Eimear Caitlin Muir-Cochrane

Demonstrating Rigor Using Thematic Analysis: A Hybrid Approach of Inductive and Deductive Coding and Theme Development

In this article, the authors describe how they used a hybrid process of inductive and deductive thematic analysis to interpret raw data in a doctoral study on the role of performance feedback in the self-assessment of nursing practice. The methodological approach integrated data-driven codes with theory-driven ones based on the tenets of social phenomenology. The authors present a detailed exemplar of the staged process of data coding and identification of themes. This process demonstrates how analysis of the raw data from interview transcripts and organizational documents progressed toward the identification of overarching themes that captured the phenomenon of performance feedback as described by participants in the study.

Midwives and assessment of perinatal mental health

Accessible summary • Childbirth is a significant life event in which women may experience emotional as well as physical changes. • This study examined what midwives thought about their mental health skills and knowledge when they worked with women with a mental illness who had just had a baby. • They reported feeling ill equipped to work with women with mental illness as well as not being aware of the resources available to them and the mothers. • Midwives need to have appropriate education, knowledge and skills to work with this vulnerable group of women. Abstract Childbirth involves many psychological and emotional changes for women. The recent Commonwealth Government of Australia, National Perinatal Mental Health Action Plan (in 2008) recommends all pregnant and postnatal women have a psychosocial assessment including completion of the Edinburgh Postnatal Depression Scale. Midwives will assess all women at antenatal ‘booking in’ to maternity services. Currently, midwives receive little education regarding mental health assessment of women. This study explored the perceptions of midwives of their own mental health skills, knowledge and experiences, when working with women with mental illness in the perinatal period. An exploratory descriptive design was utilized to survey midwives across 19 maternity sites in Victoria, Australia. Clearly, midwives lack mental health skills and knowledge, describing their lack of confidence and feeling uncomfortable and unsafe when providing care for women with mental illness. They also report little knowledge of resources available to provide appropriate services for these women. The future direction for improving maternity care will require midwives to assess mental health needs of women, and refer them on, for timely intervention. It is critical midwives are prepared and able to make this kind of assessment.

Absconding: A review of the literature 1996-2008

Absconding is a significant problem with potential for harm to patients or the general public. The consequences of absconding include physical harm, prolonged treatment time, and substantial economic costs. The aim of this systematic literature review is to synthesize quality literature about absconding from psychiatric facilities, identify gaps in knowledge, and make recommendations for practice. An electronic search yielded 39 journal articles that met the review criteria. Findings demonstrate that a single definition of absconding remains elusive, making the prevalence of absconding difficult to establish. Absconding events are multifactorial, with environmental, psychosocial, and organic aspects. Negative consequences exist including violence, aggression, and self-neglect and harm to self and others. Papers are clustered around the following themes: harm and risk, absconder profiles, absconding rates, and perceptions of nurses and patients. Nursing interventions designed to decrease absconding have been implemented with success, but only in a few studies and in Australia, none have been reported in the literature to date. Further research is required to identify appropriate nursing-based interventions that may prove useful in reducing the risk of absconding.

Improving seclusion practice: implications of a review of staff and patient views.

This review explores patient and staff perceptions and improvement suggestions regarding seclusion in psychiatric inpatient settings. After an extensive literature search, 39 empirical papers were included in the review. According to the literature, patients perceived seclusion to be a distinct negative incident. Staff thought seclusion had a therapeutic effect and believed that units could not operate effectively without seclusion, but regretted that the situation was not resolved differently. Staff and patients had suggestions to improve the seclusion experience. Common themes in relation to the implications for practice are the need for better communication and more contact between patients and staff before, during and after the seclusion event.

The scope for replacing seclusion with time out in acute inpatient psychiatry in England

BACKGROUND The use of seclusion is unpalatable to nurses and frequently unpleasant for patients. Time out is rated by nurses and patients as more acceptable. Several countries have initiated exercises to reduce the use of seclusion, but England has not. METHODS In this study, data were collected on the sequence of conflict (aggression, rule breaking, absconding etc.) and containment (coerced medication, restraint, special observation etc., including time out and seclusion) for the first 2 weeks of 522 acute admissions on 84 wards in 31 English hospitals between June 2009 and March 2010. Data were analysed to describe what preceded and followed time out and seclusion episodes in a nursing shift. RESULTS Seclusion was used with 7·5% of patients, and time out with 15·5%. Both containment methods were used with similar patients in similar circumstances, and both brought disturbed behaviour to a close in half of the cases. Some seclusion appeared to follow less serious disturbed behaviour. There was an important variation in rates of seclusion between hospitals. Seclusion and time out had equally good outcomes in the management of physical violence to others. CONCLUSIONS There is good evidence that seclusion rates can be reduced safely, and time out can sometimes be used as a substitute. A national registration and reporting system should be introduced in England, and serious efforts made to reduce seclusion use in hospitals where rates are high.

Investigation into the acceptability of door locking to staff, patients, and visitors on acute psychiatric wards

There is disagreement among psychiatric professionals about whether the doors of acute psychiatric wards should be kept locked to prevent patients from leaving and harming themselves or others. This study explored patient, staff, and visitor perceptions about the acceptability of locking the ward door on acute psychiatric inpatient wards. Interviews were conducted with 14 registered nurses, 15 patients, and six visitors from three different acute wards. Findings revealed commonalities across all groups, with general agreement that locking the door reduced absconding. Staff expressed feelings of guilt, embarrassment, and fear of being blamed when a patient absconded. Staff also reported that open wards created anxious vigilance to prevent an abscond and increased workload in allocating staff to watch the door, whereas staff on partially-locked doors also perceived an increased workload in letting people in and out of the ward. Patients had mixed feelings about the status of the door, expressing depression, a sense of stigma, and low self-esteem when the door was locked. The issue of balancing safety and security on acute psychiatric wards against the autonomy of patients is not easily resolved, and requires focused research to develop innovative nursing practices.

Naked Social Control: Seclusion and Psychiatric Nursing in Post-Liberal Society

Abstract Post-liberal societies have developed a matrix of social control faculties, ranging from subtle, covert, and pervasive self-regulatory doctrines, to coarse, overt, and authoritarian infringements on human emancipation and full citizenship. Psychiatric nurses (along with members of the other psychiatric disciplines, particularly medicine) are engaged in post-liberal injunctions of thoughts and behaviour. Furtive control of the psychiatric patient’s ‘self’ has been enacted traditionally through, for example, the requisites of the ‘therapeuticrelationship’ and the talking therapies. The psychiatric nurse and psychiatrist have now become administrators of ‘risk’ and arbitrators in the division of mentally disordered people into categories of ‘dangerousness’. The increasing adoption of physical removal and segregation of individuals who, as in-patients, are already incarcerated within the psychiatric system (thereby suffering a double-dose of social exclusion), is a blatant portrayal of stringent social control. The power to seclude exposes the reality of the psychiatric nurse’s role in the last instance – that of (naked) agent of social control. This paper exposes the incongruity between principles of mental health law (which optimise the promotion of wellbeing and the prevention of mental disorders), and the practice of seclusion that confines individuals, and removes their dignity.

The profile of absconding psychiatric inpatients in Australia

AIMS AND OBJECTIVES The purpose of this study was to examine absconding behaviour (a patient leaving the hospital without permission) in acute and rehabilitation wards of one Australian psychiatric institution to describe the characteristics of the absconding patient and these events. BACKGROUND Absconding is a significant issue in psychiatric inpatient settings, with risks that include patient harm, aggression and violence. In spite of this, limited research has been conducted in Australia on patients who abscond while receiving psychiatric care. DESIGN The study was a retrospective descriptive analysis. METHOD Absconding events from three acute and seven rehabilitation wards over a 12-month period were studied. RESULTS The rate of absconding events by detained patients was 20.82%. Gender was not significantly associated with absconding, although 61.19% of those who absconded were men diagnosed with schizophrenic disorders. Over half of acute care patients who absconded left during their first 21-day detention order. More than half of absconding events were by patients that absconded more than once. There was limited support for the efficacy of locking ward doors. Age and diagnosis emerged as particularly important factors to consider. DISCUSSION The study revealed that men are not more likely to abscond than women, that locking ward doors does not deter the determined absconders and that once a person has absconded, they are more likely to do so again. Younger patients and those with a schizophrenic disorder may be particularly likely to abscond. There also appears to be a link between continuing detention orders and an absconding event. CONCLUSIONS Findings provide new data about the profile of absconding patients in Australia. Exploration of the reasons why patients abscond and why many do so repeatedly warrants further investigation. RELEVANCE TO CLINICAL PRACTICE Risk management approaches taking into account factors associated with absconding could be trialled to reduce the incidence of absconding in psychiatric inpatient settings.

Attitudes of clinical staff toward the causes and management of aggression in acute old age psychiatry inpatient units

BackgroundIn psychiatry, most of the focus on patient aggression has been in adolescent and adult inpatient settings. This behaviour is also common in elderly people with mental illness, but little research has been conducted into this problem in old age psychiatry settings. The attitudes of clinical staff toward aggression may affect the way they manage this behaviour. The purpose of this study was to examine the attitudes of clinical staff toward the causes and management of aggression in acute old age psychiatry inpatient settings.MethodsA convenience sample of clinical staff were recruited from three locked acute old age psychiatry inpatient units in Melbourne, Australia. They completed the Management of Aggression and Violence Scale, which assessed the causes and managment of aggression in psychiatric settings.ResultsEighty-five staff completed the questionnaire, comprising registered nurses (61.1%, n = 52), enrolled nurses (27.1%, n = 23) and medical and allied health staff (11.8%, n = 10). A range of causative factors contributed to aggression. The respondents had a tendency to disagree that factors directly related to the patient contributed to this behaviour. They agreed patients were aggressive because of the environment they were in, other people contributed to them becoming aggressive, and patients from certain cultural groups were prone to these behaviours. However, there were mixed views about whether patient aggression could be prevented, and this type of behaviour took place because staff did not listen to patients. There was agreement medication was a valuable approach for the management of aggression, negotiation could be used more effectively in such challenging behaviour, and seclusion and physical restraint were sometimes used more than necessary. However, there was disagreement about whether the practice of secluding patients should be discontinued.ConclusionsAggression in acute old age psychiatry inpatient units occurs occasionally and is problematic. A range of causative factors contribute to the onset of this behaviour. Attitudes toward the management of aggression are complex and somewhat contradictory and can affect the way staff manage this behaviour; therefore, wide-ranging initiatives are needed to prevent and deal with this type of challenging behaviour.

Service provision for older people with mental health problems in a rural area of Australia

Objectives: Unmet mental health care needs of older people (aged 65 and over) have been identified as a serious problem internationally, particularly in rural areas. In this study we explored the views of health and social care providers of the barriers to effective mental health care for older people in a rural region in Australia.Method: Semi-structured interviews were conducted with 19 participants from 13 organisations providing care and support to older people in a rural region of Australia. A framework analysis approach was used to thematically analyse the data.Results: Two main themes were identified: ‘Recognising the Problem’ and ‘Service Availability and Access’. In particular the participants identified the impact of the attitudes of older people and health professionals, as well as service inadequacies and gaps in services, on the provision of mental health care to older people in a rural region.Conclusion: This study supports previous work on intrinsic and extrinsic barriers to older people with mental health problems accessing mental health services. The study also offers new insight into the difficulties that arise from the separation of physical and mental health systems for older people with multiple needs, and the impact of living in a rural region on unmet mental health care needs of older people.