Nursing Inquiry

Buus, Niels

doi: 10.1111/j.1440-1800.2008.00421.xpmid: 18786209

Hamilton, Bridget; Manias, Elizabeth

doi: 10.1111/j.1440-1800.2008.00406.xpmid: 18786210

The power of routine and special observations: producing civility in a public acute psychiatric unit This study directly addresses controlling aspects of psychiatric nursing practice, which are currently marginalised in practice and research. We first consider the discursive tensions surrounding the mandated goal of social control in public acute psychiatric units, particularly referring to those units located within medical hospitals. We attest to the enduring social control mandate in psychiatric nursing and explore ways in which it is enacted. Specific nursing practices of ‘doing the obs’ while scanning the ward and ‘special observations’ are investigated as important activities of social control, based on findings from an ethnographic study in one acute psychiatric unit in Australia. These practices are acknowledged as key modes of nursing surveillance. Contrary to past work, they are regarded as productive for engendering civil conduct among patients in acute psychiatric settings. We reframe these activities of surveillance as liberal therapeutic practices in themselves, to the extent that they assist patients to achieve treatment goals and promote self‐surveillance and self‐control. Instead of effacing practices of control, we encourage nurses to discriminate between more and less liberal modes of control in everyday practice and to build their skills in liberal controlling strategies.

Buus, Niels

doi: 10.1111/j.1440-1800.2008.00405.xpmid: 18786211

Negotiating clinical knowledge: a field study of psychiatric nurses’ everyday communication Nursing practices at psychiatric hospitals have changed significantly over the last decades. In this paper, everyday nursing practices were interpreted in light of these institutional changes. The objective was to examine how mental health nurses’ production of clinical knowledge was influenced by the particular social relations on hospital wards. Empirical data stemming from an extended fieldwork at two Danish psychiatric hospital wards were interpreted using interactionistic theory and the metaphor: ‘the game of clinical knowledge’. The results indicated that the nurses’ production of clinical knowledge was highly dependent on the individual nurses’ practical ability to participate in the game. Furthermore, the nurses colluded in their mutual communication to enable the collective display and sense of knowing that protected them against explicit signs of uncertainty about the clinic. The game of clinical knowledge influenced processes of clinical decision‐making among the nurses as the game added to a distorted widening of a ‘fictional distance’ between patients and the representations produced by the nurses.

Hurley, John; Rankin, Robert

doi: 10.1111/j.1440-1800.2008.00412.xpmid: 18786212

As mental health nursing roles expand, is education expanding mental health nurses? an emotionally intelligent view towards preparation for psychological therapies and relatedness Mental health nurses (MHN) in the UK currently occupy a challenging position. This positioning is one that offers a view of expanding roles and responsibilities in both mental health act legislation and the delivery of psychological therapies, while simultaneously generic pre‐registration training is being considered. Clearly, the view from this position, although not without challenge and internal discipline dispute, can also offer growing professional prestige, influence and respect from other health disciplines, as well as the wider public. Conversely, if the training, education and strategic enactment for new MHN roles is formulated and delivered from predominantly non‐MHN axiomatic and epistemological stances, MHN identity can be seriously and potentially permanently diminished. This paper offers the construct of emotional intelligence as a framework to respond to these future challenges through making individual MHN enablement a primacy. This enablement of MHNs through enhanced emotional intelligence competencies is argued as requiring priority over the standard approach of enhancing strategies alone.

Karlsson, Bengt; Borg, Marit; Kim, Hesook Suzie

doi: 10.1111/j.1440-1800.2008.00416.xpmid: 18786213

From good intentions to real life: introducing crisis resolution teams in Norway In Norway, as in most western countries, the adult services for people experiencing mental health problems have gone through major changes over the last decades. A report submitted to the Norwegian Parliament in 1997 summarized several areas of improvement in the provision of mental health‐care to its population, and led to the introduction of a national mental health programme in 1998 for its implementation to be completed by 2008. The most significant recent development in Norway is ‘Crisis Resolution/Home Treatment’ (CRHT) teams that provide an alternative to acute hospital care services. The major aim of this study is to explore an emerging form of community mental health‐care, and present a framework for establishment and examination of CRHT teams applying the user perspectives. An illustration of user experiences in an already established CRHT team provides a background for understanding implications of this form of service in relation to service users’ needs in acute crises.

Crowe, Marie

doi: 10.1111/j.1440-1800.2008.00417.xpmid: 18786214

Personality disorders: illegitimate subject positions The diagnosis of personality disorder is common in mental health nurse settings and is a term often used without critical consideration. In clinical practice, the term personality disorder has pejorative connotations, which arise out of the way in which these behaviours are constructed as behavioural rather than psychiatric. The discursive construction of categories of personality disorder are inculcated into clinical practice and become taken‐for‐granted by those in practice culture. The construction of some personalities as disordered and, therefore, illegitimate becomes natural. This paper provides a critical analysis of the diagnosis and suggests an approach to mental health nursing care that is more legitimising for those people who receive psychiatric diagnoses.

Jacob, Jean Daniel; Holmes, Dave; Buus, Niels

doi: 10.1111/j.1440-1800.2008.00420.xpmid: 18786215

Humanism in forensic psychiatry: the use of the tidal nursing model The humanist school of thought, which finds resonance in many conceptual models and theories designed to guide nursing practice, needs to be understood in the context of the total institution, where the individual is subjected to a mortification of the self, and denied autonomy. This article will engage in a critical reflection on how humanism has influenced nursing theorists and the subsequent production of conceptual models and theories, especially as they relate to the field of forensic psychiatric nursing. Although humanism provides optimism for nurse–patient relations, this article explores the incapability of such a philosophy to acknowledge the power relationships between individuals and its inability to explain the day‐to‐day realities experienced in forensic nursing, where the possibility of interpersonal violence reshapes nursing care. The tidal model will be discussed in detail as an example of a recently developed humanistic nursing model. Viewed from this perspective, it is clear that humanistic philosophy and its subsequent models of care are in discordance with the highly specialized field of forensic nursing.

Wand, Timothy; White, Kathryn; Patching, Joanna

doi: 10.1111/j.1440-1800.2008.00407.xpmid: 18786216

Refining the model for an emergency department‐based mental health nurse practitioner outpatient service The mental health nurse practitioner (MHNP) role based in the emergency department (ED) has emerged in response to an increase in mental health‐related presentations and subsequent concerns over waiting times, co‐ordination of care and therapeutic intervention. The MHNP role also provides scope for the delivery of specialised primary care. Nursing authors are reporting on nurse‐led outpatient clinics as a method of healthcare delivery that allows for enhanced access to health‐care, particularly following hospital discharge. However, due to a lack of in‐depth substantiation, this mode of service delivery requires more thorough investigation. This study describes the refinement phase undertaken before the implementation and pilot evaluation of a formalised and structured MHNP outpatient service in the ED of a large inner‐city hospital in Sydney, Australia. An expert advisory panel (EAP) consisting of key local informants was convened to provide feedback on and refinement to the proposed model. This related to issues such as target population, structure and process considerations, outcome measures and interface within the overall health service. Findings from the EAP meeting are presented and discussed. The importance of linking methods with the appropriate methodology in evaluating a healthcare program is highlighted.

Shattell, Mona M.; Andes, Melanie; Thomas, Sandra P.

doi: 10.1111/j.1440-1800.2008.00397.xpmid: 18786217

How patients and nurses experience the acute care psychiatric environment The concept of the therapeutic milieu was developed when patients’ hospitalizations were long, medications were few, and one‐to‐one nurse–patient interactions were the norm. However, it is not clear how the notion of ‘therapeutic milieu’ is experienced in American acute psychiatric environments today. This phenomenological study explored the experience of patients and nurses in an acute care psychiatric unit in the USA, by asking them, ‘What stands out to you about this psychiatric hospital environment?’ Three figural themes emerged, contextualized by time, which was a source of stress to both groups: for patients there was boredom, and for nurses, pressure and chaos. Although they shared some themes, nurses and patients experienced them differently. For instance, nurses felt caged‐in by the Plexiglas‐enclosed nursing station, and patients felt caged‐in by the locked doors of the unit. The findings from this US study do not support the existence of the therapeutic milieu as described in the literature. Furthermore, although the nurse–patient relationship was yearned for by nurses, it was nearly absent from patients’ descriptions. The caring experienced by patients was mainly derived from interactions with other patients.

Walsh, Jim; Stevenson, Chris; Cutcliffe, John; Zinck, Kirk

doi: 10.1111/j.1440-1800.2008.00422.xpmid: 18786218

Creating a space for recovery‐focused psychiatric nursing care Within contemporary mental health‐care, power relationships are regularly played out between psychiatric nurses and service users. These power relationships are often imperceptible to the practicing nurse. For instance, in times of distress, service users often turn to or/and ‘construct’ discourses, beliefs and knowledge that are at odds with those which psychiatric nurses rely on to inform them of the mental status of the service user. The psychiatric nurse is in the position to impose knowledge onto service users, usually in concurrence with ‘traditional or bio‐psychiatry’, without realizing or failing to acknowledge that the service user may have an alternative explanation of his/her mental health problems/experiences. In this paper, practice examples, based on the experiences of the four authors (from within and outside of services), are used to illustrate this ‘hidden’ power relationship. The authors use Foucault's ideas about: (i) government; (ii) the knowledge/power nexus and resistance; (iii) and his analytic tool of genealogy to help unravel this paradox within psychiatric nursing practice. The authors also use the emerging discourse of recovery as an alternative (and challenge) to ‘traditional bio‐psychiatry’ and consider the implications for psychiatric nursing practice.