Treading lightly: spirituality issues in mental health nursing

ABSTRACT: Spirituality has been recognized as an important part of nursing practice since its early beginnings. However, debate continues about whether and how nurses and other mental health professionals should include spirituality within their daily work. This paper aims to contribute to the discussion of spirituality within mental health nursing, through considering findings from a Heideggerian phenomenological study conducted with six people with mental illness living in regional Australia. This study aimed to provide a greater understanding of the phenomenon of spirituality by answering a primary research question, ‘What does spirituality mean for people with a mental illness?’ Participants were interviewed and data analysed using an iterative approach. Findings emerged through multiple readings and meanings were gradually constructed from the data into themes. The themes describe that spirituality is experienced uniquely for the participants, and that spirituality became vitally important to them when they became mentally unwell. In addition, issues of interest to mental health nurses were raised but not completely addressed by the study. The issues relate to potential interactions about spirituality between nurses and their patients. Although participants wanted to discuss their experiences of spirituality with others, they raised concerns about whether their mental health care providers would be accepting of their beliefs. Spirituality was deemed to be a highly individual phenomenon; it could be experienced as a journey and it was life‐sustaining. For these reasons, it is proposed that mental health professionals must be prepared to discuss patients’ spiritual needs in the context of their health concerns.     

Egyptian families caring for a relative with mental illness: a hermeneutic study

ABSTRACT: The care of people with mental illness often rests with their families. The way families manage this experience has been explored widely in the literature; however, the added complexity of migration has been given little attention. The difficulty of conducting research with people from non‐English‐speaking backgrounds often precludes their voices and experiences from being heard, further compounding marginalization and misunderstanding of their needs. The aim of this study was to understand the experience of Egyptian families caring for a relative with mental illness in Australia. Seven participants from Egyptian background, caring for a relative with mental illness, were included in this study. A hermeneutic phenomenological approach, informed by the work of Heidegger, was used. Data were collected through in‐depth audio‐taped interviews conducted in the Arabic language, which were then translated and transcribed in English. Data analysis revealed five themes: Why did it happen? How do I protect my loved ones? What has it done to me? What has it done to us? How do I survive? Findings of the study have the potential to raise health‐care professionals' awareness of the needs of Egyptian families, their beliefs, values, and coping with mental illness.     

Voiceless and vulnerable: An existential phenomenology of the patient experience in 21st century British hospitals

Current health policy, high-profile failures and increased media scrutiny have led to a significant focus on patient experience in Britain's National Health Service (NHS). Patient experience data is typically gathered through surveys of satisfaction. The study aimed to support a better understanding of the patient experience and patients' expression of it through consideration of the aspects of the patient experience on NHS wards which are by their nature impossible to capture through patient satisfaction surveys. Existential phenomenology was used to develop an in-depth exploratory narrative, expressed through the voices of the participants. Data collection involved in-depth face-to-face interviews with 12 purposively sampled participants, with analysis by means of hermeneutics. Though the individuality of each experience was apparent and cannot be overemphasised, common factors emerging from the data included uncertainty and unexpectedness, suffering and finitude, the futility of feedback and bureaucracy and absurdity. Overall, participants demonstrated how their individual personalities and expectations affected their response both to illness or injury and to their hospital admissions, highlighting feelings of vulnerability and voicelessness as a response to hospitalisation. The findings of this study provide useful insight into the patient experience on British hospital wards, and the value of an existential–phenomenological approach is demonstrated.     

'Take my hand, help me out': mental health service recipients' experience of the therapeutic relationship

ABSTRACT: The purpose of this study was to describe mental health service recipients' experience of the therapeutic relationship. The research question was ‘what is therapeutic about the therapeutic relationship?’ This study was a secondary analysis of qualitative interviews conducted with persons with mental illness as part of a study of the experience of being understood. This secondary analysis used data from 20 interviews with community‐dwelling adults with mental illness, who were asked to talk about the experience of being understood by a health‐care provider. Data were analysed using an existential phenomenological approach. Individuals experienced therapeutic relationships against a backdrop of challenges, including mental illness, domestic violence, substance abuse, and homelessness. They had therapeutic relationships with nurses (psychiatric/mental health nurses and dialysis nurses), physicians (psychiatrists and general practitioners), psychologists, social workers, and counsellors. Experiences of the therapeutic relationship were expressed in three figural themes, titled using participants' own words: ‘relate to me’, ‘know me as a person’, and ‘get to the solution’. The ways in which these participants described therapeutic relationships challenge some long‐held beliefs, such as the use of touch, self‐disclosure, and blunt feedback. A therapeutic relationship for persons with mental illness requires in‐depth personal knowledge, which is acquired only with time, understanding, and skill. Knowing the whole person, rather than knowing the person only as a service recipient, is key for practising nurses and nurse educators interested in enhancing the therapeutic potential of relationships.     

In the mind of another shame and acute psychiatric inpatient care: an exploratory study. A report on phase one: service users

In the UK and internationally, there are concerns for the quality of health care available to people with mental health problems. A number of surveys and reports suggest that hospital admission for acute psychiatric care can be stigmatizing and non-therapeutic. This paper describes the setting up and progress to date, of an ongoing qualitative research study carried out in Wales. The study explores service users' subjective experience of shame before, during and after psychiatric hospital admission. The research study's aims are to learn about situations that might influence quality of care because of shame experienced by individuals and groups of people. The study also seeks to explore specifically ways that relationships with healthcare professionals are influenced because of shame related experiences. This paper reports on phase one of the study, service users views and reviews acknowledged benefits and difficulties experienced to date. Both phases of the study encompassed mixed membership focus groups conducted by both researchers. Although the data analysis is still in progress, provisional findings of this research study suggest that an awareness of the complexities in relation to ways shame is aroused in individuals and groups of people because of mental health problems could contribute to improving the quality of care provided to service users, before, during and after hospital treatment and care. Although not initially part of the study's intentions, the views of all focus group participants so far indicate that collaborative research is found to be empowering. Information gained to date indicates that we will gain a better understanding of situations that provoke feelings of shame in established service users and those experiencing emotional distress for the first time.     

Experiences of mental health services for ‘black’ men with schizophrenia and a history of disengagement: A qualitative study

Whilst mental disorders can be disabling they are also treatable, yet engagement with services is often poor and disengagement from treatment is a major concern for mental health nurses. Participants were service users typically perceived as the most disengaged from mental health services, yet they were willing to engage in the research interviews. The seven participants were all male with a diagnosis of schizophrenia, a history of disengagement from mental health services and described their ethnicity as ‘black’. Participants were under the care of Assertive Outreach Teams and were recruited after the researcher was introduced to them by clinicians who were working with them. After ethical approval, in‐depth, semi‐structured interviews were used to elicit the experiences of participants. Through interpretative phenomenological analysis, themes were developed. Interpretative Phenomenological analysis generated four themes: (i) “People just keep hounding me”, (ii) Antipathy to Medication, (iii) Choice and the value of services, (iv) Stigmatisation and identity. By rigorously examining how service users with schizophrenia make sense of their experience of their relationship with mental health services, there is potential to give voice to the experiences of the recipients of mental health services. This study uncovered the complex nature of disengagement and in view of this there may never be a straightforward mechanism developed to engage all people with schizophrenia with mental health services. When the participants’ experiences are considered in a broader social context it may be possible to reflect on how services can be adapted to facilitate better engagement.     

The struggle for social integration in the community--the experiences of people with mental health problems

The goal of social integration is part of the ideological motivation behind the transition from institutionalized to decentralized psychiatry. Modern community mental health care considers social integration as vital for improving mental health. However, reports suggest that efforts to socially integrate people who suffer from mental health problems have not been as successful as anticipated. The aim of this study was to explore how people with mental health problems experience their ability to integrate socially into a community in central Norway. Three multistage focus groups, consisting of 17 people with mental health problems, were set up in two counties of different sizes. In this explorative study, data were analysed using a qualitative content analysis method. The participants experienced shame and fear of exclusion in their struggle to become integrated in the community. They had a sense of loneliness, had to struggle for equality and experienced being neglected. The days passed very slowly and they reported a lack of financial resources. They wanted to work or take part in other daytime activities and sought reciprocal relationships. In conclusion, those working in community mental health care need to ensure that people suffering from mental health problems experience a sense of belonging in the community, thus enabling them to develop a network and achieve social integration.     

Professional influences on the provision of mental health care for older people within a general hospital ward

Recent policy initiatives within the United Kingdom have recognized that effective care for older people can only be achieved if health care staff are willing and skilled enough to address patient needs in a holistic way. The preliminary stages of the action research project described here focused on the perceptions of nursing staff regarding the factors that impacted on their ability to address mental health needs within a general hospital ward. A phenomenological approach allowed us to identify the experience of addressing mental health needs in this setting from the perspective of the research participants. A focus group was facilitated with nursing staff whose primary professional focus was the provision of physical health care within an older adult unit. Thematic content analysis was used to analyse the focus group data, and four key themes emerged, namely 'disruption', 'role conflict', 'professional resources' and 'professional distress'. These themes provide a focus for the ongoing development of the action research methods and will embed future work in the experience of those charged with ensuring that mental health care is a key element of their practice. This study highlights the urgent need for further work in this area, as we contend that it is only by addressing the professional needs of the staff concerned, that effective patient-centred care can be ensured.     

Feeling an outsider left in uncertainty – a phenomenological study on the experiences of older hospital patients

This paper starts from a care ethical perspective on care and reports on a phenomenological study into older patients’ experiences of hospitalisation. Although hospital care for older patients is at the centre of attention, questions what is at stake and what defines quality of care are rarely discussed with a view to the perspective of older patients themselves. The qualitative observational method of shadowing was used. Ten patients of 75 years old or older were shadowed from admission until discharge. The reflective lifeworld approach, based on phenomenological philosophy, was used to analyse the collected data. For the older patients included in the study, the essential meaning of hospitalisation can be described as feeling an outsider left in uncertainty. The word ‘left’ reveals how hospitalisation is experienced as a solitary struggle with various uncertainties that are related both to the hospital environment and to the patient's personal situation. The essential meaning is composed of the following three constituents: (i) staying in an inhospitable place, (ii) feeling constrained and (iii) experiencing disruption. The busy walking back and forth of care professionals and the functional character of involvement, restrain older patients from participating and make them feel abandoned. Feeling constrained reveals the feelings brought on by the ageing body which are emphasised by hospitalisation but often neglected by hospital staff. The failure of healthcare professionals to recognise and respond to who older patients are aside from their illness exacerbate the experience of disruptions. To improve care, hospital staff must be more sensitive to older patients’ uncertainties. Also, hospital staff should provide older patients with understandable information and explanation which besides offering patients the possibility to feel involved, meets their need for recognition.     

Travelling through the system: the lived experience of people with borderline personality disorder in contact with psychiatric services

This study adopted a lived experience approach utilizing a broad research question to ask ‘How do people with borderline personality disorder (BPD) experience their contact with mental health services?’. Unstructured interviews were conducted with seven participants from one mental health trust. A grounded theory methodology was adopted to develop a theory of how people with BPD conceptualized their contact with psychiatric services and what strategies they adopted to negotiate their way through them. The study found that people with BPD valued their contact with psychiatric services despite negative experiences and encountering negative staff attitudes. It also found that relationships with others were vital in containing their distressing emotions despite their difficulty in trusting others. Overcoming these paradoxes was achieved by consistent long‐term involvement with experienced staff, containing relationships, encouraging the participants to contribute to their care through the structure of the care programme approach and improving staff understanding of their behaviour by key informants.     

Emotional comfort: the patient's perspective of a therapeutic context

BACKGROUND: Comfort is a word that is frequently used to describe both physical and emotional aspects of the hospital experience. A number of definitions exist in the literature and there is a lack of clarity in understanding this concept. OBJECTIVES: This paper describes the therapeutic context of emotional comfort that was identified in a qualitative study that sought to explain the perceived therapeutic effect of interpersonal interactions that were experienced by patients during hospitalisation. DESIGN: Grounded theory. SETTINGS: Public and private hospitals situated in Perth, Western Australia. PARTICIPANTS: 40 patient participants from a variety of settings, and 32 nurse participants. All participants were over the age of 18 and spoke English. METHODS: Formal and informal interviews, field observations. RESULTS: Patients interpreted the interpersonal interactions that they experienced during hospitalisation in terms of their experience of emotional comfort or discomfort. A central feature of emotional comfort was the patient's perception of personal control. CONCLUSIONS: This study provides a greater understanding of the concept of comfort from the perspective of hospitalised patients. It highlights that patients approach their illnesses or injuries perceiving that a connection exists between the mind and the body.     

Urban–rural differences in mental health among Chinese patients with multiple chronic conditions

Mental health is impacted by social, economic, and environmental influences related to where people live. Mental health problems commonly co‐occur with long‐term physical conditions and impact individuals’ health synergistically. Multiple chronic conditions (MCCs) including mental health problems are becoming a public health challenge globally. However, there is limited information about urban–rural differences in mental health among patients with MCCs in China. The present study aimed to identify differences in mental health between urban and rural patients with MCCs. Using a cross‐sectional design, 347 patients with MCCs were recruited from a tertiary hospital in North Anhui, China. A self‐reported questionnaire, including socio‐demographic and clinical variables, the 12‐item Short‐Form survey version 2 on quality of life, and the Hospital Anxiety and Depression Scale, was administered to outpatients. Findings showed that rural participants reported more symptoms of anxiety and depression and had worse mental health compared to urban participants. Unemployment status, lower educational level, more long‐term health conditions, and a higher degree of anxiety were associated with worse mental health. This study highlights disparities in mental health among patients with MCCs living in urban and rural areas of China. Appropriate mental health support programmes should be developed for patients with MCCs, especially for those living in rural areas.     

Mental health inpatient experiences of adults with intellectual disability

This paper presents findings from a study exploring the mental health inpatient care of people with a dual disability of intellectual disability and mental health issues from the perspective of those people with the dual disability. A mixture of semi‐structured interviews and focus group interviews were carried out with nine participants who had been admitted to an inpatient unit for mental health care exploring their experience of care. Interviews were transcribed and analyzed using open coding and Leximancer (an online data mining tool) analysis to identify dominant themes in the discourse. Analysis revealed themes around ‘Therapeutic and Meaningful Activity’, ‘Emotion Focussed Care’, and ‘Feeling Safe?’ Participants were able to identify the aspects of inpatient care that worked for them in terms of coping with time in hospital. This research suggests that there are several factors that should be considered in providing effective mental health inpatient care for people with dual disability. A number of strategies and recommendations for responding to their needs are identified and discussed.     

‘I don't want to be here but I feel safe’: Referral and admission to a child and adolescent psychiatric inpatient unit: The young person's perspective

Early and appropriate intervention can assist children and young people manage their mental illness and prevent it becoming a long‐term condition. However, satisfaction with mental health services can influence the level of engagement individuals are willing to participate in beyond the time of the initial contact or hospitalization. A qualitative design was used to identify and understand the experiences of the admission process for young people referred to the sole psychiatric inpatient unit in one Australian state for children up to the age of 18 years. Eleven young people participated in semistructured interviews that were audiotaped, transcribed, and coded. Interview data were examined through thematic analysis. Satisfaction with the inpatient experience was influenced by whether or not young people experienced a sense of connection with staff or other patients on the ward. The ability of nursing staff in identifying and catering to the individual needs of young people in their care facilitated feelings of safety, security, and acceptance, and contributed to the young person's desire to remain engaged in treatment post‐discharge. This research supports the shift towards perceiving patient satisfaction as a separate entity from service delivery and quality, with some participants able to voice dissatisfaction about the lack of services, while reporting overall satisfaction with the inpatient experience.