Len Bowers (Reference Bowers2012) held that traditional psychiatric intensive care units (PICUs) are under threat due to organisational changes in the health care system. In addition, PICUs are often assessed when exploring cost-cutting measures, since a traditional 10-bed PICU is almost never occupied by ten patients with a need for PICU environment. Whether patients who demonstrate the most severe symptoms are committed to a traditional PICU, a triage ward or an acute ward, they still need professional care and nursing competence. But the following question remains: what kind of nursing care is specifically important in this context?
I want to emphasise the role of nursing during the patient’s most critical phase of mental illness. The most visible aspects of nursing care are that patients need to be monitored, given proper medication, given physical examinations and other practical tasks. This kind of care cannot be overlooked, but stopping here relegates the nurse to being no more than a physician’s assistant. I argue that the debate about nursing care in PICUs, especially in clinical settings, tends to suffer from myopia, as the arguments are mostly about whether the patient is fulfilling the criteria to be a PICU patient or not, or frustration about why patients cannot be transferred back to acute wards when symptoms have ceased. In order to overcome such myopia, I think that it is necessary to take a step back and pose questions about nurses and their autonomous profession in relation to the PICU culture. I think that methods and observations from cultural studies may be used to reassess the nursing profession in PICUs. But first, it’s important to understand how cultural studies and psychiatry are linked.
In the early days of cultural and social anthropology, anthropologists such as Taylor, Malinowski and Mead conducted studies on foreign cultures. However, during the twentieth century, a shift took place in the discipline of anthropology, as researchers become more interested in cultures ‘at home’. In the context of psychiatric care, Erving Goffman became famous from his work on asylums, in which he coined the term total institution. Furthermore, other influential persons who have criticised institutional norms and structures were Michel Foucault, R.D. Laing and Thomas Szasz. Because of their critical approaches, they are often ‘accused’ of belonging to the anti-psychiatry movement. However, it is not my intention to comment on these key figures but rather to put focus on what knowledge and insights can be achieved from cultural studies within the culture of the PICU, and how they can benefit the nursing profession. In order to understand the structure of a culture, I stress that Edgar Schein’s (Reference Schein2010) organisational model is highly useful. Schein presented three levels that refer in the degree to which the different cultural aspects are visible to the observer: (1) artifacts and behaviours; (2) espoused values; and (3) assumptions.
What are the objectives and advantages of applying social anthropology and cultural organisation models to the context of PICUs, and how do these perspectives benefit nursing practice? I argue that many psychiatric nurses in PICUs find their roles vague when it comes to the tenets of caring and nursing. As a clinical supervisor, I have often heard psychiatric nurses say things like, ‘We can’t do anything right now but wait for the medicine to take effect’, or ‘We just have to wait for the patient to settle down’. Likewise, outsiders, such as students, relatives and patients often claim that ‘You don’t do anything – you just sit there’. If this were the case, the PICU would be nothing more than a ‘waiting room’ for the patients to recalibrate themselves in. Furthermore, I argue that such assessments among psychiatric nurses of their own roles degrade them into passive bystanders and result in what I would call ‘clinical pessimism’. So, are nurses superfluous in PICUs? I think not; rather, nurses are the health care personnel who spend the most time together with the patients in everyday care. There might be several aspects involved in why such vague ideas about their roles exist among nurses.
The issue that I want to stress in this letter is that nurses lack a language for which they can argue and claim competence within the conceptualisation of caring and nursing to give autonomy to their profession. In my doctoral dissertation (Salzmann-Erikson, 2013), I made use of ethnographic inquiry to study the PICU culture, and constructed a model of caring and nursing in intensive psychiatry. I argued that PICU culture is to be conceptualised as a culture of stability in which the goals are to prevent, maintain and restore stability when turbulence occurs. Furthermore, I conveyed forms of nursing care that are used in order to achieve stability; these are termed providing surveillance, being present, soothing, trading information, maintaining security and reducing. By conceptualizing the different levels within the PICU culture, I claim that nurses will benefit from these insights in order to better understand the important role they hold as nurses as well as the aesthetics of nursing care. Within the PICU culture, these insights can contribute to transforming the vague and passive self-images of PICU nurses, giving them a more active role in PICUs and promoting the recovery process for the patients. If PICUs should continue to hold the position as a leader in acute psychiatry, we need to look beyond competences that can be quantitatively measured for effectivity and outcomes. Therefore, I argue that developing a PICU cultural-specific language and teaching nurses to become more self-reflective in their roles in the PICU care culture may not only justify the existence of PICU; it may also shift the view of PICU as a whole, from being ‘the punitive ward’ to becoming ‘the elite ward’ where competence flourishes.
