bs_bs_banner
International Journal of Mental Health Nursing (2015) 24, 82–90
doi: 10.1111/inm.12107
Feature Article
Thematic analysis of psychiatric patients’ perceptions of nursing staff Duncan Stewart, Heather Burrow, Alex Duckworth, Jasbir Dhillon, Sarah Fife, Siobhan Kelly, Sophie Marsh-Picksley, Emma Massey, John O’Sullivan, Maria Qureshi, Steve Wright and Len Bowers Institute of Psychiatry, Kings College London, London, UK
ABSTRACT: Therapeutic and informal interactions with nurses are integral to the quality of care that psychiatric patients receive. How well these interactions are performed, and their impact on the experience and outcomes of inpatient care, have not been subject to systematic evaluation. The aim of the present study was to examine patients’ perceptions of the personal and professional qualities of nursing staff and how these contribute to the ward environment. Patients (n = 119) from 16 acute psychiatric wards were interviewed using a schedule developed by a service-user researcher. Transcriptions of interviews were coded and organized into six themes: staff duties, staff disposition, control, communication and engagement, therapeutic ward environment, and consistency. Patients recognized that nurses have a difficult and stressful job, but frequently expressed feelings of anger, frustration, and hopelessness about their experience of the wards. Patients frequently felt that nursing staff did not understand issues from their perspective or attempt to empathize with them. The findings indicate poorly-communicated and inconsistent care. Initiatives to improve patients’ experiences of acute psychiatric wards are urgently needed. KEY WORDS: attitude, interview, patient experience, psychiatric wards, qualitative.
INTRODUCTION People are admitted to psychiatric wards because they appear likely to harm themselves or others, and because they have a severe mental illness (Bowers et al. 2005). The individual might also have insufficient support and superCorrespondence: Duncan Stewart, Psychology, Social Work and Human Sciences, University of West London, Paragon House, Brentford, London TW8 9GA, UK. Email: [email protected] Duncan Stewart, BA, PhD. Heather Burrow, BSc. Alex Duckworth, BSc. Jasbir Dhillon, BSc, MSc. Sarah Fife, BSc, MSc. Siobhan Kelly, BSc, MSc. Sophie Marsh-Picksley, BSc. Emma Massey, BSc, MSc. John O’Sullivan, BSc. Maria Qureshi, BSc, MSC. Steve Wright, BSc, MSc. Len Bowers, BSc, MA, PhD, RMN. Accepted August 2014.
© 2014 Australian College of Mental Health Nurses Inc.
vision available in the community. Nursing staff are tasked with keeping patients safe, assessing their problems, treating their mental illness, meeting their basic care needs, and providing physical health care. These are achieved through the use of containment (e.g. ‘asrequired’ medication, seclusion, special observation, intensive care, manual restraint, and enforced medication), 24-hour staff presence, treatment provision, and complex organization and management (Bowers et al. 2005). Activities are provided to keep people occupied, and ward rules and policies employed to set limits on patients’ behaviour. The nature of these interventions, and the way they are implemented, are likely to be major factors in patients’ experiences of care (Lelliott & Quirk 2004). The day-to-day and therapeutic interactions with nurses are integral to the quality of care that patients receive, and the personalized interest, care, and attention from staff that these represent is greatly valued (Rydon
PATIENT PERCEPTIONS OF STAFF
2005). However, organizational factors can sometimes impinge upon nurses’ ability to fulfil this role (Gijbels 1995). There is, therefore, an obvious need for research to establish how well these interactions are performed and their impact on the experience of patients. However, systematic evaluation of patient perspectives of life on psychiatric wards is lacking. Previous studies of patient perspectives have focused on particular forms of conflict and containment experienced during hospitalization. Coercive interventions, in particular, can have a detrimental impact on relationships between patients and staff. Patients subjected to restraint have reported feelings of anger, fear, and panic, and that the use of restraint is unjustified and can provoke memories of distressing or abusive events (Bonner et al. 2002; Sequeira & Halstead 2002). Similarly, seclusion can be a profoundly negative experience for patients by provoking feelings of vulnerability and hopelessness (Van Der Merwe et al. 2013). Patients interviewed about receiving coerced medication have reported feeling angry, helpless, and embarrassed (Greenberg et al. 1996; Haglund et al. 2003), and described a fear of becoming ill or dying as a result of the medication (Haglund et al. 2003). A recent review and synthesis of qualitative research of the nurse–patient interaction in adult acute inpatient mental health units (Cleary et al. 2012) found 23 studies published in English between January 1999 and July 2010. It concluded that nurses use complex communication and interpersonal skills, which they deploy in pragmatic and non-formalized ways to generate and maintain engagement with patients. Thus, while nurses do often interact therapeutically with patients, whose ability to relate to others is often severely compromised, this might not be solely accomplished through direct engagement in activities. A review of 13 papers concerning nurse and patient interactions found that approximately 50% of staff time was spent in contact with patients, and little time was actually spent in therapeutic activity (Sharac et al. 2010). This can lead to negative feelings among patients. For example, Thomas et al. (2002) reported that patients expressed longing for a deeper connection with staff and more intensive insight-oriented therapies. While patients’ needs for safety, structure, and medication were met, they were not gaining a greater understanding of their dysfunctional patterns of behaviour. Wood and Pistrang (2004) explored patients’ accounts of acute wards, which were characterized by an overwhelming sense of vulnerability and helplessness, describing vividly how interactions between patients, the behaviour and attitudes of staff, and non-consensual treatment all impacted on their sense of safety and threat. © 2014 Australian College of Mental Health Nurses Inc.
83
In summary, only a limited number of studies address ward interactions from the perspective of patients, and their sample sizes are extremely small (Cleary et al. 2012). The aim of the present study was to examine patient perceptions of nursing staff by considering both personal and professional qualities of nurses and their contribution to the ward environment, and to apply this to a much larger sample than has been achieved by most previous research.
MATERIALS AND METHODS Sample The research was part of the Tompkins Acute Ward Study, a longitudinal, mixed-methods research project investigating care in one Mental Health Trust in England. The Trust serves a population of 650 000 in three inner London boroughs. Trusts are self-governing organizational units within the National Health Service (NHS), which provide inpatient and community health services to local populations, in conjunction with primary care and government social services departments. Three hospital sites were involved, with 13 acute wards (5, 4, and 4 on each site) and three psychiatric intensive care units (PICU) (1 on each site). Bed numbers for the acute wards ranged from 15 to 20. For the PICU, the bed numbers were eight, nine, and 15. The majority of wards had mixed-sex occupancy (1 acute ward was female only, and 1 PICU was male only). Wards were staffed by a combination of registered psychiatric nurses and health-care assistants. The whole-time equivalent staffing numbers were approximately one staff member to one bed, and the staffing and skill mix was generally consistent across the wards. With the exception of the PICU, wards at two hospitals were locked at the discretion of the nurse in charge. At the third hospital, wards (excluding the PICU) were unlocked to patients leaving, but the system was altered during the course of the study so that all wards were locked both to entry and exit during the night shift. The sample frame for potential participants included all patients on the 16 wards within the Trust. The initial intention was to randomly select from this sample frame, but difficulties with this approach arose during the fieldwork. Some patients were unable to be included in the study for the following reasons: language barriers, too unwell to participate, considerations of well-being, and safety issues. Others were on leave or otherwise engaged with activities at the time of the researcher’s visit. As a result, random selection of patients occurred after discussions with ward staff on suitability and availability of inpatients on each ward. The aim was to conduct interviews
84
with two patients on each ward every 6 months at four different time points: December 2004–February 2005, May 2005–July 2005, November–December 2005, and May–July 2006. This was to enable exploration of correlations between patient responses and other longitudinal measures captured by the Tompkins study (see Bowers et al. 2007 for further details). Two interviews per ward was the maximum that could be collected at each wave with the resources available. A total of 119 interviews were completed, representing 93% of the target total.
Data collection The interview schedule was developed specifically for this study by a service-user researcher (SUR) in consultation with two local service-user groups, all with experience of inpatient facilities. The interview was informed by an evidence-based model of conflict and containment (Bowers 2002), and addressed three factors hypothesized to contribute to the levels of conflict on psychiatric wards: positive appreciation of patients by nursing staff, the ability of nurses to regulate their own natural emotional reactions to difficult and challenging behaviour by patients, and the creation of an effective ward structure through rules and routine. Thus, the interview addressed the nature of a typical day on the ward, how staff members generally think or feel about patients on the ward, how members of staff spend their time on the ward, and what kinds of things patients are allowed or not allowed to do on the ward. It was initially piloted in order to establish face validity. The majority of interviews (n = 100) were conducted by the SUR; an experienced, independent service-user consultant who received training in conducting research interviews. Due to some practical difficulties, a small number of the interviews were conducted by university researchers (n = 19).
Ethical considerations Ethical approval for the study was obtained from the local Health Authority Research Ethics Committee and the local mental health service’s research and development office. A study information sheet was provided for each participant, and informed, written consent was obtained before each interview. Participants were assured that agreement or refusal to take part would make no difference to their care or treatment, and that they could withdraw from the study at any time if they wished. It was made clear that interviews were anonymous and confidential and would not be discussed with ward staff, interview tapes would be safely stored and transcribed, and that their data would only be accessed by the immediate research team.
D. STEWART ET AL.
Procedure Appointments were made with staff on each of the 16 wards to arrange a visit by the SUR. The ward’s patient list was obtained, and ward staff (nurses, doctors, psychologists) were asked to advise on who could be invited to participate and who, in their opinion, should be excluded. Eligible service users were then selected by randomly allocating a number to each name and then referring to a computer-generated random list of numbers. Potential interviewees were approached on the ward and told about the study by the SUR, given a study information sheet, and asked whether they would be interested in participating. On agreement, interviewees were invited to a quiet area where the SUR would explain that she had experience of using psychiatric services herself, and they were asked to read and sign a consent form. Issues of confidentiality were explained, and participants were encouraged to ask any questions they had about the study. The interview was then conducted and lasted between 30 and 45 min. At the start of each interview, participants were asked their sex, age, and ethnicity, and whether this was their first admission to a psychiatric hospital. No participants were known to the interviewers. All interviews were tape recorded, with the exception of one participant who declined to be recorded, and notes were taken for this participant instead.
Analysis The interview tapes were professionally transcribed verbatim. Thematic analysis was conducted using an inductive (data-driven rather than theoretical) approach and followed the stages described by Braun and Clarke (2006). These are: familiarization with all the data, generating codes, identifying themes, reviewing themes, defining and naming themes, and finally write up themes into a report. The first phase of the analysis was to develop an initial coding frame. The analysis utilized 10 research assistants (RA) who were employed on another project. Training in coding and thematic analysis was provided before each was asked to independently read and identify codes, definitions, and examples for the same 10 randomly-selected interviews. The RA were requested not to discuss the interviews or their coding schemes with each other during this phase of the project. Codes were then compared among the group in meetings facilitated by the lead author to develop a consensual coding structure for application to the whole data set to ensure consistency between researchers. Once the initial phase of coding was agreed on, all 119 interview transcripts were randomly divided among the RA for coding. Extracts for © 2014 Australian College of Mental Health Nurses Inc.
PATIENT PERCEPTIONS OF STAFF
each code were recorded electronically on an Excel spreadsheet. RA were instructed to inform the group of any new codes that emerged. New codes were discussed and agreed on at team meetings and via email. The next phase involved collating all the coded extracts (n = 3491) from the RA, sorting codes into themes, and collating extracts within identified themes. This was achieved in group discussion, with themes then randomly allocated to RA for write up.
RESULTS Two-thirds (66%) of the sample were male, and 62% were under 40 years old. The patients were ethnically diverse: 38% white British, 35% black/black British, 12% Asian/ Asian British, 19% other. Almost three-quarters (73%) had had a previous admission to a psychiatric hospital. The analysis identified six major themes in the data, which are described below.
Staff duties Patients in the sample frequently commented on how effectively staff carried out their roles. On the whole, patients demonstrated an understanding and appreciation of staff roles, and almost all referred to the varied duties they perceive staff to be carrying out as an integral part of their job, including some mundane tasks, as one patient observed: On the phone, on the computer, being happy, observations, giving injections, giving medication, counselling. On Sundays, they have talking groups, preparing the meals, giving out meals, changing the bed linen, finding toothbrushes [laughter], helping with the laundry, (ID029)
Knowing that nurses are capable and able to attend to basic needs and create a therapeutic environment developed a sense of trust and safety. Nurses who performed their duties were seen by some patients as caring and considerate:
85 They have a lot of problems of their own and lot of deficiencies and inefficiencies, but nothing is going to get better until that is sorted out. (ID085)
Staff disposition Patients consistently attributed the quality of their care to nurses’ perceived attitudes towards the patients and their work. Across many interviews, participants valued being treated as an individual person, and not simply in terms of their clinical characteristics. Patients repeatedly expressed the benefits of being treated in this manner as an aid to their recovery and a positive aspect to their time in hospital. As one patient succinctly stated: It feels good, it sort of, I reckon, it speeds up your recovery, because you’re not being sort of, you’re not being treated like cattle, you know? (ID034)
Although some patients described staff enjoying their work, many also reported that staff appeared to see their role as just a job or a shift to get through: I don’t think they give a damn. They just come here and do their job. They don’t care about what personal destruction they’re causing to your mind. As far as they’re concerned, your mind’s already damaged. They just come here, do their job. As long as they do their job and have no comebacks, then they don’t care. (ID025)
Some also went as far as describing staff as uncaring, dismissive, or disrespectful: It made me feel little, belittled, I felt belittled, and I just think to myself, you know, why does he have to treat me in this way? I’m a human being, I’m a person. You don’t treat a person like that. If you treat me with respect, I will treat you with respect back, but if you don’t treat me with respect, you’re not going to get my respect, and that’s my point. (ID117)
Control
Try to make sure we take our bath . . . trying to make sure that we take the medication. Try to make sure that most of us that needs to go as for the appointment is to go there. Then most of all, that’s just to make sure that we’re in good health and condition. (ID079)
This theme concerned exertion of staff control on the wards. Perceptions among the sample varied. At one end of the spectrum, most patients understood that it is necessary for staff to have some control of the ward in order to maintain order. More specifically, there were several instances of patients appreciating that staff retaining control kept patients safe from themselves and each other. For example, one patient stated that:
However, many individuals across our sample referred to occasions when nurses seemed unable to perform at a level to meet their responsibilities, not necessarily because they did not desire to, but because they did not possess the relevant skills or abilities:
Staff are always on hand. There’s always somebody in the communal area, so it just, it just ticks along it’s, the way they maintain the rules is, erm, by sort of vigilance, I suppose. They just keep their eyes open and they listen out for what’s going on. (ID107).
© 2014 Australian College of Mental Health Nurses Inc.
86
D. STEWART ET AL.
At the other end of the spectrum, patients perceived staff to have total control, with nurses employing an authoritarian style, applying rules inflexibly, and threatening consequences for rule transgression. There were examples of a sliding scale of consequences depending on the transgression or level of patient adherence:
negative aspects of staff communication. On the negative side, the interviews conveyed a sense of disorientation and helplessness. Patients reported that communication felt one way at times, such that the nurses could call on them, but they could not initiate communication with staff:
The minimum is told to calm down and remain where you are, then medium is sent to your room. The maximum has two parts. The maximum is you go on extra medication. (ID47).
When we try and get attention from them, we can’t get it. When they want attention from us, they want it 100%, they want us to be there on the spot for them. (ID064).
Therapeutic ward environment Patients referred to broader aspects of life on the wards that were not always directly within individual nurses’ control. Boredom was by far the most prevalent code in this theme, for which patients gave a variety of explanations and examples, from a lack of activities to inadequate numbers of key staff, such as occupational therapists. There was also concern that nurses were too busy to spend time with patients and organize activities for them: It’s always paper work, and they don’t get time for patients. (ID032)
There were more positive descriptions of ward activities, although several patients noted that these tended to be undertaken by more junior staff: Yes, they’ll play games. They have sat there and . . . they might play Scrabble or Monopoly or something like that, but it’s more likely to be a student nurse. (ID029)
Patients also referred to frequent changes in staff. This is a significant feature of work on inpatient wards and can take different forms, including changes over shifts or swapping staff between wards and use of bank or agency staff. Rotation patterns are designed to support and develop staff, but the patients in the present study were particularly negative about the impact of bank and agency staff. Concerns that their use was disruptive and made it more difficult to develop good relationships with nurses were summed up by this patient: There are a lot of casual (staff ). Too many casual/agency. They don’t know the individuals. They don’t know what their problems are, and one of the things that happens a lot, is these agencies are making these individuals worse. That is a massive problem in here. (ID025)
Communication and engagement Communication was defined as conveying information by speech, signs on the ward, writing, or aspects of behaviour, and was the most prevalent theme in the interviews. Overall, patients tended to agree on both positive and
Some patients were specific about the type of communication that was lacking, and noted an absence of community meetings (a forum for airing and discussing grievances with staff) and lack of ‘one-to-one’ time with nurses. Others spoke of requests made in community meetings not being followed up, which then rendered the meetings meaningless to patients and left them feeling undervalued: They listen, but they don’t do nothing. I mean they, there’s a book of minutes there what they take every week, every day, but they might as well not bother. (ID027).
Perceptions of staff included feeling that nurses engaged in a formal, professional, but rather unfriendly way. This was most exemplified by complaints that nurses would only communicate for a specific reason, such as to assess patients’ mental state or obtain a history. This interaction might be welcomed, but some patients viewed it as impersonal or a tick box exercise lacking in meaning. For example, this patient reflected on contact with staff as follows: A review to assess my progress. Apart from that, I haven’t seen the staff interacting in an informal way. (ID012)
More positive responses often singled out individual nurses who they could engage positively with. It was much less common to get positive reports for the whole staff group on a ward. It was very important and meaningful to patients that staff did everyday informal things, such as taking the time to sit and talk over a cup of tea, and that this engagement was felt as genuine. The positive communication style in a particular nurse was described by the following participant: They chat with any patients who want to chat with them, they chat to them, they find the time to chat to them. They never turn their back and say, ‘Oh I don’t have time for you’. From what I see and from what I know, from my experience, when I want to talk to somebody, they always chat, they always find the time for you. (ID118). © 2014 Australian College of Mental Health Nurses Inc.
PATIENT PERCEPTIONS OF STAFF
Some patients spoke of how nurses took the time to listen to them, and they felt listened to because actions followed requests made. Others explained that they had community groups on the wards where they felt heard. This form of proactive communication seemed to decrease patients’ frustration and isolation: Like if you’ve got any queries you ask them, like if there’s something wrong, then you ask the nurse, ‘Why can’t I do this? Why can’t I do that?’ and then you get an explanation. (ID037)
Consistency Nurses were frequently viewed by patients as behaving fairly and professionally, even in the face of less positive experiences of the wards: It’s all right. It’s all right. They treat everyone equal. (ID074).
However, rule keeping was an issue identified by many patients as being inconsistently applied, either between nurses or between patients or over time. Some degree of inconsistency might be expected. For example, a patient who knows how a ward operates is perhaps more likely to know how and when to make requests of staff so that they are more likely to be met promptly, and therefore, would seem to negotiate life on the ward more easily than one who does not. Nevertheless, some inconsistency is likely to be due to different personalities among staff members and their use of discretion in enforcing rules, and this was noted by patients: They choose certain people who they will allow to do certain things and other people they won’t. Like some patients have their music on full blast and then other patients will go in there and have their music on and they come and tell them to turn it down. (ID082)
For some patients, such variation in the application of rules without any apparent reason was a source of considerable resentment.
DISCUSSION Patient perspectives offer an essential insight into life on psychiatric wards, but are underrepresented in the research literature. Previous studies provide a fairly negative picture of the inpatient experience, and similar sentiments were expressed by patients in our sample. Patients do not like being locked in wards (often against their will) and being subject to medication and other coercive interventions. Feelings of anger, frustration, and hopelessness are commonplace, as is the view that nurses © 2014 Australian College of Mental Health Nurses Inc.
87
do not understand things from patients’ perspective. However, such feelings cannot be regarded as indicative of patients being passive receivers of care. The quantity of data presenting frustration at the slow pace on wards and the occasions of disconnect between nurses and patients indicates strongly that patients desire more meaningful contact and communication with staff. This was reinforced by the recognition among patients of the workloads of staff and expressions of sympathy for the difficulties they sometimes experience in fulfilling their duties. Patients in the present study expressed concern that communication with staff was too frequently about rule enforcement and less focused on genuine therapeutic engagement. Alexander (2006) described how inconsistencies in rule enforcement can lead to confusion among patients about their rationale, as well as feelings of victimization and distress for breaking rules about which they were not fully aware. Our findings suggest that patients on the whole do accept the need for rules, but sometimes lack clarity of how they are expected to behave. The interviews convey a sense of disorientation at the lack of explanation from staff. Such inconsistency might not have simply been between individual nurses, but have been institutionally driven, with understanding and implementation of rules varying between wards and hospitals. This was found by a previous survey of safety and security policies for over 100 acute wards that reported wide variation in the restrictions placed on patients, items banned, and the searching of patients and visitors (Bowers et al. 2002). Better communication of rules on admission would certainly help patients adjust to their surroundings. Even within the context of diverse individual patient needs and safety issues, small steps, such as involving the patient community in agreeing on expectations for behaviour on the wards and imaginative ways of displaying and disseminating these, could make a significant difference to the successful orientation of patients when they are admitted to hospital. It was very clear from the interviews that patients wanted more and better quality engagement with nursing staff, either formally through therapeutic interventions or through more general conversation and communication. Some of the reasons for this apparent lack of engagement mirror those reported by studies of nurses. Performing administrative and managerial tasks means less time for therapeutic activities, high patient turnover leads to reactive rather than planned work with patients, and lack of continuity (in patients and staff) leaves nurses unable to develop interpersonal relationships with patients (Gijbels 1995). Lack of time with patients also contributes to poor job satisfaction (Seed et al. 2010). Observational research
88
has confirmed that nurses spend a relatively high proportion of their time talking with other staff and office administration (Whittington & McLaughlin 2000). However, a recent review questioned a sole focus on directly therapeutic time spent with patients (Cleary et al. 2012). The authors argued that much nursing work occurs behind the scenes, the value of which goes unappreciated because it is not obvious, and that it does not follow that nursing activity without direct involvement with patients makes no contribution to the therapeutic work of the ward. As the authors pointed out, nursing in the often chaotic acute ward environment requires complex professional and interpersonal skills. Among the patients interviewed in the present study, background work (tasks that did not involve direct engagement with patients) went unrecognized and unsung, and many positive aspects of nurses’ work with patients were represented among their accounts. However, the interviews also bring to attention many instances and aspects of staff behaviour that are, at best, non-therapeutic, and at worst, likely to be traumatic. The impression of limited engagement with staff was reinforced by frequent complaints of boredom. This might have reflected apparent staffing difficulties on wards where patients reported a high number of bank or agency staff, but whatever the reasons, this clearly exacerbated frustration with being in hospital to the extent that patients felt it was detrimental to their recovery. The patients’ experiences are consistent with a review of the literature that found that only one-fifth of staff time is spent in direct therapeutic activities with patients, and that patients spend much of their time on their own (Sharac et al. 2010). Dissatisfaction with activities and therapy might be particularly pronounced during evenings and weekends (Chaplin et al. 2006a). There are potentially adverse clinical consequences to such lack of activity. Studies have found boredom to be a reason for patients to abscond from wards (Bowers et al. 1999; Meehan et al. 1999), and links have been found between low staffing levels, lack of activities, boredom, and the potential for aggression and violence (Chaplin et al. 2006b). While aspects of the ward environment and staffing are not so amenable to change, patients felt it reasonable to expect activities to take part in on the ward, that scheduled activities were not cancelled unless absolutely necessary, and that nurses spent time talking and perhaps helping patients make the most of opportunities to go outside when appropriate. Overall, the results are indicative of a fundamental difference between clinicians’ and patients’ perspectives on the nature and purpose of admission to hospital (Edwards 2000). Patients in the present study attached
D. STEWART ET AL.
great importance to fairness, being listened to, having activities, and being treated with respect. These aspects of life on the ward mattered to patients, but might be seen as secondary to the more immediate clinical features and outcomes that preoccupy nursing and medical staff, such as organizational expectations to minimize risk and keep patients safe, assessment, treatment, meeting basic care needs and physical health care (Bowers et al. 2005). There are similarities in the themes identified by the patients in this study with the domains of a recently formulated and validated patient reported outcome measurement scale (Evans et al. 2012). This instrument focuses on key aspects of the patient experience, such as feeling welcomed on the ward, staff taking an interest in and understanding the patient, staff being available to talk, trust in staff, having activities and one-to-one time with staff, and keeping in touch with family and friends. Other research has highlighted the importance of feeling safe while on the ward, where conflict between patients, intimidation, aggression, theft, racism, and drug use undermined their sense of security (Jones et al. 2010). Together, these concerns might guide a model of care better suited to the needs of people admitted to acute psychiatric wards, although organizational support is necessary to achieve this. There are some important limitations to the study. First, the data were several years old. We judged that the scarcity of acute inpatient perspectives in the literature and the unusually large sample available to the present study (across numerous wards and different hospital sites) meant that there was value to subjecting the data to rigorous analysis and publication. Indeed, a major advantage of such a large number of interviews was that a broad range of patient perspectives could be captured. We acknowledge that the age of the data potentially limits the relevance of the findings to current inpatient services. Since the data were collected, there has been a marked reduction in the number of available NHS beds in England and a subsequent increase in involuntary admissions (Keown et al. 2011). Under these circumstances, delivering quality care and maintaining safety in inpatient psychiatry are likely to have become more challenging. A recent meta-analysis identified associations between involuntary admissions and violence (Dack et al. 2013), while a quantitative survey found higher levels of patient dissatisfaction among acute inpatients compared to those in other services (Osborn et al. 2010). We believe, therefore, that the themes identified in the present study are still pertinent to current nursing practice. The pool of eligible patients was limited to those who were well enough to participate at the time of the research. No data © 2014 Australian College of Mental Health Nurses Inc.
PATIENT PERCEPTIONS OF STAFF
were collected on the numbers of patients who could not participate, and the final sample cannot be regarded as completely representative of all patients on the wards. We used multiple coders to analyse the data, and it is possible that there were inconsistencies between them. Nevertheless, we worked very hard to ensure that the coding frame was consensual and could be applied independently by each researcher.
CONCLUSION The findings provide an impression of inconsistent and sometimes poorly communicated care that cannot be regarded as satisfactory, but also offers pointers to where efforts to improve the patient experience might best be focused. There may be opportunities to improve the training and development of professional nursing skills, but this neglects the basic social skills that many patients in the sample felt were lacking. It might be that spending quality, therapeutic time is increasingly difficult to manage on busy acute wards or that nurses do have these skills, but they are sometimes too subtle for patients to fully appreciate them. It would appear from the current and previous studies that these shortcomings are detrimental to the satisfaction of both patients and nursing staff. Admission to a psychiatric ward can be a disempowering experience for patients, but such feelings can be minimized by treating patients with respect, giving patients more input into rules on the ward or their own treatment, providing patients with activities so they feel useful or occupied, ensuring patients are listened to by nurses, and being fair and consistent about rules. Much work needs to be done to promote and evaluate such initiatives.
REFERENCES Alexander, J. (2006). Patients’ feelings about ward nursing regimes and involvement in rule construction. Journal of Psychiatric and Mental Health Nursing, 13, 543–553. Bonner, G., Lowe, T., Rawcliffe, D. & Wellman, N. (2002). Trauma for all: A pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. Journal of Psychiatric and Mental Health Nursing, 9, 465–473. Bowers, L. (2002). Dangerous and Severe Personality Disorder: Response and Role of the Psychiatric Team. London: Routledge. Bowers, L., Jarrett, M., Clark, N., Kiyimba, F. & McFarlane, L. (1999). Absconding: Why patients leave. Journal of Psychiatric and Mental Health Nursing, 6, 199–205. © 2014 Australian College of Mental Health Nurses Inc.
89 Bowers, L., Crowhurst, N., Alexander, J. et al. (2002). Safety and security policies on psychiatric acute admission wards: Results from a London-wide survey. Journal of Psychiatric and Mental Health Nursing, 9, 427–433. Bowers, L., Simpson, A., Alexander, J. et al. (2005). The nature and purpose of acute psychiatric wards: The Tompkins acute ward study. Journal of Mental Health, 14, 625–635. Bowers, L., Hackney, D., Nijman, H. et al. (2007). A longitudinal study of conflict and containment on acute psychiatric wards. [Cited 28 April 2014]. Available from: URL: http:// www.kcl.ac.uk/iop/depts/hspr/research/ciemh/mhn/projects/ taws/TAWSreport.pdf Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. Chaplin, R., McGeorge, M. & Lelliott, P. (2006a). Violence on inpatient units for people with learning disability and mental illness: The experiences of service users and staff. British Journal of Developmental Disabilities, 52, 105–115. Chaplin, R., McGeorge, M. & Lelliott, P. (2006b). The National Audit of Violence: In-patient care for adults of working age. Psychiatric Bulletin, 30, 444–446. Cleary, M., Hunt, G. E., Horsfall, J. & Deacon, M. (2012). Nurse–patient interaction in acute adult inpatient mental health units: A review and synthesis of qualitative studies. Issues in Mental Health, 33, 66–79. Dack, C., Ross, J., Papadopoulos, C., Stewart, D. & Bowers, L. (2013). A review and meta-analysis of the patient factors associated with in-patient aggression. Acta Psychiatrica Scandinavica, 127, 255–268. Edwards, K. (2000). Service users and mental health nursing. Journal of Psychiatric and Mental Health Nursing, 7, 555– 565. Evans, J., Rose, D., Flach, C. et al. (2012). VOICE: Developing a new measure of service users’ perceptions of inpatient care, using participatory methodology. Journal of Mental Health, 21, 57–71. Gijbels, H. (1995). Mental health nursing skills in an acute admission environment: Perceptions of mental health nurses and other mental health professionals. Journal of Advanced Nursing, 21, 460–465. Greenberg, W. M., Moore-Duncan, L. & Herron, R. (1996). Patients’ attitudes toward having been forcibly medicated. Bulletin of American Academy of Psychiatry and the Law, 24, 513–524. Haglund, K., Von Knorring, L. & Von Essen, L. (2003). Forced medication in psychiatric care: Patient experiences and nurse perceptions. Journal of Psychiatric and Mental Health Nursing, 10, 65–72. Jones, J., Nolan, P., Bowers, L. et al. (2010). Psychiatric wards: Places of safety? Journal of Psychiatric and Mental Health Nursing, 17, 124–130. Keown, P., Weich, S., Bhui, K. S. & Scott, J. (2011). Association between provision f mental illness beds and rate of involuntary admissions to the NHS in England 1988–2008. British Medical Journal, 343, d3763.
90 Lelliott, P. & Quirk, A. (2004). What is life like on acute psychiatric wards? Current Opinion in Psychiatry, 17, 297–301. Meehan, T., Morrison, P. & McDougall, S. (1999). Absconding behaviour: An exploratory investigation in an acute inpatient unit. Australian and New Zealand Journal of Psychiatry, 33, 533–537. Osborn, D. P. J., Lloyd-Evans, B., Johnson, S. et al. (2010). Residential alternatives to acute in-patient care in England: Satisfaction, ward atmosphere and service use experiences. British Journal of Psychiatry, 197, s41–s45. Rydon, S. E. (2005). The attitudes, knowledge and skills needed in mental health nurses: The perspectives of users of mental health services. International Journal of Mental Health Nursing, 14, 78–87. Seed, M., Torkelson, D. J. & Alnatour, R. (2010). The role of the inpatient psychiatric nurse and its effect on job satisfaction. Issues in Mental Health Nursing, 31, 160–170. Sequeira, H. & Halstead, S. (2002). Control and restraint in the UK: Service user perspectives. British Journal of Forensic Practice, 4, 9–18.
D. STEWART ET AL. Sharac, J., McCrone, P., Sabes-Figuera, R., Csipke, E., Wood, A. & Wykes, T. (2010). Nurse and patient activities and interaction on psychiatric inpatients wards: A literature review. International Journal of Nursing Studies, 47, 909– 917. Thomas, S. P., Shattell, M. & Martin, T. (2002). What’s therapeutic about the therapeutic milieu? Archives of Psychiatric Nursing, 16, 99–107. Van Der Merwe, M., Muir-Cochrane, E., Jones, J., Tziggili, M. & Bowers, L. (2013). Improving seclusion practice: Implications of a review of staff and patient views. Journal of Psychiatric Mental Health Nursing, 20, 203–215. Whittington, S. & McLaughlin, C. (2000). Finding time for patients: An exploration of nurses’ time allocation in an acute psychiatric setting. Journal of Psychiatric and Mental Health Nursing, 7, 259–268. Wood, D. & Pistrang, N. (2004). A safe place? Service users’ experiences of an acute mental health ward. Journal of Community and Applied Social Psychology, 14, 16–28.
© 2014 Australian College of Mental Health Nurses Inc.
Copyright of International Journal of Mental Health Nursing is the property of WileyBlackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
International Journal of Mental Health Nursing (2015) 24, 82–90
doi: 10.1111/inm.12107
Feature Article
Thematic analysis of psychiatric patients’ perceptions of nursing staff Duncan Stewart, Heather Burrow, Alex Duckworth, Jasbir Dhillon, Sarah Fife, Siobhan Kelly, Sophie Marsh-Picksley, Emma Massey, John O’Sullivan, Maria Qureshi, Steve Wright and Len Bowers Institute of Psychiatry, Kings College London, London, UK
ABSTRACT: Therapeutic and informal interactions with nurses are integral to the quality of care that psychiatric patients receive. How well these interactions are performed, and their impact on the experience and outcomes of inpatient care, have not been subject to systematic evaluation. The aim of the present study was to examine patients’ perceptions of the personal and professional qualities of nursing staff and how these contribute to the ward environment. Patients (n = 119) from 16 acute psychiatric wards were interviewed using a schedule developed by a service-user researcher. Transcriptions of interviews were coded and organized into six themes: staff duties, staff disposition, control, communication and engagement, therapeutic ward environment, and consistency. Patients recognized that nurses have a difficult and stressful job, but frequently expressed feelings of anger, frustration, and hopelessness about their experience of the wards. Patients frequently felt that nursing staff did not understand issues from their perspective or attempt to empathize with them. The findings indicate poorly-communicated and inconsistent care. Initiatives to improve patients’ experiences of acute psychiatric wards are urgently needed. KEY WORDS: attitude, interview, patient experience, psychiatric wards, qualitative.
INTRODUCTION People are admitted to psychiatric wards because they appear likely to harm themselves or others, and because they have a severe mental illness (Bowers et al. 2005). The individual might also have insufficient support and superCorrespondence: Duncan Stewart, Psychology, Social Work and Human Sciences, University of West London, Paragon House, Brentford, London TW8 9GA, UK. Email: [email protected] Duncan Stewart, BA, PhD. Heather Burrow, BSc. Alex Duckworth, BSc. Jasbir Dhillon, BSc, MSc. Sarah Fife, BSc, MSc. Siobhan Kelly, BSc, MSc. Sophie Marsh-Picksley, BSc. Emma Massey, BSc, MSc. John O’Sullivan, BSc. Maria Qureshi, BSc, MSC. Steve Wright, BSc, MSc. Len Bowers, BSc, MA, PhD, RMN. Accepted August 2014.
© 2014 Australian College of Mental Health Nurses Inc.
vision available in the community. Nursing staff are tasked with keeping patients safe, assessing their problems, treating their mental illness, meeting their basic care needs, and providing physical health care. These are achieved through the use of containment (e.g. ‘asrequired’ medication, seclusion, special observation, intensive care, manual restraint, and enforced medication), 24-hour staff presence, treatment provision, and complex organization and management (Bowers et al. 2005). Activities are provided to keep people occupied, and ward rules and policies employed to set limits on patients’ behaviour. The nature of these interventions, and the way they are implemented, are likely to be major factors in patients’ experiences of care (Lelliott & Quirk 2004). The day-to-day and therapeutic interactions with nurses are integral to the quality of care that patients receive, and the personalized interest, care, and attention from staff that these represent is greatly valued (Rydon
PATIENT PERCEPTIONS OF STAFF
2005). However, organizational factors can sometimes impinge upon nurses’ ability to fulfil this role (Gijbels 1995). There is, therefore, an obvious need for research to establish how well these interactions are performed and their impact on the experience of patients. However, systematic evaluation of patient perspectives of life on psychiatric wards is lacking. Previous studies of patient perspectives have focused on particular forms of conflict and containment experienced during hospitalization. Coercive interventions, in particular, can have a detrimental impact on relationships between patients and staff. Patients subjected to restraint have reported feelings of anger, fear, and panic, and that the use of restraint is unjustified and can provoke memories of distressing or abusive events (Bonner et al. 2002; Sequeira & Halstead 2002). Similarly, seclusion can be a profoundly negative experience for patients by provoking feelings of vulnerability and hopelessness (Van Der Merwe et al. 2013). Patients interviewed about receiving coerced medication have reported feeling angry, helpless, and embarrassed (Greenberg et al. 1996; Haglund et al. 2003), and described a fear of becoming ill or dying as a result of the medication (Haglund et al. 2003). A recent review and synthesis of qualitative research of the nurse–patient interaction in adult acute inpatient mental health units (Cleary et al. 2012) found 23 studies published in English between January 1999 and July 2010. It concluded that nurses use complex communication and interpersonal skills, which they deploy in pragmatic and non-formalized ways to generate and maintain engagement with patients. Thus, while nurses do often interact therapeutically with patients, whose ability to relate to others is often severely compromised, this might not be solely accomplished through direct engagement in activities. A review of 13 papers concerning nurse and patient interactions found that approximately 50% of staff time was spent in contact with patients, and little time was actually spent in therapeutic activity (Sharac et al. 2010). This can lead to negative feelings among patients. For example, Thomas et al. (2002) reported that patients expressed longing for a deeper connection with staff and more intensive insight-oriented therapies. While patients’ needs for safety, structure, and medication were met, they were not gaining a greater understanding of their dysfunctional patterns of behaviour. Wood and Pistrang (2004) explored patients’ accounts of acute wards, which were characterized by an overwhelming sense of vulnerability and helplessness, describing vividly how interactions between patients, the behaviour and attitudes of staff, and non-consensual treatment all impacted on their sense of safety and threat. © 2014 Australian College of Mental Health Nurses Inc.
83
In summary, only a limited number of studies address ward interactions from the perspective of patients, and their sample sizes are extremely small (Cleary et al. 2012). The aim of the present study was to examine patient perceptions of nursing staff by considering both personal and professional qualities of nurses and their contribution to the ward environment, and to apply this to a much larger sample than has been achieved by most previous research.
MATERIALS AND METHODS Sample The research was part of the Tompkins Acute Ward Study, a longitudinal, mixed-methods research project investigating care in one Mental Health Trust in England. The Trust serves a population of 650 000 in three inner London boroughs. Trusts are self-governing organizational units within the National Health Service (NHS), which provide inpatient and community health services to local populations, in conjunction with primary care and government social services departments. Three hospital sites were involved, with 13 acute wards (5, 4, and 4 on each site) and three psychiatric intensive care units (PICU) (1 on each site). Bed numbers for the acute wards ranged from 15 to 20. For the PICU, the bed numbers were eight, nine, and 15. The majority of wards had mixed-sex occupancy (1 acute ward was female only, and 1 PICU was male only). Wards were staffed by a combination of registered psychiatric nurses and health-care assistants. The whole-time equivalent staffing numbers were approximately one staff member to one bed, and the staffing and skill mix was generally consistent across the wards. With the exception of the PICU, wards at two hospitals were locked at the discretion of the nurse in charge. At the third hospital, wards (excluding the PICU) were unlocked to patients leaving, but the system was altered during the course of the study so that all wards were locked both to entry and exit during the night shift. The sample frame for potential participants included all patients on the 16 wards within the Trust. The initial intention was to randomly select from this sample frame, but difficulties with this approach arose during the fieldwork. Some patients were unable to be included in the study for the following reasons: language barriers, too unwell to participate, considerations of well-being, and safety issues. Others were on leave or otherwise engaged with activities at the time of the researcher’s visit. As a result, random selection of patients occurred after discussions with ward staff on suitability and availability of inpatients on each ward. The aim was to conduct interviews
84
with two patients on each ward every 6 months at four different time points: December 2004–February 2005, May 2005–July 2005, November–December 2005, and May–July 2006. This was to enable exploration of correlations between patient responses and other longitudinal measures captured by the Tompkins study (see Bowers et al. 2007 for further details). Two interviews per ward was the maximum that could be collected at each wave with the resources available. A total of 119 interviews were completed, representing 93% of the target total.
Data collection The interview schedule was developed specifically for this study by a service-user researcher (SUR) in consultation with two local service-user groups, all with experience of inpatient facilities. The interview was informed by an evidence-based model of conflict and containment (Bowers 2002), and addressed three factors hypothesized to contribute to the levels of conflict on psychiatric wards: positive appreciation of patients by nursing staff, the ability of nurses to regulate their own natural emotional reactions to difficult and challenging behaviour by patients, and the creation of an effective ward structure through rules and routine. Thus, the interview addressed the nature of a typical day on the ward, how staff members generally think or feel about patients on the ward, how members of staff spend their time on the ward, and what kinds of things patients are allowed or not allowed to do on the ward. It was initially piloted in order to establish face validity. The majority of interviews (n = 100) were conducted by the SUR; an experienced, independent service-user consultant who received training in conducting research interviews. Due to some practical difficulties, a small number of the interviews were conducted by university researchers (n = 19).
Ethical considerations Ethical approval for the study was obtained from the local Health Authority Research Ethics Committee and the local mental health service’s research and development office. A study information sheet was provided for each participant, and informed, written consent was obtained before each interview. Participants were assured that agreement or refusal to take part would make no difference to their care or treatment, and that they could withdraw from the study at any time if they wished. It was made clear that interviews were anonymous and confidential and would not be discussed with ward staff, interview tapes would be safely stored and transcribed, and that their data would only be accessed by the immediate research team.
D. STEWART ET AL.
Procedure Appointments were made with staff on each of the 16 wards to arrange a visit by the SUR. The ward’s patient list was obtained, and ward staff (nurses, doctors, psychologists) were asked to advise on who could be invited to participate and who, in their opinion, should be excluded. Eligible service users were then selected by randomly allocating a number to each name and then referring to a computer-generated random list of numbers. Potential interviewees were approached on the ward and told about the study by the SUR, given a study information sheet, and asked whether they would be interested in participating. On agreement, interviewees were invited to a quiet area where the SUR would explain that she had experience of using psychiatric services herself, and they were asked to read and sign a consent form. Issues of confidentiality were explained, and participants were encouraged to ask any questions they had about the study. The interview was then conducted and lasted between 30 and 45 min. At the start of each interview, participants were asked their sex, age, and ethnicity, and whether this was their first admission to a psychiatric hospital. No participants were known to the interviewers. All interviews were tape recorded, with the exception of one participant who declined to be recorded, and notes were taken for this participant instead.
Analysis The interview tapes were professionally transcribed verbatim. Thematic analysis was conducted using an inductive (data-driven rather than theoretical) approach and followed the stages described by Braun and Clarke (2006). These are: familiarization with all the data, generating codes, identifying themes, reviewing themes, defining and naming themes, and finally write up themes into a report. The first phase of the analysis was to develop an initial coding frame. The analysis utilized 10 research assistants (RA) who were employed on another project. Training in coding and thematic analysis was provided before each was asked to independently read and identify codes, definitions, and examples for the same 10 randomly-selected interviews. The RA were requested not to discuss the interviews or their coding schemes with each other during this phase of the project. Codes were then compared among the group in meetings facilitated by the lead author to develop a consensual coding structure for application to the whole data set to ensure consistency between researchers. Once the initial phase of coding was agreed on, all 119 interview transcripts were randomly divided among the RA for coding. Extracts for © 2014 Australian College of Mental Health Nurses Inc.
PATIENT PERCEPTIONS OF STAFF
each code were recorded electronically on an Excel spreadsheet. RA were instructed to inform the group of any new codes that emerged. New codes were discussed and agreed on at team meetings and via email. The next phase involved collating all the coded extracts (n = 3491) from the RA, sorting codes into themes, and collating extracts within identified themes. This was achieved in group discussion, with themes then randomly allocated to RA for write up.
RESULTS Two-thirds (66%) of the sample were male, and 62% were under 40 years old. The patients were ethnically diverse: 38% white British, 35% black/black British, 12% Asian/ Asian British, 19% other. Almost three-quarters (73%) had had a previous admission to a psychiatric hospital. The analysis identified six major themes in the data, which are described below.
Staff duties Patients in the sample frequently commented on how effectively staff carried out their roles. On the whole, patients demonstrated an understanding and appreciation of staff roles, and almost all referred to the varied duties they perceive staff to be carrying out as an integral part of their job, including some mundane tasks, as one patient observed: On the phone, on the computer, being happy, observations, giving injections, giving medication, counselling. On Sundays, they have talking groups, preparing the meals, giving out meals, changing the bed linen, finding toothbrushes [laughter], helping with the laundry, (ID029)
Knowing that nurses are capable and able to attend to basic needs and create a therapeutic environment developed a sense of trust and safety. Nurses who performed their duties were seen by some patients as caring and considerate:
85 They have a lot of problems of their own and lot of deficiencies and inefficiencies, but nothing is going to get better until that is sorted out. (ID085)
Staff disposition Patients consistently attributed the quality of their care to nurses’ perceived attitudes towards the patients and their work. Across many interviews, participants valued being treated as an individual person, and not simply in terms of their clinical characteristics. Patients repeatedly expressed the benefits of being treated in this manner as an aid to their recovery and a positive aspect to their time in hospital. As one patient succinctly stated: It feels good, it sort of, I reckon, it speeds up your recovery, because you’re not being sort of, you’re not being treated like cattle, you know? (ID034)
Although some patients described staff enjoying their work, many also reported that staff appeared to see their role as just a job or a shift to get through: I don’t think they give a damn. They just come here and do their job. They don’t care about what personal destruction they’re causing to your mind. As far as they’re concerned, your mind’s already damaged. They just come here, do their job. As long as they do their job and have no comebacks, then they don’t care. (ID025)
Some also went as far as describing staff as uncaring, dismissive, or disrespectful: It made me feel little, belittled, I felt belittled, and I just think to myself, you know, why does he have to treat me in this way? I’m a human being, I’m a person. You don’t treat a person like that. If you treat me with respect, I will treat you with respect back, but if you don’t treat me with respect, you’re not going to get my respect, and that’s my point. (ID117)
Control
Try to make sure we take our bath . . . trying to make sure that we take the medication. Try to make sure that most of us that needs to go as for the appointment is to go there. Then most of all, that’s just to make sure that we’re in good health and condition. (ID079)
This theme concerned exertion of staff control on the wards. Perceptions among the sample varied. At one end of the spectrum, most patients understood that it is necessary for staff to have some control of the ward in order to maintain order. More specifically, there were several instances of patients appreciating that staff retaining control kept patients safe from themselves and each other. For example, one patient stated that:
However, many individuals across our sample referred to occasions when nurses seemed unable to perform at a level to meet their responsibilities, not necessarily because they did not desire to, but because they did not possess the relevant skills or abilities:
Staff are always on hand. There’s always somebody in the communal area, so it just, it just ticks along it’s, the way they maintain the rules is, erm, by sort of vigilance, I suppose. They just keep their eyes open and they listen out for what’s going on. (ID107).
© 2014 Australian College of Mental Health Nurses Inc.
86
D. STEWART ET AL.
At the other end of the spectrum, patients perceived staff to have total control, with nurses employing an authoritarian style, applying rules inflexibly, and threatening consequences for rule transgression. There were examples of a sliding scale of consequences depending on the transgression or level of patient adherence:
negative aspects of staff communication. On the negative side, the interviews conveyed a sense of disorientation and helplessness. Patients reported that communication felt one way at times, such that the nurses could call on them, but they could not initiate communication with staff:
The minimum is told to calm down and remain where you are, then medium is sent to your room. The maximum has two parts. The maximum is you go on extra medication. (ID47).
When we try and get attention from them, we can’t get it. When they want attention from us, they want it 100%, they want us to be there on the spot for them. (ID064).
Therapeutic ward environment Patients referred to broader aspects of life on the wards that were not always directly within individual nurses’ control. Boredom was by far the most prevalent code in this theme, for which patients gave a variety of explanations and examples, from a lack of activities to inadequate numbers of key staff, such as occupational therapists. There was also concern that nurses were too busy to spend time with patients and organize activities for them: It’s always paper work, and they don’t get time for patients. (ID032)
There were more positive descriptions of ward activities, although several patients noted that these tended to be undertaken by more junior staff: Yes, they’ll play games. They have sat there and . . . they might play Scrabble or Monopoly or something like that, but it’s more likely to be a student nurse. (ID029)
Patients also referred to frequent changes in staff. This is a significant feature of work on inpatient wards and can take different forms, including changes over shifts or swapping staff between wards and use of bank or agency staff. Rotation patterns are designed to support and develop staff, but the patients in the present study were particularly negative about the impact of bank and agency staff. Concerns that their use was disruptive and made it more difficult to develop good relationships with nurses were summed up by this patient: There are a lot of casual (staff ). Too many casual/agency. They don’t know the individuals. They don’t know what their problems are, and one of the things that happens a lot, is these agencies are making these individuals worse. That is a massive problem in here. (ID025)
Communication and engagement Communication was defined as conveying information by speech, signs on the ward, writing, or aspects of behaviour, and was the most prevalent theme in the interviews. Overall, patients tended to agree on both positive and
Some patients were specific about the type of communication that was lacking, and noted an absence of community meetings (a forum for airing and discussing grievances with staff) and lack of ‘one-to-one’ time with nurses. Others spoke of requests made in community meetings not being followed up, which then rendered the meetings meaningless to patients and left them feeling undervalued: They listen, but they don’t do nothing. I mean they, there’s a book of minutes there what they take every week, every day, but they might as well not bother. (ID027).
Perceptions of staff included feeling that nurses engaged in a formal, professional, but rather unfriendly way. This was most exemplified by complaints that nurses would only communicate for a specific reason, such as to assess patients’ mental state or obtain a history. This interaction might be welcomed, but some patients viewed it as impersonal or a tick box exercise lacking in meaning. For example, this patient reflected on contact with staff as follows: A review to assess my progress. Apart from that, I haven’t seen the staff interacting in an informal way. (ID012)
More positive responses often singled out individual nurses who they could engage positively with. It was much less common to get positive reports for the whole staff group on a ward. It was very important and meaningful to patients that staff did everyday informal things, such as taking the time to sit and talk over a cup of tea, and that this engagement was felt as genuine. The positive communication style in a particular nurse was described by the following participant: They chat with any patients who want to chat with them, they chat to them, they find the time to chat to them. They never turn their back and say, ‘Oh I don’t have time for you’. From what I see and from what I know, from my experience, when I want to talk to somebody, they always chat, they always find the time for you. (ID118). © 2014 Australian College of Mental Health Nurses Inc.
PATIENT PERCEPTIONS OF STAFF
Some patients spoke of how nurses took the time to listen to them, and they felt listened to because actions followed requests made. Others explained that they had community groups on the wards where they felt heard. This form of proactive communication seemed to decrease patients’ frustration and isolation: Like if you’ve got any queries you ask them, like if there’s something wrong, then you ask the nurse, ‘Why can’t I do this? Why can’t I do that?’ and then you get an explanation. (ID037)
Consistency Nurses were frequently viewed by patients as behaving fairly and professionally, even in the face of less positive experiences of the wards: It’s all right. It’s all right. They treat everyone equal. (ID074).
However, rule keeping was an issue identified by many patients as being inconsistently applied, either between nurses or between patients or over time. Some degree of inconsistency might be expected. For example, a patient who knows how a ward operates is perhaps more likely to know how and when to make requests of staff so that they are more likely to be met promptly, and therefore, would seem to negotiate life on the ward more easily than one who does not. Nevertheless, some inconsistency is likely to be due to different personalities among staff members and their use of discretion in enforcing rules, and this was noted by patients: They choose certain people who they will allow to do certain things and other people they won’t. Like some patients have their music on full blast and then other patients will go in there and have their music on and they come and tell them to turn it down. (ID082)
For some patients, such variation in the application of rules without any apparent reason was a source of considerable resentment.
DISCUSSION Patient perspectives offer an essential insight into life on psychiatric wards, but are underrepresented in the research literature. Previous studies provide a fairly negative picture of the inpatient experience, and similar sentiments were expressed by patients in our sample. Patients do not like being locked in wards (often against their will) and being subject to medication and other coercive interventions. Feelings of anger, frustration, and hopelessness are commonplace, as is the view that nurses © 2014 Australian College of Mental Health Nurses Inc.
87
do not understand things from patients’ perspective. However, such feelings cannot be regarded as indicative of patients being passive receivers of care. The quantity of data presenting frustration at the slow pace on wards and the occasions of disconnect between nurses and patients indicates strongly that patients desire more meaningful contact and communication with staff. This was reinforced by the recognition among patients of the workloads of staff and expressions of sympathy for the difficulties they sometimes experience in fulfilling their duties. Patients in the present study expressed concern that communication with staff was too frequently about rule enforcement and less focused on genuine therapeutic engagement. Alexander (2006) described how inconsistencies in rule enforcement can lead to confusion among patients about their rationale, as well as feelings of victimization and distress for breaking rules about which they were not fully aware. Our findings suggest that patients on the whole do accept the need for rules, but sometimes lack clarity of how they are expected to behave. The interviews convey a sense of disorientation at the lack of explanation from staff. Such inconsistency might not have simply been between individual nurses, but have been institutionally driven, with understanding and implementation of rules varying between wards and hospitals. This was found by a previous survey of safety and security policies for over 100 acute wards that reported wide variation in the restrictions placed on patients, items banned, and the searching of patients and visitors (Bowers et al. 2002). Better communication of rules on admission would certainly help patients adjust to their surroundings. Even within the context of diverse individual patient needs and safety issues, small steps, such as involving the patient community in agreeing on expectations for behaviour on the wards and imaginative ways of displaying and disseminating these, could make a significant difference to the successful orientation of patients when they are admitted to hospital. It was very clear from the interviews that patients wanted more and better quality engagement with nursing staff, either formally through therapeutic interventions or through more general conversation and communication. Some of the reasons for this apparent lack of engagement mirror those reported by studies of nurses. Performing administrative and managerial tasks means less time for therapeutic activities, high patient turnover leads to reactive rather than planned work with patients, and lack of continuity (in patients and staff) leaves nurses unable to develop interpersonal relationships with patients (Gijbels 1995). Lack of time with patients also contributes to poor job satisfaction (Seed et al. 2010). Observational research
88
has confirmed that nurses spend a relatively high proportion of their time talking with other staff and office administration (Whittington & McLaughlin 2000). However, a recent review questioned a sole focus on directly therapeutic time spent with patients (Cleary et al. 2012). The authors argued that much nursing work occurs behind the scenes, the value of which goes unappreciated because it is not obvious, and that it does not follow that nursing activity without direct involvement with patients makes no contribution to the therapeutic work of the ward. As the authors pointed out, nursing in the often chaotic acute ward environment requires complex professional and interpersonal skills. Among the patients interviewed in the present study, background work (tasks that did not involve direct engagement with patients) went unrecognized and unsung, and many positive aspects of nurses’ work with patients were represented among their accounts. However, the interviews also bring to attention many instances and aspects of staff behaviour that are, at best, non-therapeutic, and at worst, likely to be traumatic. The impression of limited engagement with staff was reinforced by frequent complaints of boredom. This might have reflected apparent staffing difficulties on wards where patients reported a high number of bank or agency staff, but whatever the reasons, this clearly exacerbated frustration with being in hospital to the extent that patients felt it was detrimental to their recovery. The patients’ experiences are consistent with a review of the literature that found that only one-fifth of staff time is spent in direct therapeutic activities with patients, and that patients spend much of their time on their own (Sharac et al. 2010). Dissatisfaction with activities and therapy might be particularly pronounced during evenings and weekends (Chaplin et al. 2006a). There are potentially adverse clinical consequences to such lack of activity. Studies have found boredom to be a reason for patients to abscond from wards (Bowers et al. 1999; Meehan et al. 1999), and links have been found between low staffing levels, lack of activities, boredom, and the potential for aggression and violence (Chaplin et al. 2006b). While aspects of the ward environment and staffing are not so amenable to change, patients felt it reasonable to expect activities to take part in on the ward, that scheduled activities were not cancelled unless absolutely necessary, and that nurses spent time talking and perhaps helping patients make the most of opportunities to go outside when appropriate. Overall, the results are indicative of a fundamental difference between clinicians’ and patients’ perspectives on the nature and purpose of admission to hospital (Edwards 2000). Patients in the present study attached
D. STEWART ET AL.
great importance to fairness, being listened to, having activities, and being treated with respect. These aspects of life on the ward mattered to patients, but might be seen as secondary to the more immediate clinical features and outcomes that preoccupy nursing and medical staff, such as organizational expectations to minimize risk and keep patients safe, assessment, treatment, meeting basic care needs and physical health care (Bowers et al. 2005). There are similarities in the themes identified by the patients in this study with the domains of a recently formulated and validated patient reported outcome measurement scale (Evans et al. 2012). This instrument focuses on key aspects of the patient experience, such as feeling welcomed on the ward, staff taking an interest in and understanding the patient, staff being available to talk, trust in staff, having activities and one-to-one time with staff, and keeping in touch with family and friends. Other research has highlighted the importance of feeling safe while on the ward, where conflict between patients, intimidation, aggression, theft, racism, and drug use undermined their sense of security (Jones et al. 2010). Together, these concerns might guide a model of care better suited to the needs of people admitted to acute psychiatric wards, although organizational support is necessary to achieve this. There are some important limitations to the study. First, the data were several years old. We judged that the scarcity of acute inpatient perspectives in the literature and the unusually large sample available to the present study (across numerous wards and different hospital sites) meant that there was value to subjecting the data to rigorous analysis and publication. Indeed, a major advantage of such a large number of interviews was that a broad range of patient perspectives could be captured. We acknowledge that the age of the data potentially limits the relevance of the findings to current inpatient services. Since the data were collected, there has been a marked reduction in the number of available NHS beds in England and a subsequent increase in involuntary admissions (Keown et al. 2011). Under these circumstances, delivering quality care and maintaining safety in inpatient psychiatry are likely to have become more challenging. A recent meta-analysis identified associations between involuntary admissions and violence (Dack et al. 2013), while a quantitative survey found higher levels of patient dissatisfaction among acute inpatients compared to those in other services (Osborn et al. 2010). We believe, therefore, that the themes identified in the present study are still pertinent to current nursing practice. The pool of eligible patients was limited to those who were well enough to participate at the time of the research. No data © 2014 Australian College of Mental Health Nurses Inc.
PATIENT PERCEPTIONS OF STAFF
were collected on the numbers of patients who could not participate, and the final sample cannot be regarded as completely representative of all patients on the wards. We used multiple coders to analyse the data, and it is possible that there were inconsistencies between them. Nevertheless, we worked very hard to ensure that the coding frame was consensual and could be applied independently by each researcher.
CONCLUSION The findings provide an impression of inconsistent and sometimes poorly communicated care that cannot be regarded as satisfactory, but also offers pointers to where efforts to improve the patient experience might best be focused. There may be opportunities to improve the training and development of professional nursing skills, but this neglects the basic social skills that many patients in the sample felt were lacking. It might be that spending quality, therapeutic time is increasingly difficult to manage on busy acute wards or that nurses do have these skills, but they are sometimes too subtle for patients to fully appreciate them. It would appear from the current and previous studies that these shortcomings are detrimental to the satisfaction of both patients and nursing staff. Admission to a psychiatric ward can be a disempowering experience for patients, but such feelings can be minimized by treating patients with respect, giving patients more input into rules on the ward or their own treatment, providing patients with activities so they feel useful or occupied, ensuring patients are listened to by nurses, and being fair and consistent about rules. Much work needs to be done to promote and evaluate such initiatives.
REFERENCES Alexander, J. (2006). Patients’ feelings about ward nursing regimes and involvement in rule construction. Journal of Psychiatric and Mental Health Nursing, 13, 543–553. Bonner, G., Lowe, T., Rawcliffe, D. & Wellman, N. (2002). Trauma for all: A pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. Journal of Psychiatric and Mental Health Nursing, 9, 465–473. Bowers, L. (2002). Dangerous and Severe Personality Disorder: Response and Role of the Psychiatric Team. London: Routledge. Bowers, L., Jarrett, M., Clark, N., Kiyimba, F. & McFarlane, L. (1999). Absconding: Why patients leave. Journal of Psychiatric and Mental Health Nursing, 6, 199–205. © 2014 Australian College of Mental Health Nurses Inc.
89 Bowers, L., Crowhurst, N., Alexander, J. et al. (2002). Safety and security policies on psychiatric acute admission wards: Results from a London-wide survey. Journal of Psychiatric and Mental Health Nursing, 9, 427–433. Bowers, L., Simpson, A., Alexander, J. et al. (2005). The nature and purpose of acute psychiatric wards: The Tompkins acute ward study. Journal of Mental Health, 14, 625–635. Bowers, L., Hackney, D., Nijman, H. et al. (2007). A longitudinal study of conflict and containment on acute psychiatric wards. [Cited 28 April 2014]. Available from: URL: http:// www.kcl.ac.uk/iop/depts/hspr/research/ciemh/mhn/projects/ taws/TAWSreport.pdf Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. Chaplin, R., McGeorge, M. & Lelliott, P. (2006a). Violence on inpatient units for people with learning disability and mental illness: The experiences of service users and staff. British Journal of Developmental Disabilities, 52, 105–115. Chaplin, R., McGeorge, M. & Lelliott, P. (2006b). The National Audit of Violence: In-patient care for adults of working age. Psychiatric Bulletin, 30, 444–446. Cleary, M., Hunt, G. E., Horsfall, J. & Deacon, M. (2012). Nurse–patient interaction in acute adult inpatient mental health units: A review and synthesis of qualitative studies. Issues in Mental Health, 33, 66–79. Dack, C., Ross, J., Papadopoulos, C., Stewart, D. & Bowers, L. (2013). A review and meta-analysis of the patient factors associated with in-patient aggression. Acta Psychiatrica Scandinavica, 127, 255–268. Edwards, K. (2000). Service users and mental health nursing. Journal of Psychiatric and Mental Health Nursing, 7, 555– 565. Evans, J., Rose, D., Flach, C. et al. (2012). VOICE: Developing a new measure of service users’ perceptions of inpatient care, using participatory methodology. Journal of Mental Health, 21, 57–71. Gijbels, H. (1995). Mental health nursing skills in an acute admission environment: Perceptions of mental health nurses and other mental health professionals. Journal of Advanced Nursing, 21, 460–465. Greenberg, W. M., Moore-Duncan, L. & Herron, R. (1996). Patients’ attitudes toward having been forcibly medicated. Bulletin of American Academy of Psychiatry and the Law, 24, 513–524. Haglund, K., Von Knorring, L. & Von Essen, L. (2003). Forced medication in psychiatric care: Patient experiences and nurse perceptions. Journal of Psychiatric and Mental Health Nursing, 10, 65–72. Jones, J., Nolan, P., Bowers, L. et al. (2010). Psychiatric wards: Places of safety? Journal of Psychiatric and Mental Health Nursing, 17, 124–130. Keown, P., Weich, S., Bhui, K. S. & Scott, J. (2011). Association between provision f mental illness beds and rate of involuntary admissions to the NHS in England 1988–2008. British Medical Journal, 343, d3763.
90 Lelliott, P. & Quirk, A. (2004). What is life like on acute psychiatric wards? Current Opinion in Psychiatry, 17, 297–301. Meehan, T., Morrison, P. & McDougall, S. (1999). Absconding behaviour: An exploratory investigation in an acute inpatient unit. Australian and New Zealand Journal of Psychiatry, 33, 533–537. Osborn, D. P. J., Lloyd-Evans, B., Johnson, S. et al. (2010). Residential alternatives to acute in-patient care in England: Satisfaction, ward atmosphere and service use experiences. British Journal of Psychiatry, 197, s41–s45. Rydon, S. E. (2005). The attitudes, knowledge and skills needed in mental health nurses: The perspectives of users of mental health services. International Journal of Mental Health Nursing, 14, 78–87. Seed, M., Torkelson, D. J. & Alnatour, R. (2010). The role of the inpatient psychiatric nurse and its effect on job satisfaction. Issues in Mental Health Nursing, 31, 160–170. Sequeira, H. & Halstead, S. (2002). Control and restraint in the UK: Service user perspectives. British Journal of Forensic Practice, 4, 9–18.
D. STEWART ET AL. Sharac, J., McCrone, P., Sabes-Figuera, R., Csipke, E., Wood, A. & Wykes, T. (2010). Nurse and patient activities and interaction on psychiatric inpatients wards: A literature review. International Journal of Nursing Studies, 47, 909– 917. Thomas, S. P., Shattell, M. & Martin, T. (2002). What’s therapeutic about the therapeutic milieu? Archives of Psychiatric Nursing, 16, 99–107. Van Der Merwe, M., Muir-Cochrane, E., Jones, J., Tziggili, M. & Bowers, L. (2013). Improving seclusion practice: Implications of a review of staff and patient views. Journal of Psychiatric Mental Health Nursing, 20, 203–215. Whittington, S. & McLaughlin, C. (2000). Finding time for patients: An exploration of nurses’ time allocation in an acute psychiatric setting. Journal of Psychiatric and Mental Health Nursing, 7, 259–268. Wood, D. & Pistrang, N. (2004). A safe place? Service users’ experiences of an acute mental health ward. Journal of Community and Applied Social Psychology, 14, 16–28.
© 2014 Australian College of Mental Health Nurses Inc.
Copyright of International Journal of Mental Health Nursing is the property of WileyBlackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
