Psychiatric Nurses' Perceptions of Therapeutic Alliance With Individuals With Schizophrenia: A Survey Study

Research on nurse-patient relationships with the schizophrenia population is sparse. The current study piloted a survey to explore therapeutic relationships. Fifty-one psychiatric nurses completed an online survey on therapeutic relationships with the schizophrenia population. Factor and chi-square analysis yielded preliminary findings. Fifteen of 16 survey items loaded onto four factors at ≥0.4. A significant association between level of education and professional certification and comfort working with patients with schizophrenia was found. Survey modifications and a larger sample size may generate useful information and clarify the relationship among education, certification, and comfort. [Journal of Psychosocial Nursing and Mental Health Services, 59(4), 21-29.].

Barriers to recovery-focused care within therapeutic relationships in nursing: Attitudes and perceptions

There are numerous barriers to the therapeutic relationship between nurses and persons with schizophrenia, such as time constraints, communication issues and the requirements of practice policies. The main point of this paper is that the nature of these barriers is such that the nurse may not conceptualize these as barriers or be aware of how his or her responses to these can further entrench existing barriers to relationship or create new ones. If the nurse is not aware of how he or she responds to time pressure, frustration or lack of clarity of practice policy and address this, there is a risk that the patient may perceive the nurse's actions as lacking in care, presence or involvement. As consumers increasingly embrace recovery approaches to mental health that prioritize therapeutic activities within the context of collaborative relationship, psychiatric nurses, with a long tradition of therapeutic relationship, can rise to meet them. It is suggested here that this can only occur if nurses are fully aware of barriers to relationship, their responses to these and the impact of these on relationship with patients. Suggestions for educational and empirical work to further raise awareness and promote understanding of this process are provided.

Ethical challenges when using coercion in mental healthcare: A systematic literature review

Background:

To better understand the kinds of ethical challenges that emerge when using coercion in mental healthcare, and the importance of these ethical challenges, this article presents a systematic review of scientific literature.

Methods:

A systematic search in the databases MEDLINE, PsychInfo, Cinahl, Sociological Abstracts and Web of Knowledge was carried out. The search terms derived from the population, intervention, comparison/setting and outcome. A total of 22 studies were included.

Ethical considerations:

The review is conducted according to the Vancouver Protocol.

Results:

There are few studies that study ethical challenges when using coercion in an explicit way. However, promoting the patient’s best interest is the most important justification for coercion. Patient autonomy is a fundamental challenge facing any use of coercion, and some kind of autonomy infringement is a key aspect of the concept of coercion. The concepts of coercion and autonomy and the relations between them are very complex. When coercion is used, a primary ethical challenge is to assess the balance between promoting good (beneficence) and inflicting harm (maleficence). In the included studies, findings explicitly related to justice are few. Some studies focus on moral distress experienced by the healthcare professionals using coercion.

Conclusion:

There is a lack of literature explicitly addressing ethical challenges related to the use of coercion in mental healthcare. It is essential for healthcare personnel to develop a strong awareness of which ethical challenges they face in connection with the use of coercion, as well as challenges related to justice. How to address ethical challenges in ways that prevent illegitimate paternalism and strengthen beneficent treatment and care and trust in connection with the use of coercion is a ‘clinical must’. By developing a more refined and rich language describing ethical challenges, clinicians may be better equipped to prevent coercion and the accompanying moral distress.

Confirming mental health care in acute psychiatric wards, as narrated by persons experiencing psychotic illness: an interview study

Background

It is important that mental health nurses meet the safety, security and care needs of persons suffering from psychotic illness to enhance these persons’ likelihood of feeling better during their time in acute psychiatric wards. Certain persons in care describe nurses’ mental health care as positive, whereas others report negative experiences and express a desire for improvements. There is limited research on how persons with psychotic illness experience nurses’ mental health care acts and how such acts help these persons feel better. Therefore, the aim of this study was to explore, describe and understand how the mental health nurses in acute psychiatric wards provide care that helps persons who experienced psychotic illness to feel better, as narrated by these persons.

Method

This study had a qualitative design; 12 persons participated in qualitative interviews. The interviews were transcribed, content analysed and interpreted using Martin Buber’s concept of confirmation.

Results

The results of this study show three categories of confirming mental health care that describe what helped the participants to feel better step-by-step: first, being confirmed as a person experiencing psychotic illness in need of endurance; second, being confirmed as a person experiencing psychotic illness in need of decreased psychotic symptoms; and third, being confirmed as a person experiencing psychotic illness in need of support in daily life. The underlying meaning of the categories and of subcategories were interpreted and formulated as the theme; confirming mental health care to persons experiencing psychotic illness.

Conclusion

Confirming mental health care acts seem to help persons to feel better in a step-wise manner during psychotic illness. Nurses’ openness and sensitivity to the changing care needs of persons who suffer from psychotic illness create moments of confirmation within caring acts that concretely help the persons to feel better and that may enhance their health. The results show the importance of taking the experiential knowledge of persons who have experienced psychotic illness seriously to develop and increase the quality of mental health care in acute psychiatric wards.

"Easy But Not Simple"--Nursing Students' Descriptions of the Process of Care in a Psychiatric Context

The nurse-patient interaction is the cornerstone of psychiatric care, yet the concept "mental health nursing" is difficult to describe. This article aims to address this problem through the experiences of nursing students. Online journals from 14 nursing students were analyzed using qualitative content analysis, resulting in three categories: Trusting the Trusting Relationship, Voicing the Unspoken Needs, and Balancing the Dynamics of Doing and Being. This study demonstrates that providing nursing care based on trusting relationships is not a demanding task, but it takes place in a complex environment that has a tendency to make easy things complicated.

The Use of Physical Restraint in Norwegian Adult Psychiatric Hospitals

Background. The use of coercion within the psychiatric services is problematic and raises a range of ethical, legal, and clinical questions. “Physical restraint” is an emergency procedure used in psychiatric hospitals to control patients that pose an imminent physical danger. We wished to review the literature published in scientific peer-reviewed journals describing studies on the use of physical restraint in Norway, in order to identify the current state of knowledge and directions for future research. Design. The databases PubMed, PsycINFO, CINAHL, Web of Science, and Embase were searched for studies relating to physical restraint (including holding) in Norwegian psychiatric hospitals, supplemented with hand searches. Results. 28 studies were included. Most of the studies were on rates of restraint, but there were also some studies on perceptions of patients and staff, case studies, and ethnographic studies. There was only one intervention study. There are differences in use between wards and institutions, which in part may be explained by differences in patient populations. Staff appear to be less negative to the use of restraint than patients. Conclusions. The studies that were identified were primarily concerned with rates of use and with patients' and staff's perspectives. More interventional studies are needed to move the field forward.

Coercion in nursing homes: Perspectives of patients and relatives

BACKGROUND

Studies have demonstrated the extensive use of coercion in Norwegian nursing homes, which represents ethical, professional as well as legal challenges to the staff. We have, however, limited knowledge of the experiences and views of nursing home patients and their relatives.

OBJECTIVES

The aim of this study is to explore the perspectives of nursing home patients and next of kin on the use of coercion; are there situations where the use of coercion can be defended, and if so, under which circumstances?

METHODS

The data are based on individual interviews with 35 patients living in six nursing homes and seven focus group interviews with 60 relatives.

ETHICAL CONSIDERATIONS

Participation was based on written informed consent, and the study was approved by the Regional Committees for Medical and Health Research Ethics.

RESULTS

More than half of the patients and the majority of the relatives accepted the use of coercion, trusting the staff to act in the patient's best interest. However, the acceptance of coercion is strongly related to the patients' lack of understanding, to prevent health risks and to preserve the patient's dignity.

CONCLUSION

The majority of nursing home patients and relatives accepted the use of coercion in specific situations, while at the same time they emphasised the need to try alternative strategies first. There is still a need for good qualitative research on the use of coercion in nursing homes, especially with a closer focus on the perspectives and experiences of nursing home patients.

Fear, danger and aggression in a Norwegian locked psychiatric ward: Dialogue and ethics of care as contributions to combating difficult situations

BACKGROUND

Fear and aggression are often reported among professionals working in locked psychiatric wards and also among the patients in the same wards. Such situations often lead to coercive intervention. In order to prevent coercion, we need to understand what happens in dangerous situations and how patients and professionals interpret them.

RESEARCH QUESTIONS

What happens when dangerous situations occur in a ward? How do professionals and patients interpret these situations and what is ethically at stake?

RESEARCH DESIGN

Participant observation and interviews.

PARTICIPANTS

A total of 12 patients and 22 professionals participated.

ETHICAL CONSIDERATIONS

This study has been accepted by the Regional Committee for Medical and Health Research Ethics in Norway.

FINDINGS

(a) Both atmosphere and material surroundings were interweaved within dangerous situations, (b) the professionals applied stereotypes when interpreting dangerous situations and (c) the professionals and the patients had different interpretations of what triggered dangerous situations.

DISCUSSION

The discussion centres on how care ethics and a dialogical practice might contribute towards combating difficult situations and the ways in which change is an ongoing ethical process of becoming.

CONCLUSION

The ethics of care and a dialogical approach are suggested as ethical frameworks for preventing fear, danger and aggression in psychiatric wards. Both frameworks can be understood as patient-driven, including the relational and contextual perspectives. It means a shift from professionally driven processes to patient-driven dialogue.

EPA Guidance on Building Trust in Mental Health Services

Purpose

To advance mental health care use by developing recommendations to increase trust from the general public and patients, those who have been in contact with services, those who have never been in contact and those who care for their families in the mental health care system.

Methods

We performed a systematic literature search and the retrieved documents were evaluated by two independent reviewers. Evidence tables were generated and recommendations were developed in an expert and stakeholder consensus process.

Results

We developed five recommendations which may increase trust in mental health care services and advance mental health care service utilization.

Discussion

Trust is a mutual, complex, multidimensional and dynamic interrelationship of a multitude of factors. Its components may vary between individuals and over time. They may include, among others, age, place of residence, ethnicity, culture, experiences as a service user, and type of disorder. For mental health care services, issues of knowledge about mental health services, confidentiality, continuity of treatment, dignity, safety and avoidance of stigma and coercion are central elements to increase trust.

Conclusion

Evidence-based recommendations to increase mutual trust of service users and psychiatrists have been developed and may help to increase mental health care service utilization.

Preventing seclusion in psychiatry: a care ethics perspective on the first five minutes at admission

In this article, an intervention aimed at improving quality of care to prevent seclusion in psychiatry by focusing on the first five minutes at admission is analyzed from a care ethics perspective. Two cases are presented from an evaluation study in a psychiatric hospital. In both cases, the nurses follow the intervention protocol, but the outcome is different. In the first case, the patient ends up in the seclusion room. In the second case, this does not happen. Analyzing the cases from a care ethics perspective, we conclude that applying the intervention in the right way implies more than following the steps laid down in the protocol. It requires a new way of thinking and acting, resulting in new relationships between nurses and patients. Care ethics theory can help clarify what good care is actually about and keep in mind what is needed to apply the intervention. Thus, care ethics theory can be highly practical and helpful in changing and improving healthcare practice.

Trust in nurse–patient relationships

The aim of this study was to report the results of a literature review of empirical studies on trust within the nurse–patient relationship. A search of electronic databases yielded 34 articles published between 1980 and 2011. Twenty-two studies used a qualitative design, and 12 studies used quantitative research methods. The context of most quantitative studies was nurse caring behaviours, whereas most qualitative studies focused on trust in the nurse–patient relationship. Most of the quantitative studies used a descriptive design, while qualitative methods included the phenomenological approach, grounded theory, ethnography and interpretive interactionism. Data collection was mainly by questionnaires or interviews. Evidence from this review suggests that the development of trust is a relational phenomenon, and a process, during which trust could be broken and re-established. Nurses’ professional competencies and interpersonal caring attributes were important in developing trust; however, various factors may hinder the trusting relationship.

Attuned understanding and psychotic suffering: a qualitative study of health-care professionals' experiences in communicating and interacting with patients

This study was initiated to examine how experiences with mental illness are perceived by health-care workers, and how insight affects assessment of their perspective and involvement. Lack of insight gives rise to problems concerning communication: if we expect what the person says and does not to have any meaning, how then can we establish a relationship based on understanding? This study was based on in-depth interviews with 11 mental health-care workers. Participants were recruited from a variety of institutions and professional backgrounds. The following topics were discussed with the participants: lack of insight, awareness of illness, and coping strategies, as well as how these factors affected treatment, cooperation, and participation. The participants describe attuned understanding as an other-oriented process, involving sensitivity to many aspects of the person's situation. Understanding is sought and is established through emotional, human contact, and practical interaction, and ends with new articulated understanding. The results suggest that the process described here can be viewed as other-oriented understanding, and not merely sympathy. It is an interdependent process of imagining oneself in the other's place, and depends on awareness of the nature of this process and on sensitivity to the person's expressions.

Mature care and nursing in psychiatry: notions regarding reciprocity in asymmetric professional relationships

The idea behind this article is to discuss the importance and to develop the concept of reciprocity in asymmetric professional relationships. As an empirical starting point for an examination of the possible forms of reciprocity between patients and nurses in psychiatry, we chose two qualitative in-depth interviews with two different patients. The manners in which these two patients relate to medical personnel--one is dependent, the other is independent--show that this presents challenges to nurses. The theoretical context is provided by the notion of mature care as it has been developed by feminist-oriented ethics of care, in contrast to the notion of altruistic care. In relation to the concept of mature care, we discuss how nursing can be perceived in demanding relationships with patients in psychiatry. Reciprocity implies that, in principle, the interests of the nurses also matter in a nurse-patient relationship. We show that reciprocity--in practice--is complicated and challenging in a number of different ways. Mature care--with its systematic inclusion of relationships and reciprocity--provides an alternative understanding of what takes place between patients and nurses compared with an altruistic notion of care. As such, mature care can be regarded as an useful paradigm for nurse-patient relationships in psychiatry.