Nursing managers' perspectives on factors contributing to abuse in psychiatric hospitals: A reflective thematic analysis.

Background: Research has identified evidence of coercion and abuse in psychiatric hospitals. The psychiatric care system in Japan is characterized by a custodial approach and long-term inpatient care, potentially increasing the risk of abuse. However, few studies have examined the occurrence and dynamics of abuse in psychiatric institutions, and there is a major research gap regarding the roles of hospital culture and management in contributing to inpatient abuse. Objective: To investigate the experiences of psychiatric nursing managers of the factors contributing to inpatient abuse in psychiatric hospitals. Design: A multisite, phenomenological, qualitative, and descriptive study. Settings: Four hospitals in Japan that were either psychiatric hospitals or general hospitals dominated by psychiatric wards. Participants: Eighteen nurse managers (including directors of nursing, deputy directors of nursing, and head nurses) working in psychiatric hospitals or in general hospitals dominated by psychiatric wards. Methods: From May 2023 to July 2023, individual semi-structured interviews were conducted with each participant to obtain data on factors contributing to abuse in psychiatric hospitals. Reflexive thematic analysis was used to analyze the data. The data were coded, and the codes organized into themes and subthemes. Results: Six themes and 23 subthemes were extracted that described participants' perspectives on systemic, personal, and environmental contributors to inpatient abuse. The themes were 'Structural challenges embedded in psychiatric care systems' (e.g., finances, staffing, working conditions); 'Organizational cultures lacking self-correction' (e.g., the insularity of psychiatric hospitals, use of outdated nursing practices); 'Dysfunctional team dynamics that undermine professional competence' (e.g., suppression of nurses' opinions and autonomy); 'Asymmetries in patient-nurse relationships' (e.g., power imbalances); 'Illness factors that complicate the detection of abuse' (e.g., interpretation of abuse as symptoms); and 'The fragility of psychiatric nurses' professional identity' (e.g., lack of skills, experience, confidence, and fulfillment). Conclusions: The results show that nurse managers play a key role in identifying institutional, personal, and relationship-based factors that contribute to inpatient abuse in psychiatric wards. The findings indicate a need for more policies to support patient-centered care and develop the role of nurse managers to create safer psychiatric wards. Study registration: Not registered. Tweetable abstract: nurse managers' perspectives on contributors to inpatient abuse in psychiatric hospitals.