Being Subject to Restrictions, Limitations and Disciplining: A Thematic Analysis of Individuals' Experiences in Psychiatric Intensive Care

ABSTRACT

The aim of this study was to describe individuals' experiences of being hospitalized in psychiatric intensive care units (PICUs). Four participants who had previously been admitted in a PICU were interviewed using open-ended questions. The data were analyzed using thematic analysis. Analysis resulted in a synthesis of the various ways patients experienced limitations: (1) Descriptions of Being Limited in the Environment, (2) Descriptions of being Limited in Interactions with Staff, (3) Descriptions of Being Limited in terms of Access to Information, and (4) Descriptions of Having Limited Freedom and Autonomy. Hospitalization is experienced as a life-changing event that shows a kaleidoscopic view of limitation. We stress that the conceptualization of limitation must be considered due to its historical origins, sociopolitical aspirations, and philosophy of care. Thus, nurse practitioners and nursing leaders are advised to put the patient's experience at the center of care, and to involve and integrate patients throughout the recovery process.

Introduction

Psychiatric intensive care units (PICUs) provide short-term care for patients who demonstrate highly challenging behaviors, are in need of close monitoring due to risks of self-harm and harm of others and who cannot be managed in acute psychiatric wards (Brown & Langrish, 2007; Stewart & Bowers, 2011). A key difference between acute and intensive care units is identified by Beer and colleagues (2008): PICUs offer higher levels of staffing and more secure facilities. PICU does not restrict admission criteria due to specific diagnosis; rather it is the patients' assessed needs—for example, the need for close monitoring—that direct the level of care. The main reasons for admitting patients into PICUs are that they pose a risk to themselves and others and that they benefit from a low-stimulus environment (Bowers et al., 2003; Pereira, Sarsam, Bhui, & Paton, 2005). Research within the field of intensive psychiatry has predominantly focused on issues such as violence prevention and management from a staff perspective (Evans & Petter, 2012; Kontio et al., 2014; Price & Baker, 2012; Stevenson, 2013). However, the undeveloped body of knowledge that concerns the firsthand experiences of being hospitalized in a PICU is almost negligible; therefore, this study aimed to promote the voices of former patients and their experiences from a PICU.

Background

Prior to this study, we conducted a database search using relevant keywords to identify the existing literature on patients' firsthand experiences of PICU hospitalizations. Surprisingly few (N = 2) articles were found. First and most notably, Wykes and Carroll (1993) conducted a survey study on patients' satisfaction levels in PICU care. They reported that patients were least satisfied with the locked doors and other behaviors of fellow patients, which were perceived as scarring. Further, dissatisfaction was correlated to the topics of ward rules and boredom; the staff earned the highest levels of satisfaction. The second article we found was published more recently. Schröder and Björk (2012) reported that patients scored quality of care highest on the topic that concerned encounters with staff. They stressed the importance of providing patients with information and allowing the patients to participate in their own care. Since the literature review on PICU experiences was comprised of such few articles, we widened the search to include acute psychiatric wards.

Patients' experiences of acute psychiatric wards

Earlier research reporting on patients' experiences of hospitalization in acute psychiatric wards gives a pessimistic picture but with promising aspects as well. Several articles report on patients' feelings of confinement due to environmental issues; acute wards are metaphorically termed as prisons (Lilja & Hellzén, 2008; Nurjannah, Fitzgerald, & Foster, 2009; Shattell, Andes, & Thomas, 2008; Stewart et al., 2015). Feelings of confinement refer to the lack of possibility to leave the unit at will, being subject to coercive measures, and being restricted in general (Alexander, 2006; Koivisto, Janhonen, & Väisänen, 2004; Kontio et al., 2011; Lilja & Hellzén, 2008). However, the few positive aspects of the environment are that acute wards were likened to a refuge and associated with safety (Chien, Chan, Lam, & Kam, 2005; Hughes, Hayward, & Finlay, 2009; Quirk, Lelliott, & Seale, 2009). Another item prominent in the literature was the staffs' impact and their ways of interacting with the patients. For example, Chien, Chan, Lam, and Kam (2005) and Amer Voogt, Goossenss, Nugter, and Achterberg (2015) reported that staff had a positive impact on patients' experiences, as they were able to control patients' aggressions; also, staff expressed caring attitudes by spending time with patients and conveying a relaxed demeanour. Other aspects that impacted patients positively were feelings of being respected and the possibility to participate in their own care (Kontio et al., 2014; Sebergsen, Norberg, & Talseth, 2016; Walsh & Boyle, 2009). On the contrary, staff can impact patients' experiences negatively by expressing an uncaring attitude, not setting aside time for the patients, being occupied with administrative tasks, and in general presenting as uninterested in the patients (Goulter, Kavanagh, & Gardner, 2015; Stenhouse, 2011; Stewart et al., 2015; Thomas, Shattell, & Martin, 2002). The existing research also covers aspects of interactions between peer patients. On the one hand, peer patients were able to provide a sense of community as they cared for each other (Shattell, Andes, & Thomas 2008; Thomas, Shattell, & Martin, 2002), but on the other hand fellow patients might be viewed as dangerous, unreliable, thieving, and bullying (Jones et al., 2010).

PICU has the task of providing care for patients in their worst phases of psychiatric illnesses. These are relatively small wards with significantly higher staff-patient ratios, and they have rapid turnover due to shorter patient stays and the care for patients who are more likely to express challenging behaviors as compared to acute wards. Therefore, it is of utmost importance to further explore and describe care recipients and their experiences of PICU hospitalizations. We argue that this insider knowledge is crucial for the development of care, as staff is able to learn from patients' firsthand experiences. Furthermore, such insights may improve the quality of care and also promote and support the recovery process of the patients. Hence, the aim of this study was to describe individuals' experiences of being hospitalized in a PICU.

Methods and materials

Qualitative research relies on textual analysis to understand social phenomena based on human experiences (Schwandt, 2001). The intention of our study was to find common threads in the experiences of former inpatients who have been hospitalized in PICUs. In order to do so we adopted the technique of using unstructured qualitative interviews as a method, as a “technique for gathering evidence” (Harding, 1987, p. 2). The interview questions were not determined in advance but were formulated in situ, depending on the participants' answers (Patel & Davidson, 2003). Hence, this study's epistemological influences were grounded in the tradition of naturalistic inquiry (cf. Lincoln & Guba, 1985; Patton, 2002; Sandelowski, 2000). Furthermore, Carter and Little (2007) theorize that just as epistemology justifies methodology, methodology justifies the methods of use. Grounded in our epistemological intentions, we adopted a qualitative descriptive research design, a methodology that originates from a participant's “narrative, life history, testimonio” (ibid, p. 1318). Due to our epistemological stance, we do not make claims of an “objective truth” (Denzin & Lincoln, 2011; Guba & Lincoln, 2000); rather the aim was to depict a synthesized description of the phenomena. Our epistemological stance is in line with the flexibility in thematic analysis in which both the essentialist and the constructionist paradigm are applicable (Braun & Clarke, 2006). Furthermore, Braun and Clarke also separate thematic analysis in terms of theoretic versus inductive. We adopted the latter since we did not use a preexisting code frame based upon theory and further demonstrate the bottom-up process in the section of Data Analysis. In addition, Braun and Clarke distinguish thematic analysis from the latent and the semantic construction of themes. We chose to not use a semantic level of presentation since this would only allow the analyst to present the findings through a manifest description of data. Rather, we wanted to go beyond the explicit words of the participants' description which, and quoting Braun and Clarke, “examine the underlying ideas, assumptions, and conceptualizations” (p. 84). The construction of the themes we present in the Result section is the result of an interpretive analysis, thus a theorizing of the experience of being hospitalized in a PICU.

Participants

To locate potential participants, we introduced the research project at staff meetings in five outpatient facilities. The staff were asked to assist us in assigning patients who were registered at their facilities. The staff were asked to identify patients based on their professional knowledge of patients and then give the information sheet to patients in conjunction with regular appointments with staff. The nurses were instructed to choose patients based on the following criteria: (1) had previously been admitted to a PICU, (2) were not restricted under the Mental Health Act at the time of being asked for participation, (3) are not currently inpatients. Furthermore, the nurses were instructed to choose patients who varied in age, sex, diagnosis, time spent in the PICU, instances of readmission and other variables that may be used to achieve variation in data (Patton, 2002). Due to the low rate of responsiveness, patients were assigned over a period of 2.5 years. Still, only four patients agreed to participate. The participant group was comprised of one woman and three men ranging between 35 and 50 years old. Since sociodemographic variables or diagnosis were not relevant for the study purpose, we did not collect that data. However, three of them were assigned from an outpatient facility for psychosis and one, from a general psychiatric outpatient facility predominantly for patients diagnosed with anxiety and bipolar diseases.

Data collection

The interviews were held at the outpatient facilities in an undisturbed room to ensure integrity. Both authors of the study interviewed two participants each. No relationship existed between the interviewer and the interviewed persons. However, one of the authors recognized both individuals since the psychiatric clinic was small. The participants were informed that neither their participation nor any information they revealed would be shared with other staff members in the clinic. None of the interviewed individuals expressed any concerns or problems related to sharing their due to this. In order to establish a relaxed atmosphere between the interviewer and interviewee, the meeting started out with small talk. Prior to the interviews all participants were provided with information about the study and their roles as voluntary participants, and they gave their informed consent to participate (Gorden, 1992). The average interview length was 44 minutes and was comprised of an average of 91 pages of text (Times New Roman font in 12pt and set to A4 page size with 1.5-line spacing). Even though the interviews were non-standardized (Patel & Davidson, 2003), all interviews started with the trigger question, “Can you please tell me about your experience of being hospitalized in the PICU?” Then, depending on the participant's answers, follow-up questions were asked. For example, participants were asked, “Can you tell me more about that?” or “What was that like?” in order to encourage the participant to further elaborate on specific topics or ideas (Gorden, 1992). During the interviews, the interviewers briefly took notes to go back to specific expressions and/or repeat what the participants had said earlier for follow-up questions such as, “Earlier you said that you talked to a fellow patient – can you tell me more about your relationship with that person?” In the end of the interviews one last question was asked to all participants: “Is there anything else you want to tell me about your experience in the PICU that I have forgotten to ask about or any topic that you would like to go back to?” All the interviews were recorded, which the participants consented to. After the formal interview was finished, the tape recorder was turned off. The participants were then asked how they felt about being interviewed about the topic to ensure that they had not been psychologically affected by the memories. None of the participant expressed a need for “debriefing” or further elaboration on anything due to the interview and to recalling memories from their experiences with being admitted to PICU.

Data analysis

A thematic analysis was conducted using the six steps described by Braun and Clarke (2006). The purpose of the thematic analysis was to find patterns in data that relate to the aim, and the analysis was as followed: Phase one (familiarization): the interviews were listened to and transcribed verbatim by the second author. During this familiarization with the data, notes were jotted down as initial ideas. Phase two (generating initial codes): As emphasized by Braun and Clarke, working systematically entails to give full and equal attention to all data. During the line-by-line coding, basic segments of information from the raw data were marked and given a code. For example, “The environment was scaled back—nothing but a bed. It's strange not to have anywhere to hang your clothes” was given the code “How the environment was experienced by the patients.” Phase three (searching for themes): Next, all codes from all interviews were filed in a separate spreadsheet, reviewed, and discussed. The purpose of this phase was to sort out similar codes and put these together into themes. In this initial phase, eleven themes were identified; some examples of themes are “information,” “autonomy,” and “interactions.” Phase four (reviewing themes): In this phase the themes were reviewed for their validity in terms of internal homogeneity and external heterogeneity. The themes were read repeatedly and the authors met and engaged in frequent discussions. The authors made revisions, as some themes were collapsed into one and some were renamed. After several revisions, the eleven themes were condensed into the four. Phase five (defining and naming themes): The data set was then reread in order to ensure that the themes correlated with the data. We constructed a thematic map on a whiteboard to be able to visualize the themes and their relationships. We discussed how the themes correlated with each other and if it was possible to find a more abstract theme that combined them. Morse (2008) defined a theme as “a meaningful ‘essence’ that runs through the data, just as a theme in opera occurs over and over again, sometimes in the foreground, sometimes in the background” (p. 727). Using this definition, we reviewed the thematic map and the data and gained insight at a more abstract level. We continued to review the themes according to the internal nuances of each theme; for example, the theme “interactions” related both to how patients perceived the staff's attitudes and to the role of the staff. This kind of differentiating within each theme was helpful in writing a cohesive narrative for each theme. Phase six (producing the report): In the last phase, we wrote a text that presented our analysis and illustrated the texts with extracts from data. As suggested by Braun and Clarke (2006), the texts went beyond descriptions of data and became analytic narratives. The author C.S. conducted the first two stages of the analysis and from the third stage, both authors engaged in defining of themes. During the analysis, we used pens, Post-It notes, and a whiteboard in the first three stages. In the later stages, we used Microsoft Word and Microsoft Excel to work with and arrange data.

Ethical considerations

Prior to the study, the administrative chief approved the study. An application was sent to the Regional Ethical Review Board (dnr. 2011/294), and this group gave an advisory opinion that there were no ethical obstacles in conducting the study. Presumptive participants were provided with information according to the Helsinki Declaration (WMA, 2008) about the study and the voluntary aspects in both written and verbal formats as well as their right to withdraw at any time without any consequences and the impact on their future care. In conjunction with the interview, the participants gave their informed consent to participate. When reporting the findings, no information would be able to be traced back to an individual person to ensure confidentiality.

Results

The results in this study offer a description of patients' experiences of being hospitalized in a PICU. The results demonstrate a synthesis of the various ways limitations are experienced due to (1) Descriptions of Being Limited in the Environment, (2) Descriptions of being Limited in Interactions with Staff, (3) Descriptions of Being Limited in terms of Access to Information, and (4) Descriptions of Having Limited Freedom and Autonomy.

Descriptions of being limited in the environment

Participants' interpreted being committed to a PICU as an implication that they were limited in the environment of the unit. The limits in the environment were described to the degree that everyday activities were no longer a given. First and foremost, the entrance door was locked, which sparked negative feelings, as it was not possible to leave the unit. Even if they as patients in a later phase of residency were allowed to leave the unit, they were still tied to the staff's agenda and had to wait to be released. Metaphorically, the PICU was likened to a prison in the sense that all their rights had been withdrawn. Sandra expressed it like this: “When you come to the unit, you don't know when you're coming out. Will you ever be well again? It's frightening.” In order to convey the experiences of the limited environment, the participants used the phrasing, “everything is locked.”

“Then it was the same with the windows … the blinds … everything … they didn't work and … there were no handles on anything, everything is like … the staff has to do everything … it was a shock.” (Sandra)

The limitations in the environment were interpreted as so foreign that they are described as shocking in relation to previous parameters of preferences. Additionally, the rooms and the overall environment were seen as counterproductive and didn't contribute to improving patients' mental health. One interviewee described a situation when she was trying to fall asleep. Outside her room, there was a bright light that made it impossible to sleep, and the blinds were broken, and in addition she was told that the door out to the unit had to be open so that the staff could watch her. We interpreted that the interviewee experienced resistance and unwillingness from the staff to find simple solutions to make the stay easier; there, the limited environment wasn't about what was possible but, rather, what was not possible.

One of the interviewees who had been committed on several occasions explained that the PICU was a small and limited environment so that the staff could watch over the patients more easily. Even if the limited environment was interpreted to be to the staff's advantage, this also means that it was to the patients' detriment that the communal areas became places for everyone's viewing, where “everyone sees everything that happens.” More than one interviewee reported experiences of witnessing other patients acting out or in some way showing their symptoms. One participant, Goran, said, “Well, I can't remember everything. I've seen … I've been there when people have died. Committed suicide. Lots of terrible things.” When the environment is limited, this results in the patients exposing themselves to an “open curtain” of a stage, so to speak, so they are the audience without the possibility to leave the show. For this reason, we interpreted this limited environment as a vulnerable place instead of a protected one. In this limited environment, it was not possible to close oneself off, meaning that one can't ensure one's own protection, even in his or her own room.

“But I know that if I'm sleeping in my bed, for example, I'm not aware, and then a person who's completely crazy can come into my room, right? And no one sees them, you just don't know. It happened to me a long time ago, he put his hands around my neck like this [the interviewee shows choking with his hands]. I woke up, I was completely shocked, it was a long time ago.” (Sandra)

Another aspect in the environment that was seen as limiting was the lack of personal space. The narrow corridors with closed doors were described as features that could lead to panic-stricken feelings because it wasn't possible to find out what was behind the doors. Even though the limiting environment provoked feelings of insecurity and confinement, descriptions of the proximity to the other patients varied. The restricted space also had the potential to add to a connection between patients, where they could help each other when the staff wasn't available.

Descriptions of being limited in interactions with staff

Participants also described limitations around access to interactions with staff members. Interviewees said that they wanted and looked for interactions with staff, both for everyday conversations but also for practical help, for example, to lock the bathroom door or get their medicine. Different factors arose that made these interactions more difficult, for example, descriptions that the staff was busy with administrative tasks or practical jobs that were prioritized over spending time with the patients. One interviewee described it as follows:

“Normally there wasn't a lot of chatting [with the staff]; it was mostly with other patients … in that it was the caretakers … they were the ones that handed out the food, so that took up their time.” (Thomas)

Patients also described that the fact that they didn't know the staff, for example, from earlier admissions, was experienced as limiting, and it led to more frequent monitoring. The staff was described as hard to reach, and there was uncertainty about their functions and roles in the ward.

“I don't know what roles the caregivers are supposed to have … but it's like … make sandwiches for breakfast … and warm up food. And then it's just to keep everything running smoothly.” (Sandra)

From another perspective, the staff's role became clearer, but it still included more limited access to the staff. Situations that were described as threatening arose, which resulted in the staff's raised awareness for a particular patient but meant even more limited access to staff for other patients. The limited interactions with the staff are described as having long-lasting effects on the care. Patients described feelings of abandonment and a feeling of being turned over to the other patients. Segregation, where patients are left on their own, were viewed as unsafe and influenced everyone in the unit, especially if there was a patient that they knew could be aggressive. In addition, the interviewees perceived that there was a culture among the staff that interactions with patients should be strict and should trigger respect, which additionally contributed less opportunities for interactions.

Descriptions of being limited in terms of access to information

Another kind of limitation was a limited access to information. The information that interviewees experienced as limited concerned in part what happened in general in the ward, but information about their own care was limited also. In situations when interviewees asked for information, their inquiries were not received as if they were something worth the staff's effort—closer to the opposite. Participants experienced that the staff excluded them from relevant information and/or that they didn't have the competency to deal with their questions. When they asked for information about medicine, the staff might answer, “It's something that's good for you,” or “It's calming.” This type of information was viewed as too simple and unsatisfactory.

“they didn't say what was wrong … I tried to figure out what was actually wrong with me. Why I was there … but no one could tell me. They gave me medicine the whole time … because I wanted to know why I was there. But no one told me, they just said that I chased after someone with a cane, and that's not enough information. I wanted to know what I was there, they said I wasn't well … I felt fine … I knew what I had done … I know about everything …” (Thomas)

We interpreted that limitation of information as an exclusion of the patient from participating in decisions and influencing decisions that were about himself. The limiting of information also was apparent in the lack of information about how the ward functioned and what was and wasn't allowed. Participants talked about situations where they were corrected by staff and told, “you're not supposed to be here” without more specific information. Further descriptions indicated that it was difficult to be told by the staff, for example, that they were not allowed to leave their rooms when no one had told them about that before. Such admonitions were perceived as reprimanding and parental-like. The interviewees gave examples of simple improvements; for example, the staff in a relaxed environment could have talked to them about their treatment and about the unit's rules and routines.

“Ohh, they could have at least told us a little … a little about the rules we … what was going on and so forth … then we could understand a little better. But no … no, it was just, ‘you're not supposed to be out like this’ and …” (Kim)

This limitation of information was even turned around, so to speak, as the staff didn't talk about what the patients were allowed to do and their rights. One participant said that the staff withheld information about the possibility to go on a walk with a staff member. According to the interviewees, to be limited in information made for a worse experience than necessary.

The limited information also involved not getting information about other patients in the ward. When participants asked the staff, they referred to confidentiality. One interviewee spoke in a nervous voice about a situation where the person witnessed another patient injuring herself by hitting her head against the wall.

“No, it feels like, they just stand there and hit [their head] … she hit it hard, like … rock hard, so, no, it was almost as if you feel uneasy, actually. Ohh, it's like you [get] … a nervous feeling … when it … gets like that.” (Kim)

In the interviews, the patients brought up wishes that the staff could have calmed and informed them more generally about these kinds of things, for example, if there was any reason to be scared for their own sakes or if the situation was safe for the other patients. Another participant talked about a situation where another patient suddenly disappeared from the ward.

“Maybe they move people who have done something. Then everyone wonders what has happened with him and so on? And they wonder where he went. You hear when you're a patient yourself what others say. You say it so that the staff doesn't hear.” (Goran)

In situations like this, rumors and questions come up among patients, and since information is limited, they don't get a satisfying answer.

Descriptions of having limited freedom and autonomy

Participants felt supervised by the staff and recounted situations when being monitored implied both limited freedom of movement and the experience of not being able to make independent decisions—this led to the category of limited freedom and autonomy. A hopelessness of not knowing what would happen emerged in the interviews, the feeling that they had to give themselves over to the doctor's decisions. In the stories, there was a resignation to the power of the system, which was personified by the doctors and the ward staff's dominating dispositions. The uncertainty of not knowing the next step in their treatment was perceived as frightening. In some cases, the participants reflected that they, in their resignation, accepted medication even if they didn't have the same perspective or agree with the decision. The limitation of freedom and autonomy inspired silent resistance, where knowledge of what the staff expects of a “healthy person” was used to their own advantage. This resistance was manifested in a performance to be able to “fly beneath the staff's sickness radar” and therefore appear healthy and obedient. We interpret this as a coping strategy to maintain a certain sense of autonomy and freedom.

“I think it can be frightening and you sit and wait to be allow to come in and talk to a doctor. You never know what's going to happen when they close the door, if you're going to get a shot or something, it's frightening.” (Sandra)

“I know nothing about medication … accepted how it was with the medicine, could try to switch to something better later.” (Goran)

The alternative was to accept their situations and passively wait for the staff to decide whether at a later stage the patients might be invited to participate in the treatment. Distinctive impressions of the limitation of freedom and autonomy were particularly dominant when patients were committed against their wills. Patients seemed to feel that the physical lock-in was associated with having all their rights taken away. One participant likened the deprivation of freedom to mandatory military service.

“I don't know if you've done your military service, but when you start out, you get there and the officers are often the hardest on everyone that first week … […] like with respect, but that was what the tone was like in, in, during PICU.” (Kim)

The participants indicate that staff acts parentally, and freedom and autonomy is limited. Further, they implied that the unit's rules were maintained through admonitions by the staff without explanations. Moreover, interviewees perceived that every line of questioning was silenced by referencing the rules of the unit. Furthermore, they gave examples of when freedom was most clearly restricted in connection with physical restraint with straps or with isolation behind locked doors.

Discussion

The purpose of this study was to describe individuals' experiences of being hospitalized in PICUs. A closer look at the data demonstrates discouraging findings regarding patients' experiences of hospitalization in terms of being physically/spatially restricted, a lack of interaction with staff, omissions of information concerning their own care and treatment, and a lack of autonomy. Thus, we interpret that hospitalization in PICUs is experienced as a life-changing event that shows a kaleidoscopic view of limitation. Since this is a small-scale study the findings have to be interpreted with caution and we underline that the results cannot be extrapolated or may not be valid for others who have experienced PICU care. Nevertheless, the results are pre-eminently valid for those four individuals who participated in this particular study, and in order to account for their experiences we will further discuss the results.

We stress that the conceptualization of limitation is complex and thus, must be considered from various views due to its historical origins, sociopolitical aspirations, and philosophy of care. First and foremost, psychiatric care incorporates a century-long history of displacement of people who demonstrated deviant behaviors (Colaizzi, 2005). Dunham and Weinberg (1960) and Goffman (1961) are examples of sociologists who theorized upon mortification of the self during the socializing process people undergo in mental hospitals. However, the conditions for patients in mental hospitals and the conditions for patients in contemporary psychiatric care facilities in Western countries cannot be equated. Nevertheless, based on our results we see a need to acknowledge the psychiatric heritage and the conditions for patients in the old asylums in order to facilitate progression and development of mental health nursing from a contemporary standpoint. In the descriptions, we found what is best conceptualized as “asylum-likened relics.” Some examples, such as being limited in the ward's environment, was analogously termed a “prison-like experience” and the ward was described as shocking. These results are consistent with several other studies (Alexander, 2006; Lilja & Hellzén, 2008; Nurjannah, FitzGerald, & Foster, 2009). Furthermore, the results demonstrate a description of limitation that incorporates the lack of personal space where everyone sees everything that happens as if it took place in front of an open curtain on a stage. The ward design was described to be constructed in a certain way to ease staff supervision of the patients. That description is also highly consistent with previous studies (Salzmann-Erikson & Eriksson, 2013). Even though scholars acknowledge the benefits of ward design in order to more easily supervise patients, several researchers have criticized surveillance in psychiatric care as nothing more than a custodial activity with few therapeutic benefits for the patients (Buchanan-Barker & Barker, 2005; Hamilton & Manias, 2007; Holmes, 2001). Moreover, staff were described by participants as being hard to reach and felt excluded from relevant information; a result which has been supported in previous studies (Eren, 2013; Ezeobele, Malecha, Mock, Mackey-Godine, & Hughes, 2014; Rose, Evans, Laker, & Wykes, 2015). The view of nurses as absent has been examined in qualitative studies accounting for the mental health nurses and their perception of work. A general perception among patients in Rose et al. (2015) study held that staff were “stuck in the office.” Few quantitative studies have explored the allocation of nurses' time in inpatient units, but Whittington and McLaughlin (2000) found that the proportion of time that nurses spent in one-to-one interactions with patients was only 6.75% whereas the majority of time was spent talking or reporting to other staff members and performing administrative tasks.

By shedding light on our results, we believe that the participants' descriptions support the necessity of sociopolitical approaches that strive to put the patient's interests first and humanize mental health care. According to the World Health Organization (WHO, 2016) executive summary, the strategy in the forthcoming ten years is to fundamentally change health services to empower individuals. In order to fulfill a philosophy in care grounded in holism, individualism, and empowering of the individual, as features of person-centered care, mental health care needs to acknowledge existing attitudes and behavior among staff and create a vision of shared governance (Morgan & Yoder (2012). Jenkins et al. (2011) cheered the far-reaching movements in Western countries to end inhumane incarcerations but contrast the problems in low-income countries whereas the human rights movement is about lack of mental care whatsoever. Nonetheless, from our point of view it is an obligation for nurse practitioners and nursing leaders to put the patient's experience at the center, and to involve and integrate patients and relatives throughout the process of care and recovery. We are in good agreement that a patient-centered and recovery-centered approach should be a foundation in care (Barker & Buchanan-Barker, 2010; Hummelvoll, Karlsson, & Borg, 2015; Muir-Cochrane & Gerace, 2016). In that progress, barriers that must be overcome are, for example, term of bureaucracy and the domination of evidenced-based medicine ideologies.

Methodological considerations

Based on the purpose of the study, the use of an epistemological stance in naturalistic inquiry (Patton, 2002; Sandelowski, 2000) was appropriate and relevant. Rich descriptions of the phenomena were possible to acquire from in-depth interviews, and after reviewing the data set, these were considered meaningful (cf. Clarke & Little, 2007; Kvale, 1996; Lincoln & Guba, 1985). We do not claim the data to be saturated. If a larger number of participants had been included in the study, it is also likely that new themes would have been found. Hence, we acknowledge that further research is certainly needed. Even though the sample size is small, we should consider that the sample size in qualitative research is not prioritized, as the relevancy is the fact that data are meaningful (Kvale, 1996). The credibility of the data lies in the good quality in the interviews. By good quality we mean features such as good sound quality, verbatim transcriptions, variation in data in terms of diversity in situations and examples (cf. Lincoln & Guba, 1985; Patton, 2002). Furthermore, by using Braun and Clarke's (2006) thematic analysis, we were able to analyze the data in depth. The thematic analysis does not seek to quantify data but, rather, to find the experiences in the participants' narratives (Vaismoradi, 2013). Moreover, we represent the participants' narratives with excerpts from the data; this is also an important aspect to enhance credibility in qualitative studies (Geertz, 1973; Patton, 2002).

Our original intention was to interview inpatients about their experiences, however, it was not approved by the Ethical Review Board. The obstacles we faced are similar to what other researchers have encountered (Hoeyer, Dahlager, & Lynöe, 2005; Oeye, Bjelland, & Skorpen, 2007). Another intention of ours was to interview at least twenty participants for this project; however, we were not able to find more than four participants. The time for data collection spanned over two and a half years. We can only speculate on why it was so difficult to find participants. One reason may have been the engagement of those nurses who assisted us and handed out the information sheet, although according the terms directed by the Ethical Review Board, other alternatives were not possible. A more progressive assigning strategy of participants was not desirable since that would have risked the therapeutic relationship. During information meetings, the staff agreed that this study was important to conduct and expressed their engagement. We do not have any data for how many information sheets were handed out and how many people declined participation. The low response rate might be because the experiences were too harsh and negative to re-live. As we could not see any definite explanation, we turned the following question: Why did the four participants agree to participate? And was their “unique” consent to participate a possible bias in the findings? It might have been that they depicted a more unsettling and negative view of PICU than the broader population of PICU patients.

Conclusions

Our study demonstrates that being subject to care in a PICU environment was extensively associated with being limited, restricted, and disciplined, where few activities could be performed without assistance of staff. Paradoxically, the results also show that patients experienced being limited in the extent to which they were able to interact with staff, as they seemed too occupied with other activities. Furthermore, the limitations also included limited access to information concerning ward rules, other patients and strategies of care as well as the exclusion from the influence of affecting and participating in one's own care. As self-agency was negligible and downplayed, limitations also affect the experiences of limited freedom and autonomy.

Relevance to clinical practice

Patients in PICUs are highly restricted and limited, and there is a need for further developing strategies that help patients maintain agency and encourage patients to be less helpless while still keeping the unit safe. We urge staff to adopt a person- and recovery-centered approach which would not only increase patients' experience of care, but also increase patients' engagement in their own process of recovery. We encourage PICU nurses in their daily work to engage in more critical reflections on patients' experiences in relation to the many forms of limitation that appear through the kaleidoscopic view that we have pointed out. We suggest that nurses holding leadership positions can initiate thorough discussions and revalue the basic assumptions and core values of the nursing practices. Through reflection, we think that it is possible for nurses to reconsider behaviors, habits, and techniques in PICU and adopt an ideology of using “least restrictive measures.”

Acknowledgments

This article is based on the second author's Master's thesis within a research project, where the first author holds the role as project leader and also supervisor. The Master's thesis has not been published elsewhere. We would like to thank Dr. Lena Wiklund Gustin for her role as examiner of the Master's thesis and for her valuable comments.

Authors' contributions and conflict of interest

Both authors have engaged in collecting data; the second author was mainly engaged in the transcription of data and the initial analysis process. The first author was engaged in data analysis in order to review themes and compare raw data and was also responsible for writing up the article. The access to data, working conditions, and contributions were determined in advance by a signed contract between the two authors. The authors declare that they have no conflict of interests.

Funding

No financial support was received except the costs for language editing, funded by the University of Gävle.

What does this paper contribute to the wider global clinical community?

•	Hospitalization in psychiatric intensive care units is experienced by patients as restricting.
•	Nurses who work in restrictive care environments can use the results to ease patients' negative feelings.