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Gwinner, Karleen & Ward, Louise (2013) P.I.C.U., H.D.U., A.O.A. Whattreatment do we provide?: Current descriptions of the function of intensivecare for inpatient Psychiatric Health Care. Mental Health Review Journal,18(3), pp. 128-143.

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For Peer Review

P.I.C.U., H.D.U., A.O.A. What treatment do we provide?

Current descriptions of the function of intensive care for

inpatient Psychiatric Health Care.

Journal: Mental Health Review Journal

Manuscript ID: MHRJ-02-2013-0008.R1

Manuscript Type: Research Paper

Keywords: psychiatric intensive care, recovery-oriented, Nurses, mental health

services, organisation, PICU

Mental Health Review Journal

For Peer Review

(Author) Year Journal

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care


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or mental health unit.

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Inclusion Criteria Exclusion Criteria International research

English language 2000 onwards,

Adult PICU Youth

Meets operational definition in acute psychiatric wards Empirical literature

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P.I.C.U., H.D.U., A.O.A. What treatment do we provide?: Current descriptions of the function of intensive care for inpatient Psychiatric Health Care.

Abstract

Purpose: This paper adds to growing research of Psychiatric Intensive Care Units (PICU) by recounting descriptions of psychiatric intensive care settings and discusses the perceptions held by Nurses of the organisational interfaces, arrangements and provisions of care in these settings.

Method: Data gathered from focus groups held with Nurses from two PICUs was used to establish terminology, defining attributes, related concepts, antecedents, values, processes, and concepts related to current practices. A literature search was conducted to permit a review of the conceptual arrangements and contemporary understanding of intensive care for people experiencing acute psychiatric illness based on the perspectives held by the nurses from the focus groups.

Findings: Dissonance between service needs and the needs and management of individual patients overshadows strategies to implement comprehensive recovery-oriented approaches. Three factors are reported in this article that influence standards and procedural practice in PICU; Organisational structures; Physical structures; and Subtype nomenclature.

Originality/value: Current descriptions from nurses substantiate wide variations in the provisions, design and classifications of psychiatric intensive care. Idiosyncratic and localized conceptions of psychiatric intensive care are not adequately entailing effective treatment and methods in support of recovery principles for improved and comprehensive outcomes. The authors suggest that more concrete descriptions, guidelines, training and policies for provision of intensive psychiatric health care encompassing the perspective of nursing professionals, would reinforce conceptual construction and thus optimum treatments within a comprehensive, recovery-oriented approach to mental health services.

Keywords; Psychiatric intensive care, nurses, recovery-oriented, mental health services, organisation, PICU


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Introduction

“We had so many chronic patients walking around, cause they are dependent on a

service and then the PICU is a mish mash of everybody requiring treatment but

what treatment do we provide?”

This statement illustrates the frustration involved in meeting the needs of people experiencing acute psychiatric distress. While much has been written about the need to minimise the impact of mental illness through a comprehensive approach to health services based on consumer driven recovery principles (Geraghty et al., 2011, Migdole et al., 2011, Ramon et al., 2007, Bertolote and McGorry, 2005, Olmos-Gallo et al., 2012), limited inquiry has focused on how acute intensive care units deliver a recovery-oriented approach as part of a comprehensive mental health service.

Intensive care of patients experiencing acute psychiatric distress is an essential, yet complex part of mental health services as a whole system. Commonly intensive care is delivered in specialized wards or units co-located with Acute Mental Health Inpatient Units mostly known as Psychiatric Intensive Care Units (PICU). PICUs are staffed by specialised nurses and equipped to provide observation, care and treatment to individuals with actual or potential life-threatening illness, or complications from which recovery is possible (Australasian Health Infrastructure Alliance, 2010). In many other countries, as in Australia standards of care are mandated by relevant guidelines such as the National standards for mental health services (Australian Health Ministers, 2009). However standards can be translated into different ideas and objectives, functionalities and according to varying context of use (Beer et al., 2001, Cleary et al., 2009a).

Despite promising developments, the arrangements for provisions of intensive psychiatric inpatient care have been described as a neglected area of thinking and research (Glick et al., 2011, Cox et al., 2010). Evidence of the effectiveness of care and treatment remain scarce (Pereira et al., 2005b, Paul and Menditto, 1993, Walsh and Boyle, 2009). The purpose of acute admission has also been insufficiently defined (Bowers et al., 2009). Audits and surveys of PICUs demonstrate conceptual discrepancies about the nature and purpose of PICU (Cleary et al., 2009a p.231, Glick et al., 2011). Additionally narratives from patient and carer experiences are too often impoverished, indicating insufficient conditions for care, treatment and engagement of a recovery-oriented approach in PICU (Geraghty et al., 2011, Horsfall et al., 2010, Cleary and Dowling, 2009).

It is timely to establish greater clarification of the complex and changing mixture involved in meeting the needs of people experiencing acute psychiatric distress. This paper draws on data from focus groups with nurses and an integrated study of current literature to depiction of the concepts and issues in PICU. The aim of this paper is to provide a critical reading of the perceptions and descriptions understood by nurses, as the vanguard of providing intensive care to patients experiencing acute psychiatric distress. The lack of specific paradigms in this area has significantly influenced the organisational and physical structures and subtype nomenclature, leading to discrepancies and less than optimum recovery-oriented approaches for nursing in PICU.


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“What sort of recovery practice would you say you practice?”

The discourse of recovery and comprehensive recovery-oriented systems, infrequently incorporate the practice of recovery principles by health professionals, which also conceive the complexities involved in meeting the needs of people with acute psychiatric distress (Amering and Schmolke, 2009). The rhetoric for a comprehensive, recovery-oriented mental health system determines recovery as a central strategy to reduce the prevalence and impact of mental health problems and mental illness (Caldas, 2011). Recovery is defined as a person’s improved capacity to lead a fulfilled life that is not dominated by illness

and treatment; and a journey toward a new and valued sense of identity, role and

purpose outside the boundaries of mental illness (The State of Queensland, 2008 p.2). For the purposes of this paper, the authors hold a key principle of recovery as valuing the expertise and needs of the individual with lived experience of mental illness in defining knowledge about their own experiences of illness and wellness, and individually negotiated approaches for support and interventions (Gwinner et al., 2012). The Study

Four focus groups were held to ascertain concepts of recovery held by Nurses working in two Psychiatric Intensive Care Units in Queensland, Australia. The focus of the study was to identify the concepts and connected expressions of recovery in relation to PICU, held by nursing professionals. Expressions identified in the focus groups were used to examine current literature for congruency with existing concepts, properties and dimensions. The analysis explicated practical and epistemic basis for nursing practice within PICU environments.

Participants and Ethics

Ethical approval was granted by the University and Health care service Human Research Ethics Committee for an investigation into the Psychiatric Intensive Care with health staff. The participants in the focus groups were nurses who operated within locked wards attached to two metropolitan district hospitals. Nurses were invited to participate in two focus groups, one at the start of the project and one following an integrative review to member check the emerging findings. Participation was voluntary and participants signed a consent form at commencement of the focus groups. The nurse informants identified many nursing practices as fundamental to appropriate and effective intensive care delivery, while also providing insight into the complexities and congruency they face.

Design

The study incorporated a qualitative approach to an integrative review and analysis of the overall data. Other studies have used and advocated an integrative review approach as important to nursing to present the varied


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perspectives on issues of concern (Dix, 1995, Vinokur-Kaplan, 1995). Integrative reviews can encompass a wide range of purposes: to define concepts, to review theories and evidence, and to analyse procedure from a number of sources (Dix, 1995). Data Collection

Four focus groups were used to elicit informants’ perspectives on various aspects of nursing and recovery-oriented practices. The data emergent from focus groups was used to identify concerns related to the complexity of psychiatric intensive nursing in PICU and establish the review framework. This approach was essential to provide explicit attention on key purpose, concepts, terms and importantly the boundaries for the literature review process. Review of the literature was done through Google scholar to allow boarder search of databases such as CINAHL, Informa Healthcare Medline, PubMed, PsycARTICLES, and Wiley. Purposive sampling of literature was combined, to enhance variables and expand explanation of the perspectives and definitions expressed in the focus groups. 40 items that met the inclusion criteria (Table 1) and augmented the focus group concerns of psychiatric intensive nursing in PICU are reported on in this article (Table 2).

Table 1. Inclusion and Exclusion criteria

Table 2. Description of the Literature

Data Analysis

A thematic analysis involved a process of examining, comparing and conceptualising, firstly the focus group data to enable recognition of emerging patterns to identify sub-themes and major themes; and secondly dividing the literature into themes related to the perspectives and definitions of the focus group. Theme identification was based on repeated occurrences of dialogue with similar content, both within and across the textual data. The most important and recurring themes in our findings and their corresponding explanatory data were cross-checked among researchers to ensure consensus. In labelling the themes, thick description was used to indicate the context from which they were drawn. The congruencies among informants’ experiences were examined and taken back to informants to corroborate the authenticity and reliability of the interpretation of these understandings. Several sources of data captured the depth and range of issues to be cross-checked, achieving convergent validity of the data (Shih, 1998).

FINDINGS

From the analysis of the data generated through the focus groups, and the literature review, three factors that significantly influenced the function and treatment provided by nursing professionals in PICU were identified; Organisational structures; Physical structures; and Subtype nomenclature. The remainder of this paper provides an interpretative account of each factor with supporting verbatim from the focus groups and the review of literature.

Organisational Structures


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The first factor, ‘organisational structures’ encapsulated contradictory

configurations in standards and procedural practice to provide intensive care of patients experiencing acute psychiatric distress. Nurses discussed issues such as different staffing ratios and skill requirements for the treating team, varied necessities for paper work, reporting and developing recovery plans and divergent values in the type of treatment and therapies provided to the patient while in PICU. One nurse proclaimed,

There is no perfect infrastructure but it is about how many clientele you are

going to have in each unit. How many beds you going to have and how that

is really going to be managed. And then of course staffing becomes an issue.

The provision of a balanced approach in PICU pivoted on the logistics of staffing. One informant stated,

PICU can be such a time bomb at times. And then it comes back to shifts and

depending on staff who are coming on shifts. You might lose your regular

staff, you’ve got casuals coming in the whole equation can change very, very

quickly.

Emergent themes were supported and extended in the literature. Studies around intensive and acute settings cited structural and organisational impediments such as understaffing, rapid patient turnover, insufficient beds numbers, and inadequate hospital–community coordination as reasons why recovery is not achieved as an embedded process within hospital settings (Crowther and Ragusa, 2011, Wynaden et al., 2001, Fourie et al., 2005, Cleary et al., 2012). Overall care is delivered through regulators that are often conflicting, with constraints on resources and funding (Bowers et al., 2008, Glick et al., 2003, Fourie et al., 2005).

Unsatisfactory admission of patients whose needs are not adequately met in other services can drive arrangements in PICU (Brown and Bass, 2004, Bowers et al., 2003). An informant from the focus groups perceived PICU as a ‘dumb off

zone’ for people who don’t ‘fit’ criteria for other services models. Other studies have identified patient admissions were more likely to come from court or prison rather than directly from the community, overtly influencing the approach to care (Bowers et al., 2008, Pereira et al., 2005b).

Meanings attached to the idea of care were assumed to prompt the types of treatment available for patients. Rather than providing short-term intensive care in PICU’s data suggests some patient groups remain ‘locked in’ for long periods of time (Bowers et al., 2008 p.62). Brown and Bass (2004) found the length of stay in PICU could range from 1-502+ days. One Nurse in the focus groups talked about the complications of dealing with patients coming through the court system.

…the biggest issue is that we then have to take classified patients. Take

them from the watch house or prison and they are very unwell and

sometimes they stay for long periods of time because of their classification

and the risk they impose and they end up staying and locked in.


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Poor communication, and a lack of adequate patient/family focused recovery information were evident (Cleary, 2004). When describing admission processes one nurse reflected on the problems associated with gaining appropriate information and knowledge of the patient, their history and their personal choices to initiate recovery processes.

We might have frequent flyers coming from the A&E (Accident and

Emergency department) or wherever, or we might have first timers. So

generally we have frequent flyers we’ve got (information) on what we need

to do, or what’s expected. But when you’ve got first timers that becomes a

different ballpark. That transition of coming … from A&E getting escorted

by a couple of big burley security guards to a PICU area and go ‘oh my god’.

If you have got the relevant information…hopefully they have gathered

enough information that’s going to give us a good grounding on what’s

going to happen and how we are going to start that recovery model, or

process (for the patient).

The literature stipulates the risk involved to supervise acutely disturbed patients in PICU which can threaten the safety of other patients and staff, whilst also being un-conducive to the overall treatment milieu (Bowers et al., 2011, Meehan et al., 2006). O’Brien and Cole (2004), suggest that patients and families consider predictable routine and therapeutic interventions are useful to alleviate acute distress. Furthermore, they found scarce incorporation of the individual needs of patients in care plans and in the overall organisation and treatment of patients. An informant from the focus groups also lamented problems with providing pre-emptive treatment options.

Psychiatric intensive care unit…these people should be intensively cared for,

and it’s a high dependency unit, these people are dependent. So…there

needs to be proactive treatment. You shouldn’t be locked into PICU and

have no… only medication even if they are considered to have improved and

that’s…. I think people haven’t got the idea of what it is. They just see it

(care) as containment.

Despite promotion of multidisciplinary care teams for recovery-oriented approaches (Beer, 2008), and also as a way to improve communication between health care providers (Hopkins et al., 2009), the data indicated implementation of routine multidisciplinary interaction was far from adequate. Informants stated,

We have a full range of 18 psychologists a range of social workers welfare

workers and artists. We've got access to an artist, access to recreational

therapist… But not in PICU!

Their social workers their OTs were meant to visit the patients in PICU. I

never saw any. Surprisingly there is little data in the literature evaluating the delivery, pattern of interactions or effectiveness of multidisciplinary teamwork in PICU (Fiddler et al., 2010). The paucity of research on effective training models in the context of multidisciplinary treatment teams and planning for inpatient mental health care


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has been identified elsewhere (Amering and Schmolke, 2009, Singh et al., 2006). However, studies of burnout in nursing have linked; weak nurse-physician relationships; and problems with roles, leadership, clinical accountability, and understanding between professionals to the quality of work life for nurses (Caldwell et al., 2006). The frustrations PICU nurses feel with inadequate collaboration by treatment teams, and to appropriately support patients in a vacuum of information was evident in the other research (Cleary, 2004, Seed et al., 2010) and in the focus group data. One nurse said,

Quite often we are waiting all day for a treating team… for instance one

patient didn't get reviewed by his treatment team last Friday1. I was

completely damming of the fact that treating teams are not seeing people

every day. Well, we are totally pissed off with it. Patient expectancies, requirements and organisational necessities often result in high levels of anxiety for nursing professionals. One informant allegorised,

I think it is just the fact of containment and of course you are the thing that

is keeping them in there… It’s like getting a bad burger at MacDonald’s; it’s

the poor girl that served it that cops it.

Physical Structures

The significance of the environment is summarised in this second theme, ‘physical structures’. Dialogue of layout, security, clinical facilities, recreational facilities, staff and patient safety, fixtures and fittings, garden areas, and private confidential staff areas were raised as concerns to adequately provide care for people experiencing acute psychiatric distress. The data indicated lack of consideration for the design of the physical environments of PICU. One informant stated,

It was never built as a specific… I mean there have been modifications over

the years but it is not ideal. Another informant protested the lack of a ‘standard’ or purpose in the design and

layout of PICU wards.

None of them are purpose built. The closest to purpose built…was forced. My

understanding was it was a very late last minute decision to make that area

a PICU…so what they did was cram in a PICU to a footprint that wasn’t

designed for it. So you have got an inadequate facility. Because in a PICU,

when they are extremely unwell you need space. You need choices for people

to be able to get away from each other.

1 In this instance ‘not being reviewed’ meant it was over 3 days before the psychiatrist assessed the patient, and a treatment/recovery plan initiated.


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Congruency about the lack of purposefulness in the design of PICU’s was found in literature. Terms like “critical issue impossible to resolve in the current building”

(Pereira et al., 2005b p.75) and “dissatisfaction with the physical environment as a

major issue” (Dix and Mathew, 2008 p. 303), indicated failure to meet acceptable requirements for intensive care (Brennan et al., 2006). Concern was raised of the preoccupation on a risk aversive environment over other important requirements in PICU (Curtis et al., 2007, Cleary et al., 2009b, Daffern et al., 2004). Informants from the focus groups discerned the physical requirements often focused on controlled and locked environments. The environment was described as, more of locked down approach.

A survey cited in Crowhurst and Bowers, (2002 p. 692) determined that patients in PICU are generally dissatisfied with restrictions placed upon their environment. Other studies convey modification of the physical structures and objects through specific rules and routines ‘which could not be questioned by the

patients’ (Salzmann-Erikson et al., 2011 p.8). Informants’ described the setting of PICU as sparse and difficult to reorganise for individual or varied treatment/therapy interventions and lacking simple resources to help orient the patient.

Even simple things like orientation …It wasn’t until I was looking for a clock

in the unit to help a person who didn’t know what day it was and where,

when they were; amongst a range of other things, that I realize we were

bereft of basic things, clocks, the date and the time ...so that I can remember

that today is Wednesday.

An audit of PICU facilities in the UK found that only 35% had en-suite amenities for patients; 25% had no enclosed gardens; 90% of units had separate smoking areas; only half the units had good quality day lighting; 70% of units had an air lock entry to the unit and over half have electronic locking systems; and 35% had no gender specific facilities (Pereira et al., 2005a p. 72). Worryingly dialogue around room configuration raised serious concern for the physical and emotional necessities of female patients, who are evidently at risk as a result of insufficient bedroom arrangements.

There is one double room, which is not really good. I don’t think there

should be double rooms in Acute Observation Areas. …cause, the patients

are so acutely unwell, they don’t want to be in there they don’t want to be

sharing a room. They don’t want to be in there. I had a patient say to me

yesterday. “ You know, why am I ... there is a stranger inside, he is going to

rape me in the middle of the night.” And there is only one toilet, one shower.

A recurrent theme was the need to curtail stimulation for patients in PICUs (Van Der Merwe et al., 2012, Alexander and Bowers, 2004, Lee et al., 2010). One study reported this was achieved through a practice of allowing ‘no stuff’, effectively governing patients’ personal possessions with rules such as, no pictures in the patients’ room (Salzmann-Erikson et al., 2011 p. 262). Informants in the focus groups discussed the rational of establishing low stimulation milieu, as opposed


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to establishing routine and providing activity as substantiated methods for reduction to aggression and dormancy. One informant noted,

You use to do your training and you were told about these areas, these non-

stimulating environments, but it has changed with the clientele that are in

there now and they need their stimulation.

These perceptions were also documented in literature (Curtis et al., 2007, Georgieva et al., 2010). Findings from a study in Norway did not support theories that a sparse environment is useful as a method to reduce symptoms of psychopathology and dangerous behaviours (Vaaler et al., 2005). Issues were raised of the confined physical space of PICU and access to appropriate resources that can be used for distraction.

When they are so agitated and so worked up you have to go and confront

these people and try and diffuse the whole situation. You have a metre by

metre to try and diffuse the whole situation. Where as if you had a bit more

area out there where they could kick the ball or punch a bag or what ever

they needed to do that would honestly take away at least 60-70% of your

incidents.’

The physical environment is reported to influence ward practice and affect staff recruitment, retention and confidence (Curtis et al., 2007, Pereira et al., 2006). One informant in the focus groups commented on the impersonal setting of PICU and empathised with patients’ desire to leave.

There is two showers and what they are is a little thing that comes out of

the wall … I don’t think I would even use the shower if I was staying

there…(I) use to think how would I get out if I was a patient in here.

Insight was gained of the lack of consideration, respect and insufficient resources to meet administration requirements in the working environment of the nursing staff in PICU.

The office is actually, has supposedly been an airlock. But it is our office.

For staff to actually have some quarantine time to actually sit without being

distracted to be able to do what they need to complete a recovery plan…you

know actually sit there for 10-15 min in front of the computer and getting

something done.

Lack of respect and provision of sufficient resources to support nurses to deal with complex needs has been highlighted by others (Crowther and Ragusa, 2011, Brennan et al., 2006, Cleary, 2004, Seed et al., 2010). Crowther and Ragusa (2011) distinguished consensus amongst nurses that Commonwealth and State governments had shirked their responsibilities for provision of mental health care for decades. Subtype Nomenclature

The final theme ‘subtype nomenclature’ illustrated the properties and


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coordination that govern the formation and use of terms assigned to PICU. The relationship between the terms their referents, meanings and the structure of language around intensive acute psychiatric care reflect the context-specific understandings of individuals, resources, experiences and practices. Of particular interest were the differences discussed by the nurse informants in the focus groups, describing contextual boundaries within the larger context of the mental health system. One informant stated,

We call it AOA because we are not allowed to call it HDU (High Dependency Unit). We went to call it HDU and they said that no that was a medical term.

So we call it AOA. Acute Observation Area.

O’Brien and Cole (2003) describe close-observation units as small 8-10 bed units, similar to PICU, indicating the variance between close-observation units and PICU is a higher than usual observation and safety regime. Close-observation units are normally locked where as PICUs have been reported as being not locked (p. 166). Conversely, suggesting that HDUs maintain tighter security than the AOA, the informants communicated,

We don’t meet the guidelines for HDU in the sense of, for the psych unit,

because….oh our AOA area doesn’t meet the criteria because the HDU has to

be more an enclosed thing with the fencing and stuff like that. Which ours

doesn’t.

Other literature refers to the classification of HDU and low-dependency units (LDU). The terms are differentiated by nurse to-patient staffing ratios of 1:5 within the LDU and 1:3 within the HDU. The configuration of HDU also included two seclusion rooms (Chalmers et al., 2012). Attention to the nomenclature of PICU that reflects the underlying bases of care is essential. Meanings of particular terms have significant implications for the delivery of high quality intensive care. The term PICU is recognised internationally and legitimatised in the UK with the establishment of a manual of standards written primarily for Psychiatric Intensive Care Units (Cresswell et al., 2009). While, Queensland Health’s current guidelines for practice in HDUs are meagre. Additionally the guidelines discourage the use of the term PICU, stating it causes confusion with Paediatric Intensive Care Units (Queensland Health, 2012). In a study to more clearly define the concept of PICU in Sweden, Salzmann-Erikson, Lutz, Ivarsson and Eriksson (2008) found no clear differentiation between acute and intensive psychiatric care according to the Swedish National Board of Health. The elaboration of similarities and differences in the idea of care in PICU can have diverse influences on the manner in which treatment is conceived. Bjorkdahl and Pamestierna (2010) defined a caring continuum in PICU on which nurses adapted two understandings related to the context-specific frameworks of care in PICU. The ballet dancer and the bulldozer:


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“One approach involved sensitive and perceptive behaviour on the part

of the nurse, with the intention of generating trust and signalling a

desire to provide care. The other approach was used by the same nurses,

who would then become guardians of the safety and structure in the

ward – sometimes by using force and coercion” (p.512). Classifications systems anchor experience and phenomena into shared understandings. How recovery-oriented care is delivered in PICU is influenced by the terminology that describes the contextual framework. While the term PICU is used more frequently in the literature, to date there is no widely accepted international terminology that defines and guides practice in PICU. The need for new, sophisticated and specialist terms related to intensive psychiatric health care, far beyond traditional notions of containment and pharmacological treatments are urgent. As, in the words of a nurse informant from the focus groups,

It really is a specialist area.

Discussion

A critical reading has been offered of the perceptions understood by nurses, as the vanguard of providing intensive care to patients experiencing acute psychiatric distress. Adopting a recovery-oriented approach for patients experiencing acute psychiatric distress construes the function of PICU as the specialised provision of intensive and efficient treatment. However rudiments, principles and practices shared in the perceptions and descriptions from nurses

demonstrate discrepancies in the provisions, design and classifications of psychiatric intensive care. More often the data assessed for this article denoted the primary function of PICU as the suppression of aggressive and violent behaviour, or ‘a punishment block’ (Dix, 2012 p. 60)

It is timely to review the consequences of engaging in a variety of practices that share only some standards and ideologies that only inadvertently relate to goals of achieving a recovery-oriented approach for people experiencing acute psychiatric distress. Review of the literature based on the nurses’ perceptions exposed the significant need for development, formation, use and application of simple, stable and internationally accepted systems in the conceptual arrangements and contemporary understanding of PICUs.

Findings show that ‘organisational structures’ place considerable demands on nurses to meet configurations that are often contradictory and conflicting (Seed et al., 2010). Staff need consistent support and clearly articulated principles to provide optimum psychiatric intensive care (Macpherson et al., 2005). Staffing issues, insufficient beds numbers and room configurations, and poor multi-discipline team engagement and communication all impacted on the provision of intensive care to patients experiencing acute psychiatric distress. The lack of a clear and coherent ideology for acute psychiatric care is worrying (Bowers, 2005 p. 232). Organisational configurations rarely reported standards or direction beyond recovery rhetoric to encapsulate the meanings individual patients


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attribute to wellness and illness and the ability to negotiate these. Notwithstanding there is significant indication of beneficial treatment interventions for people experiencing acute psychiatric distress, which can support recovery-oriented approaches (Bowers et al., 2005, Brimblecombe et al., 2007, Lakeman, 2008, Chambers et al., 2012, Janner, 2007, Seed and Torkelson, 2012, Olmos-Gallo et al., 2012).

Positive therapeutic treatment in PICU requires leadership and further research to transform the traditional focus of care on a crisis orientated model in which nurses react to situations, to being proactive in planning individualised nursing interventions (Bowers, 2012). A balanced approach to care and treatment must constructively evaluate the logistics of staffing and clearly identify admission criteria to tackle perception of PICU as a ‘dumb off zone’. There is a critical need for research into the function of multidisciplinary care teams in PICU. Principles of a recovery-oriented approach emphasise a comprehensive service approach (The State of Queensland, 2008) and therefore requires a multidisciplinary approach to care with good communication and information sharing and clear lines of responsibilities and accountability (Cleary and Dowling, 2009). Yet there is very limited literature considering the delivery, pattern of interactions or effectiveness of multidisciplinary teamwork in PICU. Emerging evidence suggests that a security ‘containment’ approach in PICU is no more useful or helpful for recovery than if the person remained in corrective services (Bowers et al., 2012), while evidence suggests that sparse and restrictive environments do not reduce symptoms of psychopathology and dangerous behaviours (Vaaler et al., 2005). The physical structures of PICU also come under criticism in light of the substantial affect on moral and capacity of nursing staff to provide routine activities and therapeutic practices (Gilbody et al., 2006, Anthony, 1993). The lack of universality in the function and paradigms related to PICU demand critical dialogue concerning preferred terms, clarity of procedures and principles of care between nurse and health professionals, governing bodies and people with lived experience of mental illness and treatment in PICU. It is critical to develop globally agreed and shared names, definitions, principles, rules and recommendations to enrich treatment and govern the purpose of PICU as a highly specialised environment. There is need for further research with subsequent research questions and designs aimed at resolving the conflicting function of PICU as the specialised provision of intensive and efficient treatment and as a space for containment.

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