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Perspectives in Psychiatric Care

ISSN 0031-5990

Stability in Intensive Psychiatry: A Concept Analysis Martin Salzmann-Erikson, RN, MHN, MSc Martin Salzmann-Erikson, RN, MHN, MSc, is a PhD-Candidate, School of Health and Medical Sciences, Örebro University, Örebro, Sweden, Dalarna University School of Health and Society, Falun, Sweden, and Division of Mental Health and Addiction, Department of Acute Psychiatry, Oslo University Hospital, Ullevål, Oslo, Norway.

Search terms: Concept analysis, intensive psychiatry, mental health nurses, nursing research, psychiatric nurses Author contact: [email protected], with a copy to the Editor: [email protected] Conflicts of Interest and Source of Funding The author reports no actual or potential conflicts of interest.

PURPOSE: The aim of this concept analysis is to describe, explore, and explain stability in the context of mental health nursing in intensive psychiatry. DESIGN AND METHODS: A modified version of Wilson’s method of concept analysis was used. FINDINGS: Stability is the ability to be resistant to changes. Stability can take different directions after a distortion: re-gaining, neo-gaining, and apo-gaining. Stability may also be achieved through active (adding or using power, making adjustments, parrying, and idling) and passive systems (environmental conditions and constituent materials). PRACTICE IMPLICATIONS: This article contributes by providing knowledge and insight for nurses on the roles they play in intensive psychiatry as stabilizers.

First Received August 16, 2012; Final Revision received April 19, 2013; Accepted for publication April 23, 2013. doi: 10.1111/ppc.12030

Cable News Network (CNN) reports that “President Asif Ali Zardari’s doctors say he is ‘stable, comfortable and is resting,’ spokesman Farhatullah Babar said” (Cable News Network [CNN] Wire Staff, 2011). Reuters reports that “The comments come less than a week before Chinese and EU leaders hold a summit in Beijing, with the EU looking to China to dip into its huge foreign exchange reserves to help the euro zone tackle a debt buildup that threatens its economic stability” (Blanchard, Martina, Wills, & Fogarty, 2012). A Fox News headline holds that “Marriage builds the economic stability of children, supports the raising of a healthy next generation, and is a cornerstone for the economic health of our nation” (Weber, 2012). Media reports include references to “stability” practically every day in different contexts. As a concept, it has relevance for anything from small-scale environments such as in atomic physics (Strassel, 2012) to large-scale environments such as solar systems and galaxies (Johnson, 2006). More relevant to the scale of our daily lives, stability exists in human interactions and is used in colloquial speech (Stability, 2012d). In this article, stability is analyzed in the context of mental health nursing in intensive psychiatry and clinical implications are presented on the basis of the results. 122

Background, Rationale, and Aim In intensive psychiatry, patients with special needs are treated in their most acute phase of mental illness (Salzmann-Erikson, Lützén, Ivarsson, & Eriksson, 2008). Earlier studies demonstrate that violent behavior (Eaton, Ghannam, & Hunt, 2000; Wynaden et al., 2001) and self-harm (Saverimuttu & Lowe, 2000) often occur during admissions. Traditional treatment interventions suggest medication,mechanical restraint,seclusion, and special observation (Cohen & Khan, 1990; Hyde & Harrower-Wilson, 1996; Wynaden et al., 2001). In contrast, another perspective of care emphasizes inter-relational aspects, encompassing the professional skills of nurses that comprise the ability to be in the moment in violent encounters (Carlsson, 2003), signaling a caring approach (Björkdahl, Palmstierna, & Hansebo, 2010) and having a humble attitude, being honest, and giving time (Lowe, 1992). However, contradictory and more controlling practices are also used to maintain control in intensive psychiatry, that is, establishing boundaries (Salzmann-Erikson et al., 2008) and ensuring sufficient power (Björkdahl et al., 2010). The care culture in intensive psychiatry was studied by Salzmann-Erikson, Lützén, Ivarsson, and Eriksson (2011). Their aim was to Perspectives in Psychiatric Care 50 (2014) 122–131 © 2013 Wiley Periodicals, Inc.

Stability in Intensive Psychiatry: A Concept Analysis

describe cultural knowledge as expressed through nursing care. Nursing care expertise was identified and described through six areas: providing surveillance, soothing, being present, trading information, maintaining security, and reducing. The culture was described as a stability-oriented culture where the main cultural goal was to create and maintain stability when turbulence occurs.Stability indicated peace and tranquility, which could, however, turn into turbulence when patients’ health status deteriorated or new patients were admitted. However, through the nurses’ specific care knowledge they were able to achieve a balance between turbulence and stability in order to achieve equilibrium. Furthermore, as the nursing care intervened in disorder and turbulence, the environment became a sanctuary for patients that offered a place to rest and recover. As presented above, nursing care in intensive psychiatry may differ, but what unites the different nursing activities is the strive for stability.However,SalzmannErikson et al. fail to fully acknowledge the significance of the concept of stability. Therefore, the aim of this concept analysis is to further describe, explore, and explain stability. Methodology and Methods A concept analysis is conducted to define, bring clarification, and describe a concept (Kim, 2010). My concept analysis is based on Wilson’s (1963) method, grounded in the ontology of relativism and the epistemological perspective of contextualism (Risjord, 2009). In terms of Wilson’s epistemology, concepts are not fixed with the possibility to determine“real meanings.”Rather, the focus is to construct a useful understanding of a concept within a specific context (Duncan, Cloutier, & Bailey, 2007; Wilson, 1963). I have adopted alternative methods for collecting and organizing data. The adopted strategies are influenced by ethnographic tools (Spradley, 1979). The data informing my concept analysis were derived from a variety of different sources. Information was gathered on the Internet and from my own experience from clinical practice as a mental health nurse in intensive psychiatry over the last 15 years. Data collection has been nonlinear and can be described as having followed a fluid process rather than following a step-by-step procedure. In the words of Wuest (1994), the concept was given meaning through dialog and relationships, by exemplifying with lived cases rather than laboratory cases. Summarizing my standpoint, this article is based on Wilson’s method of concept analysis, Spradley’s (1979) ethnographic tools, and a postpositivist approach (Rodgers, 2000; Wuest, 1994). Regarding the data derivation, five different sources were used: (a) online dictionary reading; (b) wiki surfing; (c) video clips streaming; (d) literature searches using data bases and search engines; and (e) away from keyboard experiences. 1. Online dictionary reading. A meta-search web page for dictionaries (http://www.onelook.com) was used to search for Perspectives in Psychiatric Care 50 (2014) 122–131 © 2013 Wiley Periodicals, Inc.

the concept “stability.” The result gave 37 dictionaries that included the concept. I decided to use the first 10 dictionaries listed as a convenience sample. The included dictionaries were American Heritage Dictionary of the English Language, Collins English Dictionary, Vocabulary.com, Macmillan Dictionary, Merriam-Webster’s Online Dictionary, Wordnik, Cambridge Advanced Learner’s Dictionary, Wiktionary, Compact Oxford English Dictionary, and Webster’s New World College Dictionary. I then read through these definitions and came to understand how the concept was used when decontextualized; there were synonyms, antonyms, and related words. 2. Wiki surfing. Data were further derived from the use of an online wiki. Since there are numerous wikis, the largest and broadest, Wikipedia (http://www.wikipedia.com), was chosen. Tentatively, I used Wikipedia to expand my understanding of the concept. Initially, I simply used the search term “stability.” Reading material on Wikipedia is different from reading other texts since there are numerous hyperlinks that direct the reader to additional Wikipedia documents. I read 35 Wikipedia documents and included 13 relevant documents as part of my memos. This nonlinear approach was appealing as I was able to become familiarized and get a sense of descriptions, variations, oppositions, contextualized explanations, and versatile attributes. Reading online dictionaries and using Wikipedia was a point of departure for narrowing my understandings toward the usage of the concept. Furthermore, Wikipedia guided me to more reliable sources of references, such as books and research articles and other academic sites. Along with the wiki surfing, I wrote memos which is a basic research activity particular to the ethnographic tradition, and helps the researcher to maintain a reflexive approach (Hammersley & Atkinson, 2007). During this phase, I constantly posed ethnographically oriented questions (Spradley, 1979) to the texts, for example, “What are all the kinds of stability that can be found?” and “What are all the ways stability is used in language?” 3. Video clips streaming. In addition to the wiki surfing, I derived data by using multimedia material found online. Searching for video clips, I used one of the largest Web sites for videos, YouTube (http://www.youtube.com). The search was conducted during March and April 2012. In my search for videos about stability, I simply used the search term “stability,” which gave 173,000 results. These were then filtered according to relevance without any further search limitations. Non-English language video clips were manually excluded. I used my preexisting knowledge of the data, which was captured in the memos referred to above to further narrow my search using the following keywords in different combinations with stability: aerodynamics, balance, economy, equilibrium, medicine, meteorology, mood, muscles, physics, sports, vehicle. In addition to this search strategy, I also watched “similar video clips” based on the findings. I used the filter 123

Stability in Intensive Psychiatry: A Concept Analysis

“shorter video clips,” which delimited video clips to those of about 4 min in length. I watched about 60 video clips that initially looked to be relevant, but many of these were excluded as they were not relevant, had poor video/audio quality, or were too mathematically advanced. Finally, six video clips were chosen to be included and further analyzed. The videos were not transcribed in detail, but rather I wrote intensive notes, paused, and replayed them over and over again to understand how stability was used in different contexts. 4. Literature searches using databases and search engines. The next method to derive data was traditional as it involved the scientific activity of conducting a literature search and a librarian was consulted. The following data databases were used: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, AMED, and PubMed, using the keywords stable, stabil*; nurs* (limited to English language). The search yielded hundreds of hits. From reading the titles and abstracts, I dismissed most of the articles as stability was used in a way that was irrelevant for my analysis. In addition, I used search engines like Google, Google Scholar, and Google Books. Based on my memos, more strategic keywords were used in various combinations: stability, recovery, equilibrium, deterioration, center of gravity, environment, mental health, architecture. The literature search resulted to include 13 references. 5. Away from keyboard experiences. The last means of deriving data was through use of my own away from keyboard experiences. These kinds of experiential data are highly valuable as they provide dimensions of human emotion and tangible hands-on knowledge of the concept (cf. Wuest, 1994). Spradley (1979, 1980) argues that when the ethnographer has become so familiar with the culture (read concept), the ethnographer himself becomes the informant. For this concept analysis, four experimental sessions were analyzed: (a) riding a unicycle; (b) working in psychiatric intensive care units (PICUs); (c) discussing the housing market with brokers, bankers, and friends; and (d) bench-pressing and use of balance ball in the gym. For example, I wrote a text about my experiences and sensations of riding a unicycle, how to make a jump and regain stability in the unicycle after landing.

and deepen the investigation, that is, What are the various ways to achieve stability? Finally, a contrasting question was asked, A and B are both ways of achieving stability but what are all the differences between these two? These are all examples of questions that were repeatedly asked. However, these questions should not be confused with posing isolated questions, which is a central step in a Wilsonian concept analysis (Wilson, 1963). Within my analysis, data were sorted, categorized, and compared. For example, there are different kinds of stability (domain analysis) with specific attributes (component analysis) which differ or are similar to each other and which hierarchically interrelate in different ways (taxonomy analysis) (cf. Spradley, 1979, 1980). All cases presented in the findings are fictive constructions, although they are based on my real life experience from working in locked psychiatric wards and not a result of the concept analysis. To ensure the confidentiality of the people and settings, the examples are distorted beyond recognition across time and place. Findings The analysis is presented in order as described by Wilson (1963), that is, (a) formulating the isolated questions, (b) answering the questions, (c) presenting a model case, (d) related case, (e) contrary case, (f) borderline case, (g) emotive case, and (h) practical case. Isolate Questions of Concept Besides determining which concept should be analyzed, the Wilsonian method calls upon the analyst to delimit the analysis to specific questions. The questions are different as they cover the span of concept, fact, and value questions (Wilson, 1963). In this analysis, five isolated questions were constructed: 1. What is the core meaning of stability? [fact, concept] 2. How can stability be achieved? [fact, concept] 3. What is the outcome of stability? [concept] 4. What are the threats to stability? [concept] 5. How is stability relevant in psychiatric nursing? [concept, value]

Analyzing Data This concept analysis basically follows the Wilsonian method (Wilson, 1963). However, the approach to handling qualitative data is strongly influenced by Spradley (1979, 1980). One example of how Spradley’s (1979) approach was applied is the way questions were posed to the data. Spradley distinguishes three kinds of questions. First, there are broad descriptive questions, such as What are the definitions of stability?, What are the goals of stability?, and What are the ways to achieve stability? The second kind is structural questions that narrow 124

Answering and Analyzing the Isolated Questions The isolated questions are answered first through a linguistic analysis that is focused on the semantic aspect of the concept. Thereafter, the directional and component analysis is presented. Linguistic Analysis. Stability is defined in its most simple form as “when something is not likely to move or change” (Stability, 2011a). A slightly more developed definition is Perspectives in Psychiatric Care 50 (2014) 122–131 © 2013 Wiley Periodicals, Inc.

Stability in Intensive Psychiatry: A Concept Analysis

given by another dictionary: “Stability is the state of being resistant to change and not prone to wild fluctuations in emotion” (Stability, 2011b). Furthermore, The American Heritage Dictionary’s (Stability, 2012a) fourth edition defines stability as follows: 1. The state or quality of being stable, especially: a. Resistance to change, deterioration, or displacement. b. Constancy of character or purpose; steadfastness. c. Reliability; dependability 2. The ability of an object, such as a ship or aircraft, to maintain equilibrium or resume its original, upright position after displacement, as by the sea or strong winds. According to Thesaurus (Stability, 2012b), some synonyms are adherence, balance, constancy, dependability, establishment, firmness, immovability, resoluteness, solidity; and antonyms are insecurity, instability, unsteadiness, variability, wavering. Some of the dictionaries trace the etymology of the term back to the thirteenth century when stability was used to describe persons as resolute, firm, and steadfast. Stability originates from Old French stabilité and from the Latin root of stabilitas, meaning firmness and steadfastness (Stability, 2009). As illustrated above, the concept is defined using more or less abstract terms. The dictionary that I think summarizes all the definitions is Wiktionary: “1. The condition of being stable or in equilibrium, and thus resistant to change,”“2. The tendency to recover from perturbations” (Stability, 2012c, para. 1). Furthermore, the domain analysis revealed that stability is semantically referred to as an ability, a condition, a constancy, a quality, and a resistance. As these definitions are highly abstracted, I deepened my analysis and posed the question, What are the places/contexts where stability exists? Collins English Dictionary (Stability, 2009) gives three examples of disciplines: meteorology, ecology, and electrical engineering. More in context, stability is used differently, for example, “The ability of an electrical circuit to cope with changes in the operational conditions” (Stability, 2009) and “Good tires will help you maintain stability on snowy or icy roads” (Stability, 2012d). After defining stability as such, my understanding of the concept was deepened through thorough analyses that are presented in the two subheadings below: directional analysis and component analysis. Directional Analysis of Stability. Regardless of within which context stability is achieved, stability itself has different guises and may take different directions. Stability is not just a permanent and static condition; it is flexible, fluid, and dynamic. Stability was defined as to “resume its original, upright position after displacement” (Stability, 2012a) and “tendency to recover from perturbations” (Stability, 2012c, para. 1). This yielded the question of what happens to stability when it is exposed to distortion or displacements and how is stability recovered? What is the outcome of stability? To better underPerspectives in Psychiatric Care 50 (2014) 122–131 © 2013 Wiley Periodicals, Inc.

stand the movement and directions it can take, stability was analyzed through the lenses of recovery research in mental health and through the lens of aeronautics research, that is, the study of air-flight capable machines within the atmosphere. The Federal Aviation Administration (FAA, 2004) presents three kinds of stability: positive, neutral, and negative within aeronautics. Deriving knowledge from external disciplines supports an enhanced understanding of stability in my directional analysis. In recovery research, two main perspectives dominate the field. First, the medical perspective views recovery as the regression of symptoms, ability to return to work, and capability to live an independent life without remission in disease and symptoms (Libermann & Kopelowicz, 2002). Such positivist perspectives imply that recovering from mental disorders is equal to the ability of a person to regain an earlier level of functionality; in aeronautics, recovery or stability refers similarly to a positive static state (cf. FAA, 2004)—that is, to re-gaining an original position. One can think of re-gaining in terms of a ball placed in a bowl. When the ball is pushed, it leaves its original position but returns to the center of the bowl as it loses energy. However, the service user perspective within recovery research has strongly opposed such deterministic definitions of recovery. The alternative perspective is more constructivist and individual focused and holds that recovery in mental health is a journey, not a destination to be reached or an outcome. Recovery is about finding hope, taking responsibility, finding meaning, and adopting a new identity that encompasses the presence of symptoms (Davidson, O’Connell, Tondora, Lawless, & Evans, 2005; Slade, 2009; Topor et al., 2006). From this perspective, recovery is equal to the neutral static stability found in aeronautics terms (cf. FAA, 2004). This led to the new term neo-gaining of a position after a distortion. The prefix neo means new. One can think of neo-gaining in terms of a ball placed at a flat surface. When the ball is pushed, it leaves its original position. When all the energy has been spent, the ball remains at its new position. According to the FAA, the last outcome following a distortion is a negative static stability and might be best understood using Kartalova-O’Doherty and Tedstone Doherty’s (2010) approach to reasoning. They hold that recovery in psychiatric disabilities is about fighting the symptoms; however, not everyone has the strength to keep up the fight and some give up. In terms of aeronautics, negative static stability means that the symptoms have taken over and the mind is drifting away from its original state without further directions (cf. FAA, 2004). This led to the new term apo-gaining, a designation within the turbulence. The prefix “apo-” means “away from.” In this case, the ball is placed at the top of a convex surface and continues to move until the movement is controlled. So, in conclusion, theoretically, stability can have three different outcomes: re-gaining an original position, neo-gaining a new position, or apo-gaining a designation 125

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within the state of turbulence. Besides the directional analysis of the outcomes, stability also encompasses components that will be further analyzed. Component Analysis of Stability. Stability as a concept exists in various contexts as earlier demonstrated in this analysis. The domain and taxonomy analysis showed that stability is achieved by adding or using power, making adjustments, parrying, and idling. This can be illustrated by drawing upon an example from vehicle engineering. Many car manufacturers use a technique called vehicle stability control, a stabilizing system that actively monitors the driver’s steering and acceleration, and maneuvering of the car. By adding engine power of each wheel, vehicle stability control helps to control over- and understeering and helps the driver maintain control of the vehicle (Fijalkowski, 2011; ToyotaNZ, 2011). Stability is also a central concept in naval architecture “[. . .] how a ship behaves at sea, both in still water and in waves. Stability calculations focus on the center of gravity and center of buoyancy of vessels and on how these interact” (“Ship stability,” n.d., para. 1). Perez (2005) holds that stability may be achieved in different ways, for example, by using a pump or electric actuator, mechanical bilge stabilizers, active stabilizer fins, and antiroll tanks. The most commonly used tank is the U-tank, due to its form. It has one tank on the port side and another on the starboard side which are connected at the bottom by a duct. Water moves freely in the tank in the same period as the ship moves. On the basis of the mass of the water in the tank, it produces a force that opposes rolling. Some of the antiroll tanks use a control system that modifies and maneuvers the flow of water to match the tanks’ actual ship roll period. Yet, another example of making adjustments is derived from the economics politician Sean Goertzen, a candidate for the Green Party in Winnipeg, Canada. In a video, he presents the world economy as insecure and volatile but proposes that stability can be reached by introducing the Tobin tax. In short, he argues that by introducing a tax on international currency exchanges and speculation, enough funds would be raised to completely eradicate extreme poverty in the world, which in turn would stabilize the world economy as a whole (Sean Goertzen, 2010). Jetin and de Brunhoff (2000) argued that “The Tobin tax would make a positive contribution to the stabilization of exchange rates by acting as an ‘uncertainty reducing institution’ through the influence which it would exert in the creation of expectations” (p. 205). Another action to create stability is the use of human muscles. The use of a stability ball was analyzed through an instruction video on the use of a stability ball in fitness training and through the author using the ball personally along with bench-pressing and riding a unicycle. The analysis revealed that it is possible to idle in the span of constantly parrying stability. Such parrying means that small amounts 126

of energy are supplied to the extent that equilibrium is achieved. An instructor explained, “She has her feet spaced about a foot part to give her a stable base that helps to prevent her from rocking from side to side” (American Council Exercise, 2008). In the example of riding a unicycle in a stable way, such parrying was the constant movements of the upper body: curling up, stretching, and leaning forward, backward, and latterly. Regardless of whether water creates turbulence or if weak abdominal muscles fail to hold a person’s center of gravity in position, in both examples, there are external forces acting to create disorder or some sort of imbalance. In addition, I asked, “What are all the threats to stability?” I identified 34 included terms grounded in data, for example, being afraid, being inflexible, absence of acting, making rapid or incorrect movements. The domain and taxonomy analysis resulted in five cover terms of threats to stability: attitudes, excessive use of resources and power, lack of resources and power, the position, and lack of fit. So, by synthesizing material from different contexts it is possible to conclude that stability is created, preserved, and restored through active systems by adding or using power, making adjustments, parrying, and idling. However, it is apparent that stability might be the result of other kinds of systems that are not based on the same components as active systems. Returning to the context of ship stability, there are also passive stability systems, for example, paravanes, bilge keels, fins, and passive antiroll tanks. The difference between active and passive antiroll tanks is that passive ones allow water to move freely from side to side without an active control system. Instead, the tank is dimensioned such that the time needed for the water (or other fluid) to flow from port to starboard side (and the reverse) is equal to the natural roll period of the ship and therefore ability is achieved (Perez, 2005). Furthermore, passive systems are incorporated into basic structures and the physical interior of the PICUs. Units are small, which makes it possible for staff to be close at hand at all times and have a bird’seye view of activities on the ward. In this way, the staff are better equipped to step in and avert undesirable activities or unacceptable behavior that can interfere with stability (Salzmann-Erikson et al., 2008). Such conditions make it possible to achieve stability in the PICU by using existing resources, including passive stability systems. As Salzmann-Erikson et al. (2008) conclude, the PICU offers “limited structures and closeness in care” (p. 105). Yet another example of passive stability systems is found in bridge architecture; Savor, Bleiziffer, and Radic (2009) hold that it is both the material itself (steel) and the formation of the arch that make the construction of steel arch bridges useful. So, by synthesizing data from different contexts, it is possible to conclude that stability is created, preserved, and restored by passive systems on the basis of environmental factors and constituent materials. Perspectives in Psychiatric Care 50 (2014) 122–131 © 2013 Wiley Periodicals, Inc.

Stability in Intensive Psychiatry: A Concept Analysis

Model Case Model cases are descriptions of the concept that are easily recognizable and obvious such that there is no doubt about what it is. (Wilson, 1963) It is Monday morning. The clock strikes 6:40 a.m. and the night staff sits around the coffee table in the staff room. All the patients have slept through the night and only Frank is awake as he is up early for a computed tomography scan. Frank comes up to the staff room and knocks gently on the door and when the staff gives him attention, he politely asks if it is possible to have a shower before the examination even though he knows that it should be handled by the daily contact person after the morning report. Lisa, one of the assistants, maintains her good mood and replies that she will help him as she gets up from her comfortable chair and leaves her hot morning coffee at the table. None of her colleagues make any initiative to assist her and keep on chatting. Wilma is on her way to the kitchen and sees another patient, Fanny, sitting in the sofa reading the newspaper by the TV, which is turned off, with a cup of coffee. Wilma stops and says good morning; she asks if Fanny has slept well and if she wants a refill on her coffee. Fanny replies that she has slept well and tells Wilma that she would like another cup. Contrary Case A contrary case illustrates the opposite way of describing the concept. By contrasting what it is not, the concept itself becomes more easy to understand. (Wilson, 1963) There are four staff members standing in front of a patient who is clearly demonstrating an aggressive behavior; they are trying to calm him down. The patient pushes one of the staff members in the chest and the others approach the patient and lay him on the floor. In the same instant, other staff members arrive to help hold the patient. Rita is ordered by one of her colleagues to call the physician and he also directs another of his colleagues to bring the bed with mechanical restraints. As Rita turns around to head to the telephone, another patient stops her for a cigarette; she explains quickly that the patient must wait for a few minutes. In reply, the patient reprimands her. A third patient also witnessed the situation and insisted that her fellow patient did not do anything on purpose and should be released. The situation as a whole would be best described as a turbulent situation.

In this study, the concept of equilibrium is relevant to understanding stability as these concepts are very similar. However, there is a distinction between stability and equilibrium. Stability is possible when only one of the parties acts to achieve it. For example, if a patient is not acting turbulent, that is, agitated, the staff will likely not contribute to turbulence and there will be continuous stability. However, if the patient is turbulent, that is, acting out with violent behavior, the staff will likely intervene and restore stability by using a variety of interventions, for example, establishing a dialog or, in the most extreme cases, restraining the patient physically. However, to create equilibrium, two or more parties must be involved as counterweights. Achieving equilibrium in a PICU demands that staff use their expertise to create resistance against the patient’s turbulence by collaborating with the patient through their knowledge of intensive psychiatric nursing. A seesaw can be used as a metaphor for this; nonequilibrium can be achieved by placing a very heavy person on the one side and a lightweight person on the other side. Stability is easily achieved by use of power, but equilibrium can only be achieved through communication, collaboration, adjustments, and adaptations. Using such flexibility when approaching patients is described as using oneself “as a finely tuned instrument” (Björkdahl et al., 2010, p. 512). Borderline Case A case is borderline when it is not clear what exactly in the illustration is encompassed by the concept. (Wilson, 1963) It’s Thursday morning. The two nurses, Veronica and Edward, are sitting at dinner tables that are positioned at the center of the PICU. They are making small talk with a patient who is happy because he just was told that he is no longer under custodial care and will be discharged after lunch. It is a quiet and friendly atmosphere. A few feet away sits another patient, Richard, who listens to the conversation. Suddenly, he gets up quickly from his chair so that it falls over and hits the floor and he clenches both his fists. He walks away and knocks on the wall a couple of times. At lunch, Richard returns to the dining room to pick up his food tray. While he is waiting for the food to warm up, he turns to nurse Edward and speaks with a calm and slightly subdued voice, and says, “It is best that you make sure that the doctor discharges me before evening.” Emotive Context

Related Case A related case illustrates concepts that are connected to the concept being studied, or are similar. By describing a related case, the concept under analysis becomes more apparent. (Wilson, 1963) Perspectives in Psychiatric Care 50 (2014) 122–131 © 2013 Wiley Periodicals, Inc.

The underlying anxiety or emotive context exemplifies what emotions are attributed to the concept. (Wilson, 1963) Based on the model case description of stability, emotions are connected with the concept. Staff in a PICU know that stabil127

Stability in Intensive Psychiatry: A Concept Analysis

ity will not last forever as turbulent times or turbulent episodes will take place. Anecdotal evidence supports the claim that stability is doubted among PICU staff; a commonly used saying is “the calm before the storm.” This reflects an underlying tension as it refers to emotions of uncertainty. The staff knows that at any minute things can turn turbulent, or as one healthcare assistant quoted by Deacon, Warne, and McAndrew (2006) in their study, “The trouble with this place is that you never know what’s going to happen next – anything can happen, and it does” (p. 754).

Practical Results Practical results are examples that highlight the practical use of the concept in real life. (Wilson, 1963) Stability is so interconnected with its dichotomous concept, non-stability or turbulence, that it is not possible to look at just one of the two concepts to understand practical results. Stability and turbulence are so intertwined that it is necessary to understand the one to understand its opposite. On PICUs, one often hears that “it is calm on the unit”; this expression is so common that it has become a natural part of daily greetings when staff meet each other. The practical result of this concept analysis is to gain awareness of the unconscious structures and patterns in intensive psychiatry. Let me give one concrete example. A nursing student named Sofia had 4 weeks of clinical practice in a PICU where “nothing happened.” Sofia learned how to adapt to the slow flow of the culture, which per se was very instructive, although she had expected to be active during the whole shift based on her earlier nursing experiences. She did not have an opportunity to witness turbulence and did not experience violent encounters and such. The absence of turbulent episodes during her clinical practice skewed her view of stability. She was not able to identify stability since she could not compare it with something else, nor was she able to differentiate the nuances and borderline situations and what kinds of interventions and approaches she would adopt in a turbulent situation. Discussion In this article, the concept of stability has been analyzed. The impetus for conducting this analysis lies in the observation that nursing practices in intensive psychiatry can differ considerably but are united in the fact that they all consist of some sort of controlling or stabilizing interventions (cf. Björkdahl et al., 2010; Carlsson, 2003; Cohen & Khan, 1990; Hyde & Harrower-Wilson, 1996; Salzmann-Erikson et al., 2008). Furthermore, Salzmann-Erikson et al. (2011) focused on describing cultural knowing and nursing expertise as expressed in PICUs and described this as a stability-oriented culture. However, the concept of stability was not thoroughly 128

explored or described by the authors. In this article, I have used Wilson’s (1963) method of concept analysis. Even though the method is old, it is still being used to conduct concept analysis in nursing science (Lynch & Lobo, 2012; Thompson, 2005). A modification of Wilson’s method was developed by Walker and Avant (1983, 2005). Their method is grounded in the ontology of realism and has been criticized for only including scientific literature, resulting in an arbitrary and vacuous analysis. Such an epistemology assumes that the concepts are “out there” to be studied objectively (Paley, 1996). Counter to this, Risjord (2009) argues for implementing contextualism in concept analysis and that it is the aesthetic practice of constructing context-bounded cases that forms the substantiation in Wilson’s method. First of all, as the researcher I engaged deeply with the concept on the basis of my personal experiences and lived with the concept in that I experienced it in everyday situations and activities, just as an ethnographer lives with a culture in order to go native. So, by abandoning the positivist objectivity, I adopted a postpositivist approach to subjectifying the concept. Through this intersubjective relation to the concept, I was able to understand stability through my own experience from real-life situations, which added a dimension of personal emotions to the analysis (cf. Wuest, 1994). By positioning myself as a researcher who has been partly involved in the construction of data, this has inevitably shaped the analysis and the results. A weakness in this study is that the concept has not been analyzed etymologically and I cannot comment upon the changes of the concept over time. Moreover, the result was restricted to a consideration of 13 references as it was difficult to find any specific literature that was relevant even with the assistance of a librarian. Further searching may have resulted in more references if natural science databases had been included. The Metaphysical Level of Stability This concept analysis aimed to describe, explore, and explain the concept of stability. By deeply engaging with the concept, the five isolated questions were answered. In summary, the directional analysis revealed that stability has three possible outcomes when exposed to distortion: re-gaining an original position, neo-gaining a new position, or apo-gaining a designation. Furthermore, the component analysis revealed that stability is restored through active systems that require adding or using power, making adjustments, parrying, and idling. In addition, there are also passive stabilizing systems that stem from environmental conditions and constituent materials. This part of the discussion will highlight yet another abstracted level of stability, the metaphysical level. In Wiktionary’s (“Stability,” 2012c, para. 1) definition of stability, the definition includes the ability to be resistant to change. This implies that there are some entities or external forces that Perspectives in Psychiatric Care 50 (2014) 122–131 © 2013 Wiley Periodicals, Inc.

Stability in Intensive Psychiatry: A Concept Analysis

act upon the state of stability to transform it into something else, non-stability (i.e., instability or turbulence). Such thinking also implicates ontological questions about stability and its being and becoming. It is reasonable to ask whether stability is founded in nature or a constructed projection from cultural speech—and why, either way, stability is desirable. Humans strive for stability regardless of context, as shown in this article (cf. Fijalkowski, 2011; Perez, 2005; Salzmann-Erikson et al., 2011; Sean Goertzen, 2010). Humans seem to seek stability and create entities that are resistant to change, although the opposite prevails in “nature.” According to the second law of thermodynamics, as explained by Groysman (2010), nature always strives toward disorder and chaos since there is a statistically higher probability that something will be disordered than ordered. Such change processes from a state of low entropy (more order) to high entropy (more disorder) are easily understood through the example of corrosion, a gradual destruction of metal, or rusting. Furthermore, “entropy always increases in a spontaneous process in an isolated system” (Ben-Naim, 2008, p. 9). Nature itself cannot create order, this ability is reserved for living organisms (Walker, 1992). Since destruction and disorder are inevitable without intervention or interaction, stability will gradually turn into instability, turbulence, and chaos. Clinical Implications for Nurses: Being the Stabilizer Given that nursing expertise is centered on creating, preserving, and restoring stability in PICUs, and that this is the overall goal of the culture of stability (Salzmann-Erikson et al., 2011), this concept analysis of stability offers a deeper understanding of the very core structures in the culture. Moreover, this article contributes important knowledge and insight for nurses on the roles they play in PICUs. This article can be of use to nurses as it contributes new knowledge on the active and passive systems that contribute to stability. Through the role they play in applying these systems, nurses themselves become the stabilizers to fight entropy. Further Research Throughout this article, the opposite of stability has been treated and mentioned indirectly as instability, turbulence, chaos, and disorder. More research is needed to seek out and analyze non-stability and pose further questions: how do we understand stability in relation to non-stability in a more nuanced worldview? Acknowledgments I would like to thank Associate Professor Margaret (Peggy) E. Wilson and Professor Margareta Ehnfors for being available to discuss my article.

Perspectives in Psychiatric Care 50 (2014) 122–131 © 2013 Wiley Periodicals, Inc.

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Stability in intensive psychiatry: a concept analysis.

The aim of this concept analysis is to describe, explore, and explain stability in the context of mental health nursing in intensive psychiatry...
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