Psychiatric nurses' clinical decision‐making for adults clinically judged to have childhood maltreatment‐related attachment difficulties: A qualitative study employing the steps for coding and theorization method

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Abstract
Aim: To describe how experienced psychiatric nurses notice, interpret, and respond to adult inpatients whom they clinically judge to have childhood maltreatment‐related attachment difficulties and to clarify the practical reasoning underlying these judgments. Methods: Eleven experienced psychiatric nurses from two private psychiatric hospitals in Japan were purposively sampled. Participant observation and semi‐structured interviews focused on care of adults clinically understood to have childhood maltreatment‐related attachment difficulties. Case identification relied on nurses' clinical judgment and routine team discussions or record information; no standardized attachment assessment or independent verification of childhood maltreatment history was used. Data were analyzed using the steps for coding and theorization (SCAT) method. Results: SCAT generated 54 themes or concepts organized into 10 categories and 24 subcategories. Nurses noticed recurrent relational patterns, including distrust, checking behavior, dependency‐aggression cycles, misinterpretation of staff intentions, self‐harm, and distress around proximity, and adjusted their responses to stabilize the patient–nurse dyad, avoid re‐traumatization, support emotional expression, and coordinate team care. Only a limited subset of subcategories was attachment‐specific; many others reflected broader psychiatric nursing practices applied through an attachment‐informed lens. A trauma‐focused noticing process was visible in nurses' attention to nonverbal cues and early behavioral change. Conclusions: The findings describe situated clinical reasoning rather than a new diagnostic technique or intervention model. Experienced psychiatric nurses adapted everyday psychiatric nursing practices to relational patterns they understood as childhood maltreatment‐related and attachment‐relevant. The model may inform education, supervision, and future patient‐inclusive research.

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