Time Together: A nursing intervention in psychiatric inpatient care: Feasibility and effects

Associated factors of nurse-sensitive patient outcomes: A multicentred cross-sectional study in psychiatric inpatient hospitals

WHAT IS ALREADY KNOWN?: The nurse-patient relationship in mental health care is an important focus of mental health nursing theories and research. There is limited evidence about which factors influence nurse-sensitive patient outcomes of the nurse-patient relationship. This hinders the development, planning, delivering, and quality assurance of the nurse-patient relationship in nursing practice and nursing education. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: To our best knowledge, this is the first study to examine associations between nurse-sensitive patient outcomes of the nurse-patient relationship and a range of patient characteristics and relationship-contextual factors. In this study, we found that gender, age, hospital characteristics, nurse availability when needed, nurse contact, and nurse stimulation were associated with the scores on the nurse-sensitive patient outcome scale. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Having insight into the factors associated with nurse-sensitive patient outcomes of the nurse-patient relationship can help nurses, nursing students, nursing management and also patients to enhance the nurse-patient relationship, trying to influence outcomes of nursing care. ABSTRACT: Introduction The lack of evidence on patient characteristics and relational-contextual factors influencing nurse-sensitive patient outcomes of a nurse-patient relationship is a possible threat to the quality and education of the nurse-patient relationship. Aim To measure nurse-sensitive patient outcomes of the nurse-patient relationship and to explore the associations between nurse-sensitive patient outcomes and a range of patient characteristics and relational-contextual factors. Method In a multicenter cross-sectional study, 340 inpatients from 30 units in five psychiatric hospitals completed the Mental Health Nurse-Sensitive Patient Outcome Scale. Descriptive, univariate and Linear Mixed Model analyses were conducted. Results Overall, patient-reported outcomes were moderate to good. Female participants, nurse availability when needed, more nurse contact and nurse stimulation were associated with higher outcomes. Age differences were observed for some of the outcomes. Outcomes also varied across hospitals but were not related to the number of times patients were hospitalized or to their current length of stay in the hospital. Discussion The results may help nurses to become more sensitive and responsive to factors associated with nurse-sensitive patient outcomes of the nurse-patient relationship. Implications The nurse-sensitive results can support nurses in designing future nurse-patient relationships.

Medication-free mental health treatment: a focus group study of milieu therapeutic settings

BACKGROUND

Medication-free treatment within mental health care aims to offer therapeutic support as an alternative to psychotropic medication. Introducing milieu therapy for severely mentally ill persons in a medication-free unit requires significant changes to the traditional medication-based psychiatric setting. The present study examines how milieu therapists experience working with medication-free treatment for people with severe mental health challenges. The research question was "What may be required to succeed with medication-free treatment in milieu therapeutic settings?"

METHODS

A qualitative study with four focus groups were conducted with 23 milieu therapists from three inpatient units in two mental health institutions. Thematic analysis was performed.

RESULTS

One main theme was identified: medication-free treatment involves therapists and patients working together on holistic and personal health promotion. This common thread links the four themes: helping patients to make changes in their life; having time to focus on the individual patient; being a professional companion; and working together as a team with the patient.

CONCLUSIONS

A holistic approach is necessary for medication-free treatment to succeed. This requires working together in multidisciplinary teams with a focus on the individual patient. Milieu therapists must engage and take more responsibility in the patient's process of health promotion. A change from a medical to a humanistic paradigm within mental health care is needed.

The time, places, and activities of nurses in a psychiatric inpatient context - A time and motion study with a time-geographic perspective

Nurses in psychiatric inpatient care spend less time than desired with patients and investigation of the nature of nursing in this setting is needed. This study explores how nursing activities in psychiatric inpatient wards is distributed over time, and with a time-geographic perspective show how this relates to places. Observations were used to register place, activity, and time. A constructed time-geographic chart mapped the nurses' path which showed that nurses spent little time in places where patients are. There might be constraints that affect nursing. Nurses need to evaluate where time is spent and interventions that facilitate relationships are needed.

Impact of the 'reserved therapeutic space' nursing intervention on patient health outcomes: An intervention study in acute mental health units

AIMS

To evaluate the effectiveness of the 'reserved therapeutic space' intervention for improving the nurse-patient therapeutic relationship in acute mental health units in Spain.

DESIGN

Multicentre intervention study with control group.

METHODS

The study will be carried out in 12 mental health units. The 'reserved therapeutic space' intervention to be tested has been co-designed and validated by both nurses and patients. The quality of the therapeutic relationship, the care received and perceived coercion among patients will be assessed. An estimated 131 patients per group are expected to participate. Funding was granted by the Instituto de Salud Carlos III. Co-financed by the European Union (European Regional Development Fund (ERDF) (PI21/00605)) and College of Nurses of Barcelona (PR-487/2021). The proposal was approved by all the Research Ethics Committees of participating centres.

RESULTS

This project will lead to changes in clinical practice, transforming the current models of organization and care management in mental health hospitalization units. No patient or public contribution.

Exploring the therapeutic relationship through the reflective practice of nurses in acute mental health units: A qualitative study

AIMS AND OBJECTIVES

To explore the therapeutic relationship through the reflective practice of nurses in acute mental health units.

BACKGROUND

In mental health units, the therapeutic relationship is especially relevant for increasing the effectiveness of nursing interventions. Reflective practice is considered an essential aspect for improving nursing care.

DESIGN

Action and observation stages of a participatory action research project.

METHODS

Data were collected through reflective diaries designed for the guided description and reflection of practice interactions related to the therapeutic relationship and content analysis was applied. A total of 152 nurses from 18 acute mental health units participated. The COREQ guidelines were used.

RESULTS

The results were classified into three categories as follows: (i) Nursing attitude as a core of the therapeutic relationship. For the nurses, the attitudinal component was key in the therapeutic relationship. (ii) Nursing practices that are essential to the therapeutic relationship. Nurses identified practices such as creating a conducive environment, using an appropriate verbal approach, offering help and working together with the patient as essential for establishing a therapeutic relationship in practice. (iii) Contextual factors affecting the therapeutic relationship. The nurses considered the patient's condition, the care dynamics of the unit and its regulations, as well as the structure and environment of the unit, as contextual factors involved the establishment of an adequate therapeutic relationship in daily clinical practice.

CONCLUSIONS

This study has provided knowledge of the importance and role of the nurses' attitude in the context of the nurse-patient therapeutic relationship based on the reflections of nurses in mental health units regarding their own practice.

RELEVANCE TO CLINICAL PRACTICE

These findings help nurses to increase awareness and develop improvement strategies based on their own knowledge and day-to-day difficulties. Moreover, managers can evaluate strategies that promote motivation and facilitate the involvement of nurses to improve the therapeutic relationship with patients.

The therapeutic relationship at the heart of nursing care: A participatory action research in acute mental health units

AIMS AND OBJECTIVES

To explore the process of change within the clinical practice of nurses in mental health inpatient units in the context of a participatory process to improve the nurse-patient therapeutic relationship.

DESIGN

Participatory Action Research.

METHODS

Ninety-six nurses from 18 mental health units participated. Data were collected through focus groups and reflective diaries between March 2018 and January 2020. Data were analysed using inductive content analysis. The COREQ guidelines were used.

RESULTS

The research process was carried out through two cycles of four stages each in which the nurses were able to identify the facilitating and limiting elements of their practice in relation to the therapeutic relationship. They then proposed two consensual improvement strategies for all the units, which they called reserved therapeutic space and postincident analysis. Finally, they implemented and evaluated the two strategies for change.

CONCLUSIONS

This study has shown that, despite the different cultural and structural realities of the participating units, it is possible to implement a collaborative process of change, provided the needs and expectations of both the participants and the organisations are similar.

RELEVANCE TO CLINICAL PRACTICE

The results obtained through Participatory Action Research were directly transferred to clinical practice, thus having an impact on individual nurses and patients, as well as on the collective dynamics of the teams and aspects related to the management of the units.

NO PATIENT OR PUBLIC CONTRIBUTION

Patient or public input is not directly applicable to this study. Patients were recipients of the changes that were occurring in the nurses as part of their daily clinical practice.

Delineating Quality Indicators of Inpatient Psychiatric Hospitalization

BACKGROUND

Assuring quality care is critical to the well-being and recovery of individuals receiving inpatient psychiatric treatment, yet a comprehensive map of quality inpatient care does not exist.

AIMS

To isolate and describe quality elements of inpatient psychiatric treatment.

METHODS

A survey queried psychiatric inpatient nursing leaders on what they considered to be critical elements of quality. The survey was emailed to 40 American Psychiatric Nurses Association members, and 39 individuals responded. In the survey, participants were asked to comment on the importance of six dimensions of quality as well as quality indicators used on their units.

RESULTS

Data from this survey indicate how thought leaders conceptualized quality of inpatient care. A unifying philosophy of care was endorsed as a quality element as was structure that affords staff available time on the unit-engaging with patients. While staffing levels were viewed as important, the respondents commented on the nuances between staffing and quality. Participants endorsed the importance of involving individuals in their treatment planning as well as tapping into patients' perspectives on the treatment experience.

CONCLUSIONS

The participants' responses compliment the quality literature and reinforce the need to develop a comprehensive map of quality elements. These elements interact in complex way, for instance, staffing, engagement, and teamwork is tied to the organizational structure and philosophy of care, which in turn facilitates consumer involvement in care. Thus, gauging the impact of quality on outcomes will demand consideration of the interaction of factors not just the linear relationship of one element to an outcome.

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 extent and nature of stress of conscience among healthcare workers: A scoping review

BACKGROUND

Healthcare workers experience morally stressful situations during delivery of care which may trouble their conscience. Literature emerging in the context of global pandemics suggest increased frequency of morally stressful situations in healthcare and a link with negative outcomes such as attrition and burnout. Little is known about the emerging concept of stress of conscience which could provide a meaningful way to highlight and address these morally stressful situations in healthcare.

AIM

The aim of this scoping review was to provide an overview of the literature on, (i) the extent, (ii) the factors associated, and (iii) the interventions to prevent or mitigate stress of conscience among healthcare workers.

DESIGN

The study was guided by the framework provided by Arksey and O'Malley in 2005 and the PRISMA Guidelines. Relevant healthcare databases were searched in November 2020 to identify relevant studies.

RESULTS

The search identified 24 studies for inclusion in the analysis, 19 of these were from Nordic countries, particularly Sweden. Across those studies, stress of conscience was prevalent among healthcare workers and the levels varied with demographic factors, individual personalities, perceptions of belonging and the workplace culture and environment. Stress of conscience was associated with negative outcomes such as burnout, moral burden, workplace stress, and low quality of care. Although there were few quality interventions studies, facilitating healthcare workers to provide person-centred care appears to be a promising intervention.

CONCLUSIONS

The concept of stress of conscience provides a contemporary framework to assess, highlight and discuss the degree of the negative impact of perceived violations of professional and personal values in healthcare. However, the limited studies suggest that exploring stress of conscience, including trials of potential interventions, particularly beyond Nordic countries is essential to fill the gaps in the literature.

It's Not Just in the Walls: Patient and Staff Experiences of a New Spatial Design for Psychiatric Inpatient Care

The environment in psychiatric inpatient care is key to patient recovery and staff job satisfaction. In this qualitative study of patient and staff experiences of a new spatial design in psychiatric inpatient care, we analysed data from 11 semi-structured interviews with patients and five focus group discussions with staff using qualitative content analysis. The new design contributed to feelings of safety and recovery, but patients and staff also reported some frustration and added stress. The results lead us to conclude that while the new spatial design improves some conditions for recovery and job satisfaction, the design itself is simply not enough. Changes in care environments require that both patients and staff be informed and involved in the renovation to ensure that patients feel respected and staff feel confident in using the new environment before and during treatment and follow-ups.

"What matters to me": A multi-method qualitative study exploring service users', carers' and clinicians' needs and experiences of therapeutic engagement on acute mental health wards

Nurse-patient therapeutic engagement on acute mental health wards is beneficial to service users' outcomes and nurses' job satisfaction. However, engagement is not always fulfilled in practice and interventions to improve engagement are sparse and ineffective. We explored the experiences of service users, carers, and clinicians drawing from 80 hours of non-participant observations in an acute mental health ward and semi-structured interviews with 14 service users, two carers, and 12 clinicians. Analysis of these data resulted in 28 touchpoints (emotionally significant moments) and eight overarching themes. Service users, carers, and clinicians identified a lack of high-quality, person-centred, collaborative engagement and recognized and supported efforts to improve engagement in practice. Potential solutions to inform future intervention development were identified. Our findings align with previous research highlighting negative experiences and support the need to develop multicomponent interventions through participatory methods.

A qualitative study exploring the patients' perspective from the 'Reserved Therapeutic Space' nursing intervention in acute mental health units

This study aimed to explore the perspective of people who had experienced treatment as patients at acute mental health units, regarding an intervention model to improve therapeutic relationships in the units, which had been previously designed by the nurses. The study participants were people linked to collectives for social activism in mental health. Six focus groups were held. The results were classified into three themes: (a) the meaning of a space to enable the establishment of a therapeutic relationship, (b) the procedures to implement the space, and (c) the difficulties to overcome to establish the space. For the participants, the Reserved Therapeutic Space intervention was perceived as a space where they could share expectations and needs with the nurses, considering it as both valid and useful to improve the therapeutic relationship in acute units. For the participants, the intervention should be structured in three stages: orientation, follow-up, and discharge. The content of the intervention should be proposed by the patients based on their needs and concerns. The barriers identified for carrying out the intervention were the lack of relational competence, the violation of rights, and the lack of accessibility of nurses. The facilitating elements were the availability of nurses, active listening, and empathy. The resulting intervention model includes realities of both groups, providing insights for nurses to initiate a space with patients and improve their therapeutic relationship. This intervention model could be used by managers to test its effectiveness.

Developing a theory-informed complex intervention to improve nurse-patient therapeutic engagement employing Experience-based Co-design and the Behaviour Change Wheel: an acute mental health ward case study

OBJECTIVES

Our objectives were threefold: (1) describe a collaborative, theoretically driven approach to co-designing complex interventions; (2) demonstrate the implementation of this approach to share learning with others; and (3) develop a toolkit to enhance therapeutic engagement on acute mental health wards.

DESIGN AND PARTICIPANTS

We describe a theory-driven approach to co-designing an intervention by adapting and integrating Experience-based Co-design (EBCD) with the Behaviour Change Wheel (BCW). Our case study was informed by the results of a systematic integrative review and guided by this integrated approach. We undertook 80 hours of non-participant observations, and semistructured interviews with 14 service users (7 of which were filmed), 2 carers and 12 clinicians from the same acute ward. The facilitated intervention co-design process involved two feedback workshops, one joint co-design workshop and seven small co-design team meetings. Data analysis comprised the identification of touchpoints and use of the BCW and behaviour change technique taxonomy to inform intervention development.

SETTING

This study was conducted over 12 months at an acute mental health organisation in England.

RESULTS

The co-designed Let's Talk toolkit addressed four joint service user/clinician priorities for change: (1) improve communication with withdrawn people; (2) nurses to help service users help themselves; (3) nurses to feel confident when engaging with service users; (4) improving team relations and ward culture. Intervention functions included training, education, enablement, coercion and persuasion; 14 behaviour change techniques supported these functions. We detail how we implemented our integrated co-design-behaviour change approach with service users, carers and clinicians to develop a toolkit to improve nurse-patient therapeutic engagement.

CONCLUSIONS

Our theory-driven approach enhanced both EBCD and the BCW. It introduces a robust theoretical approach to guide intervention development within the co-design process and sets out how to meaningfully involve service users and other stakeholders when designing and implementing complex interventions.

Using Q-methodology to explore mental health nurses' knowledge and skills to use recovery-focused care to reduce aggression in acute mental health settings

When nurses practise recovery-focused care, they contribute positively to the consumer's mental health recovery journey and empower the person to be actively engaged in the management of their illness. While using recovery-focused care is endorsed in mental health policy, many health professionals remain uncertain about its application with consumers who have a risk for aggression during their admission to an acute mental health inpatient setting. This paper reports on Australian research using Q-methodology that examined the knowledge and skill components of recovery-focused care that nurses use to reduce the risk for aggression. The data from forty mental health nurses revealed five factors that when implemented as part of routine practice improved the recovery outcomes for consumers with risk of aggression in the acute mental health settings. These factors were as follows: (I) acknowledge the consumers' experience of hospitalization; (II) reassure consumers who are going through a difficult time; (III) interact to explore the impact of the consumer's negative lived experiences; (IV) support co-production to reduce triggers for aggression; and (V) encourage and support consumers to take ownership of their recovery journey. These findings provide nurses with a pragmatic approach to use recovery-focused care for consumers with risk for aggression and contribute positively to the consumers' personal recovery.

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.

Time Together as an arena for mental health nursing - staff experiences of introducing and participating in a nursing intervention in psychiatric inpatient care

A lack of meaningful activities for people with mental ill health admitted to psychiatric inpatient care has been related to feelings of boredom and 'doing nothing' and is not in line with recovery-oriented care. Staff in psychiatric inpatient care report having limited time, ambiguous responsibilities, and insufficient support that counteracts their ideals of good nursing care and puts them at risk for high levels of stress and stress of conscience. Research highlights a need for interactions between patients and staff, but few nursing interventions with such a focus are described in the literature. This qualitative study aimed to illuminate staff experiences of introducing and participating in the nursing intervention Time Together, via qualitative content analysis of 17 individual semi-structured interviews with nursing staff in psychiatric inpatient care. The results show that these staff members experienced Time Together as an arena for mental health nursing. They prepared for the introduction of the intervention by laying a framework for success. Although the actual implementation led to them feeling burdened, they found that Time Together fostered relationships between patients and staff. For successful implementation, mental health nurses need to advocate the intervention. As Time Together constitutes an arena for mental health nursing, play and conversations based on reciprocity and equality can contribute to patients' recovery.

Relationship between the nursing practice environment and the therapeutic relationship in acute mental health units: A cross-sectional study

The therapeutic relationship constitutes the central axis of mental health nursing. The clinical practice environment has been empirically related to the quality of care. However, the relationship between the two constructs is unknown in the setting of mental health units. We aimed to examine whether the practice environment and nurses' characteristics influence the therapeutic relationship in mental health units. Through a cross-sectional design, data were collected via an online form completed by nurses in 18 mental health units. Linear regression was used to examine the relationship between the clinical practice environment and the therapeutic relationship. Questionnaires were completed by 198 participants. The mean age was 33.8 (SD 9.1) years, 71.7% were women, and only 20.2% had a specialist qualification in mental health. The therapeutic relationship was better when there was a more favourable practice environment (B: 3.111; 95% CI: 1.46-4.75). The most influential environment-related factor was the nursing foundations for quality of care (B: 2.124; 95% CI: 0.17-4.07). The factors associated with a high-quality therapeutic relationship were a more favourable practice environment and the presence of more foundations for quality nursing care, coupled with higher academic attainment and longer nursing experience. Institutions should take into account the importance of the nursing practice environment in mental health units. Aspects related to the quality of nursing foundations, such as training, the use of nursing language and taxonomy, and the existence of a common nursing philosophy, are influential for a high-quality therapeutic relationship.

Effective nurse-patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance

Background

Therapeutic alliance is a core part of the nursing role and key to the attainment of positive outcomes for people utilising mental health care services. However, these relationships are sometimes difficult to develop and sustain, and nursing staff would arguably benefit from evidence-based support to foster more positive relationships.

Objectives

We aimed to collate and critique papers reporting on interventions targeted at improving the nurse–patient therapeutic alliance in mental health care settings.

Design

Systematic literature review.

Data sources

The online databases of Excerpta Medica database (Embase), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched, eligible full text paper references lists reviewed for additional works and a forward citation search conducted.

Review methods

Original journal articles in English language were included where they reported on interventions targeting the nurse–patient therapeutic relationship and included a measure of alliance. Data were extracted using a pre-determined extraction form and inter-rater reliability evaluations were conducted. Information pertaining to design, participants, interventions and findings was collated. The papers were subject to quality assessment.

Results

Relatively few eligible papers (n = 8) were identified, highlighting the limitations of the evidence base in this area. A range of interventions were tested, drawing on diverse theoretical and procedural underpinnings. Only half of the studies reported statistically significant results and were largely weak in methodological quality.

Conclusions

The evidence base for methods to support nursing staff to develop and maintain good therapeutic relationships is poor, despite this being a key aspect of the nursing role and a major contributor to positive outcomes for service users. We reflect on why this might be and make specific recommendations for the development of a stronger evidence base, with the hope that this paper serves as a catalyst for a renewed research agenda into interventions that support good therapeutic relationships that serve both staff and patients.

Patients' experiences of taking part in Time Together - A nursing intervention in psychiatric inpatient care

This qualitative study aimed to illuminate patients' experiences of taking part in the nursing intervention Time Together. The data were drawn from 11 individual semi-structured interviews with patients and analysed with qualitative content analysis using an inductive approach. The results show that patients taking part in Time Together felt confirmed and participated on equal terms; thus, they experienced being seen as humans among other humans. Time Together offered patients a break, and they felt strengthened, which contributed to their hopes for recovery. Furthermore, when Time Together was absent patients felt disconfirmed, which fostered feelings of distance from staff. The results support the effectiveness of the intervention, indicating that Time Together may be a tool to facilitate patients' personal recovery. However, the success of the intervention depends on staff compliance with the predetermined structure of the intervention in combination with engagement.

Conceptualising nurse-patient therapeutic engagement on acute mental health wards: An integrative review

OBJECTIVES

The review aimed to 1) explore the constituents of nurse-patient therapeutic engagement on acute mental health wards; 2) map factors that influence engagement to the Theoretical Domains Framework and 3) integrate results into a conceptual model of engagement to inform the development of interventions to improve engagement.

DESIGN

A systematic integrative review using an established framework specific to the integrative review methodology.

DATA SOURCES

Database searches (CINAHL, PsycINFO, BNI and Cochrane Library) and hand searching identified 3414 articles. After screening, applying eligibility criteria, and quality appraisal, 37 articles were included: n = 27 empirical research studies, n = 10 expert opinion pieces, n = 1 case study and n = 1 theoretical report.

REVIEW METHODS

Peer-reviewed empirical studies, theoretical reports or expert opinion pieces that explored therapeutic engagement as a stated aim and were conducted in acute mental health inpatient settings from the patient or nurse perspective were included. Data were extracted from the introduction, results and discussion sections of empirical research, and the complete article of theoretical and expert opinion pieces. Data were coded then grouped into subthemes and themes. Data relating to influencing factors were further categorised according to the Theoretical Domains Framework. Results were synthesised into a conceptual model of engagement.

RESULTS

Five conceptually distinct, but closely related constructs of engagement - called the "Principles of Engagement" - emerged: 1) Understanding the person and their experiences; 2) Facilitating growth; 3) Therapeutic use of self; 4) Choosing the right approach and 5) Authoritative vs. emotional containment. Influences on engagement ranged across all 14 theoretical domains of the Theoretical Domains Framework.

CONCLUSION

A holistic understanding of the essential components of engagement may make it easier for nurses to recognise what they do, and to do it well. The model can be used to generate testable hypotheses about how and where to target behavioural change interventions. The Principles of Engagement must be reflected in the development of interventions to improve engagement.

Patients' experiences of isolation in psychiatric inpatient care: Insights from a meta-ethnographic study

Historically, people with mental ill-health have been isolated from society. Although mental health care has moved from closed to more open forms of care, in many societies care is still provided in locked wards, and people with mental ill-health are sometimes secluded from their fellow patients, families, friends, and visitors. The aim of this study was to illuminate patients' experiences of isolation in psychiatric inpatient care. A systematic review of qualitative research was conducted, and the key findings were subjected to meta-ethnographic synthesis. The findings were twofold: 'being admitted to prison' and 'having access to shelter'. The experience of isolated care as prison-like symbolizes patients' longing for freedom and feeling restricted and limited by rules, stripped of rights, abandoned, controlled, powerless, and unsupported. In contrast, the experience of isolation as shelter symbolizes safety and the opportunity to regain control over one's own situation. A stigmatizing public view holds that people with mental ill-health are dangerous and unpredictable and, therefore, unsafe to themselves and others. Being placed in isolation because these fears contribute to self-stigma among patients. Promoting a sheltered experience in which isolation is used with respect for patients and the reasons are made explicit may encourage recovery. A shift in emphasis in ward culture from observation to engagement is needed to reduce blame, shift patient experiences from prison to shelter, and to support autonomy as a therapeutic intervention.