Mature care? : An empirical study of interaction between psychotic patients and psychiatric nurses

It is a widespread notion that nursing should be characterised as altruistic actions of care. Do the experiences of patients and nurses in acute psychiatry reflect this notion of care, and does it represent an appropriate professional self-conception for nurses? These questions are at the core of the empirical studies conducted for this dissertation. The dissertation consists of six articles that address central ideals of nurse-patient interaction. The empirical data show that nursing practice is full of challenges and that the nurses do not manage to live up to what good psychiatric nursing is supposed to be like. The altruistic notion of care conceals the demanding nature of acute psychiatry and may serve to idealise and camouflage the exercise of power. The question arises whether the altruistic notion of care that prevails in the nursing profession ought to be revised. Mature care is proposed as a possible alternative. Inherent in the concept of mature care is an idea of the importance of the nurses’ balancing their own needs and interests against those of the patients. By including the caregiver’s interests, the idea of mature care provides an opportunity to incorporate perspectives of power

“Struck down by cancer with no old life to fall back on” a clinical study of illness experiences among Norwegian adolescent and young adult cancer survivors investigating the ethical implications of their illness narratives

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.Background: Cancer is a leading cause of death among people 15–24 years of age. Increasing numbers of cancer patients survive. Extensive cancer therapy may cause wide-ranging somatic and psychosocial challenges in the lives of the survivors. Research indicates adolescent and young adult cancer (AYA) survivors need to be seen as a distinctive group of survivors having unique health care needs. The existing literature suggests the need for specific follow-up care programs addressing the challenges of AYAs and providing them access to specialized after care, as well as a need to explore AYA cancer survivors' own illness experiences. Aims: Through the theoretical lens of narrative medicine and care ethics, our purpose was to investigate the particular challenges encountered by the AYA cancer survivors, and how they view themselves in light of their illness experiences. We ask how AYA cancer survivors are met and understood by their medical professionals? Methods: This study applied a qualitative method using a narrative research design by collecting self-stories of illness in order to conceptualize human experiences of illness among AYA cancer survivors. Eight in-depth interviews were conducted using a narrative analysis according to the narrative plots of restitution, chaos and quest, as suggested by Arthur Frank. Results: Hopelessness and a struggle to take part in the activities of daily life as survivors of cancer were revealed. Too ill to fully take part in the society, the AYA cancer survivors strive to be understood for what they are, namely young survivors. Conclusion: The survivors´stories reveal a moral imperative that needs to be honored by medical professionals in order to improve cancer care. Cancer survivorship may be a lifelong process necessitating long-term follow-up care. With the lack of specific care programs for AYA cancer survivors, follow-up care is provided by general practitioners or other medical professionals, who often lack expertise in the unique challenges faced by AYA survivors. Because they feel their needs are unmet and their stories not understood, the AYA survivors might experience a sense of abandonment By adopting a care ethics and narrative medicine approach we provide medical professionals a theoretical framework to better understand and care for AYA cancer survivors. Clinical trial number is 2012/1141.publishedVersio

Medication-free mental health treatment: a focus group study of milieu therapeutic settings

Background Medication-free treatment within mental health care aims to offer therapeutic support as an alternative to psychotropic medication. Introducing milieu therapy for severely mentally ill persons in a medication-free unit requires significant changes to the traditional medication-based psychiatric setting. The present study examines how milieu therapists experience working with medication-free treatment for people with severe mental health challenges. The research question was “What may be required to succeed with medication-free treatment in milieu therapeutic settings?” Methods A qualitative study with four focus groups were conducted with 23 milieu therapists from three inpatient units in two mental health institutions. Thematic analysis was performed. Results One main theme was identified: medication-free treatment involves therapists and patients working together on holistic and personal health promotion. This common thread links the four themes: helping patients to make changes in their life; having time to focus on the individual patient; being a professional companion; and working together as a team with the patient. Conclusions A holistic approach is necessary for medication-free treatment to succeed. This requires working together in multidisciplinary teams with a focus on the individual patient. Milieu therapists must engage and take more responsibility in the patient’s process of health promotion. A change from a medical to a humanistic paradigm within mental health care is needed.publishedVersio

Systematisk etikkrefleksjon gjør en forskjell. Et ressurshefte for etikkrefleksjonsgrupper i psykisk helsevern

Dette ressursheftet er utviklet av forskere ved Senter for medisinsk etikk (SME) ved Universitetet i Oslo. SME har gjennom en årrekke arbeidet med etikk i helsetjenesten. To viktige satsinger har vært utviklingen av Kliniske etikk-komitéer (KEK) som nå alle helseforetak er pålagt å ha,1 samt Etikk i kommunehelsetjenesten (EIK).2 På bakgrunn av at vi så behovet for en etikksatsing i psykisk helsevern, fikk vi – takket være økonomisk støtte fra Helsedirektoratet i en lengre periode (2011-2016) – muligheten til å sette fokus på etiske problemstillinger i de psykiske helsetjenestene. Prosjektet fikk navnet Psykiske helsetjenester, etikk og tvang (PET), og det har blitt ledet av Reidar Pedersen. Øvrige medarbeidere i prosjektet har vært Reidun Norvoll, Bert Molewijk, Marit Helene Hem, Tonje Lossius Husum, Reidun Førde, Olaf Gjerløw Aasland, Elisabeth Gjerberg, Lillian Lillemoen, Elin Håkonsen Martinsen, Bente Weimand, Irene Syse og Anders Tvedt

Coping with moral distress on acute psychiatric wards: A qualitative study

Background: Nurses working within acute psychiatric settings often face multifaceted moral dilemmas and incompatible demands. Methods: Qualitative individual and focus group interviews were conducted. Ethical considerations: Approval was received from the Norwegian Social Science Data Services. Ethical Research Guidelines were followed. Participants and research context: Thirty nurses working within acute psychiatric wards in two mental health hospitals. Results: Various coping strategies were used: mentally sorting through their ethical dilemmas or bringing them to the leadership, not ‘bringing problems home’ after work or loyally doing as told and trying to make oneself immune. Colleagues and work climate were important for choice of coping strategies. Discussion: Nurses’ coping strategies may influence both their clinical practice and their private life. Not facing their moral distress seemed to come at a high price. Conclusions: It seems essential for nurses working in acute psychiatric settings to come to terms with distressing events and identify and address the moral issues they face. As moral distress to a great extent is an organisational problem experienced at a personal level, it is important that a work climate is developed that is open for ethical discussions and nourishes adaptive coping strategies and moral resilience.publishedVersio

Patients with severe mental illness and the ethical challenges related to confidentiality during family involvement: a scoping review

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.Background: Despite evidence on the significant potential value of family involvement during the treatment of patients with severe mental illness, research has shown that family involvement is largely underused. The duty of confidentiality is reported to be a key barrier to family involvement. To develop more insight into this barrier, this scoping review focuses on the following question: What are the reported ethical challenges related to confidentiality when involving family in the treatment of patients with severe mental illness? Methods: A systematic search into primary studies was conducted using the following databases: Medline (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), and Web of Science core collection (Clarivate). The PICO (Population, Intervention, Comparison, Outcome) scheme and qualitative content analysis were used to make the ethical challenges more explicit. Results: Twelve studies—both qualitative and quantitative—were included. We identified the following main categories of ethical challenges: (1) the best interest of family members vs. confidentiality, (2) the patient’s best interest vs. the right to confidentiality, (3) patient trust and alliance as a reason not to involve the relatives or not to share information, and (4) using confidentiality as a smokescreen. We also identified several subcategories and illustrative and concrete examples of ethical challenges. Conclusions: Through a systematic examination, we discovered various types of ethical challenges related to confidentiality when involving the family in the treatment of patients with severe mental illness. However, research on these ethical challenges and the constituents of these challenges remains limited and often implicit. An ethical analysis will create knowledge which may facilitate a more balanced and nuanced approach to respecting the principle of confidentiality while also considering other moral principles. The duty of confidentiality does not always have to be a major barrier to family involvement; this insight and using this ethical analysis in the training of healthcare professionals may benefit the patient, the family, and the services.publishedVersio

Professional caregivers' participation in the International Caregiver Development Programme: A qualitative study of psychosocial care in nursing homes

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The significance of ethics reflection groups in mental health care: a focus group study among health care professionals

Background: Professionals within the mental health services face many ethical dilemmas and challenging situations regarding the use of coercion. The purpose of this study was to evaluate the significance of participating in systematic ethics reflection groups focusing on ethical challenges related to coercion. Methods: In 2013 and 2014, 20 focus group interviews with 127 participants were conducted. The interviews were tape recorded and transcribed verbatim. The analysis is inspired by the concept of ‘bricolage’ which means our approach was inductive. Results: Most participants report positive experiences with participating in ethics reflection groups: A systematic and well-structured approach to discuss ethical challenges, increased consciousness of formal and informal coercion, a possibility to challenge problematic concepts, attitudes and practices, improved professional competence and confidence, greater trust within the team, more constructive disagreement and room for internal critique, less judgmental reactions and more reasoned approaches, and identification of potential for improvement and alternative courses of action. On several wards, the participation of psychiatrists and psychologists in the reflection groups was missing. The impact of the perceived lack of safety in reflection groups should not be underestimated. Sometimes the method for ethics reflection was utilised in a rigid way. Direct involvement of patients and family was missing. Conclusion: This focus group study indicates the potential of ethics reflection groups to create a moral space in the workplace that promotes critical, reflective and collaborative moral deliberations. Future research, with other designs and methodologies, is needed to further investigate the impact of ethics reflection groups on improving health care practices.publishedVersio

Mature Care and Nursing in Psychiatry: Notions Regarding Reciprocity in Asymmetric Professional Relationships

The idea behind this article is to discuss the importance and to develop the concept of reciprocity in asymmetric professional relationships. As an empirical starting point for an examination of the possible forms of reciprocity between patients and nurses in psychiatry, we chose two qualitative in-depth interviews with two different patients. The manners in which these two patients relate to medical personnel—one is dependent, the other is independent—show that this presents challenges to nurses. The theoretical context is provided by the notion of mature care as it has been developed by feminist-oriented ethics of care, in contrast to the notion of altruistic care. In relation to the concept of mature care, we discuss how nursing can be perceived in demanding relationships with patients in psychiatry. Reciprocity implies that, in principle, the interests of the nurses also matter in a nurse-patient relationship. We show that reciprocity—in practice—is complicated and challenging in a number of different ways. Mature care—with its systematic inclusion of relationships and reciprocity—provides an alternative understanding of what takes place between patients and nurses compared with an altruistic notion of care. As such, mature care can be regarded as an useful paradigm for nurse-patient relationships in psychiatry