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. 2020 Dec 2;26(6):557–571. doi: 10.1177/1744987120965651

Nurses’ perspectives of an environment of optimum mental health: a grounded theory study

Miriam Carole Atieno Wagoro 1,✉, Sinegugu E Duma 2
PMCID: PMC8899306  PMID: 35265162

Abstract

Background

The Government’s aspiration to make Kenya a middle-income country and achieve the United Nations' sustainable development goal 3, ‘good health and well-being’, are threatened by poor quality of mental health services. Environment and lack of a conceptual model of nursing to guide care were some of the reasons that were attributed to poor quality of mental health services. The purpose of the study was to discover and describe an appropriate conceptual model of mental health nursing practice. This paper describes the environment which is one of the metaparadigms of a conceptual model grounded on data collected from Kenyan mental health nurses.

Methods

A grounded theory study was conducted with 33 mental health nurses selected by purposive, open and theoretical sampling procedures. The study sites were level 5 and 6 mental health facilities across the country. Data were collected over a period of 11 months through audio-recorded in-depth interviews and field notes. Analysis was performed using Straussian Grounded Theory steps of open, axial and selective coding processes aided by NVivo version 10. Dimensions and properties of environment metaparadigm grounded on nurses’ views were discovered. The study was conducted within the dictates of the institutional and national ethics and research review boards.

Results

Environment evolved as an intervening condition and a supra-system for mental health nursing. A homely environment emerged as a space with properties that nurture optimum mental health contrary to a hostile environment that precipitates mental disorders and prolongs recovery.

Conclusion

Grounded theory methodology was useful in discovering an environment metaparadigm as the context that influences mental health while nursing practice is the central phenomenon for optimum mental health. Nurses can ensure homely environments from diverse cultures and conduct comparative studies on the recovery of patients in the two environments.

Keywords: coding paradigm, intervening condition, mental disorder, metaparadigm, quality, Straussian grounded theory

Introduction

Dissatisfaction with mental health services by the Kenyan public

The longstanding dissatisfaction among the Kenyan public with the quality of health services, including mental health nursing, was a matter of national concern (Ouko, 2018; Wanjau et al., 2012). Complaints about quality of mental health nursing persisted in several reports (Kenya National Commission on Human Rights, 2011; Ministry of Health, 2010; Wagoro et al., 2017). Concerns about the deplorable hospital environments, stigma, discrimination and human rights abuses (Meyer and Ndetei, 2016; Mutiso et al., 2020) supported complaints about poor quality of mental health services. We argue that optimum environments of mental healthcare are critical in facilitating recovery of patients in Kenya with a long standing burden of mental health disorders, which is currently estimated at 25% in out-patients and 40% among in-patients (Ministry of Health, 2016; Mutiso et al. 2020; Ouko, 2018).

The context of mental health services in Kenya

Mental health services in Kenya are organised and delivered within the mainstream health services across all the 47 counties (Ouko, 2018; Wagoro, 2016). Thus, mental health services are provided within the existing county health facilities and are structured into six levels, based upon the scope and complexity of the care offered. Level 6 is the tertiary national teaching and referral hospital while level 1 is the community unit. Mathari National, Teaching and Referral Hospital is the only level 6 mental health facility in Kenya (Kiima and Jenkins, 2010), with a bed capacity of approximately 700 and 400 members of staff.

Regional (level 5) and district mental health facilities (level 4) are secondary general referral hospitals. Within these secondary referral hospitals, there are mental health units with a bed capacity of 20–25 (in level 5) and 10–15 (for level 4). Health centres (level 3), dispensaries (level 2) and community units (level 1) are considered primary healthcare facilities that mainly provide preventive care with some basic curative services, but currently do not have the capacity to provide mental health services.

Kenya experiences acute shortages of mental health professionals (Mutiso et al., 2020). A report by the Auditor General (Ouko, 2018) indicated that the ratio of psychiatrists to patients stands at 1:500,000 versus the recommended 1:30,000, while psychiatric/mental health nurses are 1:107,728 against the ideal 1:6000. Due to this shortage, mental health services are not available in levels 1–3 which are considered primary health facilities and 85% of individuals experiencing mental disorders fail to access the treatment they require (Mutiso et al., 2020; Ouko, 2018).This is a sad scenario given that 25% of out-patients whether at primary, secondary or tertiary health facilities are believed to have some form of mental health problems not only in Kenya but globally as well (Ministry of Health, 2016).

Quality mental health services in Kenya: rationale and mental health nurses’ role

Mental health is a key determinant of an individual’s well-being and overall socio-economic development, while mental disorders increase economic burden of a country (Meyer and Ndetei, 2016; MOH, 2016; Wagoro, 2016).Globally up to 32.4% of years lived with disability is attributed to mental disorders (Vigo et al., 2016). At the family level, mental illness is a source of suffering and distress to family members and significant others (Fekadu et al., 2019; Seid et al., 2018).

Mental disorders are chronic, relapsing and interfere with an individual’s ability to meaningfully take part in health promoting or economic generating activities (Fekadu et al., 2019; Marquez and Saxena, 2016). For Kenya, morbidity and mortality due to mental disorders are likely to impede achievement of the country’s industrialisation status as envisaged in the government’s vision for 2030 (Government of the Republic Kenya, 2007). Therefore, quality of mental health services is critical to facilitate recovery and community integration of patients to enable them to participate in economic development activities and propel Kenya to the middle-class economy as envisaged in the government’s blue print commonly referred to as ‘Vision 2030’.

Psychiatric nurses provide up to 90% of mental health services in Kenya and therefore significantly influence its quality (Kiima and Jenkins, 2010; Kenya National Commission on Human Rights, 2011; Wagoro, 2016). We argue that poor mental health nursing care is likely to translate to poor mental health services. To provide quality delivery of mental health nursing services, effective nursing frameworks are required to guide nursing processes. In Kenya, psychiatric nurses are guided by the Mental Health Act Chapter 248 and the Nurses Act Chapter 257 of the laws of Kenya as well as the mental health and Kenya health policies. However, these laws are not specific as a nursing conceptual model that comprises the four major metaparadigms of nursing.

Conceptual models of mental health nursing

Nurse theorists including Fawcett (2016) define a conceptual model of nursing as comprising four main metaparadigms, namely, the environment, human being, nursing and health. Conceptual models of nursing are important in clinical practice because they organise nursing processes such as critical thinking, systematic observation and interpretation of phenomena. Consequently, the nurse is able to plan interventions based on rationale and not routines. In this, way the nurse provides individualised holistic quality care that meets the client’s needs.

In Kenya, there was no conceptual model of nursing to guide processes in mental health nursing care (Department of Nursing, 2010; Wagoro et al., 2017). Recognising these facts, the Department of Nursing ([DoN], 2010) advocated for the application of conceptual models of nursing as a priority to direct mental health nursing. According to the DoN, introduction and utilisation of nursing conceptual models in the provision of evidence-based, comprehensive and client-specific care would be the only way to improve the substandard mental health nursing care that the Kenyan population consistently complained about.

However, the conceptual model needed to be customised to the nursing care context in Kenya. Hence, the necessity to develop a contextualised conceptual model according to Kenya’s unique conditions, including the environment metaparadigm that contributed to the low-quality of mental health services in Kenya (Wagoro et al., 2017).We envisioned that the use of a contextualised conceptual model of mental health nursing would revitalise the practice of mental health nursing in Kenya.

In this study, we argue that strengthening conceptual models of care requires considerations of the dynamic internal and external environmental interactions with nursing processes that foster health and recovery. We also assert that exploring nurses’ views and experiences about characteristics of an environment that nurtures mental health and accelerates recovery is crucial when developing a contextual conceptual model for mental health nursing practice. Nurses’ views are constructed from long-term experiences that include what clients express during hospitalisation and interaction with the community. The developed conceptual model with consideration of nurses’ views is thus likely to be appropriate and acceptable by the nurses. This argument is consistent with Batalden et al. (2016) who believe that perspectives of participants in healthcare services are important in determining effective strategies for appropriate contexts of care. Our focus in this paper is on the environment: first, as one of the metaparadigms of a conceptual model and secondly as an intervening condition for optimum mental health in Kenya.

The environment of mental healthcare

Deliktas et al. (2019) defined the environment metaparadigm as all concrete and abstract internal and external phenomena and processes that interact with an individual to influence their health. Environment fits in this definition since it affects standards of mental health service delivery. Kieft et al. (2014) demonstrated that patients were more satisfied with nursing care if the environment was conducive. Likewise, Hessels et al. (2015) improved nursing care by 13.5% just by improving the environment alone.

Environment as a notable contributor to poor mental healthcare in Kenya was reported in the main daily newspaper, Nation, by Okeyo and Atieno (2015), when describing the unfavourable circumstances in which patients at a regional mental health facility lived. Likewise, Reinl (2013) on Al Jazeera Television Network exposed poor conditions in the Kenya national mental health institution where patients reportedly rioted and escaped due to a poor environment of care. We support the argument by the DoN (2010), Ouko (2018) and Wagoro et al. (2017) that a deplorable environment, shortage of mental health nursing and absence of a conceptual model of nursing to direct nursing care were the main contributing factors to poor quality of mental healthcare in Kenya.

Despite complaints about the environment of mental healthcare, studies in Kenya (Bitta et al., 2017; Marangu et al. 2014) seemed to concentrate on the shortage of and the capacity building for psychiatric nurses, and other infrastructure with little attention to the environment of care.

Even nurse theorists (Bender and Feldman, 2015) placed emphasis almost entirely on the patient’s health experience and not on the nurse–patient–environment–nursing interactive processes in the facility setting when describing the environment. For example, in the nurse–patient interpersonal relationship theory, Peplau (1991) described nurse’s roles in the phases of the nurse–patient interaction without explaining how the nurse is expected to interact with a patient in a stuporous situation within the care environment. In the same way, Nightingale (1946) extensively explained how nurses need to manipulate a patient’s immediate physical environment yet was silent on the internal environment. Our conceptual model considered the interaction of nurse–patient–environment–nursing processes from the nurses’ perspectives.

In this paper, we present the findings on what mental health nurses in Kenya considered as the definition, dimensions and properties of an environment metaparadigm and its influence on quality of mental health. The nurses’ considerations about environment were subsequently integrated in the developed Kenya human interaction model of mental health nursing practice.

Methods

Strauss and Corbin’s grounded theory method

Grounded theory was selected for the study because its use would facilitate the description of the environment metaparadigm concepts grounded on empirical data obtained from the nurses. Strauss and Corbin’s (1998) method was utilised because it is more structured and therefore allowed the researchers to systematically construct and interpret data in order to develop the environment metaparadigm with characteristics based on nurses’ interaction with their patients. The procedure was also useful in exploring the distinctive standpoints about the environment that mental health nurses might have developed in the course of their interactions with patients over a period of time.

Sampling size determination and techniques

A total of 33 nurses took part in the study based on the principle of data saturation as recommended by grounded theory proponents (Aldiabat and Le Navenec, 2018; Strauss and Corbin, 1998; Thomson, 2010). Data saturation in the study was reached when data obtained from further interviews with the nurses did not yield new codes or meanings. Purposive, open and theoretical sampling procedures were utilised to identify eligible nurses from regional and national in-patient mental health hospitals across Kenya. Nurses were identified based on qualifications and years of consistent practice in mental health nursing as explained in the section below, ‘Recruitment’. An open sampling method was used to facilitate recruitment of willing and eligible nurses who were available at the study site. Theoretical sampling which involved identification of participants on the basis of emerging concepts during data analysis was also used. Theoretical sampling facilitated gathering of new data for constructing environment concepts, properties and dimensions. Additionally, nested sampling was used to allow for more information and comparison of emerging themes from nurse managers by determining their consonance, refining them and identifying their conceptual borders. Nested sampling involved getting more information on emerging themes from a smaller group of nurse managers drawn from the larger group of nurses.

Recruitment

Participants were recruited from six regional hospitals (17 participants) and the national mental health hospital (16 participants) in Kenya. Participant recruitment was purposive and involved the selection of rich sources of data: mental health units and nurses trained in mental health nursing. Registered mental health nurses with experience of at least six consecutive years of practice in a mental health facility were identified. Full disclosure of information about the study was given to nurses in a first meeting facilitated by the nurse in charge of the hospitals. A second meeting was subsequently scheduled at the convenience of the nurses who were willing to participate. At the second meeting, there was further discussion and clarification of issues of concern. Those willing to participate were recruited through written informed consent. The nurses who took part in the study comprised nurse managers at the ward, unit and hospital levels, clinical nurse practitioners and nurse educators from mental health training schools within the hospitals.

Ethical considerations

Participant’s autonomy was ensured by providing full disclosure, providing prospective participants with time to make decisions and ensuring participation through a written informed consent. Participants’ anonymity was ensured. There was no more than minimum risk foreseen in the study and the participant’s safety was ensured by complying with the terms and conditions of approval of the study by the various institutional review boards.

Data collection: instruments and procedures

Data collection was conducted for 11 months (July 2014 to May 2015) using self-administered demographic questionnaires and in-depth interview guides. Self-administered demographic questionnaires were used to obtain social, educational and professional characteristics of participants. The primary researcher used interview guides to obtain data through an in-depth interview each of which lasted 1–1.5 hours. The interviews explored the views and vision of the mental health nurse on the environment metaparadigms considering the experiences and current shortfalls. Interviews were audio recorded subject to participant approval and complemented by field notes. Follow-up interview sessions were organised through negotiated arrangements to obtain more data to clarify and validate categories as appropriate.

Data management and analysis

All audio-recorded interviews were replayed several times, transcribed verbatim in English and verified for consistency and accuracy to enhance trustworthiness. Verification was done through inter-coding as recommended by Miles and Huberman (1994) and Lombard et al. (2002). Of the transcripts, 30% were independently coded using grounded theory principles by a mental health nurse faculty in a university outside Kenya. The faculty was a grounded theory researcher and an associate professor of mental health nursing. The inter-coder reliability was undertaken at two levels. The first level was general inter-coding for each transcript while the second was on inter-coding for environment for all the transcripts. Using Miles and Huberman’s (1994) formula, acceptable inter-coder reliability score of 99% was achieved. Further verification was done through the presentation of draft concepts to the participants and other mental health nurses through a member check process. The participants accepted the draft concepts as reflecting their views.

All participants’ identification information in the transcript was replaced with a text identification label to ensure anonymity: letters P1 to P33 were used to number transcripts consecutively. Grounded theory principles of open, axial and selective coding processes were utilised for data analysis. Open coding involved scrutinising each transcript several times, examining text line by line, identifying key phrases or themes and then assigning in-vivo or conceptual codes as shown in Table 1.

Table 1.

An illustration of open coding and deriving codes for the environment metaparadigm.

Text ID Ref no Excerpt from participant’s data (Participant’s statement) Interview statement theme Free code and type
P20 2 I also feel that the environment should be friendly because if the people who are surrounding the patient are not friendly it can trigger the patient to have some feelings that maybe they are being looked down upon and this can trigger aggression Environment with unfriendly people can trigger aggression Negative influence Conceptual
P21 5 an ideal environment should be friendly like if it is in the family, there should be support, good communication between the members and may be if one gets a problem they seek help Environment should be friendly Friendly In vivo
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Next, all codes were listed and phrases that captured the main ideas represented by the codes were developed. The phrases were then reduced and subsequently clustered based on similarity in thoughts, ideas and meaning. Clusters were labelled to become concepts that were subsequently classified to categories. Codes were constantly compared with categories in order to find relationships and similarities so as to discover categories and sub-categories that formed dimensions and properties of the environment, as illustrated in Table 2.

Table 2.

An illustration of code hierarchy with category and sub-categories that emerged from initial free codes of the environment metaparadigm.

1. Homely environment 1.1. Harmonious  1.1.1. Conducive   1.1.1.1. Allows for patient monitoring   1.1.1.2. Space    1.1.1.2.1. Adequate    1.1.1.2.2. Open space    1.1.1.2.3. Non restrictive   1.1.1.3. Convenient 1.2. Therapeutic environment  1.2.1. Comfortable environment   1.2.1.1. Facilitates recovery   1.2.1.2. Promotes healing   1.2.1.3. Provides for group interaction   1.2.1.4. Encourages family interaction  1.2.2. Crucial for individuals 2. Hostile environment 2.1. Labelled  2.1.1. Stigmatised  2.1.2. Discrimination  2.1.3. Disrespect   2.1.3.1. Disregard for environmental concerns   2.1.3.2. Overcrowding 2.2. No social support  2.2.1. Neglect   2.2.1.1. Unmet basic needs   2.2.1.2. Inadequate knowledge on social support  2.2.2. Negatively perceived  2.2.3. Rejection   2.2.3.1. For isolation
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Results

Participants

A total of 20 female and 13 male nurses participated in the study. The youngest participant was 38 years while the oldest was 64 years. The mental health nursing experience of participants ranged from 6 to 31 years. The majority of the nurses, except three, had at least 10 years’ experience in mental health nursing. The views obtained were categorised under mental health nurses’ definition, dimensions and properties of the discovered environment metaparadigm. Nurses’ description of the environment both in terms of definition, dimensions and properties are subsequently described.

Definition of environment

Mental health nurses defined an environment as a physical, psychological, social and cultural space, in which an individual grows and acquires mental health. Environment is not confined to a physical place in the hospital or community as demonstrated in the following excerpts:

P2: Environment from my perspective includes the family and communities, homes, cultural experiences and so forth and is not only the hospital or the institution which are just physical structures. Environment for mental health is not confined but is out there in the worship places and everywhere.

P9: I think, that in general terms environments facilitate an individual’s positive mental growth, in order to achieve optimum mental health.

P23: An environment includes surroundings or whichever area somebody practises in, such as a hospital or community whether urban or rural.

Dimensions and properties of the environment metaparadigm

Two dimensions of the environment metaparadigm, namely the homely and hostile, were discovered from data. The two dimensions were described with respective properties within the individual, hospital, family and community. The favourable dimension is a homely environment that promotes mental health or recovery of individuals with mental disorders. A homely environment has properties that were discovered from the data as illustrated in Table 2 and Figure 1. The properties include being conducive, safe, harmonious, accommodative, therapeutic and having established routines. Below are examples of excerpts that demonstrate these dimensions and properties of an environment:

P10: A conducive environment meets all needs of an individual as identified by Abraham Maslow. The needs are physical, psychological and spiritual. This includes when one feels welcome, loved and all his/her basic needs are available in it.

P20: From my perspective, an environment includes a community, family and homes and is not only confined to the hospital or the institution. Institutions as physical structures are only part of it but environment for mental health is everywhere.

Figure 1.

Figure 1.

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The environment metaparadigm.

A homely environment was described by the participants as having the properties of mental health promotion and recovery, as expressed in the excerpt below:

P18: An environment has influence on the mental health of an individual… A therapeutic environment is always desired because it is key in promoting good mental health of clients.

Other properties of a homely environment were given by participants as safety and availability of the necessary basic needs for both clients and nurses. In fact, these properties, according to the participants, defined the environment as an intervening condition for mental health nursing. The following excerpt illustrates the property from the nurses’ perspective:

P9: A good environment ensures safety for nurses and their patients. A good environment also has all equipment that nurses require in their practice, offers comfortable, adequate living and social amenities as well as various types of therapies.

At the opposite pole of a homely environment, is a hostile environment which was also discovered from data. A hostile environment is contemptuous, precipitates mental disorders or illness and prolongs recovery. The properties characterising a hostile environment according to data analysed from participants include discrimination, lack of basic needs, disrespect, stigmatisation and neglect. Characteristics of a hostile environment given by participants is comparable to the definition given by Merriam-Webster dictionary (2011) as expressing cruel emotions towards someone. Properties of a hostile environment are supported by the following excerpt:

P7: Our patients are affected because of stigmatisation. People perceive our patients negatively once they are admitted to a mental health facility… People misinterpret any action by patients even if they are part of his/her culture because they see patients negatively. In turn the patients feel rejected… and that is a very hostile environment for the patient.

A hostile environment was also described as negative intervening conditions that delay recovery and need to be removed:

P11: Patients who feel companionless and rejected don’t recover quickly.

P12: Majority of our clients have no support from the families; their families see them as a bother and an outcast. The stigma they encounter prolongs their recovery. Nurses need to educate families to facilitate acceptance.

Another constituent of a hostile environment that was discovered from the data is unmet basic needs. From the nurses’ perspectives, the national situations formed part of the environment as long as they affected the mental health of populations:

P15: The current existing too much insecurity causes stress and anxiety all the time and interferes with people’s ability to get adequate food. Failing to meet these basic needs precipitate mental disorders.

Another property of a hostile environment that was identified by the participants based on analysed data is rejection as expressed in the excerpt below:

P33: When a patient meets rejection by family members and the community upon discharge, then that is a bad environment according to me.

The dimensions of the environment with their respective properties are illustrated in Figure 1. The round shape illustrates the nature of the environment as a space not limited to physical boundaries.

Discussion

Significance of the participant’s profile

The eligibility criterion of six years was based on the premise that comprehensive professional worldview (that comprises views, values and beliefs) is crystallised over a long period in an individual’s professional development and achievement of expertise (Bargal, 2014; Benner et al., 2009).We argued that six years were adequate for a mental health nurse to solidify their worldview on the environment metaparadigm. Our argument is consistent with Hinojosa (2019) and Whalen (2016) who selected participants with a minimum experience of 20 and five years, respectively, in their work areas when using grounded theory methodology in studying experiences and perceptions. Our perspective of including metaparadigm concepts which reflect nurses’ views, values and beliefs in the developed conceptual model is important in enhancing its acceptability and utilisation, is shared by Batalden et al. (2016) and McCrae (2012).

Definition of the environment

The definition of the environment metaparadigm as a space that is not limited to physical structure in the current study is similar to the perspective of many nurse theorists. For example, Roy described an environment as the summation of every factor that surrounds and affects the human being as individuals or groups (2009). Likewise, Orem (1995) asserted that an environment is composed of physical aspects such as biological, chemical and social contexts within which a person lives and interacts to influence their capacity to perform self-care activities.

Environment is also conceptualised as an intervening condition for nursing practice. In this regard, the environment is described both as a space within which the nurse practises as implied in Peplau’s (1991) theory and where clients live containing factors that influence the quality of nursing care. The factors of interest are physical infrastructure and resources. The nurses in the current study seemed to have placed a lot of emphasis on the importance of work and the client’s environment, and their influence on optimum quality of care contrary to many nurse theorists who emphasise on its importance to the client’s health (Bender and Feldman, 2015; Jarrin, 2012; Orem, 1995; Roy, 2009).

These two perspectives of the definition of the environment metaparadigm fit with Strauss and Corbin’s (1998) definition of intervening conditions in a coding paradigm in the development of a theory using grounded theory methodology. In the current study,an environment emerged as the intervening condition that influences nurses' interventions. Environment also influences the effects of the causal condition. In this context, the causal condition is the human being who is either experiencing or is at risk of developing a mental disorder. The nurses in the current study demonstrated that environment has properties that influence mental health outcome of an existing human being who is predisposed predisposed to mental disorders or is mentally sick. Our argument is consistent with Bitta et al. (2017) who inferred that lack of human resource as part of environment of care for the individuals with mental problems is a hindrance to mental health well being.

The definition of the environment by the nurse theorists, nurses and Strauss and Corbin (1998) is supported by Collins English Dictionary (Collins Dictionary, 2015) which describe an environment as someone’s total contexts, conditions, settings, habitat, homes and situations, in which the individual grows, survives, lives and works. Because of the similitude in the way environment is defined by both mental health nurses in the current study and Collins English Dictionary, the definition was adopted for the environment metaparadigm in the developed Kenya human interaction model for mental health nursing practice. This implies that the environment for mental health in this paper is broad and goes beyond the physical aspects and includes all properties in both the homely and hostile environments. The current study fills in this gap by considering nurses’ views on the ideal environment for quality mental health nursing practice.

Dimensions and properties of the environment

In the current research, the nurses emphasised the external environment which they described as having two dimensions specified as homely and hostile. Environment as an external entity was discovered as a supra-system that forms the surroundings of the human being with whom it interacts to impact on well-being. The perspectives of the nurses in the current study are consistent with other nurse theorists and researchers (Deliktas et al., 2019; Lindahl, 2018; Nightingale, 1946) who emphasised environmental physio-psycho-social characteristics that facilitate healing and mental well-being.

Unlike the nurses in the current study, some nurse theorists (Neuman, 2002; Orem, 1995; Roy, 2009) explicitly described the internal (intrapersonal) and external (extra-personal) environments and emphasised the interaction between them to maintain well-being. The nurses in the current study acknowledged the importance of interaction without explicitly describing its occurrence as internal and external environments. For instance, the statement by participants in the results section above concerning the environment as inclusive of cultural experiences, spiritual aspects, families and communities implies interpersonal as well as extra-personal interactions. Similarly, the statement by the participant that the patient who feels companionless and rejected does not recover quickly implies that there is interpersonal and intrapersonal interaction as advanced by Neuman (2002) and Roy (2009). We argue that lack of interpersonal interaction results in a feeling of being companionless and rejection while intrapersonal interaction between feelings and processes in mental illness delays recovery.

The homely and hostile dimensions that were discovered from the data in the current study exist along a continuum with homely environment at one end and a hostile one at the other. The properties discovered in the current study have been identified by other researchers although with emphasis on the physiological and not on the mental aspect, as in the current study. Bhanji (2012) asserted that satisfaction of the basic needs of an individual such as air, good ventilation and safety facilitates human integrity and functioning. In the same way, Nightingale (1946) implied that a homely environment is a place where the sick individual is looked after with considerations of their physical, psychological and social components. In the current study, Nightingale’s perspectives are inferred by describing properties of a homely environment as positively influencing the human being.

The properties of the environment metaparadigm were discovered at two levels. One level describes the environment’s components while the other level describes the quality of the components. In the first level, the components of the environment include physical, chemical, psychological, cultural, social and spiritual aspects. Some of the components can be inferred from Table 1 and the excerpts from participants. For example, an excerpt from P9 describes a good environment as that which is safe for patients and nurses. Safety is an example of a physical aspect of the environment.

The second level describes the quality of the components such as the physical component that was described as safe. Safety is a quality of environment that determines its dimension. As described in the previous paragraphs of this section, safety is one of the properties of a homely environment while stigma is a property of a hostile environment. We argue that describing the quality of the components gives the dimension characteristics of the environment that are described as either a homely or a hostile environment (see Figure 1).

Many nurse theorists including Orem (1995) and Roy (2009) refer to these components or properties as dimensions. In the context of the current study we refer to them as components because they don’t exist along a continuum nor do they have bipolar characteristics. Our perspective is consistent with Deliktas et al. (2019) and Lindahl (2018) who refer to them as characteristics rather than dimensions.

Mental health nurses in the current study expressed their preference for work in an environment with favourable physical, emotional or psychological, spiritual properties. Nurses’ preferences are comparable to the position held by Jarrin (2012) who was concerned that many nurse theorists forget about an environmental influence on nurses’ practice. Yet, unfavourable work environments influence mental health nursing care negatively (Madathil et al., 2014).

Strengths and limitations of the study

Nurses were committed to ensuring that their views were sought because they said it was the first time they were being asked to participate in the development of a nursing model. They were willing to negotiate an alternative day for interviews when the initial schedules would not work due to nurse shortage. Data collection processes took longer than planned because of the unfavourable dynamics of the work environment that required the researcher to reschedule interview dates. However, it was successful as data saturation was obtained.

Conclusion

Grounded theory methodology was utilised to discover an appropriate environment metaparadigm as an intervening condition and a space with dimensions and properties. Some of the properties are required for quality mental health nursing care while some are risk factors for mental disorders. Mental health nurses need to promote properties of a homely environment for optimum mental health of individuals, families and communities. The discovered environment has properties grounded on data from the nurses based on their long-term engagement with patients. This environment is therefore likely to be suitable for both patients and nurses respectively as users and providers of mental health nursing services.

Key points for policy, practice and/or research

  • Nurses need to promote a homely environment within health facilities and communities to promote mental health and facilitate recovery. These environments can be extended to the general non-mental health wards for care of all patients.

  • Nursing policies need to consider dimensions and properties of the environment that constitute a homely environment.

  • There is need for a comparative study to evaluate the rate of recovery for clients in homely and hostile environments.

  • During training, emphasis needs to be on the non-physical space as part of environment. Often students are the only taught about the physical environment to the exclusion of social, psychological, etc., yet they also influence the mental health well-being of the client.

Acknowledgements

The authors acknowledge the study participants for taking time to answer questions during the interview. The universities of Cape Town and Nairobi are appreciated for providing time and PhD scholarship. The study was part of the requirement for the PhD course.

Biography

Miriam Carole Atieno Wagoro, RN, PhD, MScN, BScN, PGDip (Intn'l research Ethics), RPN, RM, RCHN, DAN, Clinical Mental Health Nurse, Research Ethics Specialist & Senior Lecturer at University of Nairobi-School of Nursing Sciences, and Lead National Nursing Process Trainer, Kenya.

Sinegugu Evidence Duma, RN, PhD, MCur, BCur, Fellow of ANSA, Professor of Nursing and Dean of Teaching and Learning at the College of Health Sciences University of KwaZulu-Natal, South Africa.

Footnotes

Declaration of conflicting interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics: Authority to conduct the study was obtained from institutional and national review boards as follows: University of Cape Town, Faculty of Health Sciences and Human Research Ethics Committee (HREC 101/2013), University of Nairobi/Kenyatta National Hospital Ethics and Research Committee (P199/05/2013), Kenya National Council for Science and Technology (NACOSTI, P/14/9542/18060), Kenya Ministry of Health (MOH/ADM/1/1/81 Vol.11) and hospital administration of all study sites.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Miriam Carole Atieno Wagoro https://orcid.org/0000-0002-8341-2064

Contributor Information

Miriam Carole Atieno Wagoro, Senior Lecturer, School of Nursing Sciences, University of Nairobi, Kenya.

Sinegugu E Duma, Dean of Teaching and Learning, College of Health Sciences, University of Kwa Zulu-Natal, South Africa.

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