Psychiatry Nurses’ Experiences of Patient-Initiated Brief Admission from Inpatient and Outpatient Perspectives: A Qualitative Exploratory Study

Abstract Patient-initiated brief admission (PIBA) allows patients to decide when admission to psychiatric care is necessary. This may prevent long-term hospitalisation and promote patient participation. Research on psychiatric nurses’ experiences with PIBA is lacking, therefore 11 nurses were interviewed and data analysed using content analysis. Prominent categories were: improved personal development for the patient, more equal nurse-patient relationship, rapid access to a safe environment and strengthened professional collaboration. PIBA is a helpful intervention for patients in crisis, giving both patients and nurses a sense of security. Future studies should explore how this impacts nurses’ work environment and job satisfaction.


Introduction
Psychiatric nurses often encounter patients experiencing acute crises, a phase in which patients may express anger, self-harm, and have suicidal ideations (Cutcliffe & Barker, 2002).This can be particularly difficult for healthcare staff to manage and can also affect the nurse-patient relationship.In fact, the relationship between psychiatric care providers and patients is often described as challenging (Karman et al., 2015).Patients often perceive healthcare professionals working in inpatient care, to be restrictive and authoritative "boundary-keepers" (Bodner et al., 2015), which may trigger violent and aggressive behaviour by patients towards staff (Papadopoulos et al., 2012).Difficulty coping with acute and demanding situations can lead to frequent conflicts between the patient and their care provider, potentially having a negative impact on patient care (Newton-Howes & Mullen, 2011).In response to such conflict-prone situations, coercive measures such as physical restraint, forced medication, and seclusion are often applied against the patient's will to ensure the safety of both patients and staff (Wong & Bressington, 2022).Despite nurses' negative feelings and moral conflicts about physical restraint, they continue to employ it as a strategy.This highlights the need for educational interventions and strong leadership to transition to a restraint-free environment.The implications suggest that psychiatric nurses should actively work towards removing existing barriers and developing alternative skills to replace physical restraint (Wong & Bressington, 2022).To improve the nurse-patient relationship and promote person-centred care, it is essential to recognise the patient as a competent individual (Gabrielsson et al., 2015).Granting patients autonomy in their own decision-making and viewing individuals as capable of assuming responsibility, based on their physical and mental capacities, are critical features of ethical nursing practice (International Council of Nurses, 2021).
Patient-initiated brief admission (PIBA) is a nursing intervention specifically designed to offer patients the power to determine when a brief stay (typically 1 to 3 days) in inpatient care is warranted, thereby promoting their autonomy (Helleman et al., 2014a).Previous research has also shown that PIBA improves the patient-provider relationship and provides patients with an increased sense of security and autonomy (Eckerstrom et al., 2020;Lindkvist, Westling, Liljedahl, et al., 2021).In fact, inpatient care nurses have expressed that PIBA not only helps patients cope with anxiety and destructive thoughts, but also improves relationships and attitudes between patients and providers (Eckerstrom et al., 2019;Lindkvist et al., 2019).PIBA can also reduce the duration of inpatient psychiatric care in patients with high utilisation of these services (Nyttingnes & Ruud, 2020;Strand et al., 2020), and is particularly favourable for patients with borderline personality disorder (BPD) in times of crises (Eckerstrom et al., 2020;Enoksson et al., 2022;Lindkvist, Westling, Liljedahl, et al., 2021).According to outpatient staff, PIBA is particular beneficial as a crisis management intervention when providing complementary with psychotherapy, to achieve stable and durable treatment (Arnold et al., 2022).
A unique aspect of PIBA is that inpatient nurses are responsible for both admission and discharge, in contrast with regular psychiatric admissions where physicians hold that responsibility (Eckerstrom et al., 2022).PIBA has been implemented across the majority of Sweden's regions, and is most often utilised by patients diagnosed with BPD who engage in self-harm and/or experience recurrent suicidal ideations (Socialstyrelsen, 2021).Despite variations in the content of the PIBA intervention across the different regions, the overall structure of PIBA remains consistent: a three-part agreement between the patient, a nurse from inpatient care and a nurse from outpatient care, which enables the patient to be admitted to psychiatric inpatient care (Socialstyrelsen, 2021).Previous research on PIBA has mainly focused on patients' experiences.To date, thirteen qualitative interview studies have been published, seven of which are from Sweden (Eckerstrom et al., 2020;Enoksson et al., 2022;Helleman, Lundh, et al., 2018;Lindkvist, Westling, Liljedahl, et al., 2021;Lindkvist, Westling, Eberhard, et al., 2021;Strand, Bulik, et al., 2017;Strand, Gustafsson, et al., 2017), two from the Netherlands (Helleman et al., 2014b(Helleman et al., , 2016)), two from Norway (Olso et al., 2016;Rise et al., 2014), one from Australia (Mortimer-Jones et al., 2019) and one from Denmark (Ellegaard et al., 2020).A common perception derived from these articles is that the intervention provides easily accessible care when needed, with a welcoming approach from the staff.Nurses' experiences utilising PIBA have not been explored to the same extent.To our knowledge, there are only four previous publications (Arnold et al., 2022;Eckerstrom et al., 2019;Lindkvist et al., 2019;Mortimer-Jones et al., 2019).The focus on barriers and facilitators to its implementation has seldom been explored, particularly from both the inpatient and outpatient perspectives.Therefore, the current study aims to explore nurses' experiences of working with PIBA in both inpatient and outpatient care settings.

Intervention description and setting
The main objective of PIBA in Sweden is to enhance patients' coping skills, reduce anxiety, and prevent suicidal thoughts during crises by enabling them to initiate their own admission to psychiatric inpatient care (Eckerstrom et al., 2022).Patients can obtain access to a PIBA-designated room on a psychiatric inpatient ward after establishing an individual PIBA care plan, also known as a "PIBA contract" or "PIBA agreement." This agreement takes place during a discussion with an inpatient care nurse and their regular outpatient care provider, such as a psychologist or specialist nurse.The PIBA contract includes information about the: (1) goal and indications for using PIBA, including when it is not appropriate and regular admission should be sought instead, (2) structure of PIBA, i.e., duration of 1 to 3 days, 3 times per month (maximum), and instructions for what to do when the PIBA-designated room is occupied, and (3) care to be received at the ward during PIBA, such as daily conversations and participating in specific activities (Eckerstrom et al., 2022).PIBA was implemented in two psychiatric outpatient clinics and two inpatient wards located in Region Stockholm (Sweden) between 2016 and 2020.All units were specialised in treating patients with emotional instability and anxiety disorders.

Design and participants
A qualitative study design was deemed appropriate as it allows for first-hand exploration of nurses' experiences with PIBA in both psychiatric inpatient and outpatient care settings.The Consolidated criteria for reporting qualitative research (COREQ) was used to ensure comprehensive reporting on performed methodology and reflexivity (Tong et al., 2007).Purposive sampling was used to recruit nurses from the one of the participating inpatient wards and two outpatient units.The other inpatient ward had already participated in a qualitative study during the implementation phase (Eckerstrom et al., 2019).The sole inclusion criterion for participation was being a registered nurse who had worked with PIBA, regardless of age, gender, or length of nursing experience.Eligible participants from inpatient and outpatient care were sent information letters via email by the project coordinator in November 2017 and invited to participate.At that time, both the inpatient and outpatient care units had worked with PIBA for over 2 years.All 13 eligible nurses from the inpatient ward were contacted, and seven of them expressed interest in participating.Four eligible nurses working in outpatient care were contacted, all of whom wished to participate.Therefore, a total of 11 nurses participated, comprising seven women and four men.Participants' work experience within psychiatry ranged from 6 months to 15 years, five had a specialist nursing degree, two were currently pursuing a specialist degree, and four were registered nurses without a specialist degree.

Data collection
Data were collected between November 2017 and February 2018 through individual semi-structured interviews, using an interview guide developed specifically for the current study, see Appendix 1 (Supplementary material).The guide was pilot tested with no subsequent changes made.Interviews were conducted in Swedish by two Master's degree students specialising in psychiatric nursing at a location chosen by participants, specifically, their workplace.Interviews lasted 15 to 58 min (mean duration = 37 min).All interviews were audio recorded and transcribed verbatim in Swedish.

Data analysis
Data were analysed by TL and JW using latent content analysis with an inductive approach (Graneheim et al., 2017;Graneheim & Lundman, 2004), and findings were later translated to English for the purpose of this article.TL and JW read through the interview transcripts several times to gain a comprehensive understanding of their content.Next, meaning units that aligned with the study's aim were identified and coded by both analysts in parallel.Meaning units were condensed while retaining their core context and meaning, and further abstracted to codes.Subcategories were then created by searching for similarities and dissimilarities among the codes and grouping them.Through further abstraction of the subcategories' , categories were generated, see Table 1 (Lindgren et al., 2020).Coding was conducted manually on paper.Meaning units and codes were subsequently transferred to a word processing program, which was used for the remaining analysis.TL and JW met regularly with SS and JE during analysis to discuss findings and ensure that they accurately reflected participants' experiences and perspectives.These meetings were held until reporting consensus was achieved.Member checking was not performed, i.e., individual transcripts and a draft of the findings were not sent to the interviewees for comments or corrections.All remaining co-authors (NJL, LF, EASG) contributed to the final analysis to ensure reporting consistency.

Ethical considerations
This study was granted ethical approval by the Regional Ethics Committee in Stockholm, Sweden (2016/671-31/5) and followed the ethical principles of the Declaration of Helsinki (World Medical Association, 2013).Participation was voluntary and all participants were informed that they could withdraw from the study at any time without giving an explanation or consequences.All participants received written and oral information about the study prior to giving their informed consent.Data were handled confidentially, and quotes were anonymised to prevent identification of participants.

Results
Our analysis resulted in five categories, and ten subcategories, see Table 2, which are presented below.Inpatient and outpatient nurses are collectively referred to as "nurses" when presenting our findings unless the distinction is specifically expressed as "inpatient care nurses" or "outpatient care nurse".
In general, nurses had a positive outlook towards the PIBA intervention, which they believed not only gave patients easy and rapid access to a safe environment in the event it was needed, but it also gave patients the opportunity to become more self-aware and take responsibility for their own care.Additionally, PIBA was believed to have had a positive impact on nurses' relationship with their patients, and their collaboration with outpatient care.Despite this, nurses raised implementation concerns that should be considered to both improve its implementation in their setting but also other similar settings.

Opportunity to improve the patients' personal development
Nurses reported that PIBA had a positive impact on patients, as evidenced by their increased ability to deal with their mental health issues on a daily basis.Specifically, according to inpatient care nurses, patients took greater responsibility for their own well-being and learned how to prevent destructive behaviour, rather than relying on others for support.Nurses described several ways in which PIBA helped patients improve their ability to help themselves, including having the ability to take charge of their own healthcare and an increased sense of self-awareness.

Encourages patients to take charge of their own healthcare
Nurses observed that PIBA empowers patients to take greater control over their own healthcare from the start, when patients collaboratively develop an individual contract with inpatient and outpatient nurses that outlines how they wish their healthcare to be organised.PIBA allows patients to shape their own contracts, resulting in a more person-centred approach that empowers patients to feel more in control.According to nurses, this newfound sense of agency leads to more responsibility and improved decision-making, both during an inpatient stay and at outpatient appointments.Inpatient nurses noted that this change was noticeable following implementation of PIBA and was particularly distinct from how patients experience a regular admission.Nurses however described that patients need to be willing to take charge of their own healthcare to benefit from PIBA.
Through the contract, patients have the opportunity to express what is important to them.By contrast, during a regular admission, the assessment is largely based on the patient's current condition.Through PIBA, patients are given more control, as their contracts might include specific requests, such as planned supportive conversations or preference for female staff.These conditions are essential to follow to ensure that patients receive the care they need.(Nurse 7, inpatient care) Inpatient care nurses also acknowledged that they needed to learn how to relinquish control and trust patients to take responsibility for their own care.This process was sometimes described as difficult for inpatient nurses who were used to being in charge during regular admissions.Despite the challenges of relinquishing control, inpatient nurses were pleased to see how well patients with a PIBA contract were able to manage the heightened responsibility and how well they recovered after utilising PIBA and being given an increased sense of responsibility and autonomy.
…PIBA helped her [the patient] take responsibility.She was so dependent on others before PIBA, so it has strengthened her as a person as well and she has noticed that herself too, which is positive.(Nurse 3, inpatient care) Despite the observed benefits of PIBA for patients, inpatient care nurses emphasised certain risks of giving patients a greater degree of responsibility at admission, as well as during their hospital stay, especially if their symptoms deteriorate following PIBA.For example, it may be more challenging for patients experiencing mood shifts post-admission to take responsibility for their own care, including administering their own medications.Inpatient nurses described how patients can become unstable and have trouble controlling their impulses, which can lead to overconsumption of their medications and resultant mild drug intoxication, as exemplified below.
There were occasions where she [the patient] had taken too many tablets which made her mildly intoxicated, and then it becomes difficult because it is a patient who initiated their own admission and we are not familiar with their medications and such, it's something that they must take responsibility for themselves.So, it becomes more problematic of course.(Nurse 7, inpatient care)

Increases the patient's self-awareness
Nurses noted that PIBA helped patients develop better coping skills in ways they had not seen prior to its implementation.These improved coping skills enabled patients to not only to better manage their symptoms better but also to assess whether PIBA was an appropriate treatment option for them or not.
I think it has been really clear that patients have grown a lot by having access to PIBA.I didn't think it would impact them that much.We have seen patients who might have come to be admitted through PIBA, but realise themselves that they are too unstable for PIBA, so they decide to discharge themselves and go to the emergency room instead, as they believe they need another type of care.These self-insights must be absolutely superb for the patient.(Nurse 5, inpatient care) Nurses explained that the PIBA contract itself, which is written in the patient's own words, served as a platform for patients to discuss their thoughts about their psychiatric problems, symptoms, and diagnosis.This process helped patients, with the support of inpatient and outpatient nurses, to independently identify early warning signs, plan what they should do, and determine how they should act during a crisis.Nurses believed that formulating the PIBA contract contributed to the patient's personal development and growth by making them more aware of their own behaviours and identifying suitable coping strategies.This heightened awareness was reportedly helpful, as it gave patients the ability to their break destructive behaviour and request help during early-stage symptom deterioration.According to nurses, patients also expressed pride in their ability to manage their own daily struggles and make problem-solving decisions, rather than giving in to their self-harm impulses.
PIBA definitely helps patients.It strengthens the individual's capability to build on their knowledge of themselves."What do I need to recover from this symptom regression and the crisis I'm in right now?, " "How can I take care of myself?"That capability is developed through this intervention.(Nurse 9, outpatient care)

A more equal nurse-patient relationship
Nurses believed that PIBA provided all parties with a clear and non-ambiguous admission protocol that in turn contributed to an improved and more equal nurse-patient relationship.Inpatient nurses described how their interactions with patients were more equal, respectful, and positive compared to patients admitted via regular admission.Pre-implementation of PIBA, relationships were often coloured by hierarchy, with staff regarded to be in charge, which led to more friction and occasional arguments between staff and patients.Inpatient nurses felt that these arguments often centred around medication, particularly regarding when and how medicines should be taken.

Minimises ambiguity by providing a clear admission protocol
Nurses observed that PIBA's defined structure and the contract's clarity for all parties involved, contributed to an improved nurse-patient relationship.This made it easier to shift the focus from questions regarding the ward and duration of care, to more spontaneous and constructive conversations upon admission.
I think that nursing staff avoid ending up in conflicts on the ward.I work in outpatient care, but I think you avoid ending up in conflicts, such as, "Are they being truthful?"or "Is that really so?" […] now there are very clear frameworks; this is how PIBA is defined and there are no more questions asked.So, the structure probably contributes to less bickering and more unity between the different groups.(Nurse 9, outpatient care)

Improves staff attitudes towards patients
Nurses from inpatient care specifically expressed that seeing patients fare better mentally while on PIBA or when writing PIBA contracts made it easier to connect with patients and resulted in a strengthened relationship.This is in stark contrast to patients who are transferred from the emergency room during an acute crisis, with whom developing a good relationship is much more challenging.
You should never treat a patient differently when they are on PIBA than when they are on a regular admission, but I think that in some way you become more positive towards patients when they use PIBA … you see it as something positive that the patient has taken responsibility, and the patient somehow becomes more like a guest.(Nurse 7, inpatient care) Nurses believed that another factor contributing to an improved relationship with their patients was that patients were received with less scepticism from staff regarding why they felt inpatient care was necessary.Nurses felt that this was a positive effect of PIBA in comparison to regular admissions, where they noted that patients tended to exaggerate their symptoms to be admitted to the ward.Prior to PIBA, this often led to a negative spiral of suicidal threats and self-harm followed by arguments and conflicts between nurses and patients.Nurses experienced that PIBA eliminated this conflict-producing step, creating a more welcoming environment as patients admitted themselves to the ward of their own accord.
Patients [enrolled in PIBA] do not need to prove to us how bad they are feeling, they will be received well and believed regardless.No one questions their agenda, as might happen during regular admissions.(Nurse 9, outpatient care)

Easy and rapid access to a safe environment
Nurses stated that safety was an important aspect of PIBA, particularly because patients can feel secure knowing that they have the option to quickly receive inpatient care if they feel the need to break the cycle of negative feelings and destructive behaviour.

Promotes a sense of security
Nurses reported that patients in need of PIBA were informed that they could call the ward around the clock.This, they believed, allowed patients to feel seen and heard, giving them a sense of security.Nurses described how this knowledge could contribute to patients feeling calmer during crises, resulting in a decreased perceived need for inpatient care and therefore fewer admissions.They also believed that the PIBA contract's clarity made the admission predictable for the patient, further strengthening their sense of security.
From the day they sign the contract, they come a few times and then they stop coming.Sometimes they call, asking if a room is available and they settle with that.I think it gives them a sense of security just knowing that there is a place they can go, that has a room available for them, without feeling that they have to first self-harm or threaten that they are going to commit suicide, in order to get admitted.(Nurse 6, inpatient care) Outpatient care nurses also stated that knowing patients have access to PIBA gave nurses an additional sense of security, as PIBA safeguards patients who may otherwise have difficulty accessing outpatient care when their symptoms regress, especially during evenings and weekends.Inpatient care nurses expressed how nursing care, rather than pharmaceutical treatment, played a crucial role in making patients feel safe while on PIBA.
When patients come in and are in bad shape, it's usually because they are unable to cope with their day-to-day activities, so we support them to return to their usual daily routines.We also offer something called "supportive conversations, " which is probably our biggest nursing actions.(Nurse 1, inpatient care) However, inpatient care nurses observed that mixing patients admitted under compulsory care with those admitted through PIBA could be problematic and compromise the patients' sense of security.Nurses believed that these two forms of care had distinct support and care needs and, therefore, should not be combined in the same ward.The problem was further exacerbated by the fact that some non-PIBA patients could exhibit disruptive behaviours, which could prevent PIBA patients from accessing the peaceful and quiet environment they require.

Helps patients with negative feelings and destructive behaviour
Nurses believed that PIBA had several positive repercussions on patients.PIBA helped patients with destructive behaviour by decreasing the frequency of destructive acts such as self-harm and providing patients with an easier path to stabilisation.
It could be that they instead of using destructive methods, such as self-harm, addiction or God knows what, they use PIBA to break destructive patterns, behaviours when it kind of bubbles up.(Nurse 10, outpatient care) Several nurses also felt that PIBA reduced the overall number of admissions for patients who previously had long hospitalisations.In fact, many of the patients they cared for had gone from experiencing numerous episodes of self-harm and coercive care, to well-functioning after engaging in PIBA.
We had a patient who used to be hospitalized for quite long periods of time, often two-to three-week periods, and just as she was about to be discharged, her anxiety would always increase in intensity, and she would do anything to be able to stay.So we signed a contract with her and she came once or twice.She felt that that was okay as she knew she could come at any time.(Nurse 6, inpatient care) Nurses attributed the decrease in self-destructive behaviour and admissions to PIBA, which offers patients a rapid way to break negative feelings and potential negative spirals before they escalate into destructive impulses and self-harming behaviour.Nurses believed that PIBA is a suitable nursing intervention for patients who feel seriously unwell over a longer period and desired for it to be offered more widely to give patients the opportunity for swift stabilisation.However, nurses explained that PIBA rooms were not always readily available to patients seeking admission, which sometimes led to self-harming behaviour and care seeking in the emergency room.To avoid this, nurses wished to increase the number of PIBA rooms available on the ward to improve accessibility through PIBA.

Strengthened professional role and collaboration
Nurses felt that, as a purely nursing intervention, PIBA strengthened their role as a nurse.They also highlighted that PIBA facilitated better collaboration between outpatient and inpatient care.

Strengthens the nurse's professional role
Nurses experienced that PIBA unlocked new possibilities and gave them the opportunity to offer patients who self-harm new tools that were previously non-existent.
Very positive.It has been like being able to give away something very nice, exclusive, completely free of charge to the patients.And that is the future of psychiatry, I would say.(Nurse 9, outpatient care) Furthermore, inpatient care nurses felt that, as a nursing intervention, PIBA provided them with increased responsibility and professional autonomy.They felt that PIBA allowed them to grow within their professional role as it was implemented in a nursing facility where the patient does not need to consult a doctor; nurses are responsible for admission and discharge.

Improves collaboration between inpatient and outpatient care
Nurses expressed that the collaboration between outpatient and inpatient care worked well and even improved since the introduction of PIBA.Nurses also found it beneficial that outpatient and inpatient care nurses could provide two different perspectives of the patient when drafting and signing the contract.While outpatient care nurses mostly see patients when they are more stable, inpatient care nurses see patients during more intense, acute episodes when the patient's condition has worsened.When these two perspectives are brought together, nurses found that they can create a more comprehensive picture of the patient's condition, which allows both outpatient and inpatient care nurses to offer the most suitable support.Outpatient and inpatient care were described by nurses as a united front that should not be divided and which they believed, contributed to an increased sense of security for patients.PIBA united inpatient and outpatient care in a way not previously experienced, as communication and collaboration around patients across the two settings not only increased but also improved.
…it is so important because our patients often try to influence the care, they get here through their contact person located in outpatient care.And since we started with PIBA the inpatient and outpatient teams know each other much better, so it less likely for the patient to create a divide between us in a way.And that is a positive thing.It ultimately benefits our patients.Patients know that strategy will not work so they give up on it.(Nurse 6, inpatient care)

Implementation concerns and opportunities for improvement
Lack of time in the outpatient care setting was a recurrent issue raised by nurses from outpatient care that affects their ability to work with PIBA.Nevertheless, nurses retained a positive outlook towards PIBA and mentioned several factors that facilitate successful implementation of this method, including strong leadership, competence and curiosity within the workforce, strong collaborative relationships between outpatient and inpatient care, and effective communication.

Lack of time for nurses in outpatient care
Outpatient care nurses voiced that lack of time, and a high workload affected their ability to work with PIBA, although they expressed a wish to be able to dedicate more time to work with PIBA specifically.However, they acknowledged that the work associated with PIBA in outpatient care time-consuming, since contracts must be followed up and renewed as well as new contracts established.To make this more efficient, nurses from outpatient care suggested letting patients who use PIBA often to renew their contract over the phone instead of physically meeting all parties involved.

Important components for the successful implementation of PIBA
Nurses stated that essential components for the successful implementation of PIBA include competence, curiosity, strong collaborative relationships between outpatient and inpatient care nurses, addressing any concerns directly with the project group, and involving all personnel at the unit.They also emphasised the importance of staff receiving information, training, and an introduction to PIBA to ensure that all staff feel comfortable with the concept.
There is a need for a simple educational session for the staff, and to make sure that everyone gets it, both written and verbally.But they should also expect it to be a bit difficult in the beginning.(Nurse 4, inpatient care) Similarly, nurses highlighted the need to engage in clear communication with patients, by providing them with understandable information about PIBA including its purpose and how they can engage with the service.From their experience, nurses found that some patients had misconceptions about PIBA, believing it to be like a normal admission.Nurses suggested offering patients a trial PIBA admission to give them an opportunity to gain a better understanding of how PIBA works in practice.Nurses further underscored the importance of having managerial support; managers who can clearly communicated their expectations of and requirements from the staff.It was also considered critical to have a well-defined structure and clear protocols on the ward or clinic.
…we received a lot of attention from the clinic and the operations manager was very involved in this, so it's also important that management supports you.(Nurse 5, inpatient care) Nurses from inpatient care also emphasised the importance of staff viewing patients as adults, individuals capable of taking personal responsibility, a perspective which nurses from inpatient care were unaccustomed to prior to PIBA.

Discussion
In this study inpatient and outpatient nurses' views on the implementation of PIBA were explored.Overall, nurses described PIBA as a helpful crisis intervention for patients struggling to manage their psychiatric symptoms.Specifically, findings highlighted how PIBA: creates an opportunity for patients to improve their personal development by giving them more autonomy and empowering them to make their own decisions; fosters a more equal nurse-patient relationship by promoting mutual trust and improved nurse-patient collaboration; provides patients with readily accessible care which creates a sense of security for both patients and nurses; and provides an opportunity for stabilisation for patients in crises.

Patient autonomy and empowerment
In the present study, nurses described that PIBA provided an opportunity for patients to improve their personal development by taking charge of their own care and increasing their self-awareness.This allows them to independently identify early warning signs of worsened symptoms.Interviewed patients in the same setting, reported that they appreciated the encouragement from healthcare professionals and opportunity to take personal responsibility.They recognised that this enabled their increased participation in their care planning and gave them the opportunity to judge for themselves when inpatient care is necessary (Eckerstrom et al., 2020).Both the experiences of nurses in the present study, and earlier patient experiences, align with the theoretical concepts of PIBA, which include promoting patient participation and autonomy, and highlighting the importance of shared decision-making (Eckerström, 2022).Empowerment and autonomy were also considered important by mental healthcare-consumers asked to provide suggestions on how to improve the mental healthcare system in earlier surveys (Shields et al., 2019).Interviews held with nurses in the same setting as the present study during the earlier implementation phases of PIBA, elucidated that the hierarchy during regular admissions was replaced by equal partnership, and that the patients were viewed as 'co-workers' (Eckerstrom et al., 2019).They nevertheless voiced concern over shifting towards providing patients increased autonomy.This was concern was not expressed in the nurses in the current study, who had been working with PIBA for several years.Patients receiving psychiatric care in southern Sweden have expressed similar views, indicating that PIBA enabled personal development by giving patients more responsibility for their own mental health, and consequently a better understanding of how to handle symptoms, including when to seek help (Enoksson et al., 2022).A multidisciplinary Delphi expert panel of psychiatrists, advanced nurse practitioners, registered nurses, and scientists from the Netherlands found similar results regarding the importance of encouraging and reinforcing patient autonomy and responsibility through PIBA (Helleman, Goossens, et al., 2018).The positive impact of PIBA on patient autonomy, also extends beyond healthcare to the home, with relatives explaining how giving their loved ones more personal responsibility promotes better coping skills, allowing patients to take better care of themselves than before enrolling in PIBA (Hultsjo, Rosenlund, et al., 2023).

Mutual trust and nurse-patient collaboration
Nurses experienced that the PIBA contract worked as a clear admission protocol for the patients and healthcare professionals.A mutual understanding, together with nurses' positive view of PIBA, led to a more equal nurse-patient relationship.An improved care relationship was also described by healthcare professionals in previous studies (Eckerstrom et al., 2019;Lindkvist et al., 2019).This strengthened trust allows patients to feel less scrutinised by healthcare staff, suggesting that PIBA fosters growth of the therapeutic relationship (Scanlon, 2006).Seeing patients in a new light within the inpatient setting, separates PIBA from regular admissions where patients are mostly received in an acute state of mental distress.PIBA encourages inpatient psychiatric care to shift from handling acute situations and avoiding triggers and conflicts, to a more collaborative and safer environment, benefiting both staff and patients (Eckerstrom et al., 2020;Lindkvist et al., 2019).This emphasises the importance of establishing a trusting nurse-patient relationship where the patient is viewed and supported as an individual (Gabrielsson et al., 2015), rather than simply as a patient.

Readily accessible care and creating a sense of security
Nurses in the current study described how PIBA offered easily accessible support for patients when they needed it.This gave nurses, especially those working in outpatient care, a sense of security knowing that their patients could initiate brief admissions around the clock when outpatient services were unavailable.Caregivers have also been reported to express benefits of promoting smooth and accessible access to inpatient care for their loved ones.A recent study on relatives' perspectives of PIBA demonstrated that they felt reassured and safer when their loved-one gained access to PIBA; it gave them a sense of security knowing that help was only a call away and avoided dramatic hospitalisations (Hultsjo, Appelfeldt, et al., 2023).Relatives also believed that PIBA prevented worsening symptoms caused by BPD (Hultsjo, Appelfeldt, et al., 2023).Similarly, interviewed patients receiving care in the same setting as the present study, also expressed that it felt comforting knowing that help is readily available to them when they are unable to independently cope with their symptoms in their home environment (Eckerstrom et al., 2020).The increased sense of security is a central finding in several other studies exploring patients' experiences of PIBA (Enoksson et al., 2022;Helleman et al., 2014b;Lindkvist et al., 2019;Mortimer-Jones et al., 2019), and should be considered a common benefit of the intervention.However, patients' trust in the availability of PIBA can quickly turn to disappointment if the PIBA room is occupied when needed.Nurses in this study reported that occupancy issues sometimes led to self-harming behaviour.This contrast, from feeling trust to losing hope, was also described by relatives, who felt betrayed by psychiatric services when their loved ones were denied PIBA due to occupancy issues.Relatives witnessed their family members' condition worsen which eventually led to emergency care admissions (Hultsjo, Appelfeldt, et al., 2023).When PIBA was available as intended, proving rapid accessible acute care to patients, nurses experienced that not only did regular and forced admissions decrease post-implementation of PIBA, but patients shifted from experiencing major self-harm, long admissions, and forced care, to well-functioning PIBA admissions and fewer episodes of self-harm.In fact, in Norway, it has been shown that the number of inpatient days decreased significantly during the 2-year period following the introduction of PIBA (Nyttingnes & Ruud, 2020).

Opportunity for stabilisation
Nurses in the present study believed that PIBA is a valuable intervention to help patients avoid destructive behaviours and self-harm.This experience aligns with findings from a quantitative study performed in the same setting, which showed a significant decrease in anxiety symptoms between admission and discharge in patients utilising PIBA (Eckerstrom et al., 2022).Nurses also believed that PIBA is a suitable nursing intervention for patients with severe and prolonged mental distress and expressed a desire for it to be offered more widely, thereby provide more patients an opportunity for rapid stabilisation.Since the interviews were conducted, there has been a large-scale implementation of PIBA in Region Stockholm (Smitmanis Lyle et al., 2022).Patients with severe psychiatric conditions, regardless of their specific psychiatric diagnosis, will have the opportunity to utilise PIBA, and approximately 45 inpatient wards will be involved in the implementation effort.PIBA has also been implemented in child and adolescent psychiatry (Moberg & Schon, 2022).

Recommendations and opportunities for improvement
Nurses felt that PIBA positively impacted their role as nurses through increased professional autonomy, which allowed them to grow within their profession and provided them with new tools to care for patients with BPD and self-harm.This aligns with a previous study from southern Sweden, where nursing staff expressed more efficient utilisation of their nursing training and expertise, thereby enhancing their own perceived level of professionalism (Lindkvist et al., 2019).
However, in the present study, outpatient nurses expressed that lack of time and heavy workload impacted their ability to work with PIBA.Future implementation of PIBA should ensure that outpatient nurses have the necessary resources, such as designating at least two nurses to manage PIBA contracts in the outpatient unit.Other essential components for successful implementation of PIBA included viewing patients as responsible, staff education, clear communication with patients, managerial support, a strong collaborative environment between inpatient and outpatient care, and a well-defined structure and regulations in the ward or clinic.

Strengths and limitations
The current study expanded knowledge related to psychiatric nurses' experiences with PIBA in both inpatient and outpatient settings.Several strengths are worth mentioning.Rich data, multiple analysts, and a reflexive dialogue among co-authors during analysis enhance rigour, as does transparency in reporting that enables the assessment of the findings' potential transferability to similar settings.Nevertheless, this study had several limitations, which are outlined below.Firstly, the study was conducted in only one inpatient psychiatric ward and one outpatient psychiatric clinic in Stockholm, Sweden.Since PIBA can vary structurally across regions in Sweden and in countries where it has been implemented, and nurses' experiences of PIBA could be specific to the units within which they work, our findings may not be transferable to other settings.Additionally, despite efforts to interview a similar number of nurses in inpatient and outpatient care to allow for a balanced exploration of PIBA, our sample was more inpatient-heavy, potentially creating an imbalanced view of PIBA delivered in the psychiatric inpatient and outpatient settings.

Conclusions
Nurses found PIBA to be a beneficial intervention for patients, helping them better cope with worsening psychiatric symptoms.Nurses believed that PIBA provided patients with more autonomy and enhanced their sense of security by giving them the tools to assess their own well-being and ensuring readily available care during crises.This sense of security also extended to outpatient nurses who felt secure knowing that their patients care readily accessible, round-the-clock, care when necessary.Future studies should explore how this increased sense of security among nurses impacts work-related stress and coping, work life balance and job satisfaction.This promising nursing intervention may inspire further development of purely nursing interventions within psychiatric care.

Table 1 .
Visualisation of the data analysis process.

Table 2 .
Overview of the findings.