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Time Together: a nursing intervention targeting everyday life in psychiatric inpatient care : patient and staff perspectives
Umeå University, Faculty of Medicine, Department of Nursing.ORCID iD: 0000-0002-9116-5569
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Patient and staff descriptions of everyday life in psychiatric inpatient care are consistent, revealing a challenging environment with over-reliance on medication and, power imbalances. Patients and staff ask for the opportunity to develop relationships; however, the literature on nursing interventions targeting these issues is sparse. This thesis comprises four studies with a twofold overall aim. The first part constructs a theoretical understanding of everyday life processes in psychiatric inpatient care, and the second part evaluates a nursing intervention in psychiatric inpatient care.

Methods: Studies I and II used a grounded theory design with individual interviews (I, II), dyadic interviews (II) and focus group discussions (II). Study III used mixed methods, a single system experimental design with questionnaires and a qualitative process evalu­ation with logs and participant observations. Study IV used a qualitative design with individual semi structured interviews. The participants were 16 patients with experiences of psychiatric inpatient care (I), 36 staff members who worked in psychiatric inpatient care (II), 80 patients and 50 staff members in the evaluated wards (III) and 11 patients who had taken part in the nursing intervention Time Together (IV). In studies I and II the analysis followed grounded theory. In study III data were subjected to visual analysis, per­centage of non-overlapping data and qualitative content analysis, also used in study IV.

Results: Patients in psychiatric inpatient care experienced everyday life as being influenced by interactions between patients and staff, the environment and the content of care. The quality of interactions was what tied these components together. Having trustful interactions could compensate for an otherwise poor environment and a confusing care content, while adapting to absence of, or obstructive interactions contributed to experiences of the environment as stigmatizing and the care content as confusing (I). Staff had ideals regarding everyday life on the wards but obstacles hindered them from putting their ideals into practice. To cope with this, they appeared to shift their focus from the patient’s best to their own survival. This resignation made it even more difficult for them to work in a way that aligned with their ideals (II). The theoretical understanding that was constructed from study I and II revealed that what patients described as absent or obstructive interactions, or passivity, were mirrored by staff descriptions of obstacles in their everyday life on the wards. Furthermore, what patients described as trustful inter­actions and satisfying activities were mirrored by staff descriptions of having the patients’ best interest at heart. This is interpreted as when staff is able to focus on the patients’ best interests, improvements in the everyday life in psychiatric inpatient care are possible.

The nursing intervention called Time Together was feasible to introduce in psychiatric inpatient care. The intervention was enabled by shared responsibility, a friendly approach and a predictable structure, whilst it was hindered by a distant approach and unpredictable structure. Measurements showed no effect on the quality of interactions between patients and staff, but questionable effects on perceived stress and stress of conscience among staff, as well as on staff satisfaction with interactions with patients (III). Patients described their experiences of taking part in the intervention as being seen as a human among other humans, that it contributed to hope for recovery but also, that feelings of distance to staff were fostered when Time Together sessions were not offered (IV).

Conclusion: By implementing Time Together in psychiatric inpatient care, staff is allowed access to a nursing intervention that can meet patients’ needs for high-quality interactions in everyday life and that may have potential to decrease perceived stress and stress of conscience among staff and increase their satisfaction with interactions with patients. By using joint activities as bridging actions, this intervention could lead to the development of nurse-patient relationships built on reciprocity and engagement, something that is emphasised in recovery-oriented mental health nursing.

Abstract [sv]

Bakgrund: Patienters och personals beskrivningar av vardagslivet inom psykiatrisk heldygnsvård är konsekventa och avslöjar en komplex miljö med hög tilltro till medicinsk behandling och obalans i maktförhållanden. Patienter och personal efterfrågar möjligheter att utveckla relationer med varandra men omvårdnadsinterventioner med sådant fokus är sparsamt beskrivna i den vetenskapliga litteraturen. Avhandlingen har ett tvådelat syfte och omfattar fyra delstudier. Den första delen syftade till att konstruera en teoretisk förståelse för vardagliga processer inom psykiatrisk heldygnsvård och den andra delen till att utvärdera en omvårdnadsintervention inom psykiatrisk heldygnsvård.

Metod: I delstudie I och II användes en grounded theory design med individuella intervjuer (I, II), dyadiska intervjuer (II) och fokusgruppsdiskussioner (II). I delstudie III användes mixade metoder, en single system experimental design med enkäter och en kvalitativ processutvärdering med loggar och deltagande observationer. I delstudie IV användes en kvalitativ design med individuella semistrukturerade intervjuer. Deltagarna var 16 patienter med erfarenhet av psykiatrisk heldygnsvård (I), 36 personal med erfarenhet av arbete inom psykiatrisk heldygnsvård (II), 80 patienter och 50 personal från de utvärderade avdelningarna (III) och 11 patienter som deltagit i omvårdnads­interventionen Tid Tillsammans (IV). I delstudie I och II följde analysen grounded theory. I delstudie III analyserades data med hjälpa av visuell analys, percentage of non-overlapping data och kvalitativ innehållsanalys som även användes i delstudie IV.

Resultat: Patienter inom psykiatrisk heldygnsvård upplevde att vardagslivet på avdelningarna påverkades av interaktionerna med personalen, miljön och vårdens innehåll. Den gemensamma kärnan i dessa delar var kvaliteten i interaktionerna. Tillitsfulla interaktioner kompenserade för en annars fattig miljö och ett förvirrande vårdinnehåll medan anpassning till frånvaro av, eller hindrande interaktioner bidrog till upplevelser av en stigmatiserande miljö och ett förvirrande vårdinnehåll (I). Personal hade ideal gällande vardagslivet på avdelningarna men svårigheter hindrade dem från att omvandla idealen i praktiken. För att hantera detta verkade de skifta sitt fokus från patienternas bästa till att själva kunna överleva. Resignationen försvårade ytterligare för dem att kunna arbeta i linje med sina ideal (II). Den teoretiska förståelsen som konstruerats visar att det patienterna beskrev som frånvaro av, eller hindrande interaktioner samt passivitet reflekterades i personalens beskrivningar av hinder i vardagslivet på avdelningarna. Det patienterna beskrev som tillitsfulla interaktioner och tillfredsställande aktiviteter reflekterades i personalens beskrivningar av att fokusera på patienternas bästa. Detta tolkas som att när personal har möjlighet att fokuserar på patienternas bästa, då finns möjligheter till förbättringar av vardagslivet inom psykiatrisk heldygnsvård.

Omvårdnadsinterventionen Tid Tillsammans var genomförbar inom psykiatrisk hel­dygn­svård. Delat ansvar, ett vänligt bemötande och en förutsägbar struktur möjliggjorde interventionen medan ett distanserat bemötande och en oförutsägbar struktur utgjorde hinder. Mätningarna visade inga effekter på kvaliteten i interaktionerna mellan patienter och personal samt osäkra effekter på personalens upplevda stress och samvetsstress samt på personalens nöjdhet med interaktionerna med patienterna (III). Patienterna beskrev sina erfarenheter av att ha tagit del i Tid Tillsammans som att bli sedd som en människa bland andra människor, att det bidrog till hopp om återhämtning men också att känslor av distans till personalen utvecklades när Tid Tillsammans inte genomfördes (IV).

Konklusion: Genom att införa Tid Tillsammans inom psykiatrisk heldygnsvård får personal tillgång till en omvårdnadsintervention som kan möta patienternas behov av interaktioner med hög kvalitet och som kan ha potential att minska deras upplevda stress och samvetsstress samt öka deras nöjdhet med interaktionerna med patienterna. Genom att använda gemensamma aktiviteter kan relationer som bygger på ömsesidighet och engagemang mellan patienter och personal utvecklas, något som betonas inom återhämtningsinriktad psykiatrisk omvårdnad.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2018. , p. 57
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1961
Keywords [en]
engagement, everyday life, experiences, grounded theory, interaction, interprofessional teams, intervention, mental health nursing, ordinary relationships, psychiatric inpatient care, patient perspectives, single system experimental design, qualitative content analysis
Keywords [sv]
engagemang, grounded theory, interaktion, interprofessionella team, intervention, kvalitativ innehållsanalys, patientperspektiv, psykiatrisk heldygnsvård, psykiatrisk omvårdnad, single system experimental design, Tid Tillsammans, upplevelser, vardagliga relationer, vardagsliv
National Category
Nursing
Research subject
Caring Sciences
Identifiers
URN: urn:nbn:se:umu:diva-147694ISBN: 978-91-7601-877-4 (print)OAI: oai:DiVA.org:umu-147694DiVA, id: diva2:1205612
Public defence
2018-06-08, Aulan, Vårdvetarhuset, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2018-05-18 Created: 2018-05-14 Last updated: 2018-06-09Bibliographically approved
List of papers
1. Quality of interactions influences everyday life in psychiatric inpatient care: patients' perspectives
Open this publication in new window or tab >>Quality of interactions influences everyday life in psychiatric inpatient care: patients' perspectives
2016 (English)In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 11, no 1, article id 29897Article in journal (Refereed) Published
Abstract [en]

Everyday life consists of daily activities that are taken for granted. It forms the foundation for human efforts and contains elements of both comfort and boredom. Because everyday life escapes no one, life in a psychiatric ward will become ordinary while staying there. This study aims to explore everyday life in psychiatric inpatient care based on patients' experiences. We individually interviewed 16 participants with experiences of psychiatric inpatient care and analysed the data in accordance with the methods of grounded theory. Data collection and analysis continued in parallel in accordance with the method. Our results showed that everyday life is linked to the core category quality of interactions influences everyday life, and three constructed categories — staff makes the difference, looking for shelter in a stigmatizing environment, and facing a confusing care content — were related to the core category. Our results highlight the importance of ordinary relationships between staff and patients in psychiatric inpatient care. These results can be used to develop nursing interventions to improve psychiatric inpatient care and might also be used as a basis for reflective dialogues among staff.

Place, publisher, year, edition, pages
Taylor & Francis, 2016
Keywords
everyday life, experiences, grounded theory, interactions, ordinary relationships, psychiatric inpatient care, patient perspectives, trust
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-114813 (URN)10.3402/qhw.v11.29897 (DOI)000369148700001 ()26806313 (PubMedID)
Available from: 2016-01-28 Created: 2016-01-28 Last updated: 2018-06-07Bibliographically approved
2. From ideals to resignation: interprofessional teams perspectives on everyday life processes in psychiatric inpatient care
Open this publication in new window or tab >>From ideals to resignation: interprofessional teams perspectives on everyday life processes in psychiatric inpatient care
2016 (English)In: Journal of Psychiatric and Mental Health Nursing, ISSN 1351-0126, E-ISSN 1365-2850, Vol. 23, no 9-10, p. 595-604Article in journal (Refereed) Published
Abstract [en]

Introduction: Patients and ward staff describe psychiatric inpatient care as demanding, characterized by unpredictable events, yet research on interprofessional teams perspectives of everyday life processes in psychiatric inpatient care lacks. Aim: This study aims to explore everyday life processes in psychiatric inpatient care, as reported by staff in interprofessional teams. Method: A grounded theory design was used and 36 participants were interviewed. Results: The analysis resulted in a process-oriented core category From ideals to resignation. Related to this core category were three further categories: Knowing where to go, Walking a path of obstacles and Shifting focus from the patient's best interests to self-survival. The staff had ideals about care and collaboration, but a poor environment, power asymmetry, lacking structure and demands of managing chaos meant that they appeared to resign from putting their ideals into practice. Discussion: Different professions in general describe the same obstacles in everyday life on the wards but there are also profession-specific perspectives on distancing and feelings of abandonment. To our knowledge similar findings have not been reported in the international evidence. Implications: In order to support interprofessional teams to work according to their ideals, interventions such as Protected Engagement Time and reflective dialogues within the teams are suggested.

Keywords
collaboration, everyday life, experiences, grounded theory, interprofessional teams, psychiatric inpatient care
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-127166 (URN)10.1111/jpm.12349 (DOI)000389034300008 ()27785861 (PubMedID)
Available from: 2016-11-01 Created: 2016-11-01 Last updated: 2018-06-09Bibliographically approved
3. Time Together: a nursing intervention in psychiatric inpatient care : feasibility and effects
Open this publication in new window or tab >>Time Together: a nursing intervention in psychiatric inpatient care : feasibility and effects
2018 (English)In: International Journal of Mental Health Nursing, ISSN 1445-8330, E-ISSN 1447-0349Article in journal (Refereed) Epub ahead of print
Abstract [en]

The facilitation of quality time between patients and staff in psychiatric inpatient care is useful to promote recovery and reduce stress experienced by staff. However, interventions are reported to be complex to implement and are poorly described in the literature. This multisite study aimed to evaluate the feasibility and effects of the nursing intervention Time Together, using mixed methods. Data consisted of notes from participant observations and logs to evaluate feasibility, and questionnaires to evaluate effects. The primary outcome for patients was quality of interactions, and for staff, it was perceived stress. The secondary outcome for patients was anxiety and depression symptom levels, and for staff, it was stress of conscience. Data were analysed using visual analysis, percentage of nonoverlapping data, and qualitative content analysis. The results showed that Time Together was a feasible intervention, but measurements showed no effects on the two patient outcomes: quality of interactions and anxiety and depressive symptoms and, questionable effects on perceived stress and stress of conscience among staff. Shared responsibility, a friendly approach, and a predictable structure enabled Time Together, while a distant approach and an unpredictable structure hindered the intervention. In conclusion, the intervention proved to be feasible with potential to enable quality interactions between patients and staff using the enabling factors as supportive components. It also had some effects on perceived stress and stress of conscience among staff. Further evaluation is needed to build on the evidence for the intervention.

Keywords
engagement, intervention, mental health nursing, mixed methods, psychiatric inpatient care
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-147611 (URN)10.1111/inm.12468 (DOI)29691976 (PubMedID)
Available from: 2018-05-09 Created: 2018-05-09 Last updated: 2018-06-09Bibliographically approved
4. Patient experiences of taking part in Time Together – a nursing intervention in psychiatric inpatient care
Open this publication in new window or tab >>Patient experiences of taking part in Time Together – a nursing intervention in psychiatric inpatient care
(English)Manuscript (preprint) (Other academic)
National Category
Nursing
Research subject
Caring Sciences
Identifiers
urn:nbn:se:umu:diva-147693 (URN)
Available from: 2018-05-14 Created: 2018-05-14 Last updated: 2018-06-09

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