A Concept of Recovery in PICU - Storytelling Safeguarding Treatment and Responsibility Attributes of Recovery in Psychiatric Intensive Care Units

Journal of Psychiatric Intensive Care
Storytelling; Safeguarding; Treatment; and Responsibility;

attributes of recovery in Psychiatric Intensive Care Units
Journal:
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Manuscript ID:
Manuscript Type:
Keywords:
JPIC-Sep-2014-RA-012.R1
Review Article
Recovery, Psychiatric Intensive Care, Nursing practice, Inpatient,
Recovery-oriented health services
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Background and aim: In recent years policy in Australia has endorsed

recovery-oriented mental health services underpinned by the needs, rights
and values of people with lived experience of mental illness. This paper
critically reviews the idea of recovery understood by nurses at the frontline
of services for people experiencing acute psychiatric distress.
Method: Data gathered from focus groups held with nurses from two
hospitals were used to ascertain their use of terminology, understanding of
attributes and current practices that support recovery for people
experiencing acute psychiatric distress. A review of literature further
examined current nurse based evidence and nurse knowledge of recovery
approaches specific to psychiatric intensive care settings.
Results: Four defining attributes of recovery based on nurses perspectives
are shared to identify and describe strategies that may help underpin
recovery specific to psychiatric intensive care settings.
Conclusion: The four attributes described in this paper provide a pragmatic
framework with which nurses can reinforce their clinical decision-making
and negotiate the dynamic and often incongruous challenges they
experience to embed recovery-oriented culture in acute psychiatric
settings.
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Abstract:
Cambridge University Press
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Title
Storytelling; Safeguarding; Treatment; and Responsibility; attributes of recovery in
Psychiatric Intensive Care Units
Short title
A Concept of Recovery in PICU
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Abstract and Keywords
Background and aim: In recent years policy in Australia has endorsed recovery-
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oriented mental health services underpinned by the needs, rights and values of
people with lived experience of mental illness. This paper critically reviews the idea
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of recovery understood by nurses at the frontline of services for people experiencing
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acute psychiatric distress.
Method: Data gathered from focus groups held with nurses from two hospitals were
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used to ascertain their use of terminology, understanding of attributes and current
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practices that support recovery for people experiencing acute psychiatric distress. A
review of literature further examined current nurse based evidence and nurse
knowledge of recovery approaches specific to psychiatric intensive care settings.
Results: Four defining attributes of recovery based on nurses perspectives are
shared to identify and describe strategies that may help underpin recovery specific to
psychiatric intensive care settings.
Conclusion: The four attributes described in this paper provide a pragmatic
framework with which nurses can reinforce their clinical decision-making and
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negotiate the dynamic and often incongruous challenges they experience to embed
recovery-oriented culture in acute psychiatric settings.
Keywords
Inpatient, Nursing practice, Psychiatric Intensive Care, Recovery, Recovery-oriented
health services
Main Text
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Introduction
In 1993 Anthony wrote of recovery as a new vision of service delivery for people
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who have a mental illness (Anthony, 1993, p.525). He described a recovery-oriented

health system incorporating critical services of community support systems; and
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also, clinical services directed at crisis intervention and symptom relief (p. 529).
Anthonys (1993) vision of recovery, encapsulating individual resilience and the
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support of others in a nonlinear process of development, reversion, and pressing
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forward again, is an overarching objective for mental health services and a principal
focus of people with lived experience of mental illness. A recent study highlighted
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important aspects of recovery as encouraging a persons abilities to make decisions,

solve problems and perform actions based on their choice (Kartalova-O'doherty, et
al., 2012). Understanding of recovery shared by people with lived experience of
mental illness speaks to a deeper understanding of whats happening to a person,
beyond a health complaint to be removed or to move beyond (Gwinner, et al., 2012,
p. 107).
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Whilst there has been keen interest in establishing a continuum of recovery-oriented

services in Australia, as in other countries, the Fourth National Mental Health Plans
(2009) statement a recovery orientation should drive service delivery is
nevertheless, perceived as rhetoric in mental health policy rather than standard
practice across mental health services (Slade, et al., 2008). One area of critical
concern is delivery of effective recovery approaches in acute clinical settings
(Bowers, et al., 2009; Pereira, et al., 2006; Walsh & Boyle, 2009). Coercive
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treatment approaches, containment of disturbed/violent behaviour and

pharmacotherapy directly contradict concepts such as patient autonomy and
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recovery as a client-driven process and goal (Stylianos & Kehyayan, 2012). For
people who are admitted to hospital-based acute services, core values of recovery
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such as choice, self-determination, empowerment and self-responsibility are often

disregarded in the delivery of conventional procedures and interventions aimed at
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managing the acute disturbance and crisis (OHagan, 2006).
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Nurses, as the vanguard of care in acute psychiatric settings, have an essential role
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and responsibility to deliver recovery-oriented care, and thus need to be clear

themselves as to their understandings, language, and the potentially conflicting or
limiting definitions emergent in various models of recovery such as the colonization
of recovery territory by practitioners, or the ill-cured dichotomy (Bonney & Stickley,
2008). It is timely to establish greater clarity of nurses thinking about recovery and to
reinforce values and attributes aligned to a recovery-oriented culture directed at
crisis intervention and symptom relief for people experiencing acute psychiatric
distress.
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Clinical Acute Psychiatric Interventions
Crisis intervention and symptom relief for people experiencing acute psychiatric
distress is often provided in specialised units co-located in in-patient wards referred
to as psychiatric intensive care units (PICU). PICU is a tertiary level service that
provides intensive treatment, rapid assessment and stabilisation as part of the
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Australian integrated mental health system (Australasian Health Infrastructure

Alliance (AHIA) 2010). In many jurisdictions, as in Australia, acute psychiatric
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intervention is provided in small units, staffed by specialised nurses and equipped to

provide seclusion, close observation, and intense treatment to individuals with actual
(AHIA, 2010).
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or potential life-threatening illness, or complications from which recovery is possible
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PICU is more commonly described as permanently locked to prevent patients from
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absconding and harming others (van der Merwe, et al., 2009) notwithstanding,
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guidelines and principles that stress the provision of the least restrictive type of
mental health care (Australian Health Ministers, 2012; World Health Organization,
1996). Frequently, individuals assessed as at risk of harm either to themselves or
others in the community, are mandated by law and subsequently governed by a
Mental Health Act. Shared decision-making and facilitating advocacy processes for
individuals to contribute to their care and treatment, become incongruous aims
against initiating involuntary assessment and authorising involuntary treatment.
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PICU can offer opportunities to initiate early recovery approaches for patients
experiencing acute psychiatric distress. Nevertheless, several audits and surveys of
PICUs demonstrate specific difficulties in adopting recovery-oriented approaches in
PICU (Glick et al., 2011; Walsh & Boyle, 2009; Bowers et al., 2009). Significantly
there is paucity of research regarding the extent to which the principles and practices
of a recovery philosophy are achievable in the context of PICUs (Bowers et al., 2005;
Glick, et al., 2011; Gwinner & Ward, 2013). However, some global initiatives are
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exploring recovery and patient focused frameworks for improved recovery outcomes
(Chen, et al., 2013; Olmos-Gallo, et al., 2012; Slade, 2009; A. Cleary, 2009) within
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the PICU setting.
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This paper draws knowledge both from the experiences of nurses working in PICU
and current literature, to appreciate a how recovery approach is applied to nursing
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practice in PICU. Four defining attributes are shared from the experiences of nurses
that support conceptual clarity of recovery in PICU. These are Storytelling;
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The Study
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Safeguarding; Treatment; and Responsibility.
The study aimed to identify existing strategies and practices that nurses perceived
support a recovery-based model of care in the PICU, through two methods of inquiry.
The five stages of the study included, 1) a problem formulation stage, 2) a literature
search stage, 3) a data evaluation stage, 4) a data synthesis and analysis stage, and
5) final presentation stage (Whittemore & Knafl, 2005). The first method of inquiry
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employed focus groups with nurses. These were held at stage one and stage three
to obtain clear identification of nurses perceptions, experiences, and concepts of
recovery. Data from the focus groups were analysed to define the terms and
selection protocol for the literature review. Additionally the data were used to
evaluate emerging concepts from current literature (2000<) related to the nurses
accounts. The second method of inquiry involved a review of the literature to
examine nurse-based evidence and nurse knowledge of recovery approaches
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specific to psychiatric intensive care settings.
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Focus Group Participants and ethics

Ethical approval was granted by the University and health care service Human
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Research Ethics Committees. An invitation to participate in the research and

participation information sheets were emailed to nursing staff who worked within
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locked wards attached to two metropolitan district hospitals in South East

Queensland. Twelve nurses participated in the first two focus groups which
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introduced key topic areas and questions based on nursing practice and experience
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in the PICU. Following an initial literature review, a second series of focus groups
were held with the nurses (stage 3). An additional focus group was held at one site
to accommodate the interest and desire to contribute by nursing staff (N=45).
Design
The study incorporated five stages in the design as described above and illustrated
in Figure 1. Data emergent from the focus groups were synthesized to identify
concerns related to the complexity of mental health nursing in PICU and to provide
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explicit attention to the key purpose, concepts, terms and boundaries with which to
identify aspects of nursing practice that support a concept of recovery
acknowledging consumer models and perspectives. These were the used to
underpin a review of the literature (stage 2).
A review of the literature was undertaken using Google scholar to allow a broader
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search of databases such as CINAHL, Informa, Healthcare Medline, PubMed,

PsycARTICLES, and Wiley. Purposive sampling of literature was used to enhance
variables and expand explanation of the perspectives and definitions expressed in
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the focus groups. Over 300 articles were sourced. Fifty items met the final inclusion
this paper (Table 1).
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Figure 1. Study flow chart
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criteria and augmented the focus group concerns and values which are reported in
The attributes and concepts that emerged from the first two focus groups and
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nascent concepts from an initial review of the literature were taken back to the sites
in another three focus groups (stage 3). An extra group was held in one site to
accommodate additional participants and to expand on previous data collected from
the first focus groups. Data synthesis and analysis of all the literature and the focus
group data were iteratively compared in stage four. Finally, a synthesis in the form of
a model was developed to comprehensively portray a concept of recovery drawn
from the findings (stage 5).
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Data Synthesis and Analysis

Analysis involved a process of examining, comparing and conceptualising; firstly the
focus group data to obtain clear identification of nurses perceptions, experiences,
concepts of recovery and problems and to evaluate emerging concepts related to
their experiences, and secondly ordering, coding, categorising the literature into
themes related to attributes and values shared by the nurses participating in the
focus group. Theme identification was based on recurrence of ideas with similar
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content across the data. The congruencies among nurses experiences and the
literature were examined and taken back to the nurse participants to substantiate the
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interpretations and to explore further conceptual development. The two methods of

data collection captured the depth and range of issues, and achieved convergent
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validity of the data. The synthesis identified four attributes that frame a concept of
recovery specific to the context of nursing practice in psychiatric intensive care
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FINDINGS
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settings.
The nurses who participated in the study described a number of challenges to

provide recovery-oriented care in PICU. These include personal anxiety, staffing
and team communication, training and skills development, guidelines and regulations,
rules and admission practices. One nurse claimed patients coming form the prison
system could be personally confrontational or manipulative. Another nurse
elaborated,
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If you know a client has high acuity they are coming in with huge history of
aggression they have come in and they are icing they are on speed and they are just
off the rails. Firstly, you are not going to approach them by your self.
It was generally agreed there was no room to second guess a situation. The nurses
perception of the challenges and barriers to recovery approaches in PICU are
discussed more fully in another publication (Gwinner, & Ward, 2013). The purpose of
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this article is to provide greater understanding of a concept of recovery specific to the

context of nursing practice in psychiatric intensive care settings.
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Four defining attributes of a concept of recovery within the PICU were identified in
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the descriptions by nurses. They were 1.) Storytelling; 2.) Safeguarding; 3.)
Treatment; and 4.) Responsibility.
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Figure 2. A concept of recovery in PICU
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The remainder of this paper outlines these attributes as a concept of recovery held
recovery approaches by nurses in PICU.
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by nurses that has potential to guide thinking and enable solutions that promotes
Attribute 1.) Storytelling

Storytelling is a significant feature in the concept of recovery held by nurses in PICU.
It aligns to rudimentary expectations of recovery outlined by Anthony (1993) as a
subjective experience begging to be attended to and understood (p. 530). The
storytelling attribute accentuates how varied interactions between the nurse and the
patient are used to discern dimensions of subjective experience, and to more fully
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understand and engage the contexts in which recovery can be transacted.
A key factor of the storytelling attribute in recovery related to developing a nursepatient relationship as engagement with the person. She said,
...Its about creating one on one contact, you know. They want somebody to sit
there and acknowledge and talk to them.
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Building reciprocal meaning, knowledge and awareness generated in nurse-patient
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communications were cited as crucial factors underpinning nurses clinical decisionmaking in PICU. The significance of preliminary engagement that helps to establish
One nurse participant explained,
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a connection with the patient and thus, shared insight of the situation was referred to.
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Break that ice initially, then you get a better rapport and a better working
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relationship with that person in a PICU.
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The literature supports the development of connections, a trusting relationship and

shared awareness between the nurse and patient (Slade, 2010; Roy, et al., 2009).
Barker and Buchanan-Barker (2010) champion the belief that through engagement
with the person and not the illness, the nurse can attempt to build awareness of and
support the individual in their present situation. Sjostedt et al. (2001) suggest
managing the first nurse-patient encounter requires a moral commitment from the
nurse to consciously and intentionally encourage patients to enter into a relationship.
As such the nurse should attempt to understand each patients unique experiences
and feelings, which they described as an expression of inner ethical readiness by
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nurses (p.314).
Mezey et al. (2010) explored the concept of recovery with patients in forensic
settings highlighting the quality and depth of relationships and interactions between
the nurse and patient. Respect, acceptance and being related to as a fellow human
being were noted as necessary components that facilitate interpersonal agency.
Listening as a catalyst to commence the process of solving problems, clarifying
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values, preserving individual authenticity, and beneficial relationships amongst the

turmoil of illness and the hospital setting was reinforced in the literature (CoatsworthPuspoky, et al., 2006; Lorem & Hem, 2012; Stenhouse, 2011). A focus group
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participant explained listening and sharing stories enabled appreciation and

empathy.
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+ sort of a humanising thing in a sense+ being able to put yourselves in their
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shoes.
Storytelling required engaging the patients awareness and recognition of their
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current resources and limitations and the constraints within PICU as much as on
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gaining insight into their unique experiences and feelings. This can result in
incongruities that require controlling practices such as coercion, or strictly enforcing
rules to meet the immediate needs of the illness over patient choice and selfdetermination (ODonovan, 2007). An aspect of this dichotomy was conveyed in the
focus groups. A participant stated,
Thats the other problem with keeping in faith with the Mental Health Act+ Some
people you have to be assertive and direct with, there are others that you have to
coerce. There are others who wont accept the authorative nature.
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Appreciation of these tensions requires the skill to listen and respond. A participant
in the focus groups described the significance of establishing the history of
individuals in order to understand the person and to effectively negotiate complex
tensions. He said,
It is about, within your self being aware of the clientele. You are getting an
understanding of the history of this person. Once you get the history, then you get a
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clearer picture in your own head, how you are going to approach this person.
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The storytelling attribute denotes the importance of the quality and depth of the
nurse-patient relationship to moderate individual patient experiences of being
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disconnected, different, and isolated in PICU. The idea of Storytelling in PICU helped
to clarify how core principles of recovery for example, human dignity and
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collaborative relationships are used to build knowledge and awareness of the

subjective experiences of the patient.
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Attribute 2.) Safeguarding
The safeguarding attribute related to the safety and care of the patient, the patient
community, staff and others across the mental health system. Multiple factors were
cited as un-conducive to a milieu of safety in PICU, including lack of care plans,
inadequate collaboration by treatment teams, insufficient information and knowledge
of the patient, their history and their personal choices (Green et al., 2008; Bowers,
2009). The nurses involved in this study perceived such factors in the PICU as,
anxiety provoking and often positioned them as working against the patient and
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not assisting em.
One nurse participant shared reflections from a patient, saying,

I am really+I was frightened in PICU. I didnt know what those nurses were doing
to me and I came out fighting.
This speech sample suggests that patient responses might be opposite to what is
hoped for in the PICU. That is, the organisational structure, communication and
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admission processes might result in aggressive self-preservation rather than creating

a sense of safety for the individual.
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Literature related to acute care substantiates the nurses perceptions of PICU as
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stressful and potentially unsafe for patients and staff (Bowers et al., 2009; Nolan, et
al., 2011). A number of problems that increase anxiety have been highlighted in
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reports and include organisational problems, biomedical reductionism, inappropriate

interventions, understaffing, rapid patient turnover, occupancy rates, non-therapeutic
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interventions, poor communication and obscure care pathways (Deacon & Fairhurst,
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2008; Nolan, et al., 2011; Cleary et al., 2012). Managing risk while also engaging the
patient in recovery focused care was perceived to be variable and based on patient
population, comorbidity or dual diagnosis, attitudes towards and cooperation with
care and treatment, restrictions of the environment, staffing levels and consistency,
and available resources. One nurse participant stated
It depends on what the population is like, some days you think god this is going to
go like hell in a handbag.
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The nurses in the focus groups mostly described safeguarding as a risk avoidance
approach. They maintained; you dont have anything with ties or shoelaces; plastic
cutlery, plastic plates, styrofoam cups; and you should always have your radar on.
One participant spoke of a lockdown strategy, anecdotally to create a protected
environment, stating,
So there is more locked down approach+ we created a more secure environment
Conversely several studies have revealed that the locking of ward doors, placing
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some sort of restriction on people or denying a patient request, and patient turnover
as frequent precursors of incidents, aggression and violence on acute wards
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(Bowers, et al., 2009; Gilburt et al., 2010; Papadopoulos et al., 2012).
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Team and organisational cultures play a significant role in the complex interactions
of safeguarding (Chen, et al., 2013; Huang et al., 2010; Middelboe, et al., 2001).
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Corroborated by recent research (Alexander, 2006; Thibeault, et al., 2010), one

nurse participant suggested that rather than creating a safe environment, enforcing
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rules can generate safety problems if not consistently adhered to by all staff. She
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stated,
The trouble you get with patients in a locked area is the amount of rules you have.
So I think the minimal amount of rules but the rules you do have everyone sticks to.
The nurses in the study felt it was important to reinforce the safety and care of the
patient as a recovery approach. A nurse said,
Its making them feel safe, it is supporting them.
Factors cited as important for the safeguarding attribute include upholding human
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rights, involving families and integrating patient-centred approaches (Gilburt, et al.,

2010; Mayers, et al., 2010; Whitelock, 2009). Nurses emphasised that skills to build
rapport with the patient in order to support and foster patient-centeredness were
useful for safeguarding. One informant stated the significance of embedding these
skills in training as daily processes. They said
Your ability to build a rapport with someone, use your radar, use your perception,
build and use the skills that weve got as nurses+ Its important because you can
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build that into your education. You can build that into, or the process of how this
place operates.
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Safeguarding as an attribute of a recovery was perceived to require specific nursing
fear, distress and aggression.
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Attribute 3.) Treatment
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skills and training to understand and integrate humanistic approaches to alleviate
The treatment attribute emerged in this study as an underdeveloped aspect of
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recovery practiced by nurses in PICU. The literature signified the importance of

treatments to assuage experiences of hopelessness in PICU (Barker, & BuchananBarker, 2010; Bertelsen, et al. 2008; Curtis, et al., 2007; Janner, 2007). Three foci
aligned to recovery approaches were determined as beneficial in PICU. These were
pharmacology, psychotherapies, and structure and routine.
Pharmacology was highlighted as the most practiced treatment in PICU, in data from
both the focus groups and the literature. The use of pro re nata (PRN) or 'as needed'
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psychotropic medication was cited as a frequent clinical intervention used by the

nurses in the focus groups. One informant explained,
Because you are just watching and then you know to get up because this one is
starting to get a bit agitated well go and get some PRN or stuff like that.
The administration of PRN is championed as a strategy for the reduction of agitation,

distress and aggression, and to reduce physical restraint rates (Hilton & Whiteford,
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2008; Usher, et al., 2010; Winkler et al., 2011). Yet, much of the literature reported
wide variations in the rationales for PRN medication administration with little or no
Hilton & Whiteford, 2008).
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other therapeutic treatment occurring prior to administration (Curtis, et al., 2007;
Literature related to treatment options and more specifically psychotherapies
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exemplify an array of different strategies, targeting diverse populations and phases

of development for beneficial effects (Amering & Schmolke, 2009; Bertelsen et al.,
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2008; Brimblecombe, et al., 2007; Janner, 2007; Summers & Barber, 2012; Wykes,
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et al., 2008). A common focus in nursing literature was on the importance of the
nurse-patient therapeutic alliance (Bressi Nath, et al., 2012; Coatsworth-Puspoky, et
al., 2006; Priebe & Mccabe, 2008).
Time pressures, conflicting demands, role confusion, management style, staff mix,
and lack of skills were cited as explanations that impact nurses capacity to
implement structured or planned psycho-therapeutic interventions (Aston & Coffey,
2011; Chen, et al., 2013; Mullen, 2009; Radcliffe & Smith, 2007). The participants in
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the focus groups specified that there were limited opportunities for nurses to train in
the use of psychotherapies such as CBT. The lack of therapeutic activities on the
ward and uncertainty of their role in relation to the provision of therapies was alluded
to by a nurse participant.
Well for a start+ well I suppose there is no therapies+ umm we have an OT
(Occupational Therapist).
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An alternative to seclusion and restraint discussed by the focus groups was the
experimental use of sensory modulation rooms. This treatment was described in the
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focus groups as,
We have got weighted blankets and stuff like that but umm and stress balls and
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+but we have to be with them when you do stuff like that.
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There is growing evidence in the literature of the need for a stimulating, therapeutic
environment with routine and structured activities to alleviate acute distress, ensure
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safety, provide opportunities for peer and family support and an opportunity for
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patients to take responsibility for their actions (Janner, 2007; Long, et al. 2012;
Turton et al., 2011; Walsh & Boyle, 2009). Nurse participants in the focus groups
discussed a range of general activities to occupy patients. Activities included boxing
bag+they can punch a boxing bag, we had a pool table, you get coloured pencils
and pens and paints, jigsaws and playing some board games, X box, and that
sort of stuff and again depending on the acuity of the unit. Yet it was not apparent
that activities were delivered in a structured or routine way or as part of a recoveryoriented stratagem. One nurse participant commented,
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So you have one activity person two hours a day roughly so thats not bad. Its
more than others... There might be a couple of special weekends where we might
get a couple of DVDs or get some popcorn or have a movie night
The three key foci of treatment - pharmacology, psychotherapies, and structure and
routine, are significant domains with which to establish improved clinical and
recovery outcomes for acute patients. For example, the domains can be used to
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establish a positive routine, solve problems, build understanding and relationships

and support hope as a central, motivating message of recovery. The findings
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suggest that for treatment to align to a recovery approach there is a need to enhance
understanding of how the foci are correlated rather than limiting treatment offered by
quickly as possible.
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Attribute 4.) Responsibility
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nurses to observation, providing medication and moving patients out of PICU as
The responsibility attribute accentuated dignity, respect and valuing human rights on
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the one hand, while assessing and balancing personal and collective decisionmaking, risks, controls and restrictions of unpredictable behaviours and the clinical
milieu, on the other. Expediting patient empowerment, purpose, collaborative care
and ownership for recovery based on a more thorough and clear understanding of
the rights, responsibilities, needs and beliefs of the patient (Anthony, 1993 p. 523)
transpired as a critically challenging but necessary process to address patients
experiences of helplessness and powerlessness in PICU.
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Emphasis is placed on clarifying the process, identifying and reducing barriers, and
establishing the needs and beliefs of the patient for recovery in their own preference
even if the nurses were unable to engage the patients responsibility and selfdetermination for recovery at the worst stage of illness. One nurse participant stated,
It is also part of the person and whether they really want to recover as well, and
thats where you establish a rapport and try to+ find out some of the clients issues
and look at the objectives of what this person really wants and where they really
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want to go with it.
Coatsworth-Puspoky et al., (2006) suggest that engaging the patients responsibility
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and self-determination for recovery is related to shifting power in the nurse-patient

relationship as the patient sets goals, learns, solves problems and assumes control
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in caring for themselves and their recovery.
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Responsibility as an attribute of recovery in PICU was stressed as a needs-rights
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paradox for nursing practice in PICU. Human rights and choice are a basis for the
practice of shared responsibility in care (Wallcraft, 2012; Wallcraft, et al., 2011).
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However, Wallcraft et al., (2011) specifically noted, respondents to their consultation

held opposing sentiments about the application of human rights and the need to use
coercive measures, such as seclusion, or medication when someone is in an acute
state.
Patient informed consent and coercive measures, such as seclusion, or medication

are linked with professional, attitudinal, ethical, legal and moral issues, and in which
nurses as the frontline staff are often held responsible for the faults and
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shortcomings of the overall system (Cleary, et al., 2010; Hilton & Whiteford, 2008;
Nolan, et al., 2011; Sjstedt, et al., 2001). Responsible decision-making related to
such issues need complex and careful consideration to maintain a recovery focus.
Communication and de-escalation skills were considered significant tools to balance
nurse-patient accountabilities. Nurses in the focus group indicated they harness
supervision and learning in collaborative teams to support decision-making, and
review professional, ethical and moral issues. One nurse participant observed,
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When you have been in the areas and you have a bit of experience, you float off
each other, and learn from each other very, very quickly from the people who can
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deal with certain situations+ It really is a specialist area.
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Green et al. (2008) found that mental health clinicians who collaborated with their
patients to develop and evaluate plans of care that were acceptable to both clinician
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and patient, particularly regarding medications, were seen as more helpful and more
competent. Empowering people to participate in and take responsibility for their own
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care was valued by patients in the study. Establishing and sharing the goals of
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patients with other health professionals across the continuum of care was perceived
to be an important shared responsibility initiated by nurses. An informant reflected,
It stems through, right through the patient condition, how they got there in hospital in
the first place, right through the family you know. Its the tree, the food chain+ So it
is actually the responsibilities of the nurses not any other health profession at this
stage.
Responsibility to engage and sustain recovery approaches by nurses in PICU
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required complex and careful consideration of patient self-determination, practical

risks and human rights. Fostering improved communication, trust and balancing the
dynamics of patient-nurse personal and collective decision-making were accentuated
as key aspects of the responsibility attribute.
Discussion
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Four attributes that support a recovery approach, Storytelling, Safeguarding,

Treatment and Responsibility, have been outlined in this paper. These four attributes
construe recovery in a pragmatic framework rather than as representational meaning.
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This paper seeks to understand how recovery is practicably embedded in acute
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psychiatric settings.
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As observed elsewhere (Gwinner & Ward, 2013; Cleary, et al., 2012; Slade et.al.
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2008), current guidelines and practices in acute psychiatric care are not meeting the
requirements for a recovery-oriented system. More often the primary function of
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PICU is described as the suppression of aggressive and violent behaviour, or a

punishment block (Dix, 2012; Stylianos & Kehyayan, 2012). Some studies
examining nurses knowledge about recovery principles indicate recovery is poorly
articulated amid continued confusion related to contradictory concepts and
organisational policies and procedures (Cleary, et al., 2012; Browne, et al., 2012).
Consequently, there remains a fundamental and urgent need for pragmatic clarity to
enact recovery in nursing practice in intensive psychiatric care settings.
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The four attributes outlined in this paper offer potential to guide thinking and to help
negotiate the complex issues and paradoxes frequently experienced by nurses and
reported in studies of nurses and patients perceptions and experiences in PICU
(Mayers, et al. 2010; Nolan et al. 2011; Mezey, 2010; Cleary et al. 2012). For
example, the storytelling attribute provides insight into the complex layers to engage
r
Fo
effective communication strategies amongst the turmoil of the acute settings.
Pe
The storytelling attribute marked a distinction in the quality and depth of engagement
between nurses and patients to clarify how core principles such as human dignity
er
and collaborative relationships are mediated for greater interpersonal agency and
ethical readiness. The art of storytelling between nurses and patients in PICU has, to
Re
some extent, been lost in various assessment instruments and requirements to

obtain knowledge and transmit patients problems and needs to others in the mental
vi
health system. Sjostedt et al. (2001) suggest that communication and language
ew
theories may provide support for nurses dialogues with patients, expand
understanding of professional, ethical and moral awareness, and acknowledge the
responsibility of having the power to influence recovery-oriented care.
It is critical to clearly articulate safeguarding as an attribute of recovery in acute

psychiatric settings. Key factors cited as effective for safeguarding aligned to
recovery include creating a sense of safety and, upholding human rights. These are
achieved through interpersonal interactions; interventions that optimise patient
Page 23 of 49
23
experiences; staff training and education; involving patients and families with their
care decisions and management; and integrating client centred approaches in care
(Cleary, et al. 2012; Gilburt, et al., 2010; Mayers, et al., 2010; Whitelock, 2009). Yet,
factors such as legislative requirements and protecting an individuals legal,
citizenship and human rights continue to obfuscate nursing efforts to embed
recovery approaches.
r
Fo
Lakeman (2011) points out that institutional values and assumptions persist in
nursing practices that are clearly incompatible with notions of recovery. Risk
Pe
avoidance approaches continue to prevail over recovery dimensions and ultimately
er
infringe on human rights. Nascent literature indicates that aggression and violence in
psychiatric acute wards are linked to restrictions, rules, limitations, lack of flexibility
Re
and diminished human dignity (Papadopoulos, et al., 2012; Bowers et al. 2009;
Hamrin, Iennaco, & Olsen, 2009). Advocating humanistic approaches (Stylianos,&
vi
Kehyayan, 2012) to alleviate distress and aggression provides practical and
ew
preventative approaches for safeguarding aligned to recovery practices in the PICU.
Viewing treatment as an attribute of recovery through three foci (pharmacology,

psychotherapies and structure and routine) indicated there is currently greater
attention focused on nurses use of PRN medication as a treatment of choice over
the use of other important treatments useful in a recovery approach to care in the
PICU (Winkler et al., 2011). The nurse-patient therapeutic alliance was highlighted in
much of the literature (Bressi Nath, et al., 2012; Coatsworth-Puspoky, et al., 2006;
Page 24 of 49
24
Priebe & Mccabe, 2008), as was the necessity of active engagement to encourage
patient autonomy, insight and overcoming practical problems, (Chen, et al., 2013;
Slade, 2010; Turton, et al., 2011). Yet, psychotherapies, and structure and routine
emerged as underdeveloped aspects of treatment aligned to recovery and patient
focused practice. It is essential that nurses confidently embrace their expertise and
skills to broaden therapeutic treatments as a meaningful feature of a recovery in
PICU.
r
Fo
Nurses ownership of a recovery-oriented culture based on a more thorough and
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clear understanding of the rights, responsibilities, needs and beliefs of the patient
(Anthony, 1993 p. 523) is critically challenging but necessary to address patients
er
experiences of helplessness and powerlessness in PICU. Responsibility as an

attribute emergent from the study, stressed the importance of nurses attitudes and
Re
capacity for ethical, legal and moral decision-making. The data highlighted nurses
primary concern for the legitimate use of power in PICU, and stressed an imperative
vi
to ensure the integrity of the rights, the responsibilities, the needs and beliefs of the
ew
patient are met (Ward, & Syversen 2009).
Responsibility as a guiding principle of recovery maintains a focus on the expression

of individual responsibility for the patients own self-care and journeys of recovery
(Roberts & Boardman, 2013). Weisser, et al., (2011) propose a major shift in thinking
about recovery from an exclusively individual responsibility, to a shared societal
responsibility. Adopting a societal approach in PICU places an onus on balancing
nurse-patient responsibilities. Additionally this focus brings to light the structural
Page 25 of 49
25
changes required to facilitate advocacy processes for individuals to contribute to

their care and treatment, in ways that dont fundamentally impact on their rights to
self-determination and choice as a core principle of a recovery vision.
Conclusion
Recovery viewed as a pragmatic framework, as outlined in the attributes described in
this paper, begins to build clarity for nurses around embracing recovery practice in
r
Fo
the unpredictable milieu of psychiatric intensive care settings. The qualities of the
attributes presented in this paper interconnect and overlap in diverse, composite
ways. Each attribute provides a lens with which to reinforce decision-making and to
Pe
negotiate the dynamic challenges in daily interactions and communication with
er
patients experiencing acute psychiatric distress.

Importantly these attributes provide a platform with which to investigate approaches
Re
to strengthen recovery in psychiatric intensive care settings. For instance, what daily
routines and structures initiated by nurses, best augment the quality and depth of the
vi
nurse-patient relationship, which is described as a significant feature of recovery in
ew
PICU? Equally, it is critical and timely to further examine qualities of recovery related
to safeguarding, given recent legislative provisions to lock adult acute mental health
facilities in authorised mental health services across Queensland (Schoubroeck,
2013). Will this legislation to limit patient freedoms result in more frequent incidents
of violence and aggression within Queensland adult psychiatric in-patient settings?
Limitations
Page 26 of 49
26
Even though a comprehensive search of the literature was conducted it was based
on perspectives of practice and recovery by nurses in two inpatient psychiatric units,
therefore the study cannot be representative of all acute psychiatric care settings. It
cannot encapsulate a complete appraisal of other stakeholders in relation to
recovery practice and experiences in PICU for example patients and carers.
However, nurses descriptions and perceptions of recovery in PICU make it possible
to further explore these attributes with other stakeholders and in other acute
r
Fo
psychiatric settings. The findings provide implications around which further research
and policy planning may be framed. For example, further research is needed to
Pe
incorporate patients experiences and accounts, and to reinforce that the attributes
highlighted here are aligned to a recovery concept as understood by people
er
experiencing acute psychiatric distress. Additionally, further research is needed to

ascertain the resourcing and training that is required to support a recovery-oriented
ew
vi
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Author
Year
ew
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Tables
Title
Aim
Patients feelings
about ward nursing
regimes and
involvement in rule
construction
to discover the content of rules

within acute psychiatric wards;
to explore patients responses
to the rules; to evaluate the
impact of rules and rule
enforcement on nursepatient
relationships.
Recovery in Mental
Health: Reshaping
Scientific and Clinical
recovery definitions, concepts

and developments as well as
consequences for scientific
Context
Research
Method/
Approach
data
base
Qualitative
WileyBlackwell
Literature
review
WileyBlackwell
Journal
Alexander, J.
(2006)
Journal of Psychiatric
and Mental Health
Nursing
Amering, M., &
Schmolke, M. (2009)
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Vol 7.
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Anthony, W. A.
Recovery from mental

illness: The guiding
vision of the mental
health service system
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to outline the fundamental

services and assumptions of a
recovery-
(1993)
Psychosocial
Rehabilitation Journal
oriented mental health system
programs
Macro level
mental health
systems
to explore multiple
perspectives
Aston, V., & Coffey, M.
(2012)
(2008)
Issues in Mental
Health Nursing
Identifying Key Factors

Associated with
Aggression on Acute
Inpatient Psychiatric
Wards
Bressi Nath,
Alexander, & Solomon,
(2012)
Social Psychiatry and
Psychiatric
Epidemiology
Case managers
perspectives on the
therapeutic alliance: a
qualitative study.
EBSCO
Informa
Healthcar
e
evaluations of the Tidal Model

within acute care settings and
the potential contribution that
the model makes to the
development of personcentred care, within acute
settings
Acute care in
Scotland,
England, and
Ireland
Evaluation
protocol
To determine the long-term

effects of an intensive earlyintervention program (OPUS)
for first-episode psychotic
patients.
Psychiatric
Hospital,
Denmark
Singleblinded,
randomized
, controlled
clinical trial
ew
Bowers, L., Allan, T.,

Simpson, A., Jones, J.,
Van Der Merwe, M., &
Jeffery, D. (2009)
Thematic
analysis
using
Krueger
and
Caseys
framework
JAMA
vi
Archives of General
Psychiatry,
Five-year follow-up of
a randomized
multicenter trial of
intensive early
intervention vs
standard treatment for
patients with a first
episode of psychotic
illness: the OPUS trial
health
inpatient care
UK
EBSCO
health services.
Re
Bertelsen, M.,
Jeppesen, P.,
Petersen, L., Thorup,
A., Ohlenschlaeger, J.,
le Quach, P., et al.
to the concept of recovery and

how it fits within mental
Acute mental
er
Issues in Mental
Health Nursing
The tidal model of

mental health recovery
and reclamation:
application in acute
care settings
of service users and mental

health nurses with regard
Pe
Barker, P., &

Buchanan-Barker, P.
(2010)
r
Fo
& Mental Health
Nursing
Recovery: what mental

health nurses and
service users say
about the concept of
recovery
Empirical di
scussion
to assess the relationship of

patient violence to other
variables: patient
characteristics, features of the
service and physical
environment, patient routines,
staff factors, the use of
containment methods, and
other patient behaviours.
to understand the nature of the

therapeutic alliance in
intensive case management,
136 acute
psychiatric
wards in 26
NHS Trusts
in England
community
mental health
settings intensive
case
management
Multivariate
cross
sectional
design
Informa
Healthcar
e
Qualitative
analysis of
case
managers
perspective
s
Springerli
nk
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Brimblecombe, N.,
Tingle, A., & Murrells,
T.
(2007)
and Mental Health
Nursing
Chen S., Krupa T.,
Lysaght R., McCay E.,
& Piat M.,
2013
2012
WileyBlackwell
The Development of
Recovery
Competencies for Inpatient Mental Health
Providers Working with
People with Serious
Mental Illness.
to identify the most salient

recovery competencies
required of in-patient
providers.
Inpatient
context
Competenc
y
framework
Springer
Mental health nurses'

perceptions of good
work in an acute
setting
to develop insights into the

nature of good mental health
nursing work through the
perspectives of mental health
nurses in the acute mental
health environment.
qualitative
study,
WileyBlackwell
Acute
inpatient
mental health
units
Australia
NSW
Qualitative
WileyBlackwell
Literature
review
Seclusion and its

context in acute
inpatient psychiatric
care
to explore briefly some of the

contemporary debates
pertaining to seclusion
Acute
inpatient
mental health
services
to identify, analyse and

synthesize research in adult
acute inpatient mental health
units, which focused on nursepatient interaction.
Adult acute
inpatient
mental health
units
Issues in Mental
Health Nursing
Coatsworth-Puspoky,
R., Forchuk, C., &
Ward-Griffin, C. (2006)
and Mental Health
Nurse-Patient
Interaction in Acute
Adult Inpatient Mental
Health Units: a Review
and Synthesis of
Qualitative Studies
Nurseclient
processes in mental
health: recipients
perspectives
ew
Cleary, M., Hunt, G.

E., Horsfall, J., &
Deacon, M. (2011)
vi
Journal Of Medical
Ethics,
health
environments
Mental health nurses

views of recovery
within an acute setting
International Journal of
Mental Health Nursing
Cleary, M., Hunt, G.
E., & Walter, G. (2010)
Acute mental
to identify practical realities

that acute care nurses can
take to aid recovery and
identify barriers that hinder its
implementation during and
immediately after a relapse.
Re
Cleary M., Horsfall J.,

O'Hara-Aarons M., &
Hunt G.
National
review
consultatio
n
er
Inpatient
care England
Pe
Cleary, M., Horsfall, J.,

O'Hara-Aarons, M.,
Jackson, D., & Hunt,
G. E. (2012).
reports on responses received

in relation to a consultation
question on how best to
improve inpatient care
r
Fo
Administration and
Policy in Mental Health
and Mental Health
Services Research
How mental health

nursing can best
improve service users'
experiences and
outcomes in inpatient
settings: responses to
a national consultation
to explore and describe

nursing support relationships,
from the perspectives of
recipients, within the mental
health subculture
Mental
Health
Consumers
Southern
Ontario
BMJ
Journals
Literature
review
Informa
Healthcar
e
miniethnographi
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an
ethnonursin
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WileyBlackwell
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Nursing
Curtis, J., Baker, J. A.,

& Reid, A. R.
(2007)
Nursing Inquiry
Service users'
experiences of
residential alternatives
to standard acute
wards: qualitative
study of similarities
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Australian and New

Zealand Journal of
Psychiatry
Huang, D. T.,
Clermont, G., Kong, L.,
Weissfeld, L. A.,
Sexton, J. B., Rowan,
K. M., et al.
Psychiatric
unit
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to explore patients' subjective

experiences of traditional
hospital services and
residential alternatives to
hospital.
to provide recommendations
for improving care include
increased patient-clinician
collaboration, patient
empowerment, and greater
relational continuity of care
residential
alternatives
and inpatient
continuity of
patient care
WileyBlackwell
WileyBlackwell
Qualitative
BJ Psych
Qualitative
EBSCO
Literature
review
Informa
Cohort
study
combining
safety
culture
survey data
Oxford
Journals
ew
Understanding how
clinician-patient
relationships and
relational continuity of
care affect recovery
from serious mental
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Pro Re Nata
Medication for
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Time to Act.
examines the evidence for

administration of PRN
psychotropic medications and,
in the context of evidencebased best practice, current
mental health policy and
professional ethics, proposes a
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safety culture and
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unit (ICU) safety culture is
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Whiteford, H. A.
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to mental health nursing and to
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Psychiatric
Rehabilitation Journal,
Retrospecti
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Re
Green, C. A., Polen,

M. R., Janoff, S. L.,
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Wisdom, J. P.,
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20-bed
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The British Journal of

Psychiatry
The real-life practice of

acute inpatient mental
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explored the occurrence of

p.r.n. medication
administration and the type of
alternative therapeutic
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Pe
Gilburt, H., Slade, M.,

Rose, D., Lloyd-Evans,
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Osborn, D. P. (2010)
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r
Fo
Deacon, M., &

Fairhurst, E. (2008)
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International Journal
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secure
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service
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Informa
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to explore the perceptions and

experiences of a group of
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Middelboe, T.,
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Byrsting, K., & Gjerris,
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Cambridg
e
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Press
Health-care
professionals
' experiences
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Mental Health Service

Users Perceptions
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and Restraint
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literature
review
to examine how experiences

with mental illness are
perceived by health-care
workers, and how insight
affects assessment of their
perspective and involvement.
Re
Mayers, P., Keet, N.,

Winkler, G., & Flisher,
A. J.
to identify service users' views

of the constituents of an
effective therapeutic milieu for
women in secure settings and
to help identify the extent to
which services need to be
specifically tailored for women.
Acute inpatient
hospital
London
er
Attuned understanding
and psychotic
suffering: A qualitative
study of health-care
professionals'
experiences in
communicating and
interacting with
patients
report on program to help

improve the daily experiences
of acute in-patients and
treatment outcomes.
Pe
Lorem, G. F., & Hem,

M. H. (2012)
Effective therapeutic
milieus in secure
services for women:
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perspective
r
Fo
Long, C. G., Knight,

C., Bradley, L., &
Thomas, M. (2012)
From the inside out:

Star Wards' lessons
from within acute inpatient wards
To investigate the relationship

between patients' perception
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atmosphere and their
satisfaction.
Psychiatric
wards
Qualitative
two phase
study
Sage
Satisfaction
questionnai
re.
WileyBlackwell
Acta Psychiatrica
Scandinavica
Mezey, G. C.,
Kavuma, M., Turton,
P., Demetriou, A., &
Wright, C.
(2010)
Perceptions,
experiences and
meanings of recovery
in forensic psychiatric
patients.
to explore definitions,
experiences, and perceptions
of recovery in patients with
severe mental illness, currently
detained in medium secure
psychiatric provision.
The Journal of
Forensic Psychiatry &
Medium
secure
psychiatric
setting
Qualitative
Taylor
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Francis
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Psychology
Mullen, A.
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Mental health nurses

establishing
psychosocial
interventions within
acute inpatient settings
to discuss the problems with

mental health nursing practice
in acute inpatient units
highlighted in the current
literature
Acute
inpatient
units
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Review
WileyBlackwell
Nolan, P., Bradley, E.,

& Brimblecombe, N.
(2011)
ODonovan A .
(2012)
International Review of
Psychiatry
Radcliffe, J., & Smith,

R. (2007)
Psychiatric Bulletin
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Emerald
Qualitative
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WileyBlackwell
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l review
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Ethnograph
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GFMEM
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access
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in-patient
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of therapy or therapy
in itself?
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psychiatry: how
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Understanding
"recovery"
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communicati
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R. (2008)
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Acute
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reality or rhetoric?
Re
Papadopoulos, C.,
Ross, J., Stewart, D.,
Dack, C., James, K., &
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to explore psychiatric nurses'

approach and philosophical
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2007
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Journal of Mental
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to identify therapeutically
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tested in experimental studies.
to review levels of social

interaction and activity among
in-patients
6 acute
psychiatric
wards in 6
hospitals
To examine the ideas,

principles and definitions of
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well-being: the central
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to stimulate debate about how

best to reform mental health
services
to support the re-orientation of

health services around
promoting well-being
multiple
case study
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Acute
psychiatric
care in a
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100 ways to support

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patients suffering and future

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Slade, M.
to deepen nurses
understanding of the
importance first nursepatient
encounter in a psychiatric
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outpatients in a youth
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regarding their community
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Slade, M.
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Lutzen K.
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experience of being a patient
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Figure 2
1 A Concept of Recovery in PICU
Figure 1
2 Study Flow chart

A Concept of Recovery in PICU - Storytelling Safeguarding Treatment and Responsibility Attributes of Recovery in Psychiatric Intensive Care Units

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A Concept of Recovery in PICU - Storytelling Safeguarding Treatment and Responsibility Attributes of Recovery in Psychiatric Intensive Care Units

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Journal of Psychiatric Intensive Care

Storytelling; Safeguarding; Treatment; and Responsibility;

Journal of Psychiatric Intensive Care

Background and aim: In recent years policy in Australia has endorsed

Cambridge University Press

Journal of Psychiatric Intensive Care

Abstract and Keywords

of recovery understood by nurses at the frontline of services for people experiencing

acute psychiatric distress.

used to ascertain their use of terminology, understanding of attributes and current

Cambridge University Press

Journal of Psychiatric Intensive Care

who have a mental illness (Anthony, 1993, p.525). He described a recovery-oriented

support of others in a nonlinear process of development, reversion, and pressing

important aspects of recovery as encouraging a persons abilities to make decisions,

Cambridge University Press

Journal of Psychiatric Intensive Care

Whilst there has been keen interest in establishing a continuum of recovery-oriented

treatment approaches, containment of disturbed/violent behaviour and

such as choice, self-determination, empowerment and self-responsibility are often

managing the acute disturbance and crisis (OHagan, 2006).

and responsibility to deliver recovery-oriented care, and thus need to be clear

Cambridge University Press

Journal of Psychiatric Intensive Care

Clinical Acute Psychiatric Interventions

Australian integrated mental health system (Australasian Health Infrastructure

intervention is provided in small units, staffed by specialised nurses and equipped to

or potential life-threatening illness, or complications from which recovery is possible

PICU is more commonly described as permanently locked to prevent patients from

Cambridge University Press

Journal of Psychiatric Intensive Care

the PICU setting.

Safeguarding; Treatment; and Responsibility.

Cambridge University Press

Journal of Psychiatric Intensive Care

specific to psychiatric intensive care settings.

Focus Group Participants and ethics

Research Ethics Committees. An invitation to participate in the research and

locked wards attached to two metropolitan district hospitals in South East

Cambridge University Press

Journal of Psychiatric Intensive Care

search of databases such as CINAHL, Informa, Healthcare Medline, PubMed,

this paper (Table 1).

Figure 1. Study flow chart

Cambridge University Press

Journal of Psychiatric Intensive Care

Data Synthesis and Analysis

interpretations and to explore further conceptual development. The two methods of

The nurses who participated in the study described a number of challenges to

Cambridge University Press

Journal of Psychiatric Intensive Care

this article is to provide greater understanding of a concept of recovery specific to the

Figure 2. A concept of recovery in PICU

recovery approaches by nurses in PICU.

Attribute 1.) Storytelling

Cambridge University Press

Journal of Psychiatric Intensive Care

understand and engage the contexts in which recovery can be transacted.

Building reciprocal meaning, knowledge and awareness generated in nurse-patient

One nurse participant explained,

relationship with that person in a PICU.

The literature supports the development of connections, a trusting relationship and

Cambridge University Press