Journal of Advanced Nursing, 1999, 29(1), 64±71 Issues and innovations in nursing practice

Patient initiatives during the assessment

and planning of psychiatric nursing
in a hospital environment
Eila Latvala RN PhD
Lecturer, Department of Nursing Science

Sirpa Janhonen RN PhD

Professor, Department of Nursing Science

and Karl-Erik Wahlberg PhD

Psychologist, Department of Psychiatry,
University of Oulu, Oulu, Finland

Accepted for publication 19 January 1998

LATVALA E., JANHONEN S. & WAHLBERG K.-E. (1999) Journal of Advanced Nursing
29(1), 64±71
Patient initiatives during the assessment and planning of psychiatric nursing
in a hospital environment
The qualitative study reported in this paper aims to describe the planning and
assessment of psychiatric nursing in a hospital environment. The theoretical
framework consists of the three types of psychiatric nursing outlined in a
developmental model of nursing: con®rmatory, educational and catalytic.
Con®rmatory psychiatric nursing is based on a hierarchical and authoritarian
model. Educational psychiatric nursing is based on a professionally driven and
behavioural model. Catalytic psychiatric nursing is systematic, theoretical, and
research-based. Catalytic psychiatric nursing may vary, depending on the
patient's needs, from con®rmatory and educational to situationally determined
nursing. However, it always enables patient initiatives. The purpose of this
paper is to describe patient initiatives during the assessment and planning of
patient care by an interdisciplinary mental health team in a psychiatric hospital
environment, and the assessment and planning as described by nurses working
in a hospital environment. The data, which were collected in two psychiatric
hospitals by videotaping interdisciplinary teamwork situations and recording
interviews of nurses afterwards, consisted of 384 pages of written text. A total of
640 sentences were identi®ed in the text as re¯ecting the assessment of care by
the interdisciplinary team and by the nurses working in the hospital environ-
ment. Deductive content analysis techniques were used to analyse the written
data. The results showed that nursing was described by the nurses to be
catalytic in 13% of the cases, while the same nurses assessed psychiatric
nursing to be most commonly educational (40%) or con®rmatory (47%).

Keywords: psychiatric nursing, interdisciplinary team, patient initiatives

Correspondence: Eila Latvala, Department of Nursing Science,

University of Oulu, Kajaanintie 46 E, 90220 Oulu, Finland.

64 Ó 1999 Blackwell Science Ltd

Issues and innovations in nursing practice
INTRODUCTION
Psychiatric care is often implemented by an interdisci-
plinary team. The essential purpose of teamwork is to
make decisions and clinical judgements in mutual
collaboration while planning and assessing the care of a
psychiatric patient (Paunonen 1991, Janhonen 1993, LuÈt-
zen & Nordin 1993, Hall 1996). The patient and other
relevant persons may often participate in the work of the
interdisciplinary team (Miettinen 1995, Nikkonen 1996,
Haarakangas 1997). However, it is pertinent to ask what
patient initiatives are present in teamwork, since, in
practice, the patient is often a passive recipient in the
team or not present at all. The term `patient initiative', as
used in this study, refers to the signi®cance of the patient's
perspective and the patient's active participation concern-
ing the planning and assessment of his/her care (Janhonen
1993, Latvala & Janhonen 1997).
Interdisciplinary teamwork is a process re¯ecting
professional expertise (Hall & Allan 1994, Bushy 1997).
The degree to which nursing expertise can contribute to
teamwork is dependent on such matters as the team's
working ability and the nurse's knowledge of nursing
(Lorencz 1991, Paunonen 1991, Connelly et al. 1993,
LindstroÈm 1995, Miettinen 1995). However, Finnish
psychiatric nursing studies have shown that nurses and
patients differ in their opinions concerning the patients'
real abilities to participate in and in¯uence the care
provided, and, in practice, the patient and other relevant
persons are often merely passive recipients (Latvala &
Aavarinne 1993, Nikkonen 1996, Latvala & Janhonen
1997). Psychiatric nursing studies have also shown that
nurses make decisions using an authoritarian model or
models they have adopted from other disciplines, though
often in an inadequate and super®cial manner (Paunonen
1991, McKenna 1994, LindstroÈm 1995, Miettinen 1995,
Hall 1996).
On the other hand, there are no studies available which
would show the extent to which patient initiatives are
recognized in interdisciplinary psychiatric teamwork,
although the most important decisions and clinical
judgements have been made while assessing the needs
and planning the objectives of the nursing process in
interdisciplinary teams (Lauri & SalanteraÈ 1995). The
purpose of this paper is to describe the assessment and
planning of psychiatric patient care in interdisciplinary
teamwork in a psychiatric hospital environment and to
produce numerical information of patient initiatives
contributing to the assessment and planning of care.
LITERATURE REVIEW
This paper is based on the theoretical framework of earlier
qualitative studies produced in Finnish hospital environ-
ments, which have revealed three types of psychiatric
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 64±71
Psychiatric nursing
nursing: catalytic, educational and con®rmatory (Janhonen
1993, Latvala & Janhonen 1997). They differ from each other
on the essential dimensions of interaction, instruction,
participation and co-operation. These dimensions have
been described in many psychiatric nursing studies (Peplau
1992, McKenna 1994, LindstroÈm 1995, Hall 1996, Latvala &
Janhonen 1997). In this study, patient initiatives are de®ned
in terms of the catalytic type of psychiatric nursing.
The catalytic type of psychiatric nursing in a hospital
environment is systematic and rooted in an emancipatory
theory of nursing and a theoretical and research-based
practice (Kendall 1992, Peplau 1992, Janhonen 1993,
Butterworth 1995, Hall 1996, Latvala & Janhonen 1997).
Interaction is based on participatory dialogue, which
makes it possible to listen to the patient and understand
the patient's needs concerning his/her management in
daily life (Latvala & Janhonen 1997). The dialogue is
between two or more persons aiming to see and accept
their mutual personal points of view or to ®nd new
solutions through mutual understanding (Anderson &
Goolishian 1988, Markova 1990, Sarja 1995, Haarakangas
1997). Participatory dialogue in an interdisciplinary men-
tal health care team essentially means that no one is in a
privileged position, but everyone is committed to solving
problems by mutual understanding.
In catalytic psychiatric nursing, instruction consists of
motivating consultation, which means that feedback, co-
operation and the working atmosphere are important.
Motivation is a complex phenomenon. There are many
factors, such as emotions, needs and incentives, which
in¯uence people's motivation (Bandura 1986, Kendall
1992, Fleury 1996). Listening to the patient, the nurse's
ability to understand the patient's feelings and the
patient's sensitivity make motivating consultation
possible (Latvala & Janhonen 1997). Participatory dialogue
and motivating consultation enable the patient to be a
responsible participant in his/her own care (Latvala &
Janhonen 1997). Through participatory dialogue, the
patient is able to gain awareness of his/her real patterns.
Co-operation is also the key method of working with all
those who have been victimized in the patient's care
(Latvala & Janhonen 1997). Co-operation with an inter-
disciplinary team is a process of consultation. The nursing
activities should be meaningful for the patient (Kendall
1992, Fleury 1996). (Table 1)
Results similar to the descriptions of catalytic psychi-
atric nursing have been reported in psychiatry. Alanen
et al. (1986) described `need-speci®c treatment' of schizo-
phrenic psychoses and `need-adapted treatment' of new
schizophrenic patients (Alanen et al. 1991, Lehtinen
1994), where the aim is to plan and implement the
therapeutic activities ¯exibly and individually in each
case. Following the principles of `need-adapted treat-
ment', a `shared image' guiding the treatment process has
been described (Aaltonen & RaÈkkoÈlaÈinen 1994). The
65
E. Latvala et al.
Table 1 Different ways of assessing and planning patient initiatives in psychiatric nursing in a hospital environment
Catalytic
psychiatric nursing
Dimensions assessing and planning
Interaction Participatory dialogue
Instruction Motivating consultation
Participation Responsible participant
Co-operation Mutual collaboration
`shared image' is a triadic relationship between the
patient's symptoms, their referents and the staff's
interpretations. The unity of integrated treatment is
created through a process where the needs of the patient
and his/her family and professional recognition of the
therapeutic needs form a circle of gradually deepening
psychological understanding (Aaltonen & RaÈkkoÈlaÈinen
1994). On the other hand, the process of catalytic nursing
can also be compared to the processes described by social
constructivists. The core of the theory of social constructi-
vism (Gergen & College 1985) is that people come to
describe, explain, or otherwise take into account the world
they are living in. In catalytic psychiatric nursing, the
nurse±patient relationship is based on participatory
dialogue, which can also be compared to the principles
of the school of family therapy called `second-order
cybernetics' (von Foerster 1981, Sluzki 1985). According
to this school, the observer's role in constructing the
reality being observed is that the therapist co-operates
with the family and they all endeavour to recognize the
reality resources together.
The educational type of psychiatric nursing is rooted in a
behavioural model and is dependent on professional ex-
pertise. In educational psychiatric nursing, interaction is a
matter of monologue, which means, for instance, that the
nurses in an interdisciplinary mental health team focus on
assessing what is best for the patient, while the patient is a
silent outsider (Latvala & Janhonen 1997). Underlying the
monologue is a normative view of a person's possibilities to
create and change (Schegloff 1989, Markova 1990, Sarja
1995). Monologue does not result in mutual understanding
between persons. In educational psychiatric nursing, the
patient is an object of different kinds of instruction. The
core of instruction consists of normative supervision,
which means nurse-driven programmes assessed by pro-
fessionals and organization of the patient's daily life. The
main goal is to instruct the patient to manage in daily life by
modifying his/her behaviour or lifestyle in accordance with
the professionals' recommendations, in order to maintain
mental health. In educational psychiatric nursing, the
patient is a responsible recipient of his/her own care. The
patient as a responsible recipient follows the professional's
good advice and is a silent participant or not present at all
66 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 64±71
Educational Con®rmatory
psychiatric nursing psychiatric nursing
assessing and planning assessing and planning
Professional's monologue General level discussion
Normative supervision Authoritarian supervision
Responsible recipient Passive recipient
Professional-driven Hierarchical and
co-operation occasional co-operation
during the assessment and planning of his/her care.
Co-operation in the interdisciplinary team consists of
normative consultation, and the essential way of working is
co-operation with professionals (Latvala & Janhonen 1997).
(Table 1) However, this type of psychiatric nursing
approaches the principles of family therapy and the psy-
chiatric school of educational/behavioural family therapy.
According to this school, families should be instructed how
to communicate, express emotions and resolve con¯icts, to
decrease stress in the family (Anderson et al. 1986).
In con®rmatory psychiatric nursing, the nurses work
with a common sense approach, which is rooted in the
traditional model of viewing psychiatric illness as having
a speci®c physical cause related to the functional anatomy
of the brain. The patient has little or no control. In
con®rmatory psychiatric nursing, interaction is formal,
which means that the discussions in the interdisciplinary
mental health care team are hierarchical and the discus-
sion between the nurse and the patient is at a general level
(Latvala & Janhonen 1997). In con®rmatory psychiatric
nursing, instruction consists of routine and formal control.
The psychiatric patient with his/her illness is a hopeless
case, and the professionals' belief in positive change is
therefore minimal. In con®rmatory psychiatric nursing
based on a hierarchical and authoritarian model, the
patient is a passive recipient of care (Latvala & Janhonen
1997). The purpose of con®rmatory psychiatric nursing is
to ensure the best possible medication. The professionals
control the patient's use of medication. The occasional co-
operation is hierarchical and the patient is at the lowest
level of the hierarchy. The patient's activities in view of
his/her care are general and the patient is not aware of the
main goal of this care. The interdisciplinary team meets
only occasionally. (Table 1) However, this type of psychi-
atric nursing is close to the principles of family therapy
and the psychiatric school of ®rst-order cybernetics,
which is based on the assumption that the system
observed can be considered separate from the observer
and the therapist is an authority whose advice the family
has to follow (Minuchin 1985).
According to the theoretical framework, the essential
dimensions of psychiatric nursing assessment and
planning are interaction, instruction, participation and
Issues and innovations in nursing practice
co-operation, which vary from individual human psychi-
atric nursing to authoritarian formal psychiatric nursing,
from dependence to independence, from normative rules to
situational behaviour, from passive reception to active
participation and from hierarchic passiveness to real action
for a positive change. Patient initiatives are connected with
individual human nursing, independence, situational
behaviour and real action towards positive change, which
are enabled by a catalytic type of psychiatric nursing.
The aim of this paper is to describe patient initiatives
using the theoretical framework of different types
of psychiatric nursing (con®rmatory, educational and
catalytic) during the assessment and planning of
psychiatric nursing as observed on videotaped situations
in an interdisciplinary psychiatric team and as described
by psychiatric nurses in interviews.
Questions to be answered
The purpose of psychiatric nursing is to help the patient to
manage in daily life. Psychiatric nurses can help the
patient to manage through true and deep understanding of
the patient's needs for psychiatric nursing. The present
study represents an attempt to answer the following
questions.
1 To what extent were patient initiatives in psychiatric
nursing manifested during the assessment and plan-
ning of patient care in interdisciplinary teamwork in
view of the theoretical framework?
2 To what extent were patient initiatives in psychiatric
nursing assessment and planning manifested in the
nurses' descriptions in view of the theoretical frame-
work?
DATA AND METHOD
The data were collected by theoretical sampling (Glaser
1978, Strauss & Corbin 1990) in the ®rst phase of this
research. They consisted of interviews with nurses,
nursing students and patients (n ˆ 52) and videotapes
of nursing situations (n ˆ 10) (Latvala & Janhonen 1997).
This paper is based on the videotaped situations including
assessment and planning of patient care and all the
interviews with the nurses. The data analysed in this
paper consisted of six videotaped observations and
recorded interviews, including descriptions by 29 nurses
of their own actions in different care situations. The
videotaped observations were collected during nursing
report sessions and planning meetings. Each videotaped
care situation was followed by interviews with the nurses.
Each interview and videotaped session took one to one
and a half hours. Method, time and space triangulation
were used to con®rm the researcher's interpretation and
the subjects' ideas (Lincoln & Cuba 1985, Burnard 1996).
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 64±71
Psychiatric nursing
The transcribed data amounted to 384 pages. They were
analysed by ®rst extracting the sentences which described
psychiatric nursing in a hospital environment (n ˆ 640).
The foundation of the classi®cation consisted of the
theoretical framework. Each sentence was taken to
constitute a classi®cation unit. The nurses' interviews
consisted of 204 sentences which described their
evaluations of the psychiatric patients' needs for nursing
and the objectives of nursing. The videotaped situations
included 436 sentences concerning patient care assess-
ment. Deductive content analysis techniques (Rosengren
1981, Burnard 1996) were then applied to the 640
sentences, employing the classi®cation of con®rmatory,
educational and catalytic psychiatric nursing derived
from earlier research (Janhonen 1993, Latvala & Janhonen
1997). Finally, numerical values and percentages were
calculated for all the categories to illustrate the variety of
assessments of psychiatric nursing.
Credibility and ethical aspects
The data analysis and categorization were all performed
by one investigator, who also calculated the absolute and
relative frequencies. The data were categorized twice at
intervals of 2 months, and the correspondence rate was
98% (627/627 + Ð 13 ˆ 98). Reliability can be assessed
in terms of the auditability of the ®ndings, i.e. by
describing how the data were collected and reduced for
analysis, and how the categories were formed (Lincoln &
Cuba 1985). In this method, a description of a human
experience is regarded as valid or credible when other
people can recognize that experience when confronted by
it after having only read the description (Lincoln & Cuba
1985). The ethical aspects involved informing the subjects
of the research and obtaining their informed consent. They
were allowed to withdraw at any time without penalty.
The bene®ts of the research outweigh the risks, although
the degree to which this is true depends on the
investigator's ability to perform the research (Benoliel
1988, Latvala & Janhonen 1997).
RESULTS
The results are presented numerically and illustrated by
examples of the nurses' descriptions of psychiatric nurs-
ing assessment and planning. Of all the sentences
(n ˆ 640), 13% re¯ected catalytic psychiatric nursing,
40% educational nursing and 47% con®rming nursing
(Table 2). In the videotaped interdisciplinary team situa-
tions, the nursing assessment re¯ected con®rming nursing
in 34% of the cases, educational psychiatric nursing in
27% and catalytic psychiatric nursing in 7%. In the
nurses' descriptions of patients' needs, principles of
catalytic nursing were present in 0á6% of the statements,
educational nursing in 7% and con®rming nursing in 5%
67
E. Latvala et al.

Table 2 Assessment and planning of psychiatric nursing in a hospital environment (N = total number of sentences, n = part of
sentences)

Catalytic Educational Con®rming

psychiatric psychiatric psychiatric
nursing nursing nursing Total

Variables % n % n % n % N

Assessment of 0á6 4 7 47 5 33 13 84
needs for nursing
in nurses' descriptions
Planning objectives 5 32 6 39 8 49 19 120
of nursing in nurses'
descriptions
Assessment and 7 44 27 174 34 218 68 436
planning of care
in videotaped
episodes of
interdisciplinary
team work
Total 13 80 40 260 47 300 100 640

(Table 2). The nurses assessed the objectives of a patient's
nursing as catalytic in 5% of the statements, educational
in 6% and con®rmatory in 8% (Table 2). According to
these ®ndings, catalytic psychiatric nursing enables
patient initiatives.
Patient initiatives in terms of catalytic
psychiatric nursing
In the nurses' descriptions, the percentage of sentences
re¯ecting catalytic nursing was 0á6 and 5%. One example
of a catalytic description is an interview where the nurse
showed all aspects of catalytic assessment: interaction,
instruction, participation, and co-operation. The nurse
assessed her interpersonal relationship with the patient in
the following way:
His inpatient period lasted for 2 months and we have continued
our out-patient collaboration for 2 years. I think that the most
important thing at the beginning of our co-operation was that I
listened to him and our dialogue, where we discussed reality very
openly. By meeting and analysing the painful reality loss and
memories, it was possible to ®nd out the real resources and to
initiate real action for positive change. Now our collaboration is
coming to a close, we will still meet twice. He manages in his
daily life.
The second example describes catalytic psychiatric
nursing in a case where the patient was psychotic and
had great dif®culties in expressing himself because of
hallucinations and in being compliant. The patient had
been mentally ill for years, but he had made no progress.
The main problem was that he wanted to go back home all
the time. However, his parents were dead and his brothers
and sisters had moved out. The nurse described his
catalytic assessment of psychiatric nursing as follows:
We visited the patient's old home, where we discussed his
experiences of becoming mentally ill in the kitchen, in the garden,
in the living room, in the sauna. Three days later the patient said:
`Now I understand that I cannot live here. Everything has changed
since I became mentally ill. I need care in a hospital environ-
ment'. We lived with the patient in his old home for 3 days, and
during that time it was possible for him and us to understand,
experience and examine the changes that had happened after he
had fallen mentally ill.
This example shows how important it is for the nurse to
listen to the patient and, in mutual collaboration, to ®nd
out the experiences that are meaningful for understanding
and recognizing the patient's real resources. The patient
was psychotic and therefore needed very concrete contact
with his real resources. It is important that nurses listen to
the patient's deepest feelings and thoughts and under-
stand his/her essential problems in his/her own context.
Both of the above examples illustrate patient initiatives as
described by a nurse.
Educational psychiatric nursing
In the nurses' descriptions, 7 and 6% of the sentences
re¯ected educational nursing. These sentences illustrated
educational interaction, instruction, participation and co-
operation. One aspect of educational psychiatric nursing
assessment and planning is shown in the following
nurse's description, which shows that the patient was

68 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 64±71

Issues and innovations in nursing practice
not present when decisions were made concerning his
nursing. The co-operation in the interdisciplinary team is
normatively consulting, which means that all decisions
are made or con®rmed by the team. The patient is quiet or
not present in the team. For example, if the patient asks
his/her own nurse: `Can I visit my house next weekend?',
the nurse answers: `I can answer your question tomorrow
because I must discuss it ®rst in our team'. The interaction
is monologue, which makes mutual understanding
impossible:
We have planned in our interdisciplinary team that the best place
for this patient is another unit. We have organized things so that
he can move there. He was very surprised because of the change
when I told him, but he has to get used to moving to that unit.
The second example shows that the nurse assessed the
patient's behaviour in terms of an ideal model. This
example also shows that when monologue and normative
consultation were used, there were no results in this case.
One nurse described her instruction in the following way:
I have instructed the patient time after time for many years to use
the money right, but he has not learnt that. He gets a little money
every week but he spends it immediately. He is a 54-year-old man
and used to live abroad before he become mentally ill.
The nurse taught the patient to use some money every
day during the week, instead of spending it all right away.
The patient needed help with his money problems, but are
monologue and normative consultation always the best
way?
Con®rmatory psychiatric nursing
In the nurses' descriptions, the sentences pertaining to
con®rmatory nursing accounted for 5 and 8%. In
con®rmatory psychiatric nursing, the nurse's approach is
traditional and the view of nursing is that the patient has
little or no control over him/herself. The patient is passive
and not aware of what his/her nursing aims at.
Co-operation is occasional and the purpose is hence
to ensure that the norms and rules are followed. The
following example shows features of authoritarian and
formal con®rmatory psychiatric nursing. The nurse sees
the patient as a hopeless case and the patient's illness as a
stable condition which cannot be helped. One nurse
described her assessment in the following way:
I control the patient's medication, visitors and eating habits. I
think this is best for the patient. Our patients have serious mental
disorders, they have little resources and little hope. They cannot
live without control because they have not got used to that kind of
life.
According to the ®ndings, 13% of all sentences
(n ˆ 640) described the patient's needs for nursing and
only 0á6% of these were assessed as catalytic, while most
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 64±71
Psychiatric nursing
of them re¯ected educational or con®rmatory nursing.
This means that the patient is very seldom an active
participant in assessing and planning his/her care. In the
analysed video situations, 7% of all sentences described
assessment and planning congruent with the principles of
catalytic nursing. Catalytic psychiatric nursing enables
patient initiatives, which place great demands on
participatory dialogue, motivating consultation, mutual
collaboration and responsible participation by the patient
and the nurse. According to these ®ndings, patient initia-
tives are a major challenge for psychiatric nurses and
interdisciplinary teams.
DISCUSSION
The question of patient initiatives in psychiatric nursing
is both timely and interesting. As a consequence of the de-
institutionalization of psychiatric care, patient initiatives
are a challenge for psychiatric nursing, the patient, and all
those who have been victimized in psychiatric care. The
present results provide new information concerning
patient initiatives in a psychiatric hospital environment
and con®rm some earlier observations on psychiatric care
(Alanen et al. 1991, Aaltonen & RaÈkkoÈlaÈinen 1994,
Lehtinen 1994, Butterworth 1995, Hall 1996). The authors
have not tested these results in any other environment
with any other subjects. Videotape recordings provide a
credible method of data collection (Bottorff 1994). The
authors have ensured the credibility of the observations in
this context by using triangulation (Lincoln & Cuba 1985).
These results are reliable in Finnish hospital
environments, but cannot be generalized to any other
environments. The results, however, agree with the earlier
®ndings concerning participatory dialogue (Janhonen
1993, Hartrick et al. 1994, Haarakangas 1997, Bushy
1997) and the earlier observations on psychiatric nursing
concerning patients' participation in psychiatric care
(Connelly et al. 1993, McKenna 1994, Miettinen 1995,
Butterworth 1995, LindstroÈm 1995, Nikkonen 1996).
At each of these three levels of assessing psychiatric
nursing, the de®nition of patients' management varies, as
does the focus of the nursing practice. These ®ndings need
to be further developed and tested with quantitative
methods.
Catalytic psychiatric nursing allows scope for patient
initiatives in psychiatric care. Patient initiatives have been
described in family nursing by Hartrick et al. (1994) as the
`socio-environmental perspective'. Mutual collaboration
in catalytic psychiatric nursing is one of the prerequisites
for patient initiatives, and it can be compared to the
descriptions of Alanen et al. (1991) and Lehtinen (1994)
about patient initiatives using such terms as `¯exibility'
and `individuality' in need-speci®c treatment. Similar
results have also been reported by Aaltonen & RaÈkkoÈlaÈi-
nen (1994), who described patient initiatives as `shared
69
E. Latvala et al.
images' guiding the treatment process. Catalytic
psychiatric nursing is situationally determined nursing,
which is similar to the theory of social constructivism
described by Gergen & College (1985).
The catalytic type of psychiatric nursing varies
according to the patient's needs and the situation from
dependence to independence, from normative rules to
situationally determined behaviour, from assistance to
active participation and from performance to responsible
action (Morrison & Burnard 1989, Janhonen 1993,
Latvala & Janhonen 1997). Catalytic psychiatric nursing
and patient initiatives are challenges for nurses in the
psychiatric hospital environment. Most of the nurses
rely on the doctor's authority and the medical model
and work as con®rmatory supervisors controlling the
patient's coping in daily life, while the patient remains
a passive recipient. Educational psychiatric nursing
assessment and planning are nurse-driven and
professional approaches to the patient's coping in daily
life. Many psychiatric nurses work educationally and
instruct the patient with monologue to manage in daily
life as a responsible recipient.
This paper provided a description of psychiatric
nursing assessment and planning from the viewpoint
of patient initiatives. Catalytic psychiatric nursing
assessment and planning illustrated patient initiatives.
For the purposes of further research, it will be important
from the patients' perspective to describe their experi-
ences and notions of their nursing. The collaboration
between the different professional groups and the
patient's network also require further study. Not all
professional groups and not all patients are ready for
patient initiatives, which imply mutual collaboration
and participatory dialogue, which are not easy methods
for anybody (Hall & Allan 1994, Hall 1996). Patient
initiatives require the nurses to be able to tolerate the
patient's suffering. Some patients expect authoritarian
nursing. It would therefore be important to describe the
process whereby the patient can become aware of
the signi®cance of his/her active participation in his/
her own care. Methods of action research (Holter &
Schwartz-Barcott 1993, Hart & Bond 1996) could be used
to ®nd out how a practical transition to patient initiatives
could be accomplished in a hospital environment.
References
Aaltonen J. & RaÈkkoÈlaÈinen V. (1994) The shared image guiding the
treatment process. A precondition for integration of the treat-
ment of schizophrenia. British Journal of Psychiatry 164 (Suppl.
23), 97±102.
Alanen Y.O., Lehtinen K., RaÈkkoÈlaÈinen V. & Aaltonen J. (1991)
Need-adapted treatment of new schizophrenic patients: expe-
riences and results of the Turku Project. Acta Psychiatrica
Scandinavica 83(5), 363±372.
70 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 64±71
Alanen Y.O., RaÈkkoÈlaÈinen V., Laakso J., Rasimus R. & Kaljonen A.
(1986) Towards need-speci®c treatment of schizophrenic psy-
choses. Monographien aus dem Gesamtgebiete der Psychiatrie.
Psychiatry Series 41, 1±295.
Anderson H. & Goolishian H.A. (1988) Human systems as
linguistic systems: preliminary and evolving ideas about the
implications for clinical theory. Family Process 27 (4), 371±393.
Anderson C.M., Reiss D.J. & Hogarty G.E. (1986) Schizophrenia
and the family. A Practitioner's Guide to Psychoeducation and
Management. The Guilford Press, New York.
Bandura A. (1986) Social Foundations of Thought and Action: A
Social Cognitive Theory. Prentice Hall, Englewood Cliffs, New
Jersey.
Benoliel J.Q. (1988) Considering human rights in research. In
Nursing Research. Theory and Practice (Woods N. & Catanzaro
M. eds), The C.V. Mosby Company, St Louis, pp 79±96.
Bottorff J.L. (1994) Using videotaped recordings in qualitative
research. In Critical Issues in Qualitative Research Methods
(Morse J. M. ed.), Sage, Beverley Hills, California, pp. 244±259.
Burnard P. (1996) Teaching the analysis of textual data: an
experiential approach. Nurse Education Today 16(2), 278±281.
Bushy A. (1997) Empowering initiatives to improve a communi-
ty's health status. Journal of Nursing Care Quality 11(4), 32±42.
Butterworth T. (1995) The current status and future challenges of
psychiatric/mental health nursing. International Journal of
Nursing Studies 32(4), 353±365.
Connelly L.M., Keele B.S., Kleinbeck S.V.M., Schneider J.K. &
Cobb A.K. (1993) A place to be yourself: empowerment from the
client's perspective. Image ± Journal of Nursing Scholarship
25(4), 297±303.
Fleury J. (1996) Wellness motivation theory: an exploration of
theoretical relevance. Nursing Research 45(5), 277±283.
Von Foerster H. (1984) Observing Systems. Intersystems Publica-
tions, Salinas, California.
Gergen K.J. & College S. (1985) The social constructionist move-
ment in modern psychology. American Psychologist 40(3), 266±
275.
Glaser B.G. (1978) Theoretical Sensitivity. Advances in the
Methodology of Grounded Theory. University of California,
San Francisco.
Haarakangas K. (1997) The Voices in Treatment Meeting. A
dialogical analysis of the treatment meeting conversations in
family centred psychiatric treatment process in regard to the
team activity. University of JyvaÈskylaÈ, JyvaÈskylaÈ (Finnish
English summary).
Hall B.A. (1996) The psychiatric model: a critical analysis of its
undermining effects on nursing in chronic mental illness.
Advances in Nursing Science 18(3), 16±26.
Hall A.B. & Allan J.D. (1994) Self in relation: a prolegomenon for
holistic nursing. Nursing Outlook 42(3), 110±116.
Hart E. & Bond M. (1996) Making sense of action research
through the use of a typology. Journal of Advanced Nursing
23(1), 152±159.
Hartrick G., Lindsey A.E. & Hills M. (1994) Family nursing
assessment: meeting the challenge of health promotion. Journal
of Advanced Nursing 20(1), 85±91.
Holter I.M. & Schwartz-Barcott D. (1993) Action research: what is
it? How has it been used and how can it be used in nursing.
Journal of Advanced Nursing 18(2), 298±304.
Issues and innovations in nursing practice
Janhonen S. (1993) Finnish nurse instructors' view of the core of
nursing. International Journal of Nursing Studies 30(2), 157±
169.
Kendall J. (1992) Fighting back: promoting emancipatory nursing
actions. Advances in Nursing Science 15(2), 1±15.
Latvala E. & Aavarinne H. (1993) Opinions of psychiatric patients
on the aim of their treatment. Journal of Nursing Science 5(4),
172±177. (Finnish, English abstract).
Latvala E. & Janhonen S. (1997) Patient's capable of managing in
daily life ± basic process of psychiatric nursing in a hospital
environment. VaÊrd i Norden 17(4), 9±13.
Latvala E., Janhonen S. & Moring J. (1998) Ethical dilemmas in a
psychiatric nursing study. Nursing Ethics 5(1), 27±35.
Lauri S. & SalanteraÈ S. (1995) Decision-making models of Finnish
nurses and public health nurses. Journal of Advanced Nursing
21(3), 520±527.
Lehtinen K. (1994) Need adapted treatment of schizophrenia:
family interventions. British Journal of Psychiatry 164 (Suppl.
23), 89±96.
Lincoln Y.S. & Cuba E.G. (1985) Naturalistic Inquiry. Sage,
Beverley Hills, California.
LindstroÈm U. (1995) The professional paradigm of quali®ed
psychiatric nurses. Journal of Advanced Nursing 22(4), 655±662.
Lorencz B. (1991) Becoming ordinary: leaving the psychiatric
hospital. In The Illness Experiences. Dimensions of Suffering
(Morse J.M. & Johnson J.L. eds), Sage, Newbury Park, California,
pp. 140±200.
LuÈtzen K. & Nordin C. (1993) Structuring moral meaning in
psychiatric nursing practice. Scandinavian Journal of Caring
Science 7(3), 175±180.
Markova I. (1990) Introduction. In The Dynamics of Dialogue
(Markova I. & Foppa K eds), Wheatsheaf, Harvester, pp. 1±22.
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 64±71
Psychiatric nursing
McKenna H. (1994) The essential elements of a practitioners'
nursing model: a survey of psychiatric nurse managers. Journal
of Advanced Nursing 19(5), 870±877.
Miettinen S. (1995) Measuring patient's perceptions of psychiat-
ric nursing actions. Journal of Psychiatric and Mental Health
Nursing 2(5), 317±318.
Minuchin S. (1985) Families and Family Therapy. Tavistock,
London.
Morrison P. & Burnard P. (1989) Students' and trained nurses'
perceptions of their own interpersonal skills: a report and
comparison. Journal of Advanced Nursing 14(4), 321±329.
Nikkonen M. (1996) Life after mental hospital: the way of life of
deinstitutionalized psychiatric patients. Journal of Psychiatric
and Mental Health Nursing 3(6), 373±383.
Paunonen M. (1991) Changes initiated by a nursing supervision
programme: an analysis based on log-linear models. Journal of
Advanced Nursing 16(8), 982±986.
Peplau H. (1992) Interpersonal relations: a theoretical framework
for application in nursing practice. Nursing Science Quarterly
5(1), 13±18.
Rosengren K.E. (1981) Advances in Content Analysis. Sage,
Beverley Hills, California.
Sarja A. (1995) Dialogioppiminen opetuksen ohjaustilanteissa.
Kasvatus 4(26), 311±321.
Schegloff E.A. (1989) Re¯ections on language, development, and
the interactional character of talk-in-interaction. In Interaction
in Human Development (Bornstein M.H. & Bruner J.S. eds),
Lawrence Erlbaum, Hillsdale, pp. 139±153.
Sluzki C.E. (1985) A minimal map of cybernetics. The Family
Therapy Networker May/June, 26±28.
Strauss A. & Corbin J. (1990) Basics of Qualitative Research.
Grounded Theory Procedures and Techniques. Sage, London.
71