A Moral Endeavour in a Demoralizing Context
Psychiatric Inpatient Care from the Perspective of Professional Caregivers
Background
Patients in psychiatric care experience a need for and expect to develop interpersonal relationships with professional caregivers and to be respected and listened to. Despite demands for care to be person-centred and recovery-oriented, patients experience that psychiatric inpatient care fails to meet their expectations. Nursing research suggest that nurses aspire to engage with and meet the needs of patients, but that the strenuous reality of inpatient care prevents them from doing so. Exploring the content and context of psychiatric inpatient care from the perspective of professional caregivers might pro-vide valuable insights regarding what caregivers do, and more importantly it can aid in understanding why they do what they do.
Aim
This thesis aimed to explore the content and context of adult psychiatric inpatient care from the perspective of professional caregivers.
Sebastian Gabrielsson, PhD, PMHN
Department of Health Sciences, Luleå University of Technology, Sweden
Publications
Gabrielsson, S. (2015). A moral endeavour in a demoralizing context: psychiatric inpatient care from the perspective of professional caregivers. Dissertation Luleå: Luleå University of Technology. http://pure.ltu.se/ portal/files/103610457/Sebastian_Gabrielsson_webb.pdf
Gabrielsson, S., Sävenstedt, S., & Olsson, M. (2016). Taking personal responsibility: Nurses’ and assistant nurses’ experiences of good nursing practice in psychiatric inpatient care. International Journal of Mental Health
Nursing. http://dx.doi.org/10.1111/inm.12230
Gabrielsson, S., Sävenstedt, S., & Zingmark, K. (2015). Person‐centred care: clarifying the concept in the context of inpatient psychiatry. Scandinavian Journal of Caring Sciences, 29(3), 555-562. http://
dx.doi.org/10.1111/scs.12189
Gabrielsson, S., Looi, G. M. 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. http://dx.doi.org/10.1111/ scs.12111
Looi, G. M. 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. http://
dx.doi.org/10.3109/01612840.2013.879629
Are you solving problems or meeting needs?
A staff oriented, problem solving, approach to psychiatric inpatient care differs from a patient oriented approach focused on meeting the individual needs of patients. Based on staff members
rea-soning in focus group interviews, we suggest that a problem solving approach might entail a focus on staff members safety, the patients behaviour rather than motives, adhering to ward routine,
and seeking to discipline the patient to avoid unwanted behaviour . In contrast, adopting a needs oriented approach might focus on patient safety, taking actions that empower the patient,
ad-apting to the situation at hand, and trying to understand what the patient’s experience. Choice of approach affects both what actions are taken and the quality of those actions.
Does your workplace support relationship-oriented
care?
Circumstances in the psychiatric inpatient environment affect nurses’ ability to work through relationships. Shared values and nursing leadership supports being moral and treating patients with
respect, having enough time supports being present and connecting with patients, and working as a part of a competent team with critical daily discussions and diversity supports being
confi-dent and building trust.
Are you taking responsibility for your practice?
It is important that nurses in psychiatric inpatient care take personal responsibility for their professional practice. Interviews with skilled, relationship-oriented nurses and assistant nurses suggest
that good nursing practice depends on nurses taking personal responsibility for the patient as a person and for their actions towards that person. If unable to improve poor circumstances, nurses
might be forced to promote their own survival by refuting or redefining their responsibility. Nurses’ choosing to leave psychiatric inpatient care might be understood as them refuting their
re-sponsibility due to not being able to uphold good nursing practice. Refuting rere-sponsibility for one’s actions might also occur by accepting the superiority of the physician or the team and thus
placing responsibility on others. Redefining responsibility might be done by resigning in the face of an overwhelming work load and shift focus from the individual patient towards practical
tasks.
Take home
messages!
Conclusions
The main conclusions to be drawn are that, from a nursing perspective, nurses in psychiatric inpatient care need to focus on patients’ experiences and needs. For this they need sufficient resources and time to be present and develop relationships with patients. Nurses in psychiatric inpatient care also need to take personal responsibility for their professional practice. Attempts to transform psychiatric care in a person-centred direction must consider all of these aspects and their interrelatedness. Further research on psychiatric inpatient care is needed to understand more about how the content of care relates to the context of care.
Contact
Sebastian Gabrielsson Department of Health Sciences Luleå University of Technology 971 87 Luleå, Sweden
sebastian.gabrielsson@ltu.se +46705483864
www.ltu.se/staff/s/sebgab
Results
Reviewing the literature on person-centred care in inpatient psychiatry clarified how person-centred care is expected to result in quality care when interpersonal relationships are used to promote recovery. Professional caregivers’ reasoning on choice of action described different concerns in ca-regiver-patient interaction resulting in a focus on either meeting patients’ individual needs or solving staff members’ own problems. Describing pro-fessional caregivers’ perceptions of interpropro-fessional collaboration suggested that they are being constrained by difficulties in collaborating with each other and a lack of interaction with patients. Exploring nurses’ experiences of good nursing practice revealed how circumstances in the clinical sett-ting affect nurses’ ability to work through relationships.
Discussion
Main findings from the studies (I-IV) in relation to key references are visualized in the figure below. It might be argued that these findings describe the workings of two opposing forces in psychiatric inpatient care. The concept of caring as a process forms the basis for discussing the content of care as a moral endeavour in which nurses strive to do good. The concept of demoralizing organizational processes is used to discuss the context of care as demoralizing and allowing for immoral actions.
Methods
The aim was achieved by (I) clarifying the concept of person -centred care in the context of inpatient psychiatry, (II)
describing staff members’ reasoning on their choice of action and (III) perceptions of interprofessional collaboration in
challenging situations in inpatient psychiatric care settings, and (IV) exploring nurses’ experiences of good nursing
practice in the specific context of inpatient psychiatry. A sys-tematic review of the literature identified 34 scholarly papers that were analysed using evolutionary concept analysis. Focus group interviews were conducted with 26 professional
ca-regivers and analysed using qualitative content analysis. Indi-vidual qualitative interviews were conducted with 12 skilled, relationship-oriented nurses and analysed using an
inter-pretive descriptive approach to qualitative analysis.
Key references
Bauman, Z. (2010). Auschwitz och det moderna samhället [Modernity and the Ho-locaust] (Original work published 1989). Gothenburg: Daidalos.
Finfgeld-Connett, D. (2008). Meta-synthesis of caring in nursing. Journal of Cinical Nursing, 17(2), 196–204. http://doi.org/10.1111/j.1365-2702.2006.01824.x
Krippendorff, K. (2013). Content analysis: an introduction to its methodology (3rd ed.) Thousand Oaks, Calif.: SAGE.
Rodgers B.L. (1989). Concepts, analysis and the development of nursing knowledge: the evolutionary cycle. Journal of Advanced Nursing, 14, 330-335.
Thorne, S. (2008). Interpretive description. Walnut Creek, CA: Left Coast Press.
Acknowledgments
Funding for this poster presentation was provided by the Swedish Association of Psychiatric and Mental Health Nurses, and the Swedish Association of Health Professionals.
