The bulldozer and the ballet dancer: aspects of nurses' caring approaches in acute psychiatric intensive care

Abstract

Demanding conditions in acute psychiatric wards inhibit provision of safe, therapeutic care and leave nurses torn between humanistic ideals and the harsh reality of their daily work. The aim of this study was to describe nurses' caring approaches within this context. Data were collected from interviews with nurses working in acute psychiatric intensive care. Data were analysed using qualitative analysis, based on interpretive description. Results revealed a caring-approach continuum on which two approaches formed the main themes: the bulldozer and the ballet dancer. The bulldozer approach functioned as a shield of power that protected the ward from chaos. The ballet dancer approach functioned as a means of initiating relationships with patients. When examining the data from a theoretical perspective of caring and uncaring encounters in nursing, the ballet dancer approach was consistent with a caring approach, while the bulldozer approach was more complex and somewhat aligned with uncaring approaches. Conclusions drawn from the study are that although the bulldozer approach involves a risk for uncaring and harming actions, it also brings a potential for caring. This potential needs to be further explored and nurses should be encouraged to reflect on how they integrate paternalistic nursing styles with person-centred care.

Person‐centred care: clarifying the concept in the context of inpatient psychiatry

“…In the analysed papers, the consequences of person-centred care are commonly discussed as positive and desirable outcomes that contribute to the improvement of care. Authors make references to person-centred care resulting in better care in terms of quality (10,15,29,34,39) and a change of culture (9,12,25) and environment (21). Authors discuss person-centred care in relation to a reduction of coercion (9,16,17,35), the prevention of harmful actions by caregivers (11,19,25), increased safety (10,15) and effectiveness (10,15,16,22,40).…”

“…Authors consider the competence of caregivers to be important for person-centred care, discussing the significance of leadership (10,17,23), adequate staffing (11,24), knowledge (15,19,(26)(27)(28)(29) and values (10,21). Authors discuss caregivers as using adapted forms of communication (25) and being culturally sensitive and competent (14,29,30).…”

“…Relationships are discussed as mutual (15,18) and characterised by knowing and trust (34), engagement (20), closeness (27) and honesty (15,18). Caregivers are discussed as self-aware as they understand and respect patients (15), being person-centred (10), acknowledging the essence of the patient (21), listening to the patient (11,34), grasping the patient's meaning system (12), identifying with the patient as an individual (25), respecting the patient's dignity (11,19) and protecting the patients' rights (19).…”

Talking about mental health nursing: a qualitative analysis of nurses’ and service users’ accounts

“…This can lead to nurses experiencing conflicting tensions as they struggle to incorporate these opposing elements into their practice (Hannigan & Cutcliffe, 2002). Björkdahl et al, (2010) termed these divergent positions the bulldozer and the ballet dancer, as a way of encouraging nurses to reflect on how they integrate paternalistic nursing approaches with holistic care. The bulldozer approach functions as a shield of power as nurses seek to retain control and safety, whilst the ballet dancer style focuses on initiating and maintaining relationships with service users (Björkdahl et al, 2010).…”

“…Björkdahl et al, (2010) termed these divergent positions the bulldozer and the ballet dancer, as a way of encouraging nurses to reflect on how they integrate paternalistic nursing approaches with holistic care. The bulldozer approach functions as a shield of power as nurses seek to retain control and safety, whilst the ballet dancer style focuses on initiating and maintaining relationships with service users (Björkdahl et al, 2010). Whilst both elements of partnership working and control may co-exist within a mental health nurse's remit, how nurses accomplish such seemingly opposing activities is underreported in the literature.…”