Guardedness in Communications between Nurses and People Experiencing Acute Psychosis

275 Pages·2016·1.84 MB·English

Guardedness in Communications between People
Experiencing Acute Psychosis and Mental
Health Nurses

A thesis presented to Dublin City University for the Degree of Doctor of
Philosophy

By: Sean Boland
(RPN, RGN, Fam. Ther. (FTAI), MA)

June 2016

Supervisors

Dr Evelyn Gordon
Dr Mark Philbin

School of Nursing and Human Sciences

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Declaration

I hereby certify that this material, which I now submit for assessment on the
programme of study leading to the award of Doctor of Philosophy is entirely my own
work, and that I have exercised reasonable care to ensure that the work is original, and
does not to the best of my knowledge breach any law of copyright, and has not been
taken from the work of others save and to the extent that such work has been cited and
acknowledged within the text of my work.

Signed: ______________________ Date: 31st August 2016

Student ID No: 56124562

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Acknowledgements

I would like to extend my deep gratitude to the nurses and those who have experienced
acute psychosis, without whom this study would not have been possible, and to the staff
and management of the research site and Shine who assisted with the recruitment process.

I would like to posthumously express my deep appreciation to my initial supervisor,
Professor Chris Stevenson and to Dr Evelyn Gordon and Dr Mark Philbin for their
encouragement, guidance, patience and sharing of their wisdom throughout the course of
conducting this study and writing this thesis.

Last but by no means least I would also like to extend my thanks and appreciation to my
wife Susan, my children Jack, Anna and Connal, friends and colleagues for their support
and patience throughout my journey through doing this study, as significant study time
was put ahead of family time.

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Operational Definitions

Acute Psychosis
The term acute psychosis is commonly used among mental health professionals when
referring to the presence of certain experiences that are occurring for a person. Experiences,
what clinicians consider hallucinations, delusions, thought disorder and abnormal behaviour,
and is believed as central features of the diagnostic terms schizophrenia, bipolar disorder and
paranoia. The term also indicates that there is an increased intensity and severity attached to
these experiences that leads to families and some who experience these experiences, to seek
help from mental health professions.

Service Users/Patients/Clients
Within public mental health services the term patient, client and service user is used
interchangeable when referring to those who attend these services and it is noted that they are
also used interchangeable in the literature. In terms of clarity those study participants who
had experienced acute psychosis are referred to as ‘service users’ or ‘service users
experiencing acute psychoses’. Where appropriate other attendees of mental health services
that have a different diagnosis, for example depression will be referred to as ‘patients’.

Nurse
In the main the term ‘nurse’ will be used instead of mental health or psychiatric nurse.

Communication
In relation to this study the term communication refer to the process of service users/patients
and nurses interacting and conversing with each other.

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Table of Contents

Declaration i

Acknowledgements ii

Operational Definitions iii

Table of Contents ix

Abstract

Chapter 1. An Overview of the Thesis 1

1.1 Introduction 1
1.2 Background and Rationale for the Study 1
1.3 Study Aims, Methodology and Methods 2
1.4 Thesis Outline 3
1.5 Summary 3

Chapter 2. Literature Review:
Psychosis and Communications: Main Understandings and Approaches
Available to Mental Health Nurses Working in the Irish Mental Health
Services 4

2.1 Introduction 4
2.2 Psychosis: A Contested Concept 4
2.2.1 Prevalence and incidence 5
2.2.2 Medical/Psychiatric Perspectives on Psychosis 8
- Classification of Psychosis 11
- Biological/Biomedical Signs and Symptoms – What is seen and experienced 13
- Treatment of Psychosis from a Biological/Biomedical Perspective 16
2.2.3 Biopsychosocial Approaches to Psychosis 19
- Stress-Vulnerability Model 20
2.2.4 Psychosocial perspectives for Psychosis 23
- Dialogical Approaches 24
- Cognitive behavioural approach for psychosis 28
2.2.5 Alternative Explanations of the Causality of Psychosis 31
- Trauma 31
- Spirituality 32
- Critique of Biomedical Psychiatry 34
2.2.6 Subjective Experiences of Psychosis 35
- Service User and Family Subjective Accounts 36
2.2.7 Psychosis – Voluntary Support Organisations 39
- Hearing Voices Movement 39
2.2.8 Lay Understandings of Psychosis 41
2.2.9 Summary of Psychosis: A Contested Concept 42
2.3 Communication between Nurses and Service Users 44
2.3.1 Introduction 44
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2.3.2 Nurses and the Therapeutic Relationship 45
2.3.3 Communication Challenges 45
- Dual Role – Custodian and Helper 47
- Risk and Vulnerabilities 47
2.3.4 Communication Models and Approaches available to Nurses 52
- Some General Models Available to Nurses 52
2.3.5 Models and approaches regarding Talking to Service User’s Experiencing Psychosis 57
- Peplau’s Interpersonal Relations Theory 57
- Bower’s Approach to Communicating with Acutely Psychotic Service Users 59
- Forchuk and Jensen’s Approach to Nursing Service Users with Disturbing Voices and Beliefs 61
2.4 Summary 63

Chapter 3: Methodology: Classic Grounded Theory 65

3.1 Introduction 65
3.2 Underpinnings Ideas 65
3.2 The Role of Literature in a Grounded Theory Study 65
3.4 Overview of grounded theory 67
3.4.1 Debates within Grounded Theory 68
3.5 Rationale for Using Classical Grounded Theory 71
3.6 Classic Grounded Theory: Methodological Framework 73
3.6.1 The Coding Process 73
- Substantive Coding 74
3.6.2 Constant Comparative Method 75
3.6.3 Theoretical Saturation 77
3.6.4 The Core Category Emergence 77
3.6.5 Memo – Writing 78
3.7 Summary 79

Chapter 4: Methods: Applying Classic Grounded Theory Methodology 80

4.1 Introduction 80
4.2 Aims and Objectives 80
4.3 Design and Procedures 80
4.3.1 Inclusion and Exclusion Criteria 80
- Inclusion Criteria for Service Users 81
- Inclusion Criteria for Nurses 81
- Exclusion criteria for Service Users 81
- Exclusion Criteria for Nurses 82
4.3.2 The Research Setting 82
4.3.3 Gaining Access 82
4.3.4 Participant Recruitment 83
4.3.5 Participant Profiles 84
- Figure 1 Nursing Participants Profiles 84
- Figure 2 Service User Participants Profiles 85
4.3.6 Data Collection 86
4.3.7 Some Reflections on the Interviews 86
4.3.8 Tape Recording the Interviews 87
4.4 Sampling Method 88
4.5 Data Analysis: Generating the Theory 89
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4.5.1 Open Coding 89
4.5.2 Process of Identifying the Main Concern 90
4.5.3 The Process of Identifying the Core Category 91
4.4,4 Theoretical Saturation 92
4.5.5 Theoretical Memos 92
4.6 Ethical Considerations 93
4.6.1 Gaining Ethical Approval 93
4.6.2 Restraints Placed on the Study 95
4.6.3 Providing ‘Safe Measures’ for the Participants and Researcher 96
4.6.4 Informed Consent 97
4.6.4 Maintenance of Dignity 98
4.6.6 Risk to Benefit Ratio 98
4.6.7 Anonymity and confidentiality 100
4.6.8 Ethical struggles 100
4.8 Summary 101

Chapter 5: The Theory: Guardedness in Communications between People
Experiencing Acute Psychosis and Mental Health Nurses 103

5.1 Introduction 103
5.2 The Main Concern: Establishing Permissible Communications 103
- Figure 3. The Key Components of the Main Concern 104
5.3 The Core Category: Guardedness in Communications 104
- Figure 4. Core Category and Sub-Core Categories 105
5.4 Overview of the Theory: Guardedness in Communications between Service
Users Experiencing Acute Psychosis and Mental Health Nurses 106
- Figure 5.Evolution of the Theory 107
5.5 Summary 108

Chapter 6: Raising Guardedness 109

6.1 Introduction 109
6.2 Raising Guardedness 109
Figure 6. Raising Guardedness 110
6.2.1 Learning Guardedness 111
- Becoming Guarded 111
- Enacting Institutional Communications 117
6.2.2 Experiencing Risk 124
- Enacting Distrustfulness 118
- Experiencing hostility 129
6.2.3 Keeping Conversations Light 134
- Using re-assurance 134
- Playing the Game 139
6.3 Summary 143

Chapter 7: Lowering Guardedness 145

7.1 Introduction 145
7.2. Lowering Guardedness 145
Figure 7. Lowering Guardedness 146
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7.2.1 Developing Safety and Trust 146
- Making Connections 146
- Observing and timing – choosing a safe place 153
- Trusting the Other 160
7.2.2 Conversing about issues of Importance and Concern 166
- Creating joint understandings 166
- Easing worries 170
7.3 Summary 176

Chapter 8. Discussion of the Findings 177

8.1 Introduction 177
8.2 Guardedness in Communications’ as it relates to Therapeutic Communications 177
8.3 Guardedness in Communications’ as it relates to Collaboration 180
8.4 Guardedness in Communications’ as it relates to Socialisation and Therapeutic
Relationships 184
8.5 Guardedness in Communications’ as it relates to Trust and Distrust 190
- Experiencing Hostility 192
- Observing and Timing: Choosing a safe Place 193
- Trusting the Other 194
8.6 Summary 195

Chapter 9. Implications and Conclusions 196

9.1 Introductions 196
9.2 Demonstrating Trustworthiness in this Study 196
9.2.1 The ‘Fit’ of the Theory ‘guardedness in communications’ 196
9.2.2 The ‘Workability’ of the Theory ‘guardedness in communications’ 197
9.2.3 The ‘Relevance’ of the Theory ‘guardedness in communications’ 198
9.2.4 The ‘Modifiability’ of the Theory ‘guardedness in communications’ 199
9.3 Some reflections on the Study and Personal Learning 199
9.4 Limitations 200
9.5 Implications for Practice 201
9.5.1 Implications for Nurses Working in Clinical Practice 201
9.5.2 Implications for Management and culture of Organisation 202
9.5.3 Implications and Recommendations for Research 203
9.6 Summary 203

References 204

Appendices 229

Appendix A(1): Participant Information Sheet (for people who have experienced
acute psychosis) 229
Appendix A(2): Participant Information Sheet (for nurses) 232
Appendix B: Participant Informed Consent Form 234
Appendix C: Interview Topic Guide 236
Appendix D: Example of Raw Date (participants’ perspectives), Initial Field
Notes and Open Coding 237
Appendix E(1): Raising Codes to Higher Conceptual Levels (Nurse) 241
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Appendix E(2): Raising Codes to Higher Conceptual Levels (Service User) 247
Appendix F(1): Memo 6/9/2010 - Tentative Core Category: Finding Permissible
Voice 257
Appendix F (2): Memo 23/5/2011 – Tentative main Concern and Core Category:
Achieving Permissible Contact 259
Appendix F(3); Memo 5/1/2014 - Tentative Core Category: Guarded Openness 262

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Guardedness in Communications between People Experiencing Acute
Psychosis and Mental Health Nurses

Abstract

Mental health nurses are the largest cohort of clinicians working in Irish Mental Health
services, and are usually involved in the care of service users experiencing acute psychosis
either as in-patients, mental health community facilities or in the service users own home.
Some service users place value on communication with nurses as it helps with easing their
difficulties (Gilburt, Rose and Slade 2008; Russo and Hamilton 2007, however others
report not been listened to, ignored and disempowered (Octwell and Capital Members
2007). In addition, both groups worry about risk and vulnerability when communicating
with each other (Norwood 2007;Duxbury and Whittington 2005).Consequently,
understanding the process of how these two groups manage to communicate together is
worthy of study as research into this area is limited. Hence, this Classic Grounded Theory
study aimed to address these gaps by developing a substantive theory pertaining to the
phenomena of communications between nurses and service users experiencing acute
psychosis that could be used to inform mental health nursing practice (Glaser and Strauss
1967). This involved interviewing sixteen participants, seven nurses and nine service users
who had experienced acute psychosis, and getting their views about communicating
together.

The study led to the development of a substantive theory that explains how they established
what constituted permissible communication for period in time through the processes of
guardedness in communications. The theory incorporated a dynamic psychosocial process
where nurses and service users moved from raising to lowering guardedness and vice versa
depending on their sense of risk, attempts to ease distress, or consider that it is
advantageous to raise or lower their guard. This was a complex and interactional process
which was influenced by past experiences, current events, contexts and how nurses and
service users presented when communicating. This guardedness in communications also
facilitated a sense of ownership and control over what they say and do. It is proposed that
mental health nurses and service users can use appropriate guardedness to establish what
they consider are permissible communications at a moment in time, in order to enhance
their understandings of how they communicate together and hopefully to make a
difference for service users experiencing acute psychosis.

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