Introduction
In 1993, Anthony wrote of recovery as ‘a new vision of service delivery for people who have a mental illness’ (Anthony, Reference Anthony1993, p. 525). He described a recovery-oriented health system ‘incorporating critical services of community support systems; and also, clinical services directed at crisis intervention and symptom relief’ (p. 529). Anthony’s (Reference Anthony1993) vision of recovery, encapsulating individual resilience and the support of others in a nonlinear process of development, reversion, and pressing forward again, is an overarching objective for mental health services and a principal focus of people with lived experience of mental illness. A recent study highlighted important aspects of recovery as encouraging a persons’ abilities to make decisions, solve problems and perform actions based on their choice (Kartalova-O’Doherty et al. Reference Kartalova-O’Doherty, Stevenson and Higgins2012). An understanding of recovery shared by people with lived experience of mental illness speaks to a ‘deeper understanding of what’s happening to a person, beyond a health complaint to be removed or to move beyond’ (Gwinner et al. Reference Gwinner, Knox and Brough2013, p. 107).
Whilst there has been keen interest in establishing a continuum of recovery-oriented services in Australia, as in other countries, the Australian Health Ministers’ (2003) statement that ‘a recovery orientation should drive service delivery’ is nevertheless, perceived as rhetoric in mental health policy rather than standard practice across mental health services (Slade et al. Reference Slade, Amering and Oades2008). One area of critical concern is delivery of effective recovery approaches in acute clinical settings (Bowers et al. Reference Bowers, Chaplin, Quirk and Lelliott2009a; Pereira et al. Reference Pereira, Dawson and Sarsam2006; Walsh & Boyle, Reference Walsh and Boyle2009). Coercive treatment approaches, containment of disturbed/violent behaviour and pharmacotherapy directly contradict concepts such as patient autonomy and recovery as a client-driven process and goal (Stylianos & Kehyayan, Reference Stylianos and Kehyayan2012). For people who are admitted to hospital-based acute services, core values of recovery such as choice, self-determination, empowerment and self-responsibility are often disregarded in the delivery of conventional procedures and interventions aimed at managing the acute disturbance and crisis (O’Hagan, Reference O’Hagan2006).
Nurses, as the vanguard of care in acute psychiatric settings, have an essential role and responsibility to deliver recovery-oriented care, and thus need to be clear themselves as to their understanding, language and the potentially conflicting or limiting definitions emergent in various models of recovery such as the ‘colonisation’ of recovery territory by practitioners, or the ‘ill-cured’ dichotomy (Bonney & Stickley, Reference Bonney and Stickley2008). It is timely to establish greater clarity of nurses’ thinking about recovery and to reinforce values and attributes aligned to a recovery-oriented culture directed at crisis intervention and symptom relief for people experiencing acute psychiatric distress.
Clinical acute psychiatric interventions
Crisis intervention and symptom relief for people experiencing acute psychiatric distress is often provided in specialised units co-located in inpatient wards referred to as psychiatric intensive care units (PICU). Frequently, individuals assessed as at risk of harm, either to themselves or others in the community, are mandated by law and subsequently governed by a mental health act.
PICU can offer opportunities to initiate early recovery approaches for patients experiencing acute psychiatric distress. Practitioners and researchers have stressed the paucity of research regarding the extent to which the principles and practices of a recovery philosophy are achievable in the context of a PICU (Bowers et al. Reference Bowers, Simpson, Alexander, Hackney, Nijman, Grange and Warren2005; Glick et al. Reference Glick, Sharfstein and Schwartz2011; Gwinner & Ward, Reference Gwinner and Ward2013). Nevertheless, some global initiatives are exploring recovery and patient focused frameworks for improved recovery outcomes (Cleary & Dowling Reference Cleary and Dowling2009; Slade, Reference Slade2009; Olmos-Gallo et al. Reference Olmos-Gallo, Starks, Lusczakoski, Huff and Mock2012; Chen et al. Reference Chen, Krupa, Lysaght, McCay and Piat2013) within the PICU setting.
This paper draws knowledge both from the experiences of nurses working in PICU and current literature, to appreciate a how recovery approach is applied to nursing practice in PICU. Four defining attributes are shared from the experiences of nurses that support conceptual clarity of recovery in PICU. These are: storytelling; safeguarding; treatment; and responsibility.
The Study
This study aimed to identify existing strategies and practices that nurses perceived as supporting a recovery-based model of care in the PICU, through two methods of inquiry. The five stages of the study included: (1) a problem formulation stage; (2) a literature search stage; (3) a data evaluation stage; (4) a data synthesis and analysis stage; and (5) a final presentation stage (Whittemore & Knafl, Reference Whittemore and Knafl2005). The first method of inquiry employed focus groups with nurses. These were held at stages one and three to clearly identify nurses’ perceptions, experiences and concepts of recovery. Data from the focus groups were analysed to define the terms and selection protocol for the literature review. Additionally, the data were used to evaluate emerging concepts from current literature (2000 and later) related to the nurse’s accounts. The second method of inquiry involved a review of the literature to examine nurse-based evidence and nurse knowledge of recovery approaches specific to psychiatric intensive care settings.
Focus group participants and ethics
Ethical approval was granted by the university and health care service human research ethics committees. An invitation to participate in the research and participation information sheets were emailed to nursing staff who worked within locked wards attached to two metropolitan district hospitals in South East Queensland. Twelve nurses participated in the first two focus groups which introduced key topic areas and questions based on nursing practice and experience in the PICU. Following an initial literature review, a second series of focus groups were held with the nurses (stage 3). An additional focus group was held at one site to accommodate the interest and desire to contribute by nursing staff (N=45).
Design
The study incorporated five stages in the design as described above and illustrated in Figure 1. Data from the focus groups were synthesised to identify concerns related to the complexity of mental health nursing in PICU and to explicitly inform the key purpose, concepts, terms and boundaries with which to identify aspects of nursing practice that support a concept of recovery, acknowledging consumer models and perspectives. These were used to underpin a review of the literature (stage 2).
Study flow chart.
A review of the literature was undertaken using Google Scholar to allow a broader search of databases such as CINAHL, Informa, Healthcare Medline, PubMed, PsycARTICLES and Wiley. Purposive sampling of literature was used to enhance variables and expand the explanation of the perspectives and definitions expressed in the focus groups. Over 300 articles were sourced. Fifty items met the final inclusion criteria and augmented the focus group concerns and values which are reported in this paper (Table S1, see online Supplementary materials).
The attributes and concepts that emerged from the first two focus groups and nascent concepts from an initial review of the literature were taken back to the sites in another three focus groups (stage 3). An extra group was held in one site to accommodate additional participants and to expand on previous data collected from the first focus groups. Data synthesis and analysis of all the literature and the focus group data were iteratively compared in stage four. Finally, a synthesis in the form of a model was developed to comprehensively portray a concept of recovery drawn from the findings (stage 5).
Data synthesis and analysis
Our analysis involved a process of examining, comparing and conceptualising; firstly the focus group data to obtain clear identification of nurses’ perceptions, experiences, concepts of recovery and problems and to evaluate emerging concepts related to their experiences, and secondly ordering, coding, categorising the literature into themes related to attributes and values shared by the nurses participating in the focus group. Theme identification was based on recurrence of ideas with similar content across the data. The congruencies among nurses’ experiences and the literature were examined and taken back to the nurse participants to substantiate the interpretations and to explore further conceptual development. The two methods of data collection captured the depth and range of issues, and achieved convergent validity of the data. The synthesis identified four attributes that frame a concept of recovery specific to the context of nursing practice in psychiatric intensive care settings.
Results
Four defining attributes of a concept of recovery within the PICU were identified in the analysis. They were: (1) storytelling; (2) safeguarding; (3) treatment; and (4) responsibility. These are illustrated in Figure 2.
A concept of recovery in PICU.
The remainder of this paper outlines these attributes as a concept of recovery with the potential to guide thinking and promote the use of recovery approaches by nurses in PICU.
Storytelling
Storytelling is a significant feature in the concept of recovery held by nurses in PICU. It aligns with rudimentary expectations of recovery outlined by Anthony (Reference Anthony1993, p. 530) as a ‘subjective experience begging to be attended to and understood’. The storytelling attribute accentuates how varied interactions between the nurse and the patient are used to discern dimensions of subjective experience, and to more fully understand and engage the contexts in which recovery can be transacted. One informant signified a key factor of storytelling as engagement with the person:
“... It’s about creating one on one contact, you know. They want somebody to sit there and acknowledge and talk to them.”
Building reciprocal meaning, knowledge and awareness generated in nurse–patient communications were cited as crucial factors underpinning nurses’ clinical decision-making in PICU. The significance of preliminary engagement that helps to establish a connection with the patient and thus, shared insight of the situation was referred to. One nurse participant explained:
“Break that ice initially, then you get a better rapport and a better working relationship with that person in a PICU.”
The literature supports the development of connections, a trusting relationship and shared awareness between the nurse and patient (Slade, Reference Slade2010; Roy et al. Reference Roy, Rousseau, Fortier and Mottard2009). Barker & Buchanan-Barker (Reference Barker and Buchanan-Barker2010) championed the belief that through engagement with the person and not the illness, the nurse can attempt to build awareness of and support the individual in their present situation. Sjöstedt et al. (Reference Sjöstedt, Dahlstrand, Severinsson and Lützén2001) suggested that managing the first nurse–patient encounter requires a moral commitment from the nurse to consciously and intentionally encourage the patient to enter into a relationship. As such the nurse should attempt to understand each patient’s unique experiences and feelings, which Sjöstedt et al. (Reference Sjöstedt, Dahlstrand, Severinsson and Lützén2001) described as an expression of ‘inner ethical readiness’ by nurses (p. 314).
Mezey et al. (Reference Mezey, Kavuma, Turton, Demetriou and Wright2010) explored the concept of recovery with patients in forensic settings highlighting the quality and depth of relationships and interactions between nurse and patient. Respect, acceptance and being related to as a fellow human being were noted as necessary components that facilitated interpersonal agency. Listening as a catalyst to commence the process of solving problems, clarifying values, preserving individual authenticity, and beneficial relationships amongst the turmoil of illness and the hospital setting was reinforced in the literature (Coatsworth-Puspoky et al. Reference Coatsworth-Puspoky, Forchuk and Ward-Griffin2006; Lorem & Hem, Reference Lorem and Hem2012; Stenhouse, Reference Stenhouse2011). A focus group participant explained that listening and sharing stories enabled appreciation and empathy:
“… sort of a humanising thing in a sense … being able to put yourselves in their shoes.”
Storytelling required engaging the patient’s awareness, and a recognition of both their current resources and limitations and the constraints within PICU as much as on gaining insight into their unique experiences and feelings. This can result in incongruities that require controlling practices such as coercion, or strictly enforcing rules to meet the immediate needs of the illness over patient choice and self-determination (O’Donovan, Reference O’Donovan2007). An aspect of this dichotomy was conveyed in the focus groups:
“That’s the other problem with keeping in faith with the Mental Health Act … Some people you have to be assertive and direct with, there are others that you have to coerce. There are others who won’t accept the authoritative nature.”
Appreciation of these tensions requires the skill to listen and respond. A participant in the focus groups described the significance of establishing the history of individuals in order to understand the person and to effectively negotiate complex tensions:
“It is about, within yourself, being aware of the clientele. You are getting an understanding of the history of this person. Once you get the history, then you get a clearer picture in your own head, how you are going to approach this person.”
The storytelling attribute denotes the importance of the quality and depth of the nurse–patient relationship to moderate individual patient experiences of being disconnected, different, and isolated in PICU. The idea of storytelling in PICU helped to clarify how core principles of recovery for example, human dignity and collaborative relationships are used to build knowledge and awareness of the subjective experiences of the patient.
Safeguarding
The safeguarding attribute related to the safety and care of the patient, the patient community, staff and others across the mental health system. The nurses involved in this study perceived the PICU as an, ‘anxiety provoking’ and fearful environment for both patients and staff. One nurse participant shared reflections from a patient, saying:
“I am really … I was frightened in PICU. I didn’t know what those nurses were doing to me and I came out fighting.”
This speech sample suggests that patient responses might be the opposite of what is hoped for in the PICU. That is, the environment might result in aggressive self-preservation rather than creating a sense of safety for the individual.
Literature related to acute care substantiates the nurse’s perceptions of the PICU environment as stressful and potentially unsafe for patients and staff (Bowers et al. Reference Bowers, Allan, Simpson, Jones, van der Merwe and Jeffery2009b; Nolan et al. Reference Nolan, Bradley and Brimblecombe2011). A number of problems that increase anxiety have been highlighted in reports and include organisational problems, biomedical reductionism, inappropriate interventions, occupancy rates, non-therapeutic interventions and obscure care pathways (Deacon & Fairhurst, Reference Deacon and Fairhurst2008; Nolan et al. Reference Nolan, Bradley and Brimblecombe2011). Managing risk whilst also engaging the patient in recovery focused care was perceived to be variable and based on patient population, comorbidity or dual diagnosis, attitudes towards and cooperation with care and treatment, restrictions of the environment, staffing levels and consistency, and available resources. One nurse participant stated:
“It depends on what the population is like, some days you think god this is going to go like hell in a handbag.”
The nurses in the focus groups mostly described safeguarding as a risk avoidance approach. They maintained: “you don’t have anything with ties or shoelaces”; “plastic cutlery, plastic plates, styrofoam cups”; and “you should always have your radar on”. One participant spoke anecdotally of a lockdown strategy to create a protected environment, stating:
“So there is more locked down approach … we created a more secure environment.”
Conversely, several studies have identified the locking of ward doors, placing some sort of restriction on people or denying a patient request, and patient turnover as frequent precursors of incidents, aggression and violence on acute wards (Bowers et al. Reference Bowers, Allan, Simpson, Jones, van der Merwe and Jeffery2009b; Gilburt et al. Reference Gilburt, Slade, Rose, Lloyd-Evans, Johnson and Osborn2010; Papadopoulos et al. Reference Papadopoulos, Ross, Stewart, Dack, James and Bowers2012).
Team and organisational cultures play a significant role in the complex interactions of safeguarding (Chen et al. Reference Chen, Krupa, Lysaght, McCay and Piat2013; Huang et al. Reference Huang, Clermont, Kong, Weissfeld, Sexton, Rowan and Angus2010; Middelboe et al. Reference Middelboe, Schjødt, Byrsting and Gjerris2001). Corroborated by recent research (Alexander, Reference Alexander2006; Thibeault et al. Reference Thibeault, Trudeau, d’Entremont and Brown2010), one nurse participant suggested that rather than creating a safe environment, enforcing rules can generate safety problems if not consistently adhered to:
“The trouble you get with patients in a locked area is the amount of rules you have. So I think the minimal amount of rules but the rules you do have everyone sticks to.”
Factors cited as important for the safeguarding attribute include upholding human rights, involving families and integrating patient-centred approaches (Gilburt et al. Reference Gilburt, Slade, Rose, Lloyd-Evans, Johnson and Osborn2010; Mayers et al. Reference Mayers, Keet, Winkler and Flisher2010; Whitelock, Reference Whitelock2009). Nurses emphasised that the skills required to build a rapport with the patient in order to support and foster patient-centeredness were useful for safeguarding. One informant stated the significance of embedding these skills in training as daily processes:
“Your ability to build a rapport with someone, use your radar, use your perception, build and use the skills that we’ve got as nurses … It’s important because you can build that into your education. You can build that into [the process of providing care] and how this place operates.”
Safeguarding as an attribute of a recovery was perceived to require specific nursing skills and training to understand and integrate humanistic approaches to alleviate fear, distress and aggression.
Treatment
The treatment attribute emerged in this study as an underdeveloped aspect of recovery practiced by nurses in PICU. The literature highlighted the importance of treatments to assuage experiences of hopelessness in PICU (Barker & Buchanan-Barker, Reference Barker and Buchanan-Barker2010; Bertelsen et al. Reference Bertelsen, Jeppesen, Petersen, Thorup, Øhlenschlæger, le Quach, Christensen, Krarup, Jørgensen and Nordentoft2008; Curtis et al. Reference Curtis, Baker and Reid2007; Janner, Reference Janner2007). Three foci aligned to recovery approaches were determined as beneficial in PICU. These were pharmacology, psychotherapies, and structure and routine.
Pharmacology was highlighted as the most practiced treatment in PICU, in data from both the focus groups and the literature. The use of pro re nata (PRN) or ‘as needed’ psychotropic medication was cited as a frequent clinical intervention used by the nurses in the focus groups. One informant explained:
“Because you are just watching and then you know to get up because this one is starting to get a bit agitated we’ll go and get some PRN or stuff like that.”
The administration of PRN is championed as a strategy for the reduction of agitation, distress and aggression, and to reduce physical restraint rates (Hilton & Whiteford, Reference Hilton and Whiteford2008; Usher et al. Reference Usher, Baker and Holmes2010; Winkler et al. Reference Winkler, Naderi-Heiden, Strnad, Pjrek, Scharfetter, Kasper and Frey2011). Yet, much of the literature reported wide variations in the rationales for PRN medication administration with little or no other therapeutic treatment occurring prior to administration (Curtis et al. Reference Curtis, Baker and Reid2007; Hilton & Whiteford, Reference Hilton and Whiteford2008).
Literature related to treatment options, and more specifically psychotherapies, exemplified an array of different strategies, targeting diverse populations and phases of development for beneficial effects (Amering & Schmolke, Reference Amering and Schmolke2009, ch. 7; Bertelsen et al. Reference Bertelsen, Jeppesen, Petersen, Thorup, Øhlenschlæger, le Quach, Christensen, Krarup, Jørgensen and Nordentoft2008; Brimblecombe et al. Reference Brimblecombe, Tingle and Murrells2007; Janner, Reference Janner2007; Summers & Barber, Reference Summers and Barber2012; Wykes et al. Reference Wykes, Steel, Everitt and Tarrier2008). A common focus in nursing literature was on the importance of the nurse–patient therapeutic alliance (Bressi Nath et al. Reference Bressi Nath, Alexander and Solomon2012; Coatsworth-Puspoky et al. Reference Coatsworth-Puspoky, Forchuk and Ward-Griffin2006; Priebe & McCabe, Reference Priebe and McCabe2008).
Time pressures, conflicting demands, role confusion, management style, staff mix, and lack of skills were cited as explanations that impact nurses’ capacity to implement structured or planned psychotherapeutic interventions (Radcliffe & Smith Reference Radcliffe and Smith2007; Mullen, Reference Mullen2009; Aston & Coffey, 2012; Chen et al. Reference Chen, Krupa, Lysaght, McCay and Piat2013). The participants in the focus groups specified that there were limited opportunities for nurses to train in the use of psychotherapies such as cognitive behavioural therapy. The lack of therapeutic activities on the ward and uncertainty of their role in relation to the provision of therapies was alluded to by a nurse participant:
“Well for a start … well I suppose there [are] no therapies … umm we have an OT [occupational therapist].”
An alternative to seclusion and restraint discussed by the focus groups was the experimental use of sensory modulation rooms. This treatment was described in the focus groups:
“We have got weighted blankets and stuff like that but umm and stress balls and … but we have to be with them when you do stuff like that.”
There is growing evidence in the literature of the need for a stimulating, therapeutic environment with routine and structured activities to alleviate acute distress, ensure safety, provide opportunities for peer and family support and an opportunity for patients to take responsibility for their actions (Janner, Reference Janner2007; Walsh & Boyle, Reference Walsh and Boyle2009; Turton et al. Reference Turton, Demetriou, Boland, Gillard, Kavuma, Mezey and Wright2011; Long et al. Reference Long, Knight, Bradley and Thomas2012). Nurse participants in the focus groups discussed a range of general activities to occupy patients. Activities included: “boxing bag … they can punch a boxing bag”, “we had a pool table”, “you get coloured pencils and pens and paints”, “jigsaws” and “playing some board games, X box, and that sort of stuff and again depending on the acuity of the unit.” Yet it was not apparent that activities were delivered in a structured or routine way or as part of a recovery-oriented stratagem. One nurse participant commented:
“So you have one activity person two hours a day roughly – so that’s not bad. It’s more than others... There might be a couple of special weekends where we might get a couple of DVDs or get some popcorn or have a movie night.”
The three key foci of treatment – pharmacology, psychotherapies, and structure and routine – are significant domains with which to establish improved clinical and recovery outcomes for acute patients. For example, the domains can be used to establish a positive routine, solve problems, build understanding and relationships, and support hope as a central, motivating message of recovery. The findings suggest that for treatment to align to a recovery approach there is a need to enhance understanding of how the foci are correlated rather than limiting treatment offered by nurses to observation, providing medication and moving patients out of PICU as quickly as possible.
Responsibility
The responsibility attribute accentuated dignity, respect and valuing human rights on the one hand, while assessing and balancing personal and collective decision-making, risks, controls and restrictions of unpredictable behaviours and the clinical milieu, on the other. Expediting patient empowerment, purpose, collaborative care and ownership for recovery based on ‘a more thorough and clear understanding of the rights, responsibilities, needs and beliefs of the patient’ (Anthony, Reference Anthony1993, p. 523) transpired as a critically challenging but necessary process to address patients’ experiences of helplessness and powerlessness in PICU.
Emphasis is placed on clarifying the process, identifying and reducing barriers, and establishing the needs and beliefs of the patient for recovery through their own preference, even if the nurses were unable to engage the patient’s responsibility and self-determination for recovery at the worst stage of illness. One nurse participant stated:
“It is also part of the person and whether they really want to recover as well, and that’s where you establish a rapport and try to … find out some of the client’s issues and look at the objectives of what this person really wants and where they really want to go with it.”
Coatsworth-Puspoky et al. (Reference Coatsworth-Puspoky, Forchuk and Ward-Griffin2006) suggested that engaging the patient’s responsibility and self-determination for recovery is related to shifting power in the nurse–patient relationship as the patient sets goals, learns, solves problems and assumes control in caring for themselves and their recovery.
Responsibility as an attribute of recovery in PICU was stressed as a needs–rights paradox for nursing practice in PICU. Human rights and choice are a basis for the practice of shared responsibility in care (Wallcraft et al. Reference Wallcraft, Amering, Freidin, Davar, Froggatt, Jafri, Javed, Katontoka, Raja, Rataemane, Steffen, Tyano, Underhill, Wahlberg, Warner and Herrman2011; Wallcraft, Reference Wallcraft2012). However, Wallcraft et al. (Reference Wallcraft, Amering, Freidin, Davar, Froggatt, Jafri, Javed, Katontoka, Raja, Rataemane, Steffen, Tyano, Underhill, Wahlberg, Warner and Herrman2011) specifically noted that respondents to their consultation held opposing sentiments about the application of human rights and the need to use coercive measures, such as seclusion, or medication when someone is in an acute state.
Patient informed consent and coercive measures, such as seclusion, or medication are linked with professional, attitudinal, ethical, legal and moral issues. As the frontline staff, nurses are often held responsible for the faults and shortcomings of the overall system (Hilton & Whiteford, Reference Hilton and Whiteford2008; Cleary et al. Reference Cleary, Hunt and Walter2010; Nolan et al. Reference Nolan, Bradley and Brimblecombe2011; Sjöstedt et al. Reference Sjöstedt, Dahlstrand, Severinsson and Lützén2001). Responsible decision-making related to such issues needs complex and careful consideration to maintain a recovery focus. Communication and de-escalation skills were considered significant tools to balance nurse–patient accountabilities. Nurses in the focus group harnessed supervision and learning in collaborative teams to support decision-making and review professional, ethical and moral issues. One observed:
“When you have been in the areas and you have a bit of experience, you float off each other and learn from each other very, very quickly, from the people who can deal with certain situations … It really is a specialist area.”
Green et al. (Reference Green, Polen, Janoff, Castleton, Wisdom, Vuckovic and Oken2008) found that mental health clinicians who collaborated with their patients to develop and evaluate plans of care that were acceptable to both clinician and patient, particularly regarding medications, were seen as more helpful and more competent. Empowering people to participate in and take responsibility for their own care was valued by patients in the study. Establishing and sharing the goals of patients with other health professionals across the continuum of care was perceived to be an important shared responsibility initiated by nurses. An informant reflected:
“It stems through, right through the patient condition, how they got there in hospital in the first place, right through the family you know. It’s the tree, the food chain … So it is actually the responsibilities of the nurses not any other health profession at this stage.”
Responsibility to engage and sustain recovery approaches by nurses in PICU required complex and careful consideration of patient self-determination, practical risks and human rights. Fostering improved communication, trust and balancing the dynamics of patient–nurse personal and collective decision-making were accentuated as key aspects of the responsibility attribute.
Discussion
Four attributes that support a recovery approach, storytelling, safeguarding, treatment and responsibility, have been outlined in this paper. These four attributes construe recovery in a pragmatic framework rather than as representational meaning. This paper seeks to understand how recovery is practicably embedded in acute psychiatric settings.
As observed elsewhere (Slade et al. 2008; Cleary et al. Reference Cleary, Horsfall, O’Hara-Aarons and Hunt2012a; Gwinner & Ward, Reference Gwinner and Ward2013) current guidelines and practices in acute psychiatric care are not meeting the requirements for a recovery-oriented system. More often the primary function of a PICU is described as the suppression of aggressive and violent behaviour, or ‘a punishment block’ (Dix, Reference Dix2012; Stylianos & Kehyayan, Reference Stylianos and Kehyayan2012). Some studies examining nurses’ knowledge about recovery principles have indicated that recovery is poorly articulated amid continued confusion related to contradictory concepts and organizational policies and procedures (Browne et al. Reference Browne, Cashin and Graham2012; Cleary et al. Reference Cleary, Horsfall, O’Hara-Aarons and Hunt2012a). Consequently, there remains a fundamental and urgent need for pragmatic clarity to enact recovery in nursing practice in intensive psychiatric care settings.
The four attributes outlined in this paper offer the potential to guide thinking and to help negotiate the complex issues and paradoxes frequently experienced by nurses and reported in studies of nurses’ and patients’ perceptions and experiences in PICU (Mayers et al. Reference Mayers, Keet, Winkler and Flisher2010; Mezey, Reference Mezey, Kavuma, Turton, Demetriou and Wright2010; Nolan et al. Reference Nolan, Bradley and Brimblecombe2011; Cleary et al. Reference Cleary, Horsfall, O’Hara-Aarons, Jackson and Hunt2012b). For example, the storytelling attribute provides insight into the complex layers, to engage effective communication strategies amongst the turmoil of the acute settings.
The storytelling attribute marked a distinction in the quality and depth of engagement between nurses and patients to clarify how core principles such as human dignity and collaborative relationships are mediated for greater interpersonal agency and ethical readiness. The art of storytelling between nurses and patients in PICU has, to some extent, been lost in various assessment instruments and requirements to obtain knowledge and transmit patients’ problems and needs to others in the mental health system. Sjostedt et al. (2001) suggested that communication and language theories may provide support for nurses’ dialogues with patients, expand understanding of professional, ethical and moral awareness, and acknowledge the responsibility of having the power to influence recovery-oriented care.
It is critical to clearly articulate safeguarding as an attribute of recovery in acute psychiatric settings. Key factors cited as effective for safeguarding aligned to recovery include creating a sense of safety and, upholding human rights. These are achieved through interpersonal interactions; interventions that optimise patient experiences; staff training and education; involving patients and families with their care decisions and management; and integrating client centred approaches in care (Whitelock, Reference Whitelock2009; Gilburt et al. Reference Gilburt, Slade, Rose, Lloyd-Evans, Johnson and Osborn2010; Mayers et al. Reference Mayers, Keet, Winkler and Flisher2010; Cleary et al. Reference Cleary, Horsfall, O’Hara-Aarons, Jackson and Hunt2012b). Yet factors such as legislative requirements and protecting an individual’s legal, citizenship and human rights continue to obfuscate nursing efforts to embed recovery approaches.
Lakeman (Reference Lakeman2011) pointed out that institutional values and assumptions persist in nursing practices that are clearly incompatible with notions of recovery. Risk avoidance approaches continue to prevail over recovery dimensions and ultimately infringe on human rights. Nascent literature indicates that aggression and violence in psychiatric acute wards are linked to restrictions, rules, limitations, lack of flexibility and diminished human dignity (Bowers et al. Reference Bowers, Allan, Simpson, Jones, van der Merwe and Jeffery2009b; Hamrin et al. Reference Hamrin, Iennaco and Olsen2009; Papadopoulos et al. Reference Papadopoulos, Ross, Stewart, Dack, James and Bowers2012). Advocating humanistic approaches (Stylianos & Kehyayan, Reference Stylianos and Kehyayan2012) to alleviate distress and aggression provides practical and preventative approaches for safeguarding, aligned to recovery practices in the PICU.
Viewing treatment as an attribute of recovery through three foci (pharmacology, psychotherapies and structure and routine) indicated there is currently greater attention focused on nurses’ use of PRN medication as a treatment of choice over the use of other important treatments useful in a recovery approach to care in the PICU (Winkler et al. Reference Winkler, Naderi-Heiden, Strnad, Pjrek, Scharfetter, Kasper and Frey2011). The nurse–patient therapeutic alliance was highlighted in much of the literature (Coatsworth-Puspoky et al. Reference Coatsworth-Puspoky, Forchuk and Ward-Griffin2006; Priebe & McCabe, Reference Priebe and McCabe2008; Bressi Nath et al. Reference Bressi Nath, Alexander and Solomon2012) as was the necessity of active engagement to encourage patient autonomy, insight and overcoming practical problems (Slade, Reference Slade2010; Turton et al. Reference Turton, Demetriou, Boland, Gillard, Kavuma, Mezey and Wright2011; Chen et al. Reference Chen, Krupa, Lysaght, McCay and Piat2013). Yet psychotherapies, and structure and routine, emerged as underdeveloped aspects of treatment aligned to recovery and patient-focused practice. It is essential that nurses confidently embrace their expertise and skills to broaden therapeutic treatments as a meaningful feature of a recovery in PICU.
Nurses’ ownership of a recovery-oriented culture based on ‘a more thorough and clear understanding of the rights, responsibilities, needs and beliefs of the patient’ (Anthony, Reference Anthony1993 p. 523) is critically challenging, but necessary to address patients’ experiences of helplessness and powerlessness in PICU. Responsibility as an attribute emergent from the study, stressed the importance of nurses’ attitudes and capacity for ethical, legal and moral decision-making. The data highlighted nurses’ primary concern for the legitimate use of power in PICU, and stressed an imperative to ensure the integrity of the rights, the responsibilities, the needs and beliefs of the patient are met (Ward & Syversen Reference Ward and Syversen2009).
Responsibility as a guiding principle of recovery maintains a focus on the expression of individual responsibility for the patient’s own self-care and journeys of recovery (Roberts & Boardman, Reference Roberts and Boardman2013). Weisser, et al. (Reference Weisser, Morrow and Jamer2011) proposed a major shift in thinking about recovery from an exclusively individual responsibility, to a shared societal responsibility. Adopting a societal approach in PICU places an onus on balancing nurse–patient responsibilities. Additionally, this focus brings to light the structural changes required to facilitate advocacy processes for individuals to contribute to their care and treatment, in ways that don’t fundamentally impact on their rights to self-determination and choice as a core principle of a recovery vision.
Conclusion
Recovery viewed as a pragmatic framework, as outlined in the attributes described in this paper, begins to build clarity for nurses around embracing recovery practice in the unpredictable milieu of psychiatric intensive care settings. The qualities of the attributes presented in this paper interconnect and overlap in diverse, composite ways. Each attribute provides a lens with which to reinforce decision-making and to negotiate the dynamic challenges in daily interactions and communication with patients experiencing acute psychiatric distress.
Importantly, these attributes provide a platform with which to investigate approaches to strengthen recovery in psychiatric intensive care settings. For instance, what daily routines and structures initiated by nurses, best augment the quality and depth of the nurse–patient relationship, which is described as a significant feature of recovery in PICU? Equally, it is critical and timely to further examine qualities of recovery related to safeguarding, given recent legislative provisions to lock adult acute mental health facilities in authorised mental health services across Queensland (Schoubroeck, Reference Schoubroeck2013). Will this legislation to limit patient freedoms result in more frequent incidents of violence and aggression within Queensland adult psychiatric inpatient settings?
Limitations
Even though a comprehensive search of the literature was conducted, it was based on perspectives of practice and recovery by nurses in two inpatient psychiatric units; therefore the study cannot be representative of all acute psychiatric care settings. It cannot encapsulate a complete appraisal of stakeholders in relation to recovery practice and experiences in PICU. However, nurses’ descriptions and perceptions of recovery in PICU make it possible to further explore these attributes with other stakeholders and in other acute psychiatric settings. The findings provide implications around which further research and policy planning may be framed. For example, further research is needed to incorporate patients’ experiences and accounts, and to reinforce that the attributes highlighted here are aligned to a recovery as understood by people experiencing acute psychiatric distress. Additionally, further research is needed to ascertain the resourcing and training that is required to support a recovery-oriented culture in acute psychiatric settings.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
Supplementary material
To view supplementary material for this article, please visit http://dx.doi.org/10.1017/S1742646414000181
