Abuse in health care: a concept analysis

Scand J Caring Sci; 2012; 26; 123–132 Abuse in health care: a concept analysis Aims and objectives: To analyse the concept of abuse in health care. This analysis also covers how abuse in health care is different from the related concepts of medical error, patient satisfaction and personal identity threat. Background: Abuse in health care is an emerging concept in need of a clear analysis and definition. At the same time, boundaries to the related concepts are not demarcated. Design: Concept analysis as developed by Walker and Avant. Method: The databases Cumulative Index to Nursing and Allied Health Literature, Medline, and Google Scholar were used to obtain articles published between 1997 and 2009. A total of eleven articles are referred to on abuse in health care, four on medical error, six on patient satisfaction and three on personal identity threat. Results: Abuse in health care is defined by patients’ subjective experiences of encounters with the health care system, characterized by devoid of care, where patients suffer and feel they lose their value as human beings. The events are most often unintended. We also found differences with the aforementioned related concepts: medical error does not share the patients’ perspective, and patient satisfaction does not offer room for patients’ abusive experiences. The concept of personal identity threat shares all attributes with abuse in health care, but it lacks an antecedent that signifies the social structures underlying the phenomenon. Conclusions: Abuse in health care covers a phenomenon that has severe consequences but is invisible if seen from a medical error or patient satisfaction perspective.     

Brief admission for patients with emotional instability and self‐harm: A qualitative analysis of patients’ experiences during crisis

Previous studies report that individuals diagnosed with borderline personality disorder have been met by negative attitudes from healthcare professionals and their care needs have often been neglected during hospitalizations. When symptoms of emotional instability are combined with self‐harm, the resulting crisis often becomes difficult to handle for patients and healthcare professionals. To meet their care needs during these crises, an intervention called ‘brief admission’ (BA) has been developed. The purpose of BA is to provide a timeout, in situations of increased stress and threat, in order to foster self‐management in a safe environment. In the present study, we explored the following research questions: What are patients’ experiences with BA? What do patients consider to be the key components of BA? What improvements are considered relevant by patients? A qualitative design was employed, and 15 patients (13 females, 2 males; mean age 38.5 ± 12.9, range 20–67 years) were interviewed using a semi‐structured interview guide. Thematic analyses were performed, which yielded four themes related to the patients’ experiences: ‘a timeout when life is tough’, ‘it is comforting to know that help exists’, ‘encouraged to take personal responsibility’, and ‘it is helpful to see the problems from a different perspective’. Four themes also described the key components: ‘a clear treatment plan’, ‘a smooth admission procedure’, ‘a friendly and welcoming approach from the staff’, and ‘daily conversations’. Lastly, three themes described areas for improvements: ‘feeling guilty about seeking BA’, ‘room occupancy issues’, and ‘differences in staff’s competence’. Collectively, the findings indicate that BA constructively supports patients with emotional instability and self‐harm during a period of crisis.     

How patients' experiences contribute to decision making: illustrations from DIPEx (personal experiences of health and illness)

Aim To describe how people use their and other people’s experiences (‘experiential evidence’) in making health care decisions. Background People faced with health decisions may employ not only clinical evidence and advice, but also their own previous experiences and the experiences of others who have faced similar decisions. Professionals have taken little notice of people’s use of such experiential evidence and its importance in practice; acknowledging it would improve communication with patients. Methods The data come from the DIPEx (personal experiences of health and illness) project, which involves rigorous analysis of narrative interviews of people with particular conditions, chosen to represent the widest practicable range of experiences of each condition. Each collection consists of 40–50 interviews. Results The analyses of people’s experiences are summarized for patients and professionals on a website ( http://www.dipex.org ) and illustrated by clips (video, audio or written) from the interviews. We draw on the qualitative research conducted for DIPEx to consider some of the different ways that people integrate experiential information when they face decisions about antenatal screening, childhood immunization and treatment for cancer. Conclusions Other patients’ experiences are an important part of the evidence that people use when making decisions about health care. People are naturally drawn to other people’s stories, which add salience to medical information and make facts palatable and memorable. Patients’ experiences are not an alternative to the evidence base – they are part of it; to dismiss them as ‘anecdotes’ is a serious misunderstanding. There are established methods, grounded in social science traditions, which can be used to research and report patients’ experiences. Health professionals, as well as patients, need to consider and value this experiential evidence. Implications for Nursing Management Managers and clinicians can help patients by guiding them to information resources, such as DIPEx, that present evidence‐based health information through patients’ experiences.     

From diagnosis to health: a cross‐cultural interview study with immigrants from Somalia

Scand J Caring Sci; 2010; 24; 357–365
From diagnosis to health: a cross‐cultural interview study with immigrants from Somalia Objective: Being diagnosed as having a chronic disease gives rise to emotions. Beliefs about health are culturally constructed and affect people’s decisions regarding treatment. No studies have been reported that focus on the health beliefs of immigrants of Somalian origin with diabetes and how these people experiences the diagnosis. Therefore the aim of the present study was to investigate how immigrants from Somalia living in Sweden experienced receiving the diagnosis and describe their beliefs about health. Method: The sample consisted of 19 adults with diabetes born in Somalia and now living in Sweden who were interviewed with the aid of an interpreter. The interviews were subjected to qualitative content analysis. Results: From the analysis of what the participants said about their experiences of the diagnosis there emerged three themes: ‘Existential brooding’, ‘Avoiding the diagnosis’ and ‘Accepting what is fated’. Three themes also emerged from the analysis of what they said about beliefs about health: ‘Health as absence of disease’, ‘Health as general well‐being’ and ‘Fated by a higher power’. A major finding was that women when they communicated their experiences regarding the diagnosis and health beliefs made more use of supernatural beliefs than men did. The participants, irrespective of gender, did not immediately respond with shock or other strong emotion when they received the diagnosis. Conclusions: The study provides health‐care staff with knowledge concerning a minority group’s experiences of being diagnosed as having diabetes and their beliefs about health. The findings indicate that men and women differ in how they experiences the diagnosis and how they described their health beliefs. The quality improvement of health education and nursing for patients with diabetes calls for consideration of the variation of beliefs related to cultural background and gender.     

‘I know what I need to recover’: Patients’ experiences and perceptions of forensic psychiatric inpatient care

Patients find forensic psychiatric care inadequate in that they are not treated as individuals and not involved in their own care. The purpose of this study was to describe patients’ experiences and perceptions of forensic psychiatric inpatient care. Semi‐structured interviews were conducted with 11 inpatients. A qualitative content analysis resulted in a recurring theme, ‘I know what I need to recover’, and three main categories: ‘A need for meaning in a meagre existence’, ‘A need to be a person in an impersonal context’, and ‘A need for empowerment in a restricted life’. Participants experienced and perceived forensic care as predominantly monotonous, predetermined, and not adapted to them as individuals, forcing them to fight and adapt to get through it and not lose themselves. Perceived needs were largely ignored or opposed by staff due to the content and structure of care. Findings suggest a need for reflective practices and patient involvement in order to develop and maintain a person‐centred and recovery‐oriented nursing practice. The study adds to previous research showing the importance of patients in forensic psychiatric inpatient care being listened to and involved in their care. The study is reported in accordance with the COREQ guidelines.     

Quality of life for older people living in long-stay settings in Ireland

Aim. The aim of this study was to explore the quality of life of older people living in long‐stay care in Ireland from the perspectives of residents and staff. Background. While the literature on quality of life is complex, several areas of agreement are evident. Quality of life is a multi‐dimensional concept, which cannot be explained solely in medical terms and only makes sense if presented in an holistic context. Quality of life contains both subjective and objective elements; therefore, there is a need to take account of both when measuring the concept. Method. A mixed method research design was selected for this study. Three methods were employed; focus groups (n = 7) a quantitative survey of 526 long‐stay facilities and qualitative interviews with 101 residents and 48 staff. Results. The findings revealed four thematic domains of quality of life: care environment and ethos of care, personal identity, connectedness to family and community and activities and therapies. Conclusion. The study found that there were differences in resident experiences across care study sites and important differences in staffing provision, skill mix and physical environment between private and public facilities. Several factors were also found that either enhanced or diminished residents’ potential to retain their connections and relationships with other people. Finally, residents were most likely to participate in activities which were designed to take into account their own particular interests. Relevance to clinical practice. This study articulates domains of quality of life from the perspective of residents and staff and gives support to the claims that management and organizational structures within long‐stay care facilities matter for quality of life. Clear identification of what is important to older people is important as services need to be shaped around quality of life as much as quality of care, notwithstanding the close relationship between the two.     

Coming out to talk about suicide: Gay men and suicidality

International studies report increased rates of mental health problems and subsequent suicidality among homosexual populations. While international health‐care policy is concerned with reducing suicide among young people, important research findings relating to gay people and suicidality remain unacknowledged in the Suicide Prevention Strategy for England. This qualitative study, utilizing single case studies, was used to gain an in‐depth understanding of the life experiences contributing to the suicidality of four gay men. The methodology was psychoanalytically informed, using free association narrative interviewing. The initial data analysis involved interpretation of each of the case studies and a subsequent analysis exploring the shared experiences found in each of the individual narratives. Thematically, these are described as ‘knowing and not knowing’, ‘the centrality of the father–son relationship’, ‘the loneliness of outsiderness’, ‘leading a double life’, and ‘crime and punishment’. The significance of the life experiences these themes illustrate reveal why some gay men might not only experience long‐term mental health problems, but also engage in suicidality. Individually and collectively, the analyses provide important insights for mental health nurses becoming more attuned to provide sensitive mental health care to those who have a gay sexual orientation.     

Of vigilance and invisibility--being a patient in technologically intense environments

Equipment and procedures developed during the past several decades have made the modern intensive care unit (ICU) the hospital’s most technologically advanced environment. In terms of patient care, are these advances unmitigated gains? This study aimed to develop a knowledge base of what it means to be critically ill or injured and cared for in technologically intense environments. A lifeworld perspective guided the investigation. Nine unstructured interviews with intensive care patients comprise its data. The qualitative picture uncovered by a phenomenological analysis shows that contradiction and ambivalence characterized the entire care episode. The threat of death overshadows everything and perforates the patient’s existence. Four inter‐related constituents further elucidated the patients’ experiences: the confrontation with death, the encounter with forced dependency, an incomprehensible environment and the ambiguity of being an object of clinical vigilance but invisible at the personal level. Neglect of these issues lead to alienating ‘moments’ that compromised care. Fixed at the end of a one‐eyed clinical gaze, patients described feeling marginalized, subjected to rituals of power, a stranger cared for by a stranger. The roar of technology silences the shifting needs of ill people, muffles the whispers of death and compromises the competence of the caregivers. This study challenges today’s caregiving system to develop double vision that would balance clinical competence with a holistic, integrated and comprehensive approach to care. Under such vision, subjectivity and objectivity would be equally honoured, and the broken bonds re‐forged between techne, ‘the act of nursing’, and poesis, ‘the art of nursing’.     

Patients’ experiences of isolation in psychiatric inpatient care: Insights from a meta‐ethnographic study

Historically, people with mental ill‐health have been isolated from society. Although mental health care has moved from closed to more open forms of care, in many societies care is still provided in locked wards, and people with mental ill‐health are sometimes secluded from their fellow patients, families, friends, and visitors. The aim of this study was to illuminate patients’ experiences of isolation in psychiatric inpatient care. A systematic review of qualitative research was conducted, and the key findings were subjected to meta‐ethnographic synthesis. The findings were twofold: ‘being admitted to prison’ and ‘having access to shelter’. The experience of isolated care as prison‐like symbolizes patients’ longing for freedom and feeling restricted and limited by rules, stripped of rights, abandoned, controlled, powerless, and unsupported. In contrast, the experience of isolation as shelter symbolizes safety and the opportunity to regain control over one's own situation. A stigmatizing public view holds that people with mental ill‐health are dangerous and unpredictable and, therefore, unsafe to themselves and others. Being placed in isolation because these fears contribute to self‐stigma among patients. Promoting a sheltered experience in which isolation is used with respect for patients and the reasons are made explicit may encourage recovery. A shift in emphasis in ward culture from observation to engagement is needed to reduce blame, shift patient experiences from prison to shelter, and to support autonomy as a therapeutic intervention.     

Safety,risk, and aggression: Health professionals’ experiences of caring for people affected by methamphetamine when presenting for emergency care

The crystalline form of methamphetamine, commonly known as crystal meth (crystal methamphetamine) or ICE, is a highly‐addictive and powerful stimulant. Users of crystal meth often require emergency care, and are associated with a substantial burden of care by emergency care providers. The aim of the present qualitative study was to explore health professionals’ experiences of providing care for patients affected by ICE who presented to the emergency department (ED). Nine semistructured interviews were conducted. The major theme, ‘staying safe’, was revealed, in which participants described their experiences of being exposed to potentially unsafe situations, and their responses to challenging behaviours, including aggression. The findings highlight the need for ED staff to understand the nature of ICE use and its adverse impact on the mental and physical health of users. Furthermore, it is clear that establishing and maintaining safety in the emergency care setting is of utmost importance, and should be a priority for health‐care managers.     

Our Sunshine place: A collective narrative and reflection on the experiences of a mental health crisis leading to an admission to a psychiatric inpatient unit

Acute mental health inpatient units are complex environments where tensions between clinical and personal recovery can be amplified. The focus for mental health staff is often centred on providing clinical care, whereas from the patient perspective, the admission can represent a profound existential crisis. There are very few user‐led accounts of their experiences of psychiatric inpatient unit. This project was developed in the traditions of Analytic Auto‐Ethnography, a research methodology which provides a systematic process to reflect on our own experience while still producing trustworthy findings. Through this process, a collective narrative and critical reflection of a group of over 20 individuals with experiences of either providing or receiving care in an acute psychiatric inpatient unit was developed. The narrative developed shows that for some the hospital admission was a time of healing; for others, the inpatient unit represented an alien and unsafe environment, which accentuated the strangeness of the experiences of mental ill health. Common themes among the group were that of an overarching need to make sense of what happened leading up to the admissions and to come to terms with the potential impact of the illness on identity and future. This journey can be best described as a process of healing and moving towards ‘wholeness’. Safety, connection, autonomy and control were identified as factors which either facilitated or hindered the process of successfully integrating the various experiences.     

Left alone – Swedish nurses’ and mental health workers’ experiences of being care providers in a social psychiatric dwelling context in the post‐health‐care‐restructuring era. A focus‐group interview study

Scand J Caring Sci; 2010; 24; 427–435
Left alone – Swedish nurses’ and mental health workers’ experiences of being care providers in a social psychiatric dwelling context in the post‐health‐care‐restructuring era. A focus‐group interview study The professional role of nurses and mental health workers in social psychiatry is being re‐defined towards a recovery, client‐focused perspective. Approximately 0.7 percent of the adult population in Sweden suffers from severe mental illness leading to a need for community services. The primary aims of the Mental Health Reform in 1995 in Sweden were to improve the quality of life for people with severe, long‐term mental illness and, through normalization and integration, enhancing their opportunities to communicate with and participate in society. This study examines nurses’ and mental health workers’ views and experiences of being care providers in a municipal psychiatric group dwelling context when caring for clients suffering from severe mental illness. Three focus group interviews were made and thematic content analysis was conducted. Four themes were formulated: ‘Being a general human factotum not unlike the role of parents’, ‘Having a complex and ambiguous view of clients’, ‘Working in a mainly ‘strangled’ situation’, and ‘Feeling overwhelming frustration’. The staff, for instance, experienced a heavy workload that highly involved themselves as persons and restricted organization. The individual relational aspects of the nursing role, the risk of instrumentalizing the staff due to an organizational economical teleopathy (meaning a pathological desire to react goals), and the high societal demands on accomplishing the Mental Health Reform goals are discussed. To redefine the professional role of nurses and mental health workers in the community, in Sweden known as municipality, they need support in the form of continuously education, supervision, and dialogue with politicians as well as the public in general.     

Bereavement care for older people in healthcare settings: qualitative study of experiences

Aim. This study aimed to explore the experiences of healthcare staff of caring for bereaved older people, and older people’s experiences of bereavement care. Background. Loss through death of close family members, partners and friends inhibits the physical, emotional and social well being of older people. The rising population of older people and pressure on healthcare services to reduce costs indicate the necessity of developing strategies that enable coping and independence. Design. A qualitative design drawing on phenomenological methodology was used to understand interactions between healthcare staff and bereaved older people. The study was set in hospital wards, general practice and community nursing teams, and care homes. Healthcare staff and a sample of recently bereaved older people participated. Methods. Purposive sampling took place to recruit staff with a range of roles, and older people who were 65 years of age or more, and bereaved of a family member or friend for between 6 months and 5 years. Participants took part in in‐depth interviews, and data were analysed systematically. Results. Thirty‐nine participants were recruited, and three key themes arose from the data: (i) Bereavement care depends on an established relationship between healthcare staff and the patient’s relatives; (ii) Preparation for the relative’s death may not equate to being prepared for bereavement; (iii) The ‘Open Door’ to bereavement care is only slightly ajar. Conclusions. The study identified the interactions of healthcare staff with bereaved older people in terms of the bereavement journey. Staff demonstrated awareness of difficulties the bereaved person may encounter and showed commitment to providing support. However, lack of flexibility in services restricts meaningful interactions. Implications for Practice. (i) Healthcare staff may identify gaps in services in terms of preparing relatives and follow‐up post‐bereavement; (ii) Therapeutic relationships between staff and relatives enable ongoing support; (iii) Development of practice guidelines is a key consideration.     

MRSA--global threat and personal disaster: patients' experiences

ANDERSSON H., LINDHOLM C. & FOSSUM B. (2011) MRSA – global threat and personal disaster: patients' experiences. International Nursing Review 58 , 47–53 Aim: To ascertain and describe the patients' knowledge, perceptions and experiences of being methicillin‐resistant Staphylococcus aureus (MRSA) positive. Background: Antibiotic resistant bacteria are a serious global threat. MRSA can cause wound infection, pneumonia, septicaemia and mortality. This qualitative study has focused on patients' experiences of living with MRSA. Methods: Fifteen patients with MRSA‐infected wounds were interviewed. All data were transcribed verbatim and analysed according to content analysis. Findings: Information about the MRSA diagnosis often caused a shock‐like reaction. Patients' perception of being MRSA positive was stigmatizing as plague or leprosy; they felt dirty and felt that they were a severe threat to their environment. Fears of infecting someone else and being rejected were commonly expressed. The key findings emerged as a theme: Being exposed to others' shortcomings and being a threat to others' health. Three categories were identified: understanding and emotional reactions, treatment by the healthcare professionals and consequences and expectations. Gaps in both patient and staff knowledge of MRSA led to unnecessary misunderstandings, causing fear, social isolation and suffering. Conclusions: Living with MRSA can be extremely stressful for the patients. Knowledge and empathy from staff involved in their care is crucial to optimize patients' experiences. Staff education to meet patients' demand for information and prevent contamination is essential.     

‘It should be an ordinary thing’– a qualitative study about young people’s experiences of taking the HIV‐test and receiving the test result

Scand J Caring Sci; 2010; 24; 678–683
‘It should be an ordinary thing’– a qualitative study about young people’s experiences of taking the HIV‐test and receiving the test result Aim: Increased HIV‐testing has public health benefits, but for youth there is a multitude of barriers against the test. The aim of this study is to explore how young women and men in Sweden experience HIV‐testing within primary healthcare. Method: Six focus‐group interviews were tape recorded, transcribed verbatim and analysed according to qualitative content analysis. Results: Three themes emerged, describing how the informants were met before, during and after testing; ‘Obstacles accessing the clinic’– describes their perceptions on how to overcome different barriers and enter into primary health care. ‘Quick and easy testing’– describes perceptions of the testing procedure and ‘Conflicting and unclear information about test results’– describes inconsistencies concerning communication of the test result and a concern about ‘what would happen’ in the event of an HIV‐positive finding. Most of these youth preferred the HIV‐test ‘quick and easy’ and preferred a telephone referral of the test result. A minority of them worried about HIV, and they thought that the staff seemed to be unprepared for an HIV‐positive test result. Conclusion: According to these youth, a quick and easy testing procedure together with a short pretest discussion may be sufficient and may also help normalising the testing practice. In a Swedish context, it may be common to see heterosexual youth as a risk‐free population, and this perception may act as a barrier for HIV‐testing and increase missed opportunities for early diagnose of HIV within primary care.