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Helping methods used by nurses in a psychiatric hospital environment
\ PERGAMON
International Journal of Nursing Studies 24 "0887# 235Ð241
Helping methods used by nurses in a psychiatric hospital environment Eila Latvala \ Sirpa Janhonen Department of Nursing Science\ University of Oulu\ Kajaanintie 35 E\ 89119 Oulu\ Finland Received 3 September 0886^ received in revised form 12 June 0887^ accepted 10 July 0887
Abstract This qualitative study aims to describe the helping methods used by psychiatric nurses in a hospital environment from as evidenced by video observations and nurses| and patients| descriptions[ The data\ which were collected by videotaping di}erent nursing situations and by interviewing the nurses and patients afterwards\ consisted of 419 pages of written text[ A total of 458 utterances were extracted from the text to describe the helping methods used in psychiatric nursing[ Each utterance constituted a classi_cation unit[ Deductive content analysis techniques were used to analyze the data[ The results obtained from the nurses| and patients| descriptions and the videotaped episodes showed that the most commonly used helping methods were of the con_rmatory kind "49)#\ while educational methods came second "26)# and catalytic methods third "02)#[ Þ 0887 Elsevier Science Ltd[ All rights reserved[ Keywords] Keywords] Psychiatric nursing^ Nursing helping methods^ NurseÐpatient collaboration[
0[ Introduction The purpose of this paper is to describe the helping methods used in psychiatric patient care in a hospital environment[ Today\ out!patient care and short!term in! patient periods require many helping methods within psy! chiatric nursing\ including collaboration between the nurse\ the patient and other signi_cant persons "Peternelj! Taylor and Hartley\ 0882^ Latvala and Janhonen\ 0886#[ In the psychiatric nursing practice the patient and other relevant persons are often mere passive recipients of help[ The nurses often work routinely instead of engaging in real interaction with the patient and exposing themselves to the su}ering of the patient and his:her signi_cant others[ Psychiatric helping methods\ such as the nurseÐpatient relationship\ have been studied earlier in the light of di}erent theories "Bunch\ 0872^ Peplau\ 0881^ Forchuk\ 0883#[ This paper describes psychiatric nursing helping methods as elicited from video recordings and interviews
Corresponding author[ Tel[] ¦247!7!426!4599^ fax] ¦247!7! 4264596^ e!mail] elatvalaÝcc[oulu[_[
conducted with nurses and patients[ The nurseÐpatient collaboration is essential for supporting a psychiatric pat! ient|s e}orts to manage with daily life[ The meaning of this nurseÐpatient collaboration has been emphasized since the 0869s\ and many researchers have described con~icts between the ideal model for this collaboration and the reality of the psychiatric nursing practice\ emphasizing that nurses try to establish a therapeutic collaboration with each patient\ but routine activities take up most of their time "Bunch\ 0872^ Morrison and Burnard\ 0878^ Peplau\ 0881#[ The basis for such a col! laboration is con_dentiality\ which requires the nurse to show an ability to be patient\ to understand realities and to tolerate frustration\ to be ~exible concerning the patient|s needs and to have a positive\ empathet under! stedt! standing of the patient "Haggman!Laitila and A Kurki\ 0883^ Latvala and Janhonen\ 0886#[ The factors which aggravate the patient|s symptoms in a hospital environment include hallucinations\ an inability to participate in the planning of his:her own care and not being listened to\ understood or taken seriously "Morrison\ 0882#[ The symptoms are manifested in di}erent ways and in~uence daily living from the point of view of psychiatric nursing[ Nurses use the same inter! ventions both to alleviate and to prevent symptoms[
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These include interaction with the patient\ teaching the patient\ or simply touching the patient[ Control and medication are used to prevent aggression and other harmful a}ects[ The interventions used depend on the individual nurse|s assessment of the situation and the unwritten rules of the ward "Morrison\ 0882^ Gournay\ 0884^ Morrison and Lehane\ 0885^ Latvala and Janhonen\ 0886#[
1[ Psychiatric helping methods] literature review This paper is based on the theoretical framework of earlier qualitative studies produced in Finnish hospital environments\ which have revealed three types of psy! chiatric helping methods] catalytic\ educational and con! _rmatory "Janhonen\ 0882^ Latvala and Janhonen\ 0886#[ They di}er from each other on the essential dimensions of interaction\ instruction\ activities and accountability[ These dimensions have been described in many psy! chiatric nursing studies "Bunch\ 0872^ Madden\ 0889^ Peplau\ 0881^ Forchuk\ 0883^ Hall\ 0885^ Latvala and Janhonen\ 0886#[ Catalytic psychiatric helping methods in a hospital environment are systematic and rooted in an emancipatory theory of nursing and a theoretical and research!based practice "Kendall\ 0881^ Peplau\ 0881^ Janhonen\ 0882^ Hall\ 0885^ Latvala and Janhonen\ 0886#[ NurseÐpatient collaboration is based on par! ticipatory dialogue\ which makes it possible to listen to the patient and to understand the patient|s needs con! cerning his:her management in daily life "Latvala and Janhonen\ 0886#[ The dialogue is between two or more persons willing to see and accept their mutual personal points of view or to _nd new solutions through mutual understanding "Anderson and Goolishian\ 0877^ Markova\ 0883^ Haarakangas\ 0886#[ Catalytic psy! chiatric helping methods promote growth and devel! opment on four dimensions] "0# from dependence to inde! pendence\ "1# from normative rules to situationally determined behavior\ "2# from assistance to active par! ticipation and "3# from performance to responsible action "Janhonen\ 0882^ Latvala and Janhonen\ 0886#[ The essential purpose of catalytic psychiatric helping methods is to make the activities meaningful to the pati! ent[ The nurses use motivating supervision\ which means that feedback and the working atmosphere are impor! tant[ Motivation is a complex phenomenon[ There are many factors\ such as emotions\ needs and incentives\ which in~uence people|s motivation "Bandura\ 0875^ Kendall\ 0881^ Fleury\ 0885#[ Catalytic psychiatric help! ing methods\ the nurseÐpatient collaboration\ motivating supervision and meaningful activities enable the patient to become a participant of shared accountability in his:her care[ Through catalytic helping methods the pati! ent is able to gain awareness of his:her real patterns[ Results similar to the descriptions of Madden "0889# have
236
been reported from therapeutic alliance[ A therapeutic nurseÐpatient relationship aims to develop the patient|s behavior by setting mutual goals[ Moreover\ therapeutic alliance has been seen as a process in which both the nurse and the patient are "0# actively working towards the goal of developing the latter|s health behavior to be consistent with his:her current health status and lifestyle\ "1# focusing on mutual negotiation to determine the activities to be carried out in pursuit of that goal and "2# using a supportive and equitable therapeutic relationship to facilitate the attainment of that goal[ On the other hand\ the catalytic helping methods can also be compared to the processes described in the theory of Peplau "0881# of interpersonal relationship[ The catalytic psychiatric helping methods "Table 0# described here consist of nurseÐpatient collaboration\ motivating supervision\ meaningful activities and shared accountability\ and are in that sense virtually synonymous with family nursing assessment from the perspective of the socio!environ! mental model described by Hartrick et al[ "0883#\ the therapeutic alliance described by Madden "0889# and the interpersonal relationship described by Peplau "0881#[ Educational psychiatric helping methods are rooted in a behavioural model and depend on professional expert! ise[ Interaction is a matter of monologue\ which means\ for instance\ that the nurse knows what is best for the patient and\ by acting accordingly\ casts the patient in the role of a silent outsider "Latvala and Janhonen\ 0886#[ The purpose of educational psychiatric helping methods is to help the patient by means of normative supervision to manage in daily life by modifying his:her behavior or lifestyle in everyday activities in accordance with the professional|s ideal model\ in order to maintain mental health[ The essential decisions concerning care are made by professionals\ while the patient is a responsible recipi! ent[ The patient tries to conform to the professional|s ideal model and is a silent participant in his:her care "Latvala and Janhonen\ 0886# Table 0[ The educational helping methods described here consist of professionals| monologue\ normative supervision\ everyday activities and professional|s accountability[ The methods resemble the behavioural model in the family nursing assessment described by Hartrick et al[ "0883# and the principles of family therapy and the psychiatric school of educational: bevioural family therapy[ According to this school\ fam! ilies should be instructed how to communicate\ express emotions and resolve con~icts\ to decrease stress in the family "Anderson et al[\ 0875#[ Con_rmatory psychiatric helping methods are rooted in the traditional model of viewing psychiatric illness as having a speci_c physical cause related to the functional anatomy of the brain[ The patient has little or no control[ The nurse is dependent on the doctor|s authority[ The nurse con_rms that everything is done according to the norms and rules[ Interaction is formal\ which means that the discussions between the nurse and the patient are
shared accountability professional|s accountability hierarchic accountability meaningful activities everyday activities general activities motivating supervision normative supervision controlling supervision participatory dialogue professional|s monologue general level discussions
Activities Interaction
Instruction
Accountability
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at a general level "Latvala and Janhonen\ 0886#[ The instruction consist of routine and formal control[ The nurse controls the patient|s behavior according to the norms and rules\ and in the hierarchy of constituted accountability the patient is at the lowest level[ The pati! ent is not aware of the main goal of the care or the purpose of the helping methods[ The nurse organizes outdoor activities to help the patient and uses control and medication to alleviate symptoms\ e[g[ aggression or hallucinations[ The nurse administers the patient|s medication to prevent symptoms or to control the pat! ient|s condition "Latvala and Janhonen\ 0886# Table 0[ Con_rmatory psychiatric helping methods consist of gen! eral level discussions\ controlling supervision\ general activities and hierarchic accountability\ and in that sense resemble the psychiatric model described by Hall "0885# and the perspective of the medical model in the family nursing assessment described by Hartrick et al[ "0883#[ According to the theoretical framework\ the essential dimensions of psychiatric helping methods are inter! action\ instruction\ activities and accountability\ which vary from individual human psychiatric nursing to auth! oritarian formal psychiatric nursing[ The aim of this paper is to describe the psychiatric helping methods used by nurses in a hospital environment by using a theoretical framework of di}erent types of psychiatric nursing "con! _rmatory\ educational and catalytic# as observed in videotaped situations with an interdisciplinary psy! chiatric team and as described by psychiatric nurses and patients in interviews[ 1[0[ Questions to be answered The purpose of psychiatric helping methods is to help the patient to manage in daily life[ The research rep! resents an attempt to answer the following questions] 0[ To what extent were psychiatric helping methods manifested in the descriptions of nurses and patients< 1[ To what extent were psychiatric helping methods manifested during the videotaped situations of patient care in interdisciplinary teamwork<
Catalytic helping methods Educational helping methods Con_rmatory helping methods
2[ Data and method
Variables
Table 0 Di}erent types of psychiatric helping methods used in a hospital environment
237
The data were collected by theoretical sampling "Glaser\ 0867^ Strauss and Corbin\ 0889# in the _rst phase of the research[ They consisted of interviews of nurses and patients "N 34# and videotapes of nursing situations "N 09# "Latvala and Janhonen\ 0886#[ This paper is based on the videotaped situations including helping methods of patient care and all interviews of the nurses and patients[ The data analyzed in this paper consisted of six videotaped episodes and recorded interviews\ including descriptions by 18 nurses of their own actions
238
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in di}erent out! and in!patient care situations and descriptions by 05 patients of their care in a hospital environment[ The videotapes has been recorded during nursing report sessions and planning meetings[ Each vid! eotaped care situation was followed by interviews with all the participants[ Each interview took from 29 min to an hour and a half and each videotaped session from one hour to an hour and a half[ Method\ time and space triangulations were used to con_rm the researcher|s interpretation and the subjects| ideas "Begley\ 0885^ Bur! nard\ 0885^ Bottor}\ 0886#[ The transcribed data amounted to 419 pages[ They were analyzed by _rst extracting the utterances which described the psychiatric helping methods used in a hos! pital environment "N 458#[ The foundation of the classi! _cation consisted of the theoretical framework[ Each utterance was taken to constitute a classi_cation unit[ The nurses| and the patients| interviews consisted of 254 utterances which described the helping method of psy! chiatric nursing used[ Deductive content analysis tech! niques "Rosengren\ 0870^ Burnard\ 0885# were then applied to the 458 utterances\ employing the classi_cation into con_rmatory\ educational and catalytic helping methods\ and their contents were derived from earlier research "Janhonen\ 0882\ Latvala and Janhonen\ 0886#[ Finally\ numerical values and percentages were cal! culated for all the categories to illustrate the variety of helping methods used in psychiatric nursing[
0889^ Sandelowski\ 0882#[ In this method\ a description of a human experience is regarded as valid or credible when other people can recognize that experience when confronted with it after having only read the description[ The Ethical Review Committee of the Faculty of Medi! cine at the University of Oulu and the Research Board of the hospital were responsible for resolving and eva! luating the ethical questions arising in connection with this work and for recommending solutions[ The ethical aspects involved informing the subjects of the research and obtaining their informed consent[ They were allowed to withdraw at any time without penalty[ The bene_ts of the research outweigh the risks\ although the degree to which this is true depends on the investigator|s ability to perform the research "Benoliel\ 0877^ Beauchamp et al[\ 0880^ Capron\ 0880^ Latvala et al[\ 0887#[
3[ Results The results are presented numerically and illustrated by nurses| and patients| descriptions of the psychiatric helping methods[ Of all utterances "N 458#\ 02) re~ected catalytic helping methods\ 26) educational helping methods and 49) con_rming helping methods[ In the videotaped interdisciplinary team situations\ the psychiatric nursing helping methods re~ected a con! _rmatory approach in 49) of the cases\ an educational approach in 28) and a catalytic approach in 00)[ Most of the 160 utterances extracted from the descriptions by nurses described con_rmatory "31)# and educational helping methods "30)#\ the proportion of catalytic methods being 06)[ Most of the 83 utterances in the descriptions by patients re~ected con_rmatory helping methods "69)#\ while the proportion of educational methods was 15) and that of catalytic methods 3) "Table 1#[ The di}erences between the nurses| and patients| descriptions and the videotaped situations show that catalytic psychiatric nursing and catalytic helping
2[0[ Credibility and ethical aspects The data analysis and categorization were all per! formed by one investigator\ who also calculated the absolute and relative frequencies[ The data were cat! egorized twice at intervals of two months\ and the cor! respondence rate was 86) "243:243¦:−00 86#[ Reliability may be assessed in terms of the auditability of the _ndings\ i[e[ by describing how the data were collected and reduced for analysis\ and how the categories were formed "Lincoln and Cuba\ 0874^ Burns\ 0878^ Patton\
Table 1 Catalytic\ educational and con_rmatory psychiatric helping methods in a hospital environment "N total number of utterances\ n part of utterances# Nurse
Patient )
Video
Variables
n
Catalytic helping methods Educational helping methods Con_rmatory helping methods
35 009 004
06 30 31
3 13 55
3 15 69
11 79 091
00 28 49
61 103 172
02 26 49
Total
160
099
83
099
193
099
458
099
n
)
Total
n
)
N
)
249
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methods are rare in a Finnish hospital environment[ The traditional normative helping methods and con_rmatory or educational nursing\ in which the patient is more or less a passive recipient of care\ are common Table 1[ One patient described the nurseÐpatient participatory dialogue in the following way] It is very important that my own nurse listens to me\ but I can make only small decisions[ The cooperative meeting helped my family to understand what my care is about and they can help and support me better[ One patient described the meaningful activities and his accountability for his care\ which constitute the content of catalytic psychiatric nursing\ in the following way] Quite common everyday activity may become mean! ingful\ but it depends on me[ I must take part in my care and tell my own nurse and doctor what I feel to be best for me[ They can help me better if they know[ It is my duty to take part in my care as a responsible person[ One primary nurse explained how important it is for the nurse to listen to the patient and\ in mutual col! laboration\ to _nd out the experiences that are mean! ingful for understanding and recognizing the patient|s real resources] We _gured out together what is meaningful\ what makes his life meaningful\ and little by little the patient began to recognize the meaningful things in his life[ I think the most important thing at the beginning of our collaboration was that I listened to him and our dialogue about reality very openly[ The important experiences that he had had after he had fallen men! tally ill[ Educational psychiatric helping methods consisted of an ideal model guiding nursing[ An example of pro! fessional|s monologue is communication with a psychotic patient so that he:she will not revert to a psychotic state[ Normative supervision constituted the largest category of educational helping methods described by the nurses and patients[ One nurse described normative supervision as follows] I have instructed the patient time after time for many years to use the money right\ but he has not learnt that[ He gets a little money every week\ but spends it immediately[ The nurse instructed the patient to use some money every day during the week instead of spending it all right away[ The patient needed help for his money problems\ but are monologue and normative supervision always the best way< The patient|s everyday activities were seldom
mentioned as a helping method in connection with edu! cational psychiatric nursing\ but one nurse described them in the following way] In our unit\ the patients take turns in the kitchen\ which helps them to learn kitchen routines and kitchen work[ They are responsible for cleaning their own rooms and their own clothes\ and in this way the nurses can assess their ability to look after themselves[ The con_rmatory psychiatric helping methods con! sisted of working according to an authoritarian model[ A nurse described the maintenance of interaction as a helping method in the following way] Such situations occur in the sitting room\ where we sit together watching TV and talking about all sorts of things * newspapers and TV programs * and the atmosphere is cozy and nice and the patients feel good[ Everybody is accepted in spite of their fragmented personalities that are the result of mental illness[ The nurses described the use of controlling supervision in con_rmatory psychiatric nursing as activities aimed at preventing accidents when the patient is unable to control his:her emotions\ e[g[ aggression[ The patients however\ experienced such situations di}erently[ For them\ the use of controlling supervision was like a punishment for inappropriate behavior or criticism by the nurses[ Gen! eral activities as a helping method included various joint activities in! and outdoors[ Hierarchic accountability was connected with medication\ the patient|s condition and the prevention of symptoms[
4[ Discussion The question of collaboration in psychiatric nursing is both timely and interesting[ As a consequence of the deinstitutionalization of psychiatric care\ collaborative helping methods are a challenge for psychiatric nursing\ the patient and all those who are victimized in psychiatric care[ The present and earlier results point to medication\ normative rules and a passive role of the patient as gen! eral features of psychiatric nursing "Bunch\ 0872^ Mor! rison and Lehane\ 0885^ Jones and Meleis\ 0882^ Hall\ 0885^ Latvala and Janhonen\ 0886#[ The present results provide new information concerning collaboration in a psychiatric hospital environment and con_rm some earl! ier observations on psychiatric care "Bunch\ 0872^ stedt!Kurki\ Forchuk\ 0883^ Haggman!Laitila and A 0883^ Hall\ 0885^ Salo\ 0885#[ The researchers have not\ however\ tested these results in any other environment or with any other subjects[ Videotape recordings provide a credible method of data collection "Bottor}\ 0883#[ The authors have ensured the credibility of the observations in this context by using triangulation "Lincoln and Cuba\
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0874^ Begley\ 0885#[ These results are reliable in Finnish hospital environments\ but cannot be generalized to any other environment[ The results\ however\ agree with the earlier _ndings concerning participatory dialogue "Jan! honen\ 0882^ Hartrick et al[\ 0883^ Haarakangas\ 0886# and the earlier observations on psychiatric nursing con! cerning collaboration in psychiatric care "Madden\ 0889^ Peplau\ 0881^ Peternelj!Taylor and Hartley\ 0882^ Gour! nay\ 0884#[ At each level of these three types of psychiatric helping methods\ the de_nition of patients| management varies\ as does the focus of nursing practice[ These _n! dings need to be further developed and tested with quan! titative methods[ Many aspects of psychiatric nursing still support a passive role of the patient in his:her own care\ including the possibility to the door to the unit or to place the patient in isolation[ Catalytic helping methods are a chal! lenge to psychiatric nursing\ and this is also true of col! laborative methods\ such as participatory dialogue\ in the context of locked units and isolation[ The present data included many references to patients being isolated because of violence\ instances which the nurses described as use of control and the patients as punishment[ There were also some who had not been violent\ but had still been isolated[ It is an interesting question how col! laborative helping methods can be used as an alternative to isolation[ The general opinion has it that an increase of sta} can help to reduce the isolation of patients\ but catalytic nursing calls for a change in the attitudes of psychiatric nurses and for greater understanding\ accept! ance\ rapport\ trust and scienti_c knowledge of psy! chiatric nursing\ and also an ability to see things from the viewpoint of a psychiatric patient[ The education of nursing students to become aware of catalytic nursing during their training and to learn to use collaborative helping methods is also a major challenge[ With the advent of deinstitutionalization\ the family is _nally being recognized as one of the most signi_cant sources of support for a person who is mentally ill[ Col! laboration between families\ professionals and patients can improve the quality of life for all those victimized by mental illness "Peternelj!Taylor and Hartley\ 0882^ Latvala and Janhonen\ 0886#[ In the present case\ cata! lytic psychiatric helping methods were de_ned as sup! porting patients in making informed decisions and having con_dential participatory dialogue[ This can help them to become aware of their potential as active and equal participants in the process of care\ making use of the resources which they have been able to identify together with the nurses "Jones and Meleis\ 0882^ Janhonen\ 0882^ Hartrick et al[\ 0883#[ The result is that the patients can gain more control over their own personal abilities\ a greater awareness of their environment and real resources and a closer attachment to their particular social context "Morrison and Burnard\ 0878^ Janhonen\ 0882^ Latvala and Janhonen\ 0886#[
240
References Anderson\ C[M[\ Reiss\ D[J[\ Hogarty\ G[E[\ 0875[ Schizo! phrenia and the Family] a Practitioner|s Guide to Psy! choeducation and Management[ The Guilford Press\ New York[ Anderson\ H[\ Goolishian\ H[A[\ 0877[ Human systems as linguistic systems] preliminary and evolving ideas about the implications for clinical theory[ Family Process 16\ 260Ð282[ Beauchamp\ T[L[\ Cook\ R[R[\ Fayerweather\ G[K[\ Thar\ W[E[\ Cowles\ S[R[\ Spivey\ G[H[\ 0880[ Ethical guidelines for epidemiologist[ Journal of Clinical Epidemiology 33 "Suppl[ 0#\ 040SÐ058S[ Bandura\ A[\ 0875[ Social Foundations of Thought and Action] a Social Cognitive Theory[ N[J[ Prentice Hall\ Englewood Cli}s[ Begley\ C[M[\ 0885[ Using triangulation in nursing research[ Journal of Advanced Nursing 13\ 011Ð017[ Benoliel\ J[Q[\ 0877[ Considering human rights in research[ In] Woods\ N[\ Catanzaro\ M[ "Eds[#\ Nursing Research] Theory and Practice[ The Mosby Company\ St[ Louis[ pp[ 68Ð85[ Bottor}\ J[L[\ 0883[ Using videotaped recordings in qualitative research[ In] Morse\ J[M[ "Ed[#\ Critical Issues in Qualitative Research Methods[ Sage Publications\ California\ pp[ 134Ð 150[ Bottor}\ J[L[\ 0886[ Linking qualitative and quantitative research] new avenues for programmatic research[ In] Morse\ J[M[ "Ed[#\ Completing a Qualitative Project] Details and Dialogue[ Sage Publications\ California\ pp[ 116Ð138[ Bunch\ E[H[\ 0872[ Everyday Reality of the Psychiatric Nurse] a Study of Communication Patterns between the Schizophrenic and the Psychiatric Nurse Gyldendal Norsk Forlag[ A:S\ Oslo[ Burnard\ P[\ 0885[ Teaching the analysis of textual data] an experiential approach[ Nurse Education Today 1\ 167Ð170[ Burns\ N[\ 0878[ Standards for qualitative research[ Nursing Science Quarterly 1\ 33Ð41[ Capron\ A[M[\ 0880[ Protection of research subjects] do special rules apply in epidemiology<[ Journal of Clinical Epi! demiology 33 "Suppl[ 0#\ 70SÐ78S[ Fleury\ J[\ 0885[ Wellness motivation theory] an exploration of theoretical relevance[ Nursing Research 34\ 166Ð172[ Forchuk\ C[\ 0883[ The orientation phase of the nurseÐclient relationship] testing Peplau|s theory[ Journal of Advanced Nursing 19\ 421Ð426[ Haarakangas\ K[\ 0886[ The Voices in Treatment Meeting] a Dialogical Analysis of the Treatment Meeting Conversations in Family!centered Psychiatric Treatment Process in Regard to the Team Activity[ University of Jyvaskyla\ Jyvaskyla[ Hall\ B[A[\ 0885[ The psychiatric model] a critical analysis of its undermining e}ects on nursing in chronic mental illness[ Advances in Nursing Science 2\ 05Ð15[ Hartrick\ G[\ Lindsey\ A[E[\ Hills\ M[\ 0883[ family nursing assessment] meeting the challenge of health promotion[ Jour! nal of Advanced Nursing 19\ 74Ð80[ stedt!Kurki\ P[\ 0883[ What is expected Haggman!Laitila\ A[\ A of the nurseÐclient interaction and how these expectations are realized in Finnish health care[ International Journal of Nursing Studies 20\ 124Ð150[ Glaser\ B[G[\ 0867[ Theoretical Sensitivity] Advances in the Methodology of Grounded Theory[ University of California\ San Francisco[
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Gournay\ K[\ 0884[ Mental health nurses working purposefully with people with serious and enduring mental illness] an inter! national perspective[ International Journal of Nursing Studies 21\ 230Ð241[ Janhonen\ S[\ 0882[ Finnish nurse instructors| view of the core of nursing[ International Journal of Nursing Studies 29\ 046Ð 058[ Jones\ P[S[\ Meleis\ A[I[\ 0882[ Health is empowerment[ Advances in Nursing Science 04\ 0Ð03[ Kendall\ J[\ 0881[ Fighting back] promoting empancipatory nursing actions[ Advances in Nursing Science 04\ 0Ð04[ Latvala\ E[\ Janhonen\ S[\ 0886[ Patient|s capable of managing] basic process of psychiatric nursing in hospital environment[ Vard i Norden 06\ 8Ð02[ Latvala\ E[\ Janhonen\ S[\ Moring\ J[\ 0887[ Ethical dilemmas in psychiatric nursing study[ Nursing Ethics 4\ 16Ð24[ Lincoln\ Y[S[\ Cuba\ E[G[\ 0874[ Naturalistic Inquiry[ Sage Pub! lications\ Beverley Hills\ CA[ Madden\ B[P[\ 0889[ The hybrid model for concept development] its value for the study of therapeutic alliance[ Advances in Nursing Science 2\ 64Ð76[ Markova\ I[\ 0883[ Introduction[ In] Markova\ I[\ Foppa\ K[\ "Eds[#\ The Dynamics of Dialogue[ Weatsheaf\ Harvester\ pp[ 0Ð11[ Morrison\ P[\ Burnard\ P[\ 0878[ Students| and trained nurses| perceptions of their own interpersonal skills] a report and comparison[ Journal of Advanced Nursing 03\ 210Ð218[
Morrison\ E[F[\ 0882[ A comparison of perceptions of aggression and violence by psychiatric nurses[ International Journal of Nursing Studies 29\ 150Ð157[ Morrison\ P[\ Lehane\ M[\ 0885[ A study of the o.cial records of seclusion[ International Journal of Nursing Studies 22\ 112Ð 124[ Patton\ M[Q[\ 0889[ Qualitative Evaluation and Research Methods[ Sage Publications\ Newbury Park\ CA[ Peplau\ H[\ 0881[ Interpersonal relations] a theoretical frame! work for application in nursing practice[ Nursing Science Quarterly 0\ 02Ð07[ Peternelj!Taylor\ C[A[\ Hartley\ V[L[\ 0882[ Living with mental illness] professional:family collaboration[ Journal of Psycho! social Nursing and Mental Health Services 2\ 12Ð17[ Rosengren\ K[E[ "Ed[#\ 0870[ Advances in Content Analysis[ Sage Publications\ CA[ Salo\ M[\ 0885[ Sietamisesta solidaarisuuteen] Mielisaira! alareformit Italiassa ja Suomessa[ "From Tolerance to Soli! darity] Reformation of Mental Hospital in Italy and in Finland#[ Vastapaino\ Tampere[ Sandelowski\ M[\ 0882[ Rigor or rigor mortis] the problem of rigor in qualitative research revisited[ Advances in Nursing Science 05\ 0Ð7[ Strauss\ A[L[\ Corbin\ J[\ 0889[ Basics of Qualitative Research] Grounded Theory Procedures and Techniques[ Sage Pub! lications\ London[
International Journal of Nursing Studies 24 "0887# 235Ð241
Helping methods used by nurses in a psychiatric hospital environment Eila Latvala \ Sirpa Janhonen Department of Nursing Science\ University of Oulu\ Kajaanintie 35 E\ 89119 Oulu\ Finland Received 3 September 0886^ received in revised form 12 June 0887^ accepted 10 July 0887
Abstract This qualitative study aims to describe the helping methods used by psychiatric nurses in a hospital environment from as evidenced by video observations and nurses| and patients| descriptions[ The data\ which were collected by videotaping di}erent nursing situations and by interviewing the nurses and patients afterwards\ consisted of 419 pages of written text[ A total of 458 utterances were extracted from the text to describe the helping methods used in psychiatric nursing[ Each utterance constituted a classi_cation unit[ Deductive content analysis techniques were used to analyze the data[ The results obtained from the nurses| and patients| descriptions and the videotaped episodes showed that the most commonly used helping methods were of the con_rmatory kind "49)#\ while educational methods came second "26)# and catalytic methods third "02)#[ Þ 0887 Elsevier Science Ltd[ All rights reserved[ Keywords] Keywords] Psychiatric nursing^ Nursing helping methods^ NurseÐpatient collaboration[
0[ Introduction The purpose of this paper is to describe the helping methods used in psychiatric patient care in a hospital environment[ Today\ out!patient care and short!term in! patient periods require many helping methods within psy! chiatric nursing\ including collaboration between the nurse\ the patient and other signi_cant persons "Peternelj! Taylor and Hartley\ 0882^ Latvala and Janhonen\ 0886#[ In the psychiatric nursing practice the patient and other relevant persons are often mere passive recipients of help[ The nurses often work routinely instead of engaging in real interaction with the patient and exposing themselves to the su}ering of the patient and his:her signi_cant others[ Psychiatric helping methods\ such as the nurseÐpatient relationship\ have been studied earlier in the light of di}erent theories "Bunch\ 0872^ Peplau\ 0881^ Forchuk\ 0883#[ This paper describes psychiatric nursing helping methods as elicited from video recordings and interviews
Corresponding author[ Tel[] ¦247!7!426!4599^ fax] ¦247!7! 4264596^ e!mail] elatvalaÝcc[oulu[_[
conducted with nurses and patients[ The nurseÐpatient collaboration is essential for supporting a psychiatric pat! ient|s e}orts to manage with daily life[ The meaning of this nurseÐpatient collaboration has been emphasized since the 0869s\ and many researchers have described con~icts between the ideal model for this collaboration and the reality of the psychiatric nursing practice\ emphasizing that nurses try to establish a therapeutic collaboration with each patient\ but routine activities take up most of their time "Bunch\ 0872^ Morrison and Burnard\ 0878^ Peplau\ 0881#[ The basis for such a col! laboration is con_dentiality\ which requires the nurse to show an ability to be patient\ to understand realities and to tolerate frustration\ to be ~exible concerning the patient|s needs and to have a positive\ empathet under! stedt! standing of the patient "Haggman!Laitila and A Kurki\ 0883^ Latvala and Janhonen\ 0886#[ The factors which aggravate the patient|s symptoms in a hospital environment include hallucinations\ an inability to participate in the planning of his:her own care and not being listened to\ understood or taken seriously "Morrison\ 0882#[ The symptoms are manifested in di}erent ways and in~uence daily living from the point of view of psychiatric nursing[ Nurses use the same inter! ventions both to alleviate and to prevent symptoms[
9919!6378:87:, ! see front matter Þ 0887 Elsevier Science Ltd[ All rights reserved[ PII] S 9 9 1 9 ! 6 3 7 8 " 8 7 # 9 9 9 4 0 ! 9
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These include interaction with the patient\ teaching the patient\ or simply touching the patient[ Control and medication are used to prevent aggression and other harmful a}ects[ The interventions used depend on the individual nurse|s assessment of the situation and the unwritten rules of the ward "Morrison\ 0882^ Gournay\ 0884^ Morrison and Lehane\ 0885^ Latvala and Janhonen\ 0886#[
1[ Psychiatric helping methods] literature review This paper is based on the theoretical framework of earlier qualitative studies produced in Finnish hospital environments\ which have revealed three types of psy! chiatric helping methods] catalytic\ educational and con! _rmatory "Janhonen\ 0882^ Latvala and Janhonen\ 0886#[ They di}er from each other on the essential dimensions of interaction\ instruction\ activities and accountability[ These dimensions have been described in many psy! chiatric nursing studies "Bunch\ 0872^ Madden\ 0889^ Peplau\ 0881^ Forchuk\ 0883^ Hall\ 0885^ Latvala and Janhonen\ 0886#[ Catalytic psychiatric helping methods in a hospital environment are systematic and rooted in an emancipatory theory of nursing and a theoretical and research!based practice "Kendall\ 0881^ Peplau\ 0881^ Janhonen\ 0882^ Hall\ 0885^ Latvala and Janhonen\ 0886#[ NurseÐpatient collaboration is based on par! ticipatory dialogue\ which makes it possible to listen to the patient and to understand the patient|s needs con! cerning his:her management in daily life "Latvala and Janhonen\ 0886#[ The dialogue is between two or more persons willing to see and accept their mutual personal points of view or to _nd new solutions through mutual understanding "Anderson and Goolishian\ 0877^ Markova\ 0883^ Haarakangas\ 0886#[ Catalytic psy! chiatric helping methods promote growth and devel! opment on four dimensions] "0# from dependence to inde! pendence\ "1# from normative rules to situationally determined behavior\ "2# from assistance to active par! ticipation and "3# from performance to responsible action "Janhonen\ 0882^ Latvala and Janhonen\ 0886#[ The essential purpose of catalytic psychiatric helping methods is to make the activities meaningful to the pati! ent[ The nurses use motivating supervision\ which means that feedback and the working atmosphere are impor! tant[ Motivation is a complex phenomenon[ There are many factors\ such as emotions\ needs and incentives\ which in~uence people|s motivation "Bandura\ 0875^ Kendall\ 0881^ Fleury\ 0885#[ Catalytic psychiatric help! ing methods\ the nurseÐpatient collaboration\ motivating supervision and meaningful activities enable the patient to become a participant of shared accountability in his:her care[ Through catalytic helping methods the pati! ent is able to gain awareness of his:her real patterns[ Results similar to the descriptions of Madden "0889# have
236
been reported from therapeutic alliance[ A therapeutic nurseÐpatient relationship aims to develop the patient|s behavior by setting mutual goals[ Moreover\ therapeutic alliance has been seen as a process in which both the nurse and the patient are "0# actively working towards the goal of developing the latter|s health behavior to be consistent with his:her current health status and lifestyle\ "1# focusing on mutual negotiation to determine the activities to be carried out in pursuit of that goal and "2# using a supportive and equitable therapeutic relationship to facilitate the attainment of that goal[ On the other hand\ the catalytic helping methods can also be compared to the processes described in the theory of Peplau "0881# of interpersonal relationship[ The catalytic psychiatric helping methods "Table 0# described here consist of nurseÐpatient collaboration\ motivating supervision\ meaningful activities and shared accountability\ and are in that sense virtually synonymous with family nursing assessment from the perspective of the socio!environ! mental model described by Hartrick et al[ "0883#\ the therapeutic alliance described by Madden "0889# and the interpersonal relationship described by Peplau "0881#[ Educational psychiatric helping methods are rooted in a behavioural model and depend on professional expert! ise[ Interaction is a matter of monologue\ which means\ for instance\ that the nurse knows what is best for the patient and\ by acting accordingly\ casts the patient in the role of a silent outsider "Latvala and Janhonen\ 0886#[ The purpose of educational psychiatric helping methods is to help the patient by means of normative supervision to manage in daily life by modifying his:her behavior or lifestyle in everyday activities in accordance with the professional|s ideal model\ in order to maintain mental health[ The essential decisions concerning care are made by professionals\ while the patient is a responsible recipi! ent[ The patient tries to conform to the professional|s ideal model and is a silent participant in his:her care "Latvala and Janhonen\ 0886# Table 0[ The educational helping methods described here consist of professionals| monologue\ normative supervision\ everyday activities and professional|s accountability[ The methods resemble the behavioural model in the family nursing assessment described by Hartrick et al[ "0883# and the principles of family therapy and the psychiatric school of educational: bevioural family therapy[ According to this school\ fam! ilies should be instructed how to communicate\ express emotions and resolve con~icts\ to decrease stress in the family "Anderson et al[\ 0875#[ Con_rmatory psychiatric helping methods are rooted in the traditional model of viewing psychiatric illness as having a speci_c physical cause related to the functional anatomy of the brain[ The patient has little or no control[ The nurse is dependent on the doctor|s authority[ The nurse con_rms that everything is done according to the norms and rules[ Interaction is formal\ which means that the discussions between the nurse and the patient are
shared accountability professional|s accountability hierarchic accountability meaningful activities everyday activities general activities motivating supervision normative supervision controlling supervision participatory dialogue professional|s monologue general level discussions
Activities Interaction
Instruction
Accountability
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at a general level "Latvala and Janhonen\ 0886#[ The instruction consist of routine and formal control[ The nurse controls the patient|s behavior according to the norms and rules\ and in the hierarchy of constituted accountability the patient is at the lowest level[ The pati! ent is not aware of the main goal of the care or the purpose of the helping methods[ The nurse organizes outdoor activities to help the patient and uses control and medication to alleviate symptoms\ e[g[ aggression or hallucinations[ The nurse administers the patient|s medication to prevent symptoms or to control the pat! ient|s condition "Latvala and Janhonen\ 0886# Table 0[ Con_rmatory psychiatric helping methods consist of gen! eral level discussions\ controlling supervision\ general activities and hierarchic accountability\ and in that sense resemble the psychiatric model described by Hall "0885# and the perspective of the medical model in the family nursing assessment described by Hartrick et al[ "0883#[ According to the theoretical framework\ the essential dimensions of psychiatric helping methods are inter! action\ instruction\ activities and accountability\ which vary from individual human psychiatric nursing to auth! oritarian formal psychiatric nursing[ The aim of this paper is to describe the psychiatric helping methods used by nurses in a hospital environment by using a theoretical framework of di}erent types of psychiatric nursing "con! _rmatory\ educational and catalytic# as observed in videotaped situations with an interdisciplinary psy! chiatric team and as described by psychiatric nurses and patients in interviews[ 1[0[ Questions to be answered The purpose of psychiatric helping methods is to help the patient to manage in daily life[ The research rep! resents an attempt to answer the following questions] 0[ To what extent were psychiatric helping methods manifested in the descriptions of nurses and patients< 1[ To what extent were psychiatric helping methods manifested during the videotaped situations of patient care in interdisciplinary teamwork<
Catalytic helping methods Educational helping methods Con_rmatory helping methods
2[ Data and method
Variables
Table 0 Di}erent types of psychiatric helping methods used in a hospital environment
237
The data were collected by theoretical sampling "Glaser\ 0867^ Strauss and Corbin\ 0889# in the _rst phase of the research[ They consisted of interviews of nurses and patients "N 34# and videotapes of nursing situations "N 09# "Latvala and Janhonen\ 0886#[ This paper is based on the videotaped situations including helping methods of patient care and all interviews of the nurses and patients[ The data analyzed in this paper consisted of six videotaped episodes and recorded interviews\ including descriptions by 18 nurses of their own actions
238
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in di}erent out! and in!patient care situations and descriptions by 05 patients of their care in a hospital environment[ The videotapes has been recorded during nursing report sessions and planning meetings[ Each vid! eotaped care situation was followed by interviews with all the participants[ Each interview took from 29 min to an hour and a half and each videotaped session from one hour to an hour and a half[ Method\ time and space triangulations were used to con_rm the researcher|s interpretation and the subjects| ideas "Begley\ 0885^ Bur! nard\ 0885^ Bottor}\ 0886#[ The transcribed data amounted to 419 pages[ They were analyzed by _rst extracting the utterances which described the psychiatric helping methods used in a hos! pital environment "N 458#[ The foundation of the classi! _cation consisted of the theoretical framework[ Each utterance was taken to constitute a classi_cation unit[ The nurses| and the patients| interviews consisted of 254 utterances which described the helping method of psy! chiatric nursing used[ Deductive content analysis tech! niques "Rosengren\ 0870^ Burnard\ 0885# were then applied to the 458 utterances\ employing the classi_cation into con_rmatory\ educational and catalytic helping methods\ and their contents were derived from earlier research "Janhonen\ 0882\ Latvala and Janhonen\ 0886#[ Finally\ numerical values and percentages were cal! culated for all the categories to illustrate the variety of helping methods used in psychiatric nursing[
0889^ Sandelowski\ 0882#[ In this method\ a description of a human experience is regarded as valid or credible when other people can recognize that experience when confronted with it after having only read the description[ The Ethical Review Committee of the Faculty of Medi! cine at the University of Oulu and the Research Board of the hospital were responsible for resolving and eva! luating the ethical questions arising in connection with this work and for recommending solutions[ The ethical aspects involved informing the subjects of the research and obtaining their informed consent[ They were allowed to withdraw at any time without penalty[ The bene_ts of the research outweigh the risks\ although the degree to which this is true depends on the investigator|s ability to perform the research "Benoliel\ 0877^ Beauchamp et al[\ 0880^ Capron\ 0880^ Latvala et al[\ 0887#[
3[ Results The results are presented numerically and illustrated by nurses| and patients| descriptions of the psychiatric helping methods[ Of all utterances "N 458#\ 02) re~ected catalytic helping methods\ 26) educational helping methods and 49) con_rming helping methods[ In the videotaped interdisciplinary team situations\ the psychiatric nursing helping methods re~ected a con! _rmatory approach in 49) of the cases\ an educational approach in 28) and a catalytic approach in 00)[ Most of the 160 utterances extracted from the descriptions by nurses described con_rmatory "31)# and educational helping methods "30)#\ the proportion of catalytic methods being 06)[ Most of the 83 utterances in the descriptions by patients re~ected con_rmatory helping methods "69)#\ while the proportion of educational methods was 15) and that of catalytic methods 3) "Table 1#[ The di}erences between the nurses| and patients| descriptions and the videotaped situations show that catalytic psychiatric nursing and catalytic helping
2[0[ Credibility and ethical aspects The data analysis and categorization were all per! formed by one investigator\ who also calculated the absolute and relative frequencies[ The data were cat! egorized twice at intervals of two months\ and the cor! respondence rate was 86) "243:243¦:−00 86#[ Reliability may be assessed in terms of the auditability of the _ndings\ i[e[ by describing how the data were collected and reduced for analysis\ and how the categories were formed "Lincoln and Cuba\ 0874^ Burns\ 0878^ Patton\
Table 1 Catalytic\ educational and con_rmatory psychiatric helping methods in a hospital environment "N total number of utterances\ n part of utterances# Nurse
Patient )
Video
Variables
n
Catalytic helping methods Educational helping methods Con_rmatory helping methods
35 009 004
06 30 31
3 13 55
3 15 69
11 79 091
00 28 49
61 103 172
02 26 49
Total
160
099
83
099
193
099
458
099
n
)
Total
n
)
N
)
249
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methods are rare in a Finnish hospital environment[ The traditional normative helping methods and con_rmatory or educational nursing\ in which the patient is more or less a passive recipient of care\ are common Table 1[ One patient described the nurseÐpatient participatory dialogue in the following way] It is very important that my own nurse listens to me\ but I can make only small decisions[ The cooperative meeting helped my family to understand what my care is about and they can help and support me better[ One patient described the meaningful activities and his accountability for his care\ which constitute the content of catalytic psychiatric nursing\ in the following way] Quite common everyday activity may become mean! ingful\ but it depends on me[ I must take part in my care and tell my own nurse and doctor what I feel to be best for me[ They can help me better if they know[ It is my duty to take part in my care as a responsible person[ One primary nurse explained how important it is for the nurse to listen to the patient and\ in mutual col! laboration\ to _nd out the experiences that are mean! ingful for understanding and recognizing the patient|s real resources] We _gured out together what is meaningful\ what makes his life meaningful\ and little by little the patient began to recognize the meaningful things in his life[ I think the most important thing at the beginning of our collaboration was that I listened to him and our dialogue about reality very openly[ The important experiences that he had had after he had fallen men! tally ill[ Educational psychiatric helping methods consisted of an ideal model guiding nursing[ An example of pro! fessional|s monologue is communication with a psychotic patient so that he:she will not revert to a psychotic state[ Normative supervision constituted the largest category of educational helping methods described by the nurses and patients[ One nurse described normative supervision as follows] I have instructed the patient time after time for many years to use the money right\ but he has not learnt that[ He gets a little money every week\ but spends it immediately[ The nurse instructed the patient to use some money every day during the week instead of spending it all right away[ The patient needed help for his money problems\ but are monologue and normative supervision always the best way< The patient|s everyday activities were seldom
mentioned as a helping method in connection with edu! cational psychiatric nursing\ but one nurse described them in the following way] In our unit\ the patients take turns in the kitchen\ which helps them to learn kitchen routines and kitchen work[ They are responsible for cleaning their own rooms and their own clothes\ and in this way the nurses can assess their ability to look after themselves[ The con_rmatory psychiatric helping methods con! sisted of working according to an authoritarian model[ A nurse described the maintenance of interaction as a helping method in the following way] Such situations occur in the sitting room\ where we sit together watching TV and talking about all sorts of things * newspapers and TV programs * and the atmosphere is cozy and nice and the patients feel good[ Everybody is accepted in spite of their fragmented personalities that are the result of mental illness[ The nurses described the use of controlling supervision in con_rmatory psychiatric nursing as activities aimed at preventing accidents when the patient is unable to control his:her emotions\ e[g[ aggression[ The patients however\ experienced such situations di}erently[ For them\ the use of controlling supervision was like a punishment for inappropriate behavior or criticism by the nurses[ Gen! eral activities as a helping method included various joint activities in! and outdoors[ Hierarchic accountability was connected with medication\ the patient|s condition and the prevention of symptoms[
4[ Discussion The question of collaboration in psychiatric nursing is both timely and interesting[ As a consequence of the deinstitutionalization of psychiatric care\ collaborative helping methods are a challenge for psychiatric nursing\ the patient and all those who are victimized in psychiatric care[ The present and earlier results point to medication\ normative rules and a passive role of the patient as gen! eral features of psychiatric nursing "Bunch\ 0872^ Mor! rison and Lehane\ 0885^ Jones and Meleis\ 0882^ Hall\ 0885^ Latvala and Janhonen\ 0886#[ The present results provide new information concerning collaboration in a psychiatric hospital environment and con_rm some earl! ier observations on psychiatric care "Bunch\ 0872^ stedt!Kurki\ Forchuk\ 0883^ Haggman!Laitila and A 0883^ Hall\ 0885^ Salo\ 0885#[ The researchers have not\ however\ tested these results in any other environment or with any other subjects[ Videotape recordings provide a credible method of data collection "Bottor}\ 0883#[ The authors have ensured the credibility of the observations in this context by using triangulation "Lincoln and Cuba\
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0874^ Begley\ 0885#[ These results are reliable in Finnish hospital environments\ but cannot be generalized to any other environment[ The results\ however\ agree with the earlier _ndings concerning participatory dialogue "Jan! honen\ 0882^ Hartrick et al[\ 0883^ Haarakangas\ 0886# and the earlier observations on psychiatric nursing con! cerning collaboration in psychiatric care "Madden\ 0889^ Peplau\ 0881^ Peternelj!Taylor and Hartley\ 0882^ Gour! nay\ 0884#[ At each level of these three types of psychiatric helping methods\ the de_nition of patients| management varies\ as does the focus of nursing practice[ These _n! dings need to be further developed and tested with quan! titative methods[ Many aspects of psychiatric nursing still support a passive role of the patient in his:her own care\ including the possibility to the door to the unit or to place the patient in isolation[ Catalytic helping methods are a chal! lenge to psychiatric nursing\ and this is also true of col! laborative methods\ such as participatory dialogue\ in the context of locked units and isolation[ The present data included many references to patients being isolated because of violence\ instances which the nurses described as use of control and the patients as punishment[ There were also some who had not been violent\ but had still been isolated[ It is an interesting question how col! laborative helping methods can be used as an alternative to isolation[ The general opinion has it that an increase of sta} can help to reduce the isolation of patients\ but catalytic nursing calls for a change in the attitudes of psychiatric nurses and for greater understanding\ accept! ance\ rapport\ trust and scienti_c knowledge of psy! chiatric nursing\ and also an ability to see things from the viewpoint of a psychiatric patient[ The education of nursing students to become aware of catalytic nursing during their training and to learn to use collaborative helping methods is also a major challenge[ With the advent of deinstitutionalization\ the family is _nally being recognized as one of the most signi_cant sources of support for a person who is mentally ill[ Col! laboration between families\ professionals and patients can improve the quality of life for all those victimized by mental illness "Peternelj!Taylor and Hartley\ 0882^ Latvala and Janhonen\ 0886#[ In the present case\ cata! lytic psychiatric helping methods were de_ned as sup! porting patients in making informed decisions and having con_dential participatory dialogue[ This can help them to become aware of their potential as active and equal participants in the process of care\ making use of the resources which they have been able to identify together with the nurses "Jones and Meleis\ 0882^ Janhonen\ 0882^ Hartrick et al[\ 0883#[ The result is that the patients can gain more control over their own personal abilities\ a greater awareness of their environment and real resources and a closer attachment to their particular social context "Morrison and Burnard\ 0878^ Janhonen\ 0882^ Latvala and Janhonen\ 0886#[
240
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Morrison\ E[F[\ 0882[ A comparison of perceptions of aggression and violence by psychiatric nurses[ International Journal of Nursing Studies 29\ 150Ð157[ Morrison\ P[\ Lehane\ M[\ 0885[ A study of the o.cial records of seclusion[ International Journal of Nursing Studies 22\ 112Ð 124[ Patton\ M[Q[\ 0889[ Qualitative Evaluation and Research Methods[ Sage Publications\ Newbury Park\ CA[ Peplau\ H[\ 0881[ Interpersonal relations] a theoretical frame! work for application in nursing practice[ Nursing Science Quarterly 0\ 02Ð07[ Peternelj!Taylor\ C[A[\ Hartley\ V[L[\ 0882[ Living with mental illness] professional:family collaboration[ Journal of Psycho! social Nursing and Mental Health Services 2\ 12Ð17[ Rosengren\ K[E[ "Ed[#\ 0870[ Advances in Content Analysis[ Sage Publications\ CA[ Salo\ M[\ 0885[ Sietamisesta solidaarisuuteen] Mielisaira! alareformit Italiassa ja Suomessa[ "From Tolerance to Soli! darity] Reformation of Mental Hospital in Italy and in Finland#[ Vastapaino\ Tampere[ Sandelowski\ M[\ 0882[ Rigor or rigor mortis] the problem of rigor in qualitative research revisited[ Advances in Nursing Science 05\ 0Ð7[ Strauss\ A[L[\ Corbin\ J[\ 0889[ Basics of Qualitative Research] Grounded Theory Procedures and Techniques[ Sage Pub! lications\ London[