Electroconvulsive therapy and the work of mental health nurses: A grounded theory study

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  • 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.

    doi:10.1016/j.ijnurstu.2006.08.011

    Tel.: +44 01224 262645

    E-mail address: j.gass@rgu.ac.uk.paradoxically, 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

    Abstract

    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

    www.elsevier.com/locate/ijnurstu

  • ing

    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.

    1. Introduction

    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.

    2. Method

    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

    grounds.

    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

    eld.

    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

    possible.

    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

    collected.

    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

    this.

    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.

    3. Findings

    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

    pieces.

    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

    poised.

    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

    setting.

    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

    nurse.

    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

    crucial:

    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

    process:

    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

    uncaring.

    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

    uncommon experience:

    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.

    3.3. Dilemmas

    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

    nurse:

    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

    unfolds:

    Well, it used to be very pro-active and you used to

    have a, have a role and now its on the sidelines just

    stand back.

    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

    nursepatient relationship:

    It makes you feel terrible because youre physically

    manhandling somebody.

    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

    patient.

    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.

    ENGAGED

    PRESENT

  • 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.

    3.4.1. Engaged

    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

    world.

    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

    that.

    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

    thing.

    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

    humanistic relationships.

    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

    be signicant.

    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.

    3.4.2. Present

    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

    treatment process.

    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

    the nurse.

    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

    relationship.

    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

    involved.

    3.4.3. Detached

    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

    anaesthetic medication

    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

    change.

    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

    well.

    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

    drama.

    4. Discussion

    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.

    5. Conclusion

    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

  • Clarke, L., 1995. Psychiatric nursing and electroconvulsive

    7 (1), 3542.

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    Nursing Times 96 (5), 13.

    Coppock, V., Hopton, J., 2000. Critical Perspectives on Mental

    Health. Routledge, London (Introduction, 8).

    Cutcliffe, J.R., 2005. Adapt or adopt: developing and transgres-

    sing the methodological boundaries of grounded theory.

    Journal of Advanced Nursing 51 (4), 414420.

    Cutcliffe, J.R., Barker, P., 2002. Considering the case of the

    suicidal client and the case for engagement and inspiring

    hope or observation. Journal of Psychiatric and Mental

    Health Nursing 9, 611621.

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    and custody may be possible.

    The updating of technical skills of ward nurses

    relevant to treatment and recovery areas is important

    and the role of the ECT nurse is crucial to this and

    should be strengthened to ensure consistent provision of

    care. This could involve regular updating of ECT

    practice and include the practical activities involved

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    Generalisation from these ndings to other popula-

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    However, it is possible for being there to be indicative

    of nurses relationships not only ECT but other

    nursepatient contexts. It is, therefore, recommended

    that the characteristics of the dimension of being there

    be explored in these wider contexts.

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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

    DiscussionConclusionReferences

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