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


    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: 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


    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


  • 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


    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



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