Clients' perceptions of client-nurse relationships in local authority psychiatric services: a qualitative study

The influence of a self-determination theory grounded clinical placement on nursing student's therapeutic relationship skills: A pre-test/post-test study

For undergraduate nursing students, an integral mode of learning is their clinical placements. Learning within the clinical setting is influenced by factors such as the facilitators, peers, unit, or department the student is placed on. What is not known is the role of a social context that is grounded in Self-Determination Theory and how this influences the development of therapeutic relationship skills among undergraduate nursing students. The aim of this study was to examine the role of autonomy support in the professional learning of undergraduate nursing students. This study employed a two-group pre-test and post-test design, with undergraduate nursing students placed in either an autonomy-supportive group or a comparison group in an Australian context. Therapeutic relationship skills were assessed at the beginning and end of their compulsory mental health clinical placement. Participants were 210 (n = 210) Australian undergraduate nursing students. Using a tertile split, 140 students were placed into one of two groups based on their perception of autonomy support at the post-test time point. Pre- and post-test therapeutic relationship data were collected for both groups. A repeated measures analysis of variance was used to examine whether engagement in different clinical placements would illicit significant differences in therapeutic relationship skills. Undergraduate nursing students who were engaged in the autonomy-supportive setting had significantly higher scores associated with the therapeutic relationship subscales: Positive Collaboration and Positive Clinical Input. The importance of the social context is underscored, which is strongly influenced by the educational leader, typically referred to as a nurse facilitator.

Rather a Competent Practitioner than a Compassionate Healer: Patients' Satisfaction with Interactions in Psychiatric Inpatient Care

Interactions with staff are important aspects in patients' experiences of psychiatric inpatient care (PIC). This study aimed to evaluate patients' satisfaction with their interactions with PIC staff and whether sociodemographic factors, depression and anxiety symptoms were associated with their perceptions of these interactions. In this cross-sectional study, we collected data from 84 patients receiving inpatient care in three psychiatric settings in Sweden. The patients' perceptions of interactions with staff and self-reported degrees of depression and anxiety were evaluated through questionnaires. Overall, patients were satisfied with the patient-staff interaction. However, significantly higher scores were related to staffs' practical competence than to their compassion. Older patients reported significantly more satisfaction than younger patients with their most recent meeting with staff. Tailored nursing interventions may improve staff's compassionate capacity. Further research in larger samples is needed to improve our understanding of the factors associated with how patients perceive their interactions with staff.

An integrative review exploring the experiences of service users carrying a diagnosis of personality disorder and student mental health nurses and the time they share together

OBJECTIVES

This integrative review provides a collective understanding of the experiences of student mental health nurses and service users carrying a diagnosis of personality disorder and the time they share together.

DESIGN

Published studies about the time service users and students share together were systematically selected in order to integrate their findings in a thematic analysis.

DATA SOURCES

Various databases were searched from 1984 until 2020. Specific search terms were used.

REVIEW METHODS

37 studies were included in the integrative review. The studies were from peer reviewed nursing, student, psychology and health related journals. A quality appraisal was completed using Walsh and Downe (2006) framework.

FINDINGS

Four themes emerged from a thematic analysis of the integrative review. These were; With 'Impact of time' as an overarching theme.

CONCLUSION

A positive environment which considers time and focuses on seeing the person, as an individual can lead to the development of therapeutic relationships; a core element of the Nursing and Midwifery Council standards for nursing registration in the UK (Nursing and Midwifery Council, 2018). Students attempting to build such relationships need to be mindful of service users' and their own attachment experiences and the impact these can have on experiences of transference and countertransference, particularly for service users carrying a personality disorder diagnosis. It is important for students to be aware of the supportive impact of positive environments and how doing 'everyday stuff' can make a person feel human despite residing in potentially dehumanizing places.

Therapeutic relationships: Making space to practice in chaotic institutional environments

WHAT IS KNOWN ABOUT THE SUBJECT?: While therapeutic relationships remain core to mental health nursing practice and patient recovery, increased managerialism and focus on risk has impacted nurses' therapeutic practice with patients. While there is anecdotal evidence of the impact there has been little research that demonstrates nurses experience of therapeutic engagement within the current context. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper reports on qualitative research that highlights nurses' strong attempts to create the space for therapeutic engagement with clients. This research provides evidence of the constraints on practice imposed by new managerial processes and suggests potential means of responding to them. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses are committed to working therapeutically but struggle to balance this against new managerial demands imposed across many OECD countries. The New Zealand government has recently reported on positive changes to mental health provision but does not suggest changes to the structures that impede good practice. This research indicates that structural change is essential to therapeutic engagement. ABSTRACT: Introduction Increasing managerialism, driven in part by notions of risk, compromises the mental health nurses therapeutic engagement with clients potentially impacting their recovery. While the importance of therapeutic relationships in mental health recovery is acknowledged, there is little evidence about how managerial processes encroach on this relationship. Aim To explore mental health nurses experience of engaging in therapeutic relationships within the current practice environment. Method This paper utilized an interpretive phenomenological approach, using interviews with mental health nurses. Results Managerial processes significantly impacted the practice of nurses who struggled to make space for therapeutic relationships within a chaotic milieu. The chaos is associated with increasing austerity within the health system; this has resulted in high staff turnover and staff shortages. Discussion Managerial demands dominate the practice field at the expense of therapeutic engagement between nurses and clients ultimately affecting client recovery. While nurses' integrity means they desperately try to make space for the therapeutic work, they often become burnt out and disheartened. Implications for practice While nurses are often blamed for failures in the system, the structures that disable nurses in their attempts to practice therapeutically require urgent responses, strengthening professional organizations and engaging in democratic partnerships with consumer groups.

Part and Parcel: A Qualitative Interview Study Examining the Experience of Client Rudeness by Mental Health Workers

Considerable research has demonstrated that workplace rudeness can have a variety of negative consequences. However, although research has examined the impact of patient aggression, no research has examined patient or client rudeness towards those who work in mental health roles. The present study investigated the nature of client rudeness, how mental health workers respond and the coping strategies used. Eighteen participants from a range of mental health roles and experience levels participated in semi-structured interviews based on their experience of client rudeness. Thematic analysis revealed that participants experienced a variety of client behaviours they classified as rude, the majority of which were verbal. Reasons for rudeness included the client's personal history, mood, and mental health, and as such rudeness was conceptualised as simply a part of the job. Client rudeness was found to have both negative and positive outcomes on a range of areas including work and client relationships. Participants identified supervisors and colleagues as key sources of support for coping with rudeness. These findings suggest that rudeness is "part and parcel" of a mental health practitioner's role. Supervisor support and further training are recommended to help practitioners deal with rudeness in practice.

"They're Really PD Today"

The therapeutic relationship is of particular importance when working with patients with antisocial personality disorder, but despite this, there is a paucity of literature exploring student nurses' perceptions of developing a therapeutic relationship with such patients. Hence, this qualitative study explored the perceptions of second-year mental health nursing students of developing a therapeutic relationship with this patient group. Student nurses from a University in the Northwest of England participated in two focus groups, to compare the perceptions of a group of student nurses who had experience in secure settings (forensic hospital) with those who had not. Four key themes emerged: diagnosis, safety, engagement, and finally environmental influences. Both groups commented on looking beyond the diagnosis and seeing the person. The student nurses cited other staff in their clinical placement areas as hugely influential in terms of the development of their perceptions of patients with antisocial personality disorder and how to relate to them.

It's a Long Way From the Office to the Creek Bed

Mental health nursing in remote Australian Aboriginal communities provides opportunities and challenges unique from other experiences of nursing. The purpose of this article was to explore how mental health nurses experience working in remote communities and how they developed relevant knowledge and skills. Six remote area mental health nurses participated in audiotaped conversational style interviews. Narratives were transcribed and analyzed thematically. Themes identified were being focused on relationships, adapting to the culture, struggling with two contexts, being enraptured by place, and being transformed. The participants adapted and developed ways of working at the interface of another culture and also derived personal and professional benefit from the experience.

Getting to know the person behind the illness - the significance of interacting with patients hospitalised in forensic psychiatric settings

AIMS AND OBJECTIVES

To describe what nurses want to accomplish in relationships with patients who are hospitalised in forensic psychiatric settings.

BACKGROUND

Relationships between staff and patients in forensic psychiatric settings should be grounded in trust and confidence, and the patients need opportunities for emotional reconciliation. However, relationships can be challenging for nurses, who sometimes distance themselves from patients' expressions of suffering. The role of forensic mental health nurses is nebulous, as are the prescriptives and the implementation of nursing practices.

DESIGN

Qualitative descriptive design.

METHODS

In-depth interviews with five nurses who all work in forensic psychiatric settings.

RESULTS

We present a descriptive analysis of what nurses want to accomplish in relationships with patients who are hospitalised in forensic psychiatric settings. The results are presented in two main categories: (1) getting to know the person behind the illness and (2) making a difference.

CONCLUSION

Care in forensic psychiatry needs to shift towards a more long-term view of the role of nursing, focusing less on the traditional and stereotypical identity of the productive nurse and more on the care given when nurses slow down and take the time to see the patients as individuals. Establishing trusting relationships with patients in forensic psychiatric settings is viewed as a less oppressive way to control patients and guide them in directions that are preferable for the nurses and for the society.

RELEVANCE TO CLINICAL PRACTICE

Nurses may use simple strategies in their daily practice such as sitting on the sofa with patients to establish trust. We stress that nurses should abandon policing roles and custodial activities in favour of guiding principles that promote individual recovery, treatment and health-promoting care.

Reciprocity in therapeutic relationships: A conceptual review

Reciprocity has generally been understood as a process of giving and taking, within an exchange of emotions or services, and has long been recognized as a central part of human life. However, an understanding of reciprocity in professional helping relationships has seldom received attention, despite movements in mental health care towards more collaborative approaches between service users and professionals. In this review, a systematic search of the published papers was conducted in order to explore how reciprocity is conceptualized and understood as part of the dyadic therapeutic relationship between professionals and service users. Eleven papers met our inclusion criteria and a narrative synthesis was used to synthesize the key concepts of reciprocity. The concepts of: 'dynamic equilibrium', 'shared affect', 'asymmetric alliance', and 'recognition as a fellow human being' were recurrent in understandings of reciprocity in professional contexts. These conceptualizations of reciprocity were also linked to specific behavioural and psychological processes. The findings suggest that reciprocity may be conceptualized and incorporated as a component of mental health care, with recurrent and observable processes which may be harnessed to promote positive outcomes for service users. To this end, we make recommendations for further research to progress and develop reciprocal processes in mental health care.

Reducing or increasing violence in forensic care: a qualitative study of inpatient experiences

Semi-structured interviews with 13 forensic psychiatric inpatients that had decreased their assessed risk of violence were analyzed using interpretive description. The main contribution from this study is a detailed description of patients' own strategies to avoid violence. Participants described having an ongoing inner dialog in which they encouraged themselves, thereby increasing their self-esteem and trying to accept their current situation. An unsafe and overcrowded ward with uninterested and nonchalant staff increased the risk of aggressive behavior. In the process of decreasing violence, the patients and the forensic psychiatric nursing staff interacted to create and maintain a safe environment.

To do good might hurt bad: exploring nurses' understanding and approach to suffering in forensic psychiatric settings

Patients in forensic psychiatric settings not only have to deal with their mental illness, but also memories of criminal activities and being involuntarily hospitalized. The aim of the present study was to explore how nurses working in forensic psychiatric services understand and approach patients' experiences of suffering. Data were generated by semistructured interviews with psychiatric nurses from two different forensic psychiatric units in Sweden. Data were analysed by means of a hermeneutic approach inspired by Ricoeur's hermeneutics. The findings are reflected in four main themes: (i) ignoring suffering; (ii) explaining suffering as a natural and inevitable part of daily life in the forensic context; (iii) ascribing meaning to suffering; and, (iv) being present in suffering. To engage in alleviating suffering is a struggle that demands courage and the strength to reflect on its character and consequences. To encounter suffering means that nurses are not only confronted with patients' suffering, but also their own reactions to those patients. If suffering is not recognized or encountered, there is a risk that actions may have a negative impact on patients.

Therapeutic relationships from the psychiatric nurses' perspectives: an interpretative phenomenological study

PURPOSE

The aim of the present study was to explore the attributes of the therapeutic relationship from the perspective of psychiatric nurses in the United Arab Emirates.

DESIGN AND METHODS

Interpretive phenomenology formed the framework of the study. Data were collected through unstructured recorded interviews with 17 nurses.

FINDINGS

Study findings revealed that nurses emphasized the importance of the therapeutic relationship. The analysis resulted in four main themes and nine subthemes. The main themes were: provision of physical care, conveying safety and security, protection, and companionship.

PRACTICE IMPLICATIONS

Psychiatric nurses can internalize these themes in their practice to improve client outcomes. These themes need to be emphasized in psychiatric mental health nursing courses as well as in nursing management in the orientation of new clinical psychiatric nurses.

Patients' experiences of supportive conversation as long-term treatment in a Swedish psychiatric outpatient care context: a phenomenological study

This study aims to describe patients' experiences of supportive conversation as long-term treatment in a psychiatric outpatient context. A focus group interview was conducted with six female patients (aged 40-60 years). Five key constituents captured the essence of the general structure of supportive conversation: being treated as a responsible person, sensing intimate contact and togetherness, perceiving stability in the relationship, learning to manage daily living, and growing as a person. Supportive conversations have a positive influence on the patient's state of mind and enhance self-confidence, thereby giving the inner strength to grow as a person.

Therapeutic Relationship Between Male Nursing Students and Female Patients

This article explores the therapeutic relationship between male nursing students and female patients, through the use of autobiography in a qualitative approach. For this study, 18 male nursing students enrolled in master's and bachelor's programs in Hong Kong were recruited. They were asked to make records in a diary and draw pictures of their therapeutic relationship with female patients from their clinical experiences and then participate in a focus group interview. Content analysis was carried out on the collected data. The essential factors influencing the development of a therapeutic relationship were found to be gender, symbolic meanings, and career features. Good experiences were also discussed. The results shed light on the experiences of male nursing students and how they make sense of their therapeutic relationship with female patients.

Caring relationships in home-based nursing care - registered nurses' experiences

The caring relationship between the nurse and the person in need of nursing care has been described as a key concept in nursing and could facilitate health and healing by involving the person’s genuine needs. The aim of this study was to explore registered nurses’ experiences of their relationships with persons in need of home-based nursing care. Individual interviews with nurses (n=13 registered nurses and 11 district nurses) working in home-based nursing care were performed. A thematic content analysis was used to analyze the transcribed interviews and resulted in the main theme Good nursing care is built on trusting relationship and five sub-themes, Establishing the relationship in home-based nursing care, Conscious efforts maintains the relationship, Reciprocity is a requirement in the relationship, Working in different levels of relationships and Limitations and boundaries in the relationship. A trusting relationship between the nurse and the person in need of healthcare is a prerequisite for good home-based nursing care whether it is based on face-to-face encounters or remote encounters through distance-spanning technology. A trusting relationship could reduce the asymmetry of the caring relationship which could strengthen the person’s position. The relationship requires conscious efforts from the nurse and a choice of level of the relationship. The trusting relationship was reciprocal and meant that the nurse had to communicate something about themself as the person needs to know who is entering the home and who is communicating through distance-spanning technology.

Validation of the Verbal and Social Interaction questionnaire: carers' focus in the carer-resident relationship in supported housing facilities for persons with psychiatric disabilities (VSI-SH)

A questionnaire to measure the verbal and social interactions between carers and residents in supported housing facilities for persons with psychiatric disabilities has been developed. It is an adaptation of a questionnaire originally used in a forensic psychiatric setting. The aim of the present study was thus to investigate the construct validity and the reliability of this new version of the Verbal and Social Interactions questionnaire for use in supported housing facilities (VSI-SH). Two hundred and twenty-three carers from municipal and privately run housing facilities completed the questionnaire. A factor analysis was performed, which resulted in six factors. The number of items was reduced from the original 47 to 30 in order to minimize factorial complexity and multiple loadings. The reliability was tested with Cronbach's alpha and good internal consistency for the questionnaire and five of the six factors was found. The resulting six factors and the items were compared to the conceptual model and four of the six factors corresponded well with the categories in this original theoretical model. The questionnaire can be a useful contribution to the study of interactions between carers and residents in supported housing facilities for persons with psychiatric disabilities.

Perceptions of mental health nurses and patients about health promotion in mental health care: a literature review

The aim of this review was to examine the perceptions of patients with mental disorders and mental health nurses of health promotion targeting physical activity and eating habits in mental health care. An electronic search strategy was conducted. Furthermore, references were searched by hand-searching the reference lists of the retrieved articles from the electronic databases. The literature on perceptions of health promotion and lifestyle interventions in mental health care principally consist of qualitative studies using interviews and focus groups. Positive perceptions of both mental health nurses and patients towards health promotion targeting physical activity and eating habits in mental health care were identified. Contrary, several barriers for integrating healthy lifestyles into the daily life of patients were described. Patients usually want to learn more about healthy lifestyles, but see the ability to change their physical health as beyond their control. In this sense, support from mental health nurses is considered as important. Despite the awareness of the importance of health promotion in mental health care, it appears that visions and attitudes towards the potential of health promotion are in need of change.

Involvement in mental health and substance abuse work: conceptions of service users

Service user involvement (SUI) is a principal and a guideline in social and health care and also in mental health and substance abuse work. In practice, however, there are indicators of SUI remaining rhetoric rather than reality. The purpose of this study was to analyse and describe service users' conceptions of SUI in mental health and substance abuse work. The following study question was addressed: what are service users' conceptions of service user involvement in mental health and substance abuse work? In total, 27 users of services participated in the study, and the data was gathered by means of interviews. A phenomenographic approach was applied in order to explore the qualitative variations in participants' conceptions of SUI. As a result of the data analysis, four main categories of description representing service users' conceptions of service user involvement were formed: service users have the best expertise, opinions are not heard, systems make the rules, and courage and readiness to participate. In mental health and substance abuse work, SUI is still insufficiently achieved and there are obstacles to be taken into consideration. Nurses are in a key position to promote and encourage service user involvement.

Service users' experiences of a therapeutic group programme in an acute psychiatric inpatient unit

Psychiatric nurses have been facilitating therapeutic groups in acute psychiatric inpatient units for many years; however, there is a lack of nursing research related to this important aspect of care. This paper reports the findings of a study which aimed to gain an understanding of service users' experiences in relation to therapeutic group activities in an acute inpatient unit. A qualitative descriptive study was undertaken with eight service users in one acute psychiatric inpatient unit in Ireland. Data were collected using in-depth semi-structured interviews and analysed using Burnard's method of thematic content analysis. Several themes emerged from the findings which are presented in this paper.

'Take my hand, help me out': mental health service recipients' experience of the therapeutic relationship

The purpose of this study was to describe mental health service recipients' experience of the therapeutic relationship. The research question was 'what is therapeutic about the therapeutic relationship?' This study was a secondary analysis of qualitative interviews conducted with persons with mental illness as part of a study of the experience of being understood. This secondary analysis used data from 20 interviews with community-dwelling adults with mental illness, who were asked to talk about the experience of being understood by a health-care provider. Data were analysed using an existential phenomenological approach. Individuals experienced therapeutic relationships against a backdrop of challenges, including mental illness, domestic violence, substance abuse, and homelessness. They had therapeutic relationships with nurses (psychiatric/mental health nurses and dialysis nurses), physicians (psychiatrists and general practitioners), psychologists, social workers, and counsellors. Experiences of the therapeutic relationship were expressed in three figural themes, titled using participants' own words: 'relate to me', 'know me as a person', and 'get to the solution'. The ways in which these participants described therapeutic relationships challenge some long-held beliefs, such as the use of touch, self-disclosure, and blunt feedback. A therapeutic relationship for persons with mental illness requires in-depth personal knowledge, which is acquired only with time, understanding, and skill. Knowing the whole person, rather than knowing the person only as a service recipient, is key for practising nurses and nurse educators interested in enhancing the therapeutic potential of relationships.

Extending the boundaries: autoethnography as an emergent method in mental health nursing research

An exploration of the 'self' is generally considered a fundamental and necessary place from which to commence practice as a mental health nurse. Self-awareness and attention to one's own feelings, thoughts, and experiences can contribute to the therapeutic use of self in effective provision of mental health nursing care. This purposeful use of self, inherent in the role of the mental health nurse, may also be seen as synchronous to the role of the qualitative researcher who seeks to uncover the meaning of others' experiences. Autoethnography is a qualitative research method that connects the researcher's personal self to the broader cultural context. Evocative writing, where the writer shares personal stories on their experiences, is used to extend understanding of a particular social issue. This paper will argue how this emerging method in social science research is of particular relevance to mental health nursing research and practice.