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Journal of Psychiatric Intensive Care

Storytelling; Safeguarding; Treatment; and Responsibility;


attributes of recovery in Psychiatric Intensive Care Units

Journal:

Journal of Psychiatric Intensive Care

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Manuscript ID:
Manuscript Type:
Keywords:

JPIC-Sep-2014-RA-012.R1
Review Article
Recovery, Psychiatric Intensive Care, Nursing practice, Inpatient,
Recovery-oriented health services

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Background and aim: In recent years policy in Australia has endorsed


recovery-oriented mental health services underpinned by the needs, rights
and values of people with lived experience of mental illness. This paper
critically reviews the idea of recovery understood by nurses at the frontline
of services for people experiencing acute psychiatric distress.
Method: Data gathered from focus groups held with nurses from two
hospitals were used to ascertain their use of terminology, understanding of
attributes and current practices that support recovery for people
experiencing acute psychiatric distress. A review of literature further
examined current nurse based evidence and nurse knowledge of recovery
approaches specific to psychiatric intensive care settings.
Results: Four defining attributes of recovery based on nurses perspectives
are shared to identify and describe strategies that may help underpin
recovery specific to psychiatric intensive care settings.
Conclusion: The four attributes described in this paper provide a pragmatic
framework with which nurses can reinforce their clinical decision-making
and negotiate the dynamic and often incongruous challenges they
experience to embed recovery-oriented culture in acute psychiatric
settings.

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Abstract:

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Journal of Psychiatric Intensive Care

Title
Storytelling; Safeguarding; Treatment; and Responsibility; attributes of recovery in
Psychiatric Intensive Care Units
Short title
A Concept of Recovery in PICU

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Abstract and Keywords

Background and aim: In recent years policy in Australia has endorsed recovery-

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oriented mental health services underpinned by the needs, rights and values of
people with lived experience of mental illness. This paper critically reviews the idea

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of recovery understood by nurses at the frontline of services for people experiencing

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acute psychiatric distress.

Method: Data gathered from focus groups held with nurses from two hospitals were

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used to ascertain their use of terminology, understanding of attributes and current

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practices that support recovery for people experiencing acute psychiatric distress. A
review of literature further examined current nurse based evidence and nurse
knowledge of recovery approaches specific to psychiatric intensive care settings.
Results: Four defining attributes of recovery based on nurses perspectives are
shared to identify and describe strategies that may help underpin recovery specific to
psychiatric intensive care settings.
Conclusion: The four attributes described in this paper provide a pragmatic
framework with which nurses can reinforce their clinical decision-making and

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Journal of Psychiatric Intensive Care

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negotiate the dynamic and often incongruous challenges they experience to embed
recovery-oriented culture in acute psychiatric settings.
Keywords
Inpatient, Nursing practice, Psychiatric Intensive Care, Recovery, Recovery-oriented
health services
Main Text

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Introduction

In 1993 Anthony wrote of recovery as a new vision of service delivery for people

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who have a mental illness (Anthony, 1993, p.525). He described a recovery-oriented


health system incorporating critical services of community support systems; and

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also, clinical services directed at crisis intervention and symptom relief (p. 529).
Anthonys (1993) vision of recovery, encapsulating individual resilience and the

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support of others in a nonlinear process of development, reversion, and pressing

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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

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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., 2012). Understanding of recovery shared by people with lived experience of
mental illness speaks to a deeper understanding of whats happening to a person,
beyond a health complaint to be removed or to move beyond (Gwinner, et al., 2012,
p. 107).

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Journal of Psychiatric Intensive Care

Whilst there has been keen interest in establishing a continuum of recovery-oriented


services in Australia, as in other countries, the Fourth National Mental Health Plans
(2009) statement 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., 2008). One area of critical
concern is delivery of effective recovery approaches in acute clinical settings
(Bowers, et al., 2009; Pereira, et al., 2006; Walsh & Boyle, 2009). Coercive

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treatment approaches, containment of disturbed/violent behaviour and


pharmacotherapy directly contradict concepts such as patient autonomy and

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recovery as a client-driven process and goal (Stylianos & Kehyayan, 2012). For
people who are admitted to hospital-based acute services, core values of recovery

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such as choice, self-determination, empowerment and self-responsibility are often


disregarded in the delivery of conventional procedures and interventions aimed at

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managing the acute disturbance and crisis (OHagan, 2006).

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Nurses, as the vanguard of care in acute psychiatric settings, have an essential role

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and responsibility to deliver recovery-oriented care, and thus need to be clear


themselves as to their understandings, language, and the potentially conflicting or
limiting definitions emergent in various models of recovery such as the colonization
of recovery territory by practitioners, or the ill-cured dichotomy (Bonney & Stickley,
2008). 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.

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Clinical Acute Psychiatric Interventions

Crisis intervention and symptom relief for people experiencing acute psychiatric
distress is often provided in specialised units co-located in in-patient wards referred
to as psychiatric intensive care units (PICU). PICU is a tertiary level service that
provides intensive treatment, rapid assessment and stabilisation as part of the

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Australian integrated mental health system (Australasian Health Infrastructure


Alliance (AHIA) 2010). In many jurisdictions, as in Australia, acute psychiatric

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intervention is provided in small units, staffed by specialised nurses and equipped to


provide seclusion, close observation, and intense treatment to individuals with actual

(AHIA, 2010).

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or potential life-threatening illness, or complications from which recovery is possible

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PICU is more commonly described as permanently locked to prevent patients from

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absconding and harming others (van der Merwe, et al., 2009) notwithstanding,

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guidelines and principles that stress the provision of the least restrictive type of
mental health care (Australian Health Ministers, 2012; World Health Organization,
1996). 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. Shared decision-making and facilitating advocacy processes for
individuals to contribute to their care and treatment, become incongruous aims
against initiating involuntary assessment and authorising involuntary treatment.

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Journal of Psychiatric Intensive Care

PICU can offer opportunities to initiate early recovery approaches for patients
experiencing acute psychiatric distress. Nevertheless, several audits and surveys of
PICUs demonstrate specific difficulties in adopting recovery-oriented approaches in
PICU (Glick et al., 2011; Walsh & Boyle, 2009; Bowers et al., 2009). Significantly
there is paucity of research regarding the extent to which the principles and practices
of a recovery philosophy are achievable in the context of PICUs (Bowers et al., 2005;
Glick, et al., 2011; Gwinner & Ward, 2013). However, some global initiatives are

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exploring recovery and patient focused frameworks for improved recovery outcomes
(Chen, et al., 2013; Olmos-Gallo, et al., 2012; Slade, 2009; A. Cleary, 2009) within

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the PICU setting.

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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

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practice in PICU. Four defining attributes are shared from the experiences of nurses
that support conceptual clarity of recovery in PICU. These are Storytelling;

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The Study

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Safeguarding; Treatment; and Responsibility.

The study aimed to identify existing strategies and practices that nurses perceived
support 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) final presentation stage (Whittemore & Knafl, 2005). The first method of inquiry

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employed focus groups with nurses. These were held at stage one and stage three
to obtain clear identification of 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<) related to the nurses
accounts. The second method of inquiry involved a review of the literature to
examine nurse-based evidence and nurse knowledge of recovery approaches

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specific to psychiatric intensive care settings.

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Focus Group Participants and ethics


Ethical approval was granted by the University and health care service Human

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Research Ethics Committees. An invitation to participate in the research and


participation information sheets were emailed to nursing staff who worked within

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locked wards attached to two metropolitan district hospitals in South East


Queensland. Twelve nurses participated in the first two focus groups which

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introduced key topic areas and questions based on nursing practice and experience

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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 emergent from the focus groups were synthesized to identify
concerns related to the complexity of mental health nursing in PICU and to provide

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Journal of Psychiatric Intensive Care

explicit attention to 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 the used to
underpin a review of the literature (stage 2).

A review of the literature was undertaken using Google scholar to allow a broader

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search of databases such as CINAHL, Informa, Healthcare Medline, PubMed,


PsycARTICLES, and Wiley. Purposive sampling of literature was used to enhance
variables and expand explanation of the perspectives and definitions expressed in

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the focus groups. Over 300 articles were sourced. Fifty items met the final inclusion

this paper (Table 1).

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Figure 1. Study flow chart

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criteria and augmented the focus group concerns and values which are reported in

The attributes and concepts that emerged from the first two focus groups and

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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).

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Data Synthesis and Analysis


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

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content across the data. The congruencies among nurses experiences and the
literature were examined and taken back to the nurse participants to substantiate the

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interpretations and to explore further conceptual development. The two methods of


data collection captured the depth and range of issues, and achieved convergent

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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

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FINDINGS

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settings.

The nurses who participated in the study described a number of challenges to


provide recovery-oriented care in PICU. These include personal anxiety, staffing
and team communication, training and skills development, guidelines and regulations,
rules and admission practices. One nurse claimed patients coming form the prison
system could be personally confrontational or manipulative. Another nurse
elaborated,

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Journal of Psychiatric Intensive Care

If you know a client has high acuity they are coming in with huge history of
aggression they have come in and they are icing they are on speed and they are just
off the rails. Firstly, you are not going to approach them by your self.

It was generally agreed there was no room to second guess a situation. The nurses
perception of the challenges and barriers to recovery approaches in PICU are
discussed more fully in another publication (Gwinner, & Ward, 2013). The purpose of

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this article is to provide greater understanding of a concept of recovery specific to the


context of nursing practice in psychiatric intensive care settings.

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Four defining attributes of a concept of recovery within the PICU were identified in

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the descriptions by nurses. They were 1.) Storytelling; 2.) Safeguarding; 3.)
Treatment; and 4.) Responsibility.

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Figure 2. A concept of recovery in PICU

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The remainder of this paper outlines these attributes as a concept of recovery held

recovery approaches by nurses in PICU.

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by nurses that has potential to guide thinking and enable solutions that promotes

Attribute 1.) Storytelling


Storytelling is a significant feature in the concept of recovery held by nurses in PICU.
It aligns to rudimentary expectations of recovery outlined by Anthony (1993) as a
subjective experience begging to be attended to and understood (p. 530). 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

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understand and engage the contexts in which recovery can be transacted.

A key factor of the storytelling attribute in recovery related to developing a nursepatient relationship as engagement with the person. She said,
...Its about creating one on one contact, you know. They want somebody to sit
there and acknowledge and talk to them.

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Building reciprocal meaning, knowledge and awareness generated in nurse-patient

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communications were cited as crucial factors underpinning nurses clinical decisionmaking in PICU. The significance of preliminary engagement that helps to establish

One nurse participant explained,

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a connection with the patient and thus, shared insight of the situation was referred to.

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Break that ice initially, then you get a better rapport and a better working

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relationship with that person in a PICU.

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The literature supports the development of connections, a trusting relationship and


shared awareness between the nurse and patient (Slade, 2010; Roy, et al., 2009).
Barker and Buchanan-Barker (2010) champion 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. Sjostedt et al. (2001) suggest
managing the first nurse-patient encounter requires a moral commitment from the
nurse to consciously and intentionally encourage patients to enter into a relationship.
As such the nurse should attempt to understand each patients unique experiences
and feelings, which they described as an expression of inner ethical readiness by

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nurses (p.314).
Mezey et al. (2010) explored the concept of recovery with patients in forensic
settings highlighting the quality and depth of relationships and interactions between
the nurse and patient. Respect, acceptance and being related to as a fellow human
being were noted as necessary components that facilitate interpersonal agency.
Listening as a catalyst to commence the process of solving problems, clarifying

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values, preserving individual authenticity, and beneficial relationships amongst the


turmoil of illness and the hospital setting was reinforced in the literature (CoatsworthPuspoky, et al., 2006; Lorem & Hem, 2012; Stenhouse, 2011). A focus group

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participant explained listening and sharing stories enabled appreciation and


empathy.

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+ sort of a humanising thing in a sense+ being able to put yourselves in their

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shoes.

Storytelling required engaging the patients awareness and recognition of their

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current resources and limitations and the constraints within PICU as much as on

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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 selfdetermination (ODonovan, 2007). An aspect of this dichotomy was conveyed in the
focus groups. A participant stated,
Thats 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 wont accept the authorative nature.

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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. He said,
It is about, within your self 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

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clearer picture in your own head, how you are going to approach this person.

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The storytelling attribute denotes the importance of the quality and depth of the
nurse-patient relationship to moderate individual patient experiences of being

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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

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collaborative relationships are used to build knowledge and awareness of the


subjective experiences of the patient.

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Attribute 2.) Safeguarding

The safeguarding attribute related to the safety and care of the patient, the patient
community, staff and others across the mental health system. Multiple factors were
cited as un-conducive to a milieu of safety in PICU, including lack of care plans,
inadequate collaboration by treatment teams, insufficient information and knowledge
of the patient, their history and their personal choices (Green et al., 2008; Bowers,
2009). The nurses involved in this study perceived such factors in the PICU as,
anxiety provoking and often positioned them as working against the patient and

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not assisting em.

One nurse participant shared reflections from a patient, saying,


I am really+I was frightened in PICU. I didnt know what those nurses were doing
to me and I came out fighting.
This speech sample suggests that patient responses might be opposite to what is
hoped for in the PICU. That is, the organisational structure, communication and

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admission processes might result in aggressive self-preservation rather than creating


a sense of safety for the individual.

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Literature related to acute care substantiates the nurses perceptions of PICU as

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stressful and potentially unsafe for patients and staff (Bowers et al., 2009; Nolan, et
al., 2011). A number of problems that increase anxiety have been highlighted in

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reports and include organisational problems, biomedical reductionism, inappropriate


interventions, understaffing, rapid patient turnover, occupancy rates, non-therapeutic

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interventions, poor communication and obscure care pathways (Deacon & Fairhurst,

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2008; Nolan, et al., 2011; Cleary et al., 2012). Managing risk while 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.

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The nurses in the focus groups mostly described safeguarding as a risk avoidance
approach. They maintained; you dont have anything with ties or shoelaces; plastic
cutlery, plastic plates, styrofoam cups; and you should always have your radar on.
One participant spoke of a lockdown strategy, anecdotally to create a protected
environment, stating,
So there is more locked down approach+ we created a more secure environment
Conversely several studies have revealed that the locking of ward doors, placing

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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

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(Bowers, et al., 2009; Gilburt et al., 2010; Papadopoulos et al., 2012).

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Team and organisational cultures play a significant role in the complex interactions
of safeguarding (Chen, et al., 2013; Huang et al., 2010; Middelboe, et al., 2001).

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Corroborated by recent research (Alexander, 2006; Thibeault, et al., 2010), one


nurse participant suggested that rather than creating a safe environment, enforcing

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rules can generate safety problems if not consistently adhered to by all staff. She

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stated,

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.

The nurses in the study felt it was important to reinforce the safety and care of the
patient as a recovery approach. A nurse said,
Its making them feel safe, it is supporting them.
Factors cited as important for the safeguarding attribute include upholding human

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rights, involving families and integrating patient-centred approaches (Gilburt, et al.,


2010; Mayers, et al., 2010; Whitelock, 2009). Nurses emphasised that skills to build
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. They said
Your ability to build a rapport with someone, use your radar, use your perception,
build and use the skills that weve got as nurses+ Its important because you can

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build that into your education. You can build that into, or the process of how this
place operates.

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Safeguarding as an attribute of a recovery was perceived to require specific nursing

fear, distress and aggression.

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Attribute 3.) Treatment

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skills and training to understand and integrate humanistic approaches to alleviate

The treatment attribute emerged in this study as an underdeveloped aspect of

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recovery practiced by nurses in PICU. The literature signified the importance of


treatments to assuage experiences of hopelessness in PICU (Barker, & BuchananBarker, 2010; Bertelsen, et al. 2008; Curtis, et al., 2007; Janner, 2007). 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'

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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 well 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,

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2008; Usher, et al., 2010; Winkler et al., 2011). Yet, much of the literature reported
wide variations in the rationales for PRN medication administration with little or no

Hilton & Whiteford, 2008).

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other therapeutic treatment occurring prior to administration (Curtis, et al., 2007;

Literature related to treatment options and more specifically psychotherapies

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exemplify an array of different strategies, targeting diverse populations and phases


of development for beneficial effects (Amering & Schmolke, 2009; Bertelsen et al.,

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2008; Brimblecombe, et al., 2007; Janner, 2007; Summers & Barber, 2012; Wykes,

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et al., 2008). A common focus in nursing literature was on the importance of the
nurse-patient therapeutic alliance (Bressi Nath, et al., 2012; Coatsworth-Puspoky, et
al., 2006; Priebe & Mccabe, 2008).

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 psycho-therapeutic interventions (Aston & Coffey,
2011; Chen, et al., 2013; Mullen, 2009; Radcliffe & Smith, 2007). The participants in

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the focus groups specified that there were limited opportunities for nurses to train in
the use of psychotherapies such as CBT. 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 is no therapies+ umm we have an OT
(Occupational Therapist).

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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

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focus groups as,

We have got weighted blankets and stuff like that but umm and stress balls and

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+but we have to be with them when you do stuff like that.

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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

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safety, provide opportunities for peer and family support and an opportunity for

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patients to take responsibility for their actions (Janner, 2007; Long, et al. 2012;
Turton et al., 2011; Walsh & Boyle, 2009). 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 recoveryoriented stratagem. One nurse participant commented,

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So you have one activity person two hours a day roughly so thats not bad. Its
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

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establish a positive routine, solve problems, build understanding and relationships


and support hope as a central, motivating message of recovery. The findings

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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

quickly as possible.

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Attribute 4.) Responsibility

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nurses to observation, providing medication and moving patients out of PICU as

The responsibility attribute accentuated dignity, respect and valuing human rights on

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the one hand, while assessing and balancing personal and collective decisionmaking, 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, 1993 p. 523)
transpired as a critically challenging but necessary process to address patients
experiences of helplessness and powerlessness in PICU.

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Emphasis is placed on clarifying the process, identifying and reducing barriers, and
establishing the needs and beliefs of the patient for recovery in their own preference
even if the nurses were unable to engage the patients responsibility and selfdetermination 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
thats where you establish a rapport and try to+ find out some of the clients issues
and look at the objectives of what this person really wants and where they really

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want to go with it.

Coatsworth-Puspoky et al., (2006) suggest that engaging the patients responsibility

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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

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in caring for themselves and their recovery.

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Responsibility as an attribute of recovery in PICU was stressed as a needs-rights

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paradox for nursing practice in PICU. Human rights and choice are a basis for the
practice of shared responsibility in care (Wallcraft, 2012; Wallcraft, et al., 2011).

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However, Wallcraft et al., (2011) specifically noted, 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, and in which
nurses as the frontline staff are often held responsible for the faults and

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shortcomings of the overall system (Cleary, et al., 2010; Hilton & Whiteford, 2008;
Nolan, et al., 2011; Sjstedt, et al., 2001). Responsible decision-making related to
such issues need 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 indicated they harness
supervision and learning in collaborative teams to support decision-making, and
review professional, ethical and moral issues. One nurse participant observed,

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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

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deal with certain situations+ It really is a specialist area.

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Green et al. (2008) found that mental health clinicians who collaborated with their
patients to develop and evaluate plans of care that were acceptable to both clinician

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and patient, particularly regarding medications, were seen as more helpful and more
competent. Empowering people to participate in and take responsibility for their own

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care was valued by patients in the study. Establishing and sharing the goals of

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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. Its 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

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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

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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.

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This paper seeks to understand how recovery is practicably embedded in acute

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psychiatric settings.

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As observed elsewhere (Gwinner & Ward, 2013; Cleary, et al., 2012; Slade et.al.

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2008), current guidelines and practices in acute psychiatric care are not meeting the
requirements for a recovery-oriented system. More often the primary function of

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PICU is described as the suppression of aggressive and violent behaviour, or a


punishment block (Dix, 2012; Stylianos & Kehyayan, 2012). Some studies
examining nurses knowledge about recovery principles indicate recovery is poorly
articulated amid continued confusion related to contradictory concepts and
organisational policies and procedures (Cleary, et al., 2012; Browne, et al., 2012).
Consequently, there remains a fundamental and urgent need for pragmatic clarity to
enact recovery in nursing practice in intensive psychiatric care settings.

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22

The four attributes outlined in this paper offer 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. 2010; Nolan et al. 2011; Mezey, 2010; Cleary et al. 2012). For
example, the storytelling attribute provides insight into the complex layers to engage

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effective communication strategies amongst the turmoil of the acute settings.

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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

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and collaborative relationships are mediated for greater interpersonal agency and
ethical readiness. The art of storytelling between nurses and patients in PICU has, to

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some extent, been lost in various assessment instruments and requirements to


obtain knowledge and transmit patients problems and needs to others in the mental

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health system. Sjostedt et al. (2001) suggest that communication and language

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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

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23

experiences; staff training and education; involving patients and families with their
care decisions and management; and integrating client centred approaches in care
(Cleary, et al. 2012; Gilburt, et al., 2010; Mayers, et al., 2010; Whitelock, 2009). Yet,
factors such as legislative requirements and protecting an individuals legal,
citizenship and human rights continue to obfuscate nursing efforts to embed
recovery approaches.

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Lakeman (2011) points out that institutional values and assumptions persist in
nursing practices that are clearly incompatible with notions of recovery. Risk

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avoidance approaches continue to prevail over recovery dimensions and ultimately

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infringe on human rights. Nascent literature indicates that aggression and violence in
psychiatric acute wards are linked to restrictions, rules, limitations, lack of flexibility

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and diminished human dignity (Papadopoulos, et al., 2012; Bowers et al. 2009;
Hamrin, Iennaco, & Olsen, 2009). Advocating humanistic approaches (Stylianos,&

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Kehyayan, 2012) to alleviate distress and aggression provides practical and

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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., 2011). The nurse-patient therapeutic alliance was highlighted in
much of the literature (Bressi Nath, et al., 2012; Coatsworth-Puspoky, et al., 2006;

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24

Priebe & Mccabe, 2008), as was the necessity of active engagement to encourage
patient autonomy, insight and overcoming practical problems, (Chen, et al., 2013;
Slade, 2010; Turton, et al., 2011). 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.

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Nurses ownership of a recovery-oriented culture based on a more thorough and

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clear understanding of the rights, responsibilities, needs and beliefs of the patient
(Anthony, 1993 p. 523) is critically challenging but necessary to address patients

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experiences of helplessness and powerlessness in PICU. Responsibility as an


attribute emergent from the study, stressed the importance of nurses attitudes and

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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

vi

to ensure the integrity of the rights, the responsibilities, the needs and beliefs of the

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patient are met (Ward, & Syversen 2009).

Responsibility as a guiding principle of recovery maintains a focus on the expression


of individual responsibility for the patients own self-care and journeys of recovery
(Roberts & Boardman, 2013). Weisser, et al., (2011) propose 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

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25

changes required to facilitate advocacy processes for individuals to contribute to


their care and treatment, in ways that dont 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

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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

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negotiate the dynamic challenges in daily interactions and communication with

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patients experiencing acute psychiatric distress.


Importantly these attributes provide a platform with which to investigate approaches

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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

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nurse-patient relationship, which is described as a significant feature of recovery in

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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,
2013). Will this legislation to limit patient freedoms result in more frequent incidents
of violence and aggression within Queensland adult psychiatric in-patient settings?

Limitations

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26

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 other stakeholders in relation to
recovery practice and experiences in PICU for example patients and carers.
However, nurses descriptions and perceptions of recovery in PICU make it possible
to further explore these attributes with other stakeholders and in other acute

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psychiatric settings. The findings provide implications around which further research
and policy planning may be framed. For example, further research is needed to

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incorporate patients experiences and accounts, and to reinforce that the attributes
highlighted here are aligned to a recovery concept as understood by people

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experiencing acute psychiatric distress. Additionally, further research is needed to


ascertain the resourcing and training that is required to support a recovery-oriented

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Walsh, J., & Boyle, J. (2009). Improving acute psychiatric hospital services according

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empowerment. Issues In Mental Health Nursing, 30(1), 31-38.


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Ward, T., & Syversen, K. (2009). Human dignity and vulnerable agency: An ethical
framework for forensic practice. Aggression and Violent Behavior, 14(2), 94105. doi: 10.1016/j.avb.2008.12.002
Weisser, J., Jamer, B., & Morrow, M. (2011). A critical exploration of social inequities
in the mental health recovery literature: Centre for the Study of Gender, Social
Inequities and Mental Health, Simon Fraser University.

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Whitelock, A. (2009). Safeguarding in mental health: Towards a rights-based


approach. The Journal of Adult Protection, 11(4), 30-42.
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Table 1
Author
Year

ew

vi

Tables

Title

Aim

Patients feelings
about ward nursing
regimes and
involvement in rule
construction

to discover the content of rules


within acute psychiatric wards;
to explore patients responses
to the rules; to evaluate the
impact of rules and rule
enforcement on nursepatient
relationships.

Recovery in Mental
Health: Reshaping
Scientific and Clinical

recovery definitions, concepts


and developments as well as
consequences for scientific

Context

Research
Method/
Approach

data
base

Qualitative

WileyBlackwell

Literature
review

WileyBlackwell

Journal
Alexander, J.
(2006)
Journal of Psychiatric
and Mental Health
Nursing
Amering, M., &
Schmolke, M. (2009)

Cambridge University Press

Acute
psychiatric w
ard nursing
regimes,

Recovery
oriented

Page 39 of 49

Journal of Psychiatric Intensive Care

39

Vol 7.

Responsibilities

and clinical responsibilities

Anthony, W. A.

Recovery from mental


illness: The guiding
vision of the mental
health service system
in the 1990s

to outline the fundamental


services and assumptions of a
recovery-

(1993)
Psychosocial
Rehabilitation Journal

oriented mental health system

programs

Macro level
mental health
systems

to explore multiple
perspectives
Aston, V., & Coffey, M.
(2012)

(2008)

Issues in Mental
Health Nursing

Identifying Key Factors


Associated with
Aggression on Acute
Inpatient Psychiatric
Wards

Bressi Nath,
Alexander, & Solomon,
(2012)
Social Psychiatry and
Psychiatric
Epidemiology

Case managers
perspectives on the
therapeutic alliance: a
qualitative study.

EBSCO

Informa
Healthcar
e

evaluations of the Tidal Model


within acute care settings and
the potential contribution that
the model makes to the
development of personcentred care, within acute
settings

Acute care in
Scotland,
England, and
Ireland

Evaluation
protocol

To determine the long-term


effects of an intensive earlyintervention program (OPUS)
for first-episode psychotic
patients.

Psychiatric
Hospital,
Denmark

Singleblinded,
randomized
, controlled
clinical trial

ew

Bowers, L., Allan, T.,


Simpson, A., Jones, J.,
Van Der Merwe, M., &
Jeffery, D. (2009)

Thematic
analysis
using
Krueger
and
Caseys
framework

JAMA

vi

Archives of General
Psychiatry,

Five-year follow-up of
a randomized
multicenter trial of
intensive early
intervention vs
standard treatment for
patients with a first
episode of psychotic
illness: the OPUS trial

health
inpatient care
UK

EBSCO

health services.

Re

Bertelsen, M.,
Jeppesen, P.,
Petersen, L., Thorup,
A., Ohlenschlaeger, J.,
le Quach, P., et al.

to the concept of recovery and


how it fits within mental

Acute mental

er

Issues in Mental
Health Nursing

The tidal model of


mental health recovery
and reclamation:
application in acute
care settings

of service users and mental


health nurses with regard

Pe

Barker, P., &


Buchanan-Barker, P.
(2010)

r
Fo

Journal of Psychiatric
& Mental Health
Nursing

Recovery: what mental


health nurses and
service users say
about the concept of
recovery

Empirical di
scussion

to assess the relationship of


patient violence to other
variables: patient
characteristics, features of the
service and physical
environment, patient routines,
staff factors, the use of
containment methods, and
other patient behaviours.

to understand the nature of the


therapeutic alliance in
intensive case management,

Cambridge University Press

136 acute
psychiatric

wards in 26
NHS Trusts
in England

community
mental health
settings intensive
case
management

Multivariate
cross
sectional
design

Informa
Healthcar
e

Qualitative
analysis of
case
managers
perspective
s

Springerli
nk

Journal of Psychiatric Intensive Care

Page 40 of 49

40

Brimblecombe, N.,
Tingle, A., & Murrells,
T.
(2007)
Journal of Psychiatric
and Mental Health
Nursing
Chen S., Krupa T.,
Lysaght R., McCay E.,
& Piat M.,
2013

2012

WileyBlackwell

The Development of
Recovery
Competencies for Inpatient Mental Health
Providers Working with
People with Serious
Mental Illness.

to identify the most salient


recovery competencies
required of in-patient
providers.

Inpatient
context

Competenc
y
framework

Springer

Mental health nurses'


perceptions of good
work in an acute
setting

to develop insights into the


nature of good mental health
nursing work through the
perspectives of mental health
nurses in the acute mental
health environment.

qualitative
study,

WileyBlackwell

Acute
inpatient
mental health
units
Australia
NSW

Qualitative

WileyBlackwell

Literature
review

Seclusion and its


context in acute
inpatient psychiatric
care

to explore briefly some of the


contemporary debates
pertaining to seclusion

Acute
inpatient
mental health
services

to identify, analyse and


synthesize research in adult
acute inpatient mental health
units, which focused on nursepatient interaction.

Adult acute
inpatient
mental health
units

Issues in Mental
Health Nursing
Coatsworth-Puspoky,
R., Forchuk, C., &
Ward-Griffin, C. (2006)
Journal of Psychiatric
and Mental Health

Nurse-Patient
Interaction in Acute
Adult Inpatient Mental
Health Units: a Review
and Synthesis of
Qualitative Studies

Nurseclient
processes in mental
health: recipients
perspectives

ew

Cleary, M., Hunt, G.


E., Horsfall, J., &
Deacon, M. (2011)

vi

Journal Of Medical
Ethics,

health
environments

Mental health nurses


views of recovery
within an acute setting

International Journal of
Mental Health Nursing
Cleary, M., Hunt, G.
E., & Walter, G. (2010)

Acute mental

to identify practical realities


that acute care nurses can
take to aid recovery and
identify barriers that hinder its
implementation during and
immediately after a relapse.

Re

Cleary M., Horsfall J.,


O'Hara-Aarons M., &
Hunt G.

National
review
consultatio
n

er

International Journal of
Mental Health Nursing

Inpatient
care England

Pe

Cleary, M., Horsfall, J.,


O'Hara-Aarons, M.,
Jackson, D., & Hunt,
G. E. (2012).

reports on responses received


in relation to a consultation
question on how best to
improve inpatient care

r
Fo

Administration and
Policy in Mental Health
and Mental Health
Services Research

How mental health


nursing can best
improve service users'
experiences and
outcomes in inpatient
settings: responses to
a national consultation

to explore and describe


nursing support relationships,
from the perspectives of
recipients, within the mental
health subculture

Cambridge University Press

Mental
Health
Consumers
Southern
Ontario

BMJ
Journals

Literature
review

Informa
Healthcar
e

miniethnographi
c design,
an
ethnonursin
g research

WileyBlackwell

Page 41 of 49

Journal of Psychiatric Intensive Care

41

Nursing

Curtis, J., Baker, J. A.,


& Reid, A. R.
(2007)
International Journal of
Mental Health Nursing

Nursing Inquiry

Service users'
experiences of
residential alternatives
to standard acute
wards: qualitative
study of similarities
and differences.

Australian and New


Zealand Journal of
Psychiatry

Huang, D. T.,
Clermont, G., Kong, L.,
Weissfeld, L. A.,
Sexton, J. B., Rowan,
K. M., et al.

Psychiatric
unit

ethnograph
y

to explore patients' subjective


experiences of traditional
hospital services and
residential alternatives to
hospital.

to provide recommendations
for improving care include
increased patient-clinician
collaboration, patient
empowerment, and greater
relational continuity of care

residential
alternatives
and inpatient

continuity of
patient care

WileyBlackwell

WileyBlackwell

Qualitative

BJ Psych

Qualitative

EBSCO

Literature
review

Informa

Cohort
study
combining
safety
culture
survey data

Oxford
Journals

ew

Understanding how
clinician-patient
relationships and
relational continuity of
care affect recovery
from serious mental
illness: STARS study
results.

Pro Re Nata
Medication for
Psychiatric Inpatients:
Time to Act.

examines the evidence for


administration of PRN
psychotropic medications and,
in the context of evidencebased best practice, current
mental health policy and
professional ethics, proposes a
standardized Australian PRN
administration protocol.

Intensive care unit


safety culture and
outcomes: a US
multicenter study

to determine if intensive care


unit (ICU) safety culture is
independently associated with
outcomes.

Hilton, M. F., &


Whiteford, H. A.
(2008)

to assess the fit of this model


to mental health nursing and to
add to the body of work
concerning the social
organisation of nursing.

vi

Psychiatric
Rehabilitation Journal,

Retrospecti
ve study

Re

Green, C. A., Polen,


M. R., Janoff, S. L.,
Castleton, D. K.,
Wisdom, J. P.,
Vuckovic, N., et al.
(2008)

20-bed
mental health
facility

er

The British Journal of


Psychiatry

The real-life practice of


acute inpatient mental
health nurses: an
analysis of 'eight
interrelated bundles of
activity'

explored the occurrence of


p.r.n. medication
administration and the type of
alternative therapeutic
interventions that are
documented as accompanying
its administration

Pe

Gilburt, H., Slade, M.,


Rose, D., Lloyd-Evans,
B., Johnson, S., &
Osborn, D. P. (2010)

Exploration of
therapeutic
interventions that
accompany the
administration of p.r.n.
('as required')
psychotropic
medication within
acute mental health
settings: a
retrospective study.

r
Fo

Deacon, M., &


Fairhurst, E. (2008)

method

Cambridge University Press

Psychiatric
and mental
health
nursing

Intensive
care

Journal of Psychiatric Intensive Care

Page 42 of 49

42

(2010)
International Journal
for Quality in Health
Care
Janner, M.
(2007)
Journal of Psychiatric
Intensive Care

Journal of Mental
Health

(2010)

(2001)

Ward atmosphere in
acute psychiatric inpatient care: patients'
perceptions,ideals and
satisfaction

low and
medium
secure
settings

Qualitative
service
user-led
participator
y research

Informa

Qualitative

WileyBlackwell

to explore the perceptions and


experiences of a group of
service users who have been
exposed to sedation, seclusion
and restraint.

Mental health
care
providers
and mental
health
service users

ew

Middelboe, T.,
Schjdt, Torben,
Byrsting, K., & Gjerris,
A.

Cambridg
e
University
Press

Health-care
professionals
' experiences

vi

International Journal of
Social Psychiatry

Mental Health Service


Users Perceptions
and Experiences of
Sedation, Seclusion
and Restraint

Personal
experience
and
literature
review

to examine how experiences


with mental illness are
perceived by health-care
workers, and how insight
affects assessment of their
perspective and involvement.

Re

Mayers, P., Keet, N.,


Winkler, G., & Flisher,
A. J.

to identify service users' views


of the constituents of an
effective therapeutic milieu for
women in secure settings and
to help identify the extent to
which services need to be
specifically tailored for women.

Acute inpatient
hospital
London

er

International Journal of
Mental Health Nursing

Attuned understanding
and psychotic
suffering: A qualitative
study of health-care
professionals'
experiences in
communicating and
interacting with
patients

report on program to help


improve the daily experiences
of acute in-patients and
treatment outcomes.

Pe

Lorem, G. F., & Hem,


M. H. (2012)

Effective therapeutic
milieus in secure
services for women:
The service user
perspective

r
Fo

Long, C. G., Knight,


C., Bradley, L., &
Thomas, M. (2012)

From the inside out:


Star Wards' lessons
from within acute inpatient wards

To investigate the relationship


between patients' perception
of the real and ideal ward
atmosphere and their
satisfaction.

Psychiatric
wards

Qualitative
two phase
study

Sage

Satisfaction
questionnai
re.

WileyBlackwell

Acta Psychiatrica
Scandinavica
Mezey, G. C.,
Kavuma, M., Turton,
P., Demetriou, A., &
Wright, C.
(2010)

Perceptions,
experiences and
meanings of recovery
in forensic psychiatric
patients.

to explore definitions,
experiences, and perceptions
of recovery in patients with
severe mental illness, currently
detained in medium secure
psychiatric provision.

The Journal of
Forensic Psychiatry &

Cambridge University Press

Medium
secure
psychiatric
setting

Qualitative

Taylor
and
Francis

Page 43 of 49

Journal of Psychiatric Intensive Care

43

Psychology

Mullen, A.
(2009)
International Journal of
Mental Health Nursing

Mental health nurses


establishing
psychosocial
interventions within
acute inpatient settings

to discuss the problems with


mental health nursing practice
in acute inpatient units
highlighted in the current
literature

Acute
inpatient
units

Literature
Review

WileyBlackwell

Nolan, P., Bradley, E.,


& Brimblecombe, N.
(2011)

ODonovan A .

(2012)

International Review of
Psychiatry

Radcliffe, J., & Smith,


R. (2007)
Psychiatric Bulletin
Roberts, G., &
Boardman, J. (2013)

Emerald

Qualitative
descriptive
study

WileyBlackwell

systematica
l review

WileyBlackwell

within psychiatric inpatient settings

Review

Informa

Ethnograph
y

GFMEM
Open
access

Review

RC Psych

review the types and


proportions of

antecedents of violence and


aggression within psychiatric
in-patient

Psychiatric
in-patient
settings

settings.

Therapeutic
relationships in
psychiatry: The basis
of therapy or therapy
in itself?

Acute in-patient
psychiatry: how
patients spend their
time on acute
psychiatric wards
Understanding
"recovery"

Clinicianpatient
communicati
on in routine
mental
healthcare

ew

Priebe, S., & Mccabe,


R. (2008)

The antecedents of
violence and
aggression

vi

Acta Psychiatrica
Scandinavica

Acute
psychiatric
admission
units Ireland

Qualitative

reality or rhetoric?

Re

Papadopoulos, C.,
Ross, J., Stewart, D.,
Dack, C., James, K., &
Bowers, L.

to explore psychiatric nurses'


approach and philosophical
underpinnings to care.

Acute care
settings UK

er

Journal of Psychiatric
and Mental Health
Nursing

Patient-centred care in
acute psychiatric
admission units:

Pe

2007

to present the beliefs that


service users have on entry to
mental health services

r
Fo

Journal of Mental
Health Training,
Education and
Practice,

Service users' beliefs


about acute in-patient
admission.

to identify therapeutically
effective elements of
relationships and
communication that can be
tested in experimental studies.

to review levels of social


interaction and activity among
in-patients

6 acute
psychiatric
wards in 6
hospitals

To examine the ideas,


principles and definitions of
recovery and their origins.

Personal
recovery

Advances in

clinical

Cambridge University Press

Journal of Psychiatric Intensive Care

Page 44 of 49

44

Psychiatric Treatment

Roy, L., Rousseau, J.,


Fortier, P., & Mottard,
J.-P. (2009)
The British Journal of
Occupational Therapy

Sjostedt E., Dahlstrand


A.,

(2001)
Nursing Ethics

(2009)

(2010)

(2011)
Journal of Psychiatric
and Mental Health
Nursing,
Summers, R., &
Barber, J.
(2012)

Mental illness and


well-being: the central
importance of positive
psychology and
recovery approaches.
They all said you
could come and speak
to us: patients'
expectations and
experiences of help on
an acute psychiatric
inpatient ward.

to stimulate debate about how


best to reform mental health
services

to support the re-orientation of


health services around
promoting well-being

multiple
case study

Health
Referenc
e Centre

Acute
psychiatric
care in a
rural hospital,
Sweden

Guide for
mental health
staff,

Narratives
about
recovery
from mental
illness

ew

Stenhouse, R. C.

100 ways to support


recovery: A guide for
mental health
professionals:

Youth
psychosis
clinic of the
Hopital
Sacre-Coeur
in Montreal,
Quebec,
Canada

action
research

Sage

Report of
clinical
practice
and
research
programme
s

Rethink

Synthesis

Springerli
nk

vi

BMC Health Services


Research

patients suffering and future


hopes

Re

Slade, M.

to deepen nurses
understanding of the
importance first nursepatient
encounter in a psychiatric
setting according to each

er

Vol. 1

The First NursePatient Encounter in a


Psychiatric Setting:
discovering a moral
commitment in nursing

to explore the perception of


outpatients in a youth
psychosis clinic in Montreal
regarding their community
functioning.

Pe

Slade, M.

Perception of
community functioning
in young adults with
recent-onset
psychosis: implications
for practice

r
Fo

Severinsson E., &


Lutzen K.

recovery

to gain insight into the


experience of being a patient
on an acute inpatient
psychiatric ward

Acute care
settings UK

Qualitative

Review

Taylor
and
Francis

Phenomen
ological
inquiry

Mosby
Nursing

Psychodynamic
therapy: A guide to
evidence-based
practice:

A guide to evidence-based
understanding of
psychodynamic therapy and
current practice

Psychologica
l treatment
guidance

Understanding the
milieu experiences of
patients on an acute
inpatient psychiatric

to generate new understanding

Acute
inpatient
psychiatric
unit

WileyBlackwell

Vol. 16
Thibeault C., Trudeau
K., d'Entremont, M., &
Brown T.,
(2010)

of patient experiences and


suggest that the inpatient
psychiatric milieu remains an

Cambridge University Press

Page 45 of 49

Journal of Psychiatric Intensive Care

45

Archives of psychiatric
nursing

Turton, P., Demetriou,


A., Boland, W., Gillard,
S., Kavuma, M.,
Mezey, G., et al.
(2011)
Social Psychiatry and
Psychiatric
Epidemiology

(2010)

Partnerships for better


mental health
worldwide: WPA
recommendations on
best practices in
working with service
users and family
carers

Walsh, J., & Boyle, J.


(2009)
Issues in Mental
Health Nursing

Involvement of service
users in adult
safeguarding.

Mental
Health Trust
in South
London

Inpatient
units acute,
rehabilitation
and secure
located in a
regional area
of
Queensland,

qualitative
research
design to
explore
individual
perspective
s on
recovery in
face-to-face
interviews

Springer

Qualitative

WileyBlackwell

Australia

to create recommendations for


the international mental health
community on how to develop
successful partnership
working.

to summarise findings of a
review of service user and
carer involvement in safeguard
ing and recommendations for
good practice.

WPA Board
and Council,
Service
Users and
Family
Carers

literature
review and
shared
knowledge

NCBI

Task Force

Experts in
the field of
adult
safeguarding

ew

Journal of Adult
Protection

of PRN medication, by
analysing responses to two
vignettes of clinical situations.

vi

Wallcraft, J.
(2012)

To explore the clinical team


decision-making process
associated with the
prescription and administration

Re

World Psychiatry

recovery held by patients in


forensic settings

er

Wallcraft, J., Amering,


M., Freidin, J., Davar,
B., Froggatt, D., Jafri,
H., et al. (2011)

Understanding clinical
decision making for
PRN medication in
mental health inpatient
facilities

to extend understanding of the


concepts of

Pe

Journal of Psychiatric
and Mental Health
Nursing

One size fits all: or


horses for courses?
Recovery-based care
in specialist mental
health services.

r
Fo

Usher, K., Baker, J. A.,


& Holmes, C. A.

important but often neglected


component of psychiatric
treatment.

unit.

Literature
review and
consultatio
n

Emerald
Health

UK

Improving acute
psychiatric hospital
services according to
inpatient experiences.
A user-led piece of
research as a means
to empowerment

to explore psychiatric
inpatients' strategies for coping
with mental ill health and in
what ways acute inpatient
psychiatric hospital services
are facilitative to the individual
attempting recovery.

Cambridge University Press

Acute
inpatient
psychiatric
hospital

User-led
Research

Informa

Journal of Psychiatric Intensive Care

Page 46 of 49

46

Ward T., & Syversen


K.
2009
Aggression and
Violent Behavior

A critical exploration of
social inequities in the
mental health recovery
literature

to facilitate and support the


establishment of a
collaboration of key experts
and stakeholders from the field
of mental health including
decision makers, service
providers, and service users
interested in developing new
conceptualizations of mental
health recovery that are
grounded in principles of
citizen engagement (i.e.,
principles that value the
participation of people living
with mental health issues) and
that recognize the impact of
social and structural inequities
on mental health and recovery.

Literature in
Canada, the
US, the UK,
Australia,
and New
Zealand

Scoping
review

Simon
Fraser
University

Safeguarding in
mental health: towards
a rights-based
approach

implications for a new, rightsbased


approach to adult
safeguarding.

vi

outlines current clinical


practice at the psychiatric
intensive care unit of the
Medical University of Vienna
(Austria)

Intensive care in
psychiatry

(2011)
European Psychiatry

Wykes, T., Steel, C.,


Everitt, B., & Tarrier,
N.
(2008)
Schizophrenia Bulletin

Mind
association
network UK

Clinical data
of 100
consecutive
inpatients
treated at the
Viennese
PICU in the
years 2008
and 2009

ew

Winkler, D., NaderiHeiden, A., Strnad, A.,


Pjrek, E., Scharfetter,
J., Kasper, S., et al.

Science
Direct

Re

The Journal of Adult


Protection

Integrated
review of
ethical
frameworks

er

Whitelock, A.
(2009)

Forensic and
correctional
work.

Pe

Centre for the Study of


Gender, Social
Inequities and Mental
Health, Simon Fraser
University.

r
Fo

Weisser, J., Jamer, B.,


& Morrow, M. (2011)

Human dignity and


vulnerable agency: An
ethical framework for
forensic practice.

to provide a theoretical set of


tools to aid practitioners to
resolve concrete ethical issues
in forensic practice, and
therefore our treatment of
specific ethical matters such
as those associated with risk
assessment is necessarily
cursory.

Cognitive behavior
therapy for
schizophrenia: effect
sizes, clinical models,
and methodological
rigor

to explore the effect sizes of


current CBTp trials including
targeted and nontargeted
symptoms, modes of action,
and effect of methodological
rigor.

Cambridge University Press

Psychologica
l treatment
guidance

survey and
focus group
research

Emerald

Clinical
data
reviewushe
r

Science
direct

Metaanalysis
and
investigatio
n of the
effects of
trial
methodolog
y

Oxford
Journals

Page 47 of 49

Journal of Psychiatric Intensive Care

47

r
Fo
er

Pe
ew

vi

Re
Cambridge University Press

Figure 2
1 A Concept of Recovery in PICU

Figure 1
2 Study Flow chart