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Nelstrop L, Chandler-Oatts J, Cowl J, et al. The Experiences of Black Service Users in UK In-Patient Settings in Relation to the Short-Term Management of Disturbed/Violent Behaviour (Supplement). London: Royal College of Nursing (UK); 2005 Feb. (NICE Clinical Guidelines, No. 25S.)

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The Experiences of Black Service Users in UK In-Patient Settings in Relation to the Short-Term Management of Disturbed/Violent Behaviour (Supplement).

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2Methods

2.1. Aim

The aims of the study were twofold:

  • To listen to the experiences of black service users in relation to the short-term management of violence in two different settings, Bristol and London. In London, the group was made up entirely of African-Caribbean service users.
  • To listen to the views and experiences of health care professionals with experience of working with black service users, in relation to the short-term management of violence across of variety of settings.

2.2. Objectives

The objectives of the study were:

  • To describe black service users' experiences and views of the short-term management of disturbed/violent behaviour in psychiatric in-patient settings.
  • To describe the experiences and views of health care professionals with experience of working with black service users, in relation to the short-term management of disturbed/violent behaviour in psychiatric in-patient settings.
  • To draw up recommendations to improve psychiatric in-patient services.

2.3. Methods

The framework for the design and analysis of this report was taken from Richens (2003). Richens used focus groups to gather sensitive information from Pakistani women who had recent experience of the maternity services in the UK. Focus groups are commonly used to collect information or investigate individual responses to different situations or policy initiatives, particularly those that are of a sensitive nature (Gebich 1999). They are particularly useful for encouraging participation from people who are reluctant to be interviewed on an individual basis or who feel they have nothing to contribute, as well as for tapping into a given cultural context (Kitzinger 1995). Richens's work further confirms the findings of Hennings et al. 1996; Duff 1999; and Wilkins and Winslow et al. 2002; whose studies illustrates that focus groups are useful and appropriate when working with ethnic minority groups. As Richens demonstrates, focus groups can be used for ‘obtaining rich information within a particular social context’ (Richens 2003:19).

2.4. Design

Following Richens (2003), we taped and transcribed each focus group. We then treated the transcribed manuscript as a text for analysis. As in Richens (2003), we used content analysis, as outlined in Burnard (1991), to generate a number of high and low order themes from each of the texts. The thematic overlap from the two focus group texts was such that we merged these to create one set of high and low order themes. The text generated from the health care professional focus group was treated separately, and unique high and low order themes were derived.

2.5. Ethical considerations

The service user focus groups were conducted as a consultation exercise by two black advocacy organisations. These organisations recruited participants for the focus groups and a member acted as the lead facilitator for each group. Therefore formal ethical approval was not sought. However, in order to safeguard the needs of the participants a number of measures were put in place.

Firstly both these organisations offered additional one-on-one discussions with any participant who wanted to further explore issues raised by the focus groups. In addition, prior to the focus groups, each participant received an information leaflet that outlined the topics that would be discussed. This was supported by verbal information from the advocacy organisations. Despite the sensitive nature of the topic, participants had to be turned away. All participants were also asked to give prior written consent for the focus groups to be taped, transcribed and used in a report. Participants were informed that all information received would remain confidential and were reassured that any care and future treatment would not be affected as a result of their participation. Participants were also asked to respect the confidentiality of other participants. Confidentiality was further safeguarded by participant validation of the findings.

Once analysed, the focus group findings were circulated to the participants in the format of a written report. All participants were enthusiastic about the report and the approach taken. No participant wanted anything removed from the report; rather the report generated further discussion of the topic, in which the participants confirmed that the flavour of the report reflected their experiences. Validation of this nature ensures that the researchers' interpretation reflects the views of participants and that the research does not yield misleading or inaccurate conclusions about the study (Murphy et al. 2002). The participants stated that they found the focus groups and validation discussions valuable. Participants were eager that the findings generated by the focus groups should be disseminated. A small non-incentive gift payment was given out by the advocacy organisations after the focus groups to all participants. The same process was followed for the health care professional focus group, although no payment was given, only expenses were paid. A copy of the consent form used can be found in Appendix 9.

2.6. Sampling, eligibility and recruitment

Quota sampling was used to select participants for the two service user focus groups. Richens notes that Bowling defines this approach as:

a deliberate non-random method of sampling, which aims to sample a group of people, or setting, with a particular characteristic (Bowling 2002:380 cited in Richens 2003).

All participants came from black and African-Caribbean communities and had direct experience of the interventions for the short-term management of disturbed/violent behaviour in psychiatric in-patient settings being considered in the guideline. In London, all the service users were African-Caribbean. In Bristol, all belonged to the black community that is situated in and around St. Paul's.

A snowballing technique was used to select the health care professionals for the other focus group. The process started with the GDG and was continued with the experts who were nominated by the GDG. All participants had some expertise with black service users in psychiatric in-patient settings.

No participants were deliberately excluded from any focus group. A full description of the characteristics of the participants is given in section 2.7.

Prior to commencing the focus groups, information leaflets and consent forms were sent to the two service user organisations several months in advance to distribute to potential participants. This material received a positive response.

Participants were paid travelling expenses, provided with lunch and were also given a small payment, as a gesture for attending the focus groups. The money was not used as an incentive, since this was given out at the end of focus group interviews.

Recruiting participants to the study was not difficult. With reference to the two service user focus groups, while in London potential participants had to be turned away, in Bristol the situation was more difficult. Many potential participants in Bristol were constantly in and out of hospital (one participant was accompanied from hospital). The ‘revolving door’ situation in Bristol meant that a large number of participants were invited to be involved in the focus group as it was unclear who would be available to attend on the day. In the end this resulted in an overly large focus group, which is described below in section 2.7. Health care professionals were keen to participate in the focus group held in London.

2.7. Characteristics of participants

2.7.1. London service users

Number of participants:

Age range: 20-55

Sex: six females, three males

Ethnicity: African-Caribbean

Range of settings experienced: secure and acute settings.

2.7.2. Bristol service users

Number of participants:

Age range: 18-60

Sex: two females, 15 males

Ethnicity: African-Caribbean and African-Caribbean born in England. (Most participants classified themselves as ‘black’. Also included Somalian refugees, but see 2.9.1 below).

Range of settings experienced: high, medium secure, forensic, prison, acute, long-term in-patient settings.

(In addition, one female and two male advocates attended).

2.7.3. Health care professionals

Number of participants:

Age range: N/A

Sex: three females, six males

Medical specialism, training, diversity lead, management

Range of settings worked within: forensic, A&E, acute care.

2.8. Role of the facilitator and researcher

Two researchers attended each service user focus group in addition to the facilitator. One researcher was from the National Collaborating Centre for Nursing and Supportive Care; the other from the NICE Patient Involvement Unit. One of the researchers acted as a second facilitator, helping guide the discussion so that the participants only discussed their experiences of the short-term management of violence in psychiatric in-patient settings, rather than other related issues. The other researcher took notes during the focus groups to support the taped analysis and provide any additional relevant information on mood, behaviour and group dynamics. A representative from Black Orchid and Footprints UK acted as the first facilitator for each of the groups respectively.

Two researchers attended the health care professional focus group. One researcher was from the National Collaborating Centre for Nursing and Supportive Care; the other from the NICE Patient Involvement Unit. One acted as the facilitator, the other took notes during the focus group and also acted as a second facilitator.

2.9. The focus groups

2.9.1. Service user focus groups

Twenty-three participants were recruited to the focus group study and they all met the eligibility criteria. Each focus group lasted approximately one-and three-quarter hours, with a break for lunch. They were held in local settings that were familiar to the participants. The Bristol focus group was conducted in facilities at Black Orchid; the London focus group was held in the Black Persons' Community Centre in Walthamstow. The London focus group included three men and six women, as well as two researchers and the facilitator. The Bristol focus group included 12 men and two women, as well as two researchers and the facilitator. In addition, three advocates were present and three Somalian refugees. Although the refugees attended and were counted as part of that focus group, they did not participate verbally in the discussion so have not been included in the total number of participants - see Table 2.

Following Richens (2003), in addition to the facilitator, two researchers were present at each focus group. This meant that one researcher was able to help facilitate the discussion, while the other researcher was free to take notes to assist with the subsequent transcription and data analysis (Krueger and Casey 1998 cited in Richens 2003). This enabled comprehensive transcripts to be produced, by ensuring that unclear sections on the tapes did not result in lost data. It also allowed comparison between researchers for the purpose of verification.

Prior to each focus group, a brief summary of the aims and objectives of the focus group was distributed to participants. The interview schedule and research protocol (Appendix 7) aimed to obtain service users' views and experiences of:

  • interventions use for the short-term management of violence in psychiatric settings (rapid tranquillisation, seclusion, restraint, de-escalation, observation, predication)
  • the in-patient environment and its impact on disturbed/violent behaviour
  • staff and service users' relationships in psychiatric in-patient settings and their impact on disturbed/violent behaviour.

Prompts were included in the focus group schedule.

2.9.2. Health care professional focus group

Nine participants were recruited to the health care professional study and they all met the eligibility criteria. The focus group lasted approximately two hours. The focus group was held in the Royal College of Nursing headquarters in London.

Table 3

GroupFocus group participants
C9
Total: 9

Prior to each focus group a brief summary of the aims and objectives of the focus group was distributed to participants. The interview schedule and research protocol (Appendix 8) aimed to obtain healthcare professionals' views and experiences of:

  • Interventions use for the short-term management of violence in psychiatric settings (rapid tranquillisation, seclusion, restraint, de-escalation, observation, predication)
  • The in-patient environment and its impact on disturbed/violent behaviour
  • Staff and service users relationships in psychiatric in-patient settings and its impact on disturbed/violent behaviour

Prompts were included in the focus group schedule.

2.10. Informed consent

Prior to all focus groups, each participant received a copy of the information sheet. This was supported by verbal information from the service user organisations in the case of the two service user focus groups, explaining the study and what it entailed for participants. Participants were given an opportunity to ask questions and withdraw from the study, prior to being asked to sign the consent form. They were also provided with some basic background information (Appendix 9). Participants were informed that all information received would remain confidential and were reassured that any care and future treatment would not be affected as a result of their participation in the study. One participant in the service user focus group was not completely happy about signing a consent form, since he felt suspicious about what would be done with the information and feared that the focus group would achieve very little. However, after discussion, the participant did sign the consent form and participate in the focus group.

Following Richens 2003, the researchers were ware that consent in research is not a ‘one-off event’. The report of the focus groups was therefore sent to the participants to ensure they felt happy that it reflected all the issues raised, before being circulated to the GDG. In Bristol, a feedback group was held with participants.

2.11. Confidentiality

Following methods used by Richens (2003), each participant was allocated a number, and each focus group was given a letter of the alphabet as an identifier. All information collected, including cassette tapes, was stored in a locked drawer, which was only accessible to the researchers.

2.12. Data analysis

Using the methods cited in Richens (2003), the data was independently analysed by all three researchers, using the approach to content analysis described by Burnard (1991). This involves generating themes from verbatim transcripts of the focus groups, and then grouping them under reasonably exhaustive categories, in order to explore the issues that were expressed. As Burnard states, the aim of this approach is to:

produce a detailed and systematic recording of the themes and issues addressed in the interviews and to link the themes and interviews together under a reasonably exhaustive category system (Burnard 1991:462 cited in Richens 2003).

The themes were then categorised into high order themes, which reflect a natural clustering of categories, and low order (sub) themes. High order themes are the main themes and these also occurred through a natural clustering of categories; low order themes are sub orders, which relate to the main identified theme (Richens 2003). These categories are presented with supporting illustrations (that is, direct quotations) from the focus groups, in accordance with qualitative data analysis (Kitzinger 1995).

All three researchers met to finalise the high and lower order themes. The completed report was then circulated to the participants as part of respondent validation. Participants were invited to add any further thoughts or feeling to the findings. This process ensured that the researchers' interpretation reflects the views of the participants, and that the research does not yield misleading or inaccurate conclusions about the study (Murphy et al. 2002).

2.13. Limitations of the study

‘Group think’, (Carey and Smith 1994, cited in Richens 2003) - where stronger members of a group have major control or influence over group dynamics and may hinder the articulation of quieter members' views - is a danger in focus groups. In one service user focus group, and in the health care professional focus group, incidents of ‘group think’ did occur. However, to a large extent it was prevented by both facilitators and researchers being aware of it, and intervening to ensure that all members were given the opportunity to give their viewpoints and to nominate areas they would like discussed.

A further limitation of the focus group in Bristol was the size of the study and mix of participants. It was impossible to predict how many of the participants who had been invited to attend would be able to attend on the day. As there is a revolving door situation in Bristol, with service users in and out of hospital, it is difficult to see how we could have overcome this problem. However, it might have been better to invite fewer participants and have run the risk of a very small focus group. Given that only one focus group was taking place in Bristol, it was felt that it would be better to have slightly too many members than very few.

Most participants who attended the Bristol focus group came from the African-Caribbean community, however there were three Somalian refugees who spoke very little English. On reflection, it would have been better to have conducted a separate focus group or structured interviews via an interpreter with these individuals. Funding costs and time constraints made running a separate focus group for these participants impractical. Since these three participants did not speak during the focus group, they were excluded from the final results in group A.

Another issue was the mix of participants. Most participants had been in-patients with a primary diagnosis of mental illness. However, one participant did not have a mental health diagnosis, but had been admitted to a psychiatric institute on a number of occasions for drug-induced psychosis. To ensure a more homogenous group, it might have been better to exclude those with a primary or sole diagnosis of drug abuse.

Copyright © 2006, Royal College of Nursing.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic,mechanical, photocopying, recording or otherwise,without prior permission of the Publishers or a licence permitting restricted copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published,without the prior consent of the Publishers.

Bookshelf ID: NBK55899

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