The health care environment on a locked psychiatric ward and its meaning to patients and staff members

Abstract: The overall aim of this thesis was to describe the health care environment on a locked acute psychiatric ward and to elucidate its meaning to patients and staff members. The study was performed using an ethnographic method on a psychiatric ward, mainly for patients with affective disorders and eating disorders. The ward admitted both voluntary and involuntary patients, and always had the entrance door locked. In papers I and II, participant observations (250 hours), including informal interviews and collection of documents, were made. The focus was on describing the health care environment on a locked psychiatric ward and encounters between patients, staff members and visitors in the common areas of such a ward. In paper III, formal interviews with staff members (N=10) were conducted in order to elucidate the meaning of being a care provider on a locked acute psychiatric ward. In paper IV, formal interviews with patients (N=10) were made to elucidate the meaning care has to patients on a locked acute psychiatric ward. The findings show a health care environment that was characterized by control and relationships. Staff members (I) were both in control and lacked control; they attempted to master the situation in line with organisational demands and sometimes failed. Patients were controlled by staff; they were the underdogs, and tried to make themselves heard and reacted by developing counter‐strategies. The ward (II) provided a space for encounters between people, in a continuum from professional care to private meetings and social events. Both caring and uncaring relationships were seen between staff and patients or their next of kin. The patients’ relationships with each other made visible unrecognised relationships that included both supportive and intrusive elements. For staff members (III), being a care provider meant striving for good quality in care; it included a need for security and safety and having to face a demanding work environment. Their sense of responsibility for work to be done and for caring for patients’ wellbeing was both a driving force and a burden. The meaning of care to the patients (IV) included both alleviation of suffering and being exposed to stress. The care strengthened patients’ integrity and self‐determination, they were given support by staff members, next of kin and fellow patients, and the ward offered a place of refuge. Care could also mean being exposed to stress of being dependent due to lack of choice and influence on care, and trapped in a situation where they had to endure surveillance and control and having closeness to fellow patients forced on them. This thesis shows that the health care environment on a locked psychiatric ward includes a web of relationships between people on the ward and that no relationship can be viewed as insignificant for patients’ care. Control and power were parts of the relationships, between patients and staff in particular, pointing to the need to increase patient participation in care. Handling these interrelated relationships with a number of inherent fields of power can explain some of the stress experienced by staff in psychiatric inpatient care.