What makes an excellent mental health nurse? A pragmatic inquiry initiated and conducted by people with lived experience of service use

Recommendations for Mental Health Chatbot Conversations: An Integrative Review

AIM

To identify and synthesise recommendations and guidelines for mental health chatbot conversational design.

DESIGN

Integrative review.

METHODS

Suitable publications presenting recommendations or guidelines for mental health conversational design were included. The quality of included publications was assessed using Joanna Briggs Institute Critical Appraisal Tools. Thematic analysis was conducted.

DATA SOURCES

Primary searches limited to last 10 years were conducted in PubMed, Scopus, ACM Digital Library and EBSCO databases including APA PsycINFO, CINAHL, APA PsycArticles and MEDLINE in February 2023 and updated in October 2023. A secondary search was conducted in Google Scholar in May 2023.

RESULTS

Of 1684 articles screened, 16 publications were selected. Three overarching themes were developed: (1) explicit knowledge about chatbot design and domain, (2) knowing your audience and (3) creating a safe space to engage. Results highlight that creating pleasant and effective conversations with a mental health chatbot requires careful and professional planning in advance, defining the target group and working together with it to address its needs and preferences. It is essential to emphasise the pleasant user experience and safety from both technical and psychological perspectives.

CONCLUSION

Recommendations for mental health chatbot conversational design have evolved and become more specific in recent years. Recommendations set high standards for mental health chatbots. To meet that, co-design, explicit knowledge of the user needs, domain and conversational design is needed.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Mental health professionals participating in chatbot development can utilise this review. The results can also inform technical development teams not involving healthcare professionals directly.

IMPACT

Knowledge of developing mental health chatbot conversations appears scattered. In mental health chatbots, features that enhance the chatbot's ability to meet users' needs and increase safety should be considered. This review is useful for developers of mental health chatbots and other health applications used independently.

REPORTING METHOD

This integrative review was reported according to PRISMA guidelines, as applicable.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Exploring safety culture within inpatient mental health units: The results from participant observation across three mental health services

In Australia, acute inpatient units within public mental health services have become the last resort for mental health care. This research explored barriers and facilitators to safe, person-centred, recovery-oriented mental health care in these settings. It utilised participant observations conducted by mental health nurses in acute inpatient units. These units were located in three distinct facilities, each serving different areas: a large metropolitan suburban area in a State capital, a mid-sized regional city, and a small city with a large rural catchment area. Our findings highlighted that, in the three inpatient settings, nurses tended to avoid common areas they shared with consumers, except for brief, task-related visits. The prioritisation of administrative tasks seemed to arise in a situation where nurses lacked awareness of alternative practices and activities. Consumers spent prolonged periods of the day sitting in communal areas, where the main distraction was watching television. Boredom was a common issue across these environments. The nursing team structure in the inpatient units provided a mechanism for promoting a sense of psychological safety for staff and were a key element in how safety culture was sustained.

The focus on weight in the inpatient care of anorexia nervosa: A qualitative investigation of consumer perspectives

Anorexia nervosa has a high mortality rate and is often treated in the inpatient setting, where close monitoring and medical support are available. Consistent with objective biomedical benchmarks, conventional inpatient treatment is often focussed on weight gain. Consumers report that clinicians provide care focussed on weight and physical restoration without adequate consideration of their full spectrum of needs. The aim of this study was to explore consumers' perspectives of the biomedical focus on weight gain in the inpatient care of anorexia nervosa. This study employed a qualitative approach, involving semistructured interviews, and participants were recruited from relevant social media communities. This study was ethically approved by a university ethics committee and the COREQ checklist ensured ethical reporting. Ten women participated in interviews. Participants reported that the biomedical imperative of weight gain is focussed on at the exclusion of other relevant determinants of well-being, and the narrow focus on weight gain does not suitably prepare consumers for discharge. The conflict between clinicians' biomedical focus and consumers' broader unmet needs leads to harmful interpersonal dynamics and feelings of invalidation. The inpatient care of anorexia nervosa needs to develop beyond biomedically driven objectives and incorporate the merits of an approach that substantively integrates person-centred care, therapeutic relationships and trauma-informed principles.

Patients' experiences of Daily Talks: a patient-driven intervention in inpatient mental healthcare

BACKGROUND

Recovery is known to be enhanced by meaningful interactions between patients and mental health staff. However, nurses may become distanced from patients, and patients may spend most of their time in inpatient mental health care alone.

AIMS

This study aimed to explore how patients experience the intervention Daily Talks, a patient-driven innovation intended to enhance meaningful interactions between patients and staff.

METHODS

Fourteen in-depth interviews were performed with patients who participated in Daily Talks. The interviews were analysed using reflexive thematic analysis.

RESULTS

The results of the participants' experiences of Daily Talks are presented in four themes: 1.Interpersonal and active interaction where individual factors matter 2.A patient-controlled space 3.A multi-use intervention and 4.A part of the daily healthcare structure. Participants stated that Daily Talks improved the relationship between patients and their nursing staff, and they stressed the importance of patients having control over both time and content in the Daily Talks. Daily Talks was used to vent emotions and thoughts, handle situations and create strategies, and become part of a helpful structure.

CONCLUSIONS

The results support the value of Daily Talks, indicating that Daily Talks may facilitate helpful structures and meaningful relationships between patients and nursing staff.

Mental health nursing capability development: Perspectives of consumers and supporters

Mental health nursing requires a specialist range of capabilities and values. In Australian contexts, the preparation of nurses to work in mental health settings has attracted criticism from government reviews, academics, and graduate nurses. Insufficient mental health content and clinical placement experience in undergraduate nursing courses have been central to this criticism. The study aim was to identify the areas and modalities of capability development of graduate mental health nurses, from the perspectives of end point users. In order to meet the aim, a four-item cross-sectional online survey with three additional and open-ended questions was developed. The questions were co-designed with consumer academics and reviewed by consumer and carer organizations. The survey was widely distributed across Australian consumer and carer organizations, with 95 useable responses. Findings indicated strong support for lived experience being integrated into teaching teams for nurses, as well as support for undergraduate direct entry for mental health nursing. Themed content from open-ended responses reflected the survey outcomes as well as prioritizing skill development to support better therapeutic relating and nurse self-care. Key findings included strong support for greater lived experience input into mental health nurse education, specialist undergraduate preparation and a focus on developing relational capabilities in the mental health nurse workforce.

Service User and Carer Views and Expectations of Mental Health Nurses: A Systematic Review

Service users' views and expectations of mental health nurses in a UK context were previously reviewed in 2008. The aim of this systematic review is to extend previous research by reviewing international research and work published after the original review. Five databases were searched for studies of any design, published since 2008, that addressed service user and carer views and expectations of mental health nurses. Two reviewers independently completed title and abstract, full-text screening and data extraction. A narrative synthesis was undertaken. We included 49 studies. Most included studies (n = 39, 80%) were qualitative. The importance of the therapeutic relationship and service users being supported in their personal recovery by mental health nurses were core themes identified across included studies. Service users frequently expressed concern about the quality of the therapeutic relationship and indicated that nurses lacked time to spend with them. Carers reported that their concerns were not taken seriously and were often excluded from the care of their relatives. Our critical appraisal identified important sources of bias in included studies. The findings of our review are broadly consistent with previous reviews however the importance of adopting a recovery approach has emerged as a new focus.

Utilizing the mental health nursing workforce: A scoping review of mental health nursing clinical roles and identities

Despite rising international needs for mental health practitioners, the mental health nursing workforce is underutilized. This is in part due to limited understandings of their roles, identities, and capabilities. This paper aimed to collate and synthesize published research on the clinical roles of mental health nurses in order to systematically clarify their professional identity and potential. We searched for eligible studies, published between 2001 and 2021, in five electronic databases. Abstracts of retrieved studies were independently screened against exclusion and inclusion criteria (primarily that studies reported on the outcomes associated with mental health nursing roles). Decisions of whether to include studies were through researcher consensus guided by the criteria. The search yielded 324 records, of which 47 were included. Retained papers primarily focused on three themes related to mental health nursing clinical roles and capabilities. Technical roles included those associated with psychotherapy, consumer safety, and diagnosis. Non-technical roles and capabilities were also described. These included emotional intelligence, advanced communication, and reduction of power differentials. Thirdly, the retained papers reported the generative contexts that influenced clinical roles. These included prolonged proximity with consumers with tensions between therapeutic and custodial roles. The results of this scoping review suggest the mental health nurses (MHNs) have a wide scope of technical skills which they employ in clinical practice. These roles are informed by a distinctive cluster of non-technical capabilities to promote the well-being of service users. They are an adaptable and underutilized component of the mental health workforce in a context of escalating unmet needs for expert mental health care.

What are the core competencies of a mental health nurse? A concept mapping study involving five stakeholder groups

Mental health nurses aim to provide high-quality care that is safe and person-centred. Service users require individualized care, responsive to their preferences, needs, and values. The views of service users, mental health nurses, nurse academics, psychiatrists, and nurse managers about the core competencies of mental health nurses have not been explored. Our study aimed to describe and contrast the views of multiple stakeholder groups on the core competencies of mental health nurses. Concept mapping is a six-step mixed-methods study design that combines qualitative data with principal component analysis to produce a two-dimensional concept map. Forty-eight people participated in the study from five stakeholder groups that included service users and clinicians. The final concept map had eight clusters: assessment and management of risk; understanding recovery principles; person- and family-centred care; good communication skills; knowledge about mental disorders and treatment; evaluating research and promoting physical health; a sense of humour; and physical and psychological interventions. There were important differences in how service users and health professionals ranked the relative importance of the clusters. Service users reported the understanding recovery principles cluster as the most important, whilst health professionals ranked the assessment and management of risk group the most important. There may be a disconnect between what service users and other stakeholders perceive to be the core competencies of mental health nurses. There is a need for more research to examine the differing perspectives of service users and health professionals on the core competencies of mental health nurses.

Hearing the patient voice: a qualitative interview study exploring the patient experience of a nurse-led initiative to integrate and enhance primary and secondary healthcare pathways

Objective

The Transitional Care Nursing Service was a 2-year proof-of-concept trial exploring local health system readiness for incorporating integrated, person-centred models of care into existing health service structures within a provincial New Zealand context. Improved patient experience remains a priority in international and local healthcare policy directives. This qualitative study aimed to investigate patient experience by exploring the effectiveness of this integrated care person-centred service from the patients’ perspective.

Methods

Qualitative, semistructured, face-to-face interviews with 12 patients purposively sampled to achieve maximum variation of patient characteristics within the trial cohort. Interviews were audio-recorded and transcribed verbatim before analysing the data using thematic analysis supported by a general inductive approach.

Results

Findings demonstrated that patient interactions with the transitional care nurse positively influenced patient experience, self-reported outcomes and quality of life following hospitalisation and during the transition period between hospital and home. Participants perceived the nurse to be highly skilled in displaying kindness, empathy, accessibility and responsiveness, and communication skills with participants and their families. They perceived that their interactions with this individual team member working from an integrated care paradigm had a positive impact on their overall experience of care and recovery.

Conclusion

This study supports the use of integrated care principles to deliver person-centred care. The findings emphasise the need to place kindness, compassion and respect at the heart of care delivered to patients, and suggest these core values are an essential factor in improving patient experience and thus the effectiveness of our healthcare systems.

What should be the future focus of mental health nursing? Exploring the perspectives of mental health nurses, consumers, and allied health staff

The landscape of mental health care and service delivery is changing, as is our understanding of the underlying causes for mental distress. It is now apparent that biogenic explanations have been overstated and instead experiences of trauma and adversity constitute the main contributor to people's experiences of mental health challenges. The shortcomings of treatments traditionally used in mental health care are also evident, and with a contemporary focus on person-centred care, the utility of diagnostic labels has been called into question. Taking all this into consideration, this study sought to explore, what should be the future focus of mental health nursing? Three separate focus groups were conducted. One with a sample of senior clinical mental health nurses, one with a sample of consumer representatives and another with allied health professionals. The common theme across all three focus groups was the centrality of the therapeutic role of mental health nurses (MHNs). Consumers and allied health participants, in particular, advocated for a de-emphasis on medications, psychiatric diagnoses, and custodial practices. The MHNs role in health promotion, working collaboratively with consumers, being hopeful, understanding the individual perspective, and appreciating the social determinants of mental health were all highlighted in framing the future focus of MHN practice.

The development and psychometric evaluation of the Mental Health Nurse-Sensitive Patient Outcome-Scale (MH-NURSE-POS) for inpatient psychiatric hospital settings

Mental health nurses are struggling to describe their nursing identity as professional discipline in a changing mental health care. Measuring nurse-sensitive patient outcomes and demonstrating nursing's effect(s) experienced by patients contribute to (re)discover the specific nursing identity. However, a valid and reliable scale is currently lacking. The aim of this study was the development and psychometric evaluation of the Mental Health Nurse-Sensitive Patient Outcome Scale (MH-NURSE-POS) for inpatient psychiatric hospital settings. This three-staged study resulted in a scale capturing how inpatients experience the contribution of nurses in their treatment in psychiatric hospitals. First, a draft questionnaire was developed based on a literature review, an independent expert's advice, and an experts panel. Second, the content validity was tested in a two-round Delphi-procedure and focus groups with patients. A pilot test, based on cognitive interviews, confirmed the feasibility of the questionnaire. Third, the psychometric properties of the mental health nurse-sensitive patient outcomes were determined in a sample of 353 patients. The cross-sectional study included a convenience sample of five psychiatric hospitals (Belgium). The factor structure (Kaiser-Meyer-Olkin measure of sampling adequacy 0.924; Bartlett's test of sphericity χ²  = 4162.537; df = 231; P < 0.001), convergent validity by the Individualized Care Scale (Pearson correlation 0.660; P < 0.001), and reliability (Cronbach's Alpha 0.854) were evaluated. The factor analysis resulted in a four-factor solution representing growth, expression, control, and motivation. The Mental Health Nurse-Sensitive Patient Outcome Scale is a valid and reliable tool to measure the effectiveness of mental health nurses from the patient perspective.

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.

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

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

'Meet Me Where I Am': Mental health service users' perspectives on the desirable qualities of a mental health nurse

Nurses play a central role in the delivery of quality mental health services. Desired qualities of a mental health nurse, in particular therapeutic relationships, have been described in the literature, primarily reflecting the nursing paradigm. Service users' perspectives must be more fully understood to reflect contemporary mental health policy and to recognize their position at the centre of mental health service delivery and to directly influence and contribute their perspectives and experiences to mental health nursing education. A qualitative exploratory research project was undertaken to inform and enhance understanding of what service users see as the desired qualities of a mental health nurse. The project was co-produced by service users as experts by experience, and mental health nurse academics to ensure the service user perspective was privileged. This international project conducted in Europe and Australia included a series of focus groups with service users (n = 50). Data were analysed thematically. Being with me was a major theme identified and reflected the sub-themes: respect towards service users as persons; empathy, compassion and effective communication; understanding service users; knowledge of services; and fostering hope and believing that recovery is possible. These qualities specifically reflecting the service user perspective must be central to mental health nursing curricula to facilitate the development of holistic care and recovery-oriented practice. These findings were utilized to directly inform development of a co-produced mental health nursing learning module, to maximize genuine service user involvement, and to fully realize the benefits of service user led education for undergraduate nursing students.

Improving Service User Involvement in Mental Health Nursing Education: Suggestions from Those with Lived Experience

Service user involvement in mental health nursing education is increasing and a developing evidence base is demonstrating more positive attitudes towards people labelled with a mental illness. To date, most research on this approach has focussed on the perspectives of nursing students, with very limited research drawing on the expertise and opinions of service users. The aim of this study was to explore potential improvements in mental health nursing education, and ways service user involvement can be enhanced as defined by service users themselves. An international qualitative research project was undertaken involving focus groups with service users (n = 50) from Australia and five European countries. The research was coproduced between Experts by Experience (service users) and mental health nurse academics. Data were analysed thematically. Findings reflected two broad themes: (1) improvements to content, including: further emphasis on developing emotional intelligence, understanding mental distress and broader context of care; (2) Improvements to service user involvement, including: support, format, and teaching and learning techniques. These findings provide direction for maximising the benefits of service user involvement and show the value of the expertise of service users.

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

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

Using patient experience data to support improvements in inpatient mental health care: the EURIPIDES multimethod study

Background

All NHS providers collect data on patient experience, although there is limited evidence about what to measure or how to collect and use data to improve services. We studied inpatient mental health services, as these are important, costly and often unpopular services within which serious incidents occur.

Aims

To identify which approaches to collecting and using patient experience data are most useful for supporting improvements in inpatient mental health care.

Design

The study comprised five work packages: a systematic review to identify evidence-based patient experience themes relevant to inpatient mental health care (work package 1); a survey of patient experience leads in NHS mental health trusts in England to describe current approaches to collecting and using patient experience data in inpatient mental health services, and to populate the sampling frame for work package 3 (work package 2); in-depth case studies at sites selected using the work package 2 findings, analysed using a realist approach (work package 3); a consensus conference to agree on recommendations about best practice (work package 4); and health economic modelling to estimate resource requirements and potential benefits arising from the adoption of best practice (work package 5). Using a realist methodology, we analysed and presented our findings using a framework based on four stages of the patient experience data pathway, for which we coined the term CRAICh (collecting and giving, receiving and listening, analysing, and quality improvement and change). The project was supported by a patient and public involvement team that contributed to work package 1 and the development of programme theories (work package 3). Two employed survivor researchers worked on work packages 2, 3 and 4.

Setting

The study was conducted in 57 NHS providers of inpatient mental health care in England.

Participants

In work package 2, 47 NHS patient experience leads took part and, in work package 3, 62 service users, 19 carers and 101 NHS staff participated, across six trusts. Forty-four individuals attended the work package 4 consensus conference.

Results

The patient experience feedback cycle was rarely completed and, even when improvements were implemented, these tended to be environmental rather than cultural. There were few examples of triangulation with patient safety or outcomes data. We identified 18 rules for best practice in collecting and using inpatient mental health experience data, and 154 realist context–mechanism–outcome configurations that underpin and explain these.

Limitations

The study was cross-sectional in design and we relied on examples of historical service improvement. Our health economic models (in work package 5) were therefore limited in the estimation and modelling of prospective benefits associated with the collection and use of patient experience data.

Conclusions

Patient experience work is insufficiently embedded in most mental health trusts. More attention to analysis and interpretation of patient experience data is needed, particularly to ways of triangulating these with outcomes and safety data.

Future work

Further evaluative research is needed to develop and evaluate a locally adapted intervention based on the 18 rules for best practice.

Study registration

The systematic review (work package 1) is registered as PROSPERO CRD42016033556.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 21. See the NIHR Journals Library website for further project information.

The burden of caregiving among mental health nurses providing services to consumers with depression in Ghana

PURPOSE

The study aims to explore the burden of caregiving among mental health nurses providing services to consumers with depression in Ghana.

DESIGN AND METHODS

Interpretative phenomenological design and qualitative data FINDINGS: The study shows that several health system constraints and individual factors contribute to the burden of caregiving among mental health nurses. Health system challenges are the poor state of the psychiatric facility, while individual factors are stigmatizing attitudes, nonadherence to medication instructions, limited family support, and physical and verbal abuse. The coping strategies used by mental health nurses are self-motivation, emotional boundaries, and the perceived clinical outcomes of treatment.

PRACTICE IMPLICATIONS

Clinical policies, procedures, and health facility practices should adequately address caregiving challenges, to facilitate effective mental health services.

'There's more to a person than what's in front of you': Nursing students' experiences of consumer taught mental health education

Holistic and person-centred nursing care is commonly regarded as fundamental to nursing practice. These approaches are complementary to recovery which is rapidly becoming the preferred mode of practice within mental health. The willingness and ability of nurses to adopt recovery-oriented practice is essential to services realizing recovery goals. Involving consumers (referred herein as Experts by Experience) in mental health nursing education has demonstrated positive impact on the skills and attitudes of nursing students. A qualitative exploratory research project was undertaken to examine the perspectives of undergraduate nursing students to Expert by Experience-led teaching as part of a co-produced learning module developed through an international study. Focus groups were held with students at each site. Data were analysed thematically. Understanding the person behind the diagnosis was a major theme, including subthemes: person-centred care/seeing the whole person; getting to know the person, understanding, listening; and challenging the medical model, embracing recovery. Participants described recognizing consumers as far more than their psychiatric diagnoses, and the importance of person-centred care and recovery-oriented practice. Understanding the individuality of consumers, their needs and goals, is crucial in mental health and all areas of nursing practice. These findings suggest that recovery, taught by Experts by Experience, is effective and impactful on students' approach to practice. Further research addressing the impact of Experts by Experience is crucial to enhance our understanding of ways to facilitate the development of recovery-oriented practice in mental health and holistic and person-centred practice in all areas of health care.

Experiences of in-patient mental health services: systematic review

BACKGROUND

In-patients in crisis report poor experiences of mental healthcare not conducive to recovery. Concerns include coercion by staff, fear of assault from other patients, lack of therapeutic opportunities and limited support. There is little high-quality evidence on what is important to patients to inform recovery-focused care.AimsTo conduct a systematic review of published literature, identifying key themes for improving experiences of in-patient mental healthcare.

METHOD

A systematic search of online databases (MEDLINE, PsycINFO and CINAHL) for primary research published between January 2000 and January 2016. All study designs from all countries were eligible. A qualitative analysis was undertaken and study quality was appraised. A patient and public reference group contributed to the review.

RESULTS

Studies (72) from 16 countries found four dimensions were consistently related to significantly influencing in-patients' experiences of crisis and recovery-focused care: the importance of high-quality relationships; averting negative experiences of coercion; a healthy, safe and enabling physical and social environment; and authentic experiences of patient-centred care. Critical elements for patients were trust, respect, safe wards, information and explanation about clinical decisions, therapeutic activities, and family inclusion in care.

CONCLUSIONS

A number of experiences hinder recovery-focused care and must be addressed with the involvement of staff to provide high-quality in-patient services. Future evaluations of service quality and development of practice guidance should embed these four dimensions.Declaration of interestK.B. is editor of British Journal of Psychiatry and leads a national programme (Synergi Collaborative Centre) on patient experiences driving change in services and inequalities.

Using the repertory grid technique to explore the experience of compassion by mothers in a mother and baby unit

Despite differences between Mother and Baby Units (MBUs) and other inpatient psychiatric settings, research has not yet explored the nature and value of compassionate care offered by MBU staff despite the increasing importance of compassion in healthcare. This novel study investigated the experience of compassionate care by fifteen mothers admitted to a MBU in England using the Repertory Grid Technique. Our findings indicated that these women perceived their MBU care as compassionate. Compassion was central to nursing care and clearly implicated in women's recovery from mental illness. Additionally, other staff characteristics were important to mothers, including how effectively MBU staff coped with stressful situations, staff flexibility in their care approach and how they adhered to professional boundaries. It is important to facilitate the expression of compassion which partially depends on the personalities and training of staff and the cooperation of service managers in fostering compassionate care.

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

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

Mental health nurses and mental health peer workers: Self-perceptions of role-related clinical competences

In a mental healthcare that embraces a recovery-oriented practice, the employment of mental health peer workers is encouraged. Although peer workers are increasingly working together with nurses, there is a lack of research that explores how nurses and peer workers perceive their role-related competences in clinical practice. The aim of this study was to clarify and understand these self-perceptions in order to identify the specificity and potential complementarity of both roles. This insight is needed to underpin a successful partnership between both vocations. A qualitative descriptive research design based on principles of critical incident methodology was used. Twelve nurses and eight peer workers from different mental healthcare organizations participated. A total of 132 reported cases were analysed. Rigour was achieved through thick description, audit trail, investigator triangulation and peer review. Nurses relate their role-related competences predominantly with being compliant with instructions, being a team player and ensuring security and control. Peer workers relate their role-related competences with being able to maintain themselves as a peer worker, building up a relationship that is supportive for both the patient and themselves, and to utilize their lived experience. Both nurses and peer workers assign a major role to the team in determining their satisfaction with their competences. Consequently, what is perceived as important for the team appears to overshadow their self-assessment of competences. The findings highlighted the importance of paying more attention to identity construction, empowerment and role competence development of nurses and peer workers in their respective education and ongoing training.

Introducing solution-focussed brief therapy to mental health nurses across a local health district in Australia

Solution-focussed brief therapy (SFBT) can be applied to effectively address a broad range of mental health-, alcohol-, and substance-related challenges. The compatibility that SFBT has with mental health nursing practice has been widely recognized. The aim of the present mixed-methods study was to introduce and evaluate the utility of SFBT principles, strategies, and techniques to the clinical work of mental health nurses from a local health district in Sydney, Australia. Following a 4-hour introductory SFBT workshop, participants were invited to complete a one-page evaluation and undertake a follow-up individual telephone interview with a research assistant. Participants (n = 65) were positive about the workshop content and recognized the potential benefits of SFBT in clinical practice. Interviewed participants (n = 14) were enthusiastic about SFBT. However, they also identified that using SFBT was challenging, particularly as the approach was considered different to current practices in mental health services. A lack of confidence with incorporating SFBT in their clinical work was also acknowledged, and participants expressed interest in additional training, including more time to practise SFBT strategies and techniques. Widespread training for mental health nurses in SFBT is indicated, including opportunities for supervision and to observe SFBT being employed by experienced clinicians.

Capturing the Interpersonal Process of Psychiatric Nurses: A Model for Engagement

Staff members' engagement with patients is a critical element of inpatient psychiatric care, essential to safety, the hospitalization experience and the development of a culture of care. Currently broad concerns exist around the amount of time inpatient psychiatric nurses expend in patient engagement and the quality of these interactions. In this paper we present a model of engagement that clarifies necessary skills to support the engagement process. The model is based on Peplau's theory of interpersonal relations, patients' ideas on healing elements of psychiatric hospitalization and research on inpatient therapeutic relationships. We are currently using this model for a web-based teaching/learning course to cultivate interpersonal engagement, and to explicate how through operationalizing their inpatient role, nurses support patients in the development of their mental health and well-being.

Nurses experiences of delivering care in acute inpatient mental health settings: A narrative synthesis of the literature

Inpatient psychiatric care requires a balance between working with consumers' priorities and goals, managing expectations of the community, legal, professional and service responsibilities. In order to improve service delivery within acute mental health units, it is important to understand the constraints and facilitating factors for good care. We conducted a systematic narrative synthesis, where findings of qualitative studies are synthesised to generate new insights. 21 articles were identified. Our results show that personal qualities, professional skills as well as environmental factors all influence the ability to provide recovery focused care. Three overarching themes which either facilitated or hindered were identified. These included: (i) Complexity of the nursing role (clinical care; practical and emotional support: advocacy and education; enforcing aspects of the Mental Health Act. and, maintaining ward safety); (ii) Constraining factors (operational barriers; change in patient characteristic; and competing understandings of care); and (iii) Facilitating factors (ward factors; nursing tools; nurse characteristics; approach to people; approach to work and ability to self-care). We suggest that the therapeutic use of self is central to the provision of recovery oriented care. However person-centred practice can be fragile and fluid and a compassionate system of support is needed to enable an understanding of context and self. It is critical to have a work environment which fosters hope and optimism and is supportive of autonomy, ensures workload balance, and is safe.

'What makes an excellent mental health doctor?' A response integrating the experiences and views of service users with critical reflections of psychiatrists

While therapeutic relationships are appropriately recognised as the foundation of mental health service, service users commonly report suboptimal experiences. With shared understanding critical to improvement in practice, we explored service users' experiences and expectations of psychiatrists and consultations, engaging psychiatrists throughout the process. Using an iterative qualitative approach we co-produced a response to the question 'what makes an excellent mental health doctor?' Experiences and expectations of psychiatrists were explored in interviews with 22 service users. Data collection, analysis and interpretation were informed by consultation with peer workers. Findings were contextualised in formal consultations with psychiatrists. As 'masters of their craft', excellent mental health doctors engage authentically with service users as people (not diagnoses). They listen, validate experiences and empathise affectively and cognitively. They demonstrate phronesis, applying clinical knowledge compassionately. Psychiatrists share service users' aspiration of equitable partnership but competing demands and 'professional boundaries' constrain engagement. Consistent delivery of the person-centred, recovery-oriented care promoted by policy and sought by service users will require substantial revision of the structure and priorities of mental health services. The insights and experiences of service users must be integral to medical education, and systems must provide robust support to psychiatrists.

The therapeutic role of mental health nurses in psychiatric intensive care: A mixed-methods investigation in an inner-city mental health service

WHAT IS KNOWN ON THE SUBJECT?: Mental health services have been radically transformed since the 1990s, with an emphasis on care in the community. However, acute psychiatric wards remain an important component of service provision. Research shows that patients receive limited therapeutic interaction with nurses in such settings. A recent review showed that just 4%-12% of nurses' time was spent on activities that could be considered therapeutic. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE?: Whereas nurses wanted more time for individual therapeutic activity, patients were content with brief interactions. However, such contact was not always available, partly due to workload pressures. Both nurses and patients believed that a collaborative approach, involving the whole multidisciplinary team, was key to the success of therapeutic engagement. The meaning of therapeutic engagement remains nebulous. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurse education, ward management and clinical supervision should have greater emphasis on therapeutic engagement. Further research is needed to develop therapeutic engagement in acute psychiatric settings; such work should involve patients as active and equal partners.

ABSTRACT

Introduction Despite indications that therapeutic interaction is beneficial for patients and for nurses' job satisfaction in acute psychiatric care, research shows a small amount of nurses' time is spent on such activity. Aims This study investigated the actual and potential therapeutic role of the mental health nurse in psychiatric intensive care, where admission is due to violence or aggression. Methods In a mixed-methods concurrent triangulation design, clinician and patient activity was observed using a structured measurement tool, and qualitative interviews were conducted with four practitioners and six patients. Findings were generated using thematic analysis and descriptive statistics. Results Of the directly observed 234 clinician and 309 patient activities, 20.9% and 15.9%, respectively, were classified as therapeutic engagement. Interviews revealed that both clinicians and patients wanted more therapeutic contact, but whereas nurses wanted longer time to spend in individual sessions, patients preferred brief but more frequent interaction with nurses. Discussion This study shows disparity between actual and desirable levels of therapeutic interaction. Apart from organizational constraints, a fundamental problem is the lack of definition or established practices of therapeutic engagement. Implications for Practice There should be more emphasis on therapeutic engagement in nurse education, ward management and clinical supervision.

Does 'Time Together' increase quality of interaction and decrease stress? A study protocol of a multisite nursing intervention in psychiatric inpatient care, using a mixed method approach

INTRODUCTION

Despite the long-known significance of the nurse-patient relationship, research in psychiatric inpatient care still reports unfulfilled expectations of, and difficulties in, interactions and relationships between patients and staff. Interventions that create structures to allow quality interactions between patients and staff are needed to solve these problems. The aim of this project is to test effects of the nursing intervention Time Together and to evaluate the intervention process.

METHODS AND ANALYSIS

This is a multisite study with a single-system experimental design using frequent measures. The primary outcomes are quality interactions for patients and perceived stress for staff. Secondary outcomes are levels of symptoms of anxiety and depression for patients and stress of conscience for staff. A process evaluation is performed to describe contextual factors and experiences. Data are collected using questionnaires, participant observations and semistructured interviews. For analysis of quantitative data, both visual and statistical methods will be used. Qualitative data will be analysed using qualitative content analysis.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Ethical Review Board in the region (Dnr 2016/339-31). The findings will contribute to the development of nursing interventions in general, but more specifically to the development of the intervention. This is relevant both nationally and internationally as similar interventions are needed but sparse. The findings will be disseminated through conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT02981563.

Risky business: Lived experience mental health practice, nurses as potential allies

Mental health policy includes a clear expectation that consumers will participate in all aspects of the design and delivery of mental health services. This edict has led to employment roles for people with lived experience of significant mental health challenges and service use. Despite the proliferation of these roles, research into factors impacting their success or otherwise is limited. This paper presents findings from a grounded theory study investigating the experiences of Lived Experience Practitioners in the context of their employment. In-depth interviews were conducted with 13 Lived Experience Practitioners. Risk was identified as a core category, and included sub-categories: vulnerability, 'out and proud', fear to disclose, and self-care. Essentially participants described the unique vulnerabilities of their mental health challenges being known, and while there were many positives about disclosing there was also apprehension about personal information being so publically known. Self-care techniques were important mediators against these identified risks. The success of lived experience roles requires support and nurses can play an important role, given the size of the nursing workforce in mental health, the close relationships nurses enjoy with consumers and the contribution they have made to the development of lived experience roles within academia.

Interpersonal nurse-patient relationship with a young schizophrenic pregnant woman

The objective of this study was to investigate elements of the personal and psychiatric history, as well as the challenges related to motherhood, of a young schizophrenic female, through person-centered therapeutic interaction. The investigation had an exploratory scope, undertaken in a teaching hospital and data were collected during nondirective interaction on the part of the nurse with a young schizophrenic woman who had been treated in the institution for 10 years. Thematic analysis of the content was undertaken, with emphasis on the nuclei of meaning, identification of the themes and definition of the categories. The patient, called L. in this study, was 30 years old, had a two-year-old child and was three months pregnant when data were collected. Her trajectory was characterized by doubts, fears and uncertainties. The episodes of hospitalization, the coexistence with other patients, and the medications promoted insight into the symptoms, and acceptance of the diagnosis. The main challenge was experiencing pregnancy and the puerperium concomitantly with the psychiatric treatment. The interpersonal relationship established evidenced that, the young woman felling understood and that her needs were attended, overcame several difficulties she had reported and felt fulfilled and integrated into her social environment.

Coping with Violence in Mental Health Care Settings: Patient and Staff Member Perspectives on De-escalation Practices

This multiple case study explored de-escalation processes in threatening and violent situations based on patients and staff members perspectives. Our post hoc analysis indicated that de-escalation included responsive interactions influenced by the perspectives of both patients and staff members. We assembled their perspectives in a mental model consisting of three interdependent stages: (1) memories and hope, (2) safety and creativity and (3) reflective moments. The data indicated that both patients and staff strived for peaceful solutions and that a dynamic and sociological understanding of de-escalation can foster shared problem solving in violent and threatening situations.

"What is the work of Recovery Oriented Practice? A systematic literature review"

Concepts of personal and social recovery in mental illness are constantly evolving because the journey is fluid and subject to change over time. Dynamic interactions between the complexities of human nature and mental illness create ever-altering landscapes of perplexity. The acknowledged ebb and flow of recovery in the presence of chronic and serious mental illness requires health professionals to provide a flexible suite of care, delivered through skills and methods that are responsive and meaningful to the recipient. We conducted a systematic search for qualitative literature that articulated the work of personally-supportive recovery-oriented practice (ROP) to determine the specific components of recovery-supportive work. Twenty-one articles were identified as meeting the inclusion criteria and were synthesized using a coding framework derived from Normalization Process Theory. We identified three kinds of recovery-supportive work required from health professionals: alleviating stigma, delivering effective recovery-supportive responses in the presence of complex health and social situations and managing challenges associated with the work of ROP. We discuss the resources needed for ROP and the barriers that inhibit health professionals' engagement in this work. By elucidating the work of ROP, we highlighted a disparity between health professionals' aspirations and achievements. These revelations could inform service delivery in order to better support consumer recovery in serious mental illness.

Quality of interactions influences everyday life in psychiatric inpatient care--patients' perspectives

Everyday life consists of daily activities that are taken for granted. It forms the foundation for human efforts and contains elements of both comfort and boredom. Because everyday life escapes no one, life in a psychiatric ward will become ordinary while staying there. This study aims to explore everyday life in psychiatric inpatient care based on patients' experiences. We individually interviewed 16 participants with experiences of psychiatric inpatient care and analysed the data in accordance with the methods of grounded theory. Data collection and analysis continued in parallel in accordance with the method. Our results showed that everyday life is linked to the core category quality of interactions influences everyday life, and three constructed categories-staff makes the difference, looking for shelter in a stigmatizing environment, and facing a confusing care content-were related to the core category. Our results highlight the importance of ordinary relationships between staff and patients in psychiatric inpatient care. These results can be used to develop nursing interventions to improve psychiatric inpatient care and might also be used as a basis for reflective dialogues among staff.

User participation in district psychiatry. The social construction of 'users' in handovers and meetings

An ideal in mental health care is user participation. This implies inclusion and facilitation by clinicians to enable users to participate in decisions about themselves and in the design of suitable treatment. However, much of the work of clinicians consists of handovers and other meetings where patients are not present. It is therefore interesting to study how the patient perspective is handled in such meetings and whether it forms a basis for user participation. We conducted fieldwork in three different inpatient wards in Norwegian District Psychiatric Centres. We used an interactional perspective in our analysis, where speech acts, framing and footing were key concepts. The findings show that the talk in the handovers and meetings contained five main themes and that there was a clear correlation between what was said and how it was said, and whether clinicians related to the content in a decisive, person-centred or indecisive manner. We discuss potential participation statuses for patients and their limited opportunity to influence the talk and possible decisions about themselves. Our conclusion is that handover meetings primarily function as an aid in organising clinicians' work and could ultimately be seen as counteracting user participation.

Raiders of the Lost Art: A review of published evaluations of inpatient mental health care experiences emanating from the United Kingdom, Portugal, Canada, Switzerland, Germany and Australia

Forming interpersonal therapeutic relationships with mental health Service Users remains a key aspect of the practice of Psychiatric/Mental Health nurses. Given the omnipresence of the concept within the relevant literature the reader could be forgiven for asking: why would Psychiatric/Mental Health nurses opine about something so basic, so ubiquitous and so central to the theory and practice of our discipline? While the authors could locate no substantive argument that refutes the role or value of such relationships, a sizable, growing and reasonably consistent body of work has emerged, which appears to indicate that this centrality and value is not necessarily reflected in many clinical practice settings. Accordingly, we draw on the published evaluations of mental health care emanating from the United Kingdom, Portugal, Canada, Switzerland, Germany and Australia, compare these findings and highlight similarities or/and congruence and discuss a range of issues arising out of the findings. Alas, the findings seem to depict a mental health care inpatient experience that is often devoid of warm therapeutic relationships, respectful interactions, information or choice about treatment and any kind of formal/informal 'talk therapy'. Instead such care experiences are personified by: coercion, disinterest, inhumane practices, custodial and controlling practitioners and a gross over use of pharmacological 'treatments'.

What keeps nurses busy in the mental health setting?

ACCESSIBLE SUMMARY

Recent evidence suggests that the interactional work of mental health nursing has been eroded and redirected to the task-based roles of medicine. This study utilized work sampling methodology to observe the proportion of time nurses working in a mental health setting spend in direct care, indirect care and service-related activities. Nurses spent 32% of their time in direct care, 52% in indirect care and 17% in service-related activities. Mental health nurses need to re-establish their therapeutic availability to maximize consumer experiences and outcomes.

ABSTRACT

The foundation of mental health nursing has historically been grounded in an interpersonal, person-centred process of health care, yet recent evidence suggests that the interactional work of mental health nursing is being eroded. Literature emphasizes the importance of person-centred care on consumer outcomes, a model reliant upon the intimate engagement of nurses and consumers. Yet, the arrival of medical interventions in psychiatry has diverted nursing work from the therapeutic nursing role to task-based roles delegated by medicine, distancing nurses from consumers. This study used work sampling methodology to observe the proportion of time nurses working in an inpatient mental health setting spend in the activities of direct care, indirect care and service-related activities. Nurses spent 32 of their time in direct care, 52% in indirect care and 17% in service-related activities. Mental health nurses need to re-establish their therapeutic availability to maximize consumer experiences and outcomes.

Engagement as an Element of Safe Inpatient Psychiatric Environments

BACKGROUND

The American Psychiatric Nurses Association (APNA) Institute for Safe Environments (ISE) has focused on key elements that affect safety in psychiatric treatment environments; one of these key elements is patient engagement. An ISE workgroup discussed and reviewed the literature on engagement and safety in inpatient psychiatric settings. This article presents what we have learned about the role that engagement plays in inpatient treatment of severely mentally ill individuals and evidence that links nurse-patient engagement to safety.

OBJECTIVES

To describe, using supporting literature, the role that nurse-patient engagement plays in creating safe, therapeutic environments for individuals with severe mental illness.

DESIGN

(1) Define engagement and describe why it is an important element of safe treatment environments; (2) identify what helps and what hinders patients in their engagement with nurses, and nurses in their engagement with patients; (3) describe how engagement may improve unit safety; and (4) propose recommendations and set future directions for practice, research, and education.

CONCLUSION

Engagement may provide the foundation for safe, therapeutic, and recovery-oriented treatment. In the future, APNA's ISE plans to build upon this foundation by developing a clinical model of nurse-patient engagement and safety by drawing together emerging research and practice models.