och dokumenteras

både till innehåll (relationsskapande åtgärder) och till progress (utvärdering av

9 Svedberg et al. argumenterar för vikten av en mer processfokuserad omvårdnad med hälsa som ett tydligt uppsatt mål för varje omvårdnadsintervention

54

tillit). Vid behovsbedömningen ska både basala och abstrakta behov samt

förmågor identifieras liksom patientens beskrivning av sin situation och vilka

tecken som vårdarna bör känna igen och vara uppmärksamma på. I planering av

åtgärder så ska patientens förmågor och resurser vara utgångspunkten. Åtgärden

ska tydligt gå att koppla ihop med patientens individuella önskemål (om möjligt)

och behov och därmed bör det finnas en stor flexibilitet och öppenhet såväl till

val av åtgärd som till utformning och till vårdarens förhållningssätt. Rigida regler,

distanserade förhållningsätt och ett beteendekorrigerande synsätt är exempel på

faktorer som ökar risken för tvångsåtgärder.

Reflektion

För att vårdare ska kunna arbeta på ett sätt som beskrivs ovan krävs att de får

relevanta förutsättningar. Det framkommer tydligt i resultatet att de vårdare som

förstått den unika individens behov och både kunnat och vågat individanpassa

åtgärderna inte har haft något behov av att använda tvångsåtgärder. Enligt Schön

(1983) har varje arbetsrelaterad situation unika inslag, inte minst inom vården,

och därför blir det svårt att utgå från generella teorier, mallar och rutiner. Schön

anser, utifrån sin teori om reflection-in-action och reflection-on-action, att det

istället är mer meningsfullt att reflektera över varje aktuell situations egenheter

och komma fram till en för situationen/individen anpassad handlingsplan. Liksom

Dewey (1938) anser Schön att tanke och handling är sammanvävda och Schön

menar på att reflektion är svar på en störning och genom att stanna upp så kan en

skicklig praktiker se nya infallsvinklar och har då möjlighet att ompröva sina

bedömningar (Schön, 1983).

För att anamma ett sådant arbetssätt behöver vårdarna både tid och stöd för att

utveckla en professionell trygghet och självkänsla så att de har mod att ifrågasätta

55

och frångå regler och rutiner när det behövs (jmf Huckshorn, 2014)10. Samtidigt

som de behöver utrymme för kontinuerlig reflektion och utvärdering utifrån

konkreta situationer för att utveckla sin bedömningsförmåga och professionella

kompetens (jmf Thorne & Hayes, 1997)11. Vårdarna behöver även en tydlig

vetenskaplig ram att förhålla sig till, vilket i detta fall skulle vara

omvårdnadsperspektivet (Meleis, 2011)12 samtidigt som omedvetna ramar 13

(begränsningar) synliggörs och ifrågasätts (Schön, 1983). Thorne och Hayes

(1997) har också anammat Schöns tankar och menar på att både reflection-in-

action och reflection-on-action gör vårdaren både mer uppmärksam i situation

men det ökar också den professionella medveten och därmed utvecklingen av

praktiken genom att stimulera till att ”tänka omvårdnad”.

Huckshorn (2014) menar att utbildning och förebyggande arbete är viktiga

faktorer för att minska behovet av tvångåtgärder men en minst lika viktig faktor

är att minimera antalet regler på avdelningen för att därigenom minska

förekomsten av konfliktsituationer. Detta synsätt stämmer väl överens med

Hejlskov Elvéns och Abilds (2015) beskrivning av lågeffektivt bemötande som kan

vara ett lämpligt förhållningssätt inom psykiatrin för att minska behovet av

tvångsåtgärder. Det finns mycket att vinna på att hitta arbetssätt som minimerar

tvångsåtgärder då åtgärderna upplevs traumatiserande både för patienter och för

personal. Tvångsingripanden kan skada den vårdande relationen och vården

bidrar då inte till återhämtning (Huckshorn, 2004). Min tanke är att figur 2 kan

utgöra en grund för utbildning och ett stöd för reflektion både i handling och

10 Huckshorn intervjuade personal om deras erfarenheter av hur de hade kunnat minska behovet av tvångsåtgärder och en viktig faktor var att de hade minskat antalet konfliktsituationer genom att minimera avdelningens regler.

11 Thorne och Hayes beskriver omvårdnad ett individualiserat, reflexivt och kontextberoende fenomen.

12 Enligt Meleis omfattas omvårdnadsperspektivet av fyra hörnstenar humanvetenskaplig utgångspunkt, praktisk inriktning, omsorgstradition och hälsoorientering.

13 Till exempel icke vårdande vårdkulturer, regler och rigida rutiner.

56

över handling (fritt översatt från Schön, 1983) och därigenom även stimulera till

kontinuerlig bearbetning av rutiner och arbetssätt.

Interaktivt projekt

Ett viktigt nästa steg är att testa och utvärdera arbetssättet och nedan följer en

tänkt ram för ett utvärderingsprojekt. Jag anser att en hög och aktiv samverkan

mellan patient, vårdare och forskare är en viktig förutsättning för att kunna

utveckla innehållet i arbetssättet. När även mottagare och utövare är med i

forskningsprocessen, utifrån sina olika perspektiv, så tillför det ytterligare

dimensioner (Herr & Andersson, 2014). Aktionsforskningsmetodik kan vara en

lämplig approach för att utvärdera omvårdnadsarbete (Thorne & Hayes, 1997),

eller interaktiv forskning som också är en utvecklingsstödjande och interaktiv

metod men där tyngdpunkten ligger på ett kritiskt perspektiv och mer långsiktig

teoriutveckling (Svensson, 2002b).

Ett projekt skulle kunna inledas med att forskarna bjuder in brukarrepresentanter

från olika brukarorganisationer och vårdare från den enhet som utvärderingen ska

genomföras på, till en inledande träff. Syftet med träffen bör vara både att

presentera arbetssättet, i sin ursprungsform, och grundtankarna för

aktionsforskning samt lyssna in farhågor, önskemål och förslag samt se om intresse

finns för att hjälpa till med att utvärdera och utveckla arbetssättet. När det finns

intresserade personer så görs gemensamt en plan för hur projektet ska genomföras

och utvärderas. Därav är det inte möjligt att detaljplanera projektet i detta läge.

Det finns dock vissa hörnstenar som är viktiga förutsättningar, bland annat en

inledande introducerande utbildningsinsats där omvårdnad som reflekterande

praktik ska bearbetas genom olika interaktiva inslag, till exempel fallbearbetning

som ska stimulera till lärande och kritisk reflektion (jmf Dewey, 1938; Schön,

1983).

57

Projektet i stort ska givetvis genomsyras av samma grundtankar som präglar

arbetssättet, det vill säga flexibilitet, tillit, bekräftelse, utgå från förmågor, respekt

för varandras erfarenheter och kunskaper etcetera. Genomförandet bör bestå av

olika interventioner som ska ge konkret stöd och coachning till personal i

självständig reflektion i situationen men även möjlighet till individuell reflektion

över olika bedömningar och val, möjligen i nätbaserad loggboksform, samt

reflektion i grupp. I detta arbete kan ett reflektionsunderlag, se figur 2, vara ett

bra verktyg. Stödet bör även innehålla individanpassad omvårdnadshandledning

med fokus på relationsskapande faktorer, behovsbedömning och

handlingsalternativ, möjligen i form av omvårdnadskonferenser där vårdplaner

kan bearbetas. I förlängning ska ett antal sjuksköterskor kunna känna sig

tillräckligt trygga med arbetssättet så att de kan ta över stödet och

omvårdnadshandledning till personalgruppen.

Formen för utvärdering bör utformas tillsammans med de andra deltagarna i

projektet, men en möjlig väg skulle kunna vara fokusgruppsintervjuer med

antingen mottagare och utövare av arbetsmodellen åtskilda eller i mixade

grupper. Deltagarna skulle kunna utvärdera de erfarenheter de har utifrån sitt

perspektiv men också tillföra nya förslag som skulle kunna implementeras och

sedan utvärdera på nytt, i enlighet med ett abduktivt förhållningssätt (Harman,

1965; Peirce, 1990). Det skulle också vara meningsfullt att mäta exempelvis

tvångsåtgärder, hot/våldsituationer, självskadebeteende eller andra mätbara

händelser som kan anses relevanta. Efter att arbetssättet testats och utvärderats på

antal enheter, gärna med olika vårdformer exempelvis rättspsykiatri,

kommunpsykiatri, akutpsykiatri etcetera., så skulle det kunna vara möjligt att

sammanställa resultaten och eventuellt kunna formulera en modell för

kontinuerlig omvårdnadsutveckling i psykiatrisk vård.

58

Har du en relation

till patienten?

Tillit Ömsesidighet

Ärlighet Bekräftelse

Respekt

Har du identifierat

patientens behov?

Lyssna och förstå Identifiera basala

och abstrakta behov

Utgår åtgärden

från patientens

behov?

Öka välbefinnande och minska lidande Tillvarata förmågor

och resurser Medvetet förhållnings-

sätt Flexibilitet

Figur 2. Förslag på underlag för reflektion kring val av omvårdnadsåtgärd i psykia-

trisk vård. Respektive fråga besvaras med utgångspunkt i de efterföljande ledor-

den. Om någon eller några av frågorna besvaras med ”nej” föreligger en risk för

att en tänkt åtgärd inte svarar mot den individuella patientens behov.

59

Slutsats Sammanfattningsvis om vårdarna lyckas skapa en ömsesidig, tillitsfull relation till

patienten, kan förstå dennes utryckta behov och outtalade tecken samt arbetar

proaktivt, i samarbete med patienten, med åtgärder och medvetna

förhållningssätt, så finns sällan behov av tvångsåtgärder. För detta krävs att

vårdarna får stöd i att utveckla sin reflektiva förmåga och även i att få ta eget

ansvar för varje situation och därigenom bygga upp en tillit till sin egen förmåga.

61

Jag vill tacka… … i första hand alla deltagare i studierna som anförtrott mig era tankar och

erfarenheter och gjort denna avhandling möjlig

… Mai Lindstöm och Institutionen för hälsovetenskap som valt att satsa

kompetensutvecklingsmedel på mig

… Siv Söderberg för att du övertalade mig att ta steget till att bli doktorand

… min handledare Rolf Adolfsson som på distans men troget följt med från

början till slut på denna ibland lite ”guppiga” resa och att jag har fått ”plocka upp

dig från byrålådan” när jag behövt

… min handledare Stefan Sävenstedt för att du gjort motstånd men inte försökt

säga hur jag ska tänka, och för att du har haft mod att låta mig ta egna beslut

… Karin Zingmark för att du vågade tro på mig

… min huvudhandledare Åsa Engström för ditt lugn, uppmuntran och din

övertygelse samt för ditt handfasta stöd när jag behövt det - och så har jag ju

hittat en artfrände

… mina döttrar Ida-Maria och Jennie och ponnyerna Thor och Armani för att ni

varje dag påminner mig om vad som är viktigt i livet!

… min man Jimmy och lilla hunden Bamse för att ni finns och fixar där hemma

så att det alltid känns trivsamt att komma hem!

… alla mina nuvarande och tidigare arbetskamrater för otaliga intressanta och

utvecklande diskussioner om psykiatri och omvårdnad

… till alla som hjälpt mig med korrekturläsning och gett mig synpunkter på

kappans innehåll

62

… Sofia Åkerman och Thérèse Eriksson för uppmuntran och hjälp med

datainsamling och för att jag fick låna omslagsbilden

… Shedo för hjälp med datainsamling.

Störst tack till Sebastian Gabrielsson som förutom att du bidragit till att jag blivit

mer kritisk och eftertänksam, mindre naiv och generellt klokare ;) så har du varit

en avgörande förutsättning för att denna avhandling över huvudtaget blev

skriven!

63

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Summary in English Nursing as a reflective practice: Identifying and applying alternatives to coercion in

psychiatric care

Coercive measures such as restraints and forced medication are commonly used

in psychiatric care. This practice is often explained by staff as resulting from a lack

of valid alternatives. Coercive measures seem especially common in the care of

young women who self-harm, who are reported to perceive the use of coercive

measures as punishment and a barrier for seeking help.

The overall aim of this thesis was to gain further knowledge and a deeper

understanding of nursing as a process in psychiatric care from the perspective of

patients, students, and professional caregivers, with a particular focus on

alternatives to coercions in the care of persons who self-harm.

This thesis takes a pragmatic stance with the ambition of producing results that

may be put to practical use. The separate studies apply a qualitative approach in

which materials have been analyzed using content analysis. Data consists of 19

written accounts by persons with experience of being treated for self-harm and

being subject to coercive measures, 14 online reflective journals written by

student nurses during clinical placement in psychiatric care, and focus group

interviews with a total of 26 professional caregivers including nurse assistants,

nurses, physicians and ward managers experienced in compulsory psychiatric care.

The written accounts showed that persons treated in psychiatry had a wish to be

met with understanding by staff members, to develop trusting and mutual

relationships with them, and to receive care based on methods grounded in

research. Their actual experiences described care as unpredictable,

counterproductive, and based on mistrust and distance. In the online reflective

78

journals students highlighted a need to dedicate time and commit to relationship-

building, which was described as a precondition for being able to make

assessments and learn to understand patient’s individual signs of health and illness.

They described how they identified patients’ abstract needs such as the need for

security, empowerment, self-esteem and hope. Based on these, students would

individualize actions and approaches and bring forth and make use of patients’

abilities. The focus group interviews revealed how staff members, with a starting

point in challenging situations in psychiatric care, discussed possible actions

focusing either on the needs of the staff, the patient’s experience, to follow

routines or to discipline patients. Approaches and the qualities of actions would

differ distinctly depending on focus. The focus groups interviews also revealed

the staff’s perceptions of interprofessional collaboration following their

professional roles. Findings depicted how nurse assistants, despite having the least

formal competence, were the ones wielding the most power over decisions on

the use of coercive measures, due to them being closest to the patients and thus

possessing first-hand information about them.

Findings show that the perspectives of patients, students, and professional

caregivers align and converge. A meta-synthesis of the separate findings describes

nursing as a reflexive practice. Professional caregivers’ ability to establish a

trusting relationship with the patient forms the basis for a relevant assessment of

patients’ needs. This assessment of needs is the starting point for choices of

actions and approaches and for building on patients’ abilities and resources in

order to alleviate suffering and promote well-being. But the path to choosing a

specific action is not static; actions may have a mere relationship-establishing

intent to begin with, needs may develop and change over time, actions may need

to be modified, and trust may be affected by various circumstances. This implies

that the path leading to an action is not to be understood as fixed, but rather as a

dynamic process presupposing a reflexive approach, building on interpersonal

79

relationships, and aiming to strengthen patients’ capacity for recovery and well-

being.

It may be concluded that coercive measures are uncalled-for when professional

caregivers succeed in establishing mutual, trusting relationships with patients, are

able to identify their needs and work together applying pro-active, supportive

and empowering actions and approaches.

Key words: alternatives to coercion, nursing, process, psychiatric care, self-harm,

pragmatism, qualitative content analysis

Delstudie I

Issues in Mental Health Nursing, 36:96–103, 2015Copyright © 2015 Informa Healthcare USA, Inc.ISSN: 0161-2840 print / 1096-4673 onlineDOI: 10.3109/01612840.2014.951134

A Self-Destructive Care: Self-Reports of PeopleWho Experienced Coercive Measures and theirSuggestions for Alternatives

Git-Marie Ejneborn Looi, RN, RPN, MSc, and Asa Engstrom, RN, CCN, PhDDepartment of Health Sciences, Lulea University of Technology, Lulea, Sweden

Stefan Savenstedt, RN, PhDDepartment of Health Sciences, Lulea University of Technology and Department of Researchand Development, Norrbotten County Council, Lulea, Sweden

Coercive measures are commonly used as a method of inter-vention, despite insufficient evidence for their effectiveness andbenefits. The aim of this study was to describe how people whoself-harm perceive alternatives to coercive measures in relation toactual experiences of psychiatric care. A total of 19 self-reportshave been analysed with qualitative content analysis, resulting inthree categories: a wish for understanding instead of neglect; a wishfor mutual relation instead of distrust; a wish for professionalisminstead of a counterproductive care. In conclusion, if the caregiverscan understand and collaborate with the patient, there is seldomany need for coercive measures.

INTRODUCTIONCoercive measures remain common interventions in acute

psychiatric wards (Knutzen et al., 2014). Reviews of existingliterature show that, although some research exists on outcomesof involuntary hospitalisations and the use of coercive methods,few studies take an inside perspective allowing the patient to beheard (Hooff & Goossensen, 2013; Jarret, Bowers, & Simpson,2008; Katsakou & Priebe, 2006). This paper focusses on peoplewith experiences of psychiatric inpatient care, coercion and self-harm. Listening to people’s experiences is essential to developa person-centred care where alternatives to coercive measuresare identified, tested and evaluated.

The empirical evidence regarding outcomes and impactsof involuntary hospitalisations is inconsistent and insufficient(Katsakou & Priebe, 2006). The same goes for the effectivenessand benefits of containment measures (Jarret et al., 2008;Muralidharan & Fenton, 2006; Sailas & Fenton, 2000). At thesame time, there is a considerable amount of research describing

Address correspondence to Git-Marie Ejneborn Looi, Departmentof Health Sciences, Lulea University of Technology, Lulea, 97187Sweden. E-mail: [email protected]

harmful physical and psychological effects on patients and stafffollowing the use of coercive measures (Bonner, Lowe, Raw-cliffe, & Wellman, 2002; Fisher, 1994). This implies that thereis an urgent need for additional research to clarify the manyissues in this field (Jarret et al., 2008; Nelstrop et al., 2006). Al-though coercive measures are common in European psychiatricwards, differences between the countries exist (Raboch et al.,2010). Nurses tend to view coercive measures as necessary andunavoidable, believing they have no alternatives (Haglund, vonKnorring, & von Essen, 2003; Marangos Frost & Wells, 2000).According to a literature review (Jarrett et al., 2008) concerningcoerced medications, there was a notable lack of considerationof events leading to coercion and a complete absence ofinvestigation of an alternative. Coerced medication seems likeit is a ‘taken-for-granted’ practice in inpatient psychiatric carein countries such as Sweden, site of the present study.

People with experience of psychiatric care describe episodesin which they saw involuntary admission as necessary to keepthemselves or others safe while other testimonies describe thisas an unnecessary overreaction and a practice in need of revision(Katsakou et al., 2012; Sibitz et al., 2011). Research focussed onpatients’ experiences of coercive measures (Kontio et al., 2012;Soininen et al., 2013) reveals that patients are dissatisfied withthe lack of interaction with staff and think that coercive measuresare hardly necessary at all. They suggested that alternativesshould have been offered first. It is important to find alternativesto coercion, as this type of intrusive intervention could leadto greater morbidity and mortality than alternative approaches(Muralidharan & Fenton, 2006; Sailas & Fenton, 2000).

An analysis of official statistics concerning involuntary psy-chiatric care in Sweden (Holm, Bjorkdahl, & Bjorkenstam,2011) showed that involuntary hospitalisations and the use ofmechanical restraint increase dramatically in the group of youngwomen with self-harm behaviour. Patients who self-harm de-scribe how they never feel as lonely as when they are inpatients

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SELF-REPORTS OF COERCIVE MEASURES AND SUGGESTIONS FOR ALTERNATIVES 97

in psychiatric care and their needs are neither seen nor met(Lindgren, Wilstrand, Gilje, & Olofsson, 2004).

Recent studies (Stewart, Van der Merwe, Bowers, Simpson,& Jones, 2010; Bowers et al., 2012) show that it is possibleto use alternatives to coercive measures, even if the standardof the evidence is poor. Stewart et al. (2010) argue that moreattention should be directed towards understanding how careinterventions can reduce the need for coercive measures, an is-sue that is mainly overlooked. One important aspect of such anunderstanding concerns listening to the patients’ perceptions, in-cluding their wishes and thoughts, about their own care. This isemphasised by James, Stewart and Bowers (2012) who claimedthat there is an urgent need for more research to provide mean-ingful care for people who self-harm, especially studies thatconsult service users about their experiences. In this study, wewant to contribute to this line of research and provide an oppor-tunity for people who self-harm to report on their wishes andexperiences in relation to inpatient psychiatric care.

The aim of this study was to describe how people who self-harm perceive alternatives to coercive measures in relation toactual experiences of psychiatric care.

METHODThis study applies a qualitative approach and is based on

self-reports written by persons with experiences of self-harmand being admitted to psychiatric inpatient care where coercivemeasures were used.

Participants, Data Collection and ProcedureThe participants were recruited during 2013 through mes-

sages posted in social media (Twitter, Facebook, blogs and per-sonal websites) asking potential participants in Sweden to visita homepage where they were given information about the studyand asked to participate. The requirement was that they were≥18 years of age and had experience of self-harm and of beingtreated in psychiatric inpatient care. They were asked to writea self-report in Swedish or English using an electronic form onthe website. The report should cover their experiences of thecare they had received and their perception of alternative to co-ercive treatment methods and the direct instruction was ‘writeyour story here’. The report was anonymous and no informationabout the participant was required. In all, 19 self-reports wereincluded in the study. All the reports were written in Swedish.The reports varied in length from a couple of paragraphs to sev-eral pages, most of them were one page with about 700 words.

Although no personal data was required, the information pro-vided spontaneously gave some insights regarding participants’characteristics. In some cases, the participants signed with theirnames, which suggested that there were both men and women.Several participants indicated that they had extensive experiencewith psychiatric inpatient care. The sample’s countries of originare unknown, but all self-reports indicated that they were fromSweden.

AnalysisThe texts of the self-reports were analysed in a systematic

way using a method for qualitative content analysis, allowingreplicable and valid inferences from the texts (Krippendorff,2013). Following Krippendorff, the understanding of the contentwas developed during the process of reading and analysing thetext where it was continuously reconceptualised, thus directingand redirecting the analysis.

In the process of analysis, all written self-reports were firstput together and treated as one text and read several times inorder to get an initial understanding of the content. No textwas excluded. Based on this reading, an analysis strategy wasdeveloped; text units that described the participant’s general ex-perience of psychiatric inpatient care were identified, condensedand placed in a separate group, while text units that describedexperience and perception of alternatives to coercive methodswere condensed and grouped separately. In this process, the textunits were systematically coded to facilitate tracing them backto the original text (Graneheim & Lundman, 2004).

The categorising of the content started with an analysis of thetext units belonging to the group that described experience andperception of alternative to coercive methods and then contentareas were formulated. This process was carried out step-wisetowards higher levels of abstraction until three sub-categorieswere formulated (Graneheim & Lundman, 2004). The remain-ing text units were thereafter categorised and grouped accordingto the three first identified sub-categories to connect the contentdescribing experience of coercive methods in psychiatric inpa-tient care with the perception and experience of alternative treat-ments. Finally, the whole process was reviewed and each stepdiscussed between the authors until an agreement was reachedon the formulation of three content areas and three categories.

Ethical ConsiderationsPrior to conducting the study, ethical approval was granted

from the regional ethics committee in Umea (2010-4-31M). Thecommittee was also informed of and approved alterations to theoriginal design (2012-315-32M).

RESULTSThe results of the content analysis are presented as three

categories belonging to three different content areas (Table 1).The categories describe the contrast between the participants’wishes and their experience of care.

A Wish for Understanding Instead of NeglectIn the descriptions of encounters with staff, there was often

a significant gap between what the participants hoped for andwhat they had experienced. A common thread was a wish tobe understood, confirmed and met in an open way and wherethe participants felt that they as persons were listened to in aserious way. A wish to be understood related to a hope that thestaff in the encounters could look behind their behaviour and

98 G.-M. EJNEBORN-LOOI ET AL.

TABLE 1Overview of content areas and categories

Content areas Category

Encounters A wish for understanding instead ofneglect

Relation A wish for mutual relation instead ofdistrust

Care A wish for professionalism instead of acounterproductive care

understand what they were trying to communicate. These wisheswere often in sharp contrast to the experience of encounters withthe staff, which predominantly were characterised by neglect ora fostering approach focussing on correction of their behaviour.

The experience of neglect was based on staff members’ lackof interest in realising the participants’ needs. Instead, partici-pants often felt as though they were questioned and belittled ina degrading way. Some describe feeling that the staff membersconveyed a message that they were not interested in understand-ing their problems and listening to their needs, which enhancedthe participants’ feelings of being abandoned. The presence of astaff member when restricted to constant observation did not al-ways help, since the priority often seemed more geared towardscontrol than communication and interaction.

Still I started to scratch myself, when the staff member discovering itshe got angry, arguing that I could not treat her in that way. She wasvery strong and managed to hold both my hands with only one hand,which was hurting a lot considering my wrist wounds, while she atthe same time was reading a magazine. I felt completely powerlessand neglected, especially considering that I earlier the same day hadexplained in what way they could help me. (Report 10)

Some of the participants described how the lack of under-standing from the staff and their paternalistic approach couldmake them indifferent to what happened to them, while for oth-ers, it could lead to frustration and feelings of shame. Lack ofunderstanding meant that the participants had to use differentcoping strategies, such as beating and scratching themselves,kicking a wall or doing something else that made the feeling ofpain overrun the anxiety. In these situations, the staff responseswere often coercive measures.

I was calm for a while and nobody [had two staff members as specialobservers] even tried to talk to me. I tried to stay calm but wasnot successful when not given any support. I started beating myselfagain, as a response they held down my arms. The nurse entered andwhen she realised what was going on she called the doctor and veryfast the order was, put her in the belt. (Report 13)

The feeling of powerlessness was enforced by being ignoredand not listened to. This feeling was especially enhanced whenparticipants were ignored in situations where they were undergreat emotional stress and needed support. Another contributingfactor was to experience the alertness of the staff when the

same situation escalated and coercive measures were deemednecessary.

The wish for understanding and to be listened to was en-hanced by positive experience of encounters with staff, such assituations where they just sat down next to them and talked aboutthe prevailing feelings and thoughts. Several of the participantshad the view that there was no need for coercive measures if thestaff members had listened to them, seen their needs and triedto understand their problem.

they pressed the alarm and 10 staffers came running and jumpedon me. Since I’m afraid of being restrained I fought for my life. Atsome of these occasions, a guy would come running from anotherward. Although he would only meet me under these circumstances,he would order all others out of my room and hold me like a childuntil I was calm. When he came I would calm down in like an hour.He did exactly the right thing for me. He understood that I onlyneeded someone to hold me. (Report 3)

In the participants’ wish for understanding it was importantthat the staff members could interpret their signals, see the sit-uation from their perspective and not forget the strong powerthe staff had. When staff members manage to understand thepatients’ situation, the perception was that they were able tofind individual solutions to meet the patients’ needs.

A Wish for Mutual Relation Instead of DistrustThe perceptions presented in the self-reports were that a

mutual trustful relation between the patient and staff memberscould prevent the need for coercive measures. A trustful relationwas, according to the participants, built and maintained throughhonesty and mutuality. Trust and confidence were described asthe most important conditions to improve their wellbeing. Ina trustful relation, the patient has the confidence to open upand admit to having periods of anxiety and a need for supportand comfort from the staff member. The described experienceof distrust and animosity was on the other hand destructive forbuilding and maintaining relations. In the absence of a mutualrelation, there was often a questioning of the patient and useof threats and coercive measures. As a consequence of the mu-tual mistrust, the patients tended to view the staff members asunpredictable and unreliable enemies.

I believe in trust when it comes to reducing the use of coercivemeasures. If I had felt trust instead of hatred I would have been ableto tell them how I feel instead of harming myself or getting angry(which gets you in restraints immediately). (Report 12)

The self-reports contained descriptions of how the partic-ipants experienced an atmosphere of distrust in their relationwith staff members. There was often a threat present and sim-ply the suspicion that they might consider hurting themselvescould lead to such punishment as mechanical restraint. Therewere also descriptions of broken agreements and changed con-ditions that contributed to the distrust between the patients andstaff. Sometimes it was as though the staff wanted to provokefrustration to justify the use of coercive measures.


When I heard the doctor’s order, I panicked and tried to pull thestraps to make me free at the same time as I shouted – You toldme that I didn’t have to take the injection if I accepted to takethe anti-psychotic pill. He answered – but you are still not calmand I replied – I was calm until now when you gave the order. Hejust turned around and walked away and I could not do anything.(Report 13)

There were several self-reports describing how the partic-ipants had been blamed, questioned and mistrusted in theirtalks with the doctor. They appealed for help and were in deepneed of support but were treated with mistrust and disrespectfulcomments.

The doctor told me that he pitied my parents that they had got me astheir daughter. Another claimed that I had invented and lied aboutthe sexual assaults I claimed I have been through between the age of6–12. (Report 5)

Staff members were often described as having a distancingapproach and not being engaged in the care. The participantsexperienced often that the main concern of staff was more onminimising the risk of self-harm in the wards and less on build-ing a trustful relation.

I wish to meet engaged and involved staff members and not meanwhite coats that threaten me with coercive measures. Today Iwould rather kill myself than turn to the psychiatric care for help.(Report 12)

Hearing staff members discussing and commenting on themand other patients in a disrespectful way also enhanced theatmosphere of distrust. It was also discouraging to watch howother patients were treated and how they had to endure coercivemeasures.

I have seen people been battered for no other reason than they wantedto use the toilet in the night, it is awful. (Report 11)

In contrast to the described experiences, the self-reports re-veal a clear wish to cooperate with staff members and to build atrustful relation with them. The participants had turned to psy-chiatric care to receive help and care and wished that the carecould be built on mutual trust.

I was motivated to quit with my behaviour and if the staff had setaside time and effort to build a trustful relation with me I could havetold them . . . I want to quit this shit. (Report 7)

A Wish for Professionalism Instead of aCounterproductive Care

The participants had a strong wish to be met by profession-alism. That included a wish to be cared for by staff memberswho had a competence and knowledge about their problems andneeds, used personal care plans and used interventions that wereknowledge-based. This included also an understanding that insome rare difficult situations, it could be acceptable to use co-ercive methods. In contrast, most of the participants describedexperiences of a self-defeating care, where the main focus was

on following general rules and disciplinary actions. This sug-gested the goal of the care was to minimise the time of careand prevent further admissions to inpatient psychiatric care. Inseveral of the self-reports, the inpatient psychiatric care wasdescribed as counterproductive in the sense that they had moreproblems when they left the ward than when they entered it.

There was an experience among the participants that itseemed the primary aim of the care was to keep them in cus-tody, deny their wishes, monitor them and make corrections oftheir behaviour by disciplining them. They described the careenvironment as chaotic and frightening and they had to arguefor what they felt were obvious correct care approaches, suchas not having to share a room with violent and suicidal patients,to be cared for by a female staff instead of a male when havingexperienced sexual abuse, or to see the doctor.

One day she [roommate] tries to commit suicide three times, thesecurity guards show up because she is going to be put in restraints. Ipanic and run out terrified and afflicted by the violence in there. [. . .]and then the suicidal patient is gone and I have my old roommate back(as I had asked for to start with). This whole mess just because theywouldn’t think things through to begin with. This was distressingand adding feelings of hopelessness and thoughts on killing myself.It is so unnecessary! (Report 17)

Some participants experienced that one staff member some-times tried to argue for a caring approach but was often over-ruled by the staff that wanted to use the coercive measures.Mechanical restraints were frequently described as a traumatis-ing experience connected to feelings of having to fight for theirlife. This feeling was emphasised by the fact that there oftenwere many staff members involved in the holding and some-times also policemen and they usually had bruises as a result ofthose incidents.

When I did some self-harming activity they fired off the alarm and10 staff members came running and jumped on me . . . It gave mescars in my soul. When I met my boyfriend I often became scaredwhen he tried to hold me even if I perceived it was out of love forme. (Report 3)

The use of coerced medication of sedative drugs was seldomperceived as logical. The experience of overmedication, the useof non-effective drugs and the experience of bad side-effectswere described by most of the participants.

They gave me Risperdal [anti-psychotic medicine] for 3 years. Laterwhen I did some reading on the effectiveness of Risperdal I didn’t findmuch evidence. What I did experience was disturbing side-effects,I got tired and slow-minded. When I didn’t want it they grabbedme and forced the medicine into me in a physically very offensivemanner . . . A lot of coercive measures can be performed with only theparents’ approval, without any support in the law . . . The psychiatriccare should protect children from their parents’ wish to use measuresas forced feeding, being locked in and coerced medication, in thesame way as the law protects children from maltreatment. (Report 9)

Some of the participants described the informal coercion asthe most difficult to stand and most offensive. There were severalreports of situations where they had been admitted to psychiatric


inpatient care voluntarily but still daily had to endure situationswhere different coercive measures were used. Some participantsdescribe that they do not tell how they feel and hide their self-harm behaviour to avoid punishment.

Finally I decided to hide my anxiety and pretend that everythingwas alright. Instead I self-harm during the night, hidden in my bed.(Report 10)

Some of the participants describe that they had totally lostall their hope for support from the care system and thereforealso their hope for recovery. They did not make contact with thepsychiatric healthcare system even in situations of acute needof care and treatment. Others used their own coping strategiesin order to get the care they wanted and needed.

I came to the conclusion that if I was in really bad shape and wantedto be admitted I first have to harm myself and then say that I didn’twant to be admitted. That’s the most efficient way. There’s no use inasking for help before harming oneself. (Report 4)

There were many descriptions of discontinuity in the careplans. One participant described an incident prior to being ad-mitted in which a new senior doctor had questioned her. He hadasked her if she believed that the ward was a hotel, claimingthat she was spoiled and lived a life of luxury. For the partic-ipant, it was just unbelievable how anyone could associate aninpatient psychiatric ward with a luxury hotel, ‘It is rude, veryunprofessional and not confidence building’. There were alsodescriptions of solid care plans being disrupted because of lackof continuity among the doctors. Every doctor has an individualview of what the care should look like and when the participantshad tried to argue to maintain the care plan, they were met withcontemptuous treatment and discharged from the ward with nofurther support.

The final words I will never forget, it hits me deep in my soul andsends shivers up my spine. The psychiatrist said, “you will be suicidalall your life and that’s no reason for being admitted”. Psychiatry issupposed to be there when you need it and inspire hope. Where wasthat in those words he gave me? (Report 17)

There were several concrete suggestions in the self-reports onhow to improve the care. The participants felt that it is importantto not mix people with totally different types of diagnosis andnot place people in locked wards when it was not necessary. Thecare should be based on flexibility and individualised solutionsand the care plans should be formed in cooperation with thepatient. That included an insight that there can be situationswhere coercive methods are necessary due to the patient’s severeconditions.

My clothes were taken, they change the bedclothes, remove the lightbulb and keep the light on all night. The suicide-watch sat besideme. At that point they probably did everything possible to avoidmechanical restraints, I don’t know if it would have come to that,but there wasn’t much else to do. (Report 15)

Another important suggestion was to have committed regularstaff with the right professional competence on the ward. That

includes the opportunity to talk regularly with a psychiatrist whoknows the patient and use of drug treatments only when there isevidence that they are the best alternative.

My wish is that there will be less coercive measures and more ofcare in the future. More talks with the patients about why they harmthemselves, how they want to be helped and how to change theirmindset. (Report 8)

DISCUSSIONThe results show that there is a considerable gap between par-

ticipants’ wishes and their actual experiences of psychiatric care.They did not ask for miracle treatment but asked to be listenedto, understood and met in a mutual relation with professionalcaregivers in an adapted environment. This description of partic-ipants’ negative experiences of inpatient psychiatric care is con-sistent with earlier research findings (Carlsson, Dahlberg, Eke-bergh, & Dahlberg, 2006; Lindgren, Oster, Astrom, & HallgrenGraneheim, 2011; O’Donovan, 2007; Koekkoek et al., 2010).Lindgren et al. (2011) describe that the dominant approach forpatients who self-harm was the ‘fostering repertoire’ in whichthe caregivers try to motivate the patients by putting up rules andthe patients have to earn obvious rights by following these rules.O’Donovan (2007) also found that strict enforcement of rules,lack of choices, coercion and threats, are typical responses whencaregivers describe their practice for patients who self-harm.The participants’ wishes and perceptions correspond to an un-derstanding of care that might be described as person-centredand recovery-oriented (Barker, 2001). It can be argued that pro-fessional caregivers should strive to meet the needs and wantsof these patients in a person-centred care approach to offer acare with a limited use of coercive measures.

People who self-harm are perceived as a difficult categoryof patients in psychiatric care from the staffs’ point of view(Koekkoek, van Meijel, & Hutschemaekers, 2006; Thompson,Powis, & Carradice, 2008). One way of understanding the par-ticipants’ negative experiences of the care can be by acknowl-edging that patients who self-harm evoke strong feelings inprofessional caregivers, as well as admitting that nurses ap-parently are having trouble correctly interpreting patient be-haviour. As a result, nurses may respond to the behaviours andneeds of people that self-harm with a variety of utterly dif-ferent interventions (Lindgren et al., 2011; Lindsey, 2009). Itseems credible that patients who self-harm will have stricterrules and restrictions imposed upon them than other groups ofpatients and also face the risk of discharge without follow-upas a consequence of their symptoms (e.g. self-harm) (Koekkoeket al., 2010; Looi, Gabrielsson, Savenstedt, & Zingmark, 2014;O’Donovan, 2007). According to Lindsey (2009), nurses’ de-cisions to restrain may be influenced by their own personallevel of tolerance towards the patient’s behaviour and there isa general inconsistency in their pattern of intervention choice.Koekkoek et al. (2006) show that this group of patients are lack-ing sufficient support from effective treatment strategies. This


might be explained by how a lack of strategies result in ad hocnursing care leaving nurses stressed, disempowered and lackinghope when caring for patients who self-harm (Thompson et al.,2008; Wilstrand, Lindgren, Gilje, & Olofsson, 2007). Accord-ing to Knutzen et al. (2014) the risk for frequent use of restraintscan be better explained by professional caregivers’ inadequateresponse to patient behaviour and symptoms than by patientcharacteristics.

The results showed that the participants want to be listened to.They wish that the staff members put their own preconceptionsaside and open-up to their experience and truly listen, tryingto understand what the patient needs. Koekkoek et al. (2010)confirmed that patients stress the importance of listening be-ing based on true interest and authenticity, not just professionalcourtesy. According to Barker (2001), it is crucial to allow pa-tients to verbalise their experiences and perceived meanings inorder to gain a common understanding. To achieve that kind ofnursing care, Barker advocates a narrative-based form of carepractice. Barker (2001) argues, as the results of this study alsoshow, that the process of psychiatric care can reinforce a feelingof disempowerment. Patients testify that professional caregiversoften concentrate on what patients cannot do instead of shiftingfocus and building on what they can do (Koekkoek et al., 2010).

An important aspect of listening, which was emphasised inthe results, is to respect that the patient may have differentoptions and be willing to let go some of your own power (Lind-gren et al., 2011). It is important to see the patient as a personwith strengths and knowledge. This will shift attention towardshow the patient can utilise these resources in their own care.Lloyd (2007) interviewed acute mental health nurses about howthey use empowerment and found four important componentsto achieve an empowering practice: using responsibility wisely;understanding of mental illness; working in a team; and devel-oping relationships. This means that rigid general rules are notcompatible with individualistic person-centred care and empow-ering approaches. This is not to say that everything the patientwishes for is to be accepted by staff. Sometimes, nurses mustuse their power, assume responsibility and temporarily violatethe patient’s autonomy. But if that happens, measures must betaken to restore the power balance, e.g. have a debriefing sessionas soon as possible to restore the power balance (Lloyd, 2007).

It is well known that patients in Swedish inpatient psychiatrywish for a closeness and attention of staff members but expe-rience feelings of abandonment, futility and distrust (Carlssonet al., 2006; Horberg, Sjogren, & Dahlberg, 2012; Olofsson &Jacobsson, 2001). In the results, participants described not onlyhow they long for help and support, but also how they possessabilities and knowledge that they would like to utilise in collab-oration with caregivers. Professional caregivers might perceivethis as contradictory, as patients who self-harm are traditionallyperceived as manipulative and lacking the capacity to under-stand what is best for them; a view resulting in paternalisticcare characterised by rules and containment (Lindgren et al.,2011; O’Donovan, 2007; Thompson et al., 2008). Consistent

with these views on patients who self-harm is a constant dis-trust among professional caregivers towards the patient and asa result, patients that are able to articulate their needs and seekhelp before harming themselves are assessed as not in need ofcare (Koekkoek et al., 2010).

Professional caregivers might also perceive self-harm be-haviour as intentionally directed towards persons close to them.They fear that the patient might commit suicide and then conse-quently focus on risk-reduction instead of providing support tothe person who self-harms (Thompson et al., 2008; Wilstrandet al., 2007), a finding supported by the results of this study.We suggest that both caregivers’ fear being manipulated and thepotential risk for the patient to commit suicide counteracts col-laboration and flexible care of the patient. Instead, it promotesa care based on confrontation, rules, intimidation and coercion.It would seem that skilled and confident professional caregiverswith the ability to uphold mutual, trusting relationships withpatients are better off when it comes to providing restraints-free care. Baker, Bowers and Owiti (2009) suggest that fewerrestrictions may promote better treatment acceptance and saferoutcomes. Several other studies support the notion that it is pos-sible to reduce or minimise the need for coercive measuresin inpatient psychiatry (Huckshorn, 2004; McCue, Urcuyo,Lilu, Tobias, & Chambers, 2004; Salzmann-Erikson, Lutzen,Ivarsson, & Eriksson, 2008; Stewart et al., 2010).

However, the results of this study suggest some commonwishes that might support professional caregivers in making acollaborative effort with the patient. This might lead towardsan individualised care, in which caregiver and patient cometogether without preconceptions and the patient is seen as aperson, resulting in a mutual and trusting relationship and a carepractice built on knowledge instead of a limiting fear.

LimitationsThis delimited qualitative study provides knowledge that can

increase the understanding of how patients can experience co-ercive measures and alternatives that can be used, but the studyis based on a rather small sample (n = 19). This type ofdata collection is not dependent on where the participant stays,so the accounts in this study cannot be explained by a uniquecare culture in one hospital. It has also been found that theanonymity allows far more candid answers (O’Connor, Madge,Shaw, & Wellens, 2008). A weakness with this type of self-report is that you are not able to follow-up important threadsor contact the informants for clarifying questions. As data werecollected through self-reports from a homepage, we have nobackground data about the participants, but found it not to benecessary for this study. All self-reports who offered a statementand all text in each report was included. Most of the reports werereally homogenous and very rich in content. The richness canbe explained by the time the participants had to reflect on theiranswers. Under some circumstances, it can be important to getmore spontaneous answers and then this type of data collection


is not suitable (O’Connor et al., 2008), but in this study that wasnot the aim. Another weakness with self-reports via social me-dia is that we do not know why some chose to write their story,while others do not and if the participants who chose to partic-ipate might have, e.g. significantly bad experiences. However,most of the reports included both good and bad experiences. Thetrustworthiness of the results is also supported by the system-atic and structured work with the analysis of data by the authors(Graneheim & Lundman, 2004).

CONCLUSIONS AND IMPLICATIONSThis study indicates a paradoxical situation in inpatient psy-

chiatric care putting persons who self-harm in a catch-22 sit-uation. If they do not say what they need they will not get it,but if they say what they need they are denied it. The logicbehind this is that caregivers believe patients who self-harm tobe manipulative. This is in contrast to the results of this study,which suggest that patients are actually forced to behave in a‘manipulative’ way as a response to caregivers’ disbelief. Asa result, the care will not be in line with the patient’s wishesand needs and the distrustful approach creates a psychiatric carethat is counterproductive for its own purposes and could bestbe described as self-destructive. The self-destructive care re-inforces and triggers destructive means of communication inpersons who self-harm. Patients are left feeling misunderstood,abandoned and violated. As a consequence, many of them tryby all means to avoid contact with the psychiatric care system,which often in the end results in involuntarily hospitalisationand coercive measures.

Much is to be gained if caregivers were to listen to thepatients. Starting with the descriptions offered in this study,it would seem that providing a flexible, person-centred care,adapted to a patient’s individual needs, is not that difficult. Itwould make life on the ward easier for both patients and care-givers, resulting in quality care, in which the need for coercivemeasures is minimised.

• Work proactively – pay attention to signs of deteri-oration in time and put in agreed actions as soon aspossible

• Listen, try to understand and assume that what thepatient says is true

• Implement a care plan that is individualised and flexi-ble – reject the general rules, threats and consequences

• Share your power with the patient and strive for mu-tual cooperation, both around the planning of care anddischarge

• Avoid self-harm by building a trusting relationship – asafer tool than limiting the care environment

• Achieve the patients’ needs during the hospital stayso the patient has strengthened potential at discharge,needs can relate to hope, self-esteem or empowerment

• Avoid coercion measures but never make it an overar-ching goal; it may in some cases be a justifiable actionbased on specific individual needs.

Declaration of Interest: The authors report no conflicts ofinterest. The authors alone are responsible for the content andwriting of the paper.

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Delstudie II

Easy but not simple –

Nursing students’ descriptions of the process of

care in a psychiatric context

Running title:

The process of care in a psychiatric context

Authors: Ejneborn Looi, Git-Marie, RPN, RN, MSc Sävenstedt, Stefan, RN, PhD, Professor Engström, Åsa, RN, CCN, MSc, PhD, Associate Professor Department of Health Sciences, Luleå University of Technology, Luleå, Sweden Corresponding author: Git-Marie Ejneborn-Looi Department of Health Sciences, Luleå University of Technology, 971 87 Luleå, Sweden E-mail: [email protected] Phone: +46703281236 Fax: +46920491399

1

Abstract

The nurse-patient interaction is the cornerstone of psychiatric care, yet the

concept “mental health nursing” is difficult to describe. This paper aims to

address this problem through the experiences of nursing students. Online

journals from 14 nursing students were analyzed using qualitative content

analysis, resulting in three categories: “Trusting the trusting relationship”,

“Voicing the unspoken needs” and “Balancing the dynamics of doing and

being”. The study demonstrates that providing nursing care based on

trusting relationships is not a demanding task, but it takes place in a

complex environment with a tendency to make easy things complicated.

Key words: the process of care, mental health nursing, relationship, need

assessment, interventions

2

Both researchers and clinicians struggle to articulate the content of nursing

practice in psychiatric mental health care. This paper aims to address this

challenge through nursing students’ descriptions of their work with

patients in different types of psychiatric care settings. Their work in this

paper will be called “the process of care” and includes building

relationships, assessing needs and abilities, and implementing interventions

(actions including a conscious approach).

The nursing process traditionally starts with an assessment (data

collection). It continues with planning, implementation of the chosen

nursing intervention, and evaluation (Yura & Walsh, 1988). Others add

making a diagnosis to the process (Carnevali, 1983; Gordon, 2002). In

these descriptions of the nursing process, the nurse-patient relationship is

seldom included or may simply be taken for granted. In contrast,

Halldorsdottir (2008) argues that the nurse-patient relationship is the most

fundamental aspect of professional nursing. If the relationship reaches what

Halldorsdottir calls “a life-giving nurse-patient relationship”, it can

significantly empower the patient and increase his or her feelings of health

and well-being, summarized as empowerment (Halldorsdottir, 2008).

From their literature review, Cleary, Hunt, Horsfall and Deacon (2012)

describe that the nurse-patient interaction continues to be the cornerstone

of psychiatric inpatient care, and mental health nursing, often described as

an empowering process, distinctly stresses the nurse-patient relationship as

an essential factor (Barker & Buchanan-Barker, 2010; Lakeman, 2012;

Svedberg, 2011). However, according to Looi and Hellzén (2006),

insecurity about how nurses are expected to act in a nurse-patient

relationship results in different approaches that are strongly influenced by

each nurse’s personal view of what the “right” caring approach entails.

Barker and Buchanan-Barker (2008; 2011) consider that that the concept

3

“mental health nursing” is still a myth, i.e. many professionals believe in it

and value it highly, yet describing and defining the concept is difficult and

quite vague.

The nursing students who participated in this study formulate and reflect

on the process of care in online journals, e.g. what they are doing, how

they do it, and why they do it. According to Dewey (1938), when a

theory has been tried out in practice, reflecting upon the experience is a

good opportunity to develop knowledge. Using reflective journals as a

pedagogic tool for nursing students during their clinical placement offers

positive experiences (Kok & Chabeli, 2002; Landeen, Byrne, & Brown,

1995). It is also known that a good patient-student relationship can benefit

both the patient’s health and the student’s learning process (Suikkala &

Leino-Kilpi, 2001; 2005). However, using nursing students’ experiences

recorded in reflective online journals doesn’t seem to be common, and it

appears that the process of care, from establishing relationships to the

implementation of an intervention, has not yet been described from their

perspectives.

The students in this study were included due to their successful work with

patients with changeling behavior. The aim of this study is to investigate

the process of care by describing these nursing students’ reasoning and

experiences related to creating relationships, conducting needs assessments,

and choosing interventions in psychiatric care.

4

METHOD

This study applies a qualitative design and has an abductive approach,

which can be suitable for renewing patterns and acquiring a deeper

understanding of caring (Eriksson & Lindström, 1997). The data is based

on nursing students’ descriptions of their work in different psychiatric

inpatient settings as recorded in reflective online journals.

Context

The psychiatric nursing care course took place during the second year of a

three-year university course to become a registered nurse in Sweden. The

nursing students previously had about 10 weeks’ experience of nursing

practice within somatic care. The full-time course was 5 weeks in

duration, and practical skills and theoretical knowledge were combined,

practised and examined. Workplace training was conducted in different

areas of psychiatry: forensic psychiatry (5), municipal psychiatry (2),

addiction unit (1), emergency psychiatry (3), and general psychiatry (3).

The patients for whom the students cared suffered mostly from different

types of schizophrenia, severe depression, neuropsychiatric diagnoses, and

self-harming behaviours. Most were admitted involuntarily.

The nursing students’ assignment was to work with a patient and attempt

to establish a relationship, identify needs, and plan, perform, and evaluate

the chosen interventions. The students continuously documented their

work in reflective online journals; those chosen for this study contained

approximately 5,000–15,000 words each. The students reflected on and

argued for their assessments and choices, and they received feedback from

a lecturer a couple of times during the course.

5

Participants

Seventeen (17) former students (16 women and one man) who had

succeeded in establishing relationships with patients known to be

“challenging” were selected and asked if they were interested in

participating in the study. The requests were sent by post, and students

could respond either by post or email. A lack of a response was interpreted

as a no. Fourteen (14) students, all female, agreed to participate, two did

not respond, and one letter was returned because it had been sent to the

wrong address.

Analysis

The analysis commenced by reading the nursing students’ journals. The

text that described aspects of the care process was sorted into three content

areas (cf. Graneheim & Lundman, 2004): relationships, needs and

interventions. Next, the texts from each content area were divided into

meaning units and were assigned a numerical code so that each meaning

unit could be traced back to each journal. Then, each content area was

analyzed separately, first by reading the text to understand what each

content area was about in more detail, and then to categorize the meaning

units step-wise (cf. Graneheim & Lundman, 2004) to find out what the

students did, how they did it, and for what reason. This process was

discussed and reflected upon by the authors until six sub-categories were

formulated in the three content areas that formed the three final categories

(Table 1).

Methodological considerations

The lectors’ feedback to the nursing students could have affected the

content of the journals and therefore the results. The authors remained

aware of this possibility as they reviewed journals, and only those that

6

received minimal feedback were selected. The feedback was also included

in the initial stages of analysis; this allowed the co-authors to assess the

relationship between the nursing students’ descriptions and the lector’s

feedback, thus reducing the risk that lector would influence the direction

students took. Another risk was that students might have embellished their

work, as they are in a dependent position and will be assessed by the

lector. However, the lector had a continuing dialogue with the supervisor

and clinical lecturer in which they confirmed the descriptions; the risk

seemed mostly to be that they had toned down their own significance and

contributions.

Ethical considerations

Ethical approval was granted by the regional Ethics Committee in Umea

(2010-4-31M), which was also informed of the original design (2012-315-

32M) and approved alterations to it.

7

RESULTS and DISCUSSION

The results were developed from journals written by nursing students who

had successfully managed to create a trusting relationship with patients

who were recognized as “challenging” and who, working with the

patient, had begun a positive health process. The results are shown from

three content areas, categories and sub-categories (Table 1), and together

they form “the process of care”. This involves working with the patient

on different areas (relationships, needs, interventions). The process is not

linear; the nursing students could move back and forth between the

different areas, depending on external and internal factors and renewed

assessments. The same intervention could, in some cases, have the goal of

creating relationships and, in other cases, be chosen with the aim of

satisfying an individual need. However, a trustworthy relationship was

seen as vital to achieving a high quality of nursing care.

------------------------------------- INSERT TABLE 1 ABOUT HERE -------------------------------

Result: Trusting the trusting relationship

The nursing students made a case for a secure and trusting relationship as a

precondition for identifying the patients’ real needs and resources. In

regard to trust, the patients felt secure with the nursing students and had

sufficient confidence to be able to express their thoughts and experiences

about their current situation. Without a trusting relationship, there was a

clear risk of misinterpretation and of needs being overlooked or patients

attributing needs they did not have. All of the nursing students described

that a trusting relationship was a precondition for helping patients feel that

the students were involved in their care.

8

How to support a trusting relationship

By being easily approachable and showing that they had time and an

interest in the patients, the students created opportunities for interactions.

Being confirmatory and showing genuine interest in the patient as an

individual was the most frequently described condition for creating

relationships. Students demonstrated their interest by listening, trying to

understand, and being present in the patient’s pain and suffering, thereby

strengthening the relationship. They also found that it was just as

important to be approachable and to listen when the patient was well and

described his or her interests, wishes and other issues that were important

for the patient to raise. Another important aspect that illustrated their

acknowledgment of patients was that many students described feeling and

clearly showing a sincere and genuine happiness about patients’

improvements and successes.

The nursing students also offered to talk about their own interests and

experiences and to answer patients’ questions. This meant that a feeling of

mutuality could increase if patients and students were close in age or had

similar interests, such as the same tastes in music or sports. Defending a

patient’s integrity and showing respect were described as necessary

prerequisites. These could be achieved in many ways, but in general, the

nursing students considered that it was important to approach the patient

when the patient wanted to be approached and to always ask about the

patient’s preferences. Doing so also strengthened the patient’s autonomy

by encouraging him or her to make as many decisions as possible and trust

his or her own ability.

The staff were totally impressed that I have been able to create such a

good relationship with him in such a short time. By really just being,

9

I try not to stress him but allow him to decide what our meeting will

be like. (Student 9)

Honesty was also an important factor in creating relationships. The

students described being careful to make only promises that they were sure

they could keep. They were also clear about why they were on the ward

and how long they would be there so that patients wouldn’t feel let down

and abandoned. In addition, the nursing students used different kinds of

“tools” to encourage building the relationship; for example, they could

choose to introduce various documents that gave them a reason to follow

up with a patient.

Through the sleep diary, it became easier to create a safe and trusting

relationship when the patient had a reason to sit down with me and

talk about his own self-assessment. The sleep diary itself was not

important, but it was a good thing to have when he took the

initiative to talk to me about it, but in fact we always got on to other

matters. (Student 1)

The nursing students used different conversation techniques. The majority

described using open-ended questions and active listening, while some

said they spoke with a lower pitch or a softer voice. They also reflected on

their body language; for example, they sat down to signal that they had

time and were interested in what the patient had to say. Inviting patients

to play games or engage in conversations where they had opportunities to

demonstrate their knowledge were other measures that the students found

strengthened their relationships with the patients.

10

How to know if it is a trusting relationship

The nursing students clearly described knowing when a trusting

relationship had advanced. They described small, subtle signs such as

smiles and eye contact and more tangible ones, such as the patient turning

to them for companionship or help with a variety of things.

Patients might shake students’ hands or give them a hug, as well as

cooperating in their own care and treatment. The nursing students

considered that these meant a more-trustworthy relationship had been

created.

My patient asked me if it was my last day tomorrow, and then he

wondered if I could give him the injection. So this morning the

patient asked for the injection on his own initiative. The other staff

were surprised that he came and asked for his injection (he was

usually given a forced injection). (Student 6)

What obstacles are encountered in building relationships

The nursing students also identified several obstacles to building

relationships. For instance, they were well aware of the risk that their

prejudices could affect the conditions for creating a relationship, and

several students described hearing reports about patients who had been

labelled as “hopeless” or aggressive”. A strategy that emerged from several

students was that they wanted to get to know patients before they started

to read about their diagnoses and past histories so the information

wouldn’t influence them. Several students also described being afraid of

certain patients initially but quickly changing their opinions, while others

were fearful of doing something “wrong” and therefore hesitated to make

contact with a patient.

11

She felt so alone and lacking support as she sat in the room with the

doctor’s, nurse’s, daughter’s and my eyes on her. I wanted to move

closer and show by touch that she was safe, but I didn’t dare. No one

else made an attempt to do it either, and I think I got scared of being

a bit too forward. I still regret it … (student 10)

In some cases, the students described how a patient’s personality or

symptoms could complicate creating relationships. They described that

some patients didn’t want their company, and then the only response was

to accept their wishes; however, it could also be a question of the patient

being deeply depressed or paranoid.

The nursing students also discussed the risk of harming the relationship by

carrying out treatments that patients didn’t wish to receive. However, this

meant that the relationship could also be strengthened if students managed

to perform their duties in a way that was beneficial for and agreeable to

the patient.

Maybe she’s scared of injections and this might result in our first

meeting not turning out that positively. But, at the same time, if she

is scared, I can try keeping her fear at bay with calmness and

carefulness. (Student 5)

Discussion: Trusting the trusting relationship

In many cases, the nursing students managed in a short time to achieve a

trustworthy relationship with admittedly “challenging” patients where the

staff had “failed”, which was surprising for both staff and nursing students.

To understand the nursing students’ success, we looked at what they were

doing and the approach they were using, but we also considered the

situations that the students had compared to the nurses (and whether those

conditions could be applied organization-wide). One possible reason

12

could be that the patients perceived the students as more trustworthy and

less threatening because they didn’t have the same authority as the nurses.

Students identified trust as the most important quality in the relationship.

However, according to Hem, Heggen and Ruyter (2008), achieving a

trusting relationship between the nurse and the patient is challenging.

Hem et al. argue the need for trusting relationships in psychiatric care, but

achieving them requires radical change. This kind of improvement is not

realized by increasing staff or raising pay; it requires a change in the

professional nursing role that includes developing effective countercultural

skills. This, in turn, calls for professional development in practice,

education and research (Hem et al., 2008). The nursing students had a

clear mission – to learn how to create a trusting relationship with the

patient, and in that learning process they consciously reflected and

evaluated not only their own actions and approaches but also the responses

of patients in order to develop their skills in relationship-building. It is

well known that reflection and self-reflection are important factors for

nursing students’ progress in personal and practical skills (Cameron &

Mitchell, 1993; Kelly, Hager, & Gallagher, 2014). However, reflection

alone is not enough, according to Dewey’s holistic theory of knowing.

Reflection and action must be combined and are interdependent in the

same way theory and practice are (Hartman, 2003). Taken together,

theory, practise and reflection might have given the students a set of tools

to develop skills to be able to think “outside the box” of traditional care

on the ward, which might be compared to Hem et al.’s (2008)

descriptions of countercultural competence and be one of several

explanations for the students high level of success in creating trusting

relationships.

Another difference was related to the nurses’ many responsibilities and

lack of time compared to the nursing students, who needed to care for

13

only one patient at a time. In a review (Cleary et al., 2012) about nurse-

patient interaction, the authors write that showing interest in the patient

and what they call an integrated triad including listening, understanding,

and responding were critical factors from the patients’ perspectives. These

results about what patients want align well with the students’ descriptions

of their work in this study.

However, if the nurse listens but does not try to understand and respond

to the patient, listening could have the opposite effect and cause the

patient to feel rejected (Hem & Heggen, 2004). According to Hem and

Heggen, a nurse’s rejection of a patient can have two causes, internal

factors (for example, unclear roles and responsibilities; cf. Hem et al.,

2008) and external factors such as inadequate staffing (e.g. not enough

time for the patient). A study by Shattell, Andes and Thomas (2008) found

that if the nurse-to-patient ratio is very low, nurses describe having to be

task-oriented and unable to focus on each patient’s needs. We cannot

know about the staff ratio on the different wards, but based on the nursing

students’ experiences and actual research, if we agree that the nurse-

patient relationship is important for the quality of care, then providing

nurses with adequate working conditions regarding both internal and

external factors is critical.

14

Result: Voicing the unspoken needs

The nursing students described different ways of gathering information

about a patient in order to make an assessment of his or her individual

needs, and then being able to choose the appropriate measures. The most

common and frequent description was that, while they were talking to

patients and listening to try to understand their overall situations, students

were also cognizant of the need to attempt to identify patients’ different

resources and abilities. They also talked with staff and, when appropriate,

with relatives of the patients. Reading medical journals and patients’ self-

assessments was also included in gathering information.

How can different behaviours be understood

In addition to the usual data collection as described above, needs

assessments included identifying and interpreting different signs. The

students were very receptive and tried to understand patients’ different

signals and behaviours. For example, in cases where the patients had been

delusional or deeply depressed, the students believed that it was important

to try to understand what the different behaviours meant since the patients

were unable to express their own needs.

Because he doesn’t have an insight into his illness, I can’t ask him

what the problem is or what he wants. His only problem is that he’s

locked up in totally the wrong place, but during observations and

conversations with him, I have the feeling that he is in need of

security, trust and participation. He’s a man who believes that his

surroundings are poisoning him, and he doesn’t trust anyone.

(Student 6)

15

In other cases, the students were told that behaviours were linked to the

clinical picture, such as when it was difficult to get the patient’s attention

and he or she was withdrawn. However, the students were of the opinion

that withdrawal could have a number of causes and purposes. By this, they

meant that some patients withdrew because they had a pointless and dull

existence, whilst others felt abandoned and felt no affinity with the staff.

In other cases, the students interpreted a patient’s distancing himself or

herself as a coping strategy. Therefore, they considered it important to

learn to read how the patient felt and make new assessments daily to

identify an individual balance between closeness and distance in order to

show respect for the patient without abandoning him or her.

Students also met patients who displayed threatening behaviours, but they

interpreted these more as expressions of the patient’s illness and feeling

frustrated.

I know that he can scare both patients and staff with his behaviour,

which is an expression for him feeling ill; he is often misunderstood,

and he has expressed his gratitude because I have dared to meet him

and suppressed the process. (Student 5)

A nursing student described that staff said she should watch out for a

“chronically aggressive woman”, but instead, she saw a woman with a

chaotic life situation and in despair who felt mistrusted and wrongly

judged. Often, students interpreted a patient’s behaviour more positively

and saw opportunities for the patient’s development; they experienced

rigid rules as often making it more difficult to make individual assessments

of a patient’s needs.

16

Staff forbade a young girl with an eating disorder to heat up food

after 8 p.m. because there’d be too much noise. I wonder about the

reasoning then; I would be happy no matter what time of day a

patient with anorexia nervosa wants to eat. (Student 10)

The students also saw numerous small signs they considered extremely

important to take into consideration.

It is difficult to explain, but she gets so happy when she has her hair

plaited and feels pretty. If she had totally given up hope, she

wouldn’t have cared at all, I believe. Deep inside there is a spark of

life that needs to be reawakened. (Student 1)

The students felt it was obvious to prioritize patients who felt unwell and

saw different behaviours as signals that they would try to respond to. They

found it difficult to understand how staff could reach the opposite

assessment and take an opposing action.

Strongly disputing a decision to leave a hyperventilating, crying,

anxiety-ridden young girl whose upbringing has been insecure (and

who’s experienced so many things I don’t even want to think about)

alone so as not to give her unnecessary attention … I think that her

way of saying that she doesn’t feel well is just by sitting in the

corridor. What kind of pain do we then cause her by ignoring her?

Are we not there to pay attention to the patients? A girl who’s been

fighting her whole life for somebody’s attention and not even when

she is genuinely feeling bad does she get the attention … (Student

10)

17

The nursing students also thought that behaviours they interpreted as

positive signs could, in the staff’s assessment, be used instead against the

patient; students felt these signs could be significant, for example, for a

diagnosis or for the patient being discharged.

“It can’t be true that she’s so depressed because she sits on the sofa

and sometimes smiles.” It’s great that she can smile! But that doesn’t

tell the whole truth about how people feel. (Student 5)

How can a patient’s needs be assessed

The nursing students identified a number of patient needs, some very

specific but most more abstract in nature. The students were of the

opinion that the need for increased self-esteem could express itself through

the patient not demanding anything or having no confidence in his or her

abilities. Some nursing students connected low self-esteem to a patient’s

unkempt appearance, arguing that this could indicate the patient believed

he or she was unworthy of being clean and looking nice. Because many

patients had experienced a number of failures in life, the students reasoned

that the care often focused on the patient’s shortcomings and problems.

I noted that he was looking for some kind of praise or

acknowledgement. Then afterwards I thought about this as he gets a

lot of negative comments because he’s filthy, his clothes are dirty or

his sheets are soiled with snuff. He doesn’t get many positive

comments. (Student 13)

The students felt that many needs were connected, and if they were

successful in satisfying one need, this could contribute to reinforcing other

needs, and hope was a normal positive “side effect”. The need for

increased hopefulness was identified in essentially all patients. The students

argued that many patients described having no belief in the future; they

18

had no energy to fight because “there is no point” and felt that their

existence was pointless. The nursing students argued that patients had a

need for increased participation and empowerment based on that they

rarely participated in decisions concerning their care. The students also

thought that the patients often had insufficient knowledge and

information about their own illness and treatment and lacked coping

strategies for different symptoms such as anxiety, uneasiness, and

restlessness, which the students considered as decreasing patients’ feelings

of empowerment and control over their situation.

Motivation and the need to take the initiative were other common

assessments. Nevertheless, most of the students were very careful when

distinguishing these needs. One student described that it was important to

meet the patient’s need to strengthen his or her sense of initiative “… for

him to get started and do all the things he is motivated to do and that he thinks are

fun and that makes him feel good”. Students also argued that, when they saw

that a patient had received adequate support, he or she was successful in

carrying out different activities; they felt this indicated that the patient had

the will and motivation but lacked the power and ability to get started.

They inferred that, if motivation was lacking, patients might have had the

ability to begin and carry out an activity but lacked the desire and interest

to do so.

It’s not possible to design interventions that motivate the patient to

achieve our goals. It’s important to work out the goals together; we

have listened to what the patient wants to achieve and that the

patient feels involved and motivated to achieve these goals.

Otherwise, we’ll never reach these goals, and it’s also good because

they aren’t the patient’s goals. (Student 1)

19

Trust and confidence were also frequently occurring needs identified by

the students. They were of the opinion that lack of trust could be

manifested by patients not saying how they really felt or being fearful

about eating food or taking their medication. A patient could also

experience the environment as unsafe and frightening. In other cases,

examinations and treatments could be sources of insecurity or the fear that

they wouldn’t have a secure existence when they were discharged.

Discussion: Voicing the unspoken needs

In this study, the nursing students often saw signs and conducted

assessments different from those of staff. This could be for a number of

reasons, and one that is obvious is the students’ lack of experience

compared to most of the nurses. Another is that the students appear to

have focused on patients’ abilities and had a more salutogenic perspective

compared to the nurses, whose perspective could have been more

pathogenic (cf. Jormfeldt, 2011; Svedberg, 2011). Jormfeldt (2011) argues

that promoting health is important in supporting the patient’s self-esteem

and empowerment. Empowerment appears to be the most important

intervention in health promotion from both the patient and staff

perspective (Svedberg, Hansson, & Svensson, 2009). The nursing students’

descriptions are similar to what Svedberg et al. call an empowerment

approach, and this is described additionally when students attempt to

improve relationships with patients and implement interventions.

Furthermore, when they assess a patient, they often identify a need for

enhanced empowerment and improved self-esteem. Research results show

that while low self-esteem should be seen as a risk factor, improved self-

esteem can have a protective function in both physical and mental health

care (Mann, Hosman, Schaalma, & de Vries, 2004).

20

In nursing theories, experience is defined as an important factor for the

quality of care (Benner, 2001; Haldordottir, 2008), but most of the

students had no psychiatric care experience. However, in the psychiatric

context, it sometimes appears that many years of experience can be a

impediment because experienced nurses can be less sensitive in regard to

patients’ needs and may have a more symptom-oriented approach

(Hellzén, Kristiansen, & Norbergh, 2003). In another study, Hellzén

(2004) found that the main factor in regard to how much time a nurse

spent with a patient depended on whether the nurse liked the patient or

not. The students’ lack of experience could have exerted a positive effect,

in the sense that they did not know patients or have much knowledge

about their psychiatric diagnoses. Instead, they have as their assignment

the clear instruction to focus on understanding patients’ needs. Another

possible difficulty for staff as opposed to students is that staff have to deal

with the caring culture, and a common staff approach can lead to a

personal conflict between a focus on relationships with one’s colleagues

versus a patient’s situation and needs (Enarsson, Sandman, & Hellzén,

2008; Looi, Gabrielsson, Sävenstedt, & Zingmark, 2014). Some students

were also critical about the staff’s assessments and argued that some rules

and treatments could have been harmful to patients. The students’ critical

reflections conform to patients’ experiences (Looi, Engström, &

Sävenstedt, 2015).

A third difference between the registered nurses and the nursing students

involved responsibilities. Sometimes patients are assessed as violent, and

assessing the potential for violence is an important task for nurses so that

preventive interventions can be implemented (Björkdahl, Olsson, &

Palmstierna, 2006). The nursing students had no responsibilities in regard

to this kind of task, but when a student met a patient who was considered

aggressive, the student often interpreted the aggressive behaviour

21

differently, and the patient did not express any aggressive behaviours

towards the nursing student. Carlsson, Dahlberg, Ekebergh and Dahlberg

(2006) argue that it is possible to prevent violent encounters with

“authentic personal” and “undisguised” care, approaches similar to what

the nursing students described.

Thus, it seems like the nursing students’ basis for assessments was

understanding and respect for each patient’s own story, “positive”

understanding of patients’ behaviours, and a focus on their capabilities.

Students’ lack of experience can, to some extent, be compensated by not

having been influenced by the caring culture within the institution/ward.

The nursing students had no preconceived opinions and didn’t have to

take the caring culture into account, which might have helped them to

see needs from the patient’s perspective (cf. Looi et al., 2014).

22

Result: Balancing the dynamics of doing and being

The nursing students carried out different types of interventions to meet

individual needs and take advantage of patients’ abilities and resources.

Their descriptions of planning and carrying out interventions described an

approach and an action. It was important that both were included and

visible in the interventions.

What to do, how to do it, and how to be

The nursing students demonstrated that it wasn’t possible to decide on a

specific action in order to address a specific need; rather, different types of

actions were used to address the same needs and vice versa. Conversely,

several approaches were described for more specific needs. For example,

the students were deliberate about listening to and acknowledging the

patients and their abilities to strengthen their self-esteem and intrinsic

value. It was also about providing them with the space and opportunity to

give something back to the nursing students, which was seen as important

for strengthening patients’ self-esteem. Examples of steps taken to

strengthen self-esteem, motivation, and hopefulness include letting

patients teach the students something they were good at, like playing an

instrument, needlework, or a sport.

I’ll let the patient teach me to play a song on the piano; this can

improve his self-esteem when he feels that he is really good at

something and has skills that he can share with others, but also the

feeling of other’s appreciation when he shares his skills and plays

beautifully on the piano. (Student 1)

Sometimes the tables were turned, and a nursing student taught the

patient something, for example, to play a game or make jewellery. The

nursing students could also take excursions with patients, going for coffee

23

or visiting the library with the aim of motivating the patient, breaking the

isolation, and promoting hopefulness. Further steps that the nursing

students mentioned for promoting hope and self-esteem were showing

interest in some of the items patients had created, for example, paintings

and poems. This could also entail the student helping the patient to plait

her hair or put on makeup or giving a massage. Some measures were

clearly connected to tangible needs like hygiene, nutrition or sleep, but

the students added factors that could also satisfy other, more abstract

needs.

After showering I saw that she had very dry skin, so I carefully

rubbed cream onto her, and her husband said that she likes to have a

massage so I took the opportunity to carefully massage the lotion onto

her legs, also with the aim to increase blood circulation, considering

her immobilization, as well as to increase well-being and self-esteem.

(Student 5)

Conversations and walks were frequently occurring measures described by

the nursing students, but in some cases the students chose unique measures

to satisfy individual needs.

Yesterday a male opiate addict and I were taking the drainpipe away

from the sink to clean it. We had fun together, and he enjoyed

having something to do despite the fact that it was a pretty disgusting

task. Otherwise, he only walked around nervously waiting for his

medication. (Student 7)

Rearranging the furniture in a patient’s room was a measure aimed to

create a sense of safety for a paranoid patient who didn’t dare to be in the

room. Teaching the patient different coping strategies to handle worry,

anger, and anxiety was also a common measure aimed at strengthening the

24

patient’s feeling of control and empowerment and thereby contributing to

a sense of security.

The approaches that the nursing students described to encourage

participation and empowerment might include the patient being able to

choose between different activities and decide both the design and time of

the activity, with the aim of encouraging and respecting the patient’s

autonomy and participation in decision-making. The students could also

choose some unusual approaches to traditional steps, for example, not only

giving information but also satisfying abstract needs.

The schedule that he now has is a piece of A4 with times and it

doesn’t work. I thought that you could draw a clock on the

whiteboard in his room and at every specific time, he can write what

he will do during the day. Then he will get the visual part with the

clock and through that it might be easier for him to remember, and

besides, if he writes it down himself he needs to think what he will

do and to memorize it and to write down the information himself

too. The combination of several senses, I believe, will make it easier

for him to remember the things he needs to do, which in turn will

increase his self-esteem and empowerment. (Student 9)

To strengthen the patient’s ability for initiative, the student could “push”

the patient in an encouraging and supportive way both verbally and

physically, for example, by laying out things the patient needed and

guiding the patient step by step or gradually handing over the

responsibility for different tasks to the patient. They described it as

important for them to ensure that the demands on the patients were at a

reasonable level so they would feel competent and not experience failure.

Some steps could also be connected to satisfying many abstract needs at

the same time.

25

The conversation that was created around the sleep diary makes him

feel that someone has time for him, listening to him, and really takes

him seriously, which also strengthens his participation and self-

esteem; self-esteem is also strengthened by him feeling that he can

manage the task; also, his ability to take the initiative is strengthened

when he has the responsibility to take initiative to fill in his sleep

diary on a daily basis. (Student 1)

The nursing students were generally given the freedom to try out different

interventions, but in some cases, they were forced to break the ward’s

rules to show that they took the patient’s suffering seriously and could

take measures to strengthen the patient and help him or her to feel secure

or to encourage a sense of well-being.

Discussion: Balancing the dynamics of doing and being

The nursing students carried out many interventions with the patients;

some of the activities were common ones in a psychiatric ward, such as

talking and going for a walk. However, the nursing students were always

aware of the patients’ needs for planning and working together

collaboratively towards a mutual goal that aligned well with the patient’s

wishes about how care should be conducted (Looi et al., 2015). Aiming to

individualize the intervention, they made evaluations continuously and

were open to altering the intervention and their own approach. Most of

the interventions began with the patient’s abilities or focused on support

or developing the patient’s skills. This way of working is in agreement

with Svedberg’s (2011) model of the process-oriented health promotion

intervention in mental health care; alliance, empowerment, and educational

and practical support are essential concepts of this model.

26

Most of the patients that the students worked with have experienced

coercive measures. A significant difference between the student and the

staff was that the students didn’t have access to coercive measures that

could possibly have a vital significance in the whole process. In planning

and implementing interventions, the students based their decisions on the

patient’s individual needs instead of focusing on correcting behaviours and

solving problems using coercive measures, which can be common

strategies, especially if the nursing staff is under pressure (Looi et al., 2014)

or lack knowledge and hope about the patient’s recovery (Ashcraft &

Anthony, 2008).

The lack of coercive measures may have contributed to the students

having to use alternatives; thus, they developed their repertoire of care

based on mutual cooperation with the patient instead of confrontation (cf.

Ashcraft & Anthony, 2008). This could have contributed to their

successful results in stimulating positive health processes.

Conclusion

One may wonder whether students are the best choice of participants to

answer the research question. In this case, the sample was a few students

who managed surprisingly well with their work with patients with

challenging behaviour. Because they were students they had good

prerequists such as time and opportunity to prioritize a patient. They had

no access to coercive measures which might have created security for the

patient. The students did not know the workplace and were not part of

the regular staff group which meant that they had no knowledge of or

needed to relate to the current health care culture. Students have limited

professional experiences and are therefore not the best choice to describe

the experience of caring for patients in a psychiatric ward, but they have

27

other conditions which can be suitable based on their unique work

situation.

The expression “simple but not easy” is sometimes used to describe a

basically uncomplicated task that still requires considerable effort to

accomplish. The results of this study, however, suggest a situation that can

be characterized as “easy but not simple”. Providing high-quality nursing

care based on trusting relationships is basically not a demanding task, but it

takes place in a complex environment with a tendency to make easy

things complicated.

Clinical implications and further research

The description of the process of care in this paper is not supposed to be

seen as a manual to follow step by step. Rather, it is a framework for those

who work from a nursing perspective where relationships, needs and

interventions are key elements in the planning and design of patient care.

The results show the importance of the nurses has knowledge of,

understand and prioritise the relationship-building in order to lay the

foundations for nursing quality work. This means that the patient nursing

relationship should have plenty of space and priority in nursing education.

As further research it would be interesting to have the patients' perspective

based on the factors they value on the basis of particularly good care

experiences with students as carers.

Declaration of interest: The authors report no conflicts of interest. The

authors alone are responsible for the content and writing of the paper.

28

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32

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33

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Issues in Mental Health Nursing, 35:470–479, 2014Copyright © 2014 Informa Healthcare USA, Inc.ISSN: 0161-2840 print / 1096-4673 onlineDOI: 10.3109/01612840.2013.879629

Solving the Staff’s Problem or Meeting the Patients’ Needs:Staff Members’ Reasoning about Choice of Actionin Challenging Situations in Psychiatric Inpatient Care

Git-Marie Ejneborn Looi RPN, RN, MSc and Sebastian Gabrielsson, RPN,RN, MScLulea University of Technology, Department of Health Sciences, Lulea, Sweden

Stefan Savenstedt, RN, PhDLulea University of Technology, Department of Health Sciences, Lulea, Sweden, and Norrbotten CountyCouncil, Department of Research and Development, Lulea, Sweden

Karin Zingmark, RN, PhDNorrbotten County Council, Department of Research and Development, Lulea, Sweden, and LuleaUniversity of Technology, Department of Health Sciences, Lulea, Sweden

Coercion in challenging situations is often seen as a necessarycomponent of psychiatric care. This study aims to describe staffmembers’ reasoning about their choice of action in challenging sit-uations in inpatient psychiatric care. Focus group interviews with26 staff members were analyzed using qualitative content analy-sis. The results provide an overview of the integrated structure ofparticipants’ reasoning and suggest that staff members’ reasoningabout choice of action can be described as a matter of either solvingthe staff’s problems or meeting the patients’ needs. These resultscan be of use in further research, educational interventions, andstaff development activities.

In response to challenging patient-related situations in psy-chiatric settings, staff members choose from a number of pos-sible actions. To date, scant research has focused on the pro-cess of clinical reasoning and decision-making in the contextof challenging situations within psychiatric inpatient care set-tings. Marangos-Frost and Wells (2000) studied how nurses’emotional reactions to violent patients affected the use of re-striction; they found the use of restraints to be complex and thatnormative-affective factors influence nurses’ decisions. Larue,Dumais, Ahern, Bernheim, and Mailhot (2009) presented acategorization of influential factors and suggested a model ofdecision-making that regarded seclusion as centred on the bi-directional relationship of patients and staff as influenced by

Address correspondence to Git-Marie Ejneborn Looi, Lulea Uni-versity of Technology, Department of Health Sciences, Lulea, 97187Sweden. E-mail: [email protected]

environmental and organizational factors, with the team alsobeing a factor. Laiho et al. (2012) conducted a literature reviewto describe factors influencing the decision to use seclusion orrestraints. They concluded that making such a decision is a dy-namic process that consists of evaluating the patient’s behaviour,assessing risk, and implementing de-escalating interventions. Inthis process, staff members take into account the risk towardsthe patient, other patients, and themselves, as well as the needto maintain a therapeutic ward milieu.

For the purpose of this study, a challenging situation is un-derstood to be a patient-related situation that may interfere withthe ability of staff members to deliver quality care and achievedesirable outcomes. Possible responses include the use of co-ercion, which is an area of psychiatric care in need of qualityimprovement (Hooff & Goossensen, 2013). Currently, Swedishlaws regulating compulsory psychiatric care stipulate that coer-cive measures (i.e., mechanical restraints, seclusion, and forcedmedication) may be used only to the extent necessary to impelthe patient to participate voluntarily in his or her care. If suffi-cient, less-intrusive measures should be used. Holm, Bjorkdahl,and Bjorkenstam (2011) analysed official statistics regardingcompulsory psychiatric care in Sweden and found that everythird person subjected to mechanical restraints is a female be-tween 18 to 34 years of age, a group they believed to be diag-nosed predominantly with personality disorder and displayingsuicidal or self-harm behaviours. Among the many negative ex-periences associated with coercive measures and reported bystaff and patients, perhaps the most troubling are reports of co-ercive measures that traumatize patients (Sibitz et al., 2011) and

470

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CHOICE OF ACTION IN INPATIENT PSYCHIATRIC CARE 471

descriptions of coercion as acts of re-traumatization of already-traumatized persons (Bonner, Lowe, Rawcliffe, & Wellman,2002). The use of containment measures is reportedly based ontradition and common sense rather than on research-based evi-dence (Jarrett, Bowers, & Simpson, 2008; Muralidharan & Fen-ton, 2006; Sailas & Fenton, 2000), and nurses have been shownto be inconsistent in the use of coercive measures (Huckshorn,2004; Lindsey, 2009). Nurses tend to regard the use of coer-cive measures as a necessary component of psychiatric care forwhich there are no alternatives (Haglund, von Knorring, & vonEssen, 2003; Happell & Harrow, 2010; Marangos-Frost & Wells,2000). Levels of conflict behaviour and the use of containmentmeasures on psychiatric wards have been shown to be interre-lated and affected by organizational features; wards with effec-tive leadership, teamwork, structure, positive attitudes towardpatients, and low burnout rates among staff have lower rates ofcontainment events (Bowers, Nijman, Simpson, & Jones, 2011).The use of seclusion and restraint can be dramatically reducedwhen these latter characteristics are made a priority, even insettings perceived as hopeless, such as the inpatient care of per-sons who self-harm (Georgieva, de Haan, Smith, & Mulder,2010).

While the reasoning and decision-making of staff membersin this context have attracted little attention from researchers, abetter understanding of why and how staff members choose touse or not use coercion in challenging situations has the potentialto facilitate the use of alternatives to coercion. The aim of thisstudy is to describe staff members’ reasoning on their choiceof action in challenging situations in inpatient psychiatric caresettings.

MATERIALS AND METHODSIn order to describe the reasoning used by staff members as

they chose their actions in challenging situations, focus groupinterviews were conducted with staff members experienced inacute psychiatric inpatient care; the interviews were transcribedverbatim and analysed using qualitative content analysis. Theresults of a second analysis, describing staff members’ percep-tions of interprofessional collaboration, are reported elsewhere.

Participants and ProcedureStaff members working at a psychiatric clinic in Northern

Sweden were asked to participate in the study. The care climateat this clinic was considered to be representative of Swedishinpatient psychiatry in general, and thus the setting was deemedsuitable for this study. The clinic consisted of several outpatientunits and one general psychiatry inpatient unit with a 24-bedlocked ward and a 24-hour admittance and consultancy service.

A majority of nursing staff at the inpatient unit were nurs-ing assistants with training at the secondary level, followed bypsychiatric nurses (registered nurses with or without psychiatricspecialist training) with undergraduate degrees. Physicians wereexpected to function in both inpatient and outpatient care set-

tings. The ward manager primarily responsible for the inpatientunit, a psychiatric nurse, functioned as part of the clinic’s man-agement team and also had managerial responsibilities outsidethe ward. Policy required a minimum staffing of two psychi-atric nurses and three nursing assistants (at night, the mini-mum staffing requirement was one psychiatric nurse and threenursing assistants), a junior physician in close proximity to theward, and an on-call psychiatrist who was available by phone.The inpatient unit would admit adult persons presenting acutemental health problems on a voluntary or compulsory basis.The premises allowed for the use of mechanical restraints ina designated room and the possibility to secure parts of theward using locked doors. Inpatient treatment options includedpharmacological therapy and electroconvulsive therapy (ECT).Containment measures used on the ward included physical re-straint (staff members holding a patient), mechanical restraint(restricting a patient’s ability to move by using straps), specialobservations (constant and intermittent), time out (the patient isasked to stay in his or her room or another specified area), open-area seclusion (the patient is isolated in a locked section of theward and accompanied by staff), and compulsory intramuscularsedation.

A total of 26 participants including 8 nursing assistants, 10psychiatric nurses, 4 ward managers, and 4 physicians tookpart in the study. Their combined years of work experience inpsychiatric care averaged 10.5 years, with a minimum of 2 yearsof experience working in this field and a maximum of 18 years.There were 12 male and 14 female participants, with an averageage of 44.5 years and an age range from 24 to 66 years of age.The criteria for inclusion in the study were experience workingin psychiatric inpatient care and a willingness to participate.Staff members were informed about the study at staff meetingsby the first and second authors (G-MEL and SG), and they weregiven the opportunity to ask questions. Approximately 50 staffmembers received information about the study; 28 gave theirwritten informed consent to participate; two failed to attend theinterviews.

Data CollectionThe 26 participants were grouped into six focus groups with

four to six participants in each group and were divided accord-ing to profession and number of years of work experience (cf.Morgan, 1997), thus forming one group of experienced nursingassistants and one group with less experience, one group of ex-perienced psychiatric nurses and one group with less experience,and one group of ward managers and one of physicians. For thepurposes of this study, participants with fewer than five yearsof experience in inpatient psychiatry were considered “less ex-perienced.” The interviews were conducted at the participants’workplace between October 2010 and January 2011. Interviewslasted an average of 70 minutes and ranged from 42 minutes(in the case of physicians) to 87 minutes (in the case of wardmanagers). The first and second authors took turns acting as

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472 G-M. E. LOOI ET AL.

moderators during the interviews. Two senior researchers tookturns acting as assistants to keep track of time and ask addi-tional questions. The interviews were recorded and transcribedverbatim.

As a basis for the focus group interview, the moderator reada vignette describing an act of self-harm:

A young female patient has been cared for at the ward for a week. Shehas been subject to inpatient care several times before. She is nowinvoluntarily admitted after intoxicating herself with paracetamolfor unknown purposes. On several occasions, containment measureshave been taken when she has harmed herself or others at the ward.All staff members (nursing assistants, psychiatric nurses, physicians,ward manager) are sitting down having their morning coffee. Fromthe staff room, they observe the patient running through the hallwaytowards a drinking glass that has been left behind. She picks theglass up, and it breaks as she throws it to the floor. She picks up alarge piece of glass and starts cutting herself deeply in the arm asshe shouts, “Let me out!”

Following the vignette, participants were asked the broadquestion “What happens next?” and later were asked a more spe-cific question, “What would you do?” Participants were asked todiscuss these questions among themselves, and the researcherssummarised the discussions and asked encouraging and clarify-ing questions. To make sure that certain areas of interest werecovered in all groups, an interview guide was used that includedthe following pre-defined topics: mechanical restraints, specialobservation, and professional roles and responsibilities.

AnalysisThe transcribed interviews were analysed using qualitative

content analysis. This is a method of analysing written and ver-bal communication in a systematic way and making replicableand valid inferences from texts (Krippendorff, 2013). FollowingKrippendorff, the content was not understood as a pre-existingentity inherent in the text, but rather as content created duringthe process of reading and analysing the text in a specific contextthat is continuously reconceptualised as the analysis proceeds,thus directing and redirecting the analysis. The context of thisanalysis was understood to be the authors’ understanding ofstaff members’ reasoning on their choice of action in challeng-ing situations. Thus, the analysis can be described as a processin which the authors’ understanding interacted with the text,the outcome being the authors’ reformulated understanding ex-pressed as descriptions and interpretations of the content of thetext.

The analytical process was carried out systematically andstepwise. The text was read as a whole with the aim in mind.Based on this reading of the text, analytical questions corre-sponding to the aim of the study were formulated to guide theanalysis (see Table 1). The analytic process aimed to describepatterns and structures in participants’ reasoning by reviewingthe answers to these questions, thus providing a description of

TABLE 1Analytical Questions Formulated to Guide the Analysis inOrder to Describe Staff Members’ Reasoning on Choice of

Action in Challenging Situations in Psychiatric Inpatient Care

Overarching Question Specific Questions

“How can participants’reasoning on choice ofaction be described?”

1. “Why do participantsconsider certain actions?”

2. “What actions areconsidered byparticipants?”

3. “How are actionsconsidered by participantsdescribed?”

participants’ reasoning on different levels of abstraction andinterpretation (cf. Graneheim & Lundman, 2004).

The analytic process started by answering specific questions.The question, “Why do participants consider certain ac-

tions?”, was answered in several steps. First, meaning unitsin the interview text containing participants’ reasoning on theirchoice of action were identified. These were read, and fourreasons for choosing a particular action were formulated. Par-ticipants’ different reasons for their choice of action were furtheranalysed to distinguish four different focuses that characterisedtheir reasoning.

The second specific question, “What actions are consideredby participants?”, was answered by coding the meaning unitsrelated to participants’ reasoning on their choice of action ac-cording to the type of action they took. In that analysis, eighttypes of actions were identified.

The specific question, “How are the actions considered byparticipants described?”, was answered by grouping meaningunits that previously had been coded for a special action anda special reason for choosing an action together and readingthem repeatedly. The content of each group was analysed, and26 approaches were formulated that simultaneously reflectedqualities of each type of action and the consequences of thedifferent reasons for choosing an action.

As a final step, the overarching question “How can partic-ipants’ reasoning on choice of action be described?”, was an-swered by viewing the text as a whole and considering the resultsof the analysis of the specific questions. In this last step of theanalysis, a theme was identified describing modes of reasoning.

Making replicable and valid inferences from texts in eachstep of answering the analytical questions was ensured througha rigorous process (cf. Krippendorff, 2013). In this process, theformation of different results was constantly cross-reviewed,reformulated, and regularly checked against what was stated inthe original text. All study authors took part in the process ofanalysing the text, and each step was discussed until agreementwas reached (cf. Graneheim & Lundman, 2004).

.


Ethical ConsiderationsPrior to conducting the study, ethical approval was granted

by the regional ethics committee in Umea (2010-4-31M), whichalso was informed of the original design (2012-315-32M) andapproved alterations to it.

RESULTSParticipating staff members’ reasoning on the type of action

they took is presented as integrated results where the answer tothe overarching question, “How can participants’ reasoning onchoice of action be described?” is first presented as a theme.Thereafter, the integrated results of the specific questions arepresented from the bases of identified focuses of reasoning.The integrated structure of participants’ reasoning is shown inFigure 1. The results aim to describe patterns and structures inparticipants’ reasoning rather than the experiences and views ofindividual participants or groups of participants.

Modes of Reasoning: Solving the Staff’s Problemsor Meeting the Patients’ Needs

Underlying threads in the participating staff members’ rea-soning formed a theme that described participants’ reasoning asa matter of solving the staff’s problems or meeting the patients’needs. This was understood as a duality of two basic modes ofreasoning that was present throughout their discussions. In theirreasoning, participants would, on one hand, emphasise their ownperspectives and safety at the expense of the individual patient’sneeds, thus making it a priority to solve the staff’s problems.This prioritization was often described as a necessity because ofthe everyday limitations on the ward in terms of overcrowdingand staff shortages, but also as a consequence of staff possess-ing superior knowledge, and patients not knowing what’s bestfor them. On the other hand, participants expressed a desire todeliver high-quality care to patients and a need to understandpatients’ perspectives. They strived to be flexible in order tomeet the needs of individual patients, even if this occasionallymeant taking a stance contrary to the opinions of their superiorsand colleagues. Figure 1 provides a visualisation of the inte-grated structure of the content of participating staff members’reasoning.

Staff-Focused ReasoningOne reason for the choice of action described in the partici-

pating staff members’ discussions was that staff members would“look out for themselves.” Types of actions considered by par-ticipants on the basis of this included responding to the situation,talking with the patient, being with the patient, restraining thepatient, and observing the patient. Approaches described byparticipants that reflected qualities of these types of actions andthe consequences of this staff-focused reasoning are presentedbelow.

In reasoning understood to be staff-focused, participants intheir discussions emphasized the importance of keeping staff

safe when responding to the situation described in the vignette.This could mean physically restraining a patient in order to pro-tect themselves and other staff members. One participant statedthat staff would “react quite instinctively and protect themselvesand try to protect the patient if possible.” In reasoning under-stood to be staff-focused, the action of talking to the patient wasaimed at calming the patient and reducing aggression, thus mak-ing it easier to control the situation without using mechanicalrestraints. Participants described how, if mechanical restraintshad to be used, talking with the patient could “play down theincident” and, it was hoped, cause the patient to “forgive andforget.” In this type of reasoning, being able to keep one’s cooland control one’s temper when with the patient was consideredimportant, since a staff member’s losing his or her temper couldbackfire and provoke the patient. Participants stated that staffmembers who manage to appear calm seldom need to be afraid.Another strategy mentioned for protecting staff members wasnot to be alone; for example, staff members accompanied physi-cians when meeting patients. Using mechanical restraints wasdescribed as another way of protecting staff members and, indoing so, the need to gain and maintain control was empha-sized. Participants perceived that the risk for using mechanicalrestraints increases as staff members become tired and weary,since fatigue causes staff members to desire peace and quiet onthe ward, as illustrated by the following quote:

but the danger is, you have to see how it is here at the ward, becauseunfortunately it’s a downward spiral, because, I mean, it’s only lifesupport really what we’re doing here today, and staff can only copefor so long, so you can only stress it that far and try to calm, andcalm, and calm, and calm, and calm, and give and take and try stuff,like it’s good if we work together towards this goal to try to make youfeel better. You can only manage that for so long with the workloadand shortage of staff we have here, so the danger is that there will bemore coercive measures just to keep it safe.

Accounts also were given of how some staff members actu-ally enjoyed violence and had a wish to become the centre ofattention. Participants described how this would lead them toprovoke patients, resulting in the use of mechanical restraints.Finally, staff-focused reasoning on observing patients using spe-cial observations centred on making it convenient for staff. Inparticular, participants described how they sought to minimizetime spent with especially demanding patients. One participantstated that constant observation can be “very demanding, so youtend to avoid it,” and that this method can be used when physi-cians lack knowledge about a particular patient, since “it’s easyto play it safe.”

Experience-Focused ReasoningThe analysis suggested that another reason for choosing a

particular action was that the patient “needed it.” Types of ac-tions considered by participants on the basis of this reason werethe same as in the reasoning described above, with the additionof engaging the patient in activities and medicating the patient.Approaches discussed in relation to these types of actions when


FIGURE 1 Visualisation of the Integrated Structure of the Content of Participating Staff Members’ Reasoning on Choice of Action in Challenging SituationsAccording to (1) Reasons for Choice of Action, (2) Types of Actions, (3) Approaches Reflecting the Qualities of Actions and the Consequences of the Reasons forAction, (4) Focus of Reasoning, and (5) Modes of Reasoning.

participants used this kind of experience-focused reasoning aredescribed below.

When participants reasoned about how to respond to a sit-uation using an experience focus, the intention of keeping thepatient safe was salient because they wanted to protect the pa-tient from further self-harm. Talking with the patient, as a choiceof action, was described as aimed at building trust, trying to un-derstand the patient, listening to the patient talk about his or herexperiences, and together exploring alternatives to self-harm.In their discussions, participants stressed the value of proactivepreventive work, giving attention to the person instead of thewound, and validating the patient by offering him or her theirtime and attention. Instilling a sense of security among patientsby being available to them was described as a means to pre-vent self-harm, aggressive behaviour, and the use of coercivemeasures. When describing how they would engage the patientin activities, participants adopting an experience focus high-lighted the necessity of adapting activities to meet the needs

of the individual patient. Participants described different pos-sible activities arising from the patient’s needs, such as takinga walk, watching television, or solving a crossword puzzle. Inthis context, several participants also described experiences ofstaff breaking ward rules and violating ward policy in order tomeet the needs of their patients. Experience-focused reasoningdid not appear to rule out the use of coercive measures, butrather participants would stress the importance of preservingthe relationship between staff members and patients when usingcoercion. Several participants also described how they usuallysucceeded in finding alternatives to restraints, especially if theyhad a good relationship with the patient. This could mean abort-ing the use of restraints as “a question of trust, an alliance issuetowards the patient.” The importance of preserving a trustingalliance and defending the patient’s legal rights was consideredan argument for avoiding the use of restraints, even when thismeant questioning or opposing decisions that had already beenmade.

.


You can’t, just to please the physician, disregard the patient; like ifyou find another method I can’t just be thinking that I must please myphysician; then I would be guilty of misconduct as a nurse towardsmy patient.

Participants also made arguments for the use of mechani-cal restraints, which they viewed, in some cases, as a betteralternative than having several staff members manually restrainan aggressive patient or medicating the patient by force. Whentalking about observing the patient, participants with a focus onexperience stressed the importance of being flexible. Respect-ing a patient’s request for a specific staff member to carry outobservations was perceived as important. In experience-focusedreasoning, participants stressed the importance of building onthe relationship established with patients. For example, the riskof having to hold the patient by force to administer medicationwas thought to be minimized by letting the staff member withthe best relationship with the patient try talking to him or herfirst.

Routine-Focused ReasoningIn participants’ discussions, a third reason for choosing an

action was simply because “it’s what you do.” The types ofactions considered in relation to this reason were the same asfor experience-focused reasoning, but, as explained below, theapproaches described differed when participants’ reasoning wasroutine focused.

Participants adopting a routine focus stressed the importanceof being efficient in responding to patients’ behaviours. In ref-erence to the vignette described previously, for example, par-ticipants stated that running to the patient, holding her, andremoving the piece of broken glass should be done quickly andefficiently, and that, as one participant put it, what happens af-terwards was “in a way, not relevant.” Participants described theaction of talking to the patient as primarily a matter of beinginformative, the purpose being to establish rapport so they couldinform, offer an explanation, and assess the patient. Participantsusing routine-focused reasoning described being with the pa-tient primarily as a matter of socializing. Participants describedhow staff keep patients company by lingering for a moment, orthat they might order nursing observations until the patient hascalmed down. Thus, a routine focus seemed to allow for the in-tensity of staff presence to be negotiated with the patient. Whentalking about engaging the patient in activities, the participantsdescribed using structured activities, such as chain analysis andrating scales, and making formalized agreements with the pa-tients. When discussing restraining a patient using mechanicalrestraints, participants who adopted a routine focus stressed theimportance of following protocol using clear-cut coordinationand frequent assessments, as well as informing and assisting thepatient.

If you’re to bring someone to the restraining room, then maybe twopeople have to hold the person, and then someone has to open thedoor, and there’s things to be produced so you have a little strategy

to make things run as smoothly as possible so you don’t have tohustle the patient, but you get them there as swiftly and painlesslyas possible.

Some participants argued that it was not always necessary totalk to the patient and that orders should be followed through,even if alternatives existed, because “if a physician says me-chanical restraints, then mechanical restraints it is.” In acutesituations, it may not be possible to wait for a physician’s or-ders, and staff agreed that sometimes they needed to act inself-defence and apply mechanical restraints without orders.Routine-focused observing using special observations was pri-marily about assessing the patient, as the importance of observ-ing and registering mood changes in the patients was the startingpoint for some participants’ reasoning. This made it possibleto assess whether special observations in the form of constantobservation should continue, be terminated (preferably), or bereplaced by intermittent observations. When talking about med-icating the patient, participants using a routine focus thoughtit important to be decisive and to follow through. Forced med-ication could be given without a physician seeing the patientfirst, even when patients explicitly requested to see a doctor. Noroutine-focused reasoning considered discharging the patient arelevant choice of action.

Discipline-Focused ReasoningFinally, participants sometimes described how actions were

chosen because the patient “has to learn.” The types of actionsconsidered by participants on the basis of this reason includedresponding to the situation, talking with the patient, being withthe patient, engaging the patient in activities, restraining thepatient, observing the patient, medicating the patient, and alsodischarging the patient. The approaches reflecting qualities ofthese types of actions and the consequences of this type ofreasoning, which is understood to be discipline-focused, aredescribed as follows.

Staff members responding to patients on the basis ofdiscipline-focused reasoning were characterized as keeping adistance from patients. Participants described how staff mightchoose not to respond to certain patient behaviours at all bylooking the other way or choosing not to pay attention to them.Talking to the patient meant clarifying things for him or her (e.g.,telling the patient “this is unacceptable; you are not allowed todo this”). Participants described how staff would explain tothe patients that their behaviour was unacceptable and that fur-ther self-harm would lead to consequences. Patients also couldbe informed upon admission that if they hurt themselves, theywould be discharged. They might also be told to clean up theirown messes. Discipline-focused reasoning for being with thepatient stressed the need for intimidating patients. Participantsdescribed how they could choose to be present when patientstalked to the doctor, so that the patient would not dare to simulateillness or lie to the physician. When restraining patients usingmechanical restraints, participants noted that taking charge of

.


the situation was important. Participants described that the riskfor coercive measures increased if the patient had been frus-trated and boisterous, and mechanical restraints might be usedas punishment.

The harshest punishment I’ve experienced regarding patients andmechanical restraints is a patient who set his room on fire at 9 a.m.,and at 3 p.m., mechanical restraints are ordered and there was noother intention; it was pure punishment.

Participants also described how patients who do not accepthelp that is offered might be perceived as ungrateful, whichmight provoke staff and lead to mechanical restraints beingused.

. . . it can also become so provocative toward staff that you becomesomewhat angry at the whole situation, and you think you have triedto make it a little better for the patient and maybe she can’t accept itbut chooses her own measures instead; it can become provoking forstaff and then maybe you don’t think like [name of other informant]you just drag her in to the restraints room.

Concerning observing patients, discipline-focused reasoningstressed the importance of ignoring the patient during special ob-servations. Participants adopting a discipline focus consideredit important not to offer the patient their attention if that waswhat the patient wanted. They also described incidents of staffmembers leaving a patient alone during constant observations.When medicating patients by administering forced medication,participants using discipline-focused reasoning considered theuse of power to be important. Participants described how staffbeing subjected to violence during the use of restraints couldaffect the assessment of the patient and result in increased useof medication. Discipline-focused reasoning was the only typeof reasoning that entailed discharging the patient as a possiblechoice of action, warranted by a desire to act consequentially,since discipline-focused participants perceived self-harm as aviolation of ward rules and saw it as “completely justified todischarge patients who violate rules.” One participant describedthe consequence of discharge to a patient by stating that, “thenshe would have learned that if you cut yourself on the ward,then you get discharged.” Participants stressed the importanceof a routine in which an agreement is signed, with the patient,stating that self-harm will lead to discharge, so that the patientlearns not to self-harm.

DISCUSSIONThe results show that the content of staff’s reasoning on their

choice of action in challenging situations in inpatient psychi-atric care settings can be described in terms of different modesand different focuses. We propose that each focus of reason-ing described in the results can be viewed as representing oneextreme of a continuum, the endpoints of which constitute themodes of reasoning either directed at solving the staff’s prob-lem or directed at meeting the patients’ needs. The proposedrelationships between modes of reasoning and focus of reason-ing are visualised in Figure 2 and discussed here. We would

FIGURE 2 Mind Map Visualising the Duality of the Two Modes of Reasoningof Psychiatric Inpatient Staff.

like to stress that this Figure and the duality it illustrates isbased on a description of patterns and structure in participants’reasoning. It depicts various possible trails of reasoning thatpsychiatric inpatient staff members might embark on and is notto be understood as a representation of individual staff mem-bers’ perceptions of care or actual praxis. Potential relationshipsamong modes of reasoning, focus of reasoning, and the realityof inpatient psychiatric care are discussed here. Each of the fourdescribed focuses of reasoning (staff, experience, routine, anddiscipline) is discussed, building a case for the relevance of theproposed modes of reasoning (solving the staff’s problems ormeeting the patients’ needs) for psychiatric nursing knowledgeand practices. These are then compared to other concepts ofpsychiatric nursing care and conclusions are made.

The results showed that one way of reasoning was staff-focused reasoning, where staff members take particular actionsprimarily because they look out for themselves in terms of safetyand comfort; at the same time, this does not necessarily omitbeing concerned for the patient. This way of reasoning can be un-derstood in terms of risk management and the identification andavoidance of unfavourable outcomes. Concerns have been ex-pressed that an increased focus on risk management might havenegative consequences (Buchanan-Barker & Barker, 2005). Itcan be argued that risk management, although undertaken in thename of altruism, functions as an instrument of social control(O’Byrne, 2008), serving the interests of those performing itand thus reflecting a staff-focused reasoning in psychiatric care.In order to focus on the needs of individual patients, a shiftfrom risk management and observing the patient′s behaviour tounderstanding the patient’s experience is needed.

In the results, understanding the patient′s experience was seenas a possible focus of reasoning where it was important to listento and value the patient’s perspective. People who self-harm con-stitute a heterogeneous group needing individual considerations

.


in treatment (Hume & Platt, 2007). They need to be listened toand to have their experiences acknowledged and respected (Har-ris, 2000; Lindgren, Wilstrand, Gilje, & Olofsson, 2004; Weber,2002). Self-harm can be understood as a means to communicate(Harris, 2000), a coping strategy to deal with inner pain (Har-ris, 2000; Schoppmann, Schrock, Schnepp, & Buscher, 2007;Sinclair & Green, 2005), and, paradoxically, a survival strategy(Lindgren, Oster, Astrom, & Graneheim, 2011). To focus onthe subjective experience of patients is to have a person-centredapproach to psychiatry and psychiatric nursing, which also re-quires a shift from rigidly following routines to being flexibleand adapting to the situation at hand.

An additional way of reasoning was described in the resultsas a focus on routine where you do certain things because that’show they are done or have been done in the past. Routines canbe manifested as policy documents, as standardized care plans,and as informal ward rules in a ward culture. However they aremanifested, the key role of routines in this way of reasoning is toprovide a strategy for dealing with conflict. This preparednessis likely to promote rigidity rather than flexibility in staff inter-actions with patients. Enarsson, Sandman, and Hellzen (2007)describe how routines are often developed without patient inputin order to deal with disturbing events for which no routine re-sponse exists and to achieve unity and security among nurses.Routines can be seen as a covert exercise of power, afflict-ing patients who feel afraid, powerless, and compelled to obey(Enarsson, Sandman, & Hellzen, 2011). One argument in staffmembers’ reasoning for a routine focus and structure in the man-agement of patient care is that it is highly effective, and indeedthere is compelling evidence that an efficient ward structure isassociated with lower levels of conflict behaviour and contain-ment measures (Bowers et al., 2011). However, it can be arguedthat it is important to distinguish between working by rules andworking by principles when building structure. The relation-ship between rules and principles can be described as a choicebetween “binding rules interpreted by non-binding principlesand non-binding rules backed by binding principles” (Braith-waite, 2002, p. 47). In this, it is apparent that the staff memberswho focused on routine in their reasoning put a greater empha-sis on binding rules than on binding principles, which limitstheir ability to use a flexible and adaptive approach to situa-tions that arise. Shifting the focus away from routines calls forprinciples rather than rules as a basis for actions and would notnecessarily result in less structure. When the goal is to meetpatients’ individual needs, a shift from discipline to empow-erment as a guiding principle for psychiatric inpatient care isimportant.

Reasoning that focuses on discipline means that an action istaken because the patient “has to learn.” Lindgren et al. (2011)described how taking a fostering approach toward women whoself-harm restricts a staff’s ability to act because, in an author-itative position, they define acceptable behaviour and imposedemands and limits. In the context of forensic care, Horberg,Sjogren, and Dahlberg (2012) describe patients’ experiences of

adapting to staff demands as characterized by loneliness and fearof punishment. As an alternative, the results of Lindgren et al.(2011) suggest that supportive staff interacting with patientsmight render a positive experience in which the patient is metwith respect as an individual. Andreasson and Skarsater (2012)described how taking advantage of patient’s resources can pre-vent traumatization during compulsory treatment and suggestedthat spending time with help-seeking patients can prevent the useof coercive measures. We suggest that a focus on empowermentinstead of discipline might result in a shift away from seeingpatients as individuals to be corrected towards seeing them ascompetent experts in need of support and empowerment.

A mode of reasoning aimed at identifying and meeting pa-tients’ needs corresponds to such person-centred conceptionsof psychiatric nursing as those described by Peplau (1991) andBarker (2001); the problem-solving mode of reasoning mightbetter align with a more custodial approach to psychiatric carethat aims to control patient behaviour.

Describing caring approaches of nurses in acute psychi-atric intensive care wards, Bjorkdahl, Palmstierna, and Hansebo(2010) used the metaphor of a ballet dancer to illustrate a person-centred caring approach while a bulldozer represented a pater-nalistic and potentially uncaring approach. Our results, describ-ing two modes of reasoning, might, to some extent, reflect andhelp to further understand the complexity of these approaches.

Bjorkdahl et al. describe how nurses, when adopting a balletdancer approach, would signal a caring approach, put them-selves in the patient’s shoes and use themselves as finely tunedinstruments. This approach can be compared to the mode of rea-soning directed towards meeting the patients’ needs describedin our study: Meeting the patient’s needs meant solving theproblem as affecting the patient (patient focus) and as perceivedby the patient (experience focus), in the best-possible manner(situation focus), for the purpose of strengthening the patient’sability to manage the problem (empowerment focus).

Bjorkdahl et al. described the bulldozer approach as em-phasizing guarding the ward against chaos, ensuring sufficientpower and justifying the use of controlling actions, but alsokeeping a critical mind and allowing for feelings. The bulldozerapproach can be compared with the mode of reasoning we de-scribe as directed towards solving the staff’s problem: Solvingthe staff’s problem means solving the problem as it affects staff(staff focus) and as perceived by staff (behaviour focus), ina manner agreed upon amongst staff (routine focus), for thepurpose of preventing a recurrence of the problem (disciplinefocus). Bjorkdahl et al. argue that the bulldozer approach, aimedat keeping the ward safe and orderly, is associated with a risk ofuncaring and harmful actions while at the same time encompass-ing a potential for caring. We suggest that our results provide anunderstanding of how staff members, when aware of the signifi-cance of meeting the patients’ needs and not merely content withsolving the staff’s problem, are not only more likely to adopt aperson-centred, caring approach, but also to achieve the caringpotential of a paternalistic approach. Thus, understanding staff

.


members’ modes of reasoning might be useful for promotingperson-centred care.

LimitationsThis study employed a qualitative design, and therefore the

results are not generalizable. They do, however, provide knowl-edge that might promote an increased understanding of staff’sreasoning and choice of action, and facilitate such an under-standing through critical reflection (cf. Sandelowski, 1997).Preliminary findings were presented and reflected upon withstaff members in a similar setting. They found the findings to befamiliar and expressed that addressing situations using differ-ent focuses was a meaningful exercise that might help furtherdevelop the psychiatric nursing practice. It is obvious from ourclinical experience and review of the literature that the contentof staff reasoning described in this study is not unusual and hasbeen, in part, described by other researchers. The trustworthi-ness of the results also is supported by the richness of the dataand the structured and rigorous method of working with theanalysis of data (cf. Graneheim & Lundman, 2004).

CONCLUSIONTo facilitate the use of alternatives to coercive measures in

inpatient psychiatric care settings, the objective must be to iden-tify and meet patients’ individual needs and not merely to solvethe staff’s problems through the use of short-term solutions. Anunderstanding of focuses and modes in staff’s reasoning in psy-chiatric care can form a basis for further research and can leadto educational interventions aimed at better understanding howpsychiatric inpatient care can become more person-centred. Wesuggest that the results of this study be used as a pedagogicaltool in the visualisation of reasoning on choice of action in orderto facilitate critical reflection on psychiatric nursing practice ineducation and professional staff-development activities.

Declaration of Interest: The authors report no conflicts ofinterest. The authors alone are responsible for the content andwriting of the paper.

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Delstudie IV

EMP IR ICAL STUD IES

Knowledge of the patient as decision-making power: staffmembers’ perceptions of interprofessional collaboration inchallenging situations in psychiatric inpatient care

Sebastian Gabrielsson RPN, RN, MSc (PhD Student)1, Git-Marie E. Looi RPN, RN, MSc (PhD Student)1,

Karin Zingmark RN, PhD (Associate Professor)1,2 and Stefan S€avenstedt RN, PhD (Associate Professor)1,2

1Department of Health Sciences, Lule�a University of Technology, Lule�a, Sweden and 2Department of Research and Development,

Norrbotten County Council, Lule�a, Sweden

Scand J Caring Sci; 2014; 28; 784–792

Knowledge of the patient as decision-making power:

staff members’ perceptions of interprofessional

collaboration in challenging situations in psychiatric

inpatient care

Challenging situations in psychiatric inpatient settings

call for interprofessional collaboration, but the roles and

responsibilities held by members of different professions

is unclear. The aim of this study was to describe staff

members’ perceptions of interprofessional collaboration

in the context of challenging situations in psychiatric

inpatient care. Prior to the study taking place, ethical

approval was granted. Focus group interviews were con-

ducted with 26 physicians, ward managers, psychiatric

nurses, and nursing assistants. These interviews were

then transcribed and analysed using qualitative content

analysis. Results described participants’ perceptions of

shared responsibilities, profession-specific responsibilities

and professional approaches. In this, recognising knowledge

of the patient as decision-making power was understood to

be a recurring theme. This is a delimited qualitative study

that reflects the specific working conditions of the partici-

pants at the time the study was conducted. The findings

suggest that nursing assistants are the most influential

professionals due to their closeness to and first-hand

knowledge of patients. The results also point to the possi-

bility of other professionals gaining influence by getting

closer to patients and utilising their professional knowl-

edge, thus contributing to a more person-centred care.

Keywords: interprofessional collaboration, challenging

situations, focus groups, professional practice, psychiatric

inpatient care.

Submitted 11 September 2013, Accepted 9 December 2013

Introduction

Psychiatric staff members working in inpatient settings

face challenging patient-related situations in which they

are to some extent dependent upon each other and

required to collaborate interprofessionally. Teamwork has

been described as the main context in which collabora-

tive patient-centred care is provided (1), and the team

has been suggested as the heart of decision-making in

challenging situations (2). Still, the nature of interprofes-

sional roles and responsibilities and the functioning and

utility of interprofessional teams in psychiatric inpatient

settings are unclear, and it has been suggested that the

ambitions of interdisciplinary teamwork in inpatient psy-

chiatric care have not been realised (3).

Bowers et al. have shown how the use of containment

measures in psychiatric inpatient care are closely linked

to the occurrence of conflict behaviour and that both

conflict and containment are affected by organisational

features; wards with good leadership, teamwork, struc-

ture, and attitudes towards patients and low burnout

have low rates of containment events (4). Organisational

factors such as effective managers, strong nurse-physician

relationships and higher nurse-patient staffing ratios have

been associated with lower levels of nurse burnout as

well as lower levels of adverse advents which suggests

that nurses’ work environment could have a positive

effect on psychiatric nurses’ capacity to sustain a safe and

effective care environment by enabling them to utilise

their skills and achieve their goals in caring for the

patients (5, 6).

Few studies focus on analysing, describing, or prob-

lematising interprofessional variations or relations in

challenging situations. Research describing a staff

perspective, including qualitative data from multiple

Correspondence to:

Sebastian Gabrielsson, Department of Health Sciences, Lule�a

University of Technology, 971 87 Lule�a, Sweden.

E-mail: [email protected]

784 © 2014 Nordic College of Caring Science

doi: 10.1111/scs.12111

professions, report little variation on behalf of profes-

sion and give only limited insight into interprofessional

aspects. When Olofsson and Norberg (7) interviewed

physicians, nurses and patients about experiences of

actual coercive events, the results described few varia-

tions between professions and only random illumina-

tions of the relationships and interactions between

physicians and nurses. Physicians described the purpose

of coercive actions as making nurses feel safe, and a

lack of agreement between nurses and physicians was

perceived as troublesome. Kontio et al. (8) conducted

separate focus groups interviews with physicians and

nurses but found data from the different professions to

be mainly similar. Following a second analysis of the

same material, a few insights on profession-specific

roles and responsibilities can be gained, as it described

how nurses felt uncertain about their own decisions

when they were made quickly with no time for discus-

sion with other staff members, and physicians

experienced ethical dilemmas when having to make ad

hoc or post hoc decisions on information received from

nurses (9).

The successful management of challenging situations

in psychiatric inpatient settings is reliant on interprofes-

sional collaboration. The review of literature indicates

that there is a need for more research on the variations

and relations of different professions. The aim of this

study was therefore to describe staff members’ percep-

tions of interprofessional collaboration in the context of

challenging situations in psychiatric inpatient care.

Materials and methods

Focus group interviews were conducted with staff mem-

bers experienced in acute psychiatric inpatient care, tran-

scribed verbatim and analysed using qualitative content

analysis. The results of a second analysis of the same

data, describing staff members’ reasoning on choice of

action, are reported elsewhere.

Participants and procedure

The criteria for inclusion were experience of working in

psychiatric inpatient care and willingness to participate.

Participants were recruited among members of staff at a

psychiatric clinic in northern Sweden consisting of sev-

eral outpatient units and one inpatient unit with a

24-bed locked ward and a 24-hour admittance and con-

sultancy service. At the time the study was conducted,

the inpatient ward employed approximately 50 nursing

staff and was headed by two ward managers. The ward

managers shared managerial duties at the clinic with a

group of managers who would, at times, fill in for each

other. All physicians regularly and temporarily employed

at the clinic also worked at the ward interchangeably

with other responsibilities. A total of approximately 50

nursing staff members at the inpatient ward and ward

managers and physicians at the clinic were asked to par-

ticipate. Of these, 28 agreed to participate, two of which

failed to attend the interviews. Characteristics of the par-

ticipants and focus groups are presented in Table 1.

Data collection

The interviews were conducted at the participants’ work-

place between October 2010 and January 2011. The 26

participants were grouped into six focus groups with four

to six participants and divided according to profession

and length of work experience, cf Morgan (10). In the

context of this paper, the term physician refers to psychia-

trists as well as physicians in training to become psychia-

trists, while the term ward manager refers to

nonphysicians with primarily managerial responsibilities.

Psychiatric nurse refers to registered nurses with higher

education, with or without specialist psychiatric training,

and nursing assistant refers to nursing staff with second-

ary-level education, with or without specialist psychiatric

training. Characteristics of the interviews are presented

in Table 1. Authors one and two took turns acting as

Table 1 Participant and focus group characteristics

Group

no.

Profession of

participants

Number of

participants

Length of interview

(minutes)

Mean experience in

profession (years)

Mean experience in inpatient

psychiatry (years)

Gender (male/

female)

1 Psychiatric

nurses

4 72 17.625 17.375 1/3

2 Psychiatric

nurses

6 79 2.25 2.33 3/3

3 Nursing

assistants

4 79 14.25 12.75 3/1

4 Nursing

assistants

4 61 3.25 2.875 2/2

5 Ward managers 4 87 11.75 20.5 1/3

6 Physicians 4 42 13.75 5.375 2/2

Knowledge of the patient as power 785

© 2014 Nordic College of Caring Science

moderators during the interviews. Two senior researchers

took turns acting as assistants, keeping track of time and

asking additional questions. The interviews were

recorded and transcribed verbatim.

Each focus group interview began with the moderator

reading a vignette describing a challenging situation with

many possible choices of actions and responses. The vign-

ette, designed to depict a realistic and well-known sce-

nario, was developed on the basis of the first two

authors’ familiarity with psychiatric care. Before being

used in the focus group interviews, nurses experienced in

inpatient psychiatry were asked to read and comment on

drafts of the vignette, whereupon minor alterations were

made, thus ensuring the credibility and relevance of the

scenario.

Vignette: A young female patient has been cared for at the

ward for a week. She has been subject to inpatient care sev-

eral times before. She is now involuntarily admitted after

intoxicating herself with paracetamol for unknown purposes.

On several occasions, containment measures have been taken

when she has harmed herself or others at the ward. All staff

members (nursing assistants, psychiatric nurses, physicians,

ward manager) are sitting down having their morning coffee.

From the staff room, they observe how the patient runs

through the hallway towards a left-behind drinking glass.

She picks the glass up and it breaks as she throws it to the

floor. She picks up a large piece of glass and starts cutting

herself deep in the arm as she shouts: ‘Let me out!’

After reading and listening to the vignette, participants

were asked a broad question (‘What happens next?’), fol-

lowed later by a more specific question (‘What would

you do?’). Participants were asked to freely discuss these

questions; summaries were made, and encouraging and

clarifying questions were asked. To make sure that cer-

tain areas of interest were covered in all groups, an inter-

view guide with the following predefined topics were

used: mechanical restraints, special observation, and pro-

fessional roles and responsibilities. To ensure sufficient

variation in participants’ reasoning, all participants were

actively encouraged by the moderator to participate in

the discussion, and the moderator did not end the inter-

view until participants stated that they had nothing more

to add.

Analysis

The transcribed interviews were analysed using qualita-

tive content analysis in order to describe participants’

reasoning. For the purpose of this study, only the ver-

bal content of the interviews was analysed. Krippendorf

(11) describes content analysis as a method of analy-

sing written and verbal communication in a systematic

way and making replicable and valid inferences from

texts. This makes qualitative content analysis a method

suitable for describing the content of written text in a

systematic and trustworthy manner, cf Graneheim and

Lundman (12). The analytical process was carried out

systematically and step-wise and involved the simulta-

neous emergence of multiple, inter-related categories of

content.

The text was read as whole. Meaning units relevant

for the purpose of this study were extracted and sorted

according to the focus group from which they originated

and the profession they concerned. A preliminary set of

categories describing the perceptions of each profession

was formulated. Categories were compared across profes-

sions, and new levels of categories describing an under-

standing of shared responsibilities were formulated.

Categories and meaning units for each profession were

once again reviewed, resulting in a new level of catego-

ries describing profession-specific approaches. Finally, the

categories and their content were viewed as a whole, and

a common thread was identified.

Ethical considerations

Prior to the study taking place, ethical approval was

granted from the regional ethics committee in Ume�a

(2010-4-31M). Due to the richness of gathered data,

multiple analyses were performed, an alteration to the

original design of which the committee was informed

and approved of (2012-315-32M). All participants gave

their written informed consent to participate in the

study.

Results

Following the analysis of the staff members’ focus

group discussions, it was found that their perceptions

of interprofessional collaboration in relation to the chal-

lenging situation presented in the vignette could be

divided into areas of shared responsibilities and profes-

sion-specific responsibilities. In these areas, professional

approaches were identified, as physicians could be

described as distant decision-makers, ward manager as sus-

picious supervisors, psychiatric nurse as mediating modera-

tors, and nursing assistant as informed performers (Fig. 1).

Common expectations of psychiatric professionals

expressed in the interviews included the capacity to

talk to each other, to control the situation, to know the

patient and to set the stage. These skills were important

for all different professionals, but the specific contribu-

tion in these areas showed some variation depending

on profession. Looking at a comprehensive analysis of

the results, a theme emerged as a common thread that

was described as recognising knowledge of the patient as

decision-making power.

786 S. Gabrielsson et al.


Physicians – the distant decision-makers

Participants’ perceptions of physicians could be described

by labelling them as distant decision-makers, as they would

only visit the ward when called upon to make evalua-

tions and decisions mainly based on information pro-

vided by others. Physicians were believed to have little

patient contact due to being preoccupied with other

duties.

Control the situation. Physicians were expected to evaluate

and decide. They would keep their distance and usually

attend an acute situation on the ward only when called

upon after the acute problem was solved. Ward managers

did not expect physicians to take the lead unless there

was a medical emergency. Since physical engagement

was thought to affect mental clarity, decision-making and

the possibility of talking to the patient afterwards, physi-

cians would avoid getting directly involved in applying

restraints or ‘wrestling a patient’. Physicians perceived

themselves as the ones deciding which measures to be

taken. Their assessments would primarily concern the

patient’s physical status and the need for medico-surgical

measures, while their evaluations focused on the

patient’s psychiatric status and especially the risk for sui-

cide. In this, they were expected to act professional,

which meant being objective and not letting personal

feelings affect decisions. The physician was seen as an

important person bearing the medical responsibility and

having the ability to give orders to other professionals,

but participants’ views varied as to whether orders

always had to be carried out or could be refused if in the

patient’s best interest. Several nursing staff members

expressed concern that choosing to involve physicians in

a situation would automatically lead to special observa-

tions because the physician either did not know the

patient or because physicians would chose to play it safe,

a concern not expressed by physicians themselves.

Talk to each other. Physicians said they would gather

information primarily by listening to staff members who

knew the patient and the situation. Psychiatric nurses

believed that physicians had no choice but to rely on

the information they were given by the nursing staff,

especially when the physician was new and did not

know the patient, as often was the case because of high

physician turnover. Notably, nursing assistants thought

physicians had to first get to know the nursing staff

before knowing who could be trusted. Nursing assistants

also described how some psychiatrists trusted nursing

staff while others did not, the latter often leading to

more use of special observation. Some less experienced

psychiatric nurses believed that physicians relied too

heavily on information from others, but more experi-

enced psychiatric nurses did not see this as a problem.

Ward managers expected physicians’ decisions to follow

the recommendations of nursing staff, provided they

were given enough information. Some psychiatric nurses

described decision-making as a joint venture, while oth-

ers saw it as the physician making the formal decision

after listening to the nursing staff.

Know the patient. Neither themselves nor other profes-

sionals expected physicians to have much contact with

patients. The way physicians described their relationships

with patients might be characterised as knowing about the

Figure 1 Staff’s perceptions of interprofessional

collaboration in challenging situations in terms of

(1) professional approaches, (2) shared

responsibilities and (3) profession-specific

responsibilities.



patient rather than knowing the patient in a deeper

sense.

…Yes I believe it’s good when you’re doing rounds

to be able to put a face to a name, maybe you’ve

been around saying hi and seen them in the corridor

and you know who’s behind the name… (Physician

#2)

Physicians described having many other responsibilities

outside of the ward and that, as a psychiatrist, they

would see inpatients once a week at most. Nursing staff

members described the importance of physicians being

familiar with the patients and explained how this could

reduce the use of special observation. Psychiatric nurses

believed that a high physician turnover resulted in a lack

of consistency in decision-making. They wished psychia-

trists were more present on the ward and would see the

patients more often. Lack of patient contact was believed

to have a negative impact on patients’ ability to partici-

pate in their own care. Psychiatric nurses thought physi-

cians should be the one giving patients’ information

about forced medication but reported that they rarely

did.

Set the stage. Physicians believed themselves to influence

ward culture and described how psychiatrists influenced

ward policy and staff members’ thinking and approaches.

Ward managers – the suspicious supervisors

Participants’ perceptions of ward managers could be

described by labelling them as suspicious supervisors. They

were described as occupying a unique position between

and above nursing staff, physicians and patients, from

which they keep a watchful eye on other professionals.

The doings of ward managers as they described them-

selves seemed mainly unknown or unappreciated by

other professionals. Ward managers were described as

having direct contact with all other professionals as well

as patients.

Control the situation. Although ward managers themselves

expressed the possibility of taking the lead in managing

the acute situation, this view was not evident in the dis-

cussions of other professionals. Ward managers thought

they would act as role models by going first, being the

ones telling others what to do, or both. Other profession-

als merely mentioned the possibility of ward managers

helping out if necessary.

… The ward manager is usually first in line, the first

to arrive and stop her from hurting herself, at least

you try to get her aside so you can have a quiet

talk… (Ward manager #4)

Talk to each other. Ward managers described how they

would act as a third party trying to negotiate patient-

friendly agreements between nursing staff and physi-

cians. Ward managers would be approached by nursing

staff reluctant to carry out physicians’ orders or question-

ing physicians’ assessments. Physicians would turn to the

ward manager with questions regarding nursing staff pro-

cedures and responsibilities or seeking advice concerning

patient treatment. Ward mangers took it upon them-

selves to support nursing staff and manipulate or con-

vince physicians to find solutions that would satisfy both

parties and benefit the patients. This negotiating function

of ward managers was not acknowledged by other pro-

fessionals in their discussions.

… I have been called upon many times to talk to

the physician because ‘I don’t want to do this’ and

then I have persuaded the physician… most of the

time it works out just fine… (Ward manager #2)

Know the patient. Ward managers described how they

would verify information they were given by the nursing

staff against other staff members, patient records or by

talking directly to the patient. Experience taught them

which staff members could be trusted to be working in

the patient’s interest and not in the interest of their own

comfort. In evaluating information, ward managers relied

on their own experience of working in psychiatric inpa-

tient care and on their personal knowledge of patients.

Only information deemed trustworthy and relevant was

passed on from nursing staff to physicians. No mentions

of ward managers’ questioning or passing on information

were made by other professionals.

Set the stage. Ward managers themselves gave no accounts

that described how they might contribute in setting the

stage. Psychiatric nurses believed that ward managers

influenced staff attitude and approaches towards patients

through their behaviour. Nursing assistants stated that the

ward manager was responsible for ward structure, for

recruiting apt personnel and for taking action when staff

did not meet set standards of care. Physicians and nursing

assistants expected ward managers to assure that staff

members were given adequate emotional support after

participating in stressful situations.

Psychiatric nurses – the moderating mediators

Participants’ perceptions of psychiatric nurses could best

be described by the label moderating mediators, as they

were described as the ones taking action and delivering

information and, in doing so, using their knowledge to

hinder certain courses of events but facilitating others.

Psychiatric nurses were described as having more patient

contact than physicians but less than nursing assistants.

Like physicians, psychiatric nurses were believed to have

little patient contact due to being preoccupied with other

duties.



Control the situation. Psychiatric nurses described how

they would slow things down in acute situations as they

tried to find alternatives to coercion or initiate less intru-

sive measures that do not require a physician to assess

and decide. They would also make assessments prior to

calling the physician to determine the necessity and

avoid special observation if possible, and believed that

sometimes, they were indirectly the ones actually making

physicians’ decisions. Ward managers acknowledged psy-

chiatric nurses as the ones making acute decisions if

aware of the situation, notifying the physician, and, if

necessary, refusing to implement coercive measures.

Nursing assistants expected psychiatric nurses to stand

back and be ready to administer medication when

timely.

Talk to each other. Psychiatric nurses described acting as

messengers delivering information. They described being

highly involved in gathering information and making

assessments of patients, which was described as both

enjoyable andnecessary due to physicians not knowing

the patients. Based on this, they would inform and influ-

ence physicians to make well-informed and desirable

decisions that the nurses believed would benefit the

patient, as illustrated by the following quotes:

… I don’t say that special observations should be ter-

minated if I’m not damned certain… that it’s my

judging and I have a good motivation for it… I don’t

say let’s end special observations we already have

three and there’s a shortage of staff… that’s a lousy

reason to end special observations… then I need a

damn good motivation as for why it should be ended

or I won’t say that it should be… well because I

think if you have special observation then the

patients’ life is in danger, that’s why you have it…

(Inexperienced psychiatric nurse #1)

… but I think when you have been working for a

while and gained some experience that you can

stand up for what you believe and say and think…

in the beginning I think I would listen more to the

nursing assistants that had been working for a long

time and such… but now I can state my own opin-

ion and it’s almost the other way round like in the

beginning I would say ‘end special observation’

because that’s what everybody thought and now I

have more knowledge and now how it can be…

(Inexperienced psychiatric nurse #4)

Nursing assistants expressed concerns that the informa-

tion delivered by psychiatric nurses at rounds and reports

was based solely on the assessments of nursing assistants.

Psychiatric nurses also described being the ones having to

deliver negative responses to the patients because the

physician did not take the time to do it or because they

thought it better that way.

Know the patient. Psychiatric nurses described possessing

knowledge about patients that physicians did not and

took it upon them to expose the patient. This is illustrated

by the following quotes:

… and I’ve been in several talks were I know we’ve

been talking beforehand and the patient’s not well

and she explains what happened and the doctor sits

there talking and it sort of never discloses… and the

session is about to end and you almost panic and

then you have to interrupt and ask how about that

pregnancy you talked about… and the women is like

seventy-five and obviously not pregnant and it all

sort of comes forth… and it’s stuff like that… I

believe it’s our duty to help the physician make the

right assessment, disclose these things and ask the

right questions depending on the patient in front of

you… (Inexperienced psychiatric nurse #2)

… some will put on a show in front of the physician

in order to get to stay on the ward… they get insti-

tutionalised and find it so convenient… nice to stay

on the ward and get meals served and spend time

with other patients and so on… then they might

make things up that aren’t true but if we are there

with them they don’t dare… (Inexperienced nurse

#5)

Psychiatric nurses believed they had relationships with

patients that should be preserved and used when deliver-

ing and obtaining information, but they also felt that

they did not often have enough time to talk to patients

as needed.

Set the stage. Psychiatric nurses described being responsi-

ble for providing structure and for nursing care, a view

shared by nursing assistants. Psychiatric nurses believed

themselves to be role models representing the employer,

with a responsibility to share their knowledge with nurs-

ing assistants and newly employed nurses, adding a

unique nursing perspective. Nursing assistants expressed

a desire for psychiatric nurses to take on a greater

responsibility as nursing leaders. They believed that psy-

chiatric nurses should utilise their nursing knowledge

and thus contribute to the prevention of conflict

situations.

… I mean they talk about having studied nursing,

but to somehow step up and distinguish themselves,

I don’t think they do that … (Experienced nursing

assistant #1)

Nursing assistants – the informed performers

Perceptions of nursing assistants could be described by

assigning them the label informed performers. Nursing

assistants were described as spending time with and get-

ting to know the patients, while at the same time being



expected to manage acute situations and ‘wrestle the

patients’. Nursing assistants were the ones described as

having by far the most communication with and spend-

ing the most time with patients. Interprofessionally, nurs-

ing assistants would communicate primarily with

psychiatric nurses. They might also occasionally commu-

nicate directly with physicians, although psychiatric

nurses were described as the ones mainly in direct con-

tact with physicians, transferring information from nurs-

ing assistants to physicians and regulating direct contact

between the two.

Control the situation. Nursing assistants could be described

as the ones expected to handle the patient in an acute situ-

ation. They described themselves as the ones closest to

the patient, approaching and engaging the patient physi-

cally by wrestling and holding. Being closest to the

patient also usually meant being the ones making acute

assessments and decisions since no one else was around.

Physicians also saw nursing assistants as the ones being

physical, while ward managers emphasised that an expe-

rienced nursing assistant would be the one approaching

the patient and making acute decisions.

Talk to each other. Nursing assistants perceived them-

selves as the most powerful group that would influence

and determine the outcome of decisions.

… and that’s why I believe we end up [deciding on

the use of restraints] because the nurses have less

time… that somehow we often make those decisions

although you would wish, as I personally do wish,

that they would step up considerably… (Experienced

nursing assistant #1)

They also acknowledged that decisions opted for by

nursing assistants were not always in the best interest of

patients but were rather for their own convenience.

Know the patient. Nursing assistants saw themselves as

the ones closest to and possessing personal knowledge of

the patients. They expected to be the ones performing

special observations and thus spending time with them.

The participating nursing assistants saw it as their obliga-

tion to be available to and attend to the patient’s needs.

This could mean being present when a patient talked to

a physician in order to reassure the patient and help the

patient understand the physician.

Set the stage. No accounts were given as to how nursing

assistants contributed in setting the stage.

Recognising knowledge of the patient as decision-making

power

A common theme in the participants’ discussions about

challenging situations was interpreted as recognising

knowledge of the patient as decision-making power. This

theme meant that personal knowledge about the

patients’ situation, gained by being close to them, was

recognised as important and provided formal and infor-

mal decision-making power when handling challenging

situations. As distant decision-makers, physicians were the

ones making formal decisions on how to manage chal-

lenging situations. For this, they need knowledge of

patients, but being distanced, they have to rely on this

knowledge as provided by others. By being the only pro-

fessionals close to the patients, nursing assistants, as

informed performers, were the ones mainly possessing first-

hand knowledge of patients, something which they used

to influence decisions. Psychiatric nurses as moderating

mediators, being in-between nursing assistants and physi-

cians, and ward managers as suspicious supervisors, being

on the side, both use knowledge of patients to influence

decisions.

Discussion

The results described recognising knowledge of the

patient as decision-making power as a recurring theme in

perceptions of interprofessional collaboration in challeng-

ing situations in psychiatric inpatient care. From the per-

spective of organisational theory Yukl (13) described how

power can be positional or personal, and by applying his

proposed taxonomy of power to the results of this study,

we might understand more about professionals’ basis of

power and its consequences for interprofessional collabo-

ration (Fig. 2).

The kind of power yielded by patient knowledge, as

described in the results, might be understood as informa-

tion power. This kind of position power involves both

Figure 2 Schematic image of staff’s main interprofessional interfaces,

the main types of power and their relative strengths as understood in

relation to challenging situations in psychiatric inpatient care.



access to information and control over its distribution,

and it can be used as a source for upwards, downwards

and lateral influence. It would seem that nursing assis-

tants’ positions as the ones closest to the patients gives

them superior access to information in terms of knowl-

edge of patients. The position of psychiatric nurses and

ward managers gives them the possibility to control the

distribution of information but leaves them partially

dependent upon nursing assistants for knowledge of

patients. The distance of the physicians described in the

results leaves them heavily dependent on the informa-

tion of others and thus limiting their decision-making

power. That their decisions are still perceived as impor-

tant seems mainly due to their formal status, indicating

that the physician’s power in the context of challenging

situations is the kind of position power Yukl (13) calls

legitimate power – physicians are listened to and their

orders followed by nursing staff mainly out of respect for

physicians as authorities with certain legal capacities.

Yukl (13) suggests that different types of power are

associated with different outcomes to some extent. Posi-

tion power might invoke compliance or resistance in oth-

ers, while person power might invoke engagement.

Psychiatric nurses or nursing assistants’ refusal to imple-

ment physicians’ orders of restraints might be understood

as an act of resistance in the face of positional power.

This points to an important characteristic of power – it

only works if others believe you have it. Physicians’ legit-

imate power vanishes when others fail to appreciate their

authority. Accordingly, certain information and knowl-

edge only gives power when others perceive this as

important. In the context of challenging situations, our

results suggest that knowledge about patients, not profes-

sional knowledge, is what counts. Psychiatric nurses

would be expected to take on the role of nursing leader-

ship in psychiatric care (14, 15), but our results suggests

this was not the case. Psychiatric nurses were to some

extent acknowledged as having positional power as the

ones responsible for structuring care, and they might pos-

sess some referential power as role models, but, in rela-

tion to nursing assistants, they thoroughly miss out on

acquiring and exercising power of expertise through the

utilisation and sharing of nursing knowledge.

Research indicates the role of the psychiatric nurse in

inpatient psychiatry to be complex and conflicting (16,

17) and to lack clarity (18). Our results also indicate

that the psychiatric nurse is a marginal player in the

interprofessional team, not having the power of infor-

mation from knowing the patient or the power of

expertise from taking on the role of nursing leadership.

If so, nurses might, as has been suggested, give in to

the fact that times have changed and participate in

redefining their role towards that of risk management

assistants (16), or they could abandon humanism alto-

gether (19). This would not presumably contribute to

the making of a person-centred, recovery-oriented inpa-

tient psychiatric care. An alternative course of action,

supposedly more in the interest of the members of the

interprofessional team and patients alike, might be for

psychiatric nurses to position themselves closer to the

patients and reclaim the interpersonal relationship as

the core of psychiatric nursing as well as the raison

d’etre for psychiatric nurses.

It can be argued that interpersonal relationships are at

the core of psychiatric nursing and person-centred care

(20, 21). If the ambition is to deliver person-centred care,

it would seem a prerequisite that physicians as well as

psychiatric nurses have both the desire and the opportu-

nity to get to know and develop first-hand knowledge of

patients, assuming their professional perspectives of med-

icine and nursing, respectively. It would also seem rea-

sonable that all members of the interprofessional team

share their own knowledge and respect others’ knowl-

edge in the pursuit of understanding what is in the

patient’s best interest and how it can best be accom-

plished. This line of arguing corresponds to research on

interprofessional healthcare teamwork, suggesting that

difficulties in collaboration limit the possibility of a holis-

tic understanding of patients’ problems (22).

Limitations

This is a delimited qualitative study. Several of the partic-

ipants expressed that the vignette used indeed described

a familiar situation in the ward, stating that ‘this hap-

pened only yesterday’ or that they knew exactly who the

patient in the scenario was. This indicates that the vign-

ette used as common basis for the focus group discussions

was relevant for psychiatric inpatient care. The results

are however likely to reflect the specific working condi-

tions of the participants at the time the study was con-

ducted and should be handled with caution if transferred

to other settings. Most notably, the results seem to reflect

a lack of continuity in the employment of senior physi-

cians and a high patient-to-staff ratio at the ward in

question. It might be argued, however, that this is more

often than not the reality of contemporary psychiatric

inpatient care.

Conclusions

Our findings suggest that knowledge of patients is an

important means for influencing decision-making that

might need to be considered in future research and

development in the context of inpatient psychiatry. As

nursing assistants are the ones closest to the patients, this

makes them the most influential profession. For psychiat-

ric nurses to realise their potential as nursing leaders

making a substantial contribution to the interprofessional

team in delivering person-centred care, it would seem



that they need to step up closer to the patients and put

their professional knowledge into action, preferably

accompanied by physicians.

Acknowledgements

Professor Siv S€oderberg and Associate Professor Lisa Sk€ar

participated in the initial planning and data collection.

The authors would like to thank Professor Rolf Adolfsson

of Ume�a University for valuable criticism and support.

Author contributions

Sebastian Gabrielsson and Git-Marie Ejneborn Looi par-

ticipated in the acquisition of data and were responsible

for the study’s original conception and design, which

were then revised with the input of Karin Zingmark and

Stefan S€avenstedt. Sebastian Gabrielsson performed the

analysis with the assistance of Git-Marie Ejneborn Looi

and made initial interpretations of data, which were pre-

sented and repeatedly discussed with the other authors

and revised accordingly. Sebastian Gabrielsson drafted

the manuscript together with Git-Marie Ejneborn Looi,

while Karin Zingmark and Stefan S€avenstedt repeatedly

revised it critically. All authors approved the final version

to be published.

Ethical approval

Ethical approval was granted from the regional ethics

committee in Ume�a (2010-4-31M, 2012-315-32M).

Funding

This study was funded by the Department of Health Sci-

ences at Lule�a University of Technology.

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fatigue, health and well-being. (Nursing) 2013. Ann-Sofie Forslund. A Second Chance at Life: A Study About People Suffering Out-Of-

Hospital Cardiac Arrest. (Nursing) 2014. Birgitta Nordström. Experiences of standing in standing devices: voices from adults, children

and their parents. (Physiotherapy) 2014. Malin Mattsson. Patients’ experiences and patient-reported outcome measures in systemic

lupus erythematosus and systemic sclerosis. (Physiotherapy) 2014. Eva Lindgren. “It’s all about survival”: Young adults’ transitions within psychiatric care from

the perspective of young adults, relatives, and professionals. (Nursing) 2014. Annette Johansson. Implementation of Videoconsultation to Increase Accessibility to Care

and Specialist Care in Rural Areas: - Residents, patients and healthcare personnel´s views. (Nursing) 2015.

Cecilia Björklund. Temporal patterns of daily occupations and personal projects relevant for older persons’ subjective health: a health promotive perspective. (Occupational therapy) 2015.

Ann-Charlotte Kassberg. Förmåga att använda vardagsteknik efter förvärvad hjärnskada: med fokus mot arbete. (Occupational therapy) 2015.

Angelica Forsberg. Patients' experiences of undergoing surgery: From vulnerability towards recovery -including a new, altered life. (Nursing) 2015.

Maria Andersson Marchesoni. “Just deal with it” Health and social care staff´s perspectives on changing work routines by introducing ICT: Perspectives on the process and interpretation of values. (Nursing) 2015.

Sari-Anne Wiklund-Axelsson. Prerequisites for sustainable life style changes among older persons with obesity and for ICT support. (Physiotherapy) 2015.

Anna-Karin Lindqvist. Promoting adolescents' physical activity @ school. (Physiotherapy) 2015.

Ulrica Lundström. Everday life while aging with a traumatic spinal cord injury. (Occupational therapy) 2015.

Sebastian Gabrielsson. A moral endeavour in a demoralizing context: Psychiatric inpatient care from the perspective of professional caregivers. (Nursing) 2015.

Licentiate theses Marja Öhman. Living with serious chronic illness from the perspective ofpeople with serious

chronic illness, close relatives and district nurses. (Nursing) 2003. Kerstin Nyström. Experiences of parenthood and parental support during the child's first

year. (Nursing) 2004.

Eija Jumisko. Being forced to live a different everyday life: the experiences of people with traumatic brain injury and those of their close relatives. (Nursing) 2005.

Åsa Engström. Close relatives of critically ill persons in intensive and critical care: the experiences of close relatives and critical care nurses. (Nursing) 2006.

Anita Melander Wikman. Empowerment in living practice: mobile ICT as a tool for empowerment of elderly people in home health care. (Physiotherapy) 2007.

Carina Nilsson. Using information and communication technology to support people with serious chronic illness living at home. (Nursing) 2007.

Malin Olsson. Expressions of freedom in everyday life: the meaning of women's experiences of living with multiple sclerosis. (Nursing) 2007.

Lena Widerlund. Nya perspektiv men inarbetad praxis: en studie av utvecklingsstördas delaktighet och självbestämmande. (Health Science and Human Services) 2007.

Birgitta Lindberg. Fathers’ experiences of having an infant born prematurely. (Nursing) 2007.

Christina Harrefors. Elderly people’s perception about care and the use of assistive technology services (ATS). (Nursing) 2009.

Lisbeth Eriksson. Effects and patients' experiences of interactive video-based physiotherapy at home after shoulder joint replacement. (Physiotherapy) 2009.

Britt-Marie Wälivaara. Mobile distance-spanning technology in home care. Views and reasoning among persons in need of health care and general practitioners. (Nursing) 2009.

Anita Lindén. Vardagsteknik. Hinder och möjligheter efter förvärvad hjärnskada. (Health Science) 2009.

Ann-Louise Lövgren Engström. Användning av vardagsteknik i dagliga aktiviteter - svårigheter och strategier hos personer med förvärvad hjärnskada. (Health Science) 2010.

Malin Mattsson. Frågeformulär och patientupplevelser vid systemisk lupus erythematosus -en metodstudie och en kvalitativ studie. (Physiotherapy) 2011.

Catharina Nordin. Patients’ experiences of patient participation prior to and within multimodal pain rehabilitation. (Physiotherapy) 2013.

Hamzah Ahmed. Relationship Between Crystal Structure and Mechanical Properties in Cocrystals and Salts of Paracetamol. (Health Science) 2014.

For purchase information: Department of Health Science, Luleå University of Technology, S-971 87 Luleå, Sweden.

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