Stacey Wilson

New risks: the intended and unintended effects of mental health reform

In crisis situations, the authority of the nurse is legitimised by legal powers and professional knowledge. Crisis stakeholders include those who directly use services and their families, and a wide range of health, social service and justice agencies. Alternative strategies such as therapeutic risk taking from the perspective of socially inclusive recovery policy coexist in a sometimes uneasy relationship with mental health legislation. A critical discourse analysis was undertaken to examine mental health policies and guidelines, and we interviewed service users, families, nurses and the police about experiences of accessing services. For those who attempt to access services early in crisis, as is suggested to lead to a better outcome, provision of services and rights appear to be reversed by an attempt to exclude them through practices that screen them out, rather than prioritising a choice in access.

Editorial: In defence of patients.

Over the years, there has been a continuing debate over how to refer to people in our care. The choice of title that we use is more than a semantic exercise. The words that we choose are powerful metaphors that convey meaning about how we conceive those in our care and our expectations. Language induces us to comprehend objects or people in distinct ways. For the person labelled through a title, the language chosen constructs an identity that conveys meaning about their attributes, status and relationship (McLaughlin 2009). Choosing a title also conveys to others our intentions and values. Moreover, language is not power-neutral. Titles are dominant discursive formations that reflect ideological process and convey and reinforce rules for thought and action (Fairclough 2001). The discursive power of words not only shapes social expectations and relationships, the power of words can also shape culture and material outcomes. Also, as language becomes accepted and normalised, it can be more difficult to express differing views or new ideas. Thus, beyond the surface level, the finer detail of the semantics of language in healthcare is important. The term ‘patient’ is contested. There are thought to be negative connotations associated with the word ‘patient’; which is considered (by some) to be an inappropriate term for people in the nonhospital environment and for healthy people in the context of health maintenance (Pluckhan 1972). Furthermore, in some quarters, the word ‘patient’ has been seen as paternalistic, evidence of inherent power inequities and a reflection of the dominant biomedical approaches (Joseph 2013). These concerns have lead to the renaming of health care recipients to other terms such as ‘client’, ‘consumer ‘, ‘customer’ and ‘service user’. In deciding the choice between the term patient and client, consumer, service user etc., it is important to consider the underlying ideologies of the different language uses, and the implications for values and sustaining particular forms of action. In the language of healthcare, the construction of individuals as patients, clients or users conveys different and powerful meanings. The word ‘client’ particularly is in fairly wide usage and has gained some acceptance in health care discourses. The term ‘client’ was thought to reflect a rejection of biomedical domination and indicative of a more humanistic approach (Joseph 2013); reflecting more autonomy, and implying greater choice in who provides the health care for an individual. However, use of language does not, in and of itself, denote autonomy, and could in fact signify a false autonomy. Most often, people, particularly when engaging in public healthcare do not get to choose the nurses who will work with them. It is more the case that whoever is on duty at the time an individual requires nursing care, will provide that care. Thus, in reality, it is mostly the case that nurses and patients are randomly coupled together and so in this situation, use of the term client could represent a false autonomy. In the case of welfare and statefunded health services care may be seen as a product brokered for the client or consumer. The term ‘customer’ in health care delivery takes the identity of the person to a different level of assumed choice. It can be argued that there are times when consumer may be an appropriate term. However, even then, it is likely that those with access to resources, education and health literacy will benefit, and those with fewer personal resource will be less informed consumers. The drive towards ‘service user’ developed from the consumerist movement of the 1990s, rightly included the development of participation of people who access services to shape expectations and outcomes of what is on offer (Gee et al. 2015). However, there is no one single service user voice. We argue that terms such as ‘client’, ‘customer’ and ‘service user’ do not adequately capture the meaning that is imbued in the word ‘patient’. According to the dictionary meaning, to be a patient means simply to be a recipient of health care. But, there are so many more connotations to this word. To be a patient denotes being in a relationship with a health care provider. Being the patient or care provider in that relationship signifies the meaning of the relationship, and defines the roles in the relationship. For the patient, the purpose of the relationship is enhancement of personal health and well-being and the context is of being in a privileged, safe and therapeutic milieu. Use of the word ‘patient’ also provides a constant reminder to health professionals of the privileged nature of the relationship, and that, at all times, the needs of the patient within the relationship must take primacy. Customer (or patient) satisfaction is suggested as important in contemporary nursing care, yet people do not necessarily respond to situations of inadequate service in healthcare by complaining (as customers may be inclined to do in other contexts) (Evans 2010). Furthermore, conceptually, patient satisfaction does not equate to quality health care. To be personfocused, nursing must be accessible,

Betrayal in Nursing: Recognizing the Need for Authentic and Trusting Relationships

Healthy interpersonal relationships are crucial in everyday interactions and characteristics of these include authenticity, trust, fairness, mutual respect, communication and being open and honest with each other. For a range of reasons and circumstances; relationships can unravel and quickly change – especially if one feels betrayed. Betrayal is defined as “a voluntary violation of mutually known pivotal expectations of the trustor by the trusted party (trustee), which has the potential to threaten the well-being of the trustor” (Elangovan & Shapiro, 1998, p. 548). Milton defined betrayal as “to lead astray, to deceive, to betray, to be unfaithful in guarding or fulfilling a trust” (Milton, 2011, p. 207). In this column we briefly overview workplace betrayal and discuss its influence on work-based behaviors and relationships and consider the need for actions that are congruent with personal and professional values. Betrayal occurs when people engage in behaviors or acts that are perceived to be disloyal (Finkel, Rusbult, Kumashiro, & Hannon, 2002). As nurses we encounter people who have been betrayed by others in whom they have trusted, in a range of situations, including people who have experienced domestic violence (Dienemann, Glass, Hanson, & Lunsford, 2007); children and young people who have been abused by a family member/s or other significant person in their life (Martin, Van Ryzin, & Dishion, 2016; Wager, 2013), perception of institutional betrayal to veterans exposed to military sexual trauma (Monteith, Bahraini, Matarazzo, Soberay, & Smith, 2016) or older people who may have been physically or financially exploited by trusted relatives, friends or carers (Cooper, Selwood, & Livingston, 2008). In addition to these more overt acts of betrayal, Freyd (2013) warns that we can further betray people in more subtle ways, such as by the language we use to pathologize their trauma and mistreatment, which locates the problem with the victim/survivor instead of the event, thereby undermining their individual strength and dignity. Betrayal is not confined to the privacy of personal relationships, nor the clients or students nurses we work with (Cleary, Horsfall, Jackson, & Hunt, 2012; Hutchinson, Jackson, Walter, & Cleary, 2013), but may also be evident in the workplace. In nursing we need to be able to communicate with, and trust our colleagues (Cleary, Walter, Horsfall, & Jackson, 2013; Read, 2014). But collegial trust can be fragile (Jackson, 2008) and breaches can be experienced as acts of betrayal that may interfere with working relationships, team effectiveness and morale, and in turn influence consumer outcomes. In an environment of trust, people can truly be, and act, their best (Grohar-Murray & Langan, 2011). In nursing, trusting relationships with colleagues

Developing citizens: missed opportunities in health and social service provision? A view from Aotearoa New Zealand

This article is a reflection on an evaluation of multisystemic therapy services in Aotearoa New Zealand, established to treat young people aged 12–16, for alcohol and drug misuse and to decrease unwanted or “antisocial” behaviors. The therapy engaged parents/caregivers in a systems approach and did not require the young person to be directly engaged. This raised three issues. First, because the young people were not active participants, the services missed the opportunity to help the young people develop skills of self management. Second, this lack of engagement created a missed opportunity to engage the young person to re-establish or reconnect relationships that had been harmed. Finally, we reflect on the cultural fit of the service with Māori values. These issues raise a number of questions about the aims of service provision with young people and the assumptions that underpin particular types of service.