Combining Critical Ethnography and Critical Discourse Analysis in Mental Health Nursing Research.

BACKGROUND: It is uncommon to combine critical ethnography with critical discourse analysis (CDA) in health research, yet this combination has promise for managing challenges inherent in critical mental health nursing research. OBJECTIVES: This article describes a methodologically innovative way to address issues that arise in the context of critical mental health nursing research. METHODS: This article draws on two studies that each employed a combination of critical ethnography and CDA in the context of mental health nursing research, discussing the challenges and implications of this approach. RESULTS: Although the combination critical ethnography and CDA presents several challenges, it also provides a framework for researchers to sustain a critically reflective stance throughout the research process. This facilitates the process of reanalyzing and reflecting on how healthcare practices and knowledge both support and are constrained by hegemonic discourses. DISCUSSION: This combination has the potential to facilitate the production of new, emancipatory knowledge that will assist nurses in understanding issues of structural inequity within the healthcare system.

Youth, caregiver and healthcare professional perspectives on planning the implementation of a trauma-informed care programme: A qualitative study.

AIMS: To explore youth, caregiver and staff perspectives on their vision of trauma-informed care, and to identify and understand potential considerations for the implementation of a trauma-informed care programme in an inpatient mental health unit within a paediatric hospital. DESIGN AND METHODS: We applied the Interpretive Description approach, guided by complexity theory and the Implementation Roadmap, and used Applied Thematic Analysis methods. FINDINGS: Twenty-five individuals participated in individual or group interviews between March and June 2022, including 21 healthcare professionals, 3 youth and 1 caregiver. We identified two overarching themes. The first theme, 'Understanding and addressing the underlying reasons for distress', related to participants' understanding and vision of TIC in the current setting comprising: (a) 'Participants' understanding of TIC'; (b) 'Trauma screening and trauma processing within TIC'; (c) 'Taking "a more individualized approach"'; (d) 'Unit programming'; and (e) "Connecting to the community". The second theme, 'Factors that support or limit successful TIC implementation' comprises: (a) 'The need for a broad "cultural shift"'; (b) 'The physical environment on the unit'; and (c) 'Factors that may limit successful implementation'. CONCLUSION: We identified five key domains to consider within trauma-informed care implementation: (a) the centrality of engagement with youth, caregivers and staff in trauma-informed care delivery and implementation, (b) trauma-informed care core programme components, (c) factors that may support or limit success in implementing trauma-informed care within the mental health unit and (d) hospital-wide and (e) the importance of intersectoral collaboration (partnering with external organizations and sectors). IMPACT: When implementing TIC, there is an ongoing need to increase clarity regarding TIC interventions and implementation initiatives. Youth, caregiver and healthcare professional participants shared considerations important for planning the delivery and implementation of trauma-informed care in their setting. We identified five key domains to consider within trauma-informed care implementation: (a) the centrality of relational engagement, (b) trauma-informed care programme components, (c) factors that may support or limit successful implementation of trauma-informed care within the mental health unit and (d) hospital-wide and (e) the importance of intersectoral collaboration. Organizations wishing to implement trauma-informed care should consider ongoing engagement with all relevant knowledge user groups throughout the process. REPORTING METHOD: Standards for Reporting Qualitative Research (SRQR). PATIENT OR PUBLIC CONTRIBUTION: The local hospital research institute's Patient and Family Advisory Committee reviewed the draft study methods and provided feedback.

A critical ethnographic perspective on risk and dangerousness in forensic psychiatry.

In the Canadian forensic psychiatric context, the concepts of risk and dangerousness interact, intersect, and morph into the notion of significant threat to the safety of the public. Stemming from the results of a critical ethnography of the Ontario Review Board, this article unpacks the central role of forensic psychiatric nursing, as an example of a 'psych' discipline (e.g., psychiatry and psychology), in a system that is built to produce risky persons and to legitimize their detention and supervision. By using excerpt of interviews conducted with nurses, ethnographic observations of Review Board hearings, and other documentary artifacts, the findings illustrate how rationalizations of risk and dangerousness are contingent on space, time, and observer. Depending on the time of the assessment or on the health-care professional who performs it, different elements including, but not limited to, mental illness, interpersonal relationships, financial instability, and sexual vulnerability, are relied upon in very fluid, interchangeable, and discretionary ways to justify findings of dangerousness. Such a dynamic expands the reach of psychiatry's legitimacy at identifying risky conduct and controlling risky persons to domains very loosely associated with the notion of dangerousness. The work of Foucault and Castel provides the theoretical backdrop on which rests the discussion and the implications for nursing.

Intervening against the patient's wishes: pro re nata medication and the phenomenological experience of nurses working in a forensic psychiatry environment / Intervenir contre le gré du patient : médication pro re nata et vécu phénoménologique du personnel infirmier exerçant en milieu psycholégal

In forensic psychiatry environments, nurses are regularly confronted with the use of restrictive measures such as chemical restraints and are forced to constantly navigate between care and social control. The debate over the ethics of coercion and the use of control measures for violence in psychiatric settings is far from resolved. The objective of this study is to understand the ethical experience of nurses in a Canadian forensic psychiatry environment when administering PRN (when required) medication against the patient's will. The experiences of 14 nurses are analyzed from a critical ethical perspective through interpretive phenomenological analysis. Across the three main categories-certainties, paradoxes, and learning-the results show that nurses must simultaneously commit their allegiance to the patient, to the justice system, and to the culture of the "total" institution. These multiple allegiances generate paradoxes that affect the way nurses actualize their professional role.

En milieu psycholégal, les infirmières sont régulièrement confrontées à l'utilisation des mesures restrictives, telles que la contention chimique, et doivent constamment naviguer entre soin et contrôle. Le débat portant sur l'éthique de la coercition et de l'usage des mesures de contrôle pour la violence en contexte de psychiatrie est loin d'être résolu. L'objectif de cette étude est de comprendre le vécu éthique d'infirmières exerçant dans un milieu psycholégal canadien au moment d'administrer un pro re nata (PRN, médicament au besoin) contre le gré du patient. Le vécu de quatorze infirmières est analysé dans une perspective éthique critique grâce à l'analyse interprétative phénoménologique. À travers les trois catégories principales, certitudes, paradoxes et apprentissage, les résultats montrent que les infirmières doivent engager simultanément leur allégeance au patient, au système de justice et à la culture de l'institution totale. Ces allégeances multiples génèrent des paradoxes qui affectent la manière dont les infirmières actualisent leur rôle professionnel.

The experiences of francophone patients who frequently present to the emergency department for mental health reasons / Les expériences de patients francophones qui se présentent fréquemment à l'urgence pour des raisons de santé mentale

Introduction: Language and communication are pivotal to the safe care and management of people with mental health disorders, particularly when these patients are linguistic minorities. Objectives/Method: To explore these experiences within linguistic minority populations by completing a literature review and qualitative interviews. Interviews were conducted in Ottawa, Canada, with francophone patients. The studies included in the review represented the international literature on linguistic minorities in general. Results: Overall, the experiences described in the published articles were similar to the participants' own experiences, suggesting that barriers to care exist even in settings mandated to provide services in both official languages. Discussion/Conclusion: There are many barriers to the provision of mental health care services, regardless of the dominant language. However, we identified an internalized sense of responsibility felt by linguistic minority patients, who feel compelled to compensate for or fill in the language gaps of providers.

Introduction: La langue et la communication sont essentielles à la sécurité des soins et à la gestion des personnes aux prises avec un trouble de santé mentale, en particulier lorsque ces personnes sont des minorités linguistiques. Objectifs/méthode: Explorer ces réalités au sein d'une population en situation minoritaire linguistique en complément d'une revue de la littérature et des entrevues qualitatives. Les entrevues ont été menées à Ottawa, au Canada, auprès de patients francophones. Les études incluses dans la revue représentaient la littérature internationale sur les minorités linguistiques en général. Résultats: Dans l'ensemble, les expériences décrites dans les articles publiés étaient semblables aux expériences vécues des participants, ce qui suggère que des obstacles aux soins existent, même dans les contextes ayant pour mandat de fournir des services dans les deux langues officielles. Discussion/conclusion: Il y a de nombreux obstacles à la prestation de services de soins de santé mentale, et ce, quelle que soit la langue dominante. Toutefois, nous avons identifié comme distinct le sentiment intériorisé de responsabilité ressenti par les patients en situation minoritaire qui se sentent obligés de compenser ou de combler les lacunes linguistiques des prestataires.

(Re)construction identitaire et pratique infirmière en psychiatrie légale : réflexion critique sur les commissions d'examen.

Introduction : The caritative impact of nursing care provided in forensic mental health settings is rarely questioned.Context : Caritative nursing care is indirectly regulated by the Review Board (RB), a para-judicial court which ensures public safety.Objective : This study presents a critical reflection on the political and social effects of the RB, forensic psychiatry hospitals and practices of forensic mental health nurses.Method : The reflection is centered on the concepts of biopower, degradation ceremonies, moral career and identity (re)construction.Results : ‘Therapeutic’ nursing practices are useful for disciplinary purposes in the forensic psychiatric hospital, insofar as they permit the identification and management of dangerous persons. However, the practices also fall within the biopolitical scope of the RB, since they assist the latter in ensuring public safety.Discussion : The forensic psychiatric environment can prove problematic for nurses, requiring a double allegiance, whereby their responsibilities to patients (consent and confidentiality) and to the institution (protection of the public) can lead to tension.Conclusion : The analytical framework of the study allows for a reassessment of other presumed processes in psychiatric environments, which nonetheless constitute just as many rituals of identity (re)construction.

Intégration des droits humains dans la pratique du personnel infirmier faisant usage de coercition en santé mentale : recension systématique des écrits et méta-ethnographie.

Introduction and background : The last decade has seen a steady and rising use of coercion in mental health care, as well as an increase in the number of forms it takes. The application of these measures frequently relies on the work of nurses, but few studies have analyzed the human rights issues raised by these practices.Aim : To produce a qualitative synthesis of how human rights are integrated into the practice of nurses who use coercion in mental health care.Methodology : A systematic review of qualitative scientific literature published between 2008 and 2018 was conducted and supplemented by a meta-ethnographic analysis.Results : The analysis of the forty-six selected studies revealed four distinct themes : coercion in mental health care as a socio-legal object, issues of recognition of human rights in mental health care, role conflict experienced by nurses, and the conceptualization of coercion as a necessary evil or a critical incident.Discussion and conclusion : Further research is needed to understand the specifics of the continuum of support and control that characterizes the coercive work of psychiatric nurses.

Incorporating a Physical Activity Program into an Assertive Community Treatment Team: Impact and Strategies.

The objective of this brief report is to present an overview of the main benefits and key characteristics of an individualized physical activity program delivered by an assertive community treatment team in Ottawa, Canada. A mixed-method case study was conducted over a 9-month period. Findings revealed significant reductions in weight, BMI and waist circumference (p < .05) and improvements in self-esteem, autonomy, socialization and other health behaviors. Key characteristics of the program included building a relationship of trust with clients and deploying active efforts to eliminate barriers to PA engagement. Results offer preliminary evidence for integrating an individualized PA program into the ACT team model.

Exploring the Experiences of Parent Caregivers of Adult Children With Schizophrenia: A Systematic Review.

This is a qualitative evidence synthesis on the experiences of parents caring for their adult child with schizophrenia. The Joanna Briggs Methodology for systematic reviews guided the study and standard systematic review procedures were followed. Content analysis was used to synthesize findings from the five studies included into the following categories: 'Resources,' 'Loss,' 'Psychological Distress,' 'Effects on Family,' and 'Framing the Experience.' Findings suggest that parent caregivers struggle to navigate services and need greater support to protect their mental and physical health. From a research perspective, factors influencing parents' abilities to stay engaged in caregiving warrant further exploration.

Convergence and divergence: An analysis of mechanical restraints.

BACKGROUND: Psychiatric nurses are regularly confronted with the uses and effects of control interventions such as mechanical restraints. Although there are evident tensions in the literature regarding the use of mechanical restraints, very little research has focused on the lived and embodied experience of their use, whether from the patient's perspective or the perspective of nursing staff responsible for their application. RESEARCH AIMS: (1) to gain access to the bodily phenomenon of being placed in mechanical restraints; (2) to give voice to the intimate experiential understanding of this experience; and (3) through phenomenological interpretation, to understand the subjective processes and meaning-making of this experience. RESEARCH DESIGN: For this research, we adopted a distinctly ethics-oriented application of the methodology known as interpretative phenomenological analysis, that is, the interpretive dimension of the research focused on ethical practice in mental healthcare - one that is informed by experiential accounts of the lived body. PARTICIPANTS AND RESEARCH CONTEXT: A total of 40 in-depth semi-structured, nondirected interviews with both nurses (n = 21) and patients (n = 19) we conducted to meet the aims of this article. Participants were recruited from an inpatient psychiatric unit of a Canadian general hospital. ETHICAL CONSIDERATIONS: The research received research ethics board clearance from both the hospital where the study took place and the University of Ottawa. FINDINGS: The comparative analysis is presented under the following headings: (1) context of care, (2) meaning of quality of care, (3) emotional reactions and nurse-patient relationship, (4) meeting the needs and (5) need for alternatives. DISCUSSION/CONCLUSIONS: The research findings are discussed in light of current literature and implications for practice.

[Physical activity programs and severe mental illness: A case study of an Assertive Community Treatment (ACT) team]. / Programme d'activité physique et troubles graves de santé mentale : étude de cas d'une équipe communautaire de traitement intensif (ÉCTI).

Context : As a therapeutic intervention, physical activity has the potential to improve the quality of life of individuals with severe mental illnesses.Objectives : The goal of this case study was to conduct an in-depth examination of an individualized physical activity program for patients suffering from severe mental illnesses that was implemented by an Assertive Community Treatment (ACT) team in Ottawa, Canada.Method : Using a mixed-methods design, physical health parameters were measured over a nine-month period and semi-structured interviews were conducted with fourteen patients and five staff members.Results : The findings showed a significant reduction in weight following the evaluation period, as well as positive effects in terms of patients' self-esteem, autonomy, and socialization. The quality of the therapeutic relationship, the elimination of barriers, and the continued involvement of staff members were some of the key characteristics that led to the program's success.Discussion/conclusion : These promising results are an indication of the feasibility of this type of intervention among patients with severe mental illnesses as a therapeutic approach to improve their quality of life and support their recovery and social integration.

An Exploratory Study of a Nurse-Led HIV Postexposure Prophylaxis Program.

The provision of HIV medications to HIV-negative persons after exposure to HIV is known as postexposure prophylaxis (PEP). Because this prevention strategy is primarily only available in emergency rooms, we piloted a nurse-led community-based PEP program in Ottawa from September 2013 through August 2015. As part of evaluating this program, we conducted qualitative interviews with persons who initiated PEP. Twelve men who had engaged in condomless anal sex with other males participated. Thematic analysis of the interview transcripts highlighted that PEP was considered unmentionable because the participants' saw it as proof of past behavior that was perceived negatively. Our results thus revealed that PEP was stigmatized, which made our participants reluctant to answer health care professionals' "questions" about why they needed PEP. To do so was to be exposed to stigma. The use of PEP for our participants was a balance between wanting to minimize the risks of HIV acquisition against the risks of disclosing the unmentionable. We take these findings to mean that clinicians and health service policy workers should move PEP into community clinics (decentralizing it from hospitals, and increase the involvement of nurses); aim to provide all required PEP services in community settings (consolidate PEP provision in these clinics); and ensure PEP services are streamlined to remove extraneous data collection (meaning history and exam tools should be standardized to minimize needless questions that may impede PEP access). Together, these recommendations may increase patients' access to PEP, and maximize its HIV prevention effects.

[Practice in forensic psychiatry: A proposed interdisciplinary model.]

Although professional practice in forensic psychiatric environments is, in our opinion, extremely complex and requires the input of different disciplines, conceptual or theoretical models guiding this practice remain rare or poorly adapted. In this article, we propose an interdisciplinary model of practice to correct this deficiency. The objectives of this article are: to report on the literature review conducted; to report, as faithfully as possible, on our general consultation process with employees practicing in a forensic psychiatric institution; and, finally, to propose an interdisciplinary practice model resulting from this general consultation within the organization.

[Understanding the use of mechanical restraints in psychiatry: phenomenological study of nurses'lived experience].

The use of mechanical restraints in psychiatric settings is currently the subject of ethical controversy. However, both patients' and nurses' voices are absent in the debate over this controversial intervention. The objective of this qualitative study was to examine the experience of psychiatric nurses using mechanical restraints. Twentyone nurses working on either the acute psychiatric inpatient unit and/or the emergency psychiatric unit of a university affiliated Canadian hospital participated in semi-structured interviews, which were then transcribed, coded and analyzed using the interpretative phenomenological analysis (IPA) method. Three main themes were identified : 1) Practice setting ; 2) Mechanical restraint process ; and 3) Resorting to mechanical restraints. These results highlight the organizational and emotional challenges faced by psychiatric nurses. Foucault and Goffman's work were the primary theoretical sources that guided the critical analysis of this qualitative research.

[Identification and management of violence in psychiatry: Nurse and patient perceptions of safety and dangerousness]. / Identification et gestion de la violence en psychiatrie: perceptions du personnel infirmier et des patients en matiére de sécurité et dangerosité.

This paper reports the results of a study on the identification and management of violence on a psychiatric ward and in the psychiatric emergency of a Quebec hospital. The purpose of this exploratory and descriptive study was to examine patients' and nurses' perceptions and strategies for identifying and managing patient aggression and violence. Results show that the type of setting influences the way aggressive behaviour issues are perceived and managed. The types of behaviours deemed aggressive or risky also vary between the two units. Moreover, patients and nurses are similarly described by all participants as susceptible to being violent and to being a victim of violence. Prevention of aggression and violence remains a significant challenge in psychiatric nursing, where administrative and environmental constraints, the growing complexity of clinical profiles, divergent interprofessional approaches to care, and collective feelings of apprehension and vulnerability interact.

Treatment adherence redefined: a critical analysis of technotherapeutics.

Treatment adherence issues in the context of chronic illnesses have become an important concern worldwide and a top priority in the field of health-care. The development of devices that will allow healthcare providers to track treatment adherence and monitor physiological parameters with exact precision raises important questions and concerns. The aim of this study is to interrogate the use of these new technological devices which allow for previously unavailable data to be recorded on an ongoing basis and transmitted via a tiny microchip inserted into the body. Drawing on the work of Michel Foucault, we analyze how this anatomo-political and bio-political instrument serves to discipline chronically ill individuals and govern the health of entire populations who suffer from chronic conditions. To support our analysis, this article comprises three sections. First, we provide an overview of treatment adherence and technotherapeutics. Then, we explain how technotherapeutics concern the government of bodies and conducts at the individual level and population level more generally. Lastly, we provide an example of how this analysis can be connected to routine nursing practice in the field of HIV.

Expanding our understanding of sovereign power: on the creation of zones of exception in forensic psychiatry.

The purpose of this paper is to engage with the readers in a theoretical reflection on nursing practices in forensic psychiatric settings. In this paper, we argue that practices of exclusion in forensic psychiatric settings share some common ground with Agamben's description of sovereign power and, consequently, the possible creation of zones of exception in this environment. The concept of exception is, therefore, purposely used to shift our thinking, highlight the political forces surrounding exclusionary practices in forensic psychiatric nursing, and explore the ethical tensions that arise for nurses who become entangled in the control of these zones of exception. We argue that ethical and political discussions regarding this phenomenon are necessary if we wish to further understand the complexities of this field of practice and promote constructive change.

Discursive constructions of family functions in forensic psychiatry: A critical ethnographic perspective.

Significant barriers remain regarding the implementation of family-centred approaches in the domain of forensic psychiatry despite their effectiveness at increasing adherence to treatment, improving attendance to medical appointments, decreasing readmission rates and reducing episodes of relapse. We attribute these barriers to a fundamental gap in our understanding of the family function and its role within the forensic psychiatric system. Despite requesting to be included and considered as partners, some families feel excluded and sidelined, which causes distress, incomprehension and disengagement. We approached this tension at the discursive level through a critical ethnography of the Review Board and the work of Foucault on psychiatric power, which provided us with a unique opportunity to understand how the role of families are constructed and sustained in the Canadian forensic psychiatric system. To do so, we mobilized data stemming from ethnographic observations and documentary artifacts entitled 'reasons for disposition'. Data analysis allowed us to identify two discursive constructions of familial functions: (1) families as repositories of information and (2) families as supervisory agents. These results have implications for health care professionals and administrators in forensic psychiatry who are increasingly adhering to family-centred care models without questioning what such care or what such family engagement entails.

The Forensic Psychiatric Network of Observation and Documentation: At the Intersection of Review Board Hearings and Nursing Practice.

ABSTRACT: Forensic psychiatric nursing is a specialty at the junction of two well-researched intersecting systems with two mandates: criminal justice and health care. Nurses' involvement at one of the systems' points of juncture, review board (RB) hearings, has largely been left unexplored. At RB hearings, a panel of legal and healthcare professionals determines if persons unfit to stand trial (UST) or not criminally responsible on account of mental disorder (NCR) represent significant threats to the safety of the public and orders conditions aimed at keeping the community safe. The aim of this article is to present the results of a critical ethnography that explored how psychiatric and public safety discourses construct the identity of persons UST or NCR during RB hearings as well as nurses' contribution to such identity construction. The main finding is that the forensic psychiatric structure leverages nursing interventions and documentation as evidence of deviancy, so that persons UST or NCR can be objectified and produced as dangerous. Structures sustaining the forensic psychiatric system inscribe nursing care within a disciplinary scheme, rendering the care-and-custody dichotomy insufficient to explain the complex processes at play in forensic psychiatry. These findings have implications for the practice of nurses working in forensic psychiatric settings and for that of other nurses who practice on the medicolegal borderland.

Trauma-Informed Care Interventions Used in Pediatric Inpatient or Residential Treatment Mental Health Settings and Strategies to Implement Them: A Scoping Review.

Trauma-informed care (TIC) is an approach to care emerging in research and in practice that involves addressing the needs of individuals with histories of trauma. The aim of this scoping review was to examine the current literature relating to TIC interventions used in pediatric mental health inpatient and residential settings. We sought to answer the following two research questions: (a) What are the TIC interventions used in pediatric inpatient and residential treatment mental healthcare settings and what are their components? and (b) What are the implementation goals and strategies used with these TIC interventions? We conducted this scoping review according to JBI (formerly Joanna Briggs Institute) methodology for scoping reviews. We included any primary study describing a TIC intervention that was implemented at a specific site which identified and described implementation strategies used. Of 1,571 identified citations and 54 full-text articles located by handsearching, 49 met the eligibility criteria and were included, representing 21 distinct TIC interventions. We present the reported aim, ingredients, mechanism, and delivery (AIMD) of TIC interventions as well as the implementation goals and strategies used, which varied in detail, ranging from very little information to more detailed descriptions. In the context of these findings, we emphasize the complexity of TIC and of TIC interventions, and the importance of identifying and clearly reporting TIC intervention goals, intervention details, and implementation strategies. We suggest applying intervention frameworks or reporting guidelines to support clear and comprehensive reporting, which would better facilitate replication and synthesis of published TIC interventions.