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Research

Women’s experiences of being in an acute psychiatric unit: an occupational perspective Jennifer Kennedy 1 and Tracy Fortune 2 Key words: Mental illness, women, qualitative research.

Introduction: The need to address gender sensitivity and implement strategies to improve the treatment of women within inpatient mental health facilities has gained international recognition. Ascertaining service users’ perspectives is a critical prerequisite to ensure that potential strategies are appropriate. This study aimed to identify factors influencing the occupational engagement of women service users in an acute inpatient mental health unit in Melbourne, Australia. Method: In this phenomenological study, five women were interviewed about their experiences of occupational engagement. Data were analysed according to Colaizzi’s (1978) procedure, to generate an ‘essence statement’. Fieldnotes were kept and an audit trail of the analysis process was recorded. Findings: Three main themes emerged: (1) Living in hospital is difficult; (2) What we need from staff; and (3) More meaningful things to do, please. Conclusion: Study findings highlight a need for more empathetic communication with staff, more effective use of the physical environment to enable improved perceptions of safety, and more meaningful occupational opportunities.

Introduction

1 Occupational Therapist, Central

London Community Healthcare NHS Trust, London. 2 Senior Lecturer, La Trobe University, School of Occupational Therapy, Bundoora, Victoria 3086, Australia. Corresponding author: Jennifer Kennedy, Occupational Therapist, 16B Porchester Square, London W2 6AN, United Kingdom. Email: [email protected] Reference: Kennedy J, Fortune T (2014) Women’s experiences of being in an acute psychiatric unit: an occupational perspective. British Journal of Occupational Therapy, 77(6), 296–303. DOI: 10.4276/030802214X14018723138048 © The College of Occupational Therapists Ltd. Submitted: 27 February 2013. Accepted: 22 November 2013.

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Internationally, deinstitutionalization responded to, and triggered, a focus on quality care in acute psychiatric inpatient units (Clarke and Dempsey 2008, Department of Human Services [DHS] 2008, Sainsbury Centre for Mental Health [SCMH] 1998). Women service users in secure mental health settings are recognized as a vulnerable, at-risk group (DHS 2008), and considered attention, in terms of quality initiatives, is warranted. In the United Kingdom (UK), the SCMH surveyed service users about inpatient care and uncovered concerns relating to lack of freedom, undesirable staff attitudes, limited staff availability, safety, boredom, and gender issues (SCMH 1998). It was concluded that hospital care was not therapeutic, nor was it individualized, and service users’ participation in meaningful activity was limited. Consequently, the National Health Service (NHS) Executive set out to abolish mixed-gender inpatient accommodation by 2002 (Department of Health, cited in Ramsay 2005). In Australia, the need for inpatient service users to have input into service planning is a recent priority (DHS 2009). The Melbourne-based Victorian Women and Mental Health Network [VWMHN] undertook a range of projects to identify and address perceived issues in acute inpatient service provision (Clarke and Dempsey 2008, DHS 2008). Issues raised included perceptions of limited privacy, the fact that many women felt unsafe in mixed-gender areas, and that sexual assault allegations were poorly managed (Clarke and Dempsey 2008, DHS 2008). Other findings related to the need for more therapeutic activity (DHS 2008). The provision of women-only spaces was recommended, including gender-specific sleeping areas (Clarke and Dempsey 2008). Subsequently, Environmental Improvement Grants (DHS 2008) led to the establishment of women-only corridors and lounges, and it was found that women’s lounges helped women to feel safer and more relaxed, and that they promoted supportive contact between women service users and staff (VWMHN

Jennifer Kennedy and Tracy Fortune

2009). Plans for separate women’s recreational spaces, in at least 6 of 26 wards surveyed, were also noted (VWMHN 2009).

Occupation and recovery-oriented practice The notion of recovery is now well established as a useful orientation upon which to base service provision in mental health. Recovery-oriented service provision prioritizes service users’ hopes and goals relating to their ability to manage their illness and treatment (clinical recovery), which may include social and functional dimensions of living, such as the care of others within life-roles (Lloyd et al 2008). While the occupational therapy profession has long espoused a wellness and recovery orientation in mental health through enabling participation in occupations in all of the above dimensions, mental illness and placement within environments such as an acute inpatient unit can interfere with a person’s ability to participate in usual occupations, as well as with their sense of comfort and safety. Lloyd et al (2008) concur that ‘although recovery is a deeply personal, unique journey, the external environment, including the service providing treatment and care, has an impact on the course of this journey’ (p323). The extent to which environments dictate occupational engagement is therefore highly relevant, and it is this perspective that prompted the study described in this paper.

Literature review What is known of the service users’ experience of psychiatric inpatient care? Inpatient mental health environments and gender issues In a British study by Gilburt et al (2008), service users described ward conditions as unhygienic, old, in poor condition, overcrowded, understaffed, and lacking basic home comforts. Reduced autonomy issues have included reduced physical freedom (Gilburt et al 2008, Quirk et al 2006, Thibeault et al 2010) and limited control over one’s situation (for example, being unable to leave a ward unsupervised). Participants in another Canadian study by Thibeault et al (2010) spoke of the disruption caused to the ward atmosphere when a fellow inpatient was in seclusion. A lack of space and privacy were highlighted as concerns for service users in a Canadian study by Letendre (1997) and in the studies reviewed by Katsakou and Priebe (2007). Service users in a Swedish study conducted by Lilja and Hellzén (2008), a British study by Johansson et al (2009), and the Canadian study by Thibeault et al (2010), highlighted a preference for having a private area of refuge on the ward. The evidence relating to service users’ desire for gender segregation is mixed. Johnson et al (2004) found that the majority of women participants (15 out of 20) expressed a preference for an all-women setting, as did participants in a Canadian study by Gallop et al (1999). However, findings from an Australian study by Cleary and Warren (1998) revealed that the majority of women interviewed preferred the idea of mixed-gender wards, despite feeling vulnerable to men.

Desires for engagement in meaningful occupation Boredom has been highlighted by numerous researchers (for example, Borge and Fagermoen 2008, Katsakou and Priebe 2007, Letendre 1997, Lilja and Hellzén 2008, Quirk and Lelliott 2001, Shattell et al 2008). Letendre’s study reported service users’ disappointment that medication was the main therapy. The desire for more meaningful and constructive activities and /or insight-oriented therapies was reported by participants in studies conducted by Borge and Fagermoen (2008), Shattell et al (2008), and Thomas et al (2002). Moreover, service users have reported positive results from participating in an inpatient therapeutic group programme (O’Donovan and O’Mahony 2009) and an art group (Stickley and Hui 2012). The body of literature presented would appear to support an international concern with the extent to which people are meaningfully engaged in acute psychiatric units.

Perceptions of safety and the importance of staff–patient communication The evidence relating to service user’s perceptions of safety is modest but significant. Feeling fearful during hospitalization was described by most participants in Gilburt et al (2008), which revealed that feeling unsafe was associated with wardbased violence, and that a predominance of men invoked a greater feeling of vulnerability among both men and women. Samuelsson et al (2000) found that service users felt secure when they perceived staff as caring. Furthermore, participants in Stenhouse’s (2011) study reported feeling cared for when nurses spent time with them. Similarly, feeling understood and being listened to without judgement by staff has been associated with cultivating respect (Gilburt et al 2008, Samuelsson et al 2000).

Rationale for study In a political climate where service providers are encouraged to collaborate with service users in planning and governance, it is critical that service users are consulted about their experiences of receiving care and their desires for what that care might look like. A review of contemporary qualitative research which explores the experience of life as an inpatient in an adult acute psychiatric ward revealed that there were few studies relating to women inpatients’ experiences, and only two studies were found that provided an occupational perspective (Quirk et al 2006, Thibeault et al 2010). Given this gap, this study set out to explore women’s experiences of what it is like to be an inpatient in an acute psychiatric unit, and to focus on their occupational engagement, and supportive or constraining factors influencing this. A phenomenological approach was deemed appropriate given its emphasis on gaining a deeper understanding of everyday experiences and transforming them to text (Van Manen 1990).

Method Setting This phenomenological study was situated within two mixedgender wards of an adult acute psychiatric inpatient unit at


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Women’s experiences of being in an acute psychiatric unit: an occupational perspective

Table 1. Participants Name/age Length of hospital (pseudonym) stay (days) 13 Melanie/29 years Ashley/24 years 11 Trudy/59 years 20 22 Lisa/58 years Jane/48 years 16

Diagnosis

Usual occupations

Schizophrenia Borderline personality disorder Paranoid schizophrenia Situational crisis Borderline personality disorder

Single parent, enjoys shopping Going for coffee with friends, going to gym Relaxing Yoga, meditation, drinking alcohol Enjoys art therapy, being creative

Table 2. Themes Theme Living in hospital is difficult

Subtheme 1 ■ Feeling closer to like-minded people ■ Feeling unsafe

Own room

Subtheme 2 ■ ■

■ ■

What we need from staff

■ ■

No Yes Yes Yes No

Fear of physical harm Out of my comfort zone

Wanting greater division of the living space Feeling restricted To be acknowledged as important Tailored practical assistance

More meaningful things to do, please

a metropolitan hospital in Melbourne, Australia. Each ward had 30 beds with double and single rooms spaced over two corridors. All rooms and bathrooms had locks, and double rooms had an ensuite bathroom. A maximum of eight nurses were on duty during the day, and four nurses at night.

Participants Six women were recruited using a purposeful sampling approach (Llewellyn et al 2003); however, one woman was not well enough to participate so did not continue. See Table 1 for participant details. According to staff assessment during recruitment, participants were at different stages of recovery when interviewed. This provided natural variation in the sample. The study was approved by the relevant institutional ethics committees.

Data collection Semi-structured interviews lasting between 40–74 minutes were digitally recorded and transcribed. The researcher kept fieldnotes to aid analysis and the generation of emergent themes. An interview schedule guided discussion content around two key questions. Firstly, participants were asked what their experience of the ward was like and if those experiences effected their engagement in occupations on the ward. Participants’ recommendations for a more engaging environment were sought throughout each interview. Following an interim analysis of the first two interviews, questions were also asked about the creation of separate spaces and group options. This type of collaboration between researchers and participants can contribute to trustworthiness (Curtin and Fossey 2007).

Data analysis Data were analysed using an approach outlined by Colaizzi (1978), which involved the researcher transcribing interviews, extracting significant statements after reading through tran-

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scripts twice, and formulating meanings for significant statements. Each formulated meaning and significant statement was singled out and compared with others both within and between transcripts. Similar statements were placed together in clusters to aid in the identification of themes in the data. See Table 2 for identified themes. Each theme and its subthemes were described including verbatim quotations to illustrate and validate the findings. Descriptions were summarized into an ‘essence statement’, which aimed to represent the women’s experience as a collective.

Trustworthiness A number of decisions and processes were utilized that have served to enhance rigour or trustworthiness. Information provided about the setting and participants assists judgements about transferability. Credibility, dependability, and confirmability were enhanced through ensuring that the voices of participants were heard and re-presented as verbatim data to illustrate key interpretations. Triangulation of data methods included interviewing, keeping a methodological journal, and discussion between the researchers throughout data analysis. Reflexivity was addressed by ensuring that the researchers identified and ‘bracketed’ (Koch 1995) their assumptions.

Findings Living in hospital is difficult Feeling closer to like-minded people The ward was experienced as a difficult environment by all women interviewed. They used words or phrases such as: ‘disruptive’, ‘strange’, ‘loud’, ‘quiet’, ‘no boundaries’, ‘boring’, ‘relaxed’, ‘intense’, ‘hard to deal with’, ‘want to get away’, ‘under pressure’, ‘irritated’, and ‘secluded’. A common response was to avoid particular people or situations:


Like, we have an art room. And when certain patients are in the art room I won’t go in there, coz I don’t want to have to interact with them (Ashley).

Nevertheless, a number of the women also expressed their desire to connect with other service users with whom they shared similarities such as age, gender, personality, likes and dislikes, and illness experience: I think that when people are put in to a double room … consideration [should be] put in place for what sort of personalities they basically have … not just their differences but what, what things they do have in common (Jane). I mean, I know we’re in a unit but I find it different when you’re sitting ‘n’ you’re able to talk with people, you learn number one that you’re not on your own, and … everyone’s got different aspects of whatever it is (Lisa).

The proposition of a women-only lounge room was met with hesitation from three of the women, who thought it might not improve the social environment.

Feeling restricted The women expressed their frustrations of reduced independence: … I was gonna wash my hair and do all of that but I didn’t … They’ve gotta get my hairdryer out of my locker, all those things are locked away, so … (Lisa). When I was in HDU I had no Pink Lady or pad sanitary bin and basically I had to keep going up to them with it in a toilet wrapper (Melanie). … most of the time when there’s guys sitting there [at the TV], they take ownership of that space … So you don’t really go there (Jane).

Feeling unsafe Safety concerned three of the women interviewed; however, their perceptions of safety took different forms.

Fear of physical harm Two women reported fear of being harmed physically by male service users, and both wanted gender-segregated corridors: I don’t feel as safe as I would if I knew that just females were there … walking down to the loo and suddenly someone, a bloke, wants to go to the toilet too … not a comforting feeling (Jane).

Out of my comfort zone Safety was talked about in a range of different ways by three of the women. Issues included: not being able to ‘trust’; feeling ‘less free’; feeling ‘guarded’, ‘contained’, or ‘disturbed’; having discomfort; not wanting to be the only group participant; and fear of various things including other people’s illness experiences and of ‘loudness’. The outcome of feeling out of one’s comfort zone seemed to be most often expressed as a preference to be in a contained and calm environment away from the large common living area and away from other service users. Lisa spoke about how her fear stopped her from attending groups: No, it’s probably just fear of the unknown. Just fear of, fear of doing it. I just feel when I go to my room and lie on the bed that I’m safe. I can lock the door (Lisa).

What we need from staff To be acknowledged as important Descriptions of how the women felt when waiting for staff and being ignored for what was felt to be an extended time included words or phrases such as: ‘insignificant’, ‘invisible’, ‘demeaned’, ‘depressed’, ‘degraded’, and ‘a lesser person’. When Jane felt she wasn’t acknowledged she would: just retreat to my room … just stay in there (Jane).

Others commented on staff attitudes: The staff are not treating me with ‘sincerity’, and they roll their eyes back, which is a definite body language … I just, I don’t feel like I wanna participate … when things like that happen (Melanie). … I don’t mean they have to jump up out of the chair and, whatever. But … to say ‘I’ll be with you in a minute’ is greatly valued (Lisa).

Tailored practical assistance All but one woman directly referred to a need for staff to organize activities and initiate what they should or could do. Trudy was unaware of what groups were running and if she was allowed to attend, saying ‘if I was invited I would have gone’. Jane explained her need for direction: When everything’s ambiguous, it doesn’t work! … people wander around, including myself … You know, you don’t know what to do, when to do it, or how to do it (Jane).

Wanting greater division of living space Lisa, Melissa, and Trudy talked about preferring to see visitors in a private place. Jane felt she had nowhere to talk privately with other women, ‘about feelings, about boyfriends, about normal things!’, while Lisa had no appropriate place to do her exercises, and did not want to do them ‘in front of everybody’. Ashley wanted a place to ‘chill out’ and Lisa thought ‘a better division between the eating area ‘n’ the television area’ would allow people to chat in the dining area and reduce noise for people watching television.

More meaningful things to do, please Four of the women had participated in at least one group. Reasons for participating included: self-development / rehabilitation (for three women), self-expression (two), for something to do (two), and for intellectual or emotional stimulation (two). All women stated there was not enough variety in activity options. For example, Jane stated that the activity whiteboard ‘hasn’t changed in six months’. Regarding the art group, Lisa explained her hesitancy:


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I could do it, but it would be me feeling really inferior about what I’ve done, because I can’t draw. So that would be a feeling of ‘not good enough’ (Lisa).

expressed a view that a connection between group members was important and that they wanted to be in groups with people in a similar stage of recovery.

Meaningful exercise and having women-only time were desired by all women interviewed:

Safety concerns and the physical environment

Maybe they could do a women’s only group … [a] chat-type group for any thoughts (Ashley). Tai Chi or something like that that could be done out in the courtyard … strengthen the body and the mind at the same time (Lisa).

Surviving the inpatient environment — summarizing participants’ experiences To cope in the difficult social environment, the women commonly avoided particular people or situations by withdrawing from the social context; however, they also expressed greater ease, and desire to connect, with like-minded people. Concerns for safety included fear of being harmed physically by male service users, and not feeling safe to express themselves. The women were forced to rely on staff to obtain required items, which reduced their choice in what could be done when. Other service users also restricted their choice of occupation. All participants wanted a greater division of the living space, which they felt would reduce the impact of the chaotic environment, increase their sense of privacy, and facilitate their engagement in various occupations. The responsiveness of staff, and the way in which they communicated with the women, influenced how the women felt about themselves and, consequently, their desire to engage in life on the ward. The women also relied on staff to organize meaningful activities, initiate their participation, and provide guidance. More meaningful occupational opportunities, which were more carefully matched to interests and /or ability, were requested by all women. Meaningful exercise and having women-only time were similarly desired by all the women interviewed.

Discussion Desire to form social connections Although the women interviewed in this study described the acute psychiatric inpatient unit as a difficult social environment to live in, there was a shared desire to increase their sense of belonging in relation to other service users; in particular, those with whom they shared similarities. Peer support has previously been reported by service users as being beneficial for improved mental health, physical and social functioning, and increased ability and participation in activities of daily living (Bouchard et al 2010). The finding that similarities improved social connection was also found by Borge and Fagermoen (2008), who revealed that loneliness and any sense of shame reduced when inpatients met like-minded inpatients. In another qualitative study by Cowls and Hale (2005), the (mostly) women participants

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Of the five women interviewed, two were afraid of being harmed physically by male service users. Comparatively, the majority of the participants (men and women) in a study by Gilburt et al (2008) described feeling fearful of physical harm during hospitalization. In the present study, two women voiced a clear preference for female-only sleeping areas/corridors, although gender segregation of the living space was not a popular idea for the women interviewed. Given these findings, this study indicates that concerns for physical safety provide reasons for sleeping areas to be gender specific; however, any additional gender segregation of the living space should be approached with caution. The findings on this matter reflect the hesitation for women-only wards, also communicated by the women service users in the study by Cleary and Warren (1998), and in the preference expressed by some participants in the study by Gallop et al (1999) for some gender-segregated areas. The findings from the current study do not provide clear support for genderspecific wards, unlike the Johnson et al (2004) study. Perhaps of greater significance regarding safety and its impact on occupational engagement is the finding that a number of the women felt unsafe to express themselves, due to lacking trust, feeling ‘less free’, or ‘fear of the unknown’. This is a potentially novel finding relating to safety in acute inpatient units, contributing another perspective as to why safety is of particular concern to women. In response to feeling out of their comfort zone, the women tended to seek out a contained and calm place, away from the large common living area. In other studies, consumers have reported feeling supported by having a restful, relaxing place of refuge on the ward (Johansson et al 2009, Thibeault et al 2010). This finding indicates that in attempting to address women’s safety concerns, assessed purely on physical safety, strategies such as gender segregation would be inadequate. Looking beyond gender segregation, all the women wanted the ward to be divided into more distinct areas, in an attempt to reduce the chaos in the environment, increase their privacy, and provide a greater number of smaller rooms to facilitate a greater variety of occupations. The concerns regarding chaos and privacy are consistent with recommendations of the SCMH (1998) report: that psychiatric inpatient units should be organised so that people with similar needs and affinity are together, and that they be sensitive to women’s privacy needs. The present study offers an addition to the findings of the study by SCMH (1998), which is that the fulfilment of the women’s desire for greater division of the living space is likely to facilitate a greater variety of occupations.

Loss of autonomy and the staff–patient relationship One of the individual experiences commonly shared by the women was a loss of autonomy. In a practical sense, the factors


reducing their autonomy were other service users, poor access to required items, and having to wait for extended periods of time to speak to a staff member to make a request. Previous studies have also reported on a loss of autonomy for service users as a result of dependence on staff judgement and availability (Johansson et al 2006, Quirk et al 2006), and of being passive recipients of care (Daremo and Haglund 2008, Johansson et al 2009, Lovell 1995, McCloughen et al 2011, Roe and Ronen 2003). The women in this current study spoke of the emotional repercussions of being in a powerless position, and explained how the manner in which staff communicated with them and responded to their needs could have an impact on the way they felt. Frustration turned into defeat and into feelings of being ‘insignificant’, ‘invisible’, ‘demeaned’, ‘depressed’, ‘degraded’, and ‘a lesser person’, when they felt ignored and not prioritized by staff. Unfortunately, this finding was not specific to this study. Some of the previously reported emotional consequences resulting from loss of autonomy include reduced self-esteem (Roe and Ronen 2003); feeling like a failure and being dehumanized/devalued (Hagen and Nixon 2011, Katsakou and Priebe 2007, Yang et al 2012); or feeling forgotten (Daremo and Haglund 2008), unheard, and worthless (Lilja and Hellzén 2008). Moreover, when the women in the current study felt demoralized as a result of a loss of autonomy and a breakdown in staff–patient communication, this further reduced their occupational engagement, because they no longer wanted to participate in life on the ward. Conversely, service users have reported experiencing benefits from supportive relationships with staff, including strengthened integrity and self-determination (Johansson et al 2009) and normalization through informal interaction with staff (Skatvedt and Schou 2010). Although the staff–patient relationship and its affect on demoralization has been explored in the literature previously, the impact this has on occupational engagement in acute psychiatric units has not previously been reported.

More individualized care needed The need for more individualized care was highlighted as being critical to the women’s occupational engagement, as was their need for ‘activities’ to be suited to their individual abilities: for example, Lisa was unable to draw. Service users in previous studies have also reported their desires and need for more individualized care. Participants in the Johansson et al (2009) study reported that some aspects of care alleviated suffering while others provided stress. As with the current study, service users in the study by Daremo and Haglund (2008) required assistance from staff to help them initiate participation in occupations, saying they wanted staff to provide ideas of what they could do. Other studies have indicated consumer preferences to have a time schedule, rather than staff reminders, to help them initiate activities (Borge and Fagermoen 2008, Daremo and Haglund 2008). Either way, it seems important that some form of external prompt or structure be provided for service users to participate in occupation.

Desire for occupational opportunities of greater meaning To assist with their motivation to participate, the women wanted a greater variety of activity options to choose from. Similarly, service users in previous studies have reported experiencing idle time (Borge and Fagermoen 2008, Thomas et al 2002) and boredom (Letendre 1997, Quirk and Lelliott 2001, Quirk et al 2006, Shattell et al 2008), as perceiving the psychiatric unit as non-stimulating (Daremo and Haglund 2008, Lilja and Hellzén 2008), and as having limited and repetitive activities (Katsakou and Priebe 2007, Letendre 1997). Further contributing to the women’s motivation to participate in the ‘activities’ available was their interest or perception of a potential benefit from doing so. The importance of the perception of a potential benefit has been found in previous studies in which service users wanted to understand the meaning and purpose of the aspects of their care (Daremo and Haglund 2008, Johansson et al 2007, Katsakou and Priebe 2007). This finding suggests that in some cases the greater meaning that service users need to participate in occupations may be facilitated through clinicians more clearly communicating their reasoning as to why they think the intervention is suited to each particular person. This study and others have indicated service users’ desires for opportunities of greater therapeutic potential, which are more insight-oriented and constructive (Borge and Fagermoen 2006, Johnson et al 2004, Thomas et al 2002). In the Shattell et al (2008) study, participants described group therapy as meaningless because it did not address their illnesses. Comparatively, study participants involved in a therapeutic group programme reported that overall it was beneficial for their mood, confidence, overall mental health, communication skill development, including empathy, for the opportunity to reflect and learn from others, while some experienced normalization (O’Donovan and O’Mahony 2009). Participation in enjoyable and interesting occupations, as indicated in the current study, has also been reported elsewhere (Parahoo et al 1995, Stickley and Hui 2012, Thibeault et al 2010). One such occupation suggested by the women was for meaningful exercise. This suggestion is supported by research, which has found that exercise is a means for improving mental health (Acil et al 2008, Callaghan 2004, Hvalsøe and Josephsson 2003). The women in the current study also expressed a shared desire to participate in a facilitated women-only discussion group. Other studies have also highlighted that service users value sharing their experiences with other service users, as this reduced their sense of isolation (Cowls and Hale 2005, Daremo and Haglund 2008). It seems clear that processes to better ascertain the particular occupational interests and needs of service users are required to facilitate occupational engagement that, it is argued, will act to maintain and /or improve wellbeing for women service users.

Limitations of this study The study has highlighted the challenges of interviewing, over a short time frame, participants experiencing varying


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states of acuity. Future studies will need to build in greater flexibility around data collection opportunities that better match participants’ needs and availability, rather than researchers’ time constraints. Interviewing women over a number of occasions, rather than once, may have better suited women, in addition to providing greater analytic depth. Another limitation of this study was that member-checking was not utilized. Despite a small sample, numerous verbatim accounts from the women were presented.

Conclusion The adult psychiatric inpatient unit is experienced as a difficult environment to live in for women service users, who sometimes feel unsafe. It was found that a woman can feel physically safe around others yet unsafe to participate in occupations, due to emotional and self-concept issues. Findings also revealed women’s desire for, and greater ease in, connecting with similar people. It was proposed that, for the inpatient service to be safer and more sensitive to women’s needs, a focus on gender segregation alone is inadequate. It is felt that the physical environment can be utilized more effectively to improve safety, reduce chaos, and facilitate more occupations.

Implications for Future Research This study revealed a mix of understandings of what safety means for a small number of women inpatients. Further research that widens the circle of inquiry to include the experiences and perspectives of service providers, and both men and women service users, is indicated. Service providers’ and users’ experience of enhanced ward environments, and how these environments impact perceptions of safety and ability, or inclination to participate in occupations, would extend these findings further.

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Key findings Safety for women service users can mean physical safety or feeling emotionally safe/supported. Gender segregation is inadequate in addressing improved safety and sensitivity for women service users. The physical environment can be altered to improve safety, reduce chaos, and facilitate more occupations of meaning.

What the study has added The findings of this study provide support for gender segregated sleeping areas and smaller, more private day/lounge areas for targeted occupations. Findings also encourage creativity in the group options that service providers offer and a more personalized and responsive staff approach to offering practical assistance.

Acknowledgements Thanks are extended to the women interviewed, and to inpatient unit staff. The input of the late Dr Scott Presnell is also gratefully acknowledged.

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Conflict of interest: None declared. Funding: This research received no specific grant support from any funding agency in the public, commercial, or not-for-profit sectors. Research ethics: Ethics approval was granted by the La Trobe University Human Ethics Committee (UHEC) on 24/02/2009 (Application No. 08-154) and the relevant institutional ethics committee for the participating mental health service on 3/12/2008. References Acil AA, Dogan S, Dogan O (2008) The effects of physical exercises to mental state and quality of life in patients with schizophrenia. Journal of Psychiatric and Mental Health Nursing, 15(10), 808–815. Borge L, Fagermoen MS (2008) Patients’ core experiences of hospital treatment: wholeness and self-worth in time and space. Journal of Mental Health, 17(2), 193–205. Bouchard L, Montreuil M, Gros C (2010) Peer support among inpatients in an adult mental health setting. Issues in Mental Health Nursing, 31(9), 589–598. Callaghan P (2004) Exercise: a neglected intervention in mental health care? Journal of Psychiatric and Mental Health Nursing, 11(4), 476–483. Clarke H, Dempsey J (2008) Outrage becomes determination: advocating to raise awareness of women’s experience in mixed-sex psychiatric wards. Health Issues, 94(Autumn), 14–16. Cleary M, Warren R (1998) An exploratory investigation into women’s experiences in a mixed sex psychiatric admission unit. Australian and New Zealand Journal of Mental Health Nursing, 7(1), 33–40. Colaizzi P (1978) Psychological research as the phenomenologist views it. In: Valle RS, King M, eds. Existential-phenomenological alternatives for psychology. New York, NY: Oxford University Press. 48–71. Cowls J, Hale S (2005) It’s the activity that counts: what clients value in psycho-educational groups. Canadian Journal of Occupational Therapy, 72(3), 176–182. Curtin M, Fossey E (2007) Appraising the trustworthiness of qualitative studies: guidelines for occupational therapists. Australian Occupational Therapy Journal, 54(2), 88–94. Daremo Å, Haglund L (2008) Activity and participation in psychiatric institutional care. Scandinavian Journal of Occupational Therapy, 15(3), 131–142. Department of Human Services (2009) Because mental health matters: Victorian mental health reform strategy 2009–2019. Melbourne, Victoria: Mental Health and Drugs Division, Victorian Government, Department of Human Services. Available at: http://docs.health.vic.gov.au/docs/ doc/Because-Mental-Health-Matters--Victorian-Mental-Health-ReformStrategy-2009--2019 Accessed 15.05.14.

Department of Human Services (2008) The gender sensitivity and safety in adult acute inpatient units project: Final report. Melbourne, Victoria: Mental Health and Drugs Division, Victorian Government, Department of Human Services. Available at: http://health.vic.gov.au/mentalhealth/ gender-sensitivity/index.htm Accessed 15.05.14. Gallop R, Engels S, DiNunzio R, Napravnik S (1999) Abused women’s concerns about safety and the therapeutic environment during psychiatric hospitalization. Canadian Journal of Nursing Research, 31(2), 53–70. Gilburt H, Rose D, Slade M (2008) The importance of relationships in mental health care: a qualitative study of service users’ experiences of psychiatric hospital admission in the UK. BMC Health Services Research, 8, 92–103. Hagen B, Nixon G (2011) Spider in a jar: women who have recovered from psychosis and their experience of the mental health care system. Ethical Human Psychology and Psychiatry, 13(1), 47–63.


Hvalsøe B, Josephsson S (2003) Characteristics of meaningful occupations from the perspective of mentally ill people. Scandinavian Journal of Occupational Therapy, 10(2), 61–71. Johansson IM, Skärsäter I, Danielson E (2009) The meaning of care on a locked acute psychiatric ward: patients’ experiences. Nordic Journal of Psychiatry, 63(6), 501–507. Johansson IM, Skärsäter I, Danielson E (2007) Encounters in a locked psychiatric ward environment. Journal of Psychiatric and Mental Health Nursing, 14(4), 366–372. Johansson IM, Skärsäter I, Danielson E (2006) The health-care environment on a locked psychiatric ward: an ethnographic study. International Journal of Mental Health Nursing, 15(4), 242–250. Johnson S, Bingham C, Billings J, Pilling S, Morant N, Bebbington P, McNicholas S, Dalton J (2004) Women’s experiences of admission to a crisis house and to acute hospital wards: a qualitative study. Journal of Mental Health, 13(3), 247–262. Katsakou C, Priebe S (2007) Patients’ experiences of involuntary hospital admission and treatment: a review of qualitative studies. Epidemiologia e Psichiatria Sociale, 16(2), 172–178. Koch T (1995) Interpretive approaches in nursing research: the influence of Husserl and Heidegger. Journal of Advanced Nursing, 21(5), 827–836. Letendre R (1997) The everyday experience of psychiatric hospitalization: the users’ viewpoint. International Journal of Social Psychiatry, 43(4), 285–297. Lilja L, Hellzén O (2008) Former patients’ experience of psychiatric care: a qualitative investigation. International Journal of Mental Health Nursing, 17(4), 279–286. Llewellyn G, Sullivan G, Minichiello V (2003) Sampling in qualitative research. In: Minichiello V, Sullivan G, Greenwood K, Axford R, eds. Handbook of research methods for nursing and health science. 2nd ed. Frenchs Forest, NSW: Prentice Hall Health. 210–241. Lloyd C, Waghorn G, Williams PL (2008) Conceptualising recovery in mental health rehabilitation. British Journal of Occupational Therapy, 71(8), 321–328. Lovell K (1995) User satisfaction with inpatient mental health services. Journal of Psychiatric and Mental Health Nursing, 2(3), 143–150. McCloughen A, Gillies D, O’Brien L (2011) Collaboration between mental health consumers and nurses: shared understandings, dissimilar experiences. International Journal of Mental Health Nursing, 20(1), 47–55.

O’Donovan A, O’Mahony J (2009) Service users’ experiences of a therapeutic group programme in an acute psychiatric inpatient unit. Journal of Psychiatric and Mental Health Nursing, 16(6), 523–530. Parahoo K, McGurn A, McDonnell R (1995) Using research to implement change: the introduction of group activities on a psychiatric unit. Journal of Clinical Nursing, 4(3), 195–202.

Quirk A, Lelliott P (2001) What do we know about life on acute psychiatric wards in the UK? A review of the research evidence. Social Science & Medicine, 53(12), 1565–1574. Quirk A, Lelliott P, Seale C (2006) The permeable institution: an ethnographic study of three acute psychiatric wards in London. Social Science & Medicine, 63(8), 2105–2117. Ramsay R (2005) Women in psychiatry: ten years of a special interest group. Advances in Psychiatric Treatment, 11(6), 383–384. Roe D, Ronen Y (2003) Hospitalization as experienced by the psychiatric patient: a therapeutic jurisprudence perspective. International Journal of Law and Psychiatry, 26(3), 317–332. Sainsbury Centre for Mental Health (1998) Acute problems: a survey of the quality of care in acute psychiatric wards. London, UK: The Sainsbury Centre for Mental Health. Available at: http://www.scmh.org.uk/publications/ acute_problems.aspx?ID=187

Samuelsson M, Wiklander M, Asberg M, Saveman BI (2000) Psychiatric care as seen by the attempted suicide patient. Journal of Advanced Nursing, 32(3), 635–643. Shattell MM, Andes M, Thomas SP (2008) How patients and nurses experience the acute care psychiatric environment. Nursing Inquiry, 15(3), 242–250. Skatvedt A, Schou KC (2010) The potential of the commonplace: a sociological study of emotions, identity and therapeutic change. Scandinavian Journal of Public Health, 38(5 Suppl), 81–87. Stenhouse RC (2011) ‘They all said you could come and speak to us’: patients’ expectations and experiences of help on an acute psychiatric inpatient ward. Journal of Psychiatric & Mental Health Nursing, 18(1), 74–80. Stickley T, Hui A (2012) Arts In-Reach: taking ‘bricks off shoulders’ in adult mental health inpatient care. Journal of Psychiatric & Mental Health Nursing, 19(5), 402–409. Thibeault CA, Trudeau K, d’Entremont M, Brown T (2010) Understanding the milieu experiences of patients on an acute inpatient psychiatric unit. Archives of Psychiatric Nursing, 24(4), 216–226. Thomas SP, Shattell M, Martin T (2002) What’s therapeutic about the therapeutic milieu? Archives of Psychiatric Nursing, 16(3), 99–107. Van Manen M (1990) Researching lived experience: human science for an action sensitive pedagogy. 2nd edition. Albany, NY: State University of New York Press. Victorian Women and Mental Health Network (2009) Increasing safety and gender sensitivity in mixed sex psychiatric units: gathering information about clinical mental health service initiatives. Victoria, Australia:

VWMHN. Yang CT, Narayanasamy A, Chang SL (2012) Transcultural spirituality: the spiritual journey of hospitalized patients with schizophrenia in Taiwan. Journal of Advanced Nursing, 68(2), 358–367.


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