Home care of persons with long-term mental illness : nurses and mental health care workers' experiences of how changes in the organisation of psychiatric services have changed their work

Sammanfattning: The overall aim of this thesis, consisting of five studies, was to explore nurses’ and mental health care workers’ experiences of how changes in the organisation of psychiatric care influence their daily work and how these changes may have contributed to ethical problems. The specific context in focus was the homes of mentally ill persons. Implicit to this aim was the assumption that the results of this research could be used to develop educational and mentoring programs, for nurses and mental health care workers that are suited to community psychiatric and mental health nursing. The design utilises both qualitative and quantitative research methods. In study I three focus groups with psychiatric nurses and mental health care workers were conducted in order to investigate ethical problems that arise within the framework of the caregiver-patient encounter. The constant comparative method of grounded theory was used for analysing of the data. The findings describe the central theme as a conflict concerning intrusion into patient’s privacy. Four main themes were identified; 1/ Intruding in the home of the patient; 2/ Experiencing fluctuating boundaries; 3/ Respecting or transgressing the right to privacy; and 4/ Situating mutual vulnerability. As this was a small study a questionnaire was developed from the ethical problems identified in Study I and used as data collection in Study II and III to identify whether the ethical problems in Study I could be generalised to other professional care givers working in the home of the patient. Study II shows that district nurses and mental health care personnel had different views related to issues concerning privacy and autonomy in providing care to patients with mental illness. In contrast, the difference in views between psychiatric nurses and mental health care workers are few. The results in Study III emphasise the need for clinical supervision as support for the nursing staff. The group receiving supervision felt more secure in relation with the patient as well as their decision-making compared with the group that did not received supervision. In-depth interviews were conducted with 11 psychiatric nurses in Study IV and V. In study IV a constant comparative analysis revealed the core category, the process of attempting to reconstruct mental health nursing, from nurse-controlled care to clientcentred care. Subsequently, moral values, assessment of patients’ need and way of meeting patients and establishing relationship with them were also changed for the nurses in this study. In Study V a qualitative content analysis was used. The findings show that the participants attempted to achieve a form of control of the patient’s state of health. By providing support and supervision to the patient they could help him or her in activities of daily life but not take over autonomy. In conclusion, it appears that ethical problems occur when the care of severe mentally ill patients is provided in their own homes in that nurses and mental health personnel had difficulty dealing with issues concerning privacy and autonomy; supervision is significant in supporting the professional role and may solve ethical problems arising in the home care of patient.This thesis indicates that nursing educational programs should be oriented towards social mental health care and that the curriculum should to a great extent include ethics and ethical analysis of problems that arise in the home care of persons with severe mental illness.