Nurses’ and Patients’ Perceptions about Psychiatric Intensive Care—An Integrative Literature Review

Figures & data

Table 1. Search phrases used.

PubMed	(high security* OR "high intensive care" OR security* OR PICU OR HIC model* OR intensive* OR intensive care) AND (ward* OR unit* OR units* OR "Psychiatric Department, Hospital"[Mesh]) AND (experience* OR perception* OR perspective* OR viewpoint* OR "point of view" OR interpretation* OR "Perception"[Mesh]) AND (nurs* OR patien* OR patients* OR client*) AND (psychiatric* OR mental health* OR "Mental Health Services"[Mesh])
Cinahl	((("high security*" OR "high intensive care*" OR security* OR PICU OR "HIC model*" OR intensive* OR "intensive care*") AND (ward* OR unit* OR (MH "Psychiatric Units")) AND (experience* OR perception* OR perspective* OR viewpoint* OR "point of view*" OR interpretation* OR (MH "Perception+")) AND (nurs* OR patien* OR client*) AND (psychiatric* OR "mental health*" OR (MH "Psychiatric Care+" OR (MH "Mental Health Services+")))
Cochrane	(high NEXT security* OR high NEXT intensive NEXT care* OR security* OR PICU OR HIC NEXT model* OR intensive* OR intensive NEXT care) AND (ward* OR unit*) AND (experience* OR perception* OR perspective* OR viewpoint* OR point NEXT of NEXT view* OR interpretation*) AND (nurs* OR patien* OR client*) AND (psychiatric* OR mental NEXT health*)
PsycINFO	("high security*" OR "high intensive care*" OR security* OR PICU OR "HIC model*" OR intensive* OR "intensive care*") AND (ward* OR unit* OR DE "Psychiatric Hospitals" OR DE "Psychiatric Units") AND (experience* OR perception* OR perspective* OR viewpoint* OR "point of view*" OR interpretation*) AND (nurs* OR patien* OR client* OR (DE "Psychiatric Patients" OR )) AND (psychiatric* OR "mental health*" OR DE "Mental Health Services")
Web of Science	((("high security*" OR "high intensive care*" OR security* OR PICU OR "HIC model*" OR intensive* OR "intensive care*") AND (ward* OR unit*) AND (experience* OR perception* OR perspective* OR viewpoint* OR "point of view*" OR interpretation*) AND (nurs* OR patien* OR client*) AND (psychiatric* OR "mental health*")))

Figure 1. Flowchart on the article selection process.

Table 2. Full-text articles excluded (n = 11) with reasons.

Author, year, country	Reason(s) for exclusion
Ward & Gwinner, 2015, Australia.	Data from focus groups was collected only to ascertain concepts of recovery held by nurses working in PICU. Expressions identified in the focus groups were then used to conduct a literature review.
Walsh-Harrington et al. 2020, UK	The study examined solely patients perception of the new intervention (recovery skills group) and no data was about their perception of the PICU or their treatment in PICU itself.
Evatt et al. 2016, Australia	Study focused on occupational therapist perception and data was collected with screening tool that nurses filled when they evaluated patients. No data about nurses’ and patients’ experiences.
Milan 2011, UK	Article was about the authors personal experience about recovery in the PICU but did not include empirical study.
Braham et al. 2010	Study was conducted in a forensic setting.
Corsini et al. 2018	Not available in English
Bierbooms et al. 2017	Not available in English
Salzmann-Erikson 2013, Sweden	Data was collected only by observation and did not include direct experience reported by nurses nor patients.
Rooney 2009, UK.	Examined one-to-one observation in psychiatric nursing in general, not in PICU context.
Björkdahl et al. 2010, Sweden.	Did not include nurses’ perception/ experiences but focused solely in short term prediction of violence in the PICU.
Isaak et al. 2016	Study was conducted in a forensic setting.

Table 3. Articles (n = 21) included in literature review.

Authors, year, country	Aim	Setting	Method	Main findings
Ash et al., 2015, Australia	To describe the implementation of recovery-based practice into PICU; to report change in seclusion rates	10 bed PICU	Mixed methods study with qualitative interviews (n = 63) and register study with rates of seclusion	Half of participants were unhappy with the way their treatment related issues were discussed with them. Almost all (70%) perceived staff as approachable and helpful and 38% identified the environment as the most helpful aspect. Patients suggested more personal space as a helpful issue in PICU. All restrained respondents (8%) perceived restrictions as negative.
Björkdahl et al., 2010, Sweden	To describe the caring approaches of nurses working in PICUs	4 PICUs	Descriptive qualitative study with nurse interviews (n = 19). Data was analyzed using qualitative analysis.	Nurses described two distinct caring approaches that were adapted in PICU: one including nurses’ sensitive and perceptive behavior, with the intention of generating trust and offering care; another approach where nurses acted as guardians ensuring the safety and structure in the ward.
Bos et al., 2012, Netherlands	To examine how patients experience the treatment and what elements are essential	A secure 16-bed unit in a psychiatric hospital	A qualitative research design with patient interviews (n = 12). Data was analyzed with constant comparative method.	Almost all respondents rated the treatment as positive. Structure, clear roles, cooperation and safety were mentioned as key features. All respondents reported that safety was a matter of utmost priority.
Gentle 1996, UK	To describe the nurses’ perception and experiences of intensive care during the first 6 months of the ICU’s operation	PICU with two clinical areas: short and longer stay area	A descriptive qualitative study with participant observation periods (n = 12) with field notes and in-depth interviews with nurses (n = 11). Data was analyzed with content analysis.	The nurses’ primary concern was the safety of the unit. Nurses were frustrated with aspects of the physical structure compromising the security of the unit. The staff felt having to deal with difficult patients, who no one else wanted to deal with. The therapeutic nature of intensive care was ill-defined. Nurses wanted more education to strengthen their management skills.
Evans & Petter, 2012, UK	To explore what factors are involved on nurses’ sense of safety and in what ways can nursing staff be supported	Psychiatric intensive care unit, PICU	Mixed methods design with questionnaires for nurses (n = 15) and semi-structured interviews with nurses (n = 5). Qualitative data was analyzed with thematic analysis.	Respondents felt safe and supported by colleagues in general. Factors related to perceptions of safety and support were personal as well as systemic, like increased demands, lack of support from managers and fear of blame.
Hyde et al., 1998, USA	To audit the usage of a PICU and the occurrence of violent incidents over a 2-year period, and to measure patient dissatisfaction with the service	Psychiatric intensive care unit with 12 beds on a general hospital	Descriptive quantitative study with various scales (for ex SOAS); satisfaction questionnaire with patients (n = 170) discharged from PICU. Data collected was analyzed with statistical analysis.	50% of the patients admitted had at least one violent incident during their stay, totally there were 391 violent incidents. The patients were fairly satisfied with their care. There was no significant difference in dissatisfaction scores between those who experienced rapid tranquillization events (n = 76) and those who did not (n = 84). Dissatisfaction related to non-understandable provocation and the total number of violent incidents.
Iversen et al., 2011, Norway	To explore patients’ perceptions of their stay at a seclusion area; to explore the relationship between patients’ characteristics and experiences during their stay	Seclusion area with two separate spaces = ‘wings’	Quantitative cross-sectional descriptive design with VAS scale completed by patients (n = 56), patients’ legal status for hospitalization and length of stay in the seclusion area, diagnoses; PANSS-Scale and GAF-S. Data was analyzed with statistical analyses.	Patients’ perception about treatment in seclusion area was mainly positive. This was related to support from staff, respectful treatment and feeling safe. Patients who were admitted voluntarily reported significantly better experiences compared to those admitted involuntarily. Both rated the support from staff positively. Patients’ ages diagnose or legal status were not associated with patients’ experiences.
Lemmey et al., 2013, UK	To compare the quality of care in acute wards and PICU based on the experiences of patients, carers and qualified nursing staff	Psychiatric intensive care unit, PICU	Quantitative explorative design with questionnaires to patients (n = 392, n = 225), carers (n = 101, n = 73) and nurses (n = 213, n = 238) Data was analyzed using statistical analysis.	Patients reported more negative experiences of care on PICUs than nurses and rated low standards on accessing records and counseling. Nurses reported inadequate involvement in risk assessment. Nurses generally gave positive views of standards of care. In PICUs patients had more often the opportunity to have supportive one-to-one sessions with staff.
Loubster et al. 2009, UK	To determine the numbers of patients and nurses assaulted on PICUs, acute and forensic wards: to examine if nurses or patients were more likely to report problems with alcohol/drugs; to examine nurses’ perception of the cause of problems in the three wards	139 wards serving adults of working age (27 PICUs, 89 acute wards, 17 forensic wards)	Cross-sectional survey study with questionnaires to nurses (n = 1,690) and patients (n = 981) and discussion groups with nurses. Quantitative data were analyzed with statistical analysis and qualitative data with content analysis.	Nurses working on PICUs were significantly more likely to report assault than their colleagues working on acute wards. Patients on PICUs were more likely to report physical assault than their counterparts on acute wards. In all wards, nurses were much more likely than patients to report overall problems with drugs and alcohol. On PICUs, the most reported triggers for violence were restrictions, interaction between patients, smoking, illness, staff provocation and lack of privacy.
Mackay et al., 2005, UK	To explore what happens during the process of special observation for violent inpatients, what skills nurses use to carry out this intervention and what are the therapeutic merits of the process for the patient?	PICU	Descriptive qualitative design including in-depth unstructured face to face interviews with nurses (n = 6). Data was analyzed using thematic content analysis.	Three categories emerged as a result from the interviews: Procedure, Role and Skills. Nurses considered their role as therapeutic and communicating with patient and other staff as important.
McAllister & McCrae, 2017, UK	To measure therapeutic activity by nurses and to explore therapeutic role of nurses	One 14-bed PICU for male patients	The mixed method design with semi-structured interviews (nurses n = 4, patients n = 6) and quantitative observations (27 nurse, 23 patient activities). Quantitative data was analyzed using Excel. Qualitative data was analyzed with inductive content analysis.	Of the directly observed 234 clinician and 309 patient activities, 20.9% and 15.9% were classified as therapeutic engagement. Four distinct forms of nurse–patient interaction emerged: spontaneous ad hoc interactions, para-instrumental interactions, social–recreational interactions and dedicated engagement with one-to one discussions. Nurses considered personal interactions to be their aim; however, these interactions were difficult to achieve. Both clinicians and patients wanted more therapeutic contact.
O’Brien & Cole, 2004, Australia	To develop an understanding of the context and experiences of nurses, patients, and relatives in the close observation area; to develop recommendations for clinical practice guidelines	An eight-bed observation area in psychiatric unit within general hospital	A mixed method design with interviews (n = 42 including patients, relatives, carers), data from hospital records related to use of seclusion and prn medications, patient and staff-critical incident forms, and use of security. Qualitative data was analyzed using thematic analysis.	Nurses had to work in an insufficient environment and patients identified lack of privacy and lack of activities resulting in boredom. The patients lacked information about the process of treatment. Nurses identified a polarization of beliefs about the care of patients. Whilst some nurses stressed that their role was to care and ‘being there’ for the patients, others saw their role as maintaining control, medication administration, and observation. There was conflict between a therapeutic and controlling, ‘zero-tolerance’ philosophy of care.
O’Brien et al. 2013, UK.	To ascertain the number of reported assaults on staff, details of the assaults, and to establish the impact on the staff members: to explore attitudes of the staff toward assaults	A 13-bed PICU for male patients	Quantitative cross-sectional survey study with two questionnaires (staff n = 26). Data was analyzed with statistical analysis.	88% of the participants reported being assaulted over the past year either physically or verbally and 39% of assaulted staff reported negative effect in their work. 62% felt safe on the ward and 80% believed that there were appropriate safety measures. 62% of staff felt that they would be assaulted at some time during their career. Majority of the participants believed that assault was not related to poor nursing or to clinical competence, nor to staff personality.
Salzmann-Erikson, 2018, Sweden	To describe staff’s ethical and moral concerns when working as healthcare professionals in a psychiatric intensive care unit	PICU in Sweden	Descriptive qualitative inquiry with participant observation (n = 12). The data were analyzed using framework analysis.	Nurses faced ethical concerns daily as patients demonstrated challenging behavior. Three themes emerged from data. 1: concerns about staff impacting on the patients’ experience of care. 2. Concerns about establishing safe working environment. 3. Concern about becoming unprofessional due to expectations and high workload.
Salzmann-Erikson & Söderqvist, 2017, Sweden	To describe individuals’ experiences of being hospitalized in a PICU	Psychiatric intensive care unit, PICU	A qualitative descriptive research, including patient interviews (n = 4). Data were analyzed with thematic analysis.	Patients described PICU as prison like environment, and counterproductive. Personal space and privacy were lacking, and possibilities to interact with staff were limited. Patients described feelings of abandonment and segregation. Lack of information was interpreted as denying participating in one’s care decisions. Impressions of the limitation of freedom and autonomy were particularly dominant when patients were committed against their will.
Salzmann-Erikson et al., 2008, Sweden	To describe the core characteristics of a PICU; to describe which care activities are practiced at the PICU	One PICU	Qualitative critical incident technique with semi-structured questionnaire, including PICU staff (n = 18) and five informants. Data was analyzed using the procedures of CIT.	The core characteristics of the PICU are 1) the dramatic admission 2) protests and refusal of treatment 3) escalating behavior, and 4) temporary coercive measures. The care in PICU was perceived consisting of four main nursing care activities: controlling—establishing boundaries, protecting—warding off, supporting—giving intensive assistance and structuring the environment.
Schröder & Björk 2013, Sweden	To describe patients’ judgments of quality of care	Psychiatric observation and intensive care units	Cross-sectional survey with patients (n = 54), using Quality in Psychiatric Care–In-Patient (QPC-IP) instrument. Data was analyzed with statistical analysis.	Patients rated the overall quality of care as high. Highest ratings were found on the item ‘the staff respect my ability and show empathy’. Lowest ratings were found concerning the dimension Discharge. Those patients who were informed about their treatment, had the opportunity to supportive talk and knew the discharge process, rated significantly higher quality of care.
Stevenson, 2013, UK	To examine psychiatric nurses’ views on criteria for psychiatric intensive care for older adults	One 10-bed unit for adults (both genders) and one 10-bed unit for males over 65	A cross sectional survey study with semi structured questionnaires (nurses n = 138). Data was analyzed with statistical analysis.	40% of nurses working in the GAP (general adult PICU) reported having an active role in deciding admissions to PICU and one-third reported active role in deciding discharges from PICU. 20% reported that there were usually adequate intervention trials prior to PICU referral. All participants reported that staff from PICUs should assess referrals in the acute wards before transfer to PICU. Physical violence was most common reason for PICU admission.
Vaaler et al., 2005, Norway	To explore difference in symptoms, behaviors, treatment and patient satisfaction in patients treated in separate spaces	The seclusion area with two separate wings in an acute psychiatric ward	Explorative design with 56 patients in two groups; PANSS, GAF-S, SOAS-R and BVC scales. 23-item checklist to code therapeutic and control steps. Patients rating an eight-item visual analogue scale. Data were analyzed with statistical analysis.	There were no differences in changes in scores on the Positive and Negative Syndrome Scale for schizophrenia, the Brøset Violence Checklist or the Global Assessment of Function split version scale between the two patient groups. Therapeutic steps taken, number of violent episodes and length of stay was also similar. Home-like interior and furnishing in the seclusion areas created an environment with comparable treatment outcomes to the traditional dismal interior and had positive effects on many patients’ well-being.
Ward & Gwinner 2015, Australia	To better understand the skills, experience, and practice, of nurses working in the PICU/HDU in relation to a recovery model of care	PICU/HDU units of three large acute inpatient mental health care facilities	A qualitative descriptive study with nurses’ (n = 52) focus group interviews. Data was analyzed with thematic analysis.	Empathy, active listening, attending, and appropriate use of body language were considered essential in communication skills. Deescalating, strength-based philosophy and behavior management were also important. Effective communication within the PICU was complicated due to the increased levels of tension, fear, and anticipation of violence. A strong focus was placed on the physical wellbeing of the patient and the specific nursing skills to monitor it. Alternatives to seclusion and restraint were discussed.
Wykes & Carroll, 1993, UK	To gain more information about patients’ satisfaction toward their treatment in psychiatric intensive care ward	Psychiatric intensive care ward	Cross-sectional descriptive survey with structured patient satisfaction questionnaire (n = 37 patients). Data was analyzed with statistical analysis.	Respondents were satisfied with psychiatric intensive care. Helpful staff and the environment were perceived as positive. Most negative perception was related to locked doors, other patients’ disturbing behavior and rules and limitations. Respondents reported lack of nurses and that they were not available when needed. Complaints made by patients were not taken seriously.

Table 4. Example of the analysis on nurses’ experience.

Original finding	Condensed	Code	Category	Main theme
According to staff reports, sometimes other teams do not come help with dangerous situations and relying on them increases risk	Not getting enough help from other teams	Lack of teamwork	Interpersonal co-operation	PICU as a challenging work environment
Nurses reported that they have to give first priority to securing the safety	Nurses prioritize safety	Securing the ward	Safety rules and control	Balancing between different care practices

Table 5. Main themes and categories based on content analysis.

	Main themes	Categories
Nurses’ perceptions of working in a psychiatric intensive care unit	Balancing between different care practices	Safety rules and control Therapeutic and empowering engagement
	PICU as a challenging work environment	Physical features Emotional oppression Interpersonal co-operation
	Nursing interventions in PICU	Interaction with patients and patient assessment
Patients’ perceptions of care in a psychiatric intensive care unit	Issues connected with high satisfaction with nursing care	Collaboration with staff
	Issues connected with low satisfaction with nursing care	Inappropriate facilities and environment Feelings of abandonment Lack of information about care Sense of insecurity Criticism to safety precautions

Table

Appraisal of qualitative studies (n = 8)
Author(s)	Are there clear research questions?	Do the collected data allow to address the research questions?	Is the qualitative approach appropriate to answer the research question?	Are the qualitative data collection methods adequate to address the research question?	Are the findings adequately derived from the data?	Is the interpretation of results sufficiently substantiated by data?	Is there coherence between qualitative data sources, collection, analysis and interpretation?	Overall
Björkdahl et al., 2010	Y	Y	Y	Y	Y	Y	Y	7/7
Bos et al., 2012	Y	Y	Y	Y	Y	Y	Y	7/7
Gentle, 1996	Y	Y	Y	Y	Unclear	Unclear	Unclear	4/7
Mackay et al., 2005	Y	Y	Y	Y	Unclear	Y	Unclear	5/7
Salzmann-Erikson, 2018	Y	Y	Y	Y	Y	Y	Y	7/7
Salzmann-Erikson & Söderqvist, 2017	Y	Unclear	Y	Y	Y	Unclear	Y	5/7
Salzmann-Erikson et al., 2008	Y	Y	Y	Y	Y	Y	Y	7/7
Ward & Gwinner, 2015	Y	Y	Y	Y	Y	Y	Y	7/7
Appraisal of mixed method studies (n = 5)
	Are there clear research questions?	Do the collected data allow to address the research questions?	Is there an adequate rationale for using a mixed methods design to address the research question?	Are the different components of the study effectively integrated to answer the research question?	Are the outputs of the integration of qualitative and quantitative components adequately interpreted?	Are divergences and inconsistencies between quantitative and qualitative results adequately addressed?	Do the different components of the study adhere to the quality criteria of each tradition of the methods involved?	Overall
Ash et al., 2015	Y	Y	Y	Y	Y	Y	Y	7/7
O’Brien & Cole, 2004	Y	Y	Y	Y	Y	Y	Y	7/7
Evans & Petter, 2012	Y	Y	Y	Y	N	Y	Y	6/7
Loubser et al., 2009	Y	Y	Y	Y	Y	N	Y	6/7
McAllister & McCrae, 2017	Y	Y	Y	Y	Y	Y	Y	7/7
Appraisal of quantitative studies (n = 8)
	Are there clear research questions?	Do the collected data allow to address the research questions?	Is the sampling strategy relevant to address the research question?	Is the sample representative of the target population?	Are the measurements appropriate?	Is the risk of nonresponse bias low?	Is the statistical analysis appropriate to answer the research question?	Overall
Hyde et al., 1998	Y	Y	Y	Unclear	Unclear	Unclear	Unclear	3/7
Iversen et al., 2011	Y	Y	Y	Y	Y	Y	Y	7/7
Lemmey et al., 2013	Y	Y	Y	Y	Y	Unclear	Y	6/7
O’Brien et al., 2014	Y	Y	Y	Y	Y	Y	Unclear	6/7
Schröder & Björk, 2013	Y	Y	Y	Y	Y	Y	Y	7/7
Stevenson, 2013	Y	Y	Y	Unclear	Y	Y	Y	6/7
Vaaler et al., 2005	Y	Y	Y	Y	Y	Y	Y	7/7
Wykes & Carroll, 1993	Unclear	Y	Y	Y	Unclear	Unclear	Unclear	3/7

Source: Mixed methods appraisal tool (MMAT) version 2018.

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