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4 Methodological framework

4.3 Methods

Aiming to answer the study’s primary research question, three sub-studies were conducted. The methods conducted in the sub-sub-studies will be outlined in this section. A brief overview of the sub- studies is presented in Table 2 (Articles I–III).

37 Table 2 Overview over sub-studies

Title/journal Participants Data collection review after restraint in mental health care -a potential for reviews—a gift to the Ward or just another procedure? Care

37 Table 2 Overview over sub-studies

Title/journal Participants Data collection review after restraint in mental health care -a potential for reviews—a gift to the Ward or just another procedure? Care

4.2 Research design

Based on the overarching aim of the study, a descriptive and explorative design was found to be appropriate. The research questions were developed based on a phenomenological-hermeneutical approach where the aims were exploring, describing, and understanding. Gadamer (2010) emphasizes the influence of developing the right questions to achieve this understanding. As this study has an inductive approach, the research questions were thus developed with starting points in how and what (Blaikie & Priest, 2019).

4.3 Methods

Aiming to answer the study’s primary research question, three sub-studies were conducted. The methods conducted in the sub-sub-studies will be outlined in this section. A brief overview of the sub- studies is presented in Table 2 (Articles I–III).

Title/journal

Hammervold, U. E., Norvoll, R., Aas, R. W., & Sagvaag, H. (2019). Post-incident review after restraint in mental health care -a potential for knowledge development, recovery promotion and restraint prevention.

BMC Health Services Research, 19 (235), 1-13

Scientific papers (n = 12)

Scoping

review Data from the quantitative

Hammervold, U. E., Norvoll, R., Vevatne, K., & Sagvaag, H. (2020).

Post-incident reviews—a gift to the Ward or just another procedure?

Care providers’ experiences and considerations regarding post-incident reviews after restraint in mental health services. A

qualitative study.

BMC Health Services Research, 20 (499), 1-13

Hammervold, U. E., Norvoll, R., &

Sagvaag, H.

Post-incident Reviews after Restraints, – Potential and Pitfalls Patients’ experiences and considerations

Submitted: Journal of Psychiatric and Mental Health Nursing, November 2020 Table 2 Overview over sub-studies

Title/journal Participants Data collection review after restraint in mental health care -a potential for reviews—a gift to the Ward or just another procedure? Care Table 2 Overview over sub-studies

Title/journal Participants Data collection review after restraint in mental health care -a potential for reviews—a gift to the Ward or just another procedure? Care

Methodological framework

39

The context of the empirical studies is two mental health services in the same health region in Norway. The two participating services are referred to as Service 1 and Service 2. Service 1 is a university hospital that has a combination of urban and rural settings with about 457,000 inhabitants. The participants were recruited from four different ward units serving patients with serve mental health challenges as psychosis, affective disorders and/or addiction problems.

Service 2 is a community mental health centre that has a rural setting with about 150,000 inhabitants. Participants were recruited from two different wards with one defined as an acute ward. Usually, only hospitals can use coercion in Norwegian mental health services.

However, some community mental health centres are given permission to use coercion based on their emergency and acute services (Norwegian Health Directorate, 2017). The patients were reported to have similar mental health challenges as in Service 1.

The services had both implemented the PIR procedure a couple of years before I conducted the interviews. The procedures were not part of a restraint reduction program, but were an isolated procedure aiming at restraint reduction. The procedures were mainly congruent, but with some differences as illustrated in table 3.

Methodological framework

38

Title/journal Participants Data collection

Initially, it was challenging to get access to services that would allow me to conduct the empirical part of the study. I was in contact with four services before the two participating services allowed for the study.

Methodological framework

38

Title/journal Participants Data collection

Initially, it was challenging to get access to services that would allow me to conduct the empirical part of the study. I was in contact with four services before the two participating services allowed for the study.

38

Title/journal Participants Data collection

Initially, it was challenging to get access to services that would allow me to conduct the empirical part of the study. I was in contact with four services before the two participating services allowed for the study. Methodological framework The context of the empirical studies is two mental health services in the same health region in Norway. The two participating services are referred to as Service 1 and Service 2. Service 1 is a university hospital that has a combination of urban and rural settings with about 457,000 inhabitants. The participants were recruited from four different ward units serving patients with serve mental health challenges as psychosis, affective disorders and/or addiction problems.

Service 2 is a community mental health centre that has a rural setting with about 150,000 inhabitants. Participants were recruited from two different wards with one defined as an acute ward. Usually, only hospitals can use coercion in Norwegian mental health services.

However, some community mental health centres are given permission to use coercion based on their emergency and acute services (Norwegian Health Directorate, 2017). The patients were reported to have similar mental health challenges as in Service 1.

The services had both implemented the PIR procedure a couple of years before I conducted the interviews. The procedures were not part of a restraint reduction program, but were an isolated procedure aiming at restraint reduction. The procedures were mainly congruent, but with some differences as illustrated in table 3.

Methodological framework

39

The context of the empirical studies is two mental health services in the same health region in Norway. The two participating services are referred to as Service 1 and Service 2. Service 1 is a university hospital that has a combination of urban and rural settings with about 457,000 inhabitants. The participants were recruited from four different ward units serving patients with serve mental health challenges as psychosis, affective disorders and/or addiction problems.

Service 2 is a community mental health centre that has a rural setting with about 150,000 inhabitants. Participants were recruited from two different wards with one defined as an acute ward. Usually, only hospitals can use coercion in Norwegian mental health services.

However, some community mental health centres are given permission to use coercion based on their emergency and acute services (Norwegian Health Directorate, 2017). The patients were reported to have similar mental health challenges as in Service 1.

The services had both implemented the PIR procedure a couple of years before I conducted the interviews. The procedures were not part of a restraint reduction program, but were an isolated procedure aiming at restraint reduction. The procedures were mainly congruent, but with some differences as illustrated in table 3.

Methodological framework

39

The context of the empirical studies is two mental health services in the same health region in Norway. The two participating services are referred to as Service 1 and Service 2. Service 1 is a university hospital that has a combination of urban and rural settings with about 457,000 inhabitants. The participants were recruited from four different ward units serving patients with serve mental health challenges as psychosis, affective disorders and/or addiction problems.

Service 2 is a community mental health centre that has a rural setting with about 150,000 inhabitants. Participants were recruited from two different wards with one defined as an acute ward. Usually, only hospitals can use coercion in Norwegian mental health services.

However, some community mental health centres are given permission to use coercion based on their emergency and acute services (Norwegian Health Directorate, 2017). The patients were reported to have similar mental health challenges as in Service 1.

The services had both implemented the PIR procedure a couple of years before I conducted the interviews. The procedures were not part of a restraint reduction program, but were an isolated procedure aiming at restraint reduction. The procedures were mainly congruent, but with some differences as illustrated in table 3.

Methodological framework

38

Title/journal Participants Data collection

Initially, it was challenging to get access to services that would allow me to conduct the empirical part of the study. I was in contact with four services before the two participating services allowed for the study.

Methodological framework

38

Title/journal Participants Data collection

Initially, it was challenging to get access to services that would allow me to conduct the empirical part of the study. I was in contact with four services before the two participating services allowed for the study.

38

Title/journal Participants Data collection

Initially, it was challenging to get access to services that would allow me to conduct the empirical part of the study. I was in contact with four services before the two participating services allowed for the study. Methodological framework The context of the empirical studies is two mental health services in the same health region in Norway. The two participating services are referred to as Service 1 and Service 2. Service 1 is a university hospital that has a combination of urban and rural settings with about 457,000 inhabitants. The participants were recruited from four different ward units serving patients with serve mental health challenges as psychosis, affective disorders and/or addiction problems.

Service 2 is a community mental health centre that has a rural setting with about 150,000 inhabitants. Participants were recruited from two different wards with one defined as an acute ward. Usually, only hospitals can use coercion in Norwegian mental health services.

However, some community mental health centres are given permission to use coercion based on their emergency and acute services (Norwegian Health Directorate, 2017). The patients were reported to have similar mental health challenges as in Service 1.

The services had both implemented the PIR procedure a couple of years before I conducted the interviews. The procedures were not part of a restraint reduction program, but were an isolated procedure aiming at restraint reduction. The procedures were mainly congruent, but with some differences as illustrated in table 3.

Methodological framework

39

The context of the empirical studies is two mental health services in the same health region in Norway. The two participating services are referred to as Service 1 and Service 2. Service 1 is a university hospital that has a combination of urban and rural settings with about 457,000 inhabitants. The participants were recruited from four different ward units serving patients with serve mental health challenges as psychosis, affective disorders and/or addiction problems.

Service 2 is a community mental health centre that has a rural setting with about 150,000 inhabitants. Participants were recruited from two different wards with one defined as an acute ward. Usually, only hospitals can use coercion in Norwegian mental health services.

However, some community mental health centres are given permission to use coercion based on their emergency and acute services (Norwegian Health Directorate, 2017). The patients were reported to have similar mental health challenges as in Service 1.

The services had both implemented the PIR procedure a couple of years before I conducted the interviews. The procedures were not part of a restraint reduction program, but were an isolated procedure aiming at restraint reduction. The procedures were mainly congruent, but with some differences as illustrated in table 3.

Methodological framework

40

Table 3 Overview of the two participating services PIR procedures:

The services had a multidisciplinary group of therapists. Psychiatrists and psychologists had the role of individual therapists. They often led the PIRs according to the services procedures. Nurses and social educators, many of them with special education in mental health care, were the front-liners and had the daily responsibility of the milieu therapy in the

University Hospital Community Mental Health Centre

Point in

time As soon as possible after the restraint event, if possible not later than 72 hours

As soon as possible and latest by discharge

Participants Should be led by a person not involved in the restraint incident.

One care provider involved in the restraint event should participate.

Patient, eventually next of kin, contact nurse or available familiar nurse and responsible therapist

Themes in

the PIR The patient’s experience of the restraint event and how the occasion was conducted?

The patient’s

comprehensions of reasons for conducting restraint, the effect of the measure and if the patients considers that the event was inevitable.

The patient’s comprehension of the situation, the rationale for conducting restraint and the measure’s effect

What contributed to the restraint event?

What were the care providers’

arguments for conducting restraint?

How did the patient experience the restraint measure?

How did the restraint measure appear?

What does the patient want the care providers to do in similar situations?

Documen-tation PIR documented in electronic journal as a note. The patient receives a copy and may comment on the document.

PIR documented in electronic journal as a note

Methodological framework

41

wards. A central task was thus preparation of a supportive milieu that included restraint prevention, implementing restraint measures when that was considered inevitable and further taking care of the patients after restraint use (Barton et al., 2009; Riahi et al., 2016). The milieu therapists participated in PIRs, sometimes leading them, but more often in this study as the second participant serving as representative of the milieu therapist group. Other staff members in the wards were nursing assistants and employees who do not have a bachelor’s degree. They seemed not to be involved in PIRs and are consequently not focused on in this thesis.

The participating patients struggled with various mental health challenges that put them in need of being inpatients in the hospital or mental health centre for a period, either in the short or long term. Some were voluntarily admitted, while others were admitted involuntarily.

Recruitment of participants

Initially, I contacted management of the participating services, who provided permission to present the study to leaders and available care providers in the relevant care units.

The study was presented orally, focusing on background, aims, purpose, methodical approach, and ethical considerations. Those present care providers expressed immediately positively to participate in the study. I also left written information and consent forms in each ward unit.

The ward leaders contacted me then about participants, both patients and care providers, who had given their consent to set appointments for the interviews. I made the appointment for interviews with the care providers directly with the individual care provider by e-mail. No one resigned after the agreement was signed.

Appointments for interviews with the patients were done via a care provider, usually the ward leader, the doctor, or the psychologist. It was Methodological framework

40

Table 3 Overview of the two participating services PIR procedures:

The services had a multidisciplinary group of therapists. Psychiatrists and psychologists had the role of individual therapists. They often led the PIRs according to the services procedures. Nurses and social educators, many of them with special education in mental health care, were the front-liners and had the daily responsibility of the milieu therapy in the

Methodological framework

40

Table 3 Overview of the two participating services PIR procedures:

The services had a multidisciplinary group of therapists. Psychiatrists and psychologists had the role of individual therapists. They often led the PIRs according to the services procedures. Nurses and social educators, many of them with special education in mental health care, were the front-liners and had the daily responsibility of the milieu therapy in the

40

Table 3 Overview of the two participating services PIR procedures:

The services had a multidisciplinary group of therapists. Psychiatrists and psychologists had the role of individual therapists. They often led the PIRs according to the services procedures. Nurses and social educators, many of them with special education in mental health care, were the front-liners and had the daily responsibility of the milieu therapy in the

Methodological framework

41

wards. A central task was thus preparation of a supportive milieu that included restraint prevention, implementing restraint measures when that was considered inevitable and further taking care of the patients after restraint use (Barton et al., 2009; Riahi et al., 2016). The milieu therapists participated in PIRs, sometimes leading them, but more often in this study as the second participant serving as representative of the milieu therapist group. Other staff members in the wards were nursing assistants and employees who do not have a bachelor’s degree. They seemed not to be involved in PIRs and are consequently not focused on in this thesis.

The participating patients struggled with various mental health challenges that put them in need of being inpatients in the hospital or mental health centre for a period, either in the short or long term. Some were voluntarily admitted, while others were admitted involuntarily.

Recruitment of participants

Initially, I contacted management of the participating services, who provided permission to present the study to leaders and available care providers in the relevant care units.

The study was presented orally, focusing on background, aims, purpose, methodical approach, and ethical considerations. Those present care providers expressed immediately positively to participate in the study. I also left written information and consent forms in each ward unit.

The ward leaders contacted me then about participants, both patients and care providers, who had given their consent to set appointments for the interviews. I made the appointment for interviews with the care providers directly with the individual care provider by e-mail. No one resigned after the agreement was signed.

Appointments for interviews with the patients were done via a care provider, usually the ward leader, the doctor, or the psychologist. It was

Methodological framework

41

wards. A central task was thus preparation of a supportive milieu that included restraint prevention, implementing restraint measures when that was considered inevitable and further taking care of the patients after restraint use (Barton et al., 2009; Riahi et al., 2016). The milieu therapists participated in PIRs, sometimes leading them, but more often in this study as the second participant serving as representative of the milieu therapist group. Other staff members in the wards were nursing assistants and employees who do not have a bachelor’s degree. They seemed not to be involved in PIRs and are consequently not focused on in this thesis.

The participating patients struggled with various mental health challenges that put them in need of being inpatients in the hospital or mental health centre for a period, either in the short or long term. Some were voluntarily admitted, while others were admitted involuntarily.

Recruitment of participants

Initially, I contacted management of the participating services, who provided permission to present the study to leaders and available care providers in the relevant care units.

The study was presented orally, focusing on background, aims, purpose, methodical approach, and ethical considerations. Those present care providers expressed immediately positively to participate in the study. I also left written information and consent forms in each ward unit.

The ward leaders contacted me then about participants, both patients and care providers, who had given their consent to set appointments for the interviews. I made the appointment for interviews with the care providers directly with the individual care provider by e-mail. No one resigned after the agreement was signed.

Appointments for interviews with the patients were done via a care

Appointments for interviews with the patients were done via a care