Preconditions for and consequences of self-determination: the psychiatric patient's point of view

Self-Determination Among Mental Health Consumers/Survivors

It is well known that people with psychiatric disabilities lack self-determination in their lives. A number of studies have demonstrated the high rates of poverty experienced by many of these individuals, leading them to confront a variety of barriers to a higher quality of life. Moreover, concepts of self-determination and client control have not yet proliferated in the public mental health system. In spite of this, consumers/survivors have organized to demand their civil rights and full inclusion in making decisions regarding their own treatment. This article traces the history of self-determination for citizens with psychiatric disabilities, describes major barriers to self-determination, presents several theories of self-determination with potential relevance for mental health consumers/survivors, and offers ways in which self-determination and consumer control might be achieved both within and outside of service systems.

The meaning of good and bad care in the community care: older people's lived experiences

In spite of a considerable body of research in the past decades on what does or does not constitute good care for older people, there are still few studies addressing this question in which older people narrate their experiences of being dependent on community care. This study was therefore carried out aiming to explore older people's lived experiences of what good and bad care meant to them, when it was offered by community care services. Nineteen older persons in three Swedish communities participated in the study, which used a phenomenological-hermeneutic approach. Data were collected through unstructured interviews and Colaizzi's framework was utilized in the analysis of the data. The key theme arising from the analysis was that of being encountered as a human being by caregivers who, through the provision of safe and secure care, provide opportunities for living life as usual. When any of these circumstances are lacking, bad care will be the consequence. As the general intention in society is to ensure good quality of care to older people as well as others, the findings in our study should have important implications for providers of community care for older people.

Nursing Students' Perceptions of Self-Determination in Elderly People

The purpose of this study was to compare nursing students' perceptions of self-determination in elderly patients before and after clinical training in long term care institutions as a part of their course in gerontological nursing. A pre- post-test design was employed. The data were collected by questionnaires completed by students at one nurse education organization college in Finland (pre-test n ± 120, response rate 95%; post-test n ± 115, response rate 91%). The students' perceptions of elderly patients' self-determination were more positive after their clinical training period concerning to what extent elderly patients are able to control their treatment and what kind of support they received from nurses to exercise their self-determination. The students' perceptions remained stable concerning how important self-determination is to elderly patients, and how willing and knowledgeable they are about using their self-determination. Ethics teaching, together with high quality clinical training placements, should be assured early during nursing studies.

Patient participation in clinical decision-making in nursing: a comparative study of nurses' and patients' perceptions

AIM AND OBJECTIVES

The aim of this study was to compare the degree of concordance between patients and Registered Nurses' perceptions of the patients' preferences for participation in clinical decision-making in nursing care. A further aim was to compare patients' experienced participation with their preferred participatory role.

BACKGROUND

Patient participation in clinical decision-making is valuable and has an effect on quality of care. However, there is limited knowledge about patient preferences for participation and how nurses perceive their patients' preferences.

METHODS

A comparative design was adopted with a convenient sample of 80 nurse-patient dyads. A modified version of the Control Preference Scale was used in conjunction with a questionnaire developed to elicit the experienced participation of the patient.

RESULTS

A majority of the Registered Nurses perceived that their patients preferred a higher degree of participation in decision-making than did the patients. Differences in patient preferences were found in relation to age and social status but not to gender. Patients often experienced having a different role than what was initially preferred, e.g. a more passive role concerning needs related to communication, breathing and pain and a more active role related to activity and emotions/roles.

CONCLUSIONS

Registered Nurses are not always aware of their patients' perspective and tend to overestimate patients' willingness to assume an active role. Registered Nurses do not successfully involve patients in clinical decision-making in nursing care according to their own perceptions and not even to the patients' more moderate preferences of participation.

RELEVANCE TO CLINICAL PRACTICE

A thorough assessment of the individual's preferences for participation in decision-making seems to be the most appropriate approach to ascertain patient's involvement to the preferred level of participation. The categorization of patients as preferring a passive role, collaborative role or active role is seen as valuable information for Registered Nurses to tailor nursing care.

Nursing advocacy—a review of the empirical research 1990–2003

This paper provides an overview of the empirical research literature on nursing advocacy. It offers a description of the contexts, methods and issues of validity and reliability used in studies of nursing advocacy, as well as advocacy definitions, activities and consequences as results of those studies. The review focuses on empirical articles retrieved from the CINAHL and MEDLINE databases published between 1990 and 2003. It draws attention to complexity the concept of advocacy, difficulties in operationalisation, and concentration on reactive advocacy from nurses' perspective. There is a lack of research on patients' perspectives of nursing advocacy in general hospital settings.

Swedish patients' perceptions of a preoperative skin test

PREOPERATIVE PREPARATION is an important aspect of creating a safe and pleasant hospital experience for surgical patients. Evaluating patient satisfaction, however, also depends on determining patients' perceptions of the care they receive. THIS STUDY used a descriptive, qualitative method with a phenomenographic approach to determine how patients perceived undergoing a preoperative skin test that was developed to ascertain what substances might result in intraoperative reactions in patients with allergies, asthma, or eczema. OVERALL, the patients had positive perceptions of the skin test; however, the results indicate a need for improved and individualized preoperative instruction that focuses on patients from a holistic perspective.

Causes and management of patient aggression and violence: staff and patient perspectives

AIM

This paper reports a study of staff and patient perspectives on the causes of patient aggression and the way it is managed.

BACKGROUND

The incidence of aggression in healthcare is reportedly on the increase, and concerns about the management of this problem are growing.

METHOD

A convenience sample of 80 patients and 82 nurses from three inpatient mental healthcare wards were surveyed using The Management of Aggression and Violence Attitude Scale. A further five patients and five nurses from the same sample participated in a number of follow-up interviews.

RESULTS

Patients perceived environmental conditions and poor communication to be a significant precursor of aggressive behaviour. Nurses, in comparison, viewed the patients' mental illnesses to be the main reason for aggression, although the negative impact of the inpatient environment was recognized. From interview responses, it was evident that both sets of respondents were dissatisfied with a restrictive and under-resourced provision that leads to interpersonal tensions.

CONCLUSION

There are differences between the views of staff and patients about reasons for aggression and its management. Future approaches therefore need to be developed that address these opposing views. For example, training in the use of fundamental therapeutic communication skills was advocated by patients, whilst the need for greater attention to organizational deficits was advocated by nurses. A move away from reliance on the use of medication was also felt to be necessary. Evaluation of local needs and practices must be an integral part of this process.

Mental health service user involvement in England: lessons from history

This historical analysis draws attention to differing assumptions, which promote or limit user involvement in nursing practice. The meaning of the term 'user involvement' is analyzed with reference to varying models. A continuum is offered to illustrate the relationship between assumptions about people with mental health problems and their involvement in care. It is argued that the range of views concerning recipients of mental health services, from being dangerous and irrational to being considered equal partners with health professionals, creates an unresolved tension that has existed through the ages. The key to resolving this tension is for all parties openly to acknowledge conflicts between their views and those of others and engage in meaningful dialogue about them. In this way the lessons from history may be learned.

Patients' conceptions of how health processes are promoted in mental health nursing. A qualitative study

The most important goal of nursing care is to promote the subjective experience of health. The health promoting efforts of mental health care nurses must be aimed at creating encounters where the patient will be confirmed both existentially and as an individual worthy of dignity. The patient in mental health care is often viewed by the nurse as nothing more than a passive recipient of care and the belief in the patient's potential is minimal. This can lead to a situation where the patient loses control in the caring situation and feels unable to improve his/her health, which conflicts with the goal of the nursing care. The aim of the study was to describe patients' conceptions of how health processes are promoted in mental health nursing. Twelve patients with experience of mental health nursing were interviewed, and the data material was analysed using a phenomenographic approach. The results show 13 different conceptions of the phenomenon, and these were summarized into four descriptive categories: interaction, attention, development and dignity. The conceptions described show that the patients need to be treated as equals and that the nurse must trust the patient's ability to make decisions and to promote his/her health process. It is suggested that mental health nursing should be built on humanistic science and its view that every individual has the ability to grow and develop. This view is one of the most important preconditions for the promotion of health processes in mental health nursing.

Patients' experiences of psychosis in an inpatient setting

The aim of this report was to describe patients' experiences of psychosis in an inpatient setting. Mental illness, as a result of psychosis, has traditionally been defined from the viewpoint of clinical experts. Psychiatric nursing, as an interactive human activity, is more concerned with the development of the person than with the origins or causes of their present distress. Therefore, psychiatric nursing is based on eliciting personal experiences and assisting the person to reclaim her/his inner wisdom and power. The design of the study, in the report discussed below, was phenomenological. In 1998, nine patients were interviewed regarding their experiences of psychosis in an acute inpatient setting. The verbatim transcripts were analysed using Giorgi's phenomenological method. The participants experienced psychosis as an uncontrollable sense of self, which included feelings of change and a loss of control over one's self with emotional distress and physical pain. The participants described the vulnerability they had felt whilst having difficult and strange psychological feelings. The informants experienced both themselves and others sensitively, considered their family and friends important and meaningful, and found it difficult to manage their daily lives. Furthermore, the informants experienced the onset of illness as situational, the progress of illness as holistic and exhaustive, and the admission into treatment as difficult, but inevitable.

Self-respect, dignity and confidence: conceptions of integrity among male patients

BACKGROUND

Integrity is a complex and important concept in ethical reasoning and in nursing care. Integrity is part of being a human being, a wholeness, and in this sense it also refers to health. Preserving patients' integrity is an important aspect of nursing care, as a number of situations arise in which they can feel threatened or violated. Integrity can also refer to acting according to general ethical principles and rules, i.e. moral integrity.

AIM

The aim of this Swedish study was to describe how male patients conceive integrity.

METHODS

Seventeen male patients were strategically selected for interviews, which were analysed by a phenomenographical approach.

FINDINGS

The patients expressed 12 different conceptions of integrity that were summarized into three description categories: self-respect, dignity and confidence. This means that patients give themselves integrity when they believe in themselves, have the courage to set boundaries, have control over themselves and their situation, and have the possibility of being alone. Caregivers can preserve a patient's integrity by seeing him as trustworthy and as a whole person, and by showing respect. Confidence in a caring situation is characterized by trust in professionals, a balance between patients' and the caregivers' wishes, patient participation, the possibility of being free and confidentiality of information.

DISCUSSION

Integrity could be described as what something 'is' and as a 'relationship' with oneself and others. It is imperative that caregivers are aware of patients' conceptions of integrity in order to identify and preserve their integrity and also so that they treat them in accordance with moral integrity. The findings are limited to male patients, and questions about female patients' conceptions are raised.

An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: a pluralistic design

Following an initial springboard study, a further more extensive piece of research was conducted to identify and evaluate approaches used to manage patient aggression and violence on three acute mental health wards. Data were gathered using an incident form, a questionnaire and interviews. The views of patients (n = 80), nurses (n = 72) and medical staff (n = 10) were explored. Findings revealed a clear distinction between the way staff and patients view both the problem and the response. Patients' view present staff approaches as 'controlling' and believe that environmental and poor communication factors underpin aggressive behaviour. Staff, conversely, attribute aggressive behaviour to internal patient and external factors, which may explain the reason for approaches used. A strong correlation was found between type of patient aggression and response (r = 0.36, P < 0.000) and a high percentage of incidents reported were of an aggressive, as opposed to violent, nature. For example 70% of incidents involved verbal abuse or threat. Despite this, 47% (n = 103) of approaches incorporated the use of medication, restraint or seclusion. These are commonly referred to as traditional methods. Patients clearly view this controlling style as a part of the problem and an emphasis upon control and symptom reduction may be inappropriate given the type of aggression encountered. Key issues were further analysed using an internal, external and situational model, each of which endeavour to explain reasons for patient aggression from different perspectives. It is this emphasis upon sole perspectives that may both contribute to and result in the use of a limited number of management approaches adopted in practice. The integration of all three models to examine the complex nature of patient aggression and violence from a variety of perspectives may be the way forward. As a result, approaches to deal with this problem could be more meaningful and subsequently effective.

Patients' perceptions of self-determination as expressed in the context of care

AIM

The aim of this study was to describe patients' perceptions of how self-determination finds expression in the context of care.

BACKGROUND

Self-determination is an important concept within health care as well as an important patient right. New legislation on patient rights in Sweden and Europe is aimed at increased patient self-determination.

DESIGN AND METHOD

Data were collected through semi-structured, tape-recorded interviews with 17 strategically chosen patients within somatic care and analysed using a method inspired by phenomenography.

RESULTS

The analysis found three descriptive categories of the informants' perceptions: trusting, accepting and a feeling of powerlessness. The patients expressed a great sense of trust and confidence in the care provided and they accepted the health care procedures. At the same time, they expressed a feeling of powerlessness because of not being part of decision-making, as well as lacking knowledge and information about treatment strategies. The patients wished to have the right of more self-determination but lacked the strength and knowledge to be able to influence their own care.

CONCLUSIONS

Patients' perceptions of self-determination suggest that, in their encounters with the professional care, knowledge is expressed as power. The feeling of a lack of self-determination can be reduced by help and support from a nurse who allocates time for communication in order to learn the patient's needs and reach a mutual understanding.

Service user involvement in care planning: the mental health nurse's perspective

A dissonance between espoused values of consumerism within mental health care and the 'reality' of clinical practice has been firmly established in the literature, not least in terms of service user involvement in care planning. In order to begin to minimize such dissonance, it is vital that mental health nurse perceptions of service user involvement in the core activity of care planning are better understood. The main findings of this qualitative study, which uses semistructured interviews, suggest that mental health nurses value the concept of user involvement but consider it to be problematic in certain circumstances. The study reveals that nurses hold similar views about the 'meaning' of patient involvement in care planning but limited resources, individual patients characteristics and limitations in nursing care are the main inhibiting factors. Factors perceived as promoting and increasing user involvement included: provision of accurate information, 'user-friendly' documentation, mechanisms for gaining service user feedback, and high staff morale.