Vården utgör en mötesplats mellan människor och miljö. En god miljö är en viktig del för att uppnå hälsa och välbefinnande, både för patienter och för personal. Den psykiatriska vården har genomgått flera stora förändringar un- der de senaste decennierna. Flera av dessa förändringar har lett till förbätt- ringar av vården, men även till försämringar i form av personalbrist, dålig ar- betsmiljö för personalen och brister i vården av patienter. Det primära fokuset för den psykiatriska slutenvården är patienterna och att bedriva god vård för dessa. Men den psykiatriska slutenvården är också en arbetsplats för en stor mängd människor och det är viktigt att undersöka deras arbetsförhållanden. Det övergripande syftet med denna avhandling var att undersöka vårdpersona- lens uppfattningar om, och relationen mellan, vårdmiljö, psykosocial arbets- miljö och stress i den psykiatriska slutenvården.
Denna avhandling bygger på fyra olika studier. I den första studien medver- kade patienter och personal från tre allmänpsykiatriska slutenvårdsavdelning- ar och en rehabiliteringsavdelning för patienter med psykossjukdom. I de övri- ga tre studierna deltog personal från 12 olika allmänpsykiatriska slutenvårds- avdelningar. Generellt sett är avhandlingen baserad på sex enkäter som patien- ter och personal fyllt i. Dessa enkäter mäter vårdmiljö, psykosocial arbetsmil- jö, stress, samvetsstress, moralisk lyhördhet och upplevd egenkontroll. Svaren från enkäterna analyserades med hjälp av statistik för att beskriva deltagarnas uppfattningar, skillnader mellan sjuksköterskor och skötare samt förhållandet mellan de olika delarna i enkäterna.
Resultaten från den första studien visade att enkäten som mäter vårdmiljö var användbar och tillförlitlig när det gäller de flesta aspekterna. Resultaten från de övriga tre studierna visade däremot att tillförlitligheten var sämre. Det
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behövs därför fler studier som undersöker denna enkäts egenskaper. Resulta- ten i studie två till fyra visade att vårdmiljön var en viktig aspekt för persona- lens upplevda arbetsmiljö. Tydliga regler och rutiner på avdelningen var rela- terad till en hög nivå av uppmuntrande ledarskap och rolltydlighet för perso- nalen. En hög nivå av ordning och struktur, samt praktisk orientering på av- delningen, var viktigt för höga nivåer av organisationsklimatet. Låga nivåer av patientaktivitet och engagemang samt höga nivåer av vrede och aggressivitet visade sig öka risken för stress och samvetsstress hos personalen. En bristande rolltydlighet och låg grad av kontroll i arbetet ökade risken för stress och samvetsstress hos personalen. Även att uppleva den moraliska bördan som svår innebar en ökad risk för stress. En hög nivå av upplevd egenkontroll minskade däremot risken för stress.
Resultatet av denna avhandling pekar mot att förbättringar i vårdmiljön skulle kunna skapa förbättringar gällande den psykosociala arbetsmiljön för personal som arbetar i slutenvårdspsykiatrin. Exempelvis verkar utbudet av aktiviteter för patienterna på avdelningen ha betydelse, och en ökning av pati- entaktiviteter skulle både kunna skapa förbättringar i vården och minska per- sonalens stress. Att fastställa och säkerhetsställa en tydlighet när det gäller reg- ler, rutiner och personalens roller är också viktigt, både för arbetsmiljön och för att förhindra stress. Även personalens upplevda egenkontroll och arbets- kontroll tycks viktiga, och en förbättring inom dessa områden skulle kunna hjälpa till att reducera risken för stress bland personalen.
ACKNOWLEDGEMENTS
It is a true pleasure and honour for me to thank those who stood by my side while conducting this thesis. I offer my thanks and regards to everyone who supported me in any respect during this time.
First I would like to acknowledge the Faculty of Health and Society, Malmö University, who made this thesis possible.
My eternal gratitude goes to my supervisors Mona Eklund and Christine Wann-Hansson, who have supported and guided me throughout this time with great patience, support and encouragement. I am thankful for the enthu- siastic and pedagogical supervision of Mona Eklund, whose broad knowledge and understanding of the research process and subject, provided me with a deeper understanding and lifted this thesis to a level I would never have achieved on my own. I also owe my deepest gratitude to Christine Wann- Hansson, whose invaluable feedback and advice guided me through this process and enabled the development and completion of this thesis. Both my supervisors have done more than one can expect in terms of helping me and steering me away from getting too lost in my thoughts. Reflecting back on the years, I feel humble and I sincerely believe that this thesis would not be in its present form without you.
Special thanks go to all the patients and staff who participated in the studies. Thank you for giving your time, your opinions and showing an interest in my research. I am also indebted to all those ward managers, clinical directors, or- ganizational and research developers, who helped me to get access to the psy- chiatric in-patient wards and participants.
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I would like to gratefully acknowledge all my colleagues at Malmö University. Thanks to all doctoral students who offered me enthusiastic help, stimulating discussions and support during these years. My senior lectures and colleagues have made available their knowledge and support in a number of ways, which I am grateful for.
A tip of the hat to David Brunt, for excellent linguistic revision and valuable input to this thesis and the included papers.
I also appreciate the help of the library staff at Malmö University.
Many thanks to Jan-Åke Jansson for help with the data collection in Paper I. Thanks also to Slobodan Zdravkovic and Robert Svensson for statistical ad- vice.
I would like to extend my thanks to the Swedish Society of Nursing (Svensk sjuksköterskeförening) for their contribution which enabled the presentation of the present research results at national and international conferences. My warmest thanks go to my family and friends, who always showed an in- terest in my work and believed in me. Special thanks to those closest to me, my siblings and parents Ing-Marie and Stig who have always been a constant source of support and encouragement, leaving me free in all decisions about my life. I would like to heartily thank the one that my soul loves, my one and only, my best friend and husband, Andreas “Deja” Tuvesson. Thank you for all your love, trust and support. I would be lost without you.
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