Health promotion in mental health nursing – patients’ dream hospital
This is a scientific research article. It has been reviewed and approved by the editor in chief of the Norwegian Journal of Nursing Research and independent peer reviewers. It has been translated from Norwegian. The original Norwegian version can be accessed by clicking 'Norsk' in the upper right corner.
Background: Mental health promotion is garnering increasing attention and is an important area of knowledge in nursing. In this paper, mental health promotion in a Norwegian context is explored and the future of the nursing profession is discussed. Good mental health is crucial to our well-being and quality of life. The salutogenic theoretical approach to health promotion gives a complementary insight to knowledge about disease prevention based on a pathogenic approach.
Objective: To generate knowledge about the factors that people with mental disorders perceive to have strengthened their mental health during a stay in a mental health unit, and about the health promotion improvements they can envisage in the hospital of the future.
Method: The study employed an interpretative phenomenological analysis (IPA) research approach. Data was collected from in-depth interviews with 12 purposively selected, previously hospitalised mental health patients with severe mental disorders. The interviews were transcribed and analysed individually before all text was analysed collectively.
Results: The patients described the dream hospital as a living space with a predictable daily structure and clear organisation, where a broad spectrum of individually tailored care and treatment is provided, and where healthcare personnel enter into health-promoting relationships with the patients.
Conclusion: Patients described health promotion factors during stays in a mental health unit that are relevant to the responsibility for nursing. They found that receiving help with basic human needs, such as sleep and food, through a clear daily structure and individually tailored care, helps to promote their mental health. Health is created in the relationships with healthcare personnel. Nursing care in mental health care is crucial to the patients’ recovery process and is a source of better health and well-being. Nursing care for people with mental disorders should be revitalised because patients need this and find that it promotes their mental health.
Mental illness and mental health are not two sides of the same coin: they are two separate phenomena, but can impact on each other. We may suffer from a mental disorder to varying degrees or be without any illness. In contrast, mental health is an ever-present phenomenon, something that human beings have all the time, but the quality can be perceived in different ways.
In order to develop interventions that promote health and prevent illness, we need knowledge from several perspectives. When the goal is to strengthen health, we need knowledge of what serves to promote health. In the Norwegian strategy for coping with life (Mestre hele livet), good mental health is regarded as a resource for well-being and quality of life (1).
Health promotion aimed at strengthening mental health has become more prominent in international and national recommendations in recent years (2, 3). A reorientation of the health service towards more health promotion and prevention was confirmed in the Ottawa Charter as far back as 1986 (4) and was a reaction to the contemporary focus on disease and curative activities. The need for health promotion was again emphasised in the Shanghai Declaration (5).
Definition of mental health care and health
Mental health care is defined as the specialist health service’s assessment and treatment of people with mental disorders, and the associated nursing care (6). Registered nurses (RNs) have competence in the compensatory measures that can be used when mental disorders impact on self-care skills in everyday life, and in coping with life with a somatic disease or mental disorder.
RNs have knowledge of physical needs when the effects of an illness or disorder are felt. They are also well versed in basic needs, health and normal development in a life cycle perspective.
The view of health has changed since Florence Nightingale (1820–1910) believed that good health was not only about feeling well but also involved making good use of our resources (7). In 1946, the World Health Organization defined health as ‘a state of complete physical, mental and social well-being’ (8).
A Danish study from 2017 stressed that ‘mental health is what makes life worth living’ (9). In other words, mental health is not understood as the absence of illness or a mental disorder, which means that people with severe mental disorders may feel that they have good mental health.
What is salutogenesis?
Salutogenesis is an approach that focuses on the study of the origins of health (10); salus means health and genesis means origin. In order to provide comprehensive nursing care for patients with mental disorders, we need knowledge about both health and illness. A salutogenic understanding of health represents a strengths-based and resource-oriented approach.
Salutogenesis can complement pathogenic knowledge on illness. Antonovsky posed the salutogenic question ‘What creates health?’ His answer was the salutogenic health model, in which health is described as a movement, a continuum (11). Salutogenesis has been introduced as a theoretical framework for health promotion research and practice (12).
Keyes (13) has developed a mental health model based on a salutogenic orientation, in which mental health is defined as the presence of different levels of psychological, social and emotional well-being. There is a fundamental difference between mental illness and mental health (14). Mental illness is something we want to avoid and prevent, while good mental health is something we strive for and want more of.
In a study of how people with severe mental disorders experienced mental health, Mjøsund et al. (15) found that mental health was perceived as something that was always present, a dynamic aspect of life, like going up and down a spiral staircase, influenced by bodily experiences, emotions, relationships and engagement. Applying a salutogenic approach is relevant to the nursing profession (16) and generates important knowledge in the work with the mentally ill (17).
From psychiatry to mental health care
The Norwegian specialist health service has evolved from a psychiatric service into a mental healthcare service, from a biomedical approach to a more holistic orientation, where multiple perspectives are taken into account in the treatment. The psychiatric nursing profession has also undergone changes, and in line with this development is now referred to as specialist mental health and substance abuse nursing.
Discussions are needed on how to adapt the profession in line with the times. In clinical practice, RNs are responsible for exercising comprehensive care, which includes physical, social, spiritual and mental approaches. A specific, defined perspective can be applied in order to shed light on the theoretical framework for the different elements of the comprehensive care.
This article looks at mental health, but in the lived life, mental health is of course intertwined with other factors, including physical health.
A recovery-oriented health service focuses on coping with the ongoing challenges that arise as a result of being mentally ill as opposed to the disorder itself (18). In addition to treatment and symptom reduction, people with mental disorders need interventions to strengthen their mental health (19).
There are few studies into what mental health patients think promotes health, but Mjøsund et al. (20) showed how people with mental disorders found that the health promotion process was enabled through learning about their mental disorder and health. They were keen to acquire knowledge about the disorder, but also about what could improve their health and well-being (20).
Objective of the study
The objective of the study was to generate knowledge about the factors that people with mental disorders perceive to have strengthened their mental health during a stay in a mental health unit, and about potential health promotion improvements in the hospitals of the future – their dream hospital.
The qualitative methodology of interpretative phenomenological analysis (IPA) (21) was used to explore participants’ lived experiences. IPA combines a phenomenological, hermeneutic and ideographic approach with a special emphasis on meaning-making – the meaning that each person gives to their experiences.
IPA entails a double hermeneutic since the researcher’s understanding of the meaning that participants give to their experiences is the final result of the analysis.
Five research advisors with personal experience of the specialist health service were involved throughout the research process (22). This collaboration enhanced the research quality (23).
Recruitment and sample
Twelve former patients were purposively selected by RNs at four mental health units. The participants had been inpatients for at least 14 days in the past two years and, by their own account, the health service had helped during the recovery process.
The sample consisted of seven women and five men, aged 23 to 80, who had been living with severe mental disorders: two had psychosis disorders, five had bipolar disorders, two had severe depression, and three had a dual diagnosis of suffering from a mental disorder and a substance abuse problem (3).
The case histories spanned from 1 to 24 years. In total, there had been 100 admissions, both in open and closed wards. The number of admissions per person varied from one to more than 50.
Semi-structured interviews (50–120 minutes) were conducted, which were subsequently transcribed. An interview schedule based on a salutogenic orientation was used, where the opening question was as follows: ‘Could you please tell me about something that promoted your mental health during your stay at the mental health unit?’
In particular, participants’ experiences of what was good, useful and important were sought. In addition, creative thinking was encouraged as a way of generating ideas for improvement based on unconditional questions.
The data was analysed using IPA (21), and this process started during the interviews and proceeded to listening to the audio recordings repeatedly and then reading through the transcripts. Each interview was analysed before the next interview was held. Consequently, each narrative was given an individual focus.
A cross-sectional analysis was then conducted, where quotes from all the interviews were collected under tentative themes. A new review focusing on patterns, similarities, nuances and variations, correlations and contrasts resulted in three themes. A mind map and NVivo 10 were used to facilitate the analytical process.
The study was approved by the Regional Committees for Medical and Health Research Ethics (REC) (reference number 2012/566/REK) and carried out in accordance with legislation and guidelines (24).
Experiences from people with severe mental disorders are rich sources of knowledge about health promotion in inpatient care.
According to the former patients, the dream hospital is a building with a roof and walls, understood as a physical framework, with a structure in which a broad spectrum of tailored nursing and treatment is provided by healthcare personnel who enter into health-promoting relationships with the patients.
Framework and structure prepare the ground for recovery and health promotion
Inpatient stays entail being in and living in a building, a hospital ward or a district psychiatric centre (DPC). Participants emphasised the importance of a physical framework and routines for daily activities.
A meetings structure and a mealtime routine are standard in such units, but participants stressed how important these were to their experience of health promotion. Several participants shared the following view:
‘Routines are crucial for me sticking to a fixed weekly schedule, so that it happens, at ten there’s a group session, regardless. That’s one of the reasons I get admitted – to have a fixed routine, because it’s often the case that I veer off course and sleep for a long time, and sleep late and skip meals, don’t eat healthily. So, getting back to my normal daily rhythm – mainly sleep, daily medication or medication at a set time, and food, that’s what’s most important when I’m admitted.’
That’s one of the reasons I get admitted – to have a fixed routine.Study participant
Participants described how the maintenance and aesthetic standards in the units affected them. Signs of disrepair and the design of their surroundings have quite an impact, as reflected in the following quotes:
‘We could have done with some renovation work, because it’s so dilapidated. It’s not very nice. It actually affects me a lot. Being in a place that’s so ugly and dismal. So, the staff can be as nice as they want, but when the place looks this bad, it’s really demotivating.’
‘But the dismal state is allowed, which in a way helps to confirm, yes, it confirms your illness in a way maybe, and that’s how much I’m valued in my illness, and it’s not that important how it looks there.’
A broad spectrum of tailored care and treatment promotes health
At the dream hospital, the patients are treated as unique individuals, and the care is individually tailored. This requires medical knowledge of the disorders and how it is to live with a mental disorder, as well as knowledge of treatment alternatives, and the efficacy and adverse effects of medication. One patient felt strongly about the importance of an evidence-based understanding of the symptoms she was experiencing:
‘So that was the start of getting help, to make it a habit sort of, a structure in life, it’s been really important for my recovery. It’s a bit like jump leads [laughs]. Yeah, just to get you started again, just a wee bit of help with the simplest little things can be what you need to take that first step on your own, you know? Many people don’t understand it at all, why getting going can be so hard. So, it’s really nice when you come to a place where they understand.’
Participants perceived nursing and treatment of a more holistic and comprehensive nature to be more conducive to health promotion. Several expressed their frustration with what they perceived to be the excessive focus on medication:
‘In my ideal hospital, there is less use of medication and a wider range of treatment options. Because if you start on medication and keep taking it for a few years, and the older you get – you have to think more about the long-term effect of the medication instead of just thinking about ending the depression in the short term. So, it actually annoys me every time they want to put me on new medication because I’m depressed. No, I’d rather work my way through it and look at what has actually made me depressed. And I’d rather be admitted three times more than have to put up with all the medication.’
‘A broad spectrum of treatment. Treat everything, not just the bipolar label itself. For me, through the years – they have pushed one medication after the other. I’ve probably tried 14–15 different antidepressants and mood stabilisers. When I came to my therapist, all they wanted to talk about was medication. So, when I got to stay here, being admitted, how much it helped with everything. You get a roof over your head, food and sleep, medicine, you get yourself sorted – and learn about thoughts and feelings, and get therapy for everything. It’s been worth its weight in gold to me.’
One participant pinpointed the need for a more gender-differentiated approach to treatment:
‘The activities are almost invariably aimed at women, and that really annoyed me. And I withdrew from various things, and it wasn’t because I felt that I wouldn’t benefit from them, because sitting painting could probably have triggered things in me. But I missed an environment where men could be men.’
The health-promoting power of relationships
All participants emphasised the importance of having good relationships with healthcare personnel during their stay in the mental health unit. One commented as follows:
‘My primary nurse was the most important part of my stay. She became like a kind of reference point. I knew I could go to her. I knew she understood me, in a way. She was the most important part of my stay, she really was. I feel like she saved my life actually. So, if you’re asking about the primary nurse, it’s essential, I think. Having that one person you know, who is mine, and who has heard and knows my story in a bit more detail.’
The relationships were anchored in an experience of being seen and acknowledged as a person over time, by someone with a dedicated responsibility. In the conceptualisation of a dream hospital, continuity in relationships was highlighted as crucial to getting good help, as described by one participant:
‘If you need to be admitted to an institution, and if you have a therapist at an outpatient clinic, then he can come in and see you while you’re in the mental health unit, and continue afterwards. That way we would’ve avoided all the disruptions to my therapy. That’s one thing that might be ideal.’
One participant felt that the relationships and interaction with the ward staff helped his recovery and had a positive effect on him:
‘If you multiply the 24 hours in a day by 7, you get about 170 hours. So, you have a conversation with a therapist – which I was very happy with and which meant a lot to me. Two hours! But the other 168 hours [with the ward staff] – there’s no doubt in my mind where my recovery took place! The psychologist was the icing on the cake, and we had some fantastic conversations. But those around you are just as important, and the ones you interact with throughout the day.’
The findings might not be considered surprising, but they are nevertheless important. Patients in a mental health unit point out factors that can alleviate their symptoms and aid recovery, as well as improve their health and well-being – i.e. less emphasis on the negative, such as mental illness, and more on the positive, like health.
This knowledge is relevant for mental health nurses because it is part of basic nursing. According to the participants, some elements of the current health services would be included in the dream hospital.
However, has the importance of nursing care for the most ill patients diminished? Do we need to revitalise the importance of nursing in mental health units? If so, the patients themselves are good allies.
According to the participants, some elements of the current health services would be included in the dream hospital.
According to the requirements of the Mental Health Care Act, the RNs must, on the patients’ behalf, clearly describe what expert and necessary care entails (6). The arguments for care practice are anchored in the patients’ needs, as confirmed by the participants in this study.
The milieu therapy framework seemed to promote the health of the participants. Interaction principles and the atmosphere that characterises internal processes have evolved over time. Milieu therapy, encompassing all aspects of the physical and social environment, has the potential to affect a therapeutic change (25).
RNs must cover the patient’s basic needs
Since the days of Florence Nightingale, nurses have been concerned with eliminating or alleviating the patient’s suffering and safeguarding an environment that facilitates the healing process (7).
In the period leading up to admission, patients with mental disorders may notice a deterioration in their diet, changes in activity patterns and a breakdown in routines. They may also find that they are awake at night and sleeping during the day. In such cases, they should be treated by qualified RNs who focus on sleep, rest and activity, food and nutrition, personal hygiene and care, as well as human companionship.
The RN’s core competence deals with basic needs, knowledge of health and illness, as well as coping with illness and suffering in daily life. It is vital that people’s basic needs are met – they are cyclical and need to be satisfied every day. Meeting needs is an ongoing process.
According to Fause (26), the focus on basic nursing combined with knowledge of mental disorders has been reduced in mental health specialist education programmes. This is reflected in a national debate about what nursing is and what strategies should be employed to develop the nursing profession in the future (27).
In order to comply with the mental health care regulations (28), institutions must provide the medical, psychological or nursing competence that is needed for a good standard of medical treatment, psychotherapy and observation.
In my understanding of the mental health care regulations, the nursing competence is reduced here to serving in a supportive role in medical treatment, psychotherapy and observation. This is a serious devaluation of precisely what the participants in this study describe as health-promoting care.
Competent RNs are important for life and health
Based on patients’ needs, I must argue that nursing performed by competent and knowledgeable nurses is important for survival and health. The main reason for people with mental disorders being admitted to a mental health unit is their need for nursing care and to be looked after. Otherwise, they would have been treated at an outpatient clinic.
Elstad claims that ‘Basic nursing concerns life and death’ (27). When symptoms and deterioration occur, the person is unable to meet the basic needs that are required to maintain good health and well-being. Over time, failure to attend to these basic needs will be deadly.’
The participants in this study found that regular sleep, food and taking their medication at the right time were the most important factors during their stay in a mental health unit, i.e. clear nursing responsibilities. Neglecting these needs, which are a nursing responsibility, can be viewed as quality impairment and can result in a failure of care.
Stronger focus on health promotion needed
RNs have knowledge of both health promotion and illness prevention, but the current focus in the structure, organisation and reporting in mental health care is on risk, symptoms and treatment.
The current biomedical approach that is applied is perhaps at the expense of actions aimed at improving health and well-being through tailored, competent care and nursing.
Health promotion is important for everyone, but groups with long-term physical or mental disabilities and/or symptoms in particular may benefit more from health-promoting interventions.
Knowledge on health promotion therefore needs a boost in order to help patients cope with challenges, and promote experiences of meaning and joy, as well as giving them faith in their own resources (29).
Patient’s environment is also a crucial factor
The findings of the study suggest a need for more active knowledge development in nursing and health promotion based on salutogenesis. In theory, health promotion can be divided into mental, social and physical health promotion.
In the lived life and clinical nursing practice, this division is blurred, but theoretically, developing specific knowledge can lead to new concepts and targeted, defined interventions. It is the health-promoting care that patients seek and describe as important for their recovery and well-being.
Several of the participants highlighted how important aesthetic factors were to their health and well-being.
Nursing entails the safeguarding of bodily functions, but it is also important to contribute to welfare and well-being. Several of the participants highlighted how important aesthetic factors were to their health and well-being.
In the spirit of Florence Nightingale, RNs can take responsibility for facilitating the patient’s well-being, by paying attention to the physical factors surrounding patients: light, fresh air and a pleasant environment.
Denmark takes a salutogenic approach
The Act-Belong-Commit (ABC) framework for mental health based on a salutogenic approach has been introduced in Denmark to improve the mental health of the population (30). The Norwegian Network for Health Promoting Hospitals and Health Services is calling for Norway to adopt this research-based strategy to promote mental health.
ABC is intuitive and simple: activity, community and engagement. The principles of ABC can guide nursing actions both at the individual level, such as when the patient is acutely ill, and serve as a framework for public health interventions.
Being able to explore interests and engagement with the patient, and then arrange an activity together, builds on the ABC principles and promotes mental health and well-being.
The seriously depressed, psychotic elderly lady, with a keen interest in Sigrid Undset’s works, brightens up when the nurse reads aloud from the book Kransen that she had promised to bring.
This example may seem trite, but I think the description of the situation illustrates the strong element of recognition and acknowledgement that impacts on our mental health. Undertaking a positive action (Act) together (Belong) as agreed (Commit) promotes mental health.
Relationships must be built on trust and closeness
The relationships between patients and healthcare personnel are the mainstay of the health service. Health is created through interpersonal encounters. Effective relationships are built on trust and closeness over time.
Health is created through interpersonal encounters.
Patients value care that involves generosity and love, and feel appreciative when nurses think well of them and want them to be healthy. RNs with a 24/7 presence, in all parts of the health service, are in a unique position to enter into health-promoting relationships in the dream hospital of the future.
Weaknesses of the study
One weakness of the study on mental health promotion for people with severe mental disorders is that it does not address the need to safeguard physical health.
People with mental disorders may have a reduced life expectancy of 15 to 25 years and have many physical ailments and weaknesses that need to be addressed in clinical practice and in future research. Coordinated and structured comprehensive measures, with RNs as an important resource, should be put in place.
Mental health care is characterised by interdisciplinary practices, a fact that has not been discussed, in that the findings are understood from a nursing perspective.
Participants in the study recognise the importance of admission to a health institution. They feel that health promotion is served by basic human needs being met in a clear daily structure with individually tailored care. It is in the relationships with healthcare personnel that health is created.
RNs’ 24-hour continuous presence puts them in a unique position to be able to enter into health-promoting relationships through exercising nursing care. Research and theory development covering both the salutogenic and pathogenic approach will help the nursing profession to develop comprehensive nursing practices.
Nursing care for people with mental disorders should be revitalised because patients need this and find that it promotes their mental health.
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