International Journal of Nursing Stud
nd the work of mental healthde
dilemmas: uncertain role and uncertain relationships. The core category being there comprising engaged, present
and detached accounts for nurses actions in the ECT drama, approaches to difculties encountered, and,
(ECT). What this paper adds
ARTICLE IN PRESS
How nurses enact their roles in caring for patientstreated with ECT.
0020-7489/$ - see front matter r 2006 Published by Elsevier Ltd.
Tel.: +44 01224 262645
E-mail address: email@example.com, how such actions contributes to this. Slipping is postulated as the basic social psychological process
enabling nurses to manage their contact with the patient.
r 2006 Published by Elsevier Ltd.
Keywords: Electroconvulsive therapy; Mental health nurses; Grounded theory; Being there; Roles; Relationships
What is already known about the topic?
The nurses role and responsibilities are well docu-mented in respect of electroconvulsive therapy
Systematic audits and surveys have questioned the stan-dard of nursing support in the administration of ECT.regard to their properties and relationships to other codes until the point of saturation.
Results: Nurses actions in ECT characteristically involve two role groups: relational roles and treatment roles and twoand compared for similarities and differences. This determJohn Gass
School of Nursing and Midwifery, Faculty of Health and Social Care, The Robert Gordon University, Garthdee Campus, Garthdee Road,
Aberdeen, AB10 7QG, UK
Received 13 March 2006; received in revised form 17 August 2006; accepted 19 August 2006
Background: There is a long history of nursing practice in the area of electroconvulsive therapy (ECT). Opinions on the
involvement of nurses in this treatment reect the wider debate on its use in the professional and popular media. There
is extensive literature on the issues raised by this particular treatment but little research into what nurses actually do
when working with patients receiving ECT.
Objectives: The research question was: How do mental health nurses work with patients having electroconvulsive therapy?
Design: This was a Grounded Theory adopting a hybrid approach to the methodology inuenced by the differing
perspectives of both co-originators, Glaser and Strauss.
Settings: The research took place in wards and ECT departments in two hospitals in Scotland.
Participants: Twenty-four mental health nurses, including 4 students working in National Health Service hospitals in
Scotland were accessed through purposive, then theoretical sampling. This included non-participant observation of
nurses in their work with patients throughout the treatment period and unstructured interviews.
Methods: Analysis was based upon the constant comparative approach with open coding of data that was examined
ined further data collection and theoretical development withnurses: A groun
Electroconvulsive therapy ad theory studyies 45 (2008) 191202
America where Froimson et al. (1995) record that
ARTICLE IN PRESSJ. Gass / International Journal of Nursing Studies 45 (2008) 191202192two
mee-effect was memory loss and problems in concentrat-
. Of those who had received ECT within the preceding
years, 40.5% reported permanent loss of previous
mories and 36% reported difculty in concentration.oth
sid Demonstrates the challenges encountered by nursesin their work with patients and colleagues when
involved in ECT. How nurses handle their contact with the patient andcolleagues during ECT.
The terms nurse(s) and ECT nurse(s) are synonymous
with psychiatric-mental health nurse(s) within the text.
They also distinguish between those who have a specic
role in ECT treatment settings and nurses working
primarily in hospital wards or departments.
Nurses have participated in the administration of
electroconvulsive therapy (ECT) since its earliest beginning
in Europe, North America and the UK. ECT evokes
strong opinion within the nursing (Jones and Baldwin,
1993, Dawson, 1997), and medical (Masson, 1988;
Breggin, 1993; Freidberg, 1977) professions, and amongst
the general public and users of mental health services. ECT
remains a debatable treatment (Coppock and Hopton,
2000; Johnstone, 2000, p. 185) considers ECT is one of
the most controversial treatments in psychiatry.
Nursing objectors in the UK to administering ECT
have been severely dealt with through dismissal (Bailey,
1983). Even so, the debate over nursing objections to its
use continues. Clarke (1995) suggests that if it is against
their conscience nurses should be able to refuse to
participate in ECT. Coombes (2000) reporting on a
Nursing Times survey suggested 68% of respondents
wanted an extension to existing opt-out clauses in place
for abortion and in vitro fertilisation procedures to
include ECT. Keen (2000) supports opting out suggest-
ing that it is a question of to who nurses should be
accountable but recognises the restrictions placed upon
nurses through the assumption that nursing is subordi-
nate to psychiatry. Parsons (2000) disagrees, arguing
that ECT is a proven treatment and refusing to assist is
an abandonment of the nurses duty to care.
NICE (2003, p. 5) recommends ECT in those with
severe depressive illness, catatonia and prolonged or
severe manic episode to achieve short-term, rapid
improvement of severe symptoms after adequate trials
of other treatments have proven ineffective, or when the
patients condition is potentially life threatening.
However, Johnstone (2000) recognises ofcial and
unofcial views remain divided with ECT seen as safe
and effective or as a destructive process. Pedlers (2001, p.
16) survey of peoples experiences of ECT conrmed
similar problems with some respondents positive to it and
ers against it. The most commonly reported permanentbetween 1966 and 1994 only 19 publications in Amer-
ican nursing journals focused on nursing and ECT. The
research reported here provides a Scottish perspective
intended to ll this gap and further inform nurses in this
area of practice.
Using a grounded theory approach (Glaser and
Strauss, 1967; Strauss and Corbin, 1990), nurses work
with patients having ECT was explored. The differences
between the co-originators views upon the method have
been well documented (Glaser, 1992) and the researcher
acknowledges that this inuenced his methodology. The
style adopted was in the general spirit of grounded theory
but did not adhere to one specic approach. Utilising
elements of both Glaserian and Straussian (Stern, 1994,
pp. 219221) approaches to grounded theory resulted in
elements of the descriptive character of the Straussian
method and the emergent theoretical style of Glaser
(1992, 1998) being evident. Such an approach to
grounded theory development has been considered as
moving beyond the original methodological boundaries
(Cutcliffe, 2005), who argues this is better described as a
modied grounded theory.
The research question was:
How do mental health nurses work with patients
having electroconvulsive therapy? This included an
exploration of nurses roles in the context of ECT and
how they were enacted.A survey of nurses who worked in ECT clinics within
the UK reported by Mahoney (1998) identied respon-
dent frustrations. Half functioning as ECT coordinators
had no job description, a quarter received no specic
training and given previous audits of ECT services in
England (Pippard and Ellam, 1981, Pippard, 1992),
questions about the quality and standard of nursing
support for the administration of ECT are raised.
Similarly in Australia, Munday et al. (2003) identied
knowledge limitations in important aspects of ECT in
nurses who had key responsibilities for care. More
recently new standards for the practice of nursing with
patients receiving ECT from the National Association of
Lead Nurses in ECT focus on clinical and emotional
support Chatterjee (2005). The work of professional
groups, for example SEAN (2004) has done much to
enhance the quality of ECT services. Guidelines on the
nursing role and procedures involved in the administra-
tion of ECT (Bray, 2003; Halsall et al., 1995; Ritter,
1989) are helpful but little research exists about what
nurses actually do when working in the complex
situation with patients having ECT. A point illustrated
when examining the references for a review of literature
on ECT by Challiner and Grifths (2000) and in North
ARTICLE IN PRESSJ. Gass / International Journal of Nursing Studies 45 (2008) 191202 1932.1. Participants
These were qualied nurses (20) comprising ward
managers, staff nurses and enrolled nurses and students
(4) on a mental health branch programme in years 2 and
3 of their course who had received classroom-based
preparation for ECT. All participants were working in
two hospitals within a Scottish Health Board practising
in an adult or old age mental health setting where ECT
was provided on a twice weekly basis. Selection was
based on: willingness to participate; direct experience of
working with patients receiving ECT and on theoretical
The rst participant was chosen purposively in one of
the hospitals and thereafter through theoretical sam-
pling (Glaser and Strauss, 1967; Glaser, 1992, 1998)
where such concerns directed further sampling. There-
fore, participants were included on the basis of the
emerging theory with the researcher going to where the
person was practising or following up a potential key
informant on the basis of information provided in the
2.2. Data collection
Data was obtained through non-participant observa-
tion and unstructured interviews consistent with multi-
method routes of data collection in qualitative research
(Smith and Biley, 1997, p. 21). This countered the
potential for aws in the subsequent analysis when
based upon a single data source (Hammersley and
Atkinson, 1983). Through observation the researcher
was able to directly access the area of interest,
particularly nurses interactions with patients and others
prior to, during and after the patients treatment. This
involved collecting data on wards, travelling to treat-
ment, during treatment, returning to wards and during
the patients continued recovery. During periods of
observation the researcher did not take a direct role in
activities. Observation notes were sometimes made as
events were unfolding and when this was not possible
as quickly afterwards to retain as much information as
Coupled with observation in most instances, 24
interviews were made in the participants place of work,
in accordance with the approach discussed by Wimpen-
ny and Gass (2000). The researcher used unstructured
formal interviews which were tape recorded and
transcribed as quickly after the event as possible, and
informal interviewing during observation. In the tape
recorded interviews the researcher sought to bring as
little structure as possible, adopting an open-ended
stance (Rennie, 1996) but focused on the research
question. Initially, eld notes and spontaneous informal
questioning from observations revealed substantive
areas and questions for comparison. Thereafter, ageneral opening question was offered at the beginning
of the interview; for example: could you tell me of your
experience of working with the patient having ECT? In
total 78 h of observation and 21 h of interview data were
2.3. Data analysis
By comparing incident with incident, patterns identi-
ed were given a conceptual name (Glaser, 1992); this
determined further data collection and theoretical
development regarding properties and relationships to
other codes until the point of saturation. For example
very quickly it became apparent that nurses involve-
ment in ECT was important and this led to exploration
of this issue in different locations and with mental health
nurses acting in different roles such as ECT nurse or
ward nurse. Theoretical coding was supported by
writing memos and theorising about ideas as they
emerged whilst coding for categories, properties
and theoretical codes (Glaser, 1992; p. 108) at the
time they occurred. For example Selling ECT was
categorised as an important phase of the ECT drama
and, therefore, the researcher questioned the data in
the following manner: what gets the patient to treat-
ment? How do nurses handle the treatment situation?
This led to further theoretical sampling about nurses
roles with patients. This movement to a more selective
coding served to delimit the emerging theory (Glaser
1998, p. 50) and focus on the core category. The core
question had become how do nurses handle their
relationship when working with the patient? It had
become apparent that nurses had no control over
whether they would be involved in ECT and subse-
quently only control over their relationship with the
patient. Therefore, this aspect of how nurses controlled
their relationship through the interaction with the
patient directed the latter stages of theoretical sampling
and the emerging theory.
There are strengths and weaknesses in this research.
The ndings are grounded in data elicited from
participants who had personal involvement in the
phenomenon. In addition an audit trail (Parahoo,
1997) recording the researchers thinking and actions
was used showing how analytic decisions were made
(Guba and Lincoln, 1981, 1989). Peer review of the data
(Field and Morse, 1992, p. 121) and examining emergent
trends occurred through discussions with colleagues and
this coupled with returning to some participants to
discuss the emergent theory supports the credibility of
the ndings. Limitations include the small size, limited
geographical coverage and potential researcher bias due
to a single researcher data collecting, analysing and
interpreting the ndings. However, with respect to bias
some (Shipman, 1997, Morse, 1998; Cutcliffe and
McKenna, 2002) recognise there is a necessary bias in
some positive others doubtful, considering ECT inap-
ARTICLE IN PRESSJ. Gass / International Journal of Nursing Studies 45 (2008) 191202194propriate and unnecessary; (2) involvement: this was
considered inevitable with little or no choice for the
nurses; (3) perceived patient category: including reg-
ulars, rst-timers, worriers, typical cases and
refuserresisters; and (4) relationships: considered
central to the nurses activity. It is within this context
that nurses act in two characteristic roles.
3.1. Relational roles
In their relationship with patients the nurse develops
roles of information-giver, persuader and supporter;
where sustaining the relationship is viewed as an
essential part of their work. This involves providing
details about the ECT process and responding to
patients questions and concerns; the ECT nurse has a
primary role here but this function is supported by the
actions of other nurses:
I see everybody before ECT and explain to them
whats going to happen to them.such research and would not attribute signicance to
2.4. Ethical considerations
Ethical approval was obtained from an NHS Scotland
regional research ethics committee and permission for
access by writing to directors responsible for nursing
services. Participation was entirely voluntary with
informed consent obtained in writing from nurses
following a verbal and written explanation. Patients
who were not the focus of the study were provided with
a verbal and written explanation that the nurse working/
accompanying them was being studied. All patients
having treatment during periods of observation gave
consent to this. Any participant could withdraw their
consent at any stage in the study. To ensure condenti-
ality no person was identied in the data from eld notes
or interview recordings.
Consistent with the hybrid methodology the ndings
presented up to the core category include a combination of
theory and description. Nurses working relationships with
patients having ECT can be set in a context of gaining the
patients acceptance of treatment (selling ECT), attending
the treatment (getting there) and receiving treatment and
recovering (treatmentrecovery). Such a context is likened
to a drama with patients and mental health nurses playing
their respective roles. For nurses there were four contextual
properties to this drama:
(1) images of ECT: where opinions were polarised,Judging what the patient can accommodate; e.g. rst-
timers means keeping the details simple, breaking
information giving into small packages:
Its hard for them to perceive why its happening
especially if its the rst time its happened so youre
trying to break it down into chunks.
When seeking consent or when patients have doubts
persuading is important; obtaining the patients agree-
ment is always preferable:
You would hope to get someone to agree, rst and
foremost or like youve got to go through a section.
Persuading can take the form of information-giving
and backing up offers of ECT from the psychiatrist:
Some patients can like let things go in one ear and
out the other theyre just not receptive enough, they
need that back up from, from the nursing staff.
Some patients are unreceptive to the offer of ECT and
become distressed at the thought of it, here additional
details and support may inuence the patients decision
to accept treatment:
When they hear the words ECT sort of thing you
often do have to go in afterwards and pick up the
This illustrates the links between giving information,
persuasion and support. Persuasion is coupled with
support in picking up the pieces after the initial shock
experienced by the patient at the prospect of ECT.
Sometimes the persuasion occurs at a critical point e.g.
immediately before treatment:
They have had patients refuse ECT at the last minute
and Ive been able to go and sit with them and talk
them through it.
The period of waiting for treatment is a crucial time
and supporting, for example by distraction by nurses
can be helpful. This includes talking about anything,
bringing humour into the situation or focussing on
positive aspects of ECT to reduce tension:
Youll read out the jokes and have a laugh and it
seems to like pass the time quickly.
Tell them how much better theyre doing since
theyve had their ECT or just anything to keep them
These interventions are established within the rela-
tionship with the patient where sensitivity to her or his
feelings is essential:
If you know somebody well you can go on how
anxious they are, so to actually say to somebody
what they might be feeling is a great relief to them.
ARTICLE IN PRESSJ. Gass / International Journal of Nursing Studies 45 (2008) 191202 1953.2. Treatment roles
The ECT nurses supporting role to medical staff as
anaesthetic helper and treatment assistant involving
theatre work and gatekeeping contrasts with other
colleagues who do not have the same type of function.
However, a role common to both groups is that of
forcing, in which case the ECT nurses actions are
usually limited to the treatment environment. The ECT
nurse is distinguished from ward-based colleagues by a
skill prole which provides role clarity in the treatment
Shes involved with erm drawing up different things,
sometimes with the oxygen, bagging people with the
oxygen and things like that.
I think they view me differently because Im the ECT
Setting up for treatment requires specic knowledge
closely linked to the anaesthetists requirements invol-
ving work in organising the environment, checking
equipment and sometimes preparing anaesthetic agents:
In the treatment room the nurse draws up syringes of
suxemethonium, anaesthetic agents.
I do more than some of the junior doctors.
This specialist technical and supportive role enhances
the differences between the ECT nurse and other nursing
colleagues. The nurses relationship with the patient
focuses on getting there receiving the treatment and
returning to the ward. However, ECT nurses are the
gatekeepers for this process, controlling access to and
egress from the treatment subject to the authority of
medical staff. Establishing the patients consent is
If somebody came through the door and erm, er, they
disagreed they would get sent back to the ward.
This gatekeeping role may result in conict when a
nurses desire to return to the ward with the patient is
not immediately met by the ECT nurse controlling this
Ive had a student quite angry because Ive not let
them take the patient back to the ward.
There are occasions when nurses become involved in
forcing treatment usually when persuasion, inevitable
resistance and further persuasion has failed. The
patients inability to recognise her or his predicament
and accept treatment, coupled with a view that the
situation is severe and life threatening is important for
nurses when considering forcing:
I can appreciate why theyve been made to have
ECT; maybe theyre so psychotic or so depressed and
theyre unt to make the decision.The decision to treat with the support of the multi-
disciplinary team is medical, but nurses make it happen,
albeit acting in a subordinate role to medical authority.
In some cases their separation from the decision to give
ECT contrasts with the requirement for them to make
the patient comply:
Although the rest of the team agreed with it, they
would never have to do all the hard work to get him
there; they wouldnt have had to listen to him
screaming no, they were the ones that were too
Forcing may occur with or without direct physical
contact involving restraint; the absence of physical
resistance is less distressing, however, when forcing
requires physical restraint the event becomes more
distressing for those concerned:
He was so angry he spat on us the whole way to ECT
Modern practice requires the patient to be given the
treatment in purpose-built units (Freeman, 1995; Scot-
tish Ofce, 1997). A consequence is that forcing
treatment can be a public drama where the patient and
those forcing are apparent to others, and embarrass-
ment and a sense of indignity for the patient is not an
Theres visitors oating about in the corridor and its
just horrible you know.
This act is contrary to popular images of caring
professionals. Forcible treatment, for example with
medication does occur in the restricted environment
(behind closed doors) in psychiatric hospital wards. But,
in the case of forcing ECT, it may be a more public
affair and as such more stressful for the nurses involved.
Two emerged for the participants; the rst was
uncertain role. Transferring patients over for treatment
is the focal point for this dilemma. Until this point
nurses have played a signicant role in selling ECT and
getting there, however, after this opportunities for
involvement in the treatment setting are limited. The
lack of activity and a sense of not belonging for nurses
could be like being on stage with no lines to say or
without any direction:
I think sometimes you are made to sort of, feel a bit
uncomfortable sometimes and as though youre a bit
of an inconvenience you know.
A perception of being superuous to requirements
because their skill prole does not help inclusion in
activities taking place:
For some, the dilemma is recognising that forcible
intervention is wrong but that nothing can be done
about it. There is no control of the situation; the
prescription of the treatment is a medical and multi-
disciplinary team matter and nurses are required to get
the patient to the treatment. Not only does the patient
experience powerlessness in this situation but so does the
I know deep down in my gut my feeling is that ECT is
wrong no question but you still go through with it.
3.4. Being there
The core category being there is dimensional and
comprises three sub-categories: engaged, present and
detached. These inform our understanding of nurses
work with patients treated with ECT. Being there
extends along a continuum from a closeness between the
nurse and patient exemplied by a humanistic relation-
ARTICLE IN PRESSJ. Gass / International Journal of Nursing Studies 45 (2008) 191202196Because of all the paraphernalia you sort of get
elbowed out of the way for the machinery
There may be difculty in responding to technical
requests regarding the treatment but some ECT nurses
perceive their colleagues do not seek involvement and
abdicate their responsibilities to the patient:
I sometimes feel that youre sort of left reassuring the
patient plus directing everything else and I do think
the ward staff should take a more active role.
In contrast, some nurses perceive they are excluded
and liken it to being passive observers as the drama
Well, it used to be very pro-active and you used to
have a, have a role and now its on the sidelines just
Although nurses are required to attend treatment
with the patient establishing a role is difcult within
the treatment culture of the ECT environment. The
distinctions between nurses are heightened by the
strength of professional bonds between the ECT nurse
and anaesthetist. Some nurses perceived they were
excluded within this environment; inhibiting their
actions towards the patient and subsequently opting
out from this part of the treatment process.
Uncertain relationships: the second dilemma is role
dissonance when forcing treatment. This can be distres-
sing and in some cases results in the breakdown of the
It makes you feel terrible because youre physically
Offers of comfort by the nurse in a supporter role are
combined with forcing, sometimes physically restraining
the patient. The contradictory messages conveyed
(comfort and support coupled with physical restraint)
may negate any potential benets that may be derived
from the attempts at supportive interaction with the
Its youre going to be ok, were not going to hurt you
but yet we were holding him; verbal reassurance was
sort of counteracted with the physical restraint.
Consequently, nurses nd themselves acting in simul-
taneous, but contradictory roles and cannot respond in a
manner that listens to the patient. The resulting
dilemma forces self-reection and subsequent doubts:
If I was to speculate and put myself in a patients
shoes and how Id be prior to ECT I would be
thinking, well the nursing staffs supposed to be
helping me and heres me terried.DETACHED
Fig. 1. Being there.ship at one end, to a distant, unresponsive relationship
state at the other end. In between these two extremes is a
position whereby the nurse is present. As with any
dimension a subject may be located at any point upon
it hence the potential for variability (Fig. 1). This
dimension is analogous to a spherical structure compris-
ing an inner core, a middle layer and an outer layer and
surface. In being there, the case of detached can be
understood as an inner core that reveals little of the
person buried deep within. The middle layer, being
present has the person within, closer to the surface
revealing more of the individual. The outer layer equates
to being engaged with the person who is the nurse
exposed and visible at the surface.
ARTICLE IN PRESSJ. Gass / International Journal of Nursing Studies 45 (2008) 191202 197These sub-categories illustrate the nursepatient
relationship and how nurses act in the ECT drama.
Thus, the nurses actions in relational roles (informa-
tion-giver, persuader and supporter) and treatment roles
(theatre work, gatekeeper and forcing) are inuenced by
the state of being there. Fig. 2 illustrates the
hypothesized relationship between the major categories.
Fig. 2. Nurses work with patients having ECT.Nurses who are engaged develop awareness of the
patients knowledge and experience focused on under-
standing the patients feelings and concerns. Such
qualities were evident either in descriptions of working
with patients or in their actions where being engaged
means coming to know and understand the patients
Attempting to put yourself in their position, how
would you be feeling if it was you.
The patient feels I can talk to this person you know, I
can get these things off my chest.
Engaged nurses empathise with the patients experi-
ence, not merely her or his illness but of their treatment.
Me being with somebody, not just physically being with
somebody but being with somebody in your head.
This resonates with the practical or clinical work
Taylor (1994) refers to; where the quality of what she
describes as being with is expressed. This example of
the nursepatient relationship is interesting, particularly
in an environment circumscribed by the use of somatic
treatment approaches. Although these interventions areunder the authority of the psychiatric profession,
engaged nurses endeavour to continue to practise in a
manner that is consistent with a humanistic perspective.
Actions directed towards seeking understanding and
meaning in the patients experience of her or his illness
through empathising and focused towards change are,
on this occasion, centred upon the patients experience
of having ECT.
However, putting themselves in the patients position,
seeking to understand their experience evokes strong
feelings; particularly when nurses become cognisant of
their own feelings about the patients existential state.
She would become quite tearful and things and it
kinda, you know what I mean, god what am I doing
to this poor lassie, you know?
For engaged nurses, recognising and being open
about ones feelings is important. Sometimes they may
not verbalise feelings about what is happening to
patients, but nevertheless they are evident to others.
I could see it was probably hurting the staff nurse as
much as it was the patient you know, to go through
In this instance, the patients pain at being made to
have ECT was equally apparent for the nurse who,
under these circumstances was simultaneously an
instrument of coercion.
When forcing treatment occurs there is the prospect
of contradictory actions by the nurse; typically a
response which echoes conrmation of the patients
feelings followed by the opposite action of making the
patient have treatment. One nurse describes how she
wanted to be less distant and professional in her actions
with a patient forced to have ECT.
I wanted to be more empathic and easy going and,
you know, more like a friend, if you like, type of
In considering this statement two observations can be
made. Firstly, whilst the emphasis is humanistic, the
interaction is a compromise. A compromise between the
ideal as espoused (humanism) and the reality of a
coercive role (in this instance social control), and is
rooted in the overarching power of medical authority
and the necessity for the nurse to comply with her
employment status. Secondly, there is a sense in which
the nurse adopts the trappings of humanism, but this
becomes incorporated into the coercive actions to
follow. This nurse wanted to be considered as an equal
at the same level (the position espoused in being
engaged), but the reality of the situation meant that
she could not. Under these circumstances she was always
going to be in a position of authority in her role in
relation to the patient.
ARTICLE IN PRESSJ. Gass / International Journal of Nursing Studies 45 (2008) 191202198A conict of allegiance may happen when being
engaged contradicts the actions that the nurse has to
take in practice.
The dilemmas youre no sure if it works but youre
saying to folk well, aye it does work, you know what
I mean, that it can work you know.
This nurse indicates he cannot be as honest as he
would like. It appears that his own experience contra-
dicts what he is able to convey to the patient about the
treatment. In this way he covers up or masks his own
beliefs about what may happen. Unable to be authentic
he presents an image suggesting otherwise to the patient.
A reality of ECT contrary to his own experience is
presented undermining the basis of the humanism
implicit in being engaged. The patient is unaware of
this, but all the same the deception undermines the core
attitude of genuineness (being a real human being
honest and true (La Monica, 1979, p. 3)) espoused for
Covering up like this is an example of how the state of
being engaged slips this time into the state of being
present, with a professional aura. Slipping is a
compensatory basic social-psychological process en-
abling a nurse, who has been engaged to function
within the ECT drama and meet the demands made by
virtue of the roles required to be played. However, the
consequences for the relationship with the patient may
I expected the trust to have gone, well what little trust
was there really I expected it to have gone and it had.
She didnt want to speak to me, she didnt trust me.
In being present nurses actions are consistent with
an adjunct role to the psychiatrist in providing treat-
ment. It is characterised by the distancing technique
adopted by professionals aware of the potential emo-
tional difculties of getting too close to the patient.
These nurses act in a manner that avoids internalising
feelings from the patient. It is an instrumental state,
where the relationship is essential for the successful
performance of the nurses roles in the ECT drama
where enabling treatment to take place is the priority.
Unlike being engaged, the attention of the nurse who is
present is directed towards the process of treatment
rather than the patients experience. This suggests that
whilst the relationship is the central focus, it is
orientated towards an agenda created by the nurse
rather than with the patient. It is an agenda that is
explicitly governed by the ECT script.
Well you just try and try and try to get them to come
round to your way of thinking but you know whats
best, to try it, give it a shot give it a try.The nurse who is present carries out his or her role in
a professional manner exemplied by attention to the
patients needs for comfort and support during the
In the lift it feels cold and the patient appears to
shiver and the nurse comments about this. She places
her hands on his shoulders and makes a point about
the cold saying wheres the blanket?
This illustrates the distinction between present and
engaged. In the latter, the statement would have been
qualied and the nurses response addressed directly to
the patient. Whereas in this case it was an appeal to
others present. This reluctance to relate to the patients
experience was apparent when a nurse chose not to
respond to the patients concern about her memory.
Almost immediately the next patient arrives along
with a nurse who asks her to take a seat whilst she
places the notes in the anteroom. On return the
patient says to the nurse that she nds it hard to
remember what day it is, there is no response from
Here the nurse avoids being drawn into an interaction
focused upon the patients experience of ECT and her
concerns and thus avoids placing the patient and her
experience at the centre of the nurses activity. Action is
focused on the process of getting treatment.
I know its, Ive done this, its a procedure to go
through and its not very nice but I think maybe its
just how Id like it to be done if I was having ECT.
This is an egocentric interpretation of the experience,
rather than seeing it through the eyes of the patient. The
focus is upon control and is congruent with using the
Maintain that relationship with them because they
might not want to go, sometimes its been used as
consent to treatment.
The nurse who is present acknowledges this instru-
mental function. It is suggestive of a strategy where the
nurse, by cultivating the relationship, uses this as a
means of insurance for possible difculties in the future.
The relationship is used to secure treatment and
present is synonymous for how the nurse is expected
to act in both relational and treatment roles within the
drama. It is the state that is most consistent with the
patient getting treatment and is likely to achieve this
with the least amount of difculty for the nurse
The detached nurses distance from the patient
extends beyond any therapeutic distance associated with
Consequently, the boundary typical of a professional
ARTICLE IN PRESSJ. Gass / International Journal of Nursing Studies 45 (2008) 191202 199being present and occurs under two circumstances.
Firstly, the nurse engages in activity with others, usually
hospital staff, and does not attend to the patient as a
person. This does not extend to nursing activities such a
liaising with colleagues or conveying relevant informa-
tion associated with the patients care. Secondly, the
nurse is unresponsive to the patients verbal or non-
verbal cues which may indicate anxiety or concern.
The patient looks restless and is sitting in the
wheelchair. Both nurses meantime are chatting away
they talk about the television, what was on last night
and who had been seeing who.
Here the patient exists as a commodity not to be
engaged with. Another nurse also pointed towards this
type of behaviour:
I found that the patients were just left in the room
and when ECT was due just went up and gave them a
shout to rise.
The signicance of the perception of the patient being
different, contrasts with the actions of the nurse who is
engaged or present. In the former, the nurse will seek
interaction with the patient and in the latter will focus
on the treatment process.
The unresponsiveness of being detached extends not
only to the patient but other members of the treatment
team. Here the patient is to be given intravenous
The patient nds this uncomfortable, muted reassur-
ance from the anaesthetist who says she is sorry.
Again unsuccessful, the ward nurse doesnt move, the
consultant looks in her direction, it seems as though
he is trying to make contact with her but there is no
In this example, the inertia of the nurse contrasts with
the discomfort of her patient and the activity taking
place around her, centred upon treatment. The beha-
viour expected by others in the situation appeared to be
in accordance with being present to act in a profes-
sional manner and help the patient to accept the actions
of the treatment team. Quite openly, the nurse acted
outside of the expected script, by not following the cue
presented by the psychiatrist to act in a supportive role
exemplied by being present whilst the anaesthetist
inserted a cannula in the patients vein. In this case being
detached may be seen as a means for managing contact
not only with the patient but also the treatment team as
In a different situation (waiting room) the distance
between the nurse and patient is evident.
The nurse plays with his plastic staff identity badge
for a couple of minutes, thumbing it through his
hands. He seems a bit uncomfortable and dgety,distance (a feature of being present) could in these
instances be lowered.
Peplau (1987) describes the capacity to feel or
experience the same feelings as other(s) in the same
situation as empathic linkages. Such feelings can, in
turn, be transmitted by the nurse non-verbally to the
patient. It is possible that engaged nurses may develop
such (potentially therapeutic) linkages with patients.
However, in the context of forcing the patient empathic
linkage can present difculties. Simultaneously, theeventually he relaxes a little and puts his large feet
upon the coffee table, stretches and yawns but saying
nothing to the patient who remains silent sitting
slightly forward on her chair.
Here the nurse could be considered completely
disengaged preventing him from confronting not only
the patients but also his own experience in the ECT
The sub-categories of being there, and, in particular
engaged have some resonance with Barker et al. (1999)
who identied three sub-categories (Ordinary Me);
(Pseudo Ordinary or Engineered Me); and (Professional
Me) to the core of Knowing you, Knowing me in a
study exploring psychiatric nursing practice. The en-
gaged nurses relationship is compatible with, a
humanistic ideology centred on being rather than doing
(Watkins, 2001), with empathic qualities analogous to
those outlined by Zderad (1969, p. 659) who views such
relationships in terms of: I am with the other but I
know I am not the other. Being engaged means
developing an understanding of the patients experience.
However, the actions of nurses who are engaged with
their patient in the ECT drama cannot be considered to
be therapeutic in the manner described by Peplau (1952,
1962, 1994), Travelbee (1971), Taylor (1994), Horsfall
(1997) or Reynolds and Scott (1999). The nurses
circumscribed role within the ECT drama, geared
towards getting treatment, cannot be construed as
focusing upon the type of therapeutic objective asso-
ciated with the above. However, this does not mean that
the nurses interaction with the patient does not seek to
realise the therapeutic potential afforded by the time
spent with the patient.
The feelings evoked in the nurse by the patients
experience appear consistent with Peplaus description
(1994) of empathic observation. Here the nurses
discomfort within her or himself is evoked by the
patients anxiety. Empathised anxiety from the patient
in distressing situations involving ECT can be difcult
for the nurse leading to self-questioning and doubt.
and comfort the nurse should be familiar to the patient. By
ARTICLE IN PRESSJ. Gass / International Journal of Nursing Studies 45 (2008) 191202200patients anxiety and the nurses distaste at what is being
done are made apparent. In this context the states of
present and detached can be viewed as conditions that
prevent such empathic linkage occurring and therefore
role dissonance for the nurse.
Therefore, a nurse who seeks to be engaged when they
have a prescribed role of forcing is problematic. Hopton
(1997) identies such difculties when nurses espouse the
use of person-centred methods within services required to
apply prevailing mental health legislation. Similarly,
Tennant (1997) argues that the obstacles to therapeutic
nursepatient interaction have existed for years within
acute in-patient facilities because of tensions between the
nurses responsibilities as custodian and any therapeutic
ambitions that they might have. Higgins et al (1999)
recognise this dilemma and the tensions between these two
approaches rooted in differing ideologies. This is indicative
of the limitations of the one-to-one nursepatient
approach espousing holism and humanistic values identi-
ed by Evans (2001), who suggests that beyond acknowl-
edging the feelings of the patient there is little else that can
be said in this context.
In the circumstance of ECT, when it is impossible for
the nurse to make her or his perceptions transparent,
slipping is the psychosocial process that enables the
nurse to handle the situation. The difculty for
engaged nurses is one of authenticity in their relation-
ship with the patient. By slipping to being present e.g in
a forcing situation will enable the job to be done, but at
a cost to the nurse and patient. For whilst it enables the
nurse to fulll the role required in the drama, there will
be a personal dilemma (uncertain relationships) experi-
enced as a result of playing this role.
In contrast, by being present the nurse avoids
empathic links (Peplau, 1994) or what Zderad (1969)
described as part of the internalization phase in the
process of clinical empathizing. In this case, the
emotional overtones of both the patients and the
nurses situation can be kept at a distance. This is
reminiscent of Towell (1975) who noted how nurses
emphasised the importance of a good patient relation-
ship but in some instances were driven by a desire to
retain control. Here control relates to the manner by
which medical servicing with the administration of ECT
is ensured; and, the primacy of the psychiatric model
over the nursepatient relationship is accepted in
practice (Sullivan, 1998). Thus being present enables
the nurse to undertake such roles as information-giver,
persuader, supporter and sometimes forcer without
the dilemmas of those who are engaged. This
acceptance by adaptation to the prevailing biomedical
ideology (Strauss et al., 1964) is consistent with
Morralls (1998) view that nurses should embrace the
social control function associated with their degree of
contact with the patient and their historical connection
to the psychiatric profession.evading contact with the patient being detached can be
understood as an extension of the professional distance of
being present or; an extreme form of detachment Menzies
Lyth (1961) within the context of a socially constructed
defence mechanism. However, unlike the fragmentary
contact with the patient in Menzies analysis, contempor-
ary care is patient-centred where the relationship between
the user and practitioner is the core element of mental
health nursing (Scottish Executive, 2006, p. 20). Therefore
given the difference in environmental contexts the presence
of detached nurses should be a cause for concern.
Being there helps in understanding nurses relation-
ships with patients and their relational and treatment
roles during ECT. The contradiction between the
espoused humanism of the nurse who is engaged and
the requirement to make an unwilling or reluctant
patient have the treatment creates a dilemma with
respect to her or his relationship with the patient. Thus,
slipping postulated as a basic social psychological
process occurs shifting the balance of the nursepatient
relationship in the direction of being present; any nurse
who remains engaged in a situation where the
authenticity of this state of being there is compromised
will experience role dissonance and stress.
Being detached may be an indication of burn-out
and the need for professional support particularly in the
form of clinical supervision. Reviewing the ideology for
nursing practice would provide an opportunity to
examine the values that underpin the relationship
between nurses and patients and refocusing activitiesThe detached nurses relationship is typied by a
mechanistic but unresponsive presence. McKie and
Swinton (2000, p. 38), examine the virtue of care and
out of four possible meanings of care, Blustein (1991)
identied, it is to have care of (responsibility) that
they consider may provide the focus for a detached,
professional model of nursing. Such a focus might view
responsibility for getting the job done, delivering the
patient as the caring action of the nurse. The inadequacy
of this mechanistic approach to care is well documented
in adult mental health services within the eld of special
observation in patients with suicidal intent (Reid and
Long, 1993; Duffy, 1995; Barker and Cutcliffe, 1999;
Cutcliffe and Barker, 2002; Scottish Executive, 2002).
The phenomenon of detached may be explained on the
grounds of distancing as a means of defence (Menzies
Lyth, 1961; Handy, 1991) where distance provides security
for the nurse from the anxieties occurring when exposed to
the patients emotional turmoil. In this context there is no
necessity for a relationship between the nurse and patient
but merely the acceptance that in order to provide support
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Electroconvulsive therapy and the work of mental health nurses: A grounded theory studyWhat is already known about the topic?What this paper adds
IntroductionMethodParticipantsData collectionData analysisEthical considerations
FindingsRelational rolesTreatment rolesDilemmasBeing thereEngagedPresentDetached