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

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

A need for “good eyes”: Experiences told by patients diagnosed with psychosis

This study highlights experiences of psychiatric care described by patients diagnosed with psychosis. The aim was to investigate how patients, based on earlier experiences, described their wishes and needs regarding the psychiatric care system. Data comprised material from four focus groups; analysis used an inductive thematic approach. Relationships with staff emerged as a recurring theme. During periods of psychosis, patients needed staff to act as “parental figures,” providing care, safety, and help in dealing with overwhelming stimulation from the outside word. In the ensuing struggle to devise a livable life, the need for relationships recurred. In this phase, staff needed to give their time, provide support through information, and mirror the patient''s capacity and hope. The patient''s trials were described as threatened by a lack of continuity and non-listening professionals. It was important for staff to listen and understand, and to see and respect the patients'' viewpoints.     

新入职护士对精神科护理知识认知情况调查

目的了解精神病医院新入职护士对精神病护理知识的认知状况,为精神科临床新入职护士的带教提供理论依据,进一步提高精神病医院的护理质量。方法自行设计问卷,对惠州地区三所精神病医院2013年新入职的71名护理人员进行调查。结果新入职护士对精神病护理知识认知存在偏差,其中,如何与精神病人接触与交谈及对精神病人意外事件的处理项目认知度较低。学历、社会环境因素与影响精神科护理识知的认知相关(p<0.01)。教学经历、实践经历是影响新入职护士对精神科护理知识认知的主要因素。结论学校有必要对护理专业学生加强对精神科知识的理论教学与实践培训;临床对新入职护士的带教中,应制订比较系统的专科培训计划,以全面提高精神病医院的临床护理质量。     

Inpatient violence in a psychiatric hospital in the middle of the pandemic: clinical and community health aspects

Healthcare workers are at a high risk of violence all over the world. The hostility toward nurses, physicians, and hospital staff has reached the point that it can be considered a public health problem. In this paper, we focus on the harassment, aggression, and violence that many healthcare workers have encountered while treating unstable psychiatric patients in the middle of the COVID-19 pandemic. We present a case with a history of violence toward mental health workers, review psychopathological and clinical aspects, and discuss how both the COVID-19 pandemic and current challenges in psychiatric hospital settings increase the frequency and severity of these attacks and how this affects the team on inpatient psychiatric units. We used the CARE guidelines to provide the most accurate and transparent information about the patient and relevant psychosocial aspects. We also pooled more than 20 unique sources to cover all aspects of violent behaviors in all psychiatric settings for all age groups. We concluded that a lack of nursing staff, the mental burden imposed by difficult patients, and poor communication between team members are some of the factors contributing to patient violence. An incomplete understanding of the problem creates barriers to change on both personal and systematic levels. Constant violence and abuse against healthcare workers cause stress, decreased productivity, and work dissatisfaction. To improve the safety of healthcare professionals, especially in inpatient psychiatric settings, several system-based changes should be implemented.     

Challenges to HIV prevention in psychiatric settings: perceptions of South African mental health care providers

Mental health services in South Africa increasingly feel the brunt of the AIDS epidemic. Despite the high prevalence of infection in the psychiatric setting, HIV risk reduction interventions targeting South Africans with psychiatric illness remain few and far between. The attitudes of mental health care providers about sexual relations and HIV among people with mental illness continue to influence the extent to which these issues are addressed in care settings. This study examines these attitudes through the use of a semi-structured interview administered to 46 mental health care providers in four provinces of South Africa. I found that personal, contextual and political factors in the clinic and the hospital create barriers to integrating prevention activities. In particular, providers face at least three challenges to intervening in the epidemic among their patients: their own views of psychiatric illness, the transitions occurring in the mental health care system, and shifting social attitudes toward sexuality. Barriers operate at the individual level, the institutional level, and the societal level. At the individual level providers' perceptions of psychiatric symptoms shape their outlook on intervention with psychiatric patients. At the institutional level disruptive transitions in service delivery relegate HIV services to lesser importance. At the societal level, personal beliefs about sexuality and mental illness have remained slow to change despite major political changes. Minimizing barriers to implementing HIV prevention services requires institutional and health care policies that ensure adequate resources for treating people with mental illness and for staff development and support.     

Choose your method: a comparison of phenomenology, discourse analysis, and grounded theory

The purpose of this article is to compare three qualitative approaches that can be used in health research: phenomenology, discourse analysis, and grounded theory. The authors include a model that summarizes similarities and differences among the approaches, with attention to their historical development, goals, methods, audience, and products. They then illustrate how these approaches differ by applying them to the same data set. The goal in phenomenology is to study how people make meaning of their lived experience; discourse analysis examines how language is used to accomplish personal, social, and political projects; and grounded theory develops explanatory theories of basic social processes studied in context. The authors argue that by familiarizing themselves with the origins and details of these approaches, researchers can make better matches between their research question(s) and the goals and products of the study.     

The powerful pull of policy targeting: examining residualisation in Australia

Increasingly, researchers are arguing that there is a need to ‘act universally’ in order to address social and health inequalities. While, in theory, universal approaches to tackling inequalities are valuable, putting them into practice has proved to be much more difficult. Debates between universal and targeted approaches continue, both in the public health literature and social policy (a field with significant bearing on population health). These debates revolve around ideology and the intuitive appeal of targeting. In this paper, we explore how these ideologies and logics play out in the design and implementation of policy, using the Australian Social Inclusion Agenda as a case study. Based on our analysis, we suggest that a more dialogic approach to working with policy-makers is required in order to promote reflection on broader tendencies in the design and implementation of policies.     

Suicide and its psychopathological relations: a qualitative analysis of 6 cases of rational suicide

We studied the meaning given to the terms "death" and "suicide" among psychiatric inpatients. Forty-four patients who had been admitted in a psychiatric inpatient unit following a suicide attempt underwent a qualitative interview, using a "general guide interview" approach. The results were analyzed systematically to investigate the relationship between attempted suicide and mental disorder. In 6 cases there was no correlation between the attempted suicide and psychopathological symptoms. One of these patients had a psychiatric diagnosis, but this did not seem to be related to the suicide attempt. All of them made a rational a deliberate suicidal act. Conclusion: even in a psychiatric inpatient setting, suicide attempts are not always a behavioural expression of underlying psychopathological disturbances - individual and social factors also play a decisive role.     

Risk management by patients on psychiatric wards in London: An ethnographic study

The purpose of this study was to explore everyday life on acute psychiatric admission wards, focusing on the experience of patients. Using a grounded theory approach, data were collected by ethnographic methods on three wards in London, UK. This paper is concerned with the issue of how patients manage risks arising from their interaction with other patients on the ward, such as assault and sexual harassment. Patients were observed doing this in various ways including: (a) avoiding risky situations or individuals; (b) de-escalating potentially risky situations; (c) seeking safety interventions by staff or increased surveillance; and (d) protective involvement with other patients. These findings show that patients routinely take an active role in making a safe environment for themselves, partly because they cannot rely on staff to do this for them. Mental health professionals should consider how to build upon what patients are already doing to maximise ward safety.     

Compassionate containment? Balancing technical safety and therapy in the design of psychiatric wards

This paper contributes to the international literature examining design of inpatient settings for mental health care. Theoretically, it elaborates the connections between conceptual frameworks from different strands of literature relating to therapeutic landscapes, social control and the social construction of risk. It does so through a discussion of the substantive example of research to evaluate the design of a purpose built inpatient psychiatric health care facility, opened in 2010 as part of the National Health Service (NHS) in England. Findings are reported from interviews or discussion groups with staff, patients and their family and friends. This paper demonstrates a strong, and often critical awareness among members of staff and other participants about how responsibilities for risk governance of ‘persons’ are exercised through ‘technical safety’ measures and the implications for therapeutic settings. Our participants often emphasised how responsibility for technical safety was being invested in the physical infrastructure of certain ‘places’ within the hospital where risks are seen to be ‘located’. This illuminates how the spatial dimensions of social constructions of risk are incorporated into understandings about therapeutic landscapes. There were also more subtle implications, partly relating to ‘Panopticist’ theories about how the institution uses technical safety to supervise its own mechanisms, through the observation of staff behaviour as well as patients and visitors. Furthermore, staff seemed to feel that in relying on technical safety measures they were, to a degree, divesting themselves of human responsibility for risks they are required to manage. However, their critical assessment showed their concerns about how this might conflict with a more therapeutic approach and they contemplated ways that they might be able to engage more effectively with patients without the imposition of technical safety measures. These findings advance our thinking about the construction of therapeutic landscapes in theory and in practice.     

Advancing population and public health ethics regarding HIV testing: a scoping review

Recently, scholars have called for more robust population and public health ethical frameworks to inform how the health of populations and individuals ought to be improved through various approaches to HIV testing practices. Our objective is to examine the breadth, range and foci of a variety of ethical issues pertaining to HIV testing approaches within the peer-reviewed literature, and how these issues address population and/or individual interests. We identify potential tensions between individual and collective approaches as well as other concerns, including equity, justice and distribution of health and risk – hallmarks of the emergent field of population and public health ethics. Based on our review, we suggest that additional theoretical work and empirical research are required in order to inform more ethically robust debates related to population HIV testing practices. Specifically problematic were consequentialist arguments that deem testing approaches as either morally permissible or impermissible without sufficient robust empirical and/or theoretical underpinnings and about how a particular approach would unfold among individuals and populations. The current review underscores the need to continue to articulate an evidence- and theory- informed population and public health ethics pertaining to HIV testing.     

Understanding and assessing service quality in health maintenance organizations

Health maintenance organizations (HMO's) have been one of the major innovations in providing healthcare. However, as the HMO enjoyed success as an alternative delivery system, competition among individual HMO's intensified. As a result, the 1990's will require continued attention to the effective delivery of quality services to clients. Providers of healthcare services must work toward establishing a strong competitive position in the marketplace which means that they will have to understand how their customers perceive value in the services rendered. The authors examine exchange relationships that occur in the HMO and offer an approach for analyzing the dimensions of service quality demanded by the HMO's constituents. Practical ways to enhance service quality are discussed.     

AIDS jihad: integrating the Islamic concept of jihad with HIV prevention theory

Data suggest that HIV prevalence rates among Muslim populations may be increasing due to unprotected sexual intercourse and shared injection equipment, despite popular belief that adherence to religious injunctions has shielded Muslim populations from the HIV epidemic. HIV prevention programs targeting Muslim populations to date have often lacked a theoretical foundation and have neglected the important Islamic concept of jihad, or struggle. This article reviews the cultural and religious factors that may facilitate or reduce HIV risk in Muslim communities. The theory of reasoned action and a harm reduction approach are utilized to demonstrate how the important concept of jihad can be integrated with HIV prevention theory to develop HIV prevention approaches at individual and structural levels. The proposed approach to HIV prevention must be validated, refined, and evaluated for specific cultures and locales through field testing.     

整体护理的实践与体会

文章全面系统地叙述了开展整体护理全过程的关键环节;观念先行,用全新的护理理念,培养新型护理人才;循序渐进,采取渐进模式全面推广整体护理;健全科学的管理体系,保证整体护理落到实处;形成整体护理支持网络,并将整体护理作为全院的一项系统工程。     

Conversational shaping: staff members' solicitation of talk from people with an intellectual impairment

In initiating and maintaining talk with people with intellectual impairments, members of care staff use a range of recurrent conversational devices. The authors list six of the more common of these devices, explain how they work interactionally, and speculate on how they serve institutional interests. As in other dealings between staff members and the people with intellectual impairments they support, there is a pervasive dilemma between, on one hand, encouraging participation and, on the other, getting institutional jobs done. The authors show how the practices of encouraging talk that they describe move between the two horns of that dilemma.     

Team leadership and patient outcomes in US psychiatric treatment settings

Previous studies suggest that psychiatric patients mirror the behaviors of the staff members who treat them, but there is little empirical evidence about how staff dynamics affect patients over time. The goals of this study were to examine associations between: (1) team leader discipline and mutual respect among treatment team members; and (2) mutual respect among team members and improvements in patient quality of life. Two models were tested on data from psychiatric treatment teams within the US Veterans Administration. The first examined associations between the discipline of each team's emergent leader and the level of mutual respect among that team's members. The second model tested associations between mutual respect among staff and changes over time in patients' quality of life. The subjects for model 1 were psychiatric staff members (n=785) whose responses were aggregated for team-level analyses (n=78). Mutual respect was highest in social worker-led teams and lowest in physician-led teams. The subjects for model 2 were 1,638 seriously mentally ill patients in 44 of the units examined in the first model. When mutual respect among staff was greater, patients improved more over time in their satisfaction with the quality of their housing, relations with families, social life, and finances. Together, these analyses imply that mutual respect may improve patient outcomes and that leadership by some disciplines may facilitate such dynamics. In general, leaders may consider learning from other disciplines' strengths to improve their impact.     

Facilitators and barriers to the implementation of patient flow improvement strategies

Patient flow improvement strategies have been effective in reducing emergency department (ED) crowding, but little guidance is available on the implementation process. By using a qualitative research design, our objective was to identify common facilitators and barriers to the implementation of patient flow improvement strategies and successful approaches for mitigating barriers. Six hospitals participated in an 18-month Urgent Matters learning network launched in October 2008. The hospitals selected strategies to improve patient flow that could be implemented within 3 months with measurable impact. Across 6 hospitals, 8 strategies were implemented. We conducted 2 rounds of key informant interviews with improvement teams, for a total of 129 interviews. Interviews were recorded, transcribed, and coded by using a grounded theory approach to identify common themes. Factors facilitating implementation included participation in the learning network and strategic selection of team members. Common challenges included staff resistance and entrenched organizational culture. Some of the challenges were mitigated through approaches such as staff education and department leaders' constant reinforcement. Our findings indicate that several facilitators and barriers are common to the implementation of different strategies. Leveraging facilitators and developing a strategy to address common barriers may leave hospital and ED leaders better prepared to implement patient flow improvement strategies.     

Using Bayesian inference to perform meta-analysis

Bayesian modeling offers an elegant approach to meta-analysis that efficiently incorporates all sources of variability and relevant quantifiable external information. It provides a more informative summary of the likely value of parameters after observing the data than do non-Bayesian approaches. This leads to direct probabilistic inference about model parameters such as the average treatment effect, the between-study variance, and individual study treatment effects. The latter are weighted averages of the common mean and individual study means with weights reflecting the amount of information provided by each study relative to the others. Homogeneity among these posterior study estimates indicates that pooling these studies is appropriate; heterogeneity suggests that some cause of between-study variation should be explored. The author describes the construction of such models and shows how to use them to estimate a common mean and regression slopes. Two examples illustrate the additional inferences available with the Bayesian methodology.     

The social utility of community treatment orders: Applying Girard’s mimetic theory to community‐based mandated mental health care

Serious mental illness (SMI) has long posed a dilemma to society. The use of community treatment orders (CTOs), a legal means by which to deliver mandated psychiatric treatment to individuals while they live in the community, is a contemporary technique for managing SMI. CTOs (or a similar legal mechanism) are used in every province in Canada and in many jurisdictions around the world in the care and management of clients with severe and persistent mental illness (most frequently schizophrenia) who have a history of treatment non‐compliance and subsequent relapse. Although there is ongoing controversy around CTOs, their use continues to be on the rise. René Girard's mimetic theory, in which he posits the social utility of the scapegoat mechanism, may shed some light on how established cultural patterns contribute to contemporary responses to SMI: how culture depends on the reproduction of certain narratives, and how these act to shape the identity of those involved. The CTO specifically can be seen to act as a scapegoating mechanism, wherein, by singling out and controlling individuals who appear to threaten social order, social order is restored. This paper reviews Girard's theory, looks at how it has been applied to SMI, and then considers how it may illuminate the social role of the CTO. This examination may provide mental health nurses with insight into the constructed identities of their patients, as well as the role of mental health care within broader cultural narratives.     

The prevention of HIV infection from injecting drug use--a review of health promotion approaches.

This review examines the prevention of HIV infection among injecting drug users through the framework provided by the Ottawa Charter on Health Promotion. Among the key issues considered are the problems of achieving the changes in policy and service direction needed to prevent HIV infection. The role of the media in influencing public opinion is examined, together with the potential for traditional educational approaches to achieve safer practices among injecting drug users. The authors conclude that a better integrated and more comprehensive approach to HIV prevention may be needed for substantial progress to occur. A proactive response utilising outreach work is recommended for drug services, and health workers together with drug service professionals are encouraged to act as advocates in gaining public and political support for change.