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

Accessible summary • Demanding conditions in acute psychiatric wards can make it difficult for nurses to provide good care to patients. • Interviews with nurses revealed that they use different caring approaches to patients; one to build relationships and one to keep wards ordered and safe. • The approach to keep wards ordered and safe may include a risk of nurses acting in a way that leaves the patients with feelings of mistrust and a sense of being broken down. • Nurses should be encouraged to become aware of this risk and to find opportunities to choose a more caring approach while maintaining safety and security on wards. 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.