The use of coercion by staff led to a sense of mistrust. That was a sanction to force me to see my consultant that I don't wish to work with. I distrust my psychiatrist that much. Although trust was not overtly attributed to other patients, it is clear that in many cases there was an atmosphere of trust between patients that was valued. All but one of the participants recognised that the purpose of hospital in part was to provide treatment.
However, trust in staff to treat patients appropriately was not always apparent. You can see the nurse don't know what to do for them. Treatment was composed of two subcategories "medication" and "therapies. There was general acceptance of medication in the treatment of mental illness. However, there was also dissatisfaction expressed about the types of treatment received and the process of receiving treatment.
Six participants described potential overmedication leading to feelings of being "doped up. There was a strong link between the codes for medication and communication. The value of effective communication in discussions about medication is highlighted by two patients. Service user: "You know they wanted to put me on olanzapine, or the other antipsychotic thing, and I didn't want that. Because I've had it before and it was absolutely awful.
It's the worst drug I've ever taken. And I didn't want to go there so I refused all that kind of, any medication or tablets. What did the consultant do but put me on Depixol and it had a horrific effect on me, absolutely horrific. I can't blame everything on the medication, I know it was wrong of me, and they put me on it against my will, my mothers. Effective communication is also of prime concern in capacity to consent to treatment, and specifically to receiving ECT. The following participant describes being asked to sign a consent form to receive ECT while actually not having capacity.
My brother said to him, you could get her life away at the moment, but he had to have me sign it. There was a strong link between medication and coercion. All physical restraints reported were followed by forcible injection and several people reported perceived coercion in receiving treatment. In addition to treatment with medication or ECT four people also highlighted a need for talking therapies while in hospital. Therapies that were spoken of positively were founded on good relationships with the facilitator.
This included a group based on the step model run by a nurse who had been a service user herself. Therapies spoken of disparagingly included art, and music therapy. While the art therapy was not in itself ridiculed, it was deemed worthless as an activity by the following participant due to lack of communication and understanding by staff. You know like, there's nothing wrong with that it's Easter it's got to be accepted by everyone.
And they said to me, why are you drawing that? So I said, its Jesus, remember it's Jesus when he died. You know I didn't go round the trees. He said, but this picture, are you feeling like at death's door, are you feeling like you are crucified or something. I said, no I'm just drawing because of Jesus my hero dying at the cross. But they wouldn't have that, they tried to look into, thinking I was crucified inside. And I got so fed up with them and things.
Six participants raised issues associated with cultural competency in hospital and all of these experiences were negative. Experiences described include a lack of understanding by staff, and racism. A lack of cultural awareness and sensitivity by staff is demonstrated in the narrative of a young Black African woman describing the difficulties she faces as a result of her belief that her mental illness results from possession and the use of voodoo.
Two service users remarked on the difficulties faced in being nursed by non-British staff and this was explained by one interviewee as due to differences in cultural beliefs about the origin of mental illness. Finally, racism towards ethnic minority patients was reported as an experience by ethnic interviewees and witnessed by white interviewees. And that's what I experienced in the psychiatric system. Twelve participants spoke about freedom while in hospital. The focus was primarily on physical freedom, the freedom to be outside, or to leave the unit.
Such freedoms were viewed both as a basic human right, and also therapeutic in reducing feelings of confinement and being in touch with the environment. Conversely, a lack of freedom could induce mental distress. A lack of physical freedom was not expressed only by service users who were compulsorily detained. The environment, staff decision-making and resources contributed to perceived freedom. Some hospitals had no outside space for patients, while other patients, even those admitted voluntarily, were not allowed out.
Routledge Studies In Health And Social Welfare Series
Finally one patient describes being granted escorted leave but being unable to go outside due to the lack of an available staff escort. Hospitals with a lack of freedom were likened by five people to prisons, with service users fulfilling the role of prisoners receiving punishment. Freedom was concurrent with the codes coercion and trust. A denial of physical freedom was often perceived as coercive, and the denial of freedoms was attributed to a lack of trust in patients by staff. Interviewer: "And did you find the freedom helpful?
Service user: "Yeh, because then they either trust you or they don't. This category embodies the physical elements of the psychiatric hospitals experienced. The category was a minor one and while it was raised by 10 people, those sections coded were the shortest. With the exception of one report, the environment was only raised as a factor in service users' experience if it was quite poor. Descriptions of the hospital environment included a lack of basic hygiene, old buildings in poor physical condition, overcrowding with a lack of staff, and lack in basic home comforts.
There are no curtains, in the corridor or the smoking room. The windows are filthy; the furniture's filthy and burnt. It's an absolute dive.
It's disgusting and I wouldn't put a pig there let alone a human being. While Quirk and Lelliot [ 2 ] noted that of the majority of the research on service users' experiences of hospital was negative, the participants interviewed for this study identify both negative and positive experiences of being an inpatient in a psychiatric hospital.
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Central to the narratives of all interviewees were eight main themes: contrary to previous research on patients' experiences, the themes that predominated related to the emotional not physical environment in which they stayed. The difference in emphasis in the findings of this study may be due to a number of factors, of which the user-led nature of the research and the use of a user interviewer are important factors to consider. Interviewer influence has been a neglected effect in psychiatric research [ 20 ].
Interviewers may influence the type of people who consent to take part, the quality and quantity of interview data. Research suggests that user interviewers may help to engage other users whose voices are not normally heard such as those who feel alienated as a result of their experiences of hospital, and those who would not wish to share their experiences with professionals [ 21 ]. During the interview, interviewer variance in terms of race, sex and age can making a difference to the content of the completed interview [ 22 , 23 ] and the experience and enthusiasm of the researcher can influence the length and nature of the interview as well as disclosure by interviewees [ 20 ].
An acknowledgement of power differentials between interviewer and interviewee throughout the interview process [ 18 ] and an effort to empower interviewees through an emancipatory approach can also affect the traditional relationship between researcher and researched and consequently the narratives elicited [ 14 ]. Finally, analysis by insider or outsider researchers, that is, researchers with different standpoints, such as clinical or user researchers can also affect the interpretation of the interview's content and the presentation of results [ 14 ].
Confounding factors which ultimately impact on the findings of research studies are a consequence of all qualitative approaches. Such influences are often referred to as limitations of a study, however within emancipatory research the influence of an insider researcher is seen as a strength of the approach. When undertaken with rigor and reported in an open and transparent manner, emancipatory research promotes an understanding of an area from a unique perspective.
The physical and emotional components of patient experiences have only recently being recognised. Initiatives within the NHS aimed at improving the patient experience in hospital have focused largely on the physical environment. However, more recently consultation with patients, public and NHS staff has worked to define the emotional aspects of positive patient experiences and include the need to feel cared for, safe, confident and in control, being communicated with as an equal, and being treated with honesty, dignity and respect [ 24 ].
Many of these emotional experiences come as a result of positive aspects of relationships, and this emphasis on relationships in shaping experiences is clearly described by the participants in this study. The overarching theme of these interviews was that of interpersonal relationships. Human relationships can be argued to be the primary motivational force in life [ 25 ]. It is not surprising therefore that relationships while in hospital play an important role in shaping patient experiences. Service users' descriptions of their experiences were largely centred on their relationships with staff or other patients.
The importance of relationships cannot be underestimated, with increasing evidence that building and maintaining a strong therapeutic relationship can be an agent for change in itself and leads to positive client and treatment outcomes [ 26 , 27 ]. While each of the themes relating to relationships, depending of the quality of interaction, could affect the relationship in a positive or negative way, coercion was always experienced negatively and had a negative impact on relationships. Communication was the theme most central to the perception of relationships and an essential ingredient of the patient experience.
How a relationship was experienced related to the nature and quality of the communication.
Researching Trust And Health by Julie Brownlie
Leach [ 26 ] recognises the impact that a clinician's behaviour and communication style can have on practitioner-client relationships. He discusses aspects of staff engagement that elicit good communication, trust and rapport with patients, many of which can be said to be of importance to the service users interviewed.
Both studies highlight the importance of staff being approachable, non-judgemental, engaging, empathic, respectful of clients' wishes and needs, and the formation of a collaborative relationship. The largely positive relationships of service users in this study with other patients, and staff who had personal experience of mental illness may be indicative of the value of collaboration, self-disclosure by both parties in developing relationships [ 28 ].
Both safety and trust were important in influencing the patient experience and the consequences of positive therapeutic relationships in hospital. The issue of safety was key to how relationships were experienced in hospital. With one of the functions of hospital being that of a place of safety, service users defined safety both in terms of safety from themselves and safety from others.
The need for social input and the link between social isolation and suicide highlights this importance of safety for those at risk of harm [ 29 ]. However, much of the discussion with service users centred on a lack of safety on wards. The role of violence within the mental health system is a largely under researched subject [ 30 ].