TYPE Original Research
PUBLISHED 15 December 2022
DOI 10.3389/fpsyt.2022.1054028 TYPE Original Research
PUBLISHED 15 December 2022
DOI 10.3389/fpsyt.2022.1054028 Staff’s experiences of
implementing patient-initiated
brief admission for adolescents
from the perspective of
epistemic (in)justice OPEN ACCESS
EDITED BY
Julian Schwarz,
Brandenburg Medical School Theodor
Fontane, Germany
REVIEWED BY
Edward Harcourt,
University of Oxford, United Kingdom
Britt-Marie Lindgren,
Umeå University, Sweden
*CORRESPONDENCE
Jennie Moberg
jennie.moberg@socarb.su.se
SPECIALTY SECTION
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Psychiatry
RECEIVED 26 September 2022
ACCEPTED 22 November 2022
PUBLISHED 15 December 2022
CITATION
Moberg J and Schön U-K (2022)
Staff’s experiences of implementing
patient-initiated brief admission
for adolescents from the perspective
of epistemic (in)justice. Front. Psychiatry 13:1054028. doi: 10.3389/fpsyt.2022.1054028
COPYRIGHT
© 2022 Moberg and Schön. This is an
open-access article distributed under
the terms of the Creative Commons
Attribution License (CC BY). The use,
distribution or reproduction in other
forums is permitted, provided the
original author(s) and the copyright
owner(s) are credited and that the
original publication in this journal is
cited, in accordance with accepted
academic practice. No use, distribution
or reproduction is permitted which
does not comply with these terms. OPEN ACCESS
EDITED BY
Julian Schwarz,
Brandenburg Medical School Theodor
Fontane, Germany
REVIEWED BY
Edward Harcourt,
University of Oxford, United Kingdom
Britt-Marie Lindgren,
Umeå University, Sweden
*CORRESPONDENCE
Jennie Moberg
jennie.moberg@socarb.su.se
SPECIALTY SECTION
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Psychiatry
RECEIVED 26 September 2022
ACCEPTED 22 November 2022
PUBLISHED 15 December 2022
CITATION
Moberg J and Schön U-K (2022)
Staff’s experiences of implementing
patient-initiated brief admission
for adolescents from the perspective
of epistemic (in)justice. Front. Psychiatry 13:1054028. doi: 10.3389/fpsyt.2022.1054028
COPYRIGHT
© 2022 Moberg and Schön. This is an
open-access article distributed under
the terms of the Creative Commons
Attribution License (CC BY). The use,
distribution or reproduction in other
forums is permitted, provided the
original author(s) and the copyright
owner(s) are credited and that the
original publication in this journal is
cited, in accordance with accepted
academic practice. No use, distribution
or reproduction is permitted which
does not comply with these terms. Staff’s experiences of
implementing patient-initiated
brief admission for adolescents
from the perspective of
epistemic (in)justice OPEN ACCESS
EDITED BY
Julian Schwarz,
Brandenburg Medical School Theodor
Fontane, Germany
REVIEWED BY
Edward Harcourt,
University of Oxford, United Kingdom
Britt-Marie Lindgren,
Umeå University, Sweden
*CORRESPONDENCE
Jennie Moberg
jennie.moberg@socarb.su.se
SPECIALTY SECTION
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Psychiatry
RECEIVED 26 September 2022
ACCEPTED 22 November 2022
PUBLISHED 15 December 2022
CITATION
Moberg J and Schön U-K (2022)
Staff’s experiences of implementing
patient-initiated brief admission
for adolescents from the perspective
of epistemic (in)justice. Front. Psychiatry 13:1054028. doi: 10.3389/fpsyt.2022.1054028
COPYRIGHT
© 2022 Moberg and Schön. This is an
open-access article distributed under
the terms of the Creative Commons Introduction to access, PIBA has the potential to reduce the struggle for
admission that sometimes occur between patients and care staﬀ. Instead, through increased agency, PIBA may simultaneously
expand the patient’s interpretative precedence regarding the
need for admission, making room for subjective needs and
wishes for inpatient care. Through this (tentative) approach, we
suggest that there is an explicit idea that PIBA may promote
recovery and epistemic justice also for young people since they,
to a greater degree, have the possibility to deﬁne and voice
their needs rather than others deﬁning and voicing these for
them [cf. (12, 13)]. Providing PIBA to certain adolescents in
CAP may change traditional structures of power and knowledge
legitimacy. However, knowledge of its eﬀects is so far limited. In recent years, interest in young people’s agency and
position in health care and other welfare services has increased
internationally (1, 2). A similar focus can be seen in Sweden,
which has also led to a number of legal changes via, for
instance, the incorporation of the Convention on the Rights
of the Child (3) into Swedish law in 2020. This enhanced
focus has also contributed to changes in knowledge asymmetries
and the Swedish compulsory psychiatric legislation where the
child’s position and opportunities for increased rights have been
described as important prerequisites for digniﬁed and safe care
(4). Giving young people with complex mental health problems
increased agency and inﬂuence over their care is a task that in
many respects requires delicate handling, while it places a great
responsibility on the professionals [cf. (5)]. At the same time,
promoting recovery is a central perspective in psychiatry which
includes aspects of symptom management, participation, hope,
meaningfulness, and autonomy (6). However, some patient
groups return to psychiatric inpatient care where admissions
may be protracted and risk being characterized by coercion
and ineﬀective treatment (7). Also, these patients are more
exposed to epistemic violations than others (8–10), which
generally complicates agency and recovery. With the aim of
improving young people’s agency in psychiatric care, Patient-
Initiated Brief Admission (PIBA) has been introduced in Child
and Adolescent Psychiatry (CAP) in Stockholm. In summary,
PIBA is a standardized crisis management intervention (11)
drawing on increased autonomy for patients to self-assess if
they require a briefer period of inpatient care, rather than
the care apparatus being controlling in this process. OPEN ACCESS OPEN ACCESS
EDITED BY
Julian Schwarz,
Brandenburg Medical School Theodor
Fontane, Germany
REVIEWED BY
Edward Harcourt,
University of Oxford, United Kingdom
Britt-Marie Lindgren,
Umeå University, Sweden
*CORRESPONDENCE
Jennie Moberg
jennie.moberg@socarb.su.se
SPECIALTY SECTION
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Psychiatry
RECEIVED 26 September 2022
ACCEPTED 22 November 2022
PUBLISHED 15 December 2022 Jennie Moberg* and Ulla-Karin Schön Background: The implementation of Patient-Initiated Brief Admission (PIBA) in
child and adolescent psychiatry (CAP) in Sweden is ongoing. This intervention
enables adolescents between the ages of 13–17 and with complex mental
health problems to initiate a short care period for relief and support rather
than the care apparatus being controlling in this process. Offering it is likely
to promote epistemic agency, an exchange of knowledge and recovery from
mental health problems. Aim: The aim of this study was to explore staff’s perspectives of PIBA for
adolescents with complex mental health problems, and what facilitates or
hinders its implementation. Front. Psychiatry 13:1054028. doi: 10.3389/fpsyt.2022.1054028 COPYRIGHT
© 2022 Moberg and Schön. This is an
open-access article distributed under
the terms of the Creative Commons
Attribution License (CC BY). The use,
distribution or reproduction in other
forums is permitted, provided the
original author(s) and the copyright
owner(s) are credited and that the
original publication in this journal is
cited, in accordance with accepted
academic practice. No use, distribution
or reproduction is permitted which
does not comply with these terms. Methods:
Twenty
seven
employees,
21
women
and
six
men,
with
various
professions
in
CAP
were
interviewed
and
the
material
was
analyzed thematically. Results: Two overall themes emerged: “Staff’s Experiences of PIBA” and
“Managing Clinical PIBA Work.” The results were discussed in relation to
the theoretical frameworks of epistemic injustice and Normalization Process
Theory (NPT). The main ﬁndings indicate that PIBA was generally viewed
in a positive way, but that obstacles arose when it was actually put into
practice. Findings also point at an overall lack of agency among staff when
implementing this new way of working, at the same time as the need to
adapt PIBA from an adult psychiatric intervention to one for adolescents in
CAP is addressed. Conclusion: This article offers insights into the views of psychiatric staff
regarding the implementation of PIBA. OPEN ACCESS If staff wish to support epistemic Frontiers in Psychiatry Frontiers in Psychiatry 01 frontiersin.org Moberg and Schön 10.3389/fpsyt.2022.1054028 10.3389/fpsyt.2022.1054028 agency and recovery among adolescents, their agency may be an important
aspect in the continued implementation. Furthermore, in order for PIBA to
become normalized in a sustainable way, we suggest that the continued
implementation should be characterized by a youth-friendly framework. agency, epistemic injustice, recovery, implementation, power, patient-initiated brief
admission, child and adolescent mental health care, participation Frontiers in Psychiatry Moberg and Schön Introduction One
major diﬀerence compared to traditional admission is that it
is nurses and not doctors that handle the enrollment, but also
that no professional assessment is made concerning whether
the admission is justiﬁed or not—this is determined entirely
by the individual. The article explores staﬀ’s perspectives of PIBA for
adolescents
with
complex
mental
health
problems,
and
what facilitates or hinders its implementation. Two research
questions have guided this purpose. (1) How do the staﬀ
understand their work with PIBA? and (2) What experiences
do the staﬀhave of implementing PIBA? To better grasp the
implementation of PIBA in CAP, the study is based on the
framework of Normalization Process Theory (NPT). In this
context, NPT (14, 15) oﬀers a model consisting of four core
components (16): (1) Coherence (the sense-making of staﬀboth
individually and collectively when faced with operationalizing
PIBA in their units), (2) Cognitive Participation (the relational
work staﬀdo to build and sustain a community of practice
around PIBA), (3) Collective Action (the work carried out by
staﬀto enact and implement PIBA) and (4) Reﬂexive Monitoring
(explores the appraisal work of staﬀto assess and understand
the ways that PIBA aﬀect them and the adolescents). By
primarily focusing on individual and collective behavior, these
components aim to help us to understand implementation and,
above all, to normalize new interventions in clinical settings. Since implementing PIBA in CAP may be a way of promoting
epistemic justice and recovery (13) it is described as crucial
in order to grasp the underlying factors that either facilitate
or complicate this process, which is why implementation
theories become useful when trying to describe the clinical work
performed by staﬀ. The adolescent signs an agreement together with his/her
parents and caregivers from both outpatient and inpatient care
that gives them the opportunity to initiate, regardless of the time
of day, a care period of a maximum of four days three times
per month. Since inpatient care can be perceived as diﬃcult The framework of epistemic injustice (17, 18) has been
used to further deepen the understanding of the experiences of 02 frontiersin.org 10.3389/fpsyt.2022.1054028 Moberg and Schön staﬀas well as to explore how they might support adolescents
as epistemic subjects in deﬁning their need for inpatient care. According to Fricker (17), epistemic injustice, and especially
testimonial injustice, implies that someone is wronged in their
capacity as a knower. Setting—The context of CAP The units in focus in this article are part of a cohesive
child and adolescent psychiatric organization. There is a
total of 13 local outpatient units, eight outpatient units with
targeted interventions around, for example, trauma, emotional
instability, and psychosis, an emergency room and three
inpatient units with 10 beds in each. Most of the admissions
are described as voluntary, even though inpatient care also
cares for young people against their will, according to the
Compulsory Mental Care Act (38). The need for inpatient
care is described as being greater than what the places can
cater for (39), and in this context, PIBA is thus viewed as
fulﬁlling an important function regarding accessibility when
an adolescent deems that an admission is necessary. PIBA
currently aﬀects four outpatient units and one inpatient unit and
thus concerns about 130 employees. At each unit, a designated
nurse is appointed who is expected to have an insight into the
implementation process, while all staﬀmust know the basics of
PIBA and have completed a web-based staﬀtraining course to
ensure this speciﬁc knowledge. Introduction Also, being subject to this is argued to
be largely related to how diﬀerent attitudes and perceptions are
constructed concerning the social category to which a person
is considered to belong. Certain categories tend to be more
easily exposed to injustice than others, such as women, ethnic
minorities and individuals in institutional care (10, 17). These
categories often contribute to trivialized narratives, thus making
a high degree of credibility impossible, while the notion that
mental health problems complicate rational thinking makes it
easier for epistemic injustices to become self-generating. The
body of research on epistemic injustice is growing, and more
attention is being paid to children and young people (19–22),
and addresses the paternalistic view of how the care apparatus
deﬁnes what is in the “best interests” of the patients (23)
as well as the general absence of epistemic subjectivity and
lack of a co-creative climate in an individual’s encounter with
care. What is also addressed is how the stereotypical image of
mental health problems may undermine the self-knowledge of
adolescents and diminish their capacity as knowledge bearers
[cf. (24, 25)], which is why the ﬁeld of epistemic research
may be relevant when young people as epistemic subjects are
examined in greater detail. Hermeneutic injustice is another
aspect of epistemic injustice, meaning that someone’s ability to
understand their (social) experience is hindered due to biases
in our shared resources for social interpretation. According to
Fricker (17), hermeneutic injustice is the injustice of having
some signiﬁcant area of one’s social experiences obscured from
collective understanding owing to a structural identity prejudice
in the collective hermeneutical resource. When exploring staﬀ’s
collective experiences of implementing PIBA, this approach
might be helpful when trying to understand their reasoning and
certain strategies to manage the practical implementation work. research shows coherent results regarding increased satisfaction
and agency, fewer care days, increased suicide prevention work,
reduced coercion in inpatient care and an improved care climate
(29–32). These patterns of overall increased patient beneﬁts
may correlate with a recovery-oriented and person-centered
approach (33–37). During the autumn of 2019, a political
decision was made to implement PIBA in CAP in Stockholm
with the ambition of increasing patient participation and agency
among adolescents. PIBA—From adult psychiatry to the
context of adolescents When trying to modernize the psychiatric system, it
has been deemed necessary to incorporate new ways of
promoting a more constructive care environment, where
methods are continuously developed to optimize co-creation
and participation. PIBA is described as a way of working with
more complex mental health problems and is aimed at patients
who have generally had a low degree of agency and self-
determination in care. Since 2014, PIBA has been oﬀered at
several adult psychiatric clinics in Sweden. It initially started as a
project addressing three diﬀerent diagnostic groups—psychosis
(26), emotional instability with self-harming and suicidal
behavior (27) and eating disorders (28). In adult psychiatry, Introduction Since December 2020, PIBA is oﬀered to
patients who meet the inclusion criteria, namely adolescents
between 13 and 17 with an extensive need for care where
more complex ill health, for example, self-harm, emotional
instability, psychosis, and suicidal behavior, is common. Apart
from parental consent, other prerequisites for receiving PIBA
is that the adolescent has been admitted to inpatient care in
the past year and has an expected great need for care ahead. Also, the adolescent needs to express his or her own desire to
receive PIBA as well as demonstrate an understanding of the
meaning of using it. Frontiers in Psychiatry Description of the participants In all, 27 interviewees, 21 women and six men, participated. They were recruited via the manager at each respective unit,
and in each focus group there was a mixture of diﬀerent
professions such as unit managers, nurses, psychologists, care
workers, counselors, and psychiatrists. Two of the nurses were
also the designated contact persons for the implementation
of PIBA. Results An analysis of the material revealed two main themes (see
Table 1) and the following results are presented for each theme
separately. Although these themes have diﬀerent meanings,
they are nevertheless intertwined to some extent. Important
aspects are highlighted through a number of quotes followed by
numbers that refer to speciﬁc focus groups. When a quote from
the individual interview is used, the quote is, for ethical reasons,
cited as belonging to the focus group made in the same unit. Analysis The interviews were largely characterized by discussions
concerning the introduction of PIBA, and are here related to the
diﬀerent core components of NPT as well as aspects of power
and agency addressed by the framework of epistemic injustice. After transcribing the audio-recorded interviews verbatim,
the material was read through to obtain an overall picture
of the content. The coding of essential content, particularly
touching on descriptions of the conditions for implementing
PIBA and how this work has been carried out in CAP, was
performed by the ﬁrst author. After scrutinizing the transcripts,
the material was categorized meaning that adequate units were
selected, condensed, and analyzed iteratively as themes and
sub-themes emerged in accordance with a thematic content
analysis (41) inﬂuenced by the four core principles of NPT
(16). After that, discussions were held with the second author
until a consensus on the themes was reached. Further, to
better understand aspects of knowledge and power shown in
the material, the framework of epistemic injustice was used to
deepen the analysis. Materials and methods As we wanted to investigate the staﬀ’s joint understanding of
PIBA, it seemed appropriate to conduct focus group interviews
to obtain this speciﬁc knowledge since it is valuable tool for
collecting qualitative data (40). Altogether, ﬁve focus group
interviews were conducted, one in each participating unit. Four of them were conducted in the outpatient units by the
ﬁrst author (JM). The second author (U-KS) conducted one Frontiers in Psychiatry 03 frontiersin.org Moberg and Schön 10.3389/fpsyt.2022.1054028 Ethical considerations focus group interview in an inpatient unit and an additional
individual interview with a person in managerial position, who
expressed a wish for this. By using a semi-structured interview
guide inspired by the four core components of NPT (16)
concerning the implementation process, the ambition was to
follow the reasoning of the staﬀ. The guide included questions
such as “How would you describe PIBA?,” “What are the
prerequisites for implementing PIBA?” and “How does PIBA
diﬀer from regular work?.” All the interviews were held at the
ﬁve units between December 2021 and April 2022 and lasted
between 35 and 80 min. This study was granted ethical approval (Dnr: 2021-02790). All participants were given oral and written information about
the study prior to the interviews. Informed consent was
collected in connection with the interviews, and participants
were told that they could decline to answer questions or leave
the interview context at any time. Understandings of the purpose of PIBA A majority of the respondents expressed a coherent view
of how PIBA matches the overall organization, although
outpatient care portrayed PIBA in a more positive manner
which was contrasted by inpatient care who more clearly
discussed challenges with the implementation. PIBA was
generally
described
as
a
complement
to
existing
care
and not as a solitary intervention, and using PIBA for
preventive purposes where the contract enables faster access
to inpatient care, reduces assessments in the emergency
room and decreases destructiveness among adolescents was
discussed in all interviews. Staﬀviewed the reduction of
assessments prior to admission as something that promotes
the agency of adolescents. In addition, avoiding acute phases
in their mental health status was regarded as one of the
basic principles, while the knowledge that inpatient care is
within reach may contribute to increased endurance in an
adolescent who is battling against poor mental health. Not
having to persuade healthcare services that admission is
necessary, rather than having to signal ill health in various
destructive ways, was declared as one important aspect of TABLE 1 Themes and subthemes. The staﬀ’s experiences of
PIBA
Managing clinical PIBA work
Understandings of the purpose of
PIBA
Organizational readiness—Preparing for
PIBA
A shared responsibility
From theory to practice—The importance
of communication and collaboration
Practical obstacles and ambiguities
Implementing PIBA—“Just do it”? TABLE 1 Themes and subthemes. The staﬀ’s experiences of
PIBA
Managing clinical PIBA work
Understandings of the purpose of
PIBA
Organizational readiness—Preparing for
PIBA
A shared responsibility
From theory to practice—The importance
of communication and collaboration
Practical obstacles and ambiguities
Implementing PIBA—“Just do it”? TABLE 1 Themes and subthemes. TABLE 1 Themes and subthemes. The staﬀ’s experiences of
PIBA
Managing clinical PIBA work
Understandings of the purpose of
PIBA
Organizational readiness—Preparing for
PIBA
A shared responsibility
From theory to practice—The importance
of communication and collaboration
Practical obstacles and ambiguities
Implementing PIBA—“Just do it”? that crucial step and ask for help when they consider that they
are in need of it. using PIBA which connotes increased agency in a person’s
encounter with care. It makes a huge diﬀerence when you’re in the critical
situation, you’re not called into question and. . .and don’t
have to ﬁght for someone to believe in you. (FG2) I think that it’s an eﬀective way of asking for help and
support/and that it’s a very. . .functional alternative to
becoming destructive. This is how I think it can best be used. That instead of self-harming or threatening suicide. . .it’s
about “I need support now”. And then you get it. (FG1) Respondents
had
diﬀerent
views
concerning
their
introduction to PIBA. Some remembered exactly in which
context or by whom PIBA was ﬁrst presented. Others described
how they are generally ﬂooded with information from diﬀerent
sources, which is why their introduction to PIBA was generally
perceived as unclear. Some said that they had probably heard
about the implementation at a workplace meeting while others
thought they had ﬁrst heard about it during a lecture and a few
even said that they had not heard about it at all. In terms of
cognitive participation, some of the staﬀexplained that a lack
of resources aﬀected their ability to familiarize themselves with
what they were supposed to do. This understanding permeated
both outpatient and inpatient care where staﬀperceived the
decision to initiate the implementation as unclear. However, depending on whether the interviews were
conducted with staﬀin either outpatient or inpatient care,
there were diﬀerences among the participants, consequently
leading to an expression of uncertainty about the purpose. The perceptions of the staﬀwere inﬂuenced by how long
they had worked in psychiatry and their previous experience
of the relevant target groups for PIBA in CAP. The work
was more readily perceived as futile as there was no coherent
understanding of the purpose of oﬀering PIBA, or where it was
not known who had the overarching responsibility. So, it’s very vague, and I think it’s because. . .we don’t really
know the purpose. Honestly, I’d say we don’t know what
we’re doing here. Is it suicide prevention? Who assesses
those situations? (FG5) It hasn’t been that. . .instructive at all. I’d say that it hasn’t
been clear between managers here. . .and then you don’t
really know what the purpose is. that crucial step and ask for help when they consider that they
are in need of it. (FG5) The staﬀdiscussed PIBA in relation to regular practice,
where a more accessible inpatient care was understood to be
an important aspect for the adolescents. An extension of this
discussion included PIBA being seen as a promising tool to
promote knowledge justice and recovery and how this is best
utilized in practice. A number of respondents emphasized that
one of the main beneﬁts of having a contract is knowing that care
is within reach, which may help curb admissions. For example, it
was often stated that it is sometimes suﬃcient for adolescents to
call the inpatient unit to “check” whether there is a vacant bed. According to the staﬀ, this aspect has an important preventive
function in itself without adolescents actually “using” PIBA. The decision to implement PIBA was depicted as being
sanctioned on a political level, and a common understanding
was that the politicians were eager for the work to begin as
soon as possible, or as one respondent put it, “it became damn
urgent”. Among staﬀin outpatient care, PIBA became an explicit
tool to use in their work with adolescents. It was more imposed on them (inpatient care) as an. . .an
extra thing on top of the tough job they’re already
doing. . .while it was more like an oﬀer for us, and we just
said “wow, this is great!” (FG1) I think that PIBA. . .that its absolutely most important
purpose is being an asset that you can reﬂect upon as a
patient. You may not necessarily actually use it, but just as
we have our telephone hotline, I think that PIBA is exactly
the same type of experience for the patient. . .that it gives
them a sense of security knowing that it’s within reach. (FG1) Thus, the implementation decision was made at a high
level without the presence of the clinical staﬀ, and this was
generally perceived as having an impact on the employees’
attitude to PIBA. As the quote above also shows, a number of
the respondents underlined that this decision was “imposed” on
inpatient care, where hesitation and resistance arose while also
aﬀecting the overall pace of the implementation process. At the
same time, the staﬀfelt that there was an expectation to quickly
operationalize the political decision, which resulted in a lack of
both structure and ownership of PIBA. Frontiers in Psychiatry TABLE 1 Themes and subthemes. The staﬀ’s experiences of
PIBA
Managing clinical PIBA work 04 Frontiers in Psychiatry frontiersin.org 10.3389/fpsyt.2022.1054028 Moberg and Schön that crucial step and ask for help when they consider that they
are in need of it. A shared responsibility want it yourself. . .because we can’t force anyone to use
PIBA. It has to be a choice made by the patient. (FG5) want it yourself. . .because we can’t force anyone to use
PIBA. It has to be a choice made by the patient. (FG5) Although staﬀdescribed the adolescents as the actual
users of PIBA, the staﬀare themselves users of the method,
which here addresses strategies for implementing PIBA and
what becomes important to them during this work. During
the interviews, it appeared essential to strive for a uniﬁed
view of which adolescents that are eligible for PIBA to better
understand how the staﬀshould act in accordance with this
new way of working. When discussing the target group for
PIBA, the general view was that it was aimed at adolescents
between 13 and 17 with rather complex mental health problems
such as self-harming behavior, suicide attempts, emotional
instability, and psychotic episodes. However, this understanding
was not evident among staﬀin inpatient care, who requested
clariﬁcations about the adolescents that might be relevant
for PIBA. In terms of identifying adolescents, the staﬀcalled
for a joint eﬀort rather than it being imposed on speciﬁc
individuals. In addition, the fact that they did not wish to be
alone in this work was mainly about protecting themselves
from diﬀerent self-destructive behavior which was described as
sometimes occurring in contact with the adolescents. Drawing
on this, the discussion then dwelled on the actual responsibility
placed on an adolescent through a PIBA agreement. The
staﬀemphasized in particular an adolescent’s actual ability to
make such a decision for him or herself in a situation where
the adolescent needs help with their mental state, and that
this process is largely related to age, maturity and acquired
psychoeducation. By increasing the say that adolescents have
in these decisions, it may be understood that the staﬀconsider
them as epistemic subjects rather than merely care recipients. However, there were concerns that, at too young an age,
you cannot be expected to shoulder the responsibility that is
required, resulting in a “conclusion” regarding who is best
suited for PIBA. When discussing the advantages of PIBA, discussions about
the disadvantages and concerns about oﬀering it also followed. Managing clinical PIBA work Incorporating a new way of working into an already
pressured organization was portrayed as a challenge by all the
respondents, with an emphasis on the general lack of resources
in CAP. During the interviews, the implementation of PIBA
in practice was often touched upon and particularly prominent
was how to manage the overall responsibility of taking the
theoretical understanding of PIBA and incorporating it into the
clinical setting. The optimal PIBA-patient is someone who already works
with anxiety management, such as a DBT patient who’s
over 15/who’s already been diagnosed./Someone who. . .can
work with skills and has started with it and who wants to test
the skills they’ve already acquired. (FG5) Here, it seemed important to oﬀer PIBA to motivated and
determined adolescents who may use it to curb a deterioration
in their mental health in time, rather than succumb to
destructiveness. However, in relation to certain diagnoses, one
respondent expressed the following: that crucial step and ask for help when they consider that they
are in need of it. By implementing PIBA, the idea of exaggerating various
destructive behaviors may thus be reduced which, in addition
to an increased quality of life and control for adolescents, was
said to beneﬁt the entire CAP in terms of assurance that care is
available in a more unconditional way. From an epistemic justice
point of view, the respondents also emphasized how important
being believed is for adolescents for them to be able to take I think that a certain organizational resistance is based on
the lack of knowledge and that it’s something that’s just been
‘thrown’ at us. (FG5) 05 frontiersin.org Moberg and Schön 10.3389/fpsyt.2022.1054028 A shared responsibility These concerns were manifested in various ways, but mainly
addressed the dynamics and overarching structure of inpatient
care, where the possibility of promoting epistemic agency was
described as limited with the risk of adolescents becoming
hospitalized and subjected to epistemic injustice and further
paternalism. During the interviews, inpatient care was claimed
to be a temporary element in a person’s life, where “leaving”
psychiatry is a goal in itself. Due to this, PIBA becomes a strategy
to remain in care which is unsettling, according to the staﬀ. When talking about this, it was suggested that PIBA might risk
strengthening the identity of an adolescent as a “patient” by
facilitating admissions for certain adolescents who often have
extensive experiences of institutional care. Using PIBA may thus
contribute to prolonged care periods, which is something that
the staﬀneeds to take responsibility for and monitor together in
the midst of the overall implementation. Before admitting the patient. . .I think you should be vigilant
about whether the patient risks hospitalization. . .that you
identify patients who are at risk. In my experience, patients
who are hospitalized begin their journey in inpatient care. And then they can’t or don’t want to be discharged. . .then
the patient has become ‘addicted’ (to inpatient care). (FG3) Organizational readiness—Preparing
for PIBA Preparing for PIBA was explained as an indispensable
element in terms of creating procedures but also ensuring
that the organizational changes permeate all levels of care
in CAP. The perceived hasty political decision was described
as decreasing the agency of the staﬀ, which meant that they
were not provided with the best conditions for preparing in
a suﬃcient way. This was understood as having aﬀected the I’d
say
that
the
‘perfect
patient’
is
someone
who’s. . .motivated. Those
that
know
they
want. . .to
ﬁght for their mental health. Um. . .I don’t think that a
certain diagnosis is relevant. It’s mostly about. . .having to Frontiers in Psychiatry Frontiers in Psychiatry 06 frontiersin.org 10.3389/fpsyt.2022.1054028 Moberg and Schön stability of the implementation as well as the staﬀ’s attitude to it. The training that the staﬀwere expected to receive—watching
a PIBA video, receiving information orally and being shown
the designated bed—was explained as important, although the
majority of the respondents did not have the time to participate
in or complete it. Also, when preparing for PIBA, the staﬀdid
not consider it to be an adult model that could be applied to
CAP without adaptations. You probably need to sort of overcome all the obstacles
and see how you can solve them. Because as things stand
right now, it’s all very unwieldy. We’ve had diﬃculties with
communication. How should we communicate and with
whom? Just sending information between unit managers
and those with a responsibility for PIBA is a huge thing. There’s a lot that’s unclear. (FG5) Lack of collaboration was thus explained as an obstacle to
the implementation. Rather than being empowered by collective
action and performing new and meaningful tasks, working with
PIBA becomes something that needs to be balanced in the midst
of managing ordinary working tasks. Feelings of inadequacy
were said to aﬀect the everyday management of staﬀand they
also impinged the organizational attitude toward PIBA. I think they’ve just tried to implement PIBA as it looks in
adult psychiatry. Like ‘this is what it looks like in the adult
world, let’s take it to CAP’. But then. . .you have to deal
with parents (laughs), which becomes a completely diﬀerent
thing. So, I think you need to adapt the idea of PIBA for
someone under 18. (FG5) When trying to reach a consensus, the staﬀfelt that
they needed an established dialogue between outpatient and
inpatient care. Practical obstacles and ambiguities Discussions
about
practical
obstacles
regarding
the
implementation of PIBA permeated all the interviews. In
particular, the staﬀhighlighted that what they were unable to
achieve in their preparatory work, has a clear impact on the
continued implementation. However, the most pronounced
obstacle
was
portrayed
as
the
organizational
confusion
surrounding the PIBA bed in inpatient care. According to the
staﬀ, the hasty decision about implementation meant that CAP
did not have time to map out or communicate where the bed
would be situated, resulting in uncertainty and frustration. This is a consequence of. . .them getting PIBA in their lap. Their structure for this hasn’t been clear. . .staﬀhaven’t felt
safe. . .um. . .they haven’t even. . .they don’t know how to
write (the contract). And then this is what happens. (FG1) There was a lot of ambiguity about this bed and which
inpatient unit it belonged to. One time, I found out that
we no longer had it (PIBA) but we had told the emergency
room that we couldn’t enroll a patient because we didn’t
have any room since the PIBA bed was supposed to be kept
vacant. And then someone said “but you no longer have
PIBA in your unit”. . .and I was like “oh, don’t we?” And a
month later someone said “but now you have PIBA again”
(laughs). So that’s how it’s been./Also, at ﬁrst, a patient could
come (to the unit) 24/7 and then it changed so that patients
had to come before. . .8 p.m. and then it changed again to
7 p.m. but that information wasn’t communicated to the
night nurses and. . .um. . .the patients didn’t ﬁnd out so they
would appear at about 11 p.m. and were then told that they
didn’t have access to PIBA. So, this has been a process. (FG5) Organizational readiness—Preparing
for PIBA Some outpatient units described themselves as
“ready” to implement PIBA, but that the inpatient care setting
was prolonging the process. Inpatient care has had a number
of challenges to deal with, for example, the structures for
contract writing, securing training opportunities and keeping
the PIBA bed vacant. At the same time, they are faced with
high staﬀturnover and expectations of accessibility from
adolescents, parents and other healthcare providers. Based on
these conditions, the outpatient care staﬀcan subsequently see
that inpatient care would have needed more time to prepare
before the outpatient units started the implementation. You have to do it in a diﬀerent way, there must be another
‘setting’ to make people want to work with this./To get to the
point where staﬀ’s more likely to say: “we feel safe with this,
we have a readiness to be able to take care of this.” (FG4) Frontiers in Psychiatry From theory to practice—The
importance of communication and
collaboration Two diﬀerent starting points for implementing PIBA
emerged during the analysis. Since they were involved in
the preparatory work, staﬀfrom outpatient care reasoned on
a more theoretical level regarding how to put PIBA into
practice. However, when speaking to the inpatient care staﬀ,
who provide the actual care, they, in turn, reasoned in a more
practical way. Organizational aﬃliation may inﬂuence how
your understanding of PIBA is formed, at the same time as
practical conditions for the implementation aﬀect the entire
CAP with a certain focus on communication between outpatient
and inpatient care. Frontiers in Psychiatry 07 frontiersin.org Moberg and Schön 10.3389/fpsyt.2022.1054028 The staﬀalso highlighted aspects of trust in relation to what
is to be expected from staﬀin inpatient care. Uncertainties have
so far led to outpatient care not really knowing if someone
actually engages with the adolescents when they choose to use
PIBA. Oﬀering PIBA to a young person, where planning and
contract writing is done together with the guardians, means that
the staﬀmust be able to deliver on the promises that were given
prior to admission. Advocating PIBA thus requires that various
processes between enrollment and discharge continue and that
access to inpatient care is guaranteed in order not to undermine
the agency of an adolescent. These uncertainties risk aﬀecting
the staﬀ’s attitude with the result that PIBA is sometimes not
considered at all. This makes me feel unsure. I have ﬁve patients who
should be called to this meeting, but. . . I’ve mixed
emotions about that (laughs). It has to be good for the
patients./Um. . .and above all this meeting has to be actually
carried out. . .because they’re waiting and wondering “when
will it take place?”. We haven’t received any feedback from
any of them and they (inpatient care) don’t know when it’ll
be. . .when this meeting can. . .take place. (FG5) Also, the family’s involvement in PIBA was explained as
a complicated aspect during the implementation, where the
overall organizational challenges have not helped. The staﬀ
described a situation where there was a conﬂict between parents
and colleagues when trying to clarify who wanted to use PIBA—
a decisive factor since the adolescent’s agency is expected to
control this. From theory to practice—The
importance of communication and
collaboration If there is uncertainty about how and by whom
PIBA is utilized, the staﬀargued that there are no resources to
respond to diﬀerent wishes or handle complex situations when
the adolescents come to the inpatient unit. Unfortunately, I think that an obstacle is about. . .the very
practical aspects that sometimes make me think ‘she can
just as easily go to the emergency room’. . .because. . .this
PIBA bed may not be guaranteed. I don’t really trust the
organization surrounding PIBA. . .or the access to inpatient
care. I feel that we may take another road. We’ll solve this in
some way or another. (FG1) Sometimes, the parents complicate PIBA admissions, and
patients have told me that they came here (to the
inpatient unit) only because their parents ‘said so’. But also,
sometimes parents come here signaling chaos which makes
everything quite distorted. Whilst parents say they want
their child to be admitted, the patient shows great reluctance
shouting “I don’t want to be here”. . .which makes PIBA
impossible. So, in those cases it turns into a matter for the
social services. (FG5) During the implementation, the staﬀhave had to deal with
missing information, for example, the respondents sometimes
described that decisions were being made without them being
able to identify by whom—external supporter, unit manager,
section management or at an even higher level. Also, the staﬀ
currently experience ambiguities about what is expected of them
and who has what responsibility in outpatient and inpatient
care. A majority of the respondents claimed that the division
of responsibilities and cooperation was unclear, and that it is
important to illustrate how adolescents are identiﬁed, who is able
to identify them and who to turn to if you have questions. Implementing PIBA—“Just do it”? (14, 15)] meaning that important health beneﬁts among
adolescents here risk being lost [cf. (42)]. Basic prerequisites
in the implementation process were about commitment among
staﬀ, time to get acquainted with PIBA, cooperation between
outpatient and inpatient care as well as continuity for the
designated facilitators of PIBA and adequate procedures for
the writing of contracts. The absence of this organizational
foundation may aﬀect the general attitude toward PIBA. that apply to obtain an agreement and who the facilitator
in each unit is, which constitutes reﬂexive monitoring. Since
the implementation is characterized by a general confusion
and uncertainty, not discussing PIBA often enough may,
according to the staﬀ, lead to PIBA being abandoned. Jointly
monitoring the purpose and outcome of PIBA was claimed
to be important since epistemic agency is not something that
comes automatically by just implementing a method. Rather,
this eﬀort needs organizational and individual supervision, and
being reminded of this at workplace meetings makes it possible
to alleviate the risk of misunderstandings. There has to be someone who has control. . .like ‘these are
the criteria for PIBA, this is how you do it’, um. . .because
otherwise it’s easy to forget. Sometimes we sit at treatment
conferences and wonder ‘how do we do this?’. And then you
don’t really know what to do because you don’t do it (discuss
PIBA) often enough. (FG2) Apart from the practical obstacles experienced by staﬀ,
the interviews also touched upon trust, professional expertise
and leaning on each other’s knowledge as well as stable
care chains when facilitating PIBA in the clinical setting. These conditions were said to be imperative in order to
ensure organizational cohesiveness and readiness as well as
promoting the continued implementation and epistemic agency
among adolescents. Linking this to implementation theories,
NPT addresses how diﬀerent components in this process are
approached by clinicians as well as how these are adopted in
existing procedures. It also presents facilitating and hindering
factors for this endeavor in that it stresses that this new
way of working needs to be adopted correctly (43) where a
joint organizational approach requires careful planning with
an understanding of each other’s clinical everyday life. Implementing PIBA—“Just do it”? Initially, some respondents thought that implementing
PIBA would be fairly straightforward. However, the lack of
organizational readiness has led to a re-evaluation concerning
this. A number of participants described a general motivation
to “just do it” but that the commitment needed from both
outpatient and inpatient care has not been established. To
avoid stagnation, the staﬀdiscussed the importance of keeping
on trying rather than waiting for the best conditions, and
if PIBA is really incorporated in the various units, there
are also opportunities to address the management regarding
practical diﬃculties. If there’s a disagreement among colleagues about this
(PIBA)/then it must be handled in some way. . .somehow
you have to agree if a patient’s ‘ready’. And who has the
decision-making power? Is it the patient’s main therapist or
is it the doctor in the unit as well? (FG2) Being in agreement was thus described as a prerequisite if
PIBA is to function as favorably as possible, which addresses
aspects of collective action as well as the power and hierarchy
structure in CAP. Not being synchronized in this endeavor was
described as undermining the stability of the implementation
process as well as complicating the role of the contact persons
for PIBA. Due to staﬀturnover, the stability that needs
to exist around these staﬀmembers was said to be absent
which is problematic since the contact persons are expected
to participate at the meeting where the contract between
adolescents, guardians and CAP is drawn up. Without this
supportive function, the process is perceived as even more
unclear and risks not being carried out. I think we just need to ‘start doing’ it and not be afraid and
not. . .not think so much/and if we just do it, we can also
give feedback to managers that ‘this is how you could do’ or
‘this doesn’t work’ or ‘we need this to make it work.’ (FG3) Going forward, it was considered crucial to have regular
follow-ups and reminders about current adolescents, the criteria Frontiers in Psychiatry 08 frontiersin.org 10.3389/fpsyt.2022.1054028 Moberg and Schön as insuﬃcient which has contributed to the purpose of PIBA
being perceived as fragmented. In CAP, the structure of the
implementation has changed repeatedly, which the participants
described as aggravating in terms of uncertainty and frustration. These factors risk aﬀecting their view of PIBA as complicated,
resulting in an incomplete or protracted normalization [cf. Discussion Furthermore, since the decision to implement PIBA was
sanctioned on a political level, the way the staﬀreasoned
regarding this can be understood on the basis of both epistemic
injustice and implementation theories. As mentioned above,
PIBA has the potential to promote epistemic justice for
adolescents by allowing them to themselves deﬁne their need of
inpatient care. Another result is that staﬀ, especially in inpatient
care, are also actors in this process but that they, to some extent,
lack hermeneutic justice where they describe that their needs
and wishes regarding the implementation work are diminished
and/or made invisible. In terms of epistemic injustice, the staﬀ
had limited access to information, resulting in loss of knowledge,
and power [cf. (17)]. Also, their agency was virtually non-
existent and they did not participate in shaping how the work The aim of this study was to explore staﬀ’s perspectives of
PIBA for adolescents with complex mental health problems,
and what facilitates or hinders its implementation. In semi-
structured focus group interviews, outpatient and inpatient
care staﬀshared these experiences, and a number of dominant
themes have been identiﬁed and interpreted within the
theoretical frameworks of epistemic injustice and NPT. Implementing PIBA—“Just do it”? Here,
staﬀpresented diﬀerent obstacles when working with PIBA—
rather than relying on each other’s knowledge in oﬀering PIBA
to adolescents, ambiguities such as not knowing the facilitators
or which inpatient care unit is responsible for the PIBA bed
were described as barriers to PIBA being used or considered. This might complicate the above-mentioned core components
of NPT, which is a ﬁnding that is in concordance with
previous research illustrating the importance of stability and an
overarching commitment when initiating implementation work
[cf. (44)]. Among the outpatient care staﬀ, the idea of “just doing
it” was also translated into the overall importance of trying
new things and seeing the early implementation phase as work
in progress. At the same time, the importance of having a
committed management that is continuously involved in the
implementation at the same time as they have the ultimate
responsibility for the monitoring of general progress concerning
implementation was accentuated. Without a joint organizational
approach and clear directives in the process going forward, the
work will be made more diﬃcult, according to the staﬀ. If you’re going to implement this, it’s important that
you’re. . .that the entire clinic, right from the top. . . has the
will. That ‘this is what we’re going to do.’ And that it’s also
communicated to the emergency room and chief physician
and. . .everywhere. And you have to work with that for quite
some time before it settles. (FG5) Frontiers in Psychiatry Adjusting PIBA to the youth context In order for staﬀto facilitate agency and recovery among
adolescents, it was considered important to adapt PIBA from the
adult setting and thus make adjustments to the youth context
[cf. (13)] that includes parents. Part of the recovery research
on young people is about how care can be optimized and
developed to best facilitate a recovery-oriented approach (33,
37). Here, a “youth-friendly” perspective (35, 36) is argued to
be established in an overall biomedically dominated range of
care, where PIBA has the potential to realize this view as well
as becoming an extension of young people’s right to agency
and participation (1, 3–5, 34, 38). As an adolescent, being given
the opportunity to use PIBA may be associated with increased
psychoeducation which also stresses the general diﬀerences
between adults and young people’s identity development. This
developmental process usually includes aspects of ambivalence
and uncertainty that need to be taken seriously in young people’s
encounters with care [cf. (37)]. Methodological considerations When interpreting these ﬁndings, certain methodological
considerations need to be discussed. The presence of a unit
manager in four of the ﬁve units may have aﬀected the other
participants. A limitation may be linked to the (potentially)
reduced freedom that comes with a manager’s presence. Although in this context, the advantages have outweighed the
disadvantages, especially as regards the possible uncertainties
that may be clariﬁed by people in managerial positions. A majority of the participants were from outpatient care, which
means that the material and quotations may be perceived as
uneven, since the perspective of inpatient care staﬀconsists
of a smaller sample. In light of the organizational limitations
and diﬀerences in the work intensity between outpatient and
inpatient care, the inpatient care staﬀwere not interviewed as
easily as the other staﬀ. However, considerations were made that
it was important to include the perspective of inpatient care as
far as possible. Another reﬂection touches upon the fact that
the units are in diﬀerent phases regarding the implementation
of PIBA, which may aﬀect their understanding of and attitude
toward the purpose of the method. Lastly, the main author has
interpreted the material based on speciﬁc research questions
linked to epistemic injustice and implementation theories, and
thus omitted other possible themes than those presented here. Conditions for implementing PIBA When discussing the organizational conditions required
for the implementation of PIBA, they were mainly described 09 Frontiers in Psychiatry frontiersin.org 10.3389/fpsyt.2022.1054028 Moberg and Schön with PIBA was to be realized in practice. This is particularly
addressed by the staﬀin the results section when they discuss
the feeling of having PIBA “thrown” at them, meaning that they
feel that the political decision was “top down” (45), [cf. (44,
46)] because staﬀwere not involved in the diﬀerent decision-
making processes. Trying to express an opinion on the clinical
work—such as adapting PIBA from a system for adults to
one for adolescents and voicing their collective dissatisfaction
with the organizational conditions—one way of increasing
the staﬀ’s agency and enhancing recovery orientation (47), is
to reduce hermeneutic injustice (17) by recognizing staﬀas
knowledge carriers as well as to underline the need for a “bottom
up” perspective [cf. (44)]. However, it was implied that staﬀ
were not listened to when trying to voice dissatisfaction or
concerns regarding practical matters and ambiguities during the
implementation, and without acknowledging the coexistence
of multiple perspectives concerning PIBA, for example, those
of politicians, management and staﬀ, the implementation risks
failing due to resistance or abandonment which underlines the
need for adopting both top-down and bottom-up approaches in
order to facilitate normalization [cf. (43, 46)]. understandably risk their agency and at the same time endanger
their epistemic subjectivity. There were staﬀwho had practical
experience of having to manage the balancing act between, on
the one hand, recognizing the young person’s increased agency
in the choice to use the inpatient care and, on the other hand,
not knowing of this choice being in accordance with what PIBA
stands for, but rather a choice, formal or informal, made by the
parents. In reality, this can mean that the adolescents are met by
the staﬀ’s confusion and uncertainty regarding the adolescents
possibly being subject to parental guidance which may aﬀect the
admission in various ways, and especially the adolescents not
being listened to [cf. (20, 24)] or seen as credible in their choice
to use PIBA [cf. (21)]. Frontiers in Psychiatry Publisher’s note All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their aﬃliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed
or endorsed by the publisher. Conclusion and implications for
practice The involvement of parents at the admissions stage as
well as transparency regarding how the adolescents use the
contract were discussed by the staﬀ, who wished for more
adequate cooperation between CAP, adolescents and parents
in order for PIBA to function optimally. Unlike adults who,
may, without argument, renounce contact with family and
relatives, adolescents were described as a part of the family
system with a clearly limited legal space for self-determination
[cf. (2)]. During the interviews, there was some uncertainty as
to whether parents of adolescents with a PIBA contract risk
persuading or otherwise inﬂuencing them to use it, which can This article reﬂects on the implementation of PIBA in
CAP, and underlines normalization, epistemic agency and the
position of adolescents in mental health care. The results of
the study imply that the majority of the staﬀinterviewed
were positive toward the overarching ideas of PIBA and
viewed it as a possibility to increase agency and recovery
among adolescents and to legitimize their knowledge about
their mental health status. However, the interviews also 10 frontiersin.org Moberg and Schön 10.3389/fpsyt.2022.1054028 show that obstacles arise when work with PIBA is to be
put into practice, where reduced agency among inpatient
care staﬀmay be a complicating factor for a sustainable
implementation since they are expected to strengthen the agency
and recovery of adolescents simultaneously. The results thus
highlights the importance of promoting epistemic agency—such
as organizational conditions and participation in the decision-
making process—among the staﬀinvolved in implementing
PIBA. Without these conditions, promoting epistemic agency
and recovery among adolescents’ risks being reduced to merely
a tokenistic vision rather than being properly put into practice. The paradigm shift toward recovery-oriented models in mental
health care is ongoing and, to some extent, transcends CAP as
well as other welfare services. Yet, since there is no sole manual
for how agency and recovery are initiated and maintained,
there needs to be a clearer understanding of what this entails
when working with adolescents with complex mental health
problems. Further, since it is not entirely obvious how the
parents’ involvement should be shaped when PIBA is used, this
calls for more scrutiny in order for PIBA to facilitate epistemic
agency rather than hindering it due to parental involvement. In addition, to ensure that care is designed in a youth-friendly
way, further work is required where above all the structural
challenges of inpatient care are focused on. Ethics statement This study was reviewed and approved by the Swedish
Ethical Review Authority (Dnr: 2021-02790). Written informed Conﬂict of interest The authors declare that the research was conducted in the
absence of any commercial or ﬁnancial relationships that could
be construed as a potential conﬂict of interest. Funding This work was partly funded by the Region Stockholm
(grant no. RS 2020-0501). Acknowledgments We thank the participants who contributed generously to
this study. Data availability statement The datasets presented in this article are not readily available
because participants of this study disagreed about their data
being shared publicly. Requests to access the datasets should be
directed to JM, jennie.moberg@socarb.su.se. Author contributions JM elaborated the original theoretical proposal presented
in this article and wrote the original manuscript. Both authors
revised and edited the manuscript and were responsible for
its ﬁnal version. Conclusion and implications for
practice Moreover, while little
attention has been paid to the experience of adolescents using
PIBA, this should be the focus of future studies. consent
was
obtained
from
the
individual(s)
for
their
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