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Mellan frihet och trygghet: personalgemensamt förhållningssätt i psykiatrisk omvårdnad
Umeå university.ORCID iD: 0000-0002-5784-1930
2012 (Swedish)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Between freedom and safety : common staff approach in psychiatric care (English)
Abstract [sv]

Bakgrund: Personalgemensamt förhållningssätt i psykiatrisk omvårdnad har inte tidigare studerats explicit. Forskning i närliggande område, på sociala processer i psykiatrisk omvårdnad, lyfter fram interaktionen mellan patient och vårdare som betydelsefull för att förstå kommunikationsmönster och attityder. Andra studier av social ordning och makt inom psykiatrisk omvårdnad visar på att vårdare och patienter befinner sig i ett hierarkiskt system där de förra är överordnade de senare.

Syfte: Det övergripande syftet i denna avhandling är att studera fenomenet "personalgemensamt förhållningssätt" hur det uppkommer, hur det används och hur det upplevs av personal och patienter.

Metod: I studie I användes grounded theory som analysmetod då vårdare och brukare vid två kommunala gruppboenden observerades och intervjuades under en period av nio månader. I studie II genomfördes narrativa intervjuer med nio vårdare i psykiatrisk slutenvård och analyserades med fenomenologisk hermeneutik. I studie III genomfördes nio narrativa intervjuer med brukare, alla med erfarenhet av att vårdas i psykiatrisk slutenvård. Intervjuerna har analyserats med fenomenologisk hermeneutisk metod. I studie IV genomfördes en vinjettstudie med 13 vårdare och insamlade intervjudata har analyserats med kvalitativ innehållsanalys.

Resultat: Ett personalgemensamt förhållningssätt kan ses som en social process i socialpsykiatrisk omsorg och psykiatrisk slutenvård, involverande vårdare och brukare/patient, med syfte att bevara och återställa en av vårdarna definierad ordning. Om ‘ordningen’ störs försöker vårdarna återställa den genom att besluta och tillämpa ett gemensamt förhållningssätt gentemot den patient som upplevs hota ordningen (studie I). Vårdarna upplever att det är problematiskt att ge omvårdnad utifrån ett personalgemensamt förhållningssätt då kollegor tolkar situationer olika och 8

patienter kan dela upp personalen i "goda" och "onda". Det är också som vårdare att erfara att patienten kan lida av det gemensamma förhållningssättet används gentemot patienten (studie II). Patienternas upplevelser bekräftar delvis vårdarnas upplevelser – den dominerande bilden är att patienterna beskriver sig ansatta och lider då förhållningssättet används. I vissa situationer kan emellertid förhållningssättet av patienten upplevas stödjande och beskrivs främja återhämtning (studie III). Vårdarnas etiska resonemang vid använda av ett personalgemensamt förhållningssätt visar att vårdarnas argumentation för ett visst förhållningssätt är individuellt baserat och förändras beroende på hur och vem som argumentationen riktas mot, samt att vårdarna grundar sina etiska resonemang med utgångspunkt i antingen omvärlden eller i sig själva (studie IV).

Slutsats: Sammantaget visar resultatet av de fyra delstudierna att vid användande av ett personalgemensamt förhållningssätt så är vårdarnas behov överordnat patienternas behov; att anlägga och vidmakthålla förhållningssättet handlar om makt och maktutövning; att det är en svår valsituation för vårdarna att fokusera på patient eller kollegor; att patienterna ofta lider då det personalgemensamma förhållningssätet tillämpas; samt att vårdarna ofta är omedvetna om det lidande som uppstår hos patienterna. Ett personalgemensamt förhållningssätt är inte en del av en utformad vårdstrategi; det är inte en medvetet utformad vårdplanering; istället framstår det som ett sätt att kontrollera en patient när vårdarna känner sig sårbara och pressad av patientens hållning och handlingar.

Abstract [en]

Background: The common staff approach in psychiatric care has not been studied explicitly before. Earlier studies in related areas of social processes in psychiatric care highlight the importance of the interaction between the patient and the carer to understanding communication patterns and attitudes. Other studies on social order and power in psychiatric care shows carers and patients as taking part in a hierarchical system in which patients are subordinate to carers.

Aim: The overall aim of this thesis is to study the phenomenon of the common staff approach in psychiatric care, how it emerges, and how it is used and experienced by both carers and patients.

Method: In the first study, grounded theory was applied to data from observations and interviews carried out with carers and clients in two psychiatric care group dwellings. In the second and third studies, a phenomenological hermeneutic method was used to analyse narrative interviews conducted with nine careers working on psychiatric wards and nine patients with experience of psychiatric in-care, respectively. In the fourth study, qualitative content analysis was used to analyse data obtained by a vignette method from interviews with 13 carers with experience of working in psychiatric in-care.

Results: A common staff approach can be understood as a social process in municipality-level group dwellings and psychiatric in-care, imposed by carers on clients or patients with the aim of restoring a predetermined order desired by the carers. When the order is disturbed the carers try to restore it by adopting a common and consistent approach towards the single patient perceived as the threat to order.

Barriers to the success of a common staff approach, from the point of view of the carers, include the likelihood that colleagues will interpret situations differently, the chance that patients might succeed in dividing carers into 6

"good" and "bad" camps, and the knowledge that the patient suffers under a common staff approach.

The patients’ experiences partly confirm those of the carers – the dominant picture is that the patient feels persecuted and suffers under a common staff approach. However in some situations, patients can perceived the common approach as supportive and aimed to promote their recovery.

Carers’ ethical reasoning about the common staff approach is usually applied on an individual basis; it can change depending upon the patient, the situation, and the proposed approach, as well as upon how the approach might affect other patients, staff members, or the carers themselves.

Conclusions: The overall results from the four studies show that the common staff approach may meet carers’ needs, which under the approach take precedence over those of patients, but that the approach is more an exercise in asserting power and maintaining control than it is a therapeutic technique; that it is a difficult choice for the single carer to choose between the interests of the patient and the approval of colleagues; that the patient often suffers when a common staff approach is used; and that carers are seldom aware of the suffering experienced by the patient being managed by such an approach. A common staff approach has no part in a care-strategy; it is not an intentional care-plan; instead it appears to be a way for carers who feel vulnerable and under pressure to maintain order by controlling particular patients.

Place, publisher, year, edition, pages
Umeå: Umeå University medical dissertations , 2012. , 79 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1480
Keyword [en]
common staff approach; psychiatric care; social process; power; experience; grounded theory; phenomenological research, content analysis, vignette method
Keyword [sv]
personalgemensamt förhållningssätt; psykiatrisk omvårdnad; sociala processer; makt, upplevelser; grounded theory; fenomenologisk hermeneutik; innehållsanalys; vinjettmetod
National Category
Nursing
Research subject
Health and Caring Sciences, Nursing
Identifiers
URN: urn:nbn:se:lnu:diva-51597Libris ID: 13325014ISBN: 978-91-7459-370-9 (print)OAI: oai:DiVA.org:lnu-51597DiVA: diva2:915595
Public defence
2012-05-25, Aulan, Vårdvetarhuset, Umeå Universitet, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2016-04-22 Created: 2016-03-30 Last updated: 2016-04-22Bibliographically approved
List of papers
1. The preservation of order: the use of common approach among staff toward clients in long-term psychiatric care
Open this publication in new window or tab >>The preservation of order: the use of common approach among staff toward clients in long-term psychiatric care
2007 (English)In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, ISSN ISSN 1049-7323, Vol. 17, no 6, 718-729 p.Article in journal (Refereed) Published
Abstract [en]

The authors performed this grounded theory study to gain a deeper understanding of the kinds of social processes that lead to a need among psychiatric nursing staff to reach a common approach on how to act toward individual clients in long-term psychiatric care. They present a theory about the development of such common approaches among staff. The main findings were that in psychiatric group dwellings, when the internal order is perceived as having been disturbed, the staff preserve or restore the internal order by formulating and reaching a common approach. The staff negotiated with each other to achieve an agreement on how to act and behave toward the individual client. The authors isolate and describe different types of order-disturbing incidents and the common approaches taken by the staff in dealing with them. However, their data also show that staff often had difficulties in maintaining a common approach over time.

Place, publisher, year, edition, pages
Sage Publications, 2007
Keyword
common approach, grounded theory, negotiation, nursing, psychiatry, gmensamt förhållningssätt, grounded theory, förhandling, omvårdnad, psykiatri
National Category
Nursing
Research subject
Health and Caring Sciences, Nursing
Identifiers
urn:nbn:se:lnu:diva-50981 (URN)10.1177/1049732307302668 (DOI)
Available from: 2016-03-17 Created: 2016-03-17 Last updated: 2016-04-22Bibliographically approved
2. “Being good or evil”: applying a common staff approach when caring for patients with psychiatric disease
Open this publication in new window or tab >>“Being good or evil”: applying a common staff approach when caring for patients with psychiatric disease
2008 (English)In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 3, no 4, 219-229 p.Article in journal (Refereed) Published
Abstract [en]

Abstract

This study was performed to gain a deeper understanding of how psychiatric staff, when caring for patients with psychiatric disease, experience situations that include a common staff approach directed toward an individual client. Nine nurses were interviewed. The interviews were analyzed with a phenomenological-hermeneutic method in order to illuminate the livedexperience of applying a common staff approach. The results revealed several meanings: shedding light on carers’ mutual relationships; being deserted by nurse colleagues; being aware of one’s own basis of evaluation, and that of others; beingjudged by the patient as good or evil; and becoming sensitive to the patient’s suffering. The comprehensive understandingwas that the nurse has a difficult choice*to focus on relations with one’s colleagues or to focus on the situation of the patient, who seems to suffer when a common staff approach is used.

Place, publisher, year, edition, pages
CoAction Publishing, 2008
Keyword
Common staff approach, Phenomenological, Hermeneutic, Nursing, Psychiatry
National Category
Nursing
Research subject
Health and Caring Sciences, Nursing
Identifiers
urn:nbn:se:lnu:diva-51265 (URN)10.1080/17482620802042297 (DOI)
Available from: 2016-03-22 Created: 2016-03-22 Last updated: 2016-04-22Bibliographically approved
3. They can do whatever they want’’: Meanings of receiving psychiatric care based on a common staff approach
Open this publication in new window or tab >>They can do whatever they want’’: Meanings of receiving psychiatric care based on a common staff approach
2011 (English)In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, ISSN 1748-2623, Vol. 6, no 1, 1-11 p.Article in journal (Refereed) Published
Abstract [en]

This study deepens our understanding of how patients, when cared for in a psychiatric ward, experience situations that involve being handled according to a common staff approach. Interviews with nine former psychiatric in-patients were analyzed using a phenomenological–hermeneutic method to illuminate the lived experience of receiving care based on a common staff approach. The results revealed several meanings: discovering that you are as subjected to a common staff approach, becoming aware that no one cares, becoming aware that your freedom is restricted, being afflicted, becoming aware that a common staff approach is not applied by all staff, and feeling safe because someone else is responsible. The comprehensive understanding was that the patient's understanding of being cared for according to a common staff approach was to be seen and treated in accordance with others’ beliefs and valuations, not in line with the patients’ own self-image, while experiencing feelings of affliction.

Place, publisher, year, edition, pages
CoAction Publishing, 2011
Keyword
Common staff approach, phenomenological, hermeneutic, nursing, psychiatry, Personalgemensamt förhållningssätt, fenomenologi, hermeneutik, omvårdnad, psykiatri
National Category
Nursing
Research subject
Health and Caring Sciences, Nursing
Identifiers
urn:nbn:se:lnu:diva-50979 (URN)10.3402/qhw.v6i1.5296 (DOI)
Available from: 2016-03-17 Created: 2016-03-17 Last updated: 2016-04-22Bibliographically approved
4. 'There should be something gained': Carers’ ethical reasoning about using a common staff approach in psychiatric in-care
Open this publication in new window or tab >>'There should be something gained': Carers’ ethical reasoning about using a common staff approach in psychiatric in-care
2017 (English)In: Nordic journal of nursing research, ISSN 2057-1585, E-ISSN 2057-1593Article in journal (Refereed) Epub ahead of print
Abstract [en]

Thirteen carers were interviewed about their ethical reasoning when using a common staff approach to restricting smoking for a psychiatric in-patient. A constructed case structure and a vignette method were used in the interviews, and manifest content analysis of the texts exposed five ethical positions adopted by the carers: ‘best for the person’, ‘best for the patient’, ‘best for others involved with the person/patient’, ‘best for me as a carer’, and ‘best according to rules and regulations’. A second manifest content analysis of language showed terms that expressed value judgments in regard to the carers’ personal experiences. Some carers argued at first from one ethical position, but when the question was changed, they argued from an opposite ethical position. Results may be understood in light of dialog philosophy; ethical reasoning during use of a common staff approach tends to focus either on relations with others or with oneself.

Keyword
ethics, nursing, common approach, psychiatry, content analysis, vignette
National Category
Nursing
Research subject
Health and Caring Sciences, Nursing
Identifiers
urn:nbn:se:lnu:diva-51588 (URN)10.1177/2057158517699098 (DOI)
Note

Part of thesis: Mellan frihet och trygghet: personalgemensamt förhållningssätt i psykiatrisk omvårdnad

Available from: 2016-03-30 Created: 2016-03-30 Last updated: 2017-09-21Bibliographically approved

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