Therapeutic Relationships and Safety of Care in Iranian Psychiatric Inpatient Units

The Effects of a Participatory Intervention in Mental Health Units on Nurses' Perceptions of the Practice Environment: A Mixed Methods Study

BACKGROUND

The practice environment influences the quality of care and the nursing outcomes achieved in their workplaces.

AIMS

To examine the perception of the clinical practice environment among nurses working in mental health units in the context of their participation in an action research study aimed at improving the nurse-patient relationship.

METHOD

An explanatory sequential mixed methods study was designed. The data were collected in three phases in 18 mental health units (n = 95 nurses). Quantitative data were collected through the Practice Environment Scale of the Nursing Work Index, and qualitative data were collected through reflective diaries and focus groups in the context of participatory action research.

RESULTS

The nurses' assessment of their practice environment shifted from positive to negative. Nurse manager leadership was the aspect that worsened the most. In addition, the perception of their participation in the affairs of the center and nursing foundations for quality of care decreased. The nurses considered it essential to be able to influence decision-making bodies and that the institution should promote a model of care that upholds the therapeutic relationship in actual clinical practice.

CONCLUSIONS

Nurses perceived that they should be involved in organizational decisions and required more presence and understanding from managers. Furthermore, nurses stated that institutions should promote nursing foundations for quality of care. This study contributes to understanding how nurses in mental health units perceive their work environment and how it affects the improvement of the nurse-patient relationship in clinical practice.

Development of "The Safe Psychiatric Ward Battery"

This study reports the development process and psychometric testing of the safe environment in psychiatric wards instrument. In this mixed-methods study, the concept of a safe environment was explained with a qualitative study by performing semi-structured interviews with patients and staff and ward observation. Then, the items of the instrument were designed using qualitative data and a literature review. Content and construct validity, internal consistency, stability, and inter-rater agreement were evaluated. This study produced an instrument consisting of two sections. The first section was a scale (α = .920). Exploratory factor analysis of the scale identified two dimensions of "engagement" (α = .931) and "perception" of the physical environment (α = .760). The second section was a checklist with two dimensions, "accident-free living environment" and "staff empowerment." The intra-class correlation coefficients for the scale and checklist were .912 and .809, respectively. This study suggests that this instrument is a valid and reliable tool to assess safety in psychiatric wards.

The therapeutic relationship in the context of involuntary treatment orders: The perspective of nurses and patients

WHAT IS KNOWN ON THE SUBJECT?: Involuntary treatment orders are increasingly being used around the world to allow the treatment of individuals living with a mental illness deemed incapable of giving consent and who are actively refusing treatment. The use of involuntary treatment orders can impact the nurse-patient therapeutic relationship, which is essential to offer quality care and promote recovery. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Nurses and patients do not agree on the possibility to develop a therapeutic relationship, with nurses believing they can build a bond with the patients despite the challenges imposed by the involuntary treatment order, and patients rejecting this possibility. Nurses caring for patients on involuntary treatment orders feel obligated to apply the conditions of this measure, even if it damages the relationship with their patients. This difficult aspect of their work leads them to question their role in relation to the management of involuntary treatment orders. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses need to be aware of the reasons why patients on involuntary treatment orders do not believe in the possibility of building a therapeutic relationship. Nurses need to reflect on and express their concerns about the damaging effects that managing involuntary treatment orders conditions can have on the nurse-patient therapeutic relationship. ABSTRACT: Introduction Involuntary treatment orders (ITO) can impact the nurse-patient therapeutic relationship (TR) negatively. Despite the increasing use of ITOs around the world, few studies have explored their influence on the TR from the perspectives of nurses and patients. Aim To describe the TR in the context of ITOs as reported by nurses and individuals living with a mental illness. Method Secondary data analysis of qualitative interviews with nurses (n = 9) and patients (n = 6) was performed using content analysis. Results Participants described the TR as fundamentally embedded in a power imbalance amplified by the ITO, which was discussed through the conflicting roles of nurses, the legal constraints imposed on patients and nurses, the complex relation between the ITO and the TR, and the influence of mental healthcare settings' context. Discussion Nurses and patients' views were opposed, questioning the authenticity of the relationship. Implications for Practice Nurses should be aware of the patients' lack of faith in the TR to ensure that they are sensitive to patients' behaviours that may falsely suggest that a relationship is established. Further studies should explore ways to alleviate the burden of the management of ITOs on nurses and allow for a trusting relationship to be build.

Impact of collaborative nursing care on the recovery process of mental health day hospital users: a mixed-methods study protocol

INTRODUCTION

Very few collaborative nursing care interventions have been studied and shown to be effective in the context of the paradigm shift towards recovery in mental health nursing. Understanding the changes produced in the recovery process of people with mental health problems can contribute to the design and implementation of new methodologies to offer effective and person-centred care.

METHODS AND ANALYSIS

This is a mixed-methods study, which is structured in three phases. In phase one (baseline) and phase three (follow-up), quantitative data will be collected from patients at a mental health day hospitals based on a two-armed, parallel-design, non-randomised trial. In phase two, two groups will be established: an intervention group in which the intervention based on collaborative nursing care will be carried out through the codesign and implementation of activities through Participatory Action Research, and a control group in which the usual care dynamics will be continued. All the users of three mental health day hospitals who agree to participate in the study will be studied consecutively until the necessary sample size is reached. The outcomes used to evaluate the impact of the intervention will be the stage of the recovery process, the quality of the therapeutic relationship and the patient's level of positive mental health.

ETHICS AND DISSEMINATION

This study has been approved by the institutional review board of the reference hospital, FIDMAG Hermanas Hospitalarias (PR-2020-10) in July 2020. All participants will be able to voluntarily withdraw from the study at any time. For this reason, users will be given a sheet with all the precise information about the study to be carried out and written consent will be requested. Preliminary and final results will be published in peer-reviewed journals and presented at national and international congresses.

TRIAL REGISTRATION NUMBER

NCT04814576.

The impact of a participatory intervention on the therapeutic relationship in mental health nurses: A multicentre study

AIMS

To evaluate the effects of an intervention aimed at improving the therapeutic relationship, using the participatory-action research method, in terms of improving the quality of the nurse-patient therapeutic relationship.

DESIGN

A single-group pre-post research design.

METHODS

Quantitative data were collected between January 2018 and June 2019 using an online form completed by nurses from 18 mental health units (N = 95). Data were collected before and after the intervention, which consisted of the design, implementation and evaluation of strategies to improve the therapeutic relationship through participatory-action research involving nurses. The Working Alliance Inventory-Short, Interpersonal Reactivity Index, Evidence-Based Practice Questionnaire and Practice Environment Scale of the Nursing Work Index were used. The Wilcoxon rank-sum test was used together with the Spearman's correlation coefficient. Two multiple linear regressions models were constructed.

RESULTS

Overall, the intervention improved the nurse-patient therapeutic relationship. In addition, the results revealed that, above all, the improvement in evidence-based practice along with a decrease in nurses' personal distress were the factors associated with the improvement of the nurse-patient therapeutic relationship.

CONCLUSION

In mental health units, the therapeutic nurse-patient relationship can be improved through participatory interventions that include the implementation of evidence-based practices.

IMPACT

This research examined the effects of an intervention aimed at improving the therapeutic relationship among nurses working at mental health units using participatory action research. The results show that the therapeutic relationship can be improved through participatory methods where evidence-based practice is implemented and enhanced among nurses, since a better therapeutic relationship along with reduced staff discomfort are determining factors that influence the quality of the therapeutic relationship. Institutional managers should promote participatory group interventions to enable nurses to develop evidence-based aspects of the therapeutic relationship together with expanding personal aspects and self-knowledge.

Examining the association between evidence-based practice and the nurse-patient therapeutic relationship in mental health units: A cross-sectional study

AIMS

To examine the relationship between the dimensions of evidence-based practice and the therapeutic relationship and to predict the quality of the therapeutic relationship from these dimensions among nurses working in mental health units.

DESIGN

A cross-sectional design.

METHODS

Data were collected between February-April 2018 via an online form completed by nurses working at 18 mental health units. Multiple linear regressions were used to examine the relationship between the dimensions of evidence-based practice and therapeutic relationship. Questionnaires were completed by 198 nurses.

RESULTS

Higher levels of evidence-based practice were a significant predictor of a higher-quality therapeutic relationship (β: 2.276; 95% CI: 1.30-3.25). The evidence-based practice factor which most influenced an improved therapeutic relationship was the nurses' attitude (β: 2.047; 95% CI: 0.88-3.21). The therapeutic relationship dimension which was most conditioned by evidence-based practice dimensions was agreement on tasks, which was most favourable with a better attitude (β: 0.625; 95% CI: 0.09-1.16) and greater knowledge and skills for evidence-based practice (β: 0.500; 95% CI: 0.08-0.93).

CONCLUSION

In mental health settings, the therapeutic nurse-patient relationship is positively enhanced by evidenced-based practice and the nurse's level of experience, with a great influence on shared decision-making.

IMPACT

This research sought to examine the relationship between the evidence-based practice and the therapeutic relationship in mental health nursing. This study demonstrates that an improved attitude and knowledge of evidence-based practices of mental health nurses increases shared decision-making with patients, which is a basic requirement for person-centred care. Because the therapeutic relationship is considered the backbone of nursing practice in mental health units, this research will have an impact on both mental health nurses and mental health unit managers.

Patient safety in inpatient mental health settings: a systematic review

OBJECTIVES

Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.

DESIGN

Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.

RESULTS

Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.

CONCLUSIONS

Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42016034057.