The purpose of acute care settings has been to provide intensive treatment to clients experiencing mental illness, who have been assessed as high risks for harming oneself and others, or are unable to care for their basic needs without treatment (Kunyk, 2019). Psychiatric nurses have a level of responsibility for every person residing on the unit, which contributes to the need to nurse the population on the unit as a whole (Cleary, Hunt, Horsfall, & Deacon, 2012). Therefore, psychiatric nurses have a dual role of providing care for individual clients and managing the demands of the unit. This dual role may lead to competing demands and difficulty with prioritizing care needs. Although much of the literature has focused on providing care on an individual basis, there is little in the literature regarding strategies to provide care for the entire unit (Delaney & Johnson, 2006; Thibeault, Trudeau, d'Entremont, & Brown, 2010). One strategy used to care for clients in acute care settings involves situational awareness. The current article adds additional knowledge regarding situational awareness in acute care psychiatric nursing.
Psychiatric nursing involves being present with clients and caring for their immediate physical, psychological, social, emotional, and spiritual needs during life crises (Santangelo, Procter, & Fassett, 2018). Psychiatric nurses employed in acute care settings aim to balance the needs of particular clients with the demands of the unit as a whole. Caring for clients in the acute care unit requires advanced levels of awareness. Psychiatric nurses require self-awareness to apply the therapeutic use of self and develop a therapeutic relationship with clients (Eckroth-Bucher, 2010; Rasheed, 2015). Understanding or awareness of clients' needs is achieved through assessment skills and observation tasks. Assessment and observation have been identified as the foundation of psychiatric nursing practice and the groundwork for determining care needs and applying interventions (Higgins et al., 2016). Balancing unit safety and individual client care needs can be achieved through sophisticated assessment skills and observation of the tone and pace of the unit to gain an intuitive grasp of the situation and plan interventions (Delaney & Johnson, 2006).
To provide holistic care, psychiatric nurses aim to understand the ways that the environment impacts the health and well-being of clients. In acute care psychiatric nursing, the environment has been referred to as the milieu. The milieu is considered to be the psychological, physical, social, political, and spiritual components of the acute care unit (Thibeault et al., 2010). Safety is a function of the ward milieu (Thibeault et al., 2010), and safety provision is an important role of psychiatric nurses (Cleary et al., 2012). Psychiatric nurses aim to maintain a safe and secure environment, while attempting to provide therapeutic, individualized nursing care. However, clients' experiences of safety may diminish related to potential threats present in the unit environment, such as aggression from other clients residing on the unit (Stenhouse, 2013). The perception of threat can stem from tension in the unit milieu. To provide safe, holistic care, psychiatric nurses must strive to understand complex dynamics of the acute care unit.
Caring for the entire unit is a complex phenomenon filled with multiple priorities and competing demands. One of the authors (A.E.T.) has many years of experience as a psychiatric nurse in acute care. However, as a novice nurse, the concept of caring for the entire unit was foreign. Through years of experience, the author began to develop skills to meet the needs of individual clients, as well as the skills to manage the dynamics of the unit. This led the author to ponder how do psychiatric nurses care for clients on the acute care unit and what interventions do they use. There was scant literature available to describe the interventions used to care for clients on an acute care unit (Delaney & Johnson, 2006). Hermeneutic phenomenology was used to answer the question: What are the lived experiences of psychiatric nurses in delivering nursing interventions to adult clients in acute care settings?
The purpose of hermeneutic phenomenology is to explore lived experiences (van Manen, 1997); the manner by which psychiatric nurses practice is their lived experience. Six participants were recruited and interviewed.
Six expert psychiatric nurses, having considerable experience in an acute care setting, were invited to participate. An expert nurse has an intuitive grasp of clinical situations, is highly efficient in meeting client needs, and is very effective in care provision (Benner, 1984). Knowledge and skills critical to acute care psychiatric nursing center on awareness, presence, attending to the needs of clients and unit milieu, compassionate caring, and capacity to maintain a balanced practice (Delaney & Johnson, 2006).
Inclusion criteria for participants were that they currently worked in acute care psychiatric nursing practice with adult clients in a large urban Canadian prairie city, were engaged in front-line psychiatric nursing, held active psychiatric nursing registration, and were an expert psychiatric nurse as outlined by Benner (1984). Criteria also included being recognized as an expert by peers, practicing critical psychiatric nursing skills as outlined by Delaney and Johnson (2006), demonstrating an intuitive ability to establish and maintain therapeutic relationships, having many years of experience in acute care settings, and agreeing to discuss psychiatric nursing interventions. Because educational background was identified as a variable that could influence the results, RNs who worked in acute care settings were not included. Psychiatric nursing practice in rural acute care settings also was an exclusion criterion, as mental health care provision and resources in rural communities differ from services and resources available in urban communities.
These expert psychiatric nurses were recruited through purposive, snowball sampling. Potential participants were evaluated as meeting the inclusion criteria of an expert psychiatric nurse by the researcher or by another expert psychiatric nurse. Participants were recruited until sufficient data had been gathered to provide meaningful analysis. All six psychiatric nursing participants were women and worked in a large multi-unit facility in a city on the Canadian prairies.
Participants' years of psychiatric nursing experience ranged from 7 to 46. Two participants held psychiatric nursing diplomas, and four participants held undergraduate degrees in psychiatric nursing as their highest educational credential. The difference in educational preparation and years of experience did not appear to influence the findings, as all participants voiced common understandings and data saturation was reached.
In hermeneutic phenomenological research, emphasis is placed on understanding the meaning of lived experience (van Manen, 1997). The researcher aimed to understand the experience of psychiatric nurses who practice in acute care settings. The purpose of the interview was to explore and gather experiential narrative to develop an understanding of the phenomenon (van Manen, 1997). Data were collected through the use of open-ended, semi-structured research questions delivered through conversational interviews.
After obtaining approval from the ethics review board at Brandon University and consent from potential participants, interviews were conducted privately by the lead researcher (A.E.T.) at a time and place convenient for the participant. Data collection consisted of audiotaped, semi-structured interviews using 18 open-ended questions; interviews lasted 1.5 to 2 hours. Questions were both general (e.g., “What does it mean to you to be a psychiatric nurse practicing in acute care?”) and specific (e.g., “What psychiatric nursing interventions do you use?”). Participants were asked to describe the phenomenon as fully and deeply as they were able to gain understanding of the lived experiences of psychiatric nurses in acute care settings.
Interviews were transcribed verbatim by a trained transcriptionist. Data analysis began when data collection commenced. Data analysis centered on van Manen's (1997) method of phenomenology.
Hermeneutic phenomenology involves the study of the life world as experienced rather than as one conceptualizes or theorizes (van Manen, 1997). Bracketing is a strategy to identify the researchers' own beliefs about the phenomenon. However, in van Manen's method, such strategies are recognized as useful goals while not being fully achievable, as the researcher is never fully separate from influencing the data analysis. The researcher's understandings, beliefs, biases, assumptions, presumptions, and theories related to psychiatric nursing were made explicit as described by van Manen (1997).
To come to an understanding of the essential structure of the phenomenon, reflection occurred through the practice of reduction (van Manen, 1997). Reduction involved awakening to a sense of wonder and amazement of the phenomenon, and reduction was used to set aside understanding of theories and conceptualizations of the phenomenon (van Manen, 1997). The lead researcher debriefed with the research team to assist with maintaining credibility of the findings.
Phenomenological themes are the experiential structures that make up the experience (van Manen, 1997). The purpose of data analysis was to preserve the unique experiences of participants through interpretation of shared meaning (van Manen, 1997). Texts were analyzed in relation to the contextual features of the lived experience. Textual analysis remained constant through all stages of inquiry. The researcher immersed herself in the data to illuminate in-depth, rich, contextual understanding (van Manen, 1997).
Attention to phenomenological methodology was maintained throughout the research process. An audit trail was maintained to assist with trustworthiness and authenticity of the data. Data were analyzed for meaningful phenomenological themes. Texts were analyzed in relation to the contextual features of participants' lived psychiatric nursing experiences providing care in acute settings. The themes of awareness and person-centered care approaches in psychiatric nursing were identified. The theme of person-centered care is discussed in a separate article (Thomson, Racher, & Clements, 2019). The focus of this article is on the theme of Awareness and subthemes of self-awareness, awareness of the client, and situational awareness.
Awareness in Psychiatric Nursing
Awareness was described by all participants as an ongoing process of paying attention to subtle changes concerning self, the client, and the environment. Integral aspects of awareness in acute care settings included self-awareness, awareness of the client, and situational awareness. All aspects of awareness were required for psychiatric nurses to understand the complex dynamics of an acute care unit and maintain safety. Participants' increased levels of awareness led to an improved ability to determine and deliver psychiatric nursing interventions and enhance unit safety.
Participants described self-awareness as being essential to delivery of psychiatric nursing interventions. Participants stated that understanding their own thoughts, emotions, and actions was necessary to empathize with clients, develop a therapeutic relationship, and deliver the appropriate psychiatric nursing intervention. Knowing oneself was described as a key component to ensure that professional boundaries were maintained.
The process of noticing emotions that occurred within oneself was a component of self-awareness. One participant stated:
I'm really picking up on sort of the energy around the unit, the energy a specific individual is displaying. People are anxious and other people are upset; you can start feeling the same way. It's important that, as nurses, we can acknowledge that we're feeling this way and why are we feeling this way. Awareness of your feelings and how you're responding to different clients and if you need to talk about it and debrief with coworkers and do that appropriately…It's really just about reflecting and really just about understanding yourself and understanding who you are in psychiatric nursing practice.
The expert psychiatric nurses paid attention to their intuition and used this form of knowing to guide their interventions in a safe and effective manner. Intuition was described as an awareness, gut feeling, or instinct that assisted with determining the appropriate time to communicate and provide interventions. The skill of intervening, based on intuitive feelings, was fostered over years of psychiatric nursing practice. Sensations of intuition served as a signal or cue for psychiatric nurses to take action and investigate situations further. One participant described using intuition to guide when to intervene:
Be aware almost all the time…It's an ongoing, daily process…If you have a tingly feeling in the back of your neck, make sure you pay attention...If it doesn't feel right, act on it. If you feel something isn't going right or you haven't seen a patient in a while, you might get that gut feeling, “I should go and check on them.” It's an intuitive feeling that helps me to provide care.
Participants discussed reflective practice as a feature of developing self-awareness. Reflection aided the psychiatric nurse in the provision of care. Self-awareness was required as an element of personal knowing that served as the basis for developing awareness of the client.
Awareness of the Client
Participants described the process of developing awareness of the client through their ongoing assessments and observations of clients in care. Participants stated that paying attention, observing, and noticing were key actions used to increase their levels of awareness. The purpose of developing awareness of persons in care was to employ interventions that best met the needs of clients in the present moment. Knowing the client was described as a component of fostering safety.
One participant stated:
We're certainly looking at safety as the number one priority…To make sure this person is safe, comfortable, and what can we do to sort of help them get through their day and through their stay on the unit…It's also about what the patient feels they need to make them feel safe.
Another participant explained:
You observe. Being front line, you're often at the desk or just on the unit, so you're just kind of paying attention to actions of patients…All the time you're paying attention. Even when they're sleeping, you're paying attention to how much they're sleeping. You certainly have to have a really solid foundation for your assessment skills because you're getting so many people coming in and out. You just have to be really quick and efficient in what you're doing.
The process of gaining awareness was ongoing as a client's thoughts could change from moment to moment; therefore, having frequent contact, or “check-ins,” with persons in care was an important aspect of safety provision. In addition to knowing a client as an individual, the psychiatric nurses recognized the importance of being aware of all persons residing in the acute care environment as well as the unit milieu, which involved elements of situational awareness.
Participants described the importance of being aware of one's surroundings and the environment. This type of awareness has been identified as situational awareness, which involves noticing the elements of an environment, in time and space, to understand the comprehensive meaning or potential influence of the elements and predict the elements' status in the near future (Endsley, 1995). Psychiatric nurses reported that working in complex and dynamic environments required ongoing assessment of the situation, as situations were in states of flux. Situational awareness was required to understand complex environmental situations and intervene appropriately and safely. Participants described knowledge and skill using this awareness to assess the acute care milieu.
One participant reported:
To be available, to be attuned to what's going on in the environment around them [client], around all of us… You're nursing the whole unit, even though you are only responsible for certain people. A hard part is also learning how to manage staff and to run a unit is a big thing, and it's a skill, and it takes time.
Another participant stated:
You have to have really good planning and organizational skills to really sort of work on that unit. Because… it's so busy that you just have to know how to prioritize. Nurses are on top of all the clients and how one person could be impacting the rest of them. Nurses that are not aware run into trouble…You need to pay attention to the dynamics to increase the safety of everyone on the ward.
Time constraints and increased unit acuity were described as challenges to providing psychiatric nursing interventions. The expert psychiatric nurses developed skill in situational awareness to address the challenges associated with reduced time to provide care and increased acuity of the clients on the unit. To achieve situational awareness, the psychiatric nurse paid attention to the complex dynamics of the unit milieu. Psychiatric nurses scanned the environment to obtain clinical cues such as presence of objects, noise, and hazards. The scans captured the physical and social conditions of the unit milieu at that moment in time. The purpose of the scan was awareness and planning. Meaningful methods of providing psychiatric nursing care were illuminated through descriptions of self-awareness, awareness of the client, and situational awareness.
The process of becoming aware took place in the present moment, involving interplay of self-awareness, awareness of the client, and situational awareness. Reflection and clinical experience of the psychiatric nurse enhanced all forms of awareness (Jack & Miller, 2008). Self-awareness and awareness of the client have been studied extensively (Eckroth-Bucher, 2010, Jack & Miller, 2008; Rasheed, 2015; Van Sant & Patterson, 2013). The theme of situational awareness in psychiatric nursing adds to the current knowledge base.
Self-awareness involved the process of knowing, questioning, and understanding one's thoughts, feelings, beliefs, and values to consciously guide care and deliver nursing interventions (Eckroth-Bucher, 2010). Self-awareness has been described as a conscious, ongoing (Rasheed, 2015), voluntary process of introspection (Eckroth-Bucher, 2010). Self-awareness has been key to establishing therapeutic communication (Eckroth-Bucher, 2010; Van Sant & Patterson, 2013), providing person-centered care, and developing the therapeutic relationship. Intuition served as a catalyst to take action and complete assessments with clients.
Noticing, assessing, observing, and paying attention were ongoing actions of psychiatric nurses to become aware of clients. Awareness of clients was achieved through an ongoing process of observing them from a distance, as well as talking to them individually. Verbal and nonverbal clinical cues that clients displayed ranged from subtle to overt and signaled changes in the client's condition; these cues often were recognized intuitively by psychiatric nursing staff (Burbach & Thompson, 2014). Successful nursing practice involved the ability to develop a grasp of significant clinical cues for early intervention and prevention (Burbach & Thompson, 2014).
Psychiatric nurses require awareness of all persons residing on the unit along with the awareness of the milieu, or situational awareness. The subtheme of situational awareness offered insight into psychiatric nursing interventions aimed at enhancing environmental safety within acute care units. Clinical cues are observed through the practice of psychiatric nurses, who are constantly scanning and monitoring the environment to have current knowledge of the environment (Sitterding, Ebright, Broome, Patterson, & Wuchner, 2014), similar to the process described for awareness of clients.
The goal of situational awareness has been to form a holistic picture of the setting and understand the significance of events and cues to predict future states of the environment (Endsley, 1995). Acute care units have become busy, demanding, and stressful environments, and situational awareness has become critical for clinical decision making and enhanced client safety (Gluyas & Harris, 2016). Many decisions have been made in the context of dynamically changing situations; therefore, situational awareness has become crucial in psychiatric nursing.
Participants discussed the importance of taking staffing issues into consideration as part of situational awareness. Situational awareness has been used to assess the status of the milieu, client interactions and relationships, and team dynamics. Situational awareness in nursing has remained generally unexplored in psychiatric nursing literature (Sitterding, Broome, Everett, & Ebright, 2012). A comprehensive critique of the effects of managerial practices on acute care units would assist psychiatric nurses in understanding situational conditions and help ensure the safety and well-being of clients and staff (Molina-Mula, Peter, Gallo-Estrada, & Perelló-Campaner, 2018).
Self-awareness and client assessment strategies have a plethora of research available specific to psychiatric nursing (Jack & Miller, 2008; Van Sant & Patterson, 2013). The phenomenon of situational awareness, also known as situation awareness, was first identified in the field of air traffic control (Endsley, 1995). The principles and constructs of situational awareness have been adapted to other complex environments such as health care (Endsley, 1995) and have been identified as being applicable to nursing; however, little research has been conducted on situational awareness in nursing (Sitterding et al., 2014).
Similarly, scant research on situational awareness in psychiatric nursing is available; therefore, more research is needed (Patterson, Procter, & Toffoli, 2016). A concept analysis regarding psychiatric nursing situational awareness is required to serve as a foundation for understanding this complex phenomenon. Further research into ways that psychiatric nurses develop and employ situational awareness in acute care settings is required as awareness is used to enhance client and unit safety. Research on situational awareness in psychiatric nursing is needed to develop methods to incorporate this skill into nursing education.
Levels of awareness in psychiatric nurses may be increased through clinical supervision, team debriefings, journaling (Eckroth-Bucher, 2010), and portfolio development (Rasheed, 2015). Undergraduate nursing education should include aspects on the development of self-awareness, reflective practice (Rasheed, 2015), and situational awareness. Educational techniques such as simulation and psychodrama may support developm ent of awareness (Rasheed, 2015).
Computer-based simulations can assist with clinical cue recognition (Burbach & Thompson, 2014). Development of standardized computer simulation scenarios have potential to enable researchers to evaluate the efficacy of this form of teaching (Burbach & Thompson, 2014). Simulation has been used as a strategy to develop situational awareness in air traffic control educational programs (Endsley, 1995), although additional research specific to nursing is required. Simulation-based education may provide a safe environment to evaluate and develop all forms of awareness. Educators have followed reflective practice models and examined clinical situations to help students understand the balance between individual care and the milieu (Delaney & Johnson, 2006).
Limitations and Strengths
Features of this study may be considered as limitations. The first limitation is that the findings may be difficult to transfer to the larger population of psychiatric nurses, as participants were drawn from only one source and the sample was small. Including rich descriptive details as voiced by participants and adhering to the practice of reduction assisted with enhancing rigor and transferability of the study. In addition, an extensive audit trail was maintained to establish authenticity and trustworthiness of findings.
The lead researcher's professional practice as a psychiatric nurse and many years of experience working in acute care settings may be considered a strength of the study. The researcher's background, qualifications, and experience are important in qualitative research as the researcher is an instrument in data collection and analysis. The lead researcher's professional experience may have assisted with her ability to build rapport with the participants and interpret the findings.
Safety is perhaps the most important aspect of psychiatric nursing care provision. Acute care psychiatric nurses require awareness of self, clients, and the environment to safely care for individual clients while managing the complex unit milieu. Language to describe ways that psychiatric nurses care for the entire ward was lacking. Increased understanding regarding the importance of all forms of awareness will improve acute care psychiatric nurses' abilities to provide safe care to address the changes and complex demands faced in the profession.
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