Chancers, pests and poor wee souls: problems of legitimation in psychiatric nursing

Exploring Clinical Practice and Developing Clinician Self-Reflection Through Cross Self-Confrontation Methodology: An Application Within an Addiction Medicine Unit

Use of the methodology of cross self-confrontation (CSC) is limited in the field of healthcare and in the context of clinical practice. We applied this methodology within an addiction medicine unit of a university hospital, as part of an exploration of addiction-related clinical difficulties. Cross self-confrontation was used according to a 3-phase design based on video recorded clinical interviews with pairs of nurses and medical doctors. The article reports and discusses the application of CSC in a specific clinical context and illustrates the methodological process through one result. Findings suggest two major strengths of CSC in the context of clinical practice research and education: (1) the capacity to elicit tacit knowledge from daily clinical practice and (2) the ability to enhance self-reflection by questioning professionals both individually and collectively. Further use of CSC in nursing surroundings and clinical settings should be encouraged.

Credibility work and moral evaluation at the ED

This paper contributes to the understanding of triage decision making by analyzing the credibility work jointly performed by patients and staff and its contribution to the non-clinical evaluation of clientele. I argue that the assessment of credibility occurs at the intersection between staff-devised typifications and patients' interactional performance, and is mediated by staff's experiential knowledge. In ordinary circumstances, patients can achieve credibility through three interactional strategies: embodying distress, limiting the voice of the lifeworld, and conveying narrative frankness. Patients belonging to groups associate by triage workers with disreputable characteristics, such as dishonesty, have the additional task of establishing themselves as trustworthy interlocutors by mobilizing worth claims. Embodying distress and limiting the voice of the lifeworld are instrumental to asserting legitimacy, whereas narrative frankness is an interactional prerequisite for manufacturing reasonableness.

Assertive community treatment (ACT) case managers' professional identities: A focus group study

Assertive community treatment (ACT) case managers provide healthcare services to people with severe and persistent mental illness. These case managers take on generic roles in multidisciplinary teams and provide all-around services in the clients' private homes. This focus group study aimed to gain insight into Danish ACT case managers' professional identity work by examining their discussions of ethical dilemmas and collaboration in their everyday practice. Data were collected during five focus groups at three ACT teams in the North Denmark Region and subjected to discourse analysis emphasizing how identity work was accomplished through talk. The findings indicated that the case managers constructed professional identities by actively positioning themselves and the particular ACT approach in relation to other mental healthcare professionals and clients. They represented themselves as achieving better client-related outcomes by being more assertive and persistent, and as responsible caregivers who provided the help that their clients needed when other services had failed to do so. They depicted their services as being focused on the clients' well-being, and their persistent efforts to establish and sustain interpersonal relationships with clients were an important part of their service. Basic nursing tasks were described as an important part of their everyday work, and even though such tasks were not distinctive for ACT case managers, the representations of their work seemed to give them a sense of worth as professionals and legitimized a unique role in the community mental healthcare services.

Participant observation in a secure unit: Care, conflict and control

A participant observation study was carried out at a secure (forensic) unit called Delphi. This unit was one of several set up throughout Britain following the Report of the Butler Committee1. This particular unit announced in a series of statements that it now functioned as a therapeutic community of the kind described by Rapaport2. Given that conflict had always attended the relative weighting of custody and care within psychiatric institutions, it was decided to examine the veracity of their claim. It was anticipated that such a therapeutic undertaking would induce struggle and conflict among the staff. A feature of this study is its entrée strategy and style of observations: these were designed to minimise subjects' perceptions of the vigour of the research as well as to attain as uncontaminated a picture of the unit as possible. The ethics of this strategy are reviewed. Observational data were supported by interviews plus a small panel of independent verifiers. Consistent with ethnographic studies generally, results are presented as verbal statements of the participants. The discussion identifies some problems associated with qualitative research generally and suggests that further studies in this area be more specific and systematic.

Understanding "revolving door" patients in general practice: a qualitative study

Background

‘Revolving door’ patients in general practice are repeatedly removed from general practitioners’ (GP) lists. This paper reports a qualitative portion of the first mixed methods study of these marginalised patients.

Methods

We conducted qualitative semi-structured interviews with six practitioner services staff and six GPs in Scotland, utilizing Charmazian grounded theory to characterise ‘revolving door’ patients and their impact from professionals’ perspectives.

Results

‘Revolving door’ patients were reported as having three necessary characteristics; they had unreasonable expectations, exhibited inappropriate behaviours and had unmet health needs. A range of boundary breaches were reported too when ‘revolving door’ patients interacted with NHS staff.

Conclusions

We utilise the ‘sensitising concepts’ of legitimacy by drawing on literature about ‘good and bad’ patients and ‘dirty work designations.’ We relate these to the core work of general practice and explore the role that medical and moral schemas have in how health service professionals understand and work with ‘revolving door’ patients. We suggest this may have wider relevance for the problem doctor patient relationship literature.

Categorizing "frequent visitors" in the psychiatric emergency room: a semistructured interview study

Nurses can become demoralized and hostile toward frequent visitors in psychiatric emergency rooms because of the number of visits. The aim of this study was to develop more knowledge about the ways in which nurses categorize frequent visitors. Eleven nurses were interviewed, and their categorizing practices were examined from a social constructionist perspective. The results showed that the nurses did not categorize frequent visitors as particularly unlikeable or difficult to treat. Like other visitors, they could be categorized as difficult if they obstructed a smooth flow of successful referrals through the emergency room and/or there was poor rapport with the nurses.

The importance of reciprocity in relationships between community-based midwives and mothers

OBJECTIVE

to explore the emotion work experiences of community-based midwives, focusing on their relationships with clients.

DESIGN

a qualitative study using an ethnographic approach. Data were collected via observation, interview and focus groups.

SETTING

a National Health Service (NHS) Trust in South Wales, UK.

PARTICIPANTS

a purposive sample of 19 NHS community-based midwives, working in different teams and with differing lengths of clinical experience.

FINDINGS

relationships between midwives and women varied considerably, and could be the source of emotion work for midwives. A model of midwife-woman relationships is proposed, based on the concept of reciprocity. Four key situations are identified: balanced exchanges, rejected exchanges, reversed exchanges and unsustainable exchanges. Balanced exchanges occur when there is 'give and take' on both sides; these are emotionally rewarding for the midwife. The other exchanges are out of balance, and require emotion work by the midwife.

KEY CONCLUSIONS

the concept of reciprocity is a useful analytical tool that enhances understanding of midwife-woman relationships and the emotion work that these may generate. Increased understanding of these issues is important, given the current national and international policy recommendations for health-care professionals to work in partnership with clients.

IMPLICATIONS FOR PRACTICE

the midwife-woman relationship and the factors that affect it need to be explicitly addressed within educational settings, in order to further develop interpersonal and communication skills. In turn, this should enhance the emotional well-being of midwives and the quality of care that women receive. Additional research is needed to further develop and refine the model.

Closeness, chaos and crisis: the attractions of working in acute mental health care

This paper makes a case for the attractiveness of acute mental health inpatient nursing (acute nursing) and argues that an altered perception of this work is essential if we are to provide the most acutely mentally ill and vulnerable people with a stable and expert nursing workforce. The discussion draws on an ethnographic study conducted in an inner-city psychiatric unit in England and the advantages of this method for understanding nursing work are described. Within our findings, we set out two overarching themes: the contextual realities of the contemporary acute ward and features of attraction that encourage nurses to work in the acute care setting. The former includes nurses' responsibility for the total ward environment and the latter the 'comfort of closeness' and 'surviving and thriving in chaos and crisis'. In conclusion, we argue that despite the unpopularity of the acute inpatient mental health environment, the highly sophisticated skills employed by acute nurses actually ensure the promotion of health for the majority of service users.

Attitude to personality disorder among prison officers working in a dangerous and severe personality disorder unit

BACKGROUND

It is well established that staff attitudes to personality disordered patients are commonly negative, characterised by pessimism and rejection. A recent study in forensic psychiatric hospitals has described the psychological and social factors underlying positive attitudes, and suggested that staff with more positive attitudes perform better and are less stressed.

AIM

To assess whether it is possible to predict which staff will adjust positively to working with personality disordered people. More specifically to confirm links between attitude to personality disorder and: job performance; perception of managers; personal well-being; burnout; and interaction rates with inmates.

METHODS

The opening of a new Dangerous and Severe Personality Disorder unit within a UK prison allowed a longitudinal study of prison officers to be performed, in which a number of measures, including the Attitude to Personality Disorder Questionnaire (APDQ), were collected at three fixed points (at baseline, eight and sixteen months after the opening of the unit).

RESULTS

Attitude to Personality Disorder varied over the course of the study, and changes in attitude were linked to events experienced by individual officers. More positive attitude to personality disorder was associated with improved general health and job performance, decreased burnout, and favourable perception of managers.

CONCLUSIONS

Attitude to Personality Disorder has important outcomes, and is responsive to the psychosocial environment. Its measurement is not useful for staff selection, because of low stability over lengthy time periods. The APDQ has been demonstrated to be valid measure of attitude to PD, and potentially useful for outcome studies, or benchmarking between units.

Dangerous and severe personality disorder: an ethical concept?

Most clinicians and mental health practitioners are reluctant to work with people with dangerous and severe personality disorders because they believe there is nothing that mental health services can offer. Dangerous and severe personality disorder also signals a diagnosis which is problematic morally. Moral philosophy has not found an adequate way of dealing with personality disorders. This paper explores the question: What makes a person morally responsible for his actions and what is a legitimate mitigating factor? How do psychiatric nurses working with this client group understand the awful things some clients do? What concepts do they need, if they are to know how to explain and how to react? It is suggested that dangerous and severe personality disorder is best regarded as a moral category, framed in terms of goodness, badness, obligation and other ethical concepts. It seems plausible that in important ways the dangerous and severe personality disordered client does not understand morality or understands it differently. The peculiar position of the dangerous and severe personality disordered individual in our system of moral responsibility stems from his apparent inability to see the importance of the interests of others. It might be more helpful to regard personality disordered clients as we do children: partially but not fully reasonable for their actions. We might regard the dangerous and severe personality disordered client responsible for those actions which he most clearly understands, such as causing others physical pain, but not for those with which he is only superficially engaged, such as causing emotional pain. The paper concludes by suggesting that the dangerous and severe personality disordered individual does not fit easily into any conventional moral category, be it criminal, patient, animal or child, and thus an assessment of his moral accountability must take into consideration his special circumstances.

Changes in attitudes to personality disorder on a DSPD unit

BACKGROUND

Psychiatric professionals tend to have poor attitudes towards people who suffer from personality disorder. Previous studies suggest that such attitudes are influenced by sufferer behaviours, organizational factors and the characteristics of individual professionals, but do similar considerations apply outside health services?

AIM

To identify what events, experiences and factors in the course of daily work with personality-disordered people influence the attitudes and beliefs of prison staff.

METHOD

Semi-structured interviews were conducted with prison officers working in a pilot "Dangerous and Severe Personality Disorder" Unit within a UK prison. Open questions were asked about any changes in their attitudes to or beliefs about personality-disordered inmates.

RESULTS

Positive influences on attitude were: development of greater understanding of personality disorder and prisoners as individuals; improvement in inmate behaviours; education; the staff counselling programme; staff sharing support and skills; the challenge and purpose of the new role and having their views listened to. Negative influences were: delays in establishing the treatment programme; some inmate behaviours; fear and concern over their new roles and negative portrayal as a profession in the media.

CONCLUSIONS

In order to maintain a high overall positive attitude among staff to working with people with personality disorder, units should have: consistency of direction and timely implementation of anticipated developments; clear philosophy and treatment regime; substantial investment in staff training programmes and effective programmes for the provision of clinical supervision to frontline staff.

Doctors, "dirty work" patients, and "revolving doors"

Using information from research into the phenomenon of "revolving-door" psychiatric patients, the author explores general practitioners' perceptions of difficult patients and the consequences for patient management. He first considers the concept of "good and bad" as a possible subtype of dirty work. He then presents the evidence of medical irritation with patients from interview data and explores the rationalizations for the way in which patients are subsequently managed. In line with previous studies, the author argues that the construction of patients as difficult and the subsequent dynamics of exclusion lie in the breakdown of the "normal" doctor-patient relationship coupled with the doctor's need to get on with the day's workload. Moral judgments formed a part of the exclusion process.

Nurses and the 'therapeutic relationship': Caring for adolescents with anorexia nervosa

BACKGROUND

Research studies suggest that hospital programmes for young people diagnosed with anorexia nervosa have high readmission rates and limited effectiveness. Nurses caring for these adolescents face a particular set of problems in seeking to establish therapeutic relationships.

AIM

This paper reports a study with the original aim of providing rich data on the development of therapeutic relationships between adolescents diagnosed with anorexia and paediatric nurses. However, it was discovered that paediatric nurses were struggling to develop therapeutic alliances with these adolescents. The study was then modified to explore the difficulties and obstacles hindering the formation of therapeutic relationships in this context.

METHOD

The study used naturalistic inquiry. The 10 participants were Registered Nurses from the acute wards of an Australian children's hospital with at least 2 years' experience of caring for adolescents with anorexia nervosa. The data were collected using semi-structured interviews that were recorded on audiotape and then thematically analysed both manually and with the aid of the NUD*IST computer package.

FINDINGS

Participants described how they struggled to develop therapeutic relationships in this clinical environment. Three themes emerged: (1) 'Struggling for understanding' explores the difficulties nurses experienced in coming to terms with the complexities of a diagnosis of anorexia nervosa and its recovery processes. (2) 'Struggling for control' examines the power struggle between nurses and patients and the mutual distrust that often developed between them as a consequence of this struggle. (3) 'Struggling to develop therapeutic relationships' describes the difficulties some nurses had in establishing therapeutic alliances with these adolescents.

CONCLUSION

Recommendations are made for improving the nursing component of hospital treatment programmes for adolescents with anorexia nervosa in the direction of more genuinely therapeutic relationships.

Struggling for control: the care experiences of 'difficult' patients in mental health services

Although there is increasing recognition of the existence of 'difficult' patients who present particular challenges to mental health nurses, no research has been conducted into their perceptions of services and their experiences of care. This study identifies mental health service users who are defined by nurses as 'difficult' and explores their perceptions of their care experience. The results support earlier studies which suggested that 'difficult' patients challenge nurses' competence and control: despite their different roles both nurses and 'difficult' patients were aware of the struggle to gain or retain a notion of control. Respondents were able to identify the qualities of nurses and nursing interventions which had a positive effect on their care experience. Where nurses were perceived to demonstrate respect, time, skilled care and a willingness to give patients some control and choice in their own care, feelings of anger were reduced. These findings are discussed within the conceptual framework of 'power over' and 'power to' and implications for practice and research are considered.

Building a relationship: communications and relationships between staff and stroke patients on a rehabilitation ward

Communications among staff and patients on a stroke rehabilitation ward form the focus of this article, which reports on some aspects of a larger study using a grounded theory approach. Tape-recorded interviews were transcribed and analysed concurrently according to recommendations for the approach. A main theme entitled building a relationship was identified, and this process was found to occur in a context varying from participative at one end of a continuum to hierarchical at the other. Building a relationship was found to be influenced by role, personal qualities and organizational context. Appropriate relationships between role-holders were subject to negotiation, leading to a resulting congruence or incongruence between participants' expectations of each other and their roles. Personal qualities were brought into play in the process, with patients' views of staff and staff views of patients both being influential. Some of these views seemed to parallel what has been described in earlier literature as 'the sick role' and the labelling of patients as 'good' or 'bad'. Responses to personal qualities led to nurses ascribing meaning to patients' behaviour in terms of adjustment to their stroke, giving time to them to help them to adjust, and withdrawal and handing over to other staff if this strategy failed. Organizational context also had an influence on building a relationship, with time constraints being identified particularly by nurses, and the need to fit in the most essential aspects of care. Place was also important, in that nurses were confined to the ward as a work location, whereas other therapists and doctors worked in other places and sometimes had the facility to take patients off the ward to concentrate on therapy. The findings are discussed against the background of related literature and the conclusion is drawn that the crucial role of nurses in rehabilitation is not recognized and valued, and that shortages of resources-especially suitably qualified and trained nursing staff-are a negative influence on building the relationships which are vital to successful rehabilitation.

Nurses' power in interactions with patients

Power in interactions between nurses and patients, as mediated through language, is examined in this paper. The findings from an observational study confirm much previous research in that the majority of nurse-patient interactions were superficial, routinized and related to tasks. It was found that nurses exert a lot of control over interactions and the linguistic devices used to achieve this are explored. Links are established between macro-level factors, such as the institution, and the micro-level of nurse-patient encounters, to demonstrate how wider forces affect and are reflected in interactions. Examination of the interactions also reveals issues of conflict arising from the caring and controlling functions that nurses perform. It is suggested that the power dimension inherent in the relationship constitutes a barrier to open and meaningful communication between nurses and patients.

Stereotypes of women of Asian descent in midwifery: some evidence

The subject of this paper is part of a larger study which investigated the delivery of maternity care to women of South Asian descent in Britain (Bowler, 1990). An ethnographic approach was used and the main method of data collection was non-participant observation in antenatal clinics, labour and postnatal wards in a teaching hospital maternity unit. These observations were supported by data from interviews with midwives. It was found that the midwives commonly use stereotypes of women in order to help them to provide care. These stereotypes are particularly likely to be used in situations where the midwife has difficulty (through pressure of time or other circumstances) in getting to know an individual woman. The stereotype of women of Asian descent contained four main themes: communication problems; failure to comply with care and service abuse; making a fuss about nothing; a lack of normal maternal instinct. Reasons for stereotyping are explored. Effects on service provision in the areas of family planning and breast feeding are highlighted.

Patient participation: its meaning and significance in the context of caring

The ideal that patients should be participants in their own care has found wide acceptance amongst nurses. Yet within the academic discipline of nursing little has been done to clarify the nature of participation. In this paper, a phenomenology of participation is presented as it applies to the caring work of nursing. Participation requires: (a) attunement to a mutual 'stock of knowledge at hand'; (b) emotional and motivational attunement to the other's concerns; (c) taking for granted (and implicitly assuming the other takes it for granted) that one can contribute worthily; (d) feeling that one's identity is not under threat. Though it is difficult to attain, participation appears to embody many of the ideals central to current thinking in nursing. Moreover, the attempt to build participatory relationships with patients is ethically required of members of a 'caring' profession.

Research on nurse-patient relationships: problems of theory, problems of practice

Research, theoretical and educational literature on interpersonal relations between nurses and patients has proliferated since the 1960s. This has generated a range of divergent accounts of what the nurse-patient relationship (NPR) ought to be; how this should be achieved; and how the NPR is constituted in practice. In this paper--through a selective review of the literature--the development of two contending perspectives on NPR and on nurse-patient interaction (NPI) characterized as technocratic and contextual, is discussed, and related to the increasingly problematic status of the relationship between nurses and patients in nursing theory and research.

Nursing research, nursing theory and the nursing process

In recent years, practising nurses and nurse theorists have shown interest in the development of conceptual models of nursing and nursing theory. As yet, however, there exists little agreement concerning the most appropriate methodologies to be employed in such an exercise. This paper identifies a number of strategies which might usefully be adopted for this purpose. In particular, it distinguishes between inductive and hypothetico-deductive approaches to the development of nursing theory. It further attempts a clarification of the relationship between conceptual models of nursing and theories of nursing, and explores the use of the nursing process as a research technique which combines both inductive and hypothetico-deductive commitments. Finally, it argues that the systematic use of the nursing process may identify a set of research procedures with the potential to facilitate the development of nursing theory using insights from both the direct experience of practising nurses and from existing conceptual models of nursing.

Loss and grief reactions as responses to surgery

Using autobiographical material, the patient experience of major surgery (panproctocolectomy and ileostomy) is described. A number of stages are identified in the patient experience: the development of dependence before surgery; disconnectedness from the social world immediately after surgery; and reality shock as grief and loss became apparent. The data are analysed using a theoretical perspective originally developed to describe reactions to bereavement. The practical nursing and counselling implications deriving from the theoretical model are elaborated.