Perspectives in Psychiatric Care
ISSN 0031-5990
Nursing Staff’s Perceptions of Patient Safety in Psychiatric Inpatient Care Anne Kanerva, RN, MHS, Johanna Lammintakanen, PhD, and Tuula Kivinen, PhD Anne Kanerva, RN, MHS, is a Clinical Nursing Specialist, Central Finland Health Care District, Jyväskylä, Finland; Johanna Lammintakanen, PhD, is a Professor, Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland; and Tuula Kivinen, PhD, is Head of Research and Development in Nursing, Central Finland Health Care District, Jyväskylä, Finland.
Search terms: Content analysis, inpatient care, mental health care, patient safety, psychiatric care Author contact: anne.kanerva@ksshp.fi, with a copy to the Editor: [email protected] Conflict of Interest Statement The authors report no actual or potential conflicts of interest. First Received April 4, 2014; Final Revision received October 2, 2014; Accepted for publication December 8, 2014.
PURPOSE: This study aims to explore nursing staff’s perceptions of patient safety in psychiatric inpatient care. DESIGN AND METHODS: Nurses were asked to describe their perceptions in semi-structured interviews, and their responses were analyzed by inductive content analysis. FINDINGS: Nurses addressed two sets of factors: one related to the experiences of safety and the other related to the implementation of safe care. PRACTICE IMPLICATIONS: The views of the nurses contribute to formalization of organizational policies and strategies. In particular, they highlight the importance of continual training for the staff and management, considering patients’ views, and treating patients as collaborators in their care.
doi: 10.1111/ppc.12098
Patient safety is a key foundation of quality health care (Ministry of Social Affairs and Health, 2009; World Health Organization, 2010). Most discussion of patient safety in psychiatric hospitals has focused on events that cause physical harm to the patients, particularly harm potentially associated with seclusion, restraint, and medication (Jeffs, Rose, Macrae, Maione, & Macmillan, 2012). However, patient safety in psychiatric inpatient care also has numerous other perspectives. Notably, relatively little attention has been paid to near-miss situations (Jeffs et al., 2012) and the emotional harm that may be connected to psychiatric care (Brickell et al., 2009). Furthermore, various procedures affect the safety of both the patients and staff of psychiatric inpatient units (Koukia, Giannouli, Gonis, & Douzenis, 2010), including (inter alia) seclusion and restraint procedures (Bowers, Van Der Merwe, Paterson, & Steward, 2012; Brickell et al., 2009; Happell & Harrow, 2010; Hyde, Fulbrook, Fenton, & Kilshaw, 2009; Moran et al., 2009) and other containment measures to prevent self-harm (James, Steward, & Bowers, 2012). Thus, the organization’s culture—interactively formed by management, staff, and patients (Kanerva, Lammintakanen, & Kivinen, 2013)—is a critical patient safety factor. A supportive, creative culture imbued with effective leadership and collaboration enables the delivery of safe care through the Perspectives in Psychiatric Care 52 (2016) 25–31 © 2015 Wiley Periodicals, Inc.
sharing of values and norms, creation of trust, and consistent application of best practices at team, unit, and organization levels (Kaufman & McCaughan, 2013; Weaver et al., 2013). For example, management practices strongly influence how staff view patient safety (Kanerva et al., 2013). Appropriate, visible management practices and commitment to safety also promote conditions for implementation of safe care and foster a patient safety culture (Feng, Acord, Cheng, Zeng, & Song, 2011; Ginsburg et al., 2010; Richardson & Storr, 2010). However, the frontline staff are the actors who utilize created opportunities (Kanerva et al., 2013) and manifest the culture in interactions with patients. Thus, their professional skills are critical, notably their competence in medication, therapeutic activities, attending to patients’ needs (Fourie et al., 2005), management of aggressive and violent behavior, de-escalation (Azeem, Aujla, Rammerth, Binsfeld, & Jones, 2011; Lewis, Taylor, & Parks, 2009; Salzmann-Krikson, Lützén, Ivarsson, & Eriksson, 2008), and interpersonal skills (Jeffs et al., 2012; MacNeela et al., 2010; Price & Baker, 2012). Their perceptions and commitment to safety are equally critical. More attention has also recently focused on care elements that can cause patients anxiety and fear, thereby exacerbating safety risks in addition to elements that may lead to physical 25
Nursing Staff’s Perceptions of Patient Safety in Psychiatric Inpatient Care
harm (Azeem et al., 2011; Bowers et al., 2012; Happell & Harrow, 2010; Lewis et al., 2009; Steward, Van der Merwe, Bowers, Simpson, & Jones, 2010). These include widely used seclusion and restraint practices to manage aggressive behavior (Dumais, Larue, Drapeau, Menard, & Giguère Allard, 2011; Lewis et al., 2009; Moran et al., 2009). Rigid application of rules and regulations, constant observation, and inappropriate staff actions may also be traumatic experiences for patients (James et al., 2012; Steward, Bowers, & Ross, 2011). The main role of patients in delivering safe care has traditionally been as informants of personal preferences (Kanerva et al., 2013). However, as interest in patients’ experiences has risen (Kontio et al., 2012; Steward et al., 2010; Strout, 2010), more efforts have been made to gather patient’s views as important factors to consider when developing best practices (Bennetts, Cross, & Bloomer, 2011; Jeffs et al., 2012; Kontio et al., 2012; Warne & McAndrew, 2007). Despite these recent shifts in research foci, more understanding is required of several broad dimensions of patient safety in psychiatric care (Brickell et al., 2009; Kanerva et al., 2013), including the roles of culture, management, staff, and patients. There is also too little knowledge about how nurses who work in psychiatric inpatient care view patient safety, although they are the key care deliverers. Therefore, understanding their perception is essential for the development of patient safety. Thus, this article’s purpose is to explore nursing staff’s perceptions of patient safety in psychiatric inpatient care. Materials and Methods All the nurses (34) who were working in two psychiatric hospitals in Finland on morning shifts of a randomly chosen weekday were contacted by e-mail with information about the research and asked to participate. A reminder e-mail was sent 2 weeks after the first contact to those who had not responded. No response to the two e-mails was interpreted as unwillingness to take part in the research. No explanation was asked from the potential interviewees. The wards provide specialized psychiatric acute and rehabilitative care for adult patients, with any psychiatric diagnosis, to a population of 275,000 people. One of the wards is an open ward and five are closed wards. One of the closed wards can implement seclusion and restraint care, and has developed these practices aiming to reduce their use. All staff has been trained to handle threatening care situations. Altogether, 26 nurses (10 male, 16 female) replied and indicated willingness to participate. Their ages varied from 23 to 60 years (mean, 39 years), and they had 1–30 years work experience (mean, 11 years). Interviews were conducted during September and October 2011. To ensure the nurses responses would stay confidential, the interviews were conducted in separate meeting rooms outside the 26
wards and the interviewees’ names and wards where they were working were not documented. They were interviewed after they were given information about the research and its purpose. During the interviews they were given the opportunity to freely describe patient safety as they see and understand it. Interview themes also included how it appears in their work and the factors in their work that affect it from their perspective. Nurses were then asked to give examples and elaborate the factors they brought up. The interviews were digitally recorded and then transcribed verbatim. The transcribed texts were analyzed by inductive content analysis, without using a software program, by the same researcher who did the interviews and the transcription, which involves open coding, category creation, and abstraction (Elo & Kyngäs, 2008). Sentences describing patient safety factors in the texts were identified, then grouped under thematic categories and higher order headings. Each category was then named using content-characteristic words and subdivided into subcategories concerning similar issues. This resulted in the creation of two main categories of safety perceptions and several subcategories of both main categories. Ethics Ethical approval for the study was obtained from the Central Finland Health Care District Ethical Committee. The interviewees were informed about the research and its purpose, their voluntary participation, and their right to withdraw at any time in accordance with general ethical guidelines (Eriksson & Kovalainen, 2008). No identifiable information is presented to protect the participants’ privacy. Findings As mentioned earlier, and shown in Figure 1, two main thematic categories were identified in the interviewed nurses’ descriptions of patient safety: experiences of safety (factors connected to safety-related feelings) and safety of the implemented care (practical factors related to patient safety). Several subcategories of both of these main categories were also identified, as summarized below. The sentences in displayed quotations are illustrative quotations from the interview transcripts. Experiences of Safety Experiences of safety described in the nurses’ responses covered general experiences of the safety of the environment, staff’s experiences of safety, and patients’ experiences of safety. General experiences of safety refers to the overall feeling of safety for everyone in the ward. Contributing factors that the nurses mentioned included the peacefulness of the atmosphere, the absence of physical threats, and otherwise distressing behavior. Perspectives in Psychiatric Care 52 (2016) 25–31 © 2015 Wiley Periodicals, Inc.
Nursing Staff’s Perceptions of Patient Safety in Psychiatric Inpatient Care
General experiences of safety
Experiences of safety
Staff's experiences of safety
Patients' experiences of safety Patient safety in psychiatric inpatient care
Patients' experiences of being safe from other patients
Patients' experiences of being safe from staff
Holistic care understanding Shared practices of the staff
Safety of the care implementation
Figure 1. Categories and Subcategories of Patient Safety Factors in Psychiatric Inpatient Care Identified From the Nurses’ Responses
I understand this as meaning that everyone in this hospital, no matter if it is staff or patients . . . everyone can feel it is safe here. Nurses described staff’s experiences of safety as essential for their ability to work effectively. They saw the absence of feelings that there were any threats of physical or mental violence in the ward as highly important. They also regarded alarm systems to summon help quickly as being crucial for their psychological security. If you think about our situation, that staff can work and do their work safely is very important. Nurses described patients’ experiences of safety as the three factors related to these experiences: patients’ experiences of being safe from themselves, from other patients, and from staff. They regarded patient’s general experience of safety as highly important and stated that it can be enhanced through good relationships between staff and patients, staff listening to patients, and providing privacy. Perspectives in Psychiatric Care 52 (2016) 25–31 © 2015 Wiley Periodicals, Inc.
Patients' experiences of being safe from themselves
Safe care practices
Maintenance of staff's professional skills
Safe care environment
Fire safety of the ward
Care culture of the ward
Design and condition of the hospital
Laws guiding the care
Adequate resources
Nurses thought patients’ experience of being safe from themselves as important but difficult to promote. They also mentioned that these experiences could be jeopardized by patients’ poor mental health, for example, patients may perceive threats that do not exist and be unable to evaluate their situations rationally. Poor somatic health can also pose threats, leading, for example, to falls and patients hurting themselves. Safety is not only about not being afraid of physical threats—when you think about the reasons many patients come here, there is a kind of fear caused by the patient’s own thoughts. Nurses stated that patients’ experience of being safe from other patients can be threatened by other patients’ aggressive behavior even if it is directed toward another person or object. Seeing other patients’ threatening behavior can bring insecurity to the patient. Other patients can also undermine patients’ security by spreading confidential information. 27
Nursing Staff’s Perceptions of Patient Safety in Psychiatric Inpatient Care
Nothing happens here, and an important aspect is that there is no violence, you can be left in peace and you don’t need to fear other patients. Patients’ experiences of being safe from staff (the third factor affecting patients’ experience of safety) was sometimes threatened, according to the nurses, by previous negative experiences causing patients fear in the present. When this happens, the adverse experiences can badly affect both care and patient safety they said. For example you need to take a narcotic urine sample and there are two staff members supervising it; this can sometimes be an overwhelming situation. Sometimes the patient feels cornered and during this summer one older patient had that sort of experience. I understood it was related to situations that had happened decades ago when he felt he had been attacked, and he asked if he needed to struggle. Safety of the Care Implementation The nurses mentioned five factors affecting the safety of the care implementation: holistic care understanding, safe care practices, the care environment, the care culture of the ward, and laws guiding the care. Nurses described holistic care understanding as personalized implementation of care, including continuous re-evaluation of patients’ diagnoses when required, to ensure that they receive calm, appropriate, supportive care with seamless transitions, recognizing the importance of their safety in all phases. What is best for each patient is always considered and how to reach it . . . I think that when I am at work, all my actions and actions of our team focus on this, and that is crucial for patient safety. Safe care practices formed through shared practices of the staff and maintenance of their professional skills were also regarded as being important elements of care implementation. Shared practices of the staff, the nurses said, provide crucial clarity so everyone knows the established procedures and can follow them in both their everyday work and emergency situations, for instance, during fire alarms. For example, if the fire alarm rings, everyone should know how to act, where to take the patients and so on. Maintenance of staff’s professional skills (e.g., competence in providing medication, adequate nutrition, resuscitation, seclusion and restraint care, and understanding of relevant laws and fire safety) was regarded as essential. Medication care skills were mentioned most often. In the nurses’ experience, most directly harmful events in the wards were connected to it, and it is the area in which the term patient safety seemed 28
most familiar. Anticipating changes in patients’ condition was also seen as important as it helps to plan precautions and thus estimate the adequacy of medication and/or needs for extra staff. The first thing which comes to my mind is a concrete thing, medication care, which is probably the source of many harmful events that directly affect the patient, medication errors. A safe care environment was regarded as essential for safe care. This includes fire safety of the ward, design and condition of the hospital, and adequacy of resources. Nurses said that fire safety of the ward should be considered while refurbishing wards and deciding which items are safe to keep in them. For instance, they felt that some items, like ordinary carpets, could make wards more homelike but pose additional threats. Well, fire safety of course. Patients don’t have lighters, and materials of the ward are the kinds that don’t light up too easily. There are not too many items around; there isn’t much furniture in the rooms. Nurses described that the important elements of the design and condition of the hospital included the provision of spaces allowing patients privacy and opportunities to spend time in quiet surroundings. They also said that the ward layout should also allow the staff to observe the ward, the rooms should be sufficiently large and flexible for patients and staff to move easily, and the door frames should be wide. These features enable sufficient people to work in the rooms without accidents. Wide spaces were seen as important, especially in situations where patients act aggressively and several staff are present. The materials should also be carefully selected, for example, floors should not be slippery to avoid falls. In addition, outdoor areas should be well maintained, especially during winter, to prevent slips or falls due to ice or snow. Our doors are too narrow. When we need to take a patient to a seclusion room . . . three people usually walk side by side, nurse-patient-nurse—there may be five people in total and everyone should be able to go through the door at the same time smoothly without hurting themselves. Nurses saw adequate resources (the third important factor for a safe care environment) as including adequate staff, care equipment (e.g., the right belts for restraint care to avoid threats to patient safety), and medication resources. Patient safety is connected to everything starting from the staff resources, equipment resources, and availability of medicines. . . . It is always safer, of course, with more eyes observing and ears listening in the ward, assessing the situations. Perspectives in Psychiatric Care 52 (2016) 25–31 © 2015 Wiley Periodicals, Inc.
Nursing Staff’s Perceptions of Patient Safety in Psychiatric Inpatient Care
Nurses mentioned the care culture of the ward as a crucial factor of patient safety because it affects all activities, events, and the atmosphere in the ward. It was described as affecting how staff act, take responsibilities, commit to practices, and define work aims, for example, how frequently restraint and seclusion practices were used and how they were implemented by the nurses involved. They said the culture was formed gradually over time, and in some wards nurses had noticed that older working cultures still affected practices and patient safety today. Patient safety is affected by the kind of atmosphere in the ward. Our ward has a good atmosphere and students have felt this, we have got good feedback, it is easy to come to our ward, which is transmitted to patients and the kind of care they receive. Laws guiding the care were seen as important aspects of patient safety as they govern patients’ rights, enshrine the right to good care, and frame the guidelines, regarding, for example, restraint and seclusion practices. Furthermore, the nurses mentioned that confidentiality, which is also legally framed, is another important aspect of patient safety. The first thing that comes to my mind when thinking about patient safety is the law that guides the rights of the patient. Right to good care, what comes to my mind are these restraint and seclusion situations and guidelines for them. But I think that patient safety and law cover the whole care. Discussion The purpose of this article is to explore nursing staff’s perceptions of patient safety in psychiatric inpatient care. The results show that although patient safety has been widely discussed in recent years, and patient safety strategies have been formed to enhance it (e.g., Ministry of Social Affairs and Health, 2009), various aspects were not mentioned by the nurses. Generally, discussion of patient safety in this setting focuses on seclusion and restraint care, physical threats, suicide, and medication care (Jeffs et al., 2012; Kanerva et al., 2013). However, many of the interviewed nurses connected patient safety most clearly to only one of these aspects, medication care, and regarded maintenance of their professional skills in providing it as being particularly important. None of the nurses mentioned suicide, and only mentioned seclusion and restraint use when discussing the importance of shared practices, and how they currently vary with respect to patient safety. This is consistent with the findings by Koukia et al. (2010) that different hospitals and wards often have substantially differing policies. Rather than the often discussed topics, the nurses paid more attention to the skills they require to provide safe care. Poor communication can have adverse consequences, such as delays in care provision and Perspectives in Psychiatric Care 52 (2016) 25–31 © 2015 Wiley Periodicals, Inc.
thus threaten patient safety (Jeffs et al., 2012), but communication or other interpersonal skills were not mentioned by the nurses. Many nurses described the experiences of safety mainly through their own feelings of safety, which is an aspect that is often neglected in discussions of patient safety. In addition, the nurses raised issues that can be seen as being part of management’s responsibility, such as providing a safe care environment and adequate resources. They did not specifically mention these as being connected to management. Effective management can, however, enhance patient safety (Kanerva et al., 2013). It is important for management to be visibly engaged in patient safety (Ginsburg et al., 2010), organize team training to promote engagement with safe behaviors (Weaver et al., 2013), and serve as a role model (Kaufman & McCaughan, 2013). Nurses considered patient safety mainly from their own role. They did discuss patients, but as people who experience things rather than as collaborators. However, the patient’s role as collaborator is also important (Kanerva et al., 2013). Nurses also regarded patients’ experiences of safety as important but did not mention that their own experiences could be similar to those of the patients, although seclusion and restraint (for instance) can cause emotional distress to both nurses (Moran et al., 2009) and patients (Strout, 2010). The nurses also described how patients can feel threatened by other patients, staff, or their own poor medical condition. Similar findings have been reported by Jeffs et al. (2012) from both service user and provider perspectives. So when paying attention to and reacting to their own experiences of safety, nurses could also affect patients’ experience of safety. Nevertheless, the interviewed nurses appeared to perceive the patients as recipients of care rather than experts through experience who can participate in the development of patient safety. Furthermore, the nurses did not raise the potential importance of collaboration with patients or how, for example, feedback from the patients about their experiences could be used in the development of safe practices. Limitations A limitation of this study is that the analyses were performed by one researcher. However, the analysis was discussed in the research group. Another limitation of this study is that the interviewees work in the same healthcare district in one country, and thus may have culture-specific views of the topic. Furthermore, at the time of the interviews discussion of patient safety was increasing in the organization. However, psychiatric inpatient care has many similar features and faces similar challenges worldwide; thus, nursing staff perceptions may be similar regardless of where they work. It is also possible that the interviewees did not raise some issues because they expected the interviewer, who has previously worked in psychiatric inpatient care, to know about them already. To 29
Nursing Staff’s Perceptions of Patient Safety in Psychiatric Inpatient Care
minimize this risk, interviewees were asked to elaborate their answers if they pointed out that the interviewer knew what they were describing. Implications for Nursing Practice This study was undertaken to ascertain nurses’ perceptions of patient safety in psychiatric inpatient care. The interviewed nurses described it mainly through their own work. They did not explicitly note the different actors’ roles in patient safety, although safe care requires collaboration of all the actors. The results indicate that a more comprehensive perspective is required, encompassing the organization, culture, management, staff, and patient when developing practices and multidisciplinary training in patient safety. This would allow the staff to develop more holistic views and see the management and patients as collaborators. Management’s active leadership in patient safety practices is important as it has a strong influence. This promotes the implementation of practices, commitment to them, and formation of a culture that supports patient safety. Management should also both provide appropriate training, covering perspectives of all actors, and receive education about methods that can be used to support shared practice development over unit boundaries. These help management to take the required, visible, strong leading role in the development and implementation of robust patient safety-centered practices. More attention should also be paid to patients’ role in enhancing their safety. They need to be regarded as active collaborators, requiring a change in the perspectives of healthcare actors and crucially the culture of the organization. This can be fostered by involving patients, who are experts through experience, in the development of practices. They have experience of the whole care path and can recognize factors that threaten patient safety, which may not be noticed by the staff. Awareness that patients and staff may have similar experiences of issues is also beneficial to both parties. Management could enhance patients’ participation, and a culture that supports it, by inviting these experts through experience to attend courses for multidisciplinary staff and forums where administrative decisions are made. In overall conclusion, healthcare actors and patients both benefit from the development of practices that enhance patient safety and a collaborative culture that supports it. Acknowledgment No external or intramural funding was received. References Azeem, M. W., Aujla, A., Rammerth, M., Binsfeld, G., & Jones, R. B. (2011). Effectiveness of six core strategies based on trauma
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informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. Journal of Child and Adolescent Psychiatric Nursing, 24, 11–15. Bennetts, W., Cross, W., & Bloomer, M. (2011). Understanding consumer participation in mental health: Issues of power and change. International Journal of Mental Health Nursing, 20, 155–164. Bowers, L., Van Der Merwe, M., Paterson, B., & Steward, D. (2012). Manual restraint and show of force: The city-128 study. International Journal of Mental Health Nursing, 21, 30–40. Brickell, T. A., Nicholls, T. L., Procyshyn, R. M., McLean, C., Dempster, R. J., Lavoie, J. A. A., & Wang, E. (2009). Patient safety in mental health. Edmonton, Alberta: Canadian Patient Safety Institute and Ontario Hospital Association. Dumais, A., Larue, C., Drapeau, A., Menard, G., & Giguère Allard, M. (2011). Prevalence and correlates of seclusion with or without restraint in a Canadian psychiatric hospital: A 2-year retrospective audit. Journal of Psychiatric and Mental Health Nursing, 18, 394–402. Elo, S., & Kyngäs, S. H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62, 107–115. Eriksson, P., & Kovalainen, A. (2008). Qualitative methods in business research. Great Britain: Sage Publications Ltd. Feng, X. O., Acord, L., Cheng, Y. J., Zeng, J. H., & Song, J. P. (2011). The relationship between management safety commitment and patient safety culture. International Nursing Review, 58, 249–254. Fourie, W. J., McDonald, S., Connor, J., & Bartlett, S. (2005). The role of the registered nurse in an acute mental health inpatient setting in New Zealand: Perceptions versus reality. International Journal of Mental Health Nursing, 14, 134–141. Ginsburg, L. R., You-Ta, C., Berta, W. B., Norton, P. G., Ng, P., Tregunno, D., & Richardson, J. (2010). The relationship between organizational leadership for safety and learning from patient safety events. Health Services Research, 45(3), 607–632. Happell, B., & Harrow, A. (2010). Nurses’ attitudes to the use of seclusion: A review of the literature. International Journal of Mental Health Nursing, 19, 162–168. Hyde, S., Fulbrook, P., Fenton, K., & Kilshaw, M. (2009). A clinical improvement project to develop and implement a decision-making framework for the use of seclusion. International Journal of Mental Health Nursing, 18, 398–408. James, K., Steward, D., & Bowers, L. (2012). Self-harm and attempted suicide within inpatient psychiatric services: A review of the literature. International Journal of Mental Health Nursing, 21, 301–309. Jeffs, L., Rose, D., Macrae, C., Maione, M., & Macmillan, K. M. (2012). What near misses tell us about risk and safety in mental health care. Journal of Psychiatric and Mental Health Nursing, 19, 430–437. Kanerva, A., Lammintakanen, J., & Kivinen, T. (2013). Patient safety in psychiatric inpatient care: A literature review. Journal of Psychiatric and Mental Health Nursing, 20, 541–548.
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Kaufman, G., & McCaughan, D. (2013). The effect of organisational culture on patient safety. Nursing Standard, 27(43), 50–56. Kontio, R., Joffe, G., Putkonen, H., Kuosmanen, L., Hane, K., Holi, M., & Välimäki, M. (2012). Seclusion and restraint in psychiatry: Patients’ experiences and practical suggestions on how to improve practices and use alternatives. Perspectives in Psychiatric Care, 48, 16–24. Koukia, E., Giannouli, E., Gonis, N., & Douzenis, A. (2010). Security rules and banned items in psychiatric acute admission wards in Athens, Greece. International Journal of Mental Health Nursing, 19, 428–436. Lewis, M., Taylor, K., & Parks, J. (2009). Crisis prevention management: A program to reduce the use of seclusion and restraint in an inpatient mental health setting. Issues in Mental Health Nursing, 30, 159–164. MacNeela, P., Clinton, G., Place, C., Scott, A., Treacy, P., Hyde, A., & Dowd, H. (2010). Psychosocial care in mental health nursing: A think aloud study. Journal of Advanced Nursing, 66, 1297–1307. Ministry of Social Affairs and Health. (2009). Promoting patient safety together. Finnish Patient Safety Strategy 2009–2013. Publications of the Ministry of Social Affairs and Health, 2009:5. Retrieved from http://www.stm.fi/c/document_library/ get_file?folderId=39503&name=DLFE-8037.pdf Moran, A., Cocoman, A., Scott, P. A., Matthews, A., Staniuliene, V., & Valimaki, M. (2009). Restraint and seclusion: A distressing treatment option? Journal of Psychiatric and Mental Health Nursing, 16, 599–605. Price, O., & Baker, J. (2012). Key components of de-escalation techniques: A thematic synthesis. International Journal of Mental Health Nursing, 21, 310–319.
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Richardson, A., & Storr, J. (2010). Patient safety: A literature review on the impact of nursing empowerment, leadership and collaboration. International Nursing Review, 57, 12–21. Salzmann-Krikson, M., Lützén, K., Ivarsson, A., & Eriksson, H. (2008). The core characteristics and nursing care activities in psychiatric intensive care units in Sweden. International Journal of Mental Health Nursing, 17, 98–107. Steward, D., Van der Merwe, M., Bowers, L., Simpson, A., & Jones, J. (2010). A review of interventions to reduce mechanical restraint and seclusion among adult psychiatric inpatients. Issues in Mental Health Nursing, 31, 413–424. Steward, D., Bowers, L., & Ross, J. (2011). Managing risk and conflict behaviours in acute psychiatry: The dual role of constant special observation. Journal of Advanced Nursing, 68, 1340–1348. Strout, T. D. (2010). Perspectives on the experience of being physically restrained: An integrative review of the qualitative literature. International Journal of Mental Health Nursing, 19, 416–427. Warne, T., & McAndrew, S. (2007). Passive patient or engaged expert? Using a Ptolemaic approach to enhance mental health nurse education and practice. International Journal of Mental Health Nursing, 16, 224–229. Weaver, S. J., Lubomksi, L. H., Wilson, R. F., Pfoh, E. R., Martinez, K. A., & Dy, S. M. (2013). Promoting a culture of safety as a patient safety strategy. A systematic review. Annals of Internal Medicine, 158(5), 369–375. World Health Organization. (2010). A brief synopsis on patient safety. Retrieved from http://www.euro.who.int/__data/assets/ pdf_file/0015/111507/E93833.pdf
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ISSN 0031-5990
Nursing Staff’s Perceptions of Patient Safety in Psychiatric Inpatient Care Anne Kanerva, RN, MHS, Johanna Lammintakanen, PhD, and Tuula Kivinen, PhD Anne Kanerva, RN, MHS, is a Clinical Nursing Specialist, Central Finland Health Care District, Jyväskylä, Finland; Johanna Lammintakanen, PhD, is a Professor, Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland; and Tuula Kivinen, PhD, is Head of Research and Development in Nursing, Central Finland Health Care District, Jyväskylä, Finland.
Search terms: Content analysis, inpatient care, mental health care, patient safety, psychiatric care Author contact: anne.kanerva@ksshp.fi, with a copy to the Editor: [email protected] Conflict of Interest Statement The authors report no actual or potential conflicts of interest. First Received April 4, 2014; Final Revision received October 2, 2014; Accepted for publication December 8, 2014.
PURPOSE: This study aims to explore nursing staff’s perceptions of patient safety in psychiatric inpatient care. DESIGN AND METHODS: Nurses were asked to describe their perceptions in semi-structured interviews, and their responses were analyzed by inductive content analysis. FINDINGS: Nurses addressed two sets of factors: one related to the experiences of safety and the other related to the implementation of safe care. PRACTICE IMPLICATIONS: The views of the nurses contribute to formalization of organizational policies and strategies. In particular, they highlight the importance of continual training for the staff and management, considering patients’ views, and treating patients as collaborators in their care.
doi: 10.1111/ppc.12098
Patient safety is a key foundation of quality health care (Ministry of Social Affairs and Health, 2009; World Health Organization, 2010). Most discussion of patient safety in psychiatric hospitals has focused on events that cause physical harm to the patients, particularly harm potentially associated with seclusion, restraint, and medication (Jeffs, Rose, Macrae, Maione, & Macmillan, 2012). However, patient safety in psychiatric inpatient care also has numerous other perspectives. Notably, relatively little attention has been paid to near-miss situations (Jeffs et al., 2012) and the emotional harm that may be connected to psychiatric care (Brickell et al., 2009). Furthermore, various procedures affect the safety of both the patients and staff of psychiatric inpatient units (Koukia, Giannouli, Gonis, & Douzenis, 2010), including (inter alia) seclusion and restraint procedures (Bowers, Van Der Merwe, Paterson, & Steward, 2012; Brickell et al., 2009; Happell & Harrow, 2010; Hyde, Fulbrook, Fenton, & Kilshaw, 2009; Moran et al., 2009) and other containment measures to prevent self-harm (James, Steward, & Bowers, 2012). Thus, the organization’s culture—interactively formed by management, staff, and patients (Kanerva, Lammintakanen, & Kivinen, 2013)—is a critical patient safety factor. A supportive, creative culture imbued with effective leadership and collaboration enables the delivery of safe care through the Perspectives in Psychiatric Care 52 (2016) 25–31 © 2015 Wiley Periodicals, Inc.
sharing of values and norms, creation of trust, and consistent application of best practices at team, unit, and organization levels (Kaufman & McCaughan, 2013; Weaver et al., 2013). For example, management practices strongly influence how staff view patient safety (Kanerva et al., 2013). Appropriate, visible management practices and commitment to safety also promote conditions for implementation of safe care and foster a patient safety culture (Feng, Acord, Cheng, Zeng, & Song, 2011; Ginsburg et al., 2010; Richardson & Storr, 2010). However, the frontline staff are the actors who utilize created opportunities (Kanerva et al., 2013) and manifest the culture in interactions with patients. Thus, their professional skills are critical, notably their competence in medication, therapeutic activities, attending to patients’ needs (Fourie et al., 2005), management of aggressive and violent behavior, de-escalation (Azeem, Aujla, Rammerth, Binsfeld, & Jones, 2011; Lewis, Taylor, & Parks, 2009; Salzmann-Krikson, Lützén, Ivarsson, & Eriksson, 2008), and interpersonal skills (Jeffs et al., 2012; MacNeela et al., 2010; Price & Baker, 2012). Their perceptions and commitment to safety are equally critical. More attention has also recently focused on care elements that can cause patients anxiety and fear, thereby exacerbating safety risks in addition to elements that may lead to physical 25
Nursing Staff’s Perceptions of Patient Safety in Psychiatric Inpatient Care
harm (Azeem et al., 2011; Bowers et al., 2012; Happell & Harrow, 2010; Lewis et al., 2009; Steward, Van der Merwe, Bowers, Simpson, & Jones, 2010). These include widely used seclusion and restraint practices to manage aggressive behavior (Dumais, Larue, Drapeau, Menard, & Giguère Allard, 2011; Lewis et al., 2009; Moran et al., 2009). Rigid application of rules and regulations, constant observation, and inappropriate staff actions may also be traumatic experiences for patients (James et al., 2012; Steward, Bowers, & Ross, 2011). The main role of patients in delivering safe care has traditionally been as informants of personal preferences (Kanerva et al., 2013). However, as interest in patients’ experiences has risen (Kontio et al., 2012; Steward et al., 2010; Strout, 2010), more efforts have been made to gather patient’s views as important factors to consider when developing best practices (Bennetts, Cross, & Bloomer, 2011; Jeffs et al., 2012; Kontio et al., 2012; Warne & McAndrew, 2007). Despite these recent shifts in research foci, more understanding is required of several broad dimensions of patient safety in psychiatric care (Brickell et al., 2009; Kanerva et al., 2013), including the roles of culture, management, staff, and patients. There is also too little knowledge about how nurses who work in psychiatric inpatient care view patient safety, although they are the key care deliverers. Therefore, understanding their perception is essential for the development of patient safety. Thus, this article’s purpose is to explore nursing staff’s perceptions of patient safety in psychiatric inpatient care. Materials and Methods All the nurses (34) who were working in two psychiatric hospitals in Finland on morning shifts of a randomly chosen weekday were contacted by e-mail with information about the research and asked to participate. A reminder e-mail was sent 2 weeks after the first contact to those who had not responded. No response to the two e-mails was interpreted as unwillingness to take part in the research. No explanation was asked from the potential interviewees. The wards provide specialized psychiatric acute and rehabilitative care for adult patients, with any psychiatric diagnosis, to a population of 275,000 people. One of the wards is an open ward and five are closed wards. One of the closed wards can implement seclusion and restraint care, and has developed these practices aiming to reduce their use. All staff has been trained to handle threatening care situations. Altogether, 26 nurses (10 male, 16 female) replied and indicated willingness to participate. Their ages varied from 23 to 60 years (mean, 39 years), and they had 1–30 years work experience (mean, 11 years). Interviews were conducted during September and October 2011. To ensure the nurses responses would stay confidential, the interviews were conducted in separate meeting rooms outside the 26
wards and the interviewees’ names and wards where they were working were not documented. They were interviewed after they were given information about the research and its purpose. During the interviews they were given the opportunity to freely describe patient safety as they see and understand it. Interview themes also included how it appears in their work and the factors in their work that affect it from their perspective. Nurses were then asked to give examples and elaborate the factors they brought up. The interviews were digitally recorded and then transcribed verbatim. The transcribed texts were analyzed by inductive content analysis, without using a software program, by the same researcher who did the interviews and the transcription, which involves open coding, category creation, and abstraction (Elo & Kyngäs, 2008). Sentences describing patient safety factors in the texts were identified, then grouped under thematic categories and higher order headings. Each category was then named using content-characteristic words and subdivided into subcategories concerning similar issues. This resulted in the creation of two main categories of safety perceptions and several subcategories of both main categories. Ethics Ethical approval for the study was obtained from the Central Finland Health Care District Ethical Committee. The interviewees were informed about the research and its purpose, their voluntary participation, and their right to withdraw at any time in accordance with general ethical guidelines (Eriksson & Kovalainen, 2008). No identifiable information is presented to protect the participants’ privacy. Findings As mentioned earlier, and shown in Figure 1, two main thematic categories were identified in the interviewed nurses’ descriptions of patient safety: experiences of safety (factors connected to safety-related feelings) and safety of the implemented care (practical factors related to patient safety). Several subcategories of both of these main categories were also identified, as summarized below. The sentences in displayed quotations are illustrative quotations from the interview transcripts. Experiences of Safety Experiences of safety described in the nurses’ responses covered general experiences of the safety of the environment, staff’s experiences of safety, and patients’ experiences of safety. General experiences of safety refers to the overall feeling of safety for everyone in the ward. Contributing factors that the nurses mentioned included the peacefulness of the atmosphere, the absence of physical threats, and otherwise distressing behavior. Perspectives in Psychiatric Care 52 (2016) 25–31 © 2015 Wiley Periodicals, Inc.
Nursing Staff’s Perceptions of Patient Safety in Psychiatric Inpatient Care
General experiences of safety
Experiences of safety
Staff's experiences of safety
Patients' experiences of safety Patient safety in psychiatric inpatient care
Patients' experiences of being safe from other patients
Patients' experiences of being safe from staff
Holistic care understanding Shared practices of the staff
Safety of the care implementation
Figure 1. Categories and Subcategories of Patient Safety Factors in Psychiatric Inpatient Care Identified From the Nurses’ Responses
I understand this as meaning that everyone in this hospital, no matter if it is staff or patients . . . everyone can feel it is safe here. Nurses described staff’s experiences of safety as essential for their ability to work effectively. They saw the absence of feelings that there were any threats of physical or mental violence in the ward as highly important. They also regarded alarm systems to summon help quickly as being crucial for their psychological security. If you think about our situation, that staff can work and do their work safely is very important. Nurses described patients’ experiences of safety as the three factors related to these experiences: patients’ experiences of being safe from themselves, from other patients, and from staff. They regarded patient’s general experience of safety as highly important and stated that it can be enhanced through good relationships between staff and patients, staff listening to patients, and providing privacy. Perspectives in Psychiatric Care 52 (2016) 25–31 © 2015 Wiley Periodicals, Inc.
Patients' experiences of being safe from themselves
Safe care practices
Maintenance of staff's professional skills
Safe care environment
Fire safety of the ward
Care culture of the ward
Design and condition of the hospital
Laws guiding the care
Adequate resources
Nurses thought patients’ experience of being safe from themselves as important but difficult to promote. They also mentioned that these experiences could be jeopardized by patients’ poor mental health, for example, patients may perceive threats that do not exist and be unable to evaluate their situations rationally. Poor somatic health can also pose threats, leading, for example, to falls and patients hurting themselves. Safety is not only about not being afraid of physical threats—when you think about the reasons many patients come here, there is a kind of fear caused by the patient’s own thoughts. Nurses stated that patients’ experience of being safe from other patients can be threatened by other patients’ aggressive behavior even if it is directed toward another person or object. Seeing other patients’ threatening behavior can bring insecurity to the patient. Other patients can also undermine patients’ security by spreading confidential information. 27
Nursing Staff’s Perceptions of Patient Safety in Psychiatric Inpatient Care
Nothing happens here, and an important aspect is that there is no violence, you can be left in peace and you don’t need to fear other patients. Patients’ experiences of being safe from staff (the third factor affecting patients’ experience of safety) was sometimes threatened, according to the nurses, by previous negative experiences causing patients fear in the present. When this happens, the adverse experiences can badly affect both care and patient safety they said. For example you need to take a narcotic urine sample and there are two staff members supervising it; this can sometimes be an overwhelming situation. Sometimes the patient feels cornered and during this summer one older patient had that sort of experience. I understood it was related to situations that had happened decades ago when he felt he had been attacked, and he asked if he needed to struggle. Safety of the Care Implementation The nurses mentioned five factors affecting the safety of the care implementation: holistic care understanding, safe care practices, the care environment, the care culture of the ward, and laws guiding the care. Nurses described holistic care understanding as personalized implementation of care, including continuous re-evaluation of patients’ diagnoses when required, to ensure that they receive calm, appropriate, supportive care with seamless transitions, recognizing the importance of their safety in all phases. What is best for each patient is always considered and how to reach it . . . I think that when I am at work, all my actions and actions of our team focus on this, and that is crucial for patient safety. Safe care practices formed through shared practices of the staff and maintenance of their professional skills were also regarded as being important elements of care implementation. Shared practices of the staff, the nurses said, provide crucial clarity so everyone knows the established procedures and can follow them in both their everyday work and emergency situations, for instance, during fire alarms. For example, if the fire alarm rings, everyone should know how to act, where to take the patients and so on. Maintenance of staff’s professional skills (e.g., competence in providing medication, adequate nutrition, resuscitation, seclusion and restraint care, and understanding of relevant laws and fire safety) was regarded as essential. Medication care skills were mentioned most often. In the nurses’ experience, most directly harmful events in the wards were connected to it, and it is the area in which the term patient safety seemed 28
most familiar. Anticipating changes in patients’ condition was also seen as important as it helps to plan precautions and thus estimate the adequacy of medication and/or needs for extra staff. The first thing which comes to my mind is a concrete thing, medication care, which is probably the source of many harmful events that directly affect the patient, medication errors. A safe care environment was regarded as essential for safe care. This includes fire safety of the ward, design and condition of the hospital, and adequacy of resources. Nurses said that fire safety of the ward should be considered while refurbishing wards and deciding which items are safe to keep in them. For instance, they felt that some items, like ordinary carpets, could make wards more homelike but pose additional threats. Well, fire safety of course. Patients don’t have lighters, and materials of the ward are the kinds that don’t light up too easily. There are not too many items around; there isn’t much furniture in the rooms. Nurses described that the important elements of the design and condition of the hospital included the provision of spaces allowing patients privacy and opportunities to spend time in quiet surroundings. They also said that the ward layout should also allow the staff to observe the ward, the rooms should be sufficiently large and flexible for patients and staff to move easily, and the door frames should be wide. These features enable sufficient people to work in the rooms without accidents. Wide spaces were seen as important, especially in situations where patients act aggressively and several staff are present. The materials should also be carefully selected, for example, floors should not be slippery to avoid falls. In addition, outdoor areas should be well maintained, especially during winter, to prevent slips or falls due to ice or snow. Our doors are too narrow. When we need to take a patient to a seclusion room . . . three people usually walk side by side, nurse-patient-nurse—there may be five people in total and everyone should be able to go through the door at the same time smoothly without hurting themselves. Nurses saw adequate resources (the third important factor for a safe care environment) as including adequate staff, care equipment (e.g., the right belts for restraint care to avoid threats to patient safety), and medication resources. Patient safety is connected to everything starting from the staff resources, equipment resources, and availability of medicines. . . . It is always safer, of course, with more eyes observing and ears listening in the ward, assessing the situations. Perspectives in Psychiatric Care 52 (2016) 25–31 © 2015 Wiley Periodicals, Inc.
Nursing Staff’s Perceptions of Patient Safety in Psychiatric Inpatient Care
Nurses mentioned the care culture of the ward as a crucial factor of patient safety because it affects all activities, events, and the atmosphere in the ward. It was described as affecting how staff act, take responsibilities, commit to practices, and define work aims, for example, how frequently restraint and seclusion practices were used and how they were implemented by the nurses involved. They said the culture was formed gradually over time, and in some wards nurses had noticed that older working cultures still affected practices and patient safety today. Patient safety is affected by the kind of atmosphere in the ward. Our ward has a good atmosphere and students have felt this, we have got good feedback, it is easy to come to our ward, which is transmitted to patients and the kind of care they receive. Laws guiding the care were seen as important aspects of patient safety as they govern patients’ rights, enshrine the right to good care, and frame the guidelines, regarding, for example, restraint and seclusion practices. Furthermore, the nurses mentioned that confidentiality, which is also legally framed, is another important aspect of patient safety. The first thing that comes to my mind when thinking about patient safety is the law that guides the rights of the patient. Right to good care, what comes to my mind are these restraint and seclusion situations and guidelines for them. But I think that patient safety and law cover the whole care. Discussion The purpose of this article is to explore nursing staff’s perceptions of patient safety in psychiatric inpatient care. The results show that although patient safety has been widely discussed in recent years, and patient safety strategies have been formed to enhance it (e.g., Ministry of Social Affairs and Health, 2009), various aspects were not mentioned by the nurses. Generally, discussion of patient safety in this setting focuses on seclusion and restraint care, physical threats, suicide, and medication care (Jeffs et al., 2012; Kanerva et al., 2013). However, many of the interviewed nurses connected patient safety most clearly to only one of these aspects, medication care, and regarded maintenance of their professional skills in providing it as being particularly important. None of the nurses mentioned suicide, and only mentioned seclusion and restraint use when discussing the importance of shared practices, and how they currently vary with respect to patient safety. This is consistent with the findings by Koukia et al. (2010) that different hospitals and wards often have substantially differing policies. Rather than the often discussed topics, the nurses paid more attention to the skills they require to provide safe care. Poor communication can have adverse consequences, such as delays in care provision and Perspectives in Psychiatric Care 52 (2016) 25–31 © 2015 Wiley Periodicals, Inc.
thus threaten patient safety (Jeffs et al., 2012), but communication or other interpersonal skills were not mentioned by the nurses. Many nurses described the experiences of safety mainly through their own feelings of safety, which is an aspect that is often neglected in discussions of patient safety. In addition, the nurses raised issues that can be seen as being part of management’s responsibility, such as providing a safe care environment and adequate resources. They did not specifically mention these as being connected to management. Effective management can, however, enhance patient safety (Kanerva et al., 2013). It is important for management to be visibly engaged in patient safety (Ginsburg et al., 2010), organize team training to promote engagement with safe behaviors (Weaver et al., 2013), and serve as a role model (Kaufman & McCaughan, 2013). Nurses considered patient safety mainly from their own role. They did discuss patients, but as people who experience things rather than as collaborators. However, the patient’s role as collaborator is also important (Kanerva et al., 2013). Nurses also regarded patients’ experiences of safety as important but did not mention that their own experiences could be similar to those of the patients, although seclusion and restraint (for instance) can cause emotional distress to both nurses (Moran et al., 2009) and patients (Strout, 2010). The nurses also described how patients can feel threatened by other patients, staff, or their own poor medical condition. Similar findings have been reported by Jeffs et al. (2012) from both service user and provider perspectives. So when paying attention to and reacting to their own experiences of safety, nurses could also affect patients’ experience of safety. Nevertheless, the interviewed nurses appeared to perceive the patients as recipients of care rather than experts through experience who can participate in the development of patient safety. Furthermore, the nurses did not raise the potential importance of collaboration with patients or how, for example, feedback from the patients about their experiences could be used in the development of safe practices. Limitations A limitation of this study is that the analyses were performed by one researcher. However, the analysis was discussed in the research group. Another limitation of this study is that the interviewees work in the same healthcare district in one country, and thus may have culture-specific views of the topic. Furthermore, at the time of the interviews discussion of patient safety was increasing in the organization. However, psychiatric inpatient care has many similar features and faces similar challenges worldwide; thus, nursing staff perceptions may be similar regardless of where they work. It is also possible that the interviewees did not raise some issues because they expected the interviewer, who has previously worked in psychiatric inpatient care, to know about them already. To 29
Nursing Staff’s Perceptions of Patient Safety in Psychiatric Inpatient Care
minimize this risk, interviewees were asked to elaborate their answers if they pointed out that the interviewer knew what they were describing. Implications for Nursing Practice This study was undertaken to ascertain nurses’ perceptions of patient safety in psychiatric inpatient care. The interviewed nurses described it mainly through their own work. They did not explicitly note the different actors’ roles in patient safety, although safe care requires collaboration of all the actors. The results indicate that a more comprehensive perspective is required, encompassing the organization, culture, management, staff, and patient when developing practices and multidisciplinary training in patient safety. This would allow the staff to develop more holistic views and see the management and patients as collaborators. Management’s active leadership in patient safety practices is important as it has a strong influence. This promotes the implementation of practices, commitment to them, and formation of a culture that supports patient safety. Management should also both provide appropriate training, covering perspectives of all actors, and receive education about methods that can be used to support shared practice development over unit boundaries. These help management to take the required, visible, strong leading role in the development and implementation of robust patient safety-centered practices. More attention should also be paid to patients’ role in enhancing their safety. They need to be regarded as active collaborators, requiring a change in the perspectives of healthcare actors and crucially the culture of the organization. This can be fostered by involving patients, who are experts through experience, in the development of practices. They have experience of the whole care path and can recognize factors that threaten patient safety, which may not be noticed by the staff. Awareness that patients and staff may have similar experiences of issues is also beneficial to both parties. Management could enhance patients’ participation, and a culture that supports it, by inviting these experts through experience to attend courses for multidisciplinary staff and forums where administrative decisions are made. In overall conclusion, healthcare actors and patients both benefit from the development of practices that enhance patient safety and a collaborative culture that supports it. Acknowledgment No external or intramural funding was received. References Azeem, M. W., Aujla, A., Rammerth, M., Binsfeld, G., & Jones, R. B. (2011). Effectiveness of six core strategies based on trauma
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informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. Journal of Child and Adolescent Psychiatric Nursing, 24, 11–15. Bennetts, W., Cross, W., & Bloomer, M. (2011). Understanding consumer participation in mental health: Issues of power and change. International Journal of Mental Health Nursing, 20, 155–164. Bowers, L., Van Der Merwe, M., Paterson, B., & Steward, D. (2012). Manual restraint and show of force: The city-128 study. International Journal of Mental Health Nursing, 21, 30–40. Brickell, T. A., Nicholls, T. L., Procyshyn, R. M., McLean, C., Dempster, R. J., Lavoie, J. A. A., & Wang, E. (2009). Patient safety in mental health. Edmonton, Alberta: Canadian Patient Safety Institute and Ontario Hospital Association. Dumais, A., Larue, C., Drapeau, A., Menard, G., & Giguère Allard, M. (2011). Prevalence and correlates of seclusion with or without restraint in a Canadian psychiatric hospital: A 2-year retrospective audit. Journal of Psychiatric and Mental Health Nursing, 18, 394–402. Elo, S., & Kyngäs, S. H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62, 107–115. Eriksson, P., & Kovalainen, A. (2008). Qualitative methods in business research. Great Britain: Sage Publications Ltd. Feng, X. O., Acord, L., Cheng, Y. J., Zeng, J. H., & Song, J. P. (2011). The relationship between management safety commitment and patient safety culture. International Nursing Review, 58, 249–254. Fourie, W. J., McDonald, S., Connor, J., & Bartlett, S. (2005). The role of the registered nurse in an acute mental health inpatient setting in New Zealand: Perceptions versus reality. International Journal of Mental Health Nursing, 14, 134–141. Ginsburg, L. R., You-Ta, C., Berta, W. B., Norton, P. G., Ng, P., Tregunno, D., & Richardson, J. (2010). The relationship between organizational leadership for safety and learning from patient safety events. Health Services Research, 45(3), 607–632. Happell, B., & Harrow, A. (2010). Nurses’ attitudes to the use of seclusion: A review of the literature. International Journal of Mental Health Nursing, 19, 162–168. Hyde, S., Fulbrook, P., Fenton, K., & Kilshaw, M. (2009). A clinical improvement project to develop and implement a decision-making framework for the use of seclusion. International Journal of Mental Health Nursing, 18, 398–408. James, K., Steward, D., & Bowers, L. (2012). Self-harm and attempted suicide within inpatient psychiatric services: A review of the literature. International Journal of Mental Health Nursing, 21, 301–309. Jeffs, L., Rose, D., Macrae, C., Maione, M., & Macmillan, K. M. (2012). What near misses tell us about risk and safety in mental health care. Journal of Psychiatric and Mental Health Nursing, 19, 430–437. Kanerva, A., Lammintakanen, J., & Kivinen, T. (2013). Patient safety in psychiatric inpatient care: A literature review. Journal of Psychiatric and Mental Health Nursing, 20, 541–548.
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Kaufman, G., & McCaughan, D. (2013). The effect of organisational culture on patient safety. Nursing Standard, 27(43), 50–56. Kontio, R., Joffe, G., Putkonen, H., Kuosmanen, L., Hane, K., Holi, M., & Välimäki, M. (2012). Seclusion and restraint in psychiatry: Patients’ experiences and practical suggestions on how to improve practices and use alternatives. Perspectives in Psychiatric Care, 48, 16–24. Koukia, E., Giannouli, E., Gonis, N., & Douzenis, A. (2010). Security rules and banned items in psychiatric acute admission wards in Athens, Greece. International Journal of Mental Health Nursing, 19, 428–436. Lewis, M., Taylor, K., & Parks, J. (2009). Crisis prevention management: A program to reduce the use of seclusion and restraint in an inpatient mental health setting. Issues in Mental Health Nursing, 30, 159–164. MacNeela, P., Clinton, G., Place, C., Scott, A., Treacy, P., Hyde, A., & Dowd, H. (2010). Psychosocial care in mental health nursing: A think aloud study. Journal of Advanced Nursing, 66, 1297–1307. Ministry of Social Affairs and Health. (2009). Promoting patient safety together. Finnish Patient Safety Strategy 2009–2013. Publications of the Ministry of Social Affairs and Health, 2009:5. Retrieved from http://www.stm.fi/c/document_library/ get_file?folderId=39503&name=DLFE-8037.pdf Moran, A., Cocoman, A., Scott, P. A., Matthews, A., Staniuliene, V., & Valimaki, M. (2009). Restraint and seclusion: A distressing treatment option? Journal of Psychiatric and Mental Health Nursing, 16, 599–605. Price, O., & Baker, J. (2012). Key components of de-escalation techniques: A thematic synthesis. International Journal of Mental Health Nursing, 21, 310–319.
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Richardson, A., & Storr, J. (2010). Patient safety: A literature review on the impact of nursing empowerment, leadership and collaboration. International Nursing Review, 57, 12–21. Salzmann-Krikson, M., Lützén, K., Ivarsson, A., & Eriksson, H. (2008). The core characteristics and nursing care activities in psychiatric intensive care units in Sweden. International Journal of Mental Health Nursing, 17, 98–107. Steward, D., Van der Merwe, M., Bowers, L., Simpson, A., & Jones, J. (2010). A review of interventions to reduce mechanical restraint and seclusion among adult psychiatric inpatients. Issues in Mental Health Nursing, 31, 413–424. Steward, D., Bowers, L., & Ross, J. (2011). Managing risk and conflict behaviours in acute psychiatry: The dual role of constant special observation. Journal of Advanced Nursing, 68, 1340–1348. Strout, T. D. (2010). Perspectives on the experience of being physically restrained: An integrative review of the qualitative literature. International Journal of Mental Health Nursing, 19, 416–427. Warne, T., & McAndrew, S. (2007). Passive patient or engaged expert? Using a Ptolemaic approach to enhance mental health nurse education and practice. International Journal of Mental Health Nursing, 16, 224–229. Weaver, S. J., Lubomksi, L. H., Wilson, R. F., Pfoh, E. R., Martinez, K. A., & Dy, S. M. (2013). Promoting a culture of safety as a patient safety strategy. A systematic review. Annals of Internal Medicine, 158(5), 369–375. World Health Organization. (2010). A brief synopsis on patient safety. Retrieved from http://www.euro.who.int/__data/assets/ pdf_file/0015/111507/E93833.pdf
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