Therapeutic alliance, relationship building, and communication strategies-for the schizophrenia population: An integrative review

[Equal partnerships in psychiatry - therapeutic relationships from the perspective of people diagnosed with schizophrenia, experts with psychiatric experience and relatives]

To enhance the understanding of patient needs regarding the therapeutic relationship in the treatment of schizophrenia.We conducted semi-structured interviews (n=31) with people diagnosed with schizophrenia or schizoaffective disorder, their relatives, peer support workers, and experts by experience, followed by qualitative content analysis.Central needs regarding the therapeutic relationship include professionals adopting an approachable and authentic attitude, demonstrating an appreciative attitude where patients feel taken seriously, and collaboratively developing realistic perspectives on life.Structural conditions should enable and promote a respectful relationship between patients and professionals. Disclosure of own crisis experiences by professionals can further contribute to building a trusting relationship.

Treatment of a schizophrenia patient on long-term super-dose antipsychotics: a case report

Introduction

Clozapine and chlorpromazine are widely used for treating schizophrenia. However, irregular medical follow-ups are common in patients with schizophrenia, potentially leading to long-term super-dose medication. Managing such cases poses significant challenges for clinical psychiatrists.

Case presentation

This report describes a 24-year-old Han Chinese male diagnosed with schizophrenia who had been taking long-term super-doses of clozapine (18-107 tablets/day, 25 mg/tablet) and chlorpromazine (7-40 tablets/day, 50 mg/tablet) for five months due to irregular medical follow-ups. Upon hospitalization, the doses of antipsychotic drugs were gradually tapered, and the medication regimen was adjusted based on the patient's previous treatment history. Comprehensive health education about schizophrenia was also provided. The patient was followed for four years, during which his psychiatric symptoms remained under partial control.

Conclusion

Clinicians must consider individual differences in the efficacy and adverse effects of antipsychotics and weigh the benefits and risks of combination therapy. Future efforts should focus on strengthening health education for patients with schizophrenia and their families to improve treatment compliance and outcomes.

Understanding the Process of Acceptance Within the Nurse-Patient Therapeutic Relationship in Mental Health Care: A Grounded Theory

Background/Objective: Deepening knowledge about the meaning of acceptance in the context of the nurse-patient relationship will help us to understand the importance and value that people with mental health challenges attach to this attribute in the process of the therapeutic relationship. The objective of this study was to understand the process of acceptance as part of the therapeutic relationship between nurses and patients in the field of mental health. Methods: This study employed a qualitative research design using Strauss and Corbin's grounded theory approach. Using theoretical sampling, data were collected through unstructured interviews with mental health nurses and with people with mental health challenges. Results: Acceptance is a complex and dynamic process that takes place when both patients and nurses feel and make the other feel like an individual human being. Acceptance is not an automatic process; rather, it requires awareness on behalf of both parties involved in the therapeutic relationship. The creation of a non-hierarchical caring environment is fundamental for fostering mutual acceptance and engagement in the therapeutic process. Conclusions: Nurses must develop self-awareness and reflect on their attitudes and biases to provide person-centered care. Nurse training and personal development are essential requirements for achieving an effective therapeutic relationship and empowering patients in their recovery process.

Psychiatrists effect on positive symptom severity and daily functioning during pharmacotherapy for first-episode psychosis patients

Clinical outcomes after a first-episode of psychosis (FEP) are heterogeneous. Many patient-related factors such as gender and comorbidity have been studied to predict symptomatic outcomes. However, psychiatrist-related factors such as prescription behaviour and gender have received little attention. We assessed the relationship between patients' psychiatrists, psychosis severity and daily functioning in 201 patients remitted from an FEP for a duration of one year, treated by 18 different psychiatrists. We controlled for baseline severity, dose and type of antipsychotic medication, frequency of visits, and patients' education. Symptom severity, daily functioning, and antipsychotic drug use were assessed at baseline and at 3, 6, and, 12 months follow-up. We found that psychiatrists accounted for 9.1% of the explained variance in patients' symptom severity and 10.1% of the explained variance in daily functioning.These effects persisted even when controlling for factors such as baseline severity and the prescribed dose. The effect of prescribed dose on symptom severity and daily functioning differed between psychiatrists. Treatment centre, session frequency, and medication nonadherence were not related to symptom severity. Our results emphasize the importance of individual psychiatrist factors in symptomatic outcomes after an FEP. Further identification of psychiatrist-related factors such as the quality of therapeutic alliances and shared decision-making, may optimize psychiatrists' training with the goal of improving patient outcomes.

The Physical Health Nurse Consultant: Perceptions and Experiences of Those Who Care for People with Mental Illness

Mental health carers are crucial in improving the physical health outcomes of people diagnosed with a mental illness (hereafter referred to as consumers). The long-term and multifaceted mental and physical health support carers provide to consumers can contribute to caregiver burden. Consequently, carers advocate for coordinated and integrated physical healthcare to improve the physical health outcomes of consumers and alleviate caregiver burden. The aim of this qualitative exploratory study is to explore carers' perceptions and experiences with the Physical Health Nurse Consultant role. Semi-structured interviews with nine carers nominated by consumers were conducted. Interviews were transcribed and reflexively thematically analysed. Three main themes were identified: (i) Therapeutic relationship s were a catalyst for health behaviour change; (ii) Overt and covert positive changes were observed by carer and (iii) Cares' involvement in integrated mental health and physical health care. Nine carers who were nominated by consumers to be involved in their physical healthcare planning, preferred to adopt a supporting role as this prevented or reduced caregiver burden. The findings support the adoption and continuation of the Physical Health Nurse Consultant role to facilitate positive physical health outcomes for consumers and a reduction in caregiving burden. The benefits of the Physical Health Nurse Consultant provide a compelling argument to embed the role in routine practice. Mental healthcare services should advocate for continued funding and career development for such positions to provide long term benefits for consumers and carers. Future research is required to explore carer and consumer involvement in co-producing future and localised iterations of the Physical Health Nurse Consultant role. This research should also measure the outputs and outcomes of co-production to clarify how the process worked in practice.

Psychologists' experience of working with people who hear voices and their views on the idea of voice simulation training: A qualitative study

OBJECTIVES

Research indicates psychologists typically lack subjective understanding of voice hearing. Voice hearing simulation training has potential to improve understanding, empathy and confidence among clinicians, but psychologists have had limited input into its development. This study investigated psychologists' and a psychotherapist's clinical experience of working with people who hear voices and their views and recommendations for voice hearing simulation training.

DESIGN

This was a qualitative study.

METHODS

Clinical psychologists and one psychotherapist (N = 17) participated in semi-structured interviews. Thematic analysis was used to analyse transcribed data.

RESULTS

The Clinical Experience theme comprised of subthemes Barriers to engagement, Diversity of voice hearing experiences, Lack of subjective understanding, Curiosity about voice hearing, Empathy for voice hearers, Using personal experiences to relate to voices, Clinical experience increases knowledge, Importance of supervision and colleague's support, Benefits of experiential training, Limited training in non-psychosis settings and Clinical experience increases confidence. The Views on Voice Hearing Simulation Training theme comprised of subthemes Improves subjective understanding, Concern about distress, Discomfort as a strength of voice hearing simulations, Artificiality of simulation, Increases empathy and Over-estimation of understanding. The Recommendations theme comprised of subthemes Discuss artificiality, Co-production, Promote voice diversity, Support staff and Maximise inclusivity.

CONCLUSIONS

Findings indicate that clinical experience improves psychologists' confidence and knowledge, yet participants reported a lack of subjective understanding of voice hearing. Co-produced simulation training between individuals who hear voices and clinicians was anticipated to improve subjective understanding, empathy and therapeutic relationships, which could support a range of staff and improve quality of care delivered.

State-of-the-Art Review: Evaluation and Management of Delusional Infestation

Delusional infestation is a condition encountered frequently by healthcare professionals across a variety of specialties in which patients have a fixed, false belief that they are infested with living creatures, such as bugs, parasites, worms, or mites, or nonliving objects, such as fibers. Delusional infestation can be debilitating for patients, who not only present with intense psychological distress and physical discomfort but are also at risk of developing numerous dermatological and psychiatric complications. This condition poses unique diagnostic challenges, as these symptoms can occur secondary to many metabolic or infectious causes, as well as unique treatment challenges, with patients frequently refusing psychiatric care and consequently seeking evaluation by other healthcare professionals. In this review, we aim to use existing literature to provide clinicians in infectious diseases or other specialties with sufficient clinical context and treatment guidance for the appropriate management of delusional infestation.

Person-Centred Decision-Making in Mental Health: A Scoping Review

Person-centred decision-making approaches in mental health care are crucial to safeguard the autonomy of the person. The use of these approaches, however, has not been fully explored beyond the clinical and policy aspects of shared and supported decision-making. The main goal is to identify and collate studies that have made an essential contribution to the understanding of shared, supported, and other decision-making approaches related to adult mental health care, and how person-centred decision-making approaches could be applied in clinical practice. A scoping review of peer-reviewed primary research was undertaken. A preliminary search and a main search were undertaken. For the main search, eight databases were explored in two rounds, between October and November 2022, and in September 2023, limited to primary research in English, Spanish or Portuguese published from October 2012 to August 2023. From a total of 12,285 studies retrieved, 21 studies were included. These research articles, which had mixed quality ratings, focused on therapeutic relationships and communication in decision-making (30%), patients' involvement in treatment decision-making (40%), and interventions for improving patients' decision-making engagement (30%). While there is promising evidence for shared decision-making in mental health care, it is important that healthcare providers use their communicational skills to enhance the therapeutic relationship and engage patients in the process. More high-quality research on supported decision-making strategies and their implementation in mental health services is also required.

The therapeutic relationship from the perspective of patients and nurses in the first days of admission: A cross-sectional study in acute mental health units

The therapeutic relationship (TR) is essential in mental health nursing care and plays a fundamental role in the understanding and treatment of the patient's health status. Despite being a bidirectional construct, limited evidence is available to shed light on this issue in mental health units and even less so in the first days of admission. This study aimed to examine the association and differences between nurses' and patients' perspectives on the establishment of the therapeutic relationship in acute mental health units during the first days of hospitalization. A cross-sectional study was carried out in 12 Spanish mental health units. Data were collected from patients and nurses using the Working Alliance Inventory-Short (WAI-S) questionnaire. A total of 234 cases were analysed, including 234 patients and 58 nurses. The results showed a positive association between nurses' and patients' perspectives on the therapeutic relationship, but also revealed significant differences on each WAI-S dimension. Nurses assigned higher scores compared to patients on the perception of the quality of the therapeutic relationship. The dimensions with the greatest weight from the patients' perspective regarding the quality of the therapeutic relationship were the perception of greater agreement on goals and tasks among nurses. This study demonstrates the importance of establishing shared goals and tasks with nurses from the first days of hospitalization to improve the quality of the therapeutic relationship as perceived by patients. These findings underline the need to consider the different perspectives of both parties to promote a high-quality therapeutic relationship.

Assessing Cannabis Use in People with Psychosis

Introduction: Cannabis use is common in people with psychotic disorders and is associated with the exacerbation of symptoms, poor treatment adherence, and an increased risk of relapse. Accurate assessment of cannabis use is thus critical to the clinical management of psychosis. Discussion: Cannabis use is usually assessed with self-report questionnaires that were originally developed for healthy individuals or people with a cannabis use disorder. Compared to these groups, the pattern of cannabis use and the associated harms in patients with psychosis are quite different. Moreover, in people with psychosis, the accuracy of self-reported use may be impaired by psychotic symptoms, cognitive deficits, and a desire to conceal use when clinicians have advised against it. Although urinary screening for delta-9-tetrahydrocannabinol is sometimes used in the assessment of acute psychotic episodes, it is not used in routinely. Cannabis use could be assessed by measuring the concentration of cannabinoids in urine and blood, but this is rarely done in either clinical settings or research. Conclusion: Using quantitative biological measures could provide a more accurate guide to the effects of use on the disorder than asking patients or using questionnaires.

The Future of the Psychiatric Mental Health Nursing Workforce: Using Our Skill Set to Address Incongruities in Mental Health Care Delivery

The USA is dealing with well-documented issues around mental health and its treatment. The Psychiatric Mental Health (PMH) workforce is growing and practicing in a variety of roles within the mental health system. How will PMH nurses address instances when the structure of services does not meet the mental health needs of the population? In this piece, I argue that to some degree the future of the PMH workforce will be determined by how well we use our capacity and capabilities to address incongruities in service structure and population needs. Five areas of concern with mental health services are outlined; they all involve factors that can be addressed with innovative approaches and optimum utilization of the PMH workforce. Included are suggestions on how PMH nurses might direct efforts toward these service issues, particularly by using their skill set and presence in the mental health system. Strategies include forging a tighter connection between the work of advanced practice and registered nurses in delivering care. Broadly, these efforts should be directed at building models of patient-centered care that address the needs of populations, reducing disparities, and demonstrating how engagement is a critical lever of effective inpatient and community-based care.

The physical health nurse consultant and mental health consumer: An important therapeutic partnership

People diagnosed with mental illness (hereon referred to as consumers) experience a disproportionately lower life expectancy of up 30 years compared to the general population. Systemic issues such as diagnostic overshadowing and stigma from healthcare professionals have inhibited the development of positive therapeutic partnerships that enable consumers to seek and engage support for their physical health concerns. Consumers have called for healthcare professionals to skillfully develop and prioritize therapeutic partnerships whilst coordinating and providing physical healthcare. The aim of this qualitative descriptive research was to explore consumer views and experiences of their interactions with a specialist mental health nursing role, the Physical Health Nurse Consultant. Semi-structured interviews were conducted with 14 consumers from a large public Community Mental Health Service in the Australian Capital Territory. Interviews were transcribed and thematically analysed. Therapeutic partnerships were an overarching theme identified from the data and included three sub-themes: personal attributes of the Physical Health Nurse Consultant; behaviour change engagement strategies; and impact of the therapeutic partnership. Consumers described the personal and professional attributes of the Physical Health Nurse Consultant that enabled the establishment and maintenance of their highly valued therapeutic partnership. This therapeutic partnership was perceived to positively impact their personal and clinical outcomes. With increasing support from consumers, clinical practice settings should move towards embedding a Physical Health Nurse Consultant role in routine practice. Further research exploring the co-development of health behaviour change goals and, barriers and facilitators experienced by the consumers regarding the Physical Health Nurse Consultant is required to further role development.

Validity and reliability of a Chinese version of the self-evaluation of negative symptoms

The negative symptoms of schizophrenia can be present at any clinical stage, but evaluating the negative symptoms always remains challenging. To screen the negative symptoms effectively, self-evaluation should be introduced. To date, professional psychiatrists used almost all of the scales available to screen the negative symptoms but could not obtain an accurate outcome. At the same time, an advanced self-assessment scale is needed to accompany the patients' self-feeling-based treatment strategies to understand their feelings about their symptoms. Hence, Chinese self-evaluation of negative symptoms (SNS) should be introduced in China. This study aims to examine the validity and reliability of the Chinese version of SNS. Two hundred patients with schizophrenia were included in this study and were evaluated entirely with the self-assessed negative symptoms by the Chinese version. The correlation analysis was performed between SNS and the Scale for Assessment of Negative Symptoms (SANS) to assess the criterion validity of SNS for screening negative symptoms. Exploratory factor analysis was used to determine the constructive validity of the SNS. Two senior professional psychiatrists were involved in this assessment based on their clinical experience and capability to define the severity of the negative symptoms. Receiver operating characteristic curve (ROC) analysis was performed to assess the cutoff point of SNS. Cronbach's alpha coefficient and intraclass correlation (ICC) coefficient were used to determine the reliability of SNS. We have the following findings: The Chinese version of SNS demonstrated a significant correlation with the SANS (r = .774, p < .05). Exploratory factor analysis demonstrated that the factor loading varies from .442 to .788. ROC analysis demonstrated that at SNS ≥ 8, the patients demonstrated a mild severity of negative symptoms, and at SNS ≥ 15, the patients demonstrated a severe severity of negative symptoms. Subsequently, 9 < SNS < 14 was defined as a moderate severity of negative symptoms. The Cronbach's alpha and ICC coefficients of the Chinese version SNS were .877 and .774, respectively. Our results showed that the acceptable validity and reliability of the Chinese version of SNS confirmed that SNS is an ideal tool for self-assessment of the negative symptoms in patients with schizophrenia.

Nurses' perceptions of nurse-patient communication in seclusion rooms in psychiatric inpatient care: A focus group study

INTRODUCTION

Communication between nurses and patients is essential in mental health nursing. In coercive situations (e.g. seclusion), the importance of nurse-patient communication is highlighted. However, research related to nurses' perceptions of nurse-patient communication during seclusion is scant.

AIM

The aim of this study was to describe nurses' perceptions of nurse-patient communication during patient seclusion and the ways nurse-patient communication can be improved.

METHOD

A qualitative study design using focus group interviews was adopted. Thirty-two nurses working in psychiatric wards were recruited to participate. The data were analysed using inductive qualitative content analysis.

RESULTS

Nurses aimed to communicate in a patient-centred way in seclusion events, and various issues affected the quality of communication. Nurses recognized several ways to improve communication during seclusion.

DISCUSSION

Treating patients in seclusion rooms presents highly demanding care situations for nurses. Seclusion events require nurses to have good communication skills to provide ethically sound care.

CONCLUSION

Improved nurse-patient communication may contribute to shorter seclusion times and a higher quality of care. Improving nurses' communication skills may help support the dignity of the secluded patients. Safewards practices, such as respectful communication and recognizing the effect of non-verbal behaviour, could be considered when developing nurse-patient communication in seclusion events.

RELEVANCE STATEMENT

This study deepens the understanding of nurse-patient communication during seclusion events from the perspective of nurses. Caring for patients in seclusion presents challenging situations for nurses and demands that they have good communication skills. To enhance their communication skills in seclusion events, nurses require opportunities to take part in further training after education related to communication skills for demanding care situations. Knowing the appropriate ways to interact with individual patients during seclusion can help nurses create and maintain communication with patients. For mental health nursing, nurses' enhanced communication may promote increased use of noncoercive practices in psychiatric settings. For patients, improving nurses' communication skills may help support dignity and autonomy during seclusion and shorten the time spent in seclusion, resulting in a better quality of care and more positive patient experiences related to care offered in seclusion. In this, the perspectives of people with lived experience of mental health problems should be acknowledged. Components of Safewards practices, such as using respectful and individual communication and paying attention to one's non-verbal communication (Soft Words), could be useful when developing nurse-patient communication in seclusion events.

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.

Application Research of Humanistic Care and Situational Integration in Nursing of Schizophrenia in Recovery Period

Objective

To formulate corresponding nursing humanistic care measures according to the needs of patients, evaluate the intervention effect of patients, and provide reference for nursing staff to better provide nursing humanistic care for patients with schizophrenia in convalescence.

Methods

Using the random number table method, 110 inpatients with convalescent schizophrenia were randomly divided into the control group (n = 55) and the experimental group (n = 55). The sample t-test was used to compare the changes of patient insight, treatment attitude, rehabilitation efficacy, and negative emotion score before and after nursing humanistic nursing intervention, and analyze the effect of nursing humanistic care intervention.

Results

Nursing satisfaction: the nursing satisfaction of the experimental group increased from 84.6% to 96.2%, after intervention, satisfaction of the experimental group was 96.2% higher than that of 86.5% of the control group.

Conclusion

Nursing intervention measures based on needs of nursing humanistic care can improve nursing satisfaction, insight and treatment attitude of patients, enhance recovery effect of patients, reduce negative emotions of patients, and benefit recovery of patients' conditions.

The association between empathy and the physiotherapy-patient therapeutic alliance: A cross-sectional study

BACKGROUND

The central component of person-centred care is in having a therapeutic realtionship. Furthermore, the empathy of the physiotherapist is one of the most important attributes in achieving a successful therapeutic alliance.

OBJECTIVE

The aim of the research was to determine the association between the constructs of empathy and therapeutic alliance in Spanish physical therapists and the possible influence of socio-professional variables on them.

DESIGN

Cross-sectional research.

METHODS

An electronic survey including the Working Alliance Inventory-Short Form, the Interpersonal Reactivity Index and sociodemographic data with 473 Spanish physiotherapists. A descriptive, bivariate and simple lineal regression analysis was carried out.

RESULTS

Work experience has a positive influence on bonding and the agreement on objectives and tasks (0.04 < B > 0.06; p < 0.01). The perspective taking dimensions and empathic concern positively influence the agreement on achievement (0.14 < B > 0.19; p < 0.001). Personal distress inversely influences bonding and the agreement on achievements and tasks (-0.13 < B > -0.09; p < 0.01).

CONCLUSIONS

The dimensions of perspective taking and empathic concern seem to facilitate successful shared decision making in terms of treating objectives. Furthermore, the physiotherapist's personal distress acts as an obstacle to the development of the three subcomponents of the therapeutic alliance analysed.

Psychiatric nurse's perceptions of their interactions with people who hear voices: A qualitative systematic review and thematic analysis

WHAT IS KNOWN ON THE SUBJECT?: There is no qualitative systematic review of nurses' perceptions of their interactions with people hearing voices. There are some studies exploring the interventions provided by community psychiatric nurses to people hearing voices; these give a sense of what interactions may contain. WHAT THE PAPER ADDS TO THE EXISTING KNOWLEDGE?: Nurses across both community and inpatient mental healthcare settings feel uncertain about how to interact with people hearing voices, sometimes feeling like they can do little to help. Their interactions are affected by the workplace culture, education and training and concern for their own safety. Nurses rely on a therapeutic relationship for all interactions. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This is an under investigated area of mental healthcare. None the less this qualitative systematic review highlights that nurses are unclear about how to interact with service users hearing voices with the resultant outcome that service users in great distress may only be receiving minimal benefit from their interactions with the nurses caring for them. ABSTRACT: Aims and Objectives The aim of this qualitative systematic review and thematic analysis was to identify and synthesize results from studies that explored psychiatric nurses' perceptions of their interactions with service users experiencing auditory hallucinations (hearing voices). Method Qualitative systematic review and thematic analysis. Results Five studies that met the inclusion criteria were identified. Nurses reported that they felt uncertain about what to do for service users hearing voices, struggled to have interactions with voice hearers, but greatly valued the therapeutic relationship with service users. Nurses also reported that they required more education and training on how to interact effectively with people hearing voices. Finally, various workplace challenges were identified as an important factor mediating nurse interaction with service users hearing voices. Discussion Existing evidence shows that nurses lack clarity about how they can interact effectively and in a way that helps service users who are hearing voices. Significant barriers that they must overcome in order to be more certain of their role in caring for people hearing voices are difficult to engage service users and workplace challenges that were not conducive to helpful interactions and conversations. Implications for Practice Nurses caring for people hearing voices require more and better education and training with a view to them becoming more confident and competent when interacting with this service user group. Furthermore, healthy workplace cultures and maintaining a safe environment are necessary for effective caring interactions with people hearing voices.

The therapeutic relationship between a client and dietitian: A systematic integrative review of empirical literature

Aim

Scientific evidence underpins dietetics practice; however, evidence of how the therapeutic relationship influences outcomes is limited. This integrative review aims to provide a comprehensive overview of the topic of the therapeutic relationship between clients and dietitians in the individual counselling context by summarising empirical literature into qualitative themes.

Methods

An electronic literature search of the Cumulative Index of Nursing and Allied Health Literature, PsychInfo, Scopus and Web of Science databases was conducted in October 2018 and repeated in February 2021. Studies were included if they explicitly referred to the therapeutic relationship (or associated terms), were based on study data and available in full text. Extracted data were checked by a second researcher and the methodological quality was evaluated independently by two researchers using the Mixed Methods Appraisal Tool. An iterative process of qualitatively coding, categorising and comparing data to examine recurring themes was applied.

Results

Seventy‐six studies met the inclusion criteria. Five themes were identified which showed the extent and nature of research in this area. Studies revealed the therapeutic relationship: (i) is valued within clinical dietetic practice, (ii) involves complex and multifactorial interactions, (iii) is perceived as having a positive influence, (iv) requires skills training and (v) is embedded in practice models and tools.

Conclusion

Studies show the therapeutic relationship is a valued and multifactorial component of clinical dietetic practice and is perceived to positively influence the client and dietitian. Observational data are needed to assess the extent to which the strength of the therapeutic relationship might contribute to clients' health outcomes.

Development and Validation of the Psychiatric Inpatient Experience (PIX) Survey: A Novel Measure of Patient Experience Quality Improvement

Objective: Managing patient experience is critical in transforming organizational cultures into high-quality patient-centered care systems. Patient experience measurement should ideally entail a framework for understanding a patient's interactions and perceptions across the continuum of care. The purpose of this study was to develop a psychometrically valid survey via a rigorous measurement development and validation process. Methods: An initial 28-item, five-domain survey with 2 additional open-ended prompts for narrative feedback was developed and piloted using exploratory and confirmatory factor analyses on a sample of 2438 individuals. A thematic analysis was subsequently performed based on the open-ended items to elucidate primary and secondary themes of patients’ narrative feedback. Results were used to further inform a conceptual framework and item design. Results: Factor analyses produced 4 factors (treatment team relationships, nursing team presence, treatment effectiveness, and healing environment). These 4 factors are associated with inpatient psychiatric patient experience, suggesting validity. Discussion: The Psychiatric Inpatient Experience (PIX) ysurvey integrates patient experience theory as well as aspects of patient-centered care that are important to psychiatric inpatients. It provides organization and discipline-specific feedback to facilitate opportunities for patient experience improvements.

Factors influencing the outcome of integrated therapy approach in schizophrenia: A narrative review of the literature

The integration of pharmacotherapy with psychosocial interventions has an important role to play in the improvement of functional outcome of subjects with schizophrenia (SCZ), in all stages of the disorder. It is essential for the adequate management of unmet therapeutic needs, such as negative symptoms and cognitive dysfunctions which account for most of the functional impairment of subjects with SCZ and do not respond to available antipsychotics. Enhancing the knowledge on factors involved in the effectiveness of integrated treatment plans is an important step forward for SCZ care. This review aims to identify factors that might influence the impact of integrated treatments on functional outcome. Most studies on the impact of psychosocial treatments on functional outcome of subjects with SCZ did not control for the effect of prescribed antipsychotics or concomitant medications. However, several factors relevant to ongoing pharmacological treatment might influence the outcome of integrated therapy, with an impact on the adherence to treatment (e.g., therapeutic alliance and polypharmacotherapy) or on illness-related factors addressed by the psychosocial interventions (e.g., cognitive dysfunctions or motivational deficits). Indirect evidence suggests that treatment integration should consider the possible detrimental effects of different antipsychotics or concomitant medications on cognitive functions, as well as on secondary negative symptoms. Cognitive dysfunctions can interfere with participation to an integrated treatment plan and can be worsened by extrapyramidal or metabolic side effects of antipsychotics, or concomitant treatment with anticholinergics or benzodiazepines. Secondary negative symptoms, due to positive symptoms, sedation, extrapyramidal side effects or untreated depression, might cause early drop-out and poor adherence to treatment. Researchers and clinicians should examine all the above-mentioned factors and implement appropriate and personalized integrated treatments to improve the outcome of SCZ.

A qualitative study of evidence-based therapeutic process in mental health services in Ghana- context-mechanisms-outcomes

Background

Evidence-based clinical practice is an inherent component of mental health professional practice in developed countries. However, little is known about professional perspectives of evidence-based practice in mental in developing countries such as Ghana. This paper describes the processes involved in the delivery of best practice in Ghana. The paper reports on a realistic evaluation of mental health nurses and allied health professionals’ views on the evidence-based therapeutic process in Ghana.

Methods

A purposive sample of 30 mental health professionals (MHPs) was recruited to participate in semi-structured, in-depth interviews. Thematic analysis was used to analyse the data. A program theory of Context + Mechanism = Outcome (CMO) configuration was developed from the analysis.

Results

The thematic analysis identified two contexts, mechanism and outcome configurations (themes): 1) technical competency stimulates evidence-based mental health services, and 2) therapeutic relationship building ensures effective interaction. The study demonstrates that contextual factors (technical competencies and therapeutic relationship building) together with mechanisms (intentional and unintentional) help to promote quality in mental health service provision. However, contextual factors such as a lack of sign language interpreters yielded unintended outcomes including barriers to communication with providers for consumers with hearing impairment and those from linguistic minority backgrounds.

Conclusion

Government stakeholders and policymakers should prioritise policies, periodic monitoring and adequate financial incentives to support the mechanisms that promote technical competence in MHPs and the building of therapeutic relationship.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06993-1.

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.

The association between empathy and the nurse-patient therapeutic relationship in mental health units: a cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: Empathy is one of the main attributes for establishing the nurse-patient therapeutic relationship. Davis (1983) identified four components on an empathic response: perspective taking, fantasy, empathetic concern and personal distress. It is essential to deepen our knowledge on the influence of the dimensions of empathy for the construction and development of the therapeutic alliance during the different phases of the therapeutic relationship. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: A significant association exists between the dimensions of empathy and the construction and development of the therapeutic alliance during the different phases of the therapeutic relationship between nurses and patients in mental health units. This study shows that the nurses' perspective on the patient's situation improves the bond, and therefore, this skill is especially useful in the first phase or orientation phase of the therapeutic relationship. However, for the second phase or working phase of the therapeutic relationship, a greater empathic concern among nurses, together with less personal distress, improves collaborative goal setting with patients. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is important for mental health nurses to be aware of the importance of personal self-awareness and the emotional management of empathy for the construction and development of therapeutic relationships of quality with patients. Knowledge of the relationship between each of the dimensions of empathy in the different stages of the therapeutic relationship is useful for the design of educational programmes, by including training on empathic strategies. ABSTRACT: Introduction Empathy and its dimensions (perspective taking, empathic concern, personal distress and fantasy) are essential for establishing the nurse-patient therapeutic relationship. It is important to know how this influences the construction and development of the therapeutic alliance during the different phases of the therapeutic relationship. Aim To examine whether the dimensions of empathy influence the nurse-patient therapeutic relationship within mental health units. Method A cross-sectional design was used to collect data to measure the therapeutic alliance and the different dimensions of empathy via an online form completed by nurses working at 18 mental health units. Linear regressions were used in the analysis. Results A total of 198 participants completed the questionnaires. Nurses established a greater therapeutic alliance with patients when they were able to adopt their patient's perspective and experience concern. Discussion Nurses' perspective taking is an influential factor impacting the nurse-patient bond in the orientation phase, whereas experiencing greater concern and decreased emotional distress were associated with improved therapeutic alliance in the working phase. Implications for practice These findings may help gain awareness among nurses of the importance of empathy in the nurse-patient relationships, as well as inform educational programmes, by including training in empathic strategies and emotional management.

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.].

The Experience of Insomnia in Patients With Schizophrenic Disorder: A Qualitative Study

BACKGROUND

Insomnia is a health problem that particularly affects people with schizophrenia. Its repercussions go beyond the disorder itself and affect many areas of life. The aim of the present study is to explore the clinical symptoms and consequences of insomnia in patients diagnosed with schizophrenic disorder and the perceptions of these patients regarding the care they receive.

METHODS

The study takes a qualitative approach and uses semi-structured interviews to conduct a descriptive and interpretive analysis of 3 clinically different clusters of patients. These 3 clusters have been defined by using two-step cluster analysis based on the results of the ISI (Insomnia Severity Index) and EQ-5D scales (EuroQol-5D) and the presence of certain diagnostic symptoms in a sample of 170 patients. The final sample was 31 subjects. The analysis was based on a hermeneutic analysis of the patients' narratives regarding their experiences of insomnia.

RESULTS

The patients' narratives show differences in the intensity and experience of insomnia depending on the severity, as well as its impact on their quality of life. Insomnia has a huge emotional impact. Participants describe ruminations and obsessive thoughts as a key factor hindering falling asleep. Some of the everyday actions they perform encourage the chronicity of insomnia. The desired health response must include interventions that are effective, such as cognitive-behavioural therapy, and powerful, such as pharmacological solutions. Psychoeducation and advice on sleep hygiene are highly valued tools as preventive strategies.

CONCLUSIONS

To know the experience of users gives us a more comprehensive understanding of insomnia complexities and brings some new intervention strategies in patients with mental disorders. It is important that health professionals intervene preventively to stop the disorder from becoming chronic.

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.

Treating Schizophrenia: Open Conversations and Stronger Relationships Through Psychoeducation and Shared Decision-Making

Integrated pharmacological and psychosocial treatments, such as psychoeducation (PE) and shared decision-making (SDM), have been shown to significantly improve outcomes for people living with schizophrenia (PLWS). Underpinning the success of these interventions is a strong therapeutic relationship between PLWS, their carers, and their healthcare team. While many recognize the value of this relationship, implementation of the interventions necessary to facilitate its construction remain low. In this article, we identify the barriers to developing productive therapeutic relationships and explain how PE and SDM, taking into account cultural difference, can improve adherence to treatment, strengthen therapeutic relationships, and ultimately equip patients to achieve better functional outcomes.

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.

Clinical communication and the 'triangle of care' in mental health and deafness: Sign language interpreters' perspectives

Objective To explore the processes by which therapeutic alliance develops in mental health consultations with Sign Language interpreters. Method Semi-structured interviews with 7 qualified interpreters were transcribed and analysed with interpretative phenomenological analysis. Results Two key themes were generated: (1) Nurturing the triangle of care, where the therapeutic process relied on collaboration, continuity, and trust; and (2) Shared vision and knowledge, in which participants felt misunderstood and unsupported; there was a lack of deaf awareness and clinicians appeared to feel deskilled. Conclusions Interpreters should be viewed as valued members of clinical teams and have access to clinical supervision so that they can be supported in interpreting emotional distressing content. Clinicians can aim to be collaborative with interpreters and improve their knowledge of mental health issues that are relevant to deaf people. Practice Implications An aide-memoire of the role and practicalities of working with SL interpreters should be developed and disseminated to relevant services to support collaborative working with clinicians. A core competence in SL interpreter training is reflexivity. This should be embedded in educational curricula and facilitated through clinical supervision. Funding by commissioning services should be subject to services being deaf aware and interpreters being mental health aware.

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.