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

Recovery at an Adult Psychiatric Day Hospital-A Qualitative Interview Study Describing Patients' Experiences

Psychiatric Day Hospitals offer time-limited active treatment programmes that are therapeutically intensive, coordinated, and with structured clinical services within a stable environment. No previous studies have described patients' experiences of recovery-oriented care at a Psychiatric Day Hospital in a Swedish or Nordic healthcare context. The aim of the study was to explore patients' experiences of a Psychiatric Day Hospital with focus on patient recovery. A qualitative method was used; 12 in-depth interviews were performed with patients all analysed with content analysis. The theme that emerged was "A safe haven." To do something routinely and meaningful during the days, feelings of security, and to gain increased knowledge about mental ill health were concepts which felt important and contributed to recovery. Feelings of belonging and prevention of loneliness were also highlighted.

Everyday ordinariness, neglected but important for mental health nurses' therapeutic relationships: An initial exploration for applying Daniel Kahneman's two systems of thinking

Mental health nurses undertake difficult and complex roles. Therapeutic relationships and engagement between mental health nurses and people experiencing severe mental ill-health provide the core purpose and rationale for such mental health care. These relationships are influenced by factors outside of frontline mental health nurses control. They are difficult to define or describe with clarity, have limited 'quantitative' evidence of effectiveness and are frequently not experienced as therapeutic. This paper presents some initial ideas regarding 'everyday ordinariness' using psychologist Daniel Kahneman's two systems of thinking as a focus for understanding and potentially improving mental health nurse practice, and therapeutic relationships and engagement.

Environments that promote recovery in acute care mental health: nursing perspectives explored through interpretative description

BACKGROUND

A significant change in mental health care has involved the need to implement recovery-oriented practices and services. However, recovery-oriented care has been poorly defined within acute care mental health settings.

OBJECTIVES

The central aims of the study were to increase knowledge about what constitutes a recovery-oriented environment within contemporary acute care units and to inform recovery-oriented nursing practice.

METHODS

Interpretative description was applied to answer the question: What strategies and resources do nurses identify as being most conducive to fostering a recovery-oriented environment in acute care mental health units? Purposive sampling was used to recruit 11 nurses from 6 acute care units. The inclusion criteria included a minimum of 1-year patients and holding active nursing registration. Nursing experience in community-based or chronic care settings and with children and adolescents were exclusion criteria. Six nurses also participated in a focus group.

RESULTS

Key aspects of a recovery-oriented acute care environment included understanding the needs of individual patients along with the dynamics of the healthcare team. Nurses had important roles in promoting recovery-oriented environments and reported a need for increased resources to move beyond the bio-medical model and align practice with personal recovery.

CONCLUSION

A recovery-oriented environment was described as a safe, peaceful and holistic environment with adequate space to balance needs for privacy, interaction and activity. This environment is fostered through respectful communication and healthy relationships among team members, patients, family and formal supports. These nurses had the knowledge, skill and desire to promote recovery-oriented environments, yet resources such as leisure activities and group therapy were required to promote personal recovery.

Implementation and Adaptation of the Safewards Model in the New Zealand Context. Perspectives of Tāngata Whai Ora and Staff

The safety of service users and staff is paramount in cultivating a therapeutic environment within inpatient mental health units. The Safewards model, originating in the United Kingdom, aims to reduce conflict and containment rates through 10 interventions. This study used participatory action research to explore the perspective of tāngata whai ora and staff regarding the adaptation of the Safewards model to the unique New Zealand context. Such adaptation is critical due to significant health outcome disparities between Māori and non-Māori populations and the disproportionate representation of Māori within mental health services. In adhering to the principles of Te Tiriti o Waitangi, cultural adaptation becomes an imperative obligation. The study utilised qualitative content analysis and thematic analysis, drawing data from focus groups of staff (n = 15) and tāngata whai ora (n = 3). This study describes a New Zealand Safewards model, which must include Te Ao Māori, align with current practices, adapt Safewards interventions and gain acceptance. Organisational change management is pivotal in the integration of this model into nursing practice. The outcomes of this study hold the potential to contribute to the formulation and implementation of a New Zealand Safewards model, while also bearing relevance for the international adaptation of Safewards to culturally diverse countries and healthcare systems.

An analysis of the barriers and enablers to implementing the Safewards model within inpatient mental health services

Mental health inpatient units can provide a sanctuary for people to recover from mental illness. To support a therapeutic environment, the safety and well-being of service users and staff need protection through reduced conflict and containment rates. The Safewards model identifies 10 interventions to prevent conflict and containment. This paper aims to present barriers and enablers to implementing Safewards by analysing current literature on the Safewards model. It will also compare the Safewards model to New Zealand's Six Core Strategies. In a systematic search of 12 electronic databases following the PRISMA flow chart, 22 primary studies were included in this analysis. JBI tools were used for quality appraisal and deductive content analysis was used to organize and interpret data. Four categories were identified: (a) designing the Safewards interventions and implementation; (b) staff participation and perception of Safewards; (c) healthcare system influences on Safewards implementation; (d) service user participation and perception of Safewards. To support successful Safewards implementation in future practice, this review recommends that Safewards implementation is enabled through robust design of the Safewards interventions and implementation methods; staff participation and positive perception of the Safewards model; a resourced healthcare system that prioritizes Safewards implementation; service user awareness and participation in Safewards interventions. Interactionist perspectives may support the implementation of Safewards. This analysis is limited by research settings mostly being inpatient adult services and inadequate capturing of the service user voice. An ongoing review of barriers and enablers is important for supporting future Safewards implementation.

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.

'I felt alive': A qualitative study of inpatients' perspectives on good mental health nursing in South Korea

Although mental health nurses continuously strive for patients' well-being, patients still experience inpatient care negatively. To identify an individual's actual, mental health nursing care needs and offers them optimal benefits during their hospital stay, determining what patients perceive as good nursing should be prioritized. This qualitative descriptive study aimed to understand good mental health nursing from the inpatients' perspective. The data were collected through semi-structured interviews with 13 patients admitted to a psychiatric ward in South Korea, and analysed using thematic analysis. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were used to ensure transparency and rigour. The results revealed that patients experienced good mental health nursing when nurses respected their humanity, adopted a practical approach to solve problems pragmatically, and facilitated their recovery. These practices stem from mental health nurses' attitudes towards humanity based on individualized respect, professional ability to handle patients' individual needs, and offering patients hope and confidence for recovery and the future. Therefore, mental health nurses need to focus their efforts on these aspects of nursing attitudes and competencies to ensure that inpatients experience good mental health nursing.

Barriers and enablers to implementation of the therapeutic engagement questionnaire in acute mental health inpatient wards in England: A qualitative study

A strong association exists between the quality of nurse-service user therapeutic relationship and care outcomes on acute mental health inpatient wards. Despite evidence that service users desire improved therapeutic engagement, and registered mental health nurses recognize the benefits of therapeutic relationships, such interactions remain sub-optimal. There is a dearth of evidence on factors influencing implementation of interventions to support and encourage therapeutic engagement. This study aimed to understand the barriers and enablers to implementation of the Therapeutic Engagement Questionnaire (TEQ), across fifteen acute inpatient wards in seven English mental health organizations. Qualitative methods were used in which data were collected from ethnographic field notes and documentary review, coded, and analysed using thematic analysis. Theoretical framing supported data analysis and interpretation. Reporting adheres to the Standards for Reporting Qualitative Research. The TEQ as an evidence-based intervention co-produced with service users and nurses was valued and welcomed by many nurse directors, senior clinicians, and ward managers. However, a range of practical and perceptual factors impeded implementation. Furthermore, many existing contextual challenges for intervention implementation in acute inpatient wards were magnified by the COVID-19 pandemic. Suitable facilitation to address these barriers can help support implementation of the TEQ, with some transferability to implementation of other interventions in these settings. Our study suggests several facilitation methods, brought together in a conceptual model, including encouragement of reflective, facilitative discussion meetings among stakeholders and researchers, effort put into winning nurse 'buy-in' and identifying and supporting ward-level agents of change.

Factors affecting knowledge of recovery-oriented practice amongst mental health nursing and medical staff working on acute mental health inpatient units

Over recent decades, the shift to recovery-oriented practice has been central to mental health policy. Despite this emphasis, mental health services can struggle to meet this expectation. This study explores the knowledge and attitudes in relation to the recovery-oriented practice of clinical staff working at an Australian acute inpatient mental health unit. The Recovery Knowledge Inventory (RKI) is a widely used self-report tool that assesses mental health professionals' knowledge and attitudes towards recovery; higher scores indicate higher levels of recovery knowledge and attitudes. Seventy-four staff members (44 nursing staff and 30 medical staff) completed the RKI via an online survey. The study has been reported according to the STROBE checklist for cross-sectional studies. The relationships between the RKI scores and a range of variables were considered using inferential statistics, including multivariate regression. Medical staff had higher mean RKI scores than nursing staff, although this did not meet the predefined threshold for a clinically significant difference. More years of mental health experience were associated with increased mean RKI scores for medical staff. This Australian inpatient staff cohort demonstrated higher mean RKI scores than have been observed in recent international studies of mental health professions. However, the recovery knowledge and attitude levels were disappointingly similar to those shown in earlier Australian research completed over a decade ago. Efforts are needed to further enhance the recovery knowledge of clinicians working in mental health inpatient units.

Safewards: An integrative review of the literature within inpatient and forensic mental health units

Mental health inpatient units are complex and challenging environments for care and treatment. Two imperatives in these settings are to minimize restrictive practices such as seclusion and restraint and to provide recovery-oriented care. Safewards is a model and a set of ten interventions aiming to improve safety by understanding the relationship between conflict and containment as a means of reducing restrictive practices. To date, the research into Safewards has largely focused on its impact on measures of restrictive practices with limited exploration of consumer perspectives. There is a need to review the current knowledge and understanding around Safewards and its impact on consumer safety. This paper describes a mixed-methods integrative literature review of Safewards within inpatient and forensic mental health units. The aim of this review was to synthesize the current knowledge and understanding about Safewards in terms of its implementation, acceptability, effectiveness and how it meets the needs of consumers. A systematic database search using Medline, CINAHL, Embase and PsychInfo databases was followed by screening and data extraction of findings from 19 articles. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of empirical articles, and the Johanna Brigg's Institute (JBI's) Narrative, Opinion, Text-Assessment and Review Instrument (NOTARI) was used to undertake a critical appraisal of discussion articles. A constant comparative approach was taken to analysing the data and six key categories were identified: training, implementation strategy, staff acceptability, fidelity, effectiveness and consumer perspectives. The success of implementing Safewards was variously determined by a measured reduction of restrictive practices and conflict events, high fidelity and staff acceptability. The results highlighted that Safewards can be effective in reducing containment and conflict within inpatient mental health and forensic mental health units, although this outcome varied across the literature. This review also revealed the limitations of fidelity measures and the importance of involving staff in the implementation. A major gap in the literature to date is the lack of consumer perspectives on the Safewards model, with only two papers to date focusing on the consumers point of view. This is an important area that requires more research to align the Safewards model with the consumer experience and improved recovery orientation.

Challenging the Myth of "Attention Seeking" Women with Suicidality: A Grounded Theory Study about Applying Counter-Pressure to Manage System Entrapment

Some women who express suicidal intent and engage in non-lethal self-harm perceive that nurses and other health care workers label them as attention-seeking and manipulative. An understanding of women's help-seeking behaviors that challenges suicide myths is presented. The purpose of this study was to examine help-seeking for suicidality in women with histories of intimate partner violence using a multiple qualitative research design of grounded theory and photovoice. Women from New Brunswick, Canada, over the age of 19 who left an abusive partner (n = 32) were interviewed and seven local women from this sample participated in five photovoice group sessions where they collectively examined self-generated photos of their experiences. Transcripts of the interviews and group sessions were analyzed using the constant comparative approach, yielding a theoretical rendering of women's help seeking. Results include a process of Applying Counter-Pressure as a way of pushing back against System Entrapment, or the sense of being invalidated and dehumanized by health care providers with the goal to Feel Human. Findings provide an understanding of women's behavior when seeking help for suicidality and may reduce nurses' assumptions and judgments when providing care. Trauma and violence informed care provides a framework from which to guide interventions that acknowledge the role of past and ongoing trauma in women's lives, supporting nurses' capacity to be validating and helping women to continue living.

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.

Engagement between adults in suicidal crises and nurses in mental health wards: a qualitative study of patients' perspectives

OBJECTIVE

To understand how patients in suicidal crises perceive their engagement with nurses in mental hospitals.

METHODS

A qualitative study based on grounded theory was conducted. Semi-structured interviews were used with 11 hospitalised adults living through suicidal crises. The data were analysed by multiple researchers, using the constant comparison method, coding, and memo writing.

FINDINGS

The core process was: 'Feeling nurtured through an interpersonal engagement'. This process underpinned two categories: 'Feeling safe and cared for while struggling to trust' and 'Working toward alleviation and change of my suicidal ideation'. The patients valued nurses who integrated caring approaches of building trust, demonstrating compassion, and promoting safety, with healing approaches of helping them to express and explore their suicidal ideations, and develop new insights and ways of coping. This interpersonal engagement could nurture patients' feelings of being accepted and understood, and being hopeful and capable of overcoming their suicidal ideations.

CONCLUSION

The conceptual insights can inform strategies to reframe overly instrumental approaches to prevent suicide and treat suicidal ideation, and instead promote an interpersonal orientation in nursing practice that integrates caring-healing approaches.

A qualitative emancipatory inquiry into relationships between people with mental disorders and health professionals

WHAT IS KNOWN ON THE SUBJECT?: A therapeutic alliance with people with mental disorders could help increase the efficacy of treatment. The paradigm shift from a paternalistic model to one that respects the person's autonomy has led to professionals accepting the active role of people with mental disorders making decisions that affect their treatment. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: People with mental disorders perceive paternalistic and stigmatizing attitudes from health professionals, and they do not feel involved in decisions about their health, which can render effective therapeutic alliances difficult. The findings reveal that although people in Mediterranean countries are used to paternalistic treatment from health professionals due to cultural factors, people with mental disorders are increasingly critical of how they are treated and demand greater autonomy and respect in the decision to undergo drug therapy. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: In their interactions with people with mental disorders, health professionals should include efforts aimed at improving shared decision-making capabilities and avoiding paternalistic or stigmatizing attitudes. ABSTRACT: Introduction A therapeutic alliance with people is essential for the efficacy of treatments. However, the traditional paternalistic values of the Mediterranean society may be incompatible with patient autonomy. Aim To explore the therapeutic relationship from the perspective of people diagnosed with mental disorders with health professionals, including nurses. Methods This emancipatory research was performed through focus groups, with people with mental disorders who had a variety of diagnoses and experiences of acute and community-based mental health services and other healthcare services. Data were analysed using the content analysis method. Results Four main themes emerged: stereotypes and prejudice; quality of interactions and treatment; emotional and behavioural impacts; and demands. Discussion According to the participants' descriptions, health professionals are not exempt from prejudice against persons with psychiatric diagnoses. They reported experiencing abuse of power, malpractice, and overmedication. Thus, in the Mediterranean culture, professional attitudes may represent a barrier for an appropriate therapeutic alliance, and people with mental disorders do not feel involved in making decisions about their health. Implications for practice Knowing how people with mental disorders perceive their interactions with health professionals and the effects is necessary to move the care model towards more symmetric relationships that facilitate a therapeutic alliance.

Involving Mental Health Consumers in Nursing Handover: A Qualitative Study of Consumer Perspectives

A number of benefits have been identified for including consumers in nursing handover, such as improved safety and information exchange. In mental health settings these benefits may translate to improved nurse-consumer engagement and working towards the provision of recovery orientated practice. The process of including the consumer, whilst considered best practice, is not well established in mental health settings. Therefore further understanding, in regards to the consumer perspectives about this practice, is needed to inform its adoption and implementation.This qualitative descriptive study explores consumers' perspectives of their possible involvement in the nursing handover process within a mental health inpatient setting. The study took place in two mental health inpatient units in regional New South Wales, Australia. Thirteen semi-structured individual interviews were conducted with consumers, and a conventional content analysis method was used to analyse the data. Findings are presented under two categories: understanding the purpose and process of nursing handover and considering consumer involvement in handover.Findings provide insight into the views of consumers about being involved in nursing handover and further strengthen the rationale for establishing the process as part of routine practice within acute inpatient mental health units. The study also highlights the need to ensure that all processes within these settings accommodate consumer perspectives and involvement.

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

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

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

OBJECTIVES

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

DESIGN AND PARTICIPANTS

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

SETTING

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

RESULTS

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

CONCLUSIONS

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

Investigating the factor structure of a translated recovery-orientation instrument in inpatient treatment for substance use disorder

BACKGROUND

Recovery has been outlined as a process of change through which involvement and empowerment enables individuals to reach their goals and aspirations. Recovery self-assessment (RSA) is an instrument that has been acknowledged as an applicable measure of recovery-orientation in services for people with mental health problems or substance use disorder (SUD). This study aimed to translate RSA from US English to Norwegian and to investigate the factor structure of the translated version (RSA-N).

METHODS

A translate/back-translate procedure was used. Confirmatory factor analysis (CFA) was applied to investigate the factor structure of RSA-N in a sample of clinicians (n = 407) working in inpatient SUD treatment facilities.

RESULTS

The results suggested that the hypothesised five-factor structure originally obtained by the developers showed an inadequate fit with the current data sample. RSA-N was modified and restructured by removing twelve misfitting items and combining factors with high covariance using data from one subsample. The alternative three-factor structure yielded an acceptable fit for the data from a second subsample. Acceptable alpha coefficients, suggesting good internal consistency, supported the adequacy of the three-factor structure.

CONCLUSIONS

Results from the present study are in line with previous findings, which have failed to replicate the hypothesised five-factor structure without modifications. Knowledge about the degree to which SUD services are recovery-oriented may contribute to SUD services' pursuit of establishing an inpatient treatment environment that fosters change and development of inpatients. The present study's findings imply RSA-N's potential as an instrument to assess recovery-orientation in inpatient SUD treatment.

Saudi service users' perceptions and experiences of the quality of their mental health care provision in the Kingdom of Saudi Arabia (KSA): A qualitative inquiry

This paper presents, as part of a larger mixed-methods design, a study generating a theoretical understanding of issues pertinent to the quality of mental health care in the KSA from the perspective of those using services. Semi-structured interviews were undertaken with thirty service users admitted to inpatient psychiatric wards, using an interview guide developed by the researchers, based on relevant literature. Findings from the thematic analysis showed five themes: (1) The hospital as a prison: a custody versus care dilemma, (2) quality of interactions between staff and service users, (3) quality of services, (4) staff qualities and (5) suggestions for achieving quality of care. A theoretical model drawing upon Donabedian Health Care Model for Evaluating quality of care and the Andersen Behavioural Model of Health Service Use is evident from the data. Structural aspects of care include staff experience and qualifications and key enablers around social and financial support, service users' health needs and status and the physical infrastructure and ward rules. These drive processes of care based upon robust rates of interaction between staff and service users and appear central to quality of mental health care in KSA. Quality of mental health care in KSA is manifested by a therapeutic ethos with a high degree of interaction between professional carers and service users, with the former being highly educated, competent, compassionate, with a high degree of self-awareness, and specialized in mental health. We have uncovered elements of Fanon and Azoulay's 'Cultural Originality' as well as contemporary examples of Goffman's mortification of the self.

'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.

Motivational Interviewing: Reconciling Recovery-Focused Care and Mental Health Nursing Practice

Motivational interviewing (MI) is a long-established evidenced-based intervention aimed at guiding people to implement change. Originally developed by William Miller from the United States and Stephen Rollnick from the United Kingdom, a strong emphasis for MI is the underlying 'spirit', rather than merely the specific techniques within the model. The 'spirit' of MI consists of four key components: acceptance, partnership, evocation and compassion. These have direct overlap with concepts within the personal recovery model recognised as a critical framework in delivery of contemporary mental health services for consumers. Despite this recognition, recovery concepts have struggled to gain consistent traction, particularly within inpatient mental health units. This paper proposes that MI presents one strategy for integrating recovery-focused principles within routine mental health nursing (MHN) practice. An overview of MI and its relationship with recovery principles is discussed in the context of contemporary MHN practice. Evaluation results of a locally developed MI workshop for MHNs within a regional area of New South Wales (NSW) in Australia are presented to highlight the emerging evidence for this potential. Following the workshop, MHN participants showed key improvements in knowledge and confidence scores, as well as in understanding of key MI processes and strategies. The consolidation of these skills through training and a supervision framework is outlined.

The working alliance with people experiencing suicidal ideation: A qualitative study of nurses' perspectives

AIMS

This study aimed to enhance the conceptual understanding of the working alliance in the context of nursing care for people experiencing suicidal ideation.

DESIGN

A qualitative study based on grounded theory was conducted.

METHODS

Two authors conducted individual semi-structured interviews from September 2017-January 2019. Twenty-eight nurses in 13 wards of four psychiatric hospitals participated. The Qualitative Analysis Guide of Leuven was used to support constant data comparisons and the cyclic processes of data collection and data analysis.

FINDINGS

The nurses' perspectives revealed that the working alliance can be understood as an interpersonal and collaborative relational process. This relational process highlighted the core variable 'seeking connectedness and attunement with the person at risk of suicide'. The core variable underpinned three clusters: investing in the foundations of the working alliance, nourishing the clinical dimension of the working alliance and realizing an impact with the working alliance.

CONCLUSION

This study highlights the importance for nurses to assess, evaluate and respond to persons' suicidal ideation in harmony with a commitment to connect with them and attune to their perspective.

IMPACT

The relational process uncovered through this study offers valuable insights to support advanced nursing practice, where nurses meaningfully integrate relational elements of care with their contributions to suicide prevention and treatment.

'Like a human being, I was an equal, I wasn't just a patient': Service users' perspectives on their experiences of relationships with staff in mental health services

OBJECTIVES

The quality of therapeutic relationships in psychiatric services has a significant impact upon the therapeutic outcomes for people diagnosed with a severe mental illness. As previous work has not explicitly explored service users' in-depth views about the emotional impact of these relationships, the objective of this work was to bring this perspective to the fore and to gain a greater understanding about which relational components can lead to psychological change.

DESIGN

The project was conducted alongside a service user organization. An interview design was used to qualitatively explore service users' experiences and perceptions of their relationships with mental health practitioners.

METHODS

Eight individuals who had experience of the mental health system in the United Kingdom were interviewed. Interpretative phenomenological analysis was used to analyse the data.

FINDINGS

Three superordinate themes emerged from the analysis. These were (1) Trying to survive: am I a person or just an object in the system?; (2) Traumatic experiences within relationships; and (3) Helpful and transformative relationships. Further, the key transformative components of these relationships were power, safety, and identity.

CONCLUSIONS

Mental health services should be more focused upon care, rather than control. The Power Safety Identity (PSI) model, a reflexive model based upon key relational components highlighted by participants, is proposed for services and professionals to consider their work. The components of this model are managed by mental health practitioners and can determine whether these relationships maintain, increase, or alleviate psychological distress.

PRACTITIONER POINTS

Awareness of the relational components of power, safety, and identity has the potential to help practitioners reflect upon the tensions they experience in their relationships with service users. Mental health services and professionals that are sensitive to issues related to power, safety, and identity when responding to the needs of the service users can improve how individuals perceive the quality of care provided by them. Relationships between service users and mental health practitioners can encourage recovery if they are consistent, safe, trusting, provide protective power, and mirror a positive sense of self.

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.

System Entrapment: Dehumanization While Help-Seeking for Suicidality in Women Who Have Experienced Intimate Partner Violence

Attention to power imbalances when seeking help for suicidality after having been controlled within intimate partner violence (IPV) is crucial in improving health care delivery. Well documented in the literature is the correlation between suicidality and IPV and that help-seeking for each is difficult; however, a gap exists when both intersect. The process of women's help-seeking is explored in this feminist grounded theory and photovoice multiple qualitative method study. Analysis of interviews with 32 women from New Brunswick, Canada, and photovoice meetings with seven women revealed a basic psycho-social problem. System Entrapment or being dehumanized while seeking help for suicidality occurred as a result of perceived invalidation from health care providers' lack of empathy. Further harm while providing services to women feeling suicidal can be prevented with a shift from an individualist model toward a trauma and violence informed approach. Understanding the contextual factors influencing women's suicidality may reduce victim blaming.

Brief admission (BA) for patients with emotional instability and self-harm: nurses' perspectives - person-centred care in clinical practice

Purpose: Emotional instability and self-harm pose major problems for society and health care. There are effective interventions in outpatient care, but when patients need inpatient care, nurses often struggle meeting their patient’s needs. Brief admission (BA) is a newly implemented crisis intervention and novel form of inpatient care. The aim of this study is to describe nurses’ experiences working with BA related to patients with emotional instability and self-harm.

Methods: Eight nurses were interviewed according to a semi-structured interview guide. The data was analysed using qualitative content analysis.

Results: Four main categories emerged regarding nurses’ experiences with BA: provides security and continuity, fosters caring relationships, shifts focus towards patient’s health and empowers the patient. The nurse’s role shifted from “handling problems” to establishing caring relationships with a focus on the person’s health and possibilities for recovering instead of psychiatric symptoms.

Conclusions: Previous studies on patients’ perspective of BA describe positive experiences such as increased autonomy and participation in the healthcare process. This study supports those findings, albeit from the perspective of nurses. Our findings suggest that BA may reduce work-related stress experienced by nurses while caring for persons with emotional instability and self-harm. BA may also support nurses in their ability to provide more meaningful and constructive psychiatric inpatient care.

Hunting to Feel Human, the Process of Women's Help-Seeking for Suicidality After Intimate Partner Violence: A Feminist Grounded Theory and Photovoice Study

Women reach out to health care providers for a multitude of health problems in the aftermath of intimate partner violence, including suicidality; however, little is known about how they seek help. The purpose of this study was to explore how women seek help for suicidality after intimate partner violence using a feminist grounded theory and photovoice multiple qualitative research design. Interviews were conducted with 32 women from New Brunswick, Canada, and seven from this sample also participated in five photovoice meetings where they critically reflected on self-generated photos of their help-seeking experiences. Data were analyzed using the constant comparative analysis of grounded theory. Hunting to Feel Human involves fighting for a sense of belonging and personal value by perceiving validation from health care providers. Women battled System Entrapment, a feeling of being dehumanized, by Gauging for Validation and Taking the Path of Least Entrapment. Implications for health care providers include prioritizing validating interactions and adopting a relational approach to practice.

'Promoting and preserving safety and a life-oriented perspective': A qualitative study of nurses' interactions with patients experiencing suicidal ideation

Suicide prevention is an important imperative in psychiatric hospitals, where nurses have a crucial role in and make essential contributions to suicide prevention and promoting the recovery of patients experiencing suicidal ideation. The present qualitative grounded theory study aimed to uncover and understand the actions and aims of nurses in psychiatric hospitals during their interactions with patients experiencing suicidal ideation. Interviews were conducted with 26 nurses employed on 12 wards in four psychiatric hospitals. The data analysis was inspired by the Qualitative Analysis Guide of Leuven. The findings show that nurses' actions and aims in their interactions with patients experiencing suicidal ideation are captured in the core element 'promoting and preserving safety and a life-oriented perspective'. This core element represents the three interconnected elements 'managing the risk of suicide', 'guiding patients away from suicidal ideation', and 'searching for balance in the minefield'. The enhanced understanding of nurses' actions and aims can inform concrete strategies for nursing practice and education. These strategies should aim to challenge overly controlling and directing nursing approaches and support nurses' capacity and ability to connect and collaborate with patients experiencing suicidal ideation.

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.

Sound practice: Exploring the benefits of establishing a music group on an acute mental health inpatient unit

There is evidence supporting the use of formal music therapy in the treatment of mental health consumers. Despite this, it appears to be an intervention which has not been routinely offered to consumers in Australian acute mental health inpatient units, possibly due to the lack of trained music therapists (or inadequate funding to employ them), as well as the challenges posed by the acuity of presentations and the short duration of admissions. Less formal therapeutic music activities may benefit consumers within these settings. This article describes how a music group activity facilitated by clinical staff with no music therapy qualifications was established. The first phase of this evaluation is then described using a descriptive qualitative method. We undertook a series of consumer and staff focus groups to explore the impact of a music group activity on an acute mental health inpatient unit. Five themes emerged from the transcripts of the focus groups' discussions, effects on mood, relationships and engagement, social connectedness and inclusion, the ward atmosphere and noise/agitation. Positive effects were shown across these areas, suggesting that the music group activity we established was beneficial for consumers and staff, and enhanced the ward atmosphere.

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

The facilitation of quality time between patients and staff in psychiatric inpatient care is useful to promote recovery and reduce stress experienced by staff. However, interventions are reported to be complex to implement and are poorly described in the literature. This multisite study aimed to evaluate the feasibility and effects of the nursing intervention Time Together, using mixed methods. Data consisted of notes from participant observations and logs to evaluate feasibility, and questionnaires to evaluate effects. The primary outcome for patients was quality of interactions, and for staff, it was perceived stress. The secondary outcome for patients was anxiety and depression symptom levels, and for staff, it was stress of conscience. Data were analysed using visual analysis, percentage of nonoverlapping data, and qualitative content analysis. The results showed that Time Together was a feasible intervention, but measurements showed no effects on the two patient outcomes: quality of interactions and anxiety and depressive symptoms and, questionable effects on perceived stress and stress of conscience among staff. Shared responsibility, a friendly approach, and a predictable structure enabled Time Together, while a distant approach and an unpredictable structure hindered the intervention. In conclusion, the intervention proved to be feasible with potential to enable quality interactions between patients and staff using the enabling factors as supportive components. It also had some effects on perceived stress and stress of conscience among staff. Further evaluation is needed to build on the evidence for the intervention.

Therapeutic Relationships and Safety of Care in Iranian Psychiatric Inpatient Units

Enhancing therapeutic relationships between patients and staff is of central importance to improve the quality and safety of care in psychiatric inpatient units. However, there is limited evidence as to how therapeutic relationships may be enabled in this specific context. This paper presents findings of a study that explored the link between therapeutic relationships and safety in Iranian psychiatric inpatient units. In this exploratory, descriptive study, seven patients at the point of discharge and 19 staff in psychiatric inpatient units in Iran were interviewed regarding their experiences of care. The quality of staff-patient relationship in providing a safe environment was categorized into two groups of "facilitators" and "inhibitors". Facilitators of a safe environment included "supportive relationship with patients" and "improving patient capacity for self-efficacy/self-control". Inhibitors, on the other hand, included "detachment from patients" and "domination over patients", which ultimately limited safety on the ward. Findings indicate interrelated environmental, patient and staff factors mediating the potential for therapeutic relationships and quality and safety of care. Findings suggest the need for more effective preparation and support for staff working within psychiatric inpatient settings. In addition, environments more conducive to collaborative recovery-oriented practice are required to enhance therapeutic relationships and improve quality and safety of care. Both individual staff responsibility and effective leadership are required to realize change.

Recovery orientation in mental health inpatient settings: Inpatient experiences?

Offering mental health treatment in line with a recovery-oriented practice has become an objective in the mental health services in many countries. However, applying recovery-oriented practice in inpatient settings seems challenged by unclear and diverging definitions of the concept in and the organization of these settings. In Denmark, educational and organizational efforts have been made to organize inpatient services with a recovery-oriented approach. Hence, we aimed to explore whether and how these efforts are reflected in the inpatients' experiences of their care and treatment. Semi-structured interviews were conducted with 14 inpatients from two mental health inpatient wards using an interview guide based on factors from the Recovery Self-Assessment. Qualitative content analysis was applied in the analysis. Six themes covering the participants' experiences were identified. The participants felt accepted and protected in the ward and found comfort in being around other people but missed talking and engaging with health professionals. They described limited choice and influence on the course of their treatment, and low information levels regarding their treatment, which they considered to consist predominantly of medication. Furthermore, they described feeling continuously observed and assessed from a distance by health professionals. Like the sparse previous research among inpatients, the results highlight ambivalent experiences of health professionals' support and ward structure as well as the medical treatment hegemony. As such, the educational and organizational efforts of introducing recovery-oriented practices in the wards seemed not very well reflected in the participants' experiences of their stay.

Safe and Collaborative Communication Skills: A Step towards Mental Health Nurses Implementing Trauma Informed Care

Trauma Informed Care (TIC) acknowledges the presence and effects of trauma in the lives of many mental health service users and the responsibility of services to provide physical and emotional safety. One challenge of TIC is a lack of clarity about translating the philosophy into practice. This paper describes the delivery and evaluation of a trauma informed communication workshop for mental health nurses that aimed to increase their knowledge of the potential impacts of trauma on consumers, and translate TIC concepts into their communication approaches within the therapeutic relationship.

Informal coercion as a neglected form of communication in psychiatric settings in Germany and Switzerland

AIMS

Informal coercion is a frequently used form of communication among mental health professionals to influence treatment outcomes. This study investigates the recognition, attitude, and application of different forms of informal coercion by mental health professionals.

METHODS

Mental health professionals of five psychiatric institutions in Germany and Switzerland (n = 424) took part in an online survey assessing the recognition of, attitudes towards, and application of different forms of informal coercion.

RESULTS

Mental health professionals did not recognize the extent of informal coercion adequately; especially stronger forms were underestimated. Recognition and application of informal coercion was predicted by attitudes towards coercion. Furthermore, there were differences between profession of participants regarding the recognition and application of informal coercion.

CONCLUSIONS

It is important to realize that the extent of applied informal coercion in therapeutic communication is often not recognized by practitioners, although it might interfere with a sound therapeutic relationship.

Mental health nursing: Daring to be different, special and leading recovery-focused care?

How mental health nursing is differentiated from other disciplines and professions, and what special contribution mental health nurses make to health services, is a question at the heart of contemporary practice. One of the significant challenges for mental health nurses is identifying, developing and advancing those aspects of their practice that they consider differentiate them in the multi-disciplinary mental health care team and to articulate clearly what a mental health nurse is and does. This paper draws on data from interviews with 36 mental health nurses in Australia who identified their practice as autonomous. Participants were asked the question, "What's special about mental health nursing?" Constructivist grounded theory techniques were applied to the research process. Findings were formulated and expressed as the 'Ten P's of the professional profile that is mental health nursing', which are 'present', 'personal', 'participant partnering', 'professional', 'phenomenological', 'pragmatic', 'power-sharing', 'psycho-therapeutic', 'proud' and 'profound'. The combined elements of the findings present a theoretical construct of mental health nursing practice as something distinctive and special. It provides a model and exemplar for contemporary practice in mental health nursing, embracing the role of mental health nurses in the health care workforce as being well placed as providers of productive and effective care.

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.