A critical narrative analysis of shared decision-making in acute inpatient mental health care.

Shared decision-making (SDM) is a high priority in healthcare policy and is complementary to the recovery philosophy in mental health care. This agenda has been operationalised within the Values-Based Practice (VBP) framework, which offers a theoretical and practical model to promote democratic interprofessional approaches to decision-making. However, these are limited by a lack of recognition of the implications of power implicit within the mental health system. This study considers issues of power within the context of decision-making and examines to what extent decisions about patients' care on acute in-patient wards are perceived to be shared. Focus groups were conducted with 46 mental health professionals, service users, and carers. The data were analysed using the framework of critical narrative analysis (CNA). The findings of the study suggested each group constructed different identity positions, which placed them as inside or outside of the decision-making process. This reflected their view of themselves as best placed to influence a decision on behalf of the service user. In conclusion, the discourse of VBP and SDM needs to take account of how differentials of power and the positioning of speakers affect the context in which decisions take place.

How do nurses cope when values and practice conflict?

BACKGROUND: A lack of opportunity to express values in nursing practice and a conflict of ideals with organisational constraints are associated with low job satisfaction and high attrition rates. AIM: To explore the stories of mental health nurses to find how values influence their experience of nursing practice. METHOD: Twelve participants, who had between six months', and three years' experience of post-registration practice, were interviewed. RESULTS: Nurses' values were often established before they started training. Participants described values that were consistent with a commitment to person-centred care and professional and ethical principles expected by governing bodies. CONCLUSION: Mental health nurses are aware of the dissonance that arises when there is a conflict between their values and their practice. They respond to this in a variety of ways, notably through acceptance, rejection or innovation.