Thematic Analysis of Inquiries Into Concerns About Institutional Health Care

AIMS: Recent reports and inquiries indicate that the potential, identified from the early days of the asylum era, for residents of psychiatric institutions to be subject to abuse has not been eradicated. The findings and recommendations of individual inquiries are often so specific to their unique context that it can be difficult to draw general principles that have wider operationalizability. The aims of this study are to thematically analyse available inquiry reports into health care institutions from the mid-20th century to the present using a ‘generalisable’ framework in order (i) to identify the key themes underpinning the concerns raised, and (ii) to analyse how themes change (or persist) over time. METHODS: Inquiries relating to concerns about the institutional care of patients over the past 70 years were identified. In this pilot study, a selection of available reports were subject to thematic analysis to address the first phase of the study (identifying themes underpinning concerns). RESULTS: Four overarching themes were identified. The first three themes reflect the different levels of system analysis. Thus, the first theme, ‘the proximal dynamic,’ describes the nature of the interaction between staff and patients which is influenced by staff experience, attitude, and actions. The second theme, ‘the organisational dynamic’, comprises processes, policy and culture particularly, but exclusively, within the provider organisation. The third level of analysis, ‘the system dynamic’ theme, includes the influence on the concerns raised of the way the health system is configured (e.g. commissioning arrangements, and use of 'out-of-area' placements). The fourth theme, which cuts across the first three, is ‘the response to concerns’ which ranges from identifying early warning signs to responding to overt expressions of concerns (including whistleblowing). CONCLUSION: Using thematic analysis to examine past inquiries into poor institutional care of patients, this study has identified a thematic structure which (i) emphasises that problems arise in a ‘dynamic’ that can be located at three levels of analysis (proximal, organisational and system) and (ii) includes a cross-cutting theme of the way concerns are responded to. This structure can be used as a learning framework for the current provision of inpatient services that has the potential to improve care in institutions, but this will require empirical testing.