The tension between recovery and risk management, often in the form of coercion, is a pertinent topic in the world of psychiatry. Where: “recovery is built on the principle that mental health care may enrich a meaningful life despite experiencing mental illness” (Anthony, 1993). Risk management may impinge on an individual’s sense of autonomy, consequently obstructing meaning-making practices and said recovery.

Increasingly, scholars and practitioners are looking to the role of recovery principles in facilitating effective risk management (Perkins and Repper, 2016). This topic was also explored last year by Kirsten Lawson’s blog, summarising Nikopaschos et al’s (2023) retrospective service evaluation, showcasing the benefit of patient-centred risk management through trauma-informed practices.

While this topic is certainly picking up traction, there is still a glaring lack of patient voices, which is somewhat ironic considering the ‘patient-centred’ approach these scholars are calling for. Deering et al’s study, which will be summarised in the following, poses an important shift in conversation by exploring patient perspectives to better understand the role of patient involvement in risk management and recovery.

In this way, the study underscores a recovery-oriented approach, which the authors describe as one which:

acknowledges that mental distress interrupts the person’s life, but is not defined by it. To meaningfully address this disruption, it is important to involve patients, so they feel that they have a voice.

Methods

A key objective of this paper was theory development, as the patient experiences of risk management in psychiatric hospitals remain significantly understudied, highlighting the need for a deeper understanding in this critical area of healthcare. Constructivist Grounded Theory (CGT) was thus selected with the aim of capturing the multiplicity of social processes within social situations (Charmaz 2020) and of developing a theoretical framework around it.

This consisted of an iterative process, whereby analysis and data collection occurred simultaneously, informing subsequent interview questions. Through ongoing theoretical coding, the researchers identified a core category, which the final two participants were asked about in order to develop a better understanding of the validity of the evolving theory.

The authors conducted interviews with 15 participants in total, at which point they felt that theoretical sufficiency had been achieved. Two sampling methods were used to recruit participants at different stages of recovery and time since discharge, acknowledging the long-term nature of recovery.

Authors received ethical approval from the UK Health Research Authority.

Results

Recordings were analysed and generated four key themes, associated with the core category of ontological insecurity. This concept was adopted from Padget (2007) and refers to:

a state of deep uncertainty and anxiety about ones place and significance in the world and may negatively impact on recovery.

Based on their data, Deering et al subsequently, theorised ontological insecurity of inattentiveness, to describe the particular type of ontological insecurity which stems from “inattentiveness to patient needs surrounding sense making, needed for recovery”.

Sense-making was disrupted in several ways – all related to the staff’s inattentiveness – contributing to an insecurity in the self:

• The lack of staff involvement in engaging patients in risk management and clarifying its purpose created uncertainty and insecurity about what was happening to patients during their hospital stay.
• Such inattentiveness also led to participants experiencing disruptions to their social roles and daily life as well as a general sense of powerlessness with regards to their recovery.

Subcategory 1: Diverging the inside and outside world

Participants described how the risk management techniques used inside the hospital diverged from those that would be typically used outside. Crucially, conversations around meaning-making, such as the role of spirituality were not part of the practice. Common methods included distraction to manage intrusive thoughts around self-harm, without prior discussion with the patient about their needs and preferences, often effecting a sense of ontological insecurity.

I think if you believe someone to be suicidal, if aware they were having intrusive thoughts, basic things like a talk would be better [than distraction]. (P10)

Subcategory 2: Ambiguity about the rules

The lack of discussion around rules resulted in a sense of ambiguity as to how and why certain risk management practices were being implemented. Some patients attempted to circumvent resultant mistrust in staff and their intentions by acting overly compliant with the expectation that trust would build reciprocally. This imbalance in trust, caused by rule ambiguity, impeded sense-making, materialising in ontological insecurity.

I obeyed every single command, I tried to earn their trust, but they were not trusting me. (P1)

Subcategory 3: Foreboding atmosphere

Participants discussed the lack of communication with staff members around potential harm, perpetuating a sense of foreboding and unease about personal safety. Risk management appeared reactive rather than being founded on dialogue about the nature of adverse events and how to prevent them in the long term. Some participants discussed the default use of medication over conversation to manage harmful situations. The dissonance between the staff approach and what the patients deemed personally helpful often led to an insecurity in the self.

Alienated by the atmosphere […] feelings occurring ‘oh I don’t want to be here’ or, ‘I don’t know if this is good for me, or I am scared. (P13)

Subcategory 4: Management from afar

Observation rather than interaction seemed to underpin risk management, indicating staff mistrust in patients. The lack of explanation around the purpose of observation left patients unsure about the nature of their behaviours, perpetuating ontological insecurity.

Judgement without asking, made [me] feel more abnormal being watched. (P10)

Conclusions

The authors concluded:

The study provided insights into the destabilizing nature of risk management, given a lack of patient understanding and participation in its practices when admitted to hospital. Through ontological insecurity, this can impact sense-making around a meaningfulness to care that aids recovery.

Strengths and limitations

These results are supported by a number of previous studies, suggesting validity of the conclusions. In particular, several researchers have evidenced the possible disruption of daily meaning-making that occurs when patients are admitted to hospital (Molin et al, 2016). Deering et al’s study derives its main strength from providing a theory of ‘ontological insecurity of inattentiveness’ to explain the particular impact of such meaning-making disruptions on patients. The patient-centred perspective ensures that the research is grounded in the lived experiences of those directly impacted, offering more nuanced insights into how risk management practices influence the recovery process. Further to this, an element of co-production was integrated into the study, as the final two participants were consulted on the core category, allowing their insights to enhance both the accuracy and the impact of the analysis. This was especially important given the study’s aim of foregrounding patient experience and perspective.

The study is methodologically sound and demonstrates a high level of transparency in its analytical process. Constructivist Grounded Theory (CGT) was appropriately chosen for this research, as its abductive approach is well-suited for developing theory in under-researched areas, such as the perspectives explored here. The researchers used memo writing to reflect on their application of theoretical coding, ensuring that the analysis followed the focused codes, rather than forcing the data to fit preconceived notions (Giles et al., 2013).

Despite these strengths, transparency in the sampling process and in building trust—especially through discussions of the researcher’s role—was somewhat limited. Reflexivity is evident in the researcher’s acknowledgement of limitations, particularly regarding the sample’s lack of diversity, which affects the generalisability of the findings. However, the discussion of positionality was absent, leading to a rather broad consideration of researcher bias.

Another key strength of this study lies in its adoption of a discursive approach. Despite the relatively small sample size, this methodology facilitates the collection of rich, in-depth data, allowing for the exploration of multiple layers of meaning and affording significant attention to voices that are often marginalized. In doing so, the study provides a robust methodological foundation for future research, particularly in extending this approach to include other key stakeholders in inpatient settings, such as nursing staff. However, the heterogeneity of voices and the diverse processes of meaning-making simultaneously pose both a limitation and an opportunity for further inquiry. The authors’ reflexive acknowledgment of this challenge underscores the complexity of capturing varied perspectives, thereby signalling the need for broader, more comprehensive research to fully engage with this diversity.

Implications for practice

This study has clear clinical relevance as it platforms patient perspectives, deriving useful mechanisms for fostering an inpatient environment wherein trust in the self is cultivated. These mechanisms are all seen to hinge on ‘attentiveness’ and on involving patients in the meaningfulness of risk management in an effort to mitigate ontological insecurity.

The authors comment on the transference of “apparent rigour applied to mitigating risk” to “identifying opportunities to engage”. Cultivating an awareness of patient openness to dialogue with their practitioners could provide promising avenues for cooperation and recovery.

More specifically, the research reveals that these opportunities can often occur very early on in the patient’s hospital admission, as patients of varying degrees of illness acuity, reported similar experiences.

Participants discussed the role of nurses in these conversations, to take a clear and personalised approach and pay attention to what is meaningful to the particular individual. This promotion of patient participation in their care may allow for more cooperative relationships between the patient and their nurse, facilitating other aspects of the treatment and recovery pathway.

In line with other studies on care planning (Newman et al 2015; Waldemar et al 2016), Deering at al’s research could also support the re-configuration of the pharmacological focus in hospitals by involving patients in meaningful discussion around their implementation. As such, the default expectation of patient compliance could be slightly de-centred, allowing for greater security in the self.

It is important to note, however, as the authors rightly do, that risk management is notoriously complex (Boland & Bremner 2013). While reforming nursing practices in inpatient settings is crucial to aiding recovery, there exists an inevitable tension between the restriction of harmful behaviours and the incorporation of patients into their care.

An essential clinical implication of this study is the reinforcement of previous calls to recognize the significance of staff support. This involves supporting a shift in hospital culture, moving away from a blame culture—which often deters staff from involving patients in risk management due to fear of adverse events—toward a collaborative environment adapted to meaningful conversations.

Links

Primary paper

Deering, Kris, Chris Wagstaff, Jo Williams, Ivor Bermingham, and Chris Pawson. 2023. ‘Ontological Insecurity of Inattentiveness Conceptualizing How Risk Management Impact on Patient Recovery When Admitted to an Acute Psychiatric Hospital.’ International Journal of Mental Health Nursing Early View: 1–11. https://doi.org/10.1111/inm.13245

Other references

Anthony, W.A. (1993) Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16, 11–23. https://doi.org/10.1037/h0095655

Boland, B. & Bremner, S. (2013) Squaring the circle: developing clinical risk management strategies in mental healthcare organisations. Advances in Psychiatric Treatment, 19, 153–159. https://doi.org/10.1192/apt.bp.111.010009

Charmaz, K. (2020) With constructivist grounded theory you Can’t Hide: social justice research and critical inquiry in the public sphere. Qualitative Inquiry, 26, 165–176. https://doi.org/10.1177/1077800419879081

Giles, T., King, L. & De Lacey, S. (2013) The timing of the literature review in grounded theory research: an open mind versus an empty head. Advances in Nursing Science, 36, E29–E40.        10.1097/ANS.0b013e3182902035     

Molin, J., Graneheim, U.H. & Lindgren, B.M. (2016) Quality of interactions influences everyday life in psychiatric inpatient care—patients’ perspectives. International Journal of Qualitative Studies on Health and Well-Being, 11, 1–11. https://pubmed.ncbi.nlm.nih.gov/26806313/

Newman, D., O’Reilly, P., Lee, S.H., & Kennedy, C. (2015) Mental health service users’ experiences of mental health care: an integrative literature review. Journal of psychiatric and mental health nursing, 22, 171–182. https://doi.org/10.1111/jpm.12202

Padgett, D.K. (2007) There’s no place like (a) home: ontological security among persons with serious mental illness in the United States. Social Science & Medicine, 64, 1925–1936. https://psycnet.apa.org/doi/10.1016/j.socscimed.2007.02.011

Perkins, R. & Repper, J. (2016) Recovery versus risk? From managing risk to the co-production of safety and opportunity. Mental Health and Social Inclusion, 20, 101–109. https://doi.org/10.1108/MHSI-08-2015-0029

Photo credits

• Photo 1 Aldin Nasrun on Unsplash
• Photo 2 Markus Spiske on Unsplash
• Photo 3 Leiada Krozjhen on Unsplash
• Photo 4 Maik Jonietz on Unsplash