International Journal of Mental Health Nursing The importance of the therapeutic relationship in improving the patient's experience in the. The concept of therapeutic interpersonal relationships is not which these needs are met, the role that mental health nurse engagement plays. The importance of relationships in mental health care: A qualitative and therapeutic milieu for the treatment of people with acute mental health problems. . Service user: "The actual nurses, I think they sort of, understood".
Such freedoms were viewed both as a basic human right, and also therapeutic in reducing feelings of confinement and being in touch with the environment.
Conversely, a lack of freedom could induce mental distress. The environment, staff decision-making and resources contributed to perceived freedom. Some hospitals had no outside space for patients, while other patients, even those admitted voluntarily, were not allowed out. Finally one patient describes being granted escorted leave but being unable to go outside due to the lack of an available staff escort.
I didn't even have an exercise yard. A denial of physical freedom was often perceived as coercive, and the denial of freedoms was attributed to a lack of trust in patients by staff.
The category was a minor one and while it was raised by 10 people, those sections coded were the shortest. With the exception of one report, the environment was only raised as a factor in service users' experience if it was quite poor. Descriptions of the hospital environment included a lack of basic hygiene, old buildings in poor physical condition, overcrowding with a lack of staff, and lack in basic home comforts.
There are no curtains, in the corridor or the smoking room. The windows are filthy; the furniture's filthy and burnt. It's an absolute dive.
It's disgusting and I wouldn't put a pig there let alone a human being. Central to the narratives of all interviewees were eight main themes: The difference in emphasis in the findings of this study may be due to a number of factors, of which the user-led nature of the research and the use of a user interviewer are important factors to consider.
Interviewer influence has been a neglected effect in psychiatric research [ 20 ]. Interviewers may influence the type of people who consent to take part, the quality and quantity of interview data.
Research suggests that user interviewers may help to engage other users whose voices are not normally heard such as those who feel alienated as a result of their experiences of hospital, and those who would not wish to share their experiences with professionals [ 21 ].
During the interview, interviewer variance in terms of race, sex and age can making a difference to the content of the completed interview [ 2223 ] and the experience and enthusiasm of the researcher can influence the length and nature of the interview as well as disclosure by interviewees [ 20 ].
An acknowledgement of power differentials between interviewer and interviewee throughout the interview process [ 18 ] and an effort to empower interviewees through an emancipatory approach can also affect the traditional relationship between researcher and researched and consequently the narratives elicited [ 14 ]. Finally, analysis by insider or outsider researchers, that is, researchers with different standpoints, such as clinical or user researchers can also affect the interpretation of the interview's content and the presentation of results [ 14 ].
Confounding factors which ultimately impact on the findings of research studies are a consequence of all qualitative approaches. Such influences are often referred to as limitations of a study, however within emancipatory research the influence of an insider researcher is seen as a strength of the approach.
When undertaken with rigor and reported in an open and transparent manner, emancipatory research promotes an understanding of an area from a unique perspective.
The physical and emotional components of patient experiences have only recently being recognised. Initiatives within the NHS aimed at improving the patient experience in hospital have focused largely on the physical environment.
However, more recently consultation with patients, public and NHS staff has worked to define the emotional aspects of positive patient experiences and include the need to feel cared for, safe, confident and in control, being communicated with as an equal, and being treated with honesty, dignity and respect [ 24 ]. Many of these emotional experiences come as a result of positive aspects of relationships, and this emphasis on relationships in shaping experiences is clearly described by the participants in this study.
The overarching theme of these interviews was that of interpersonal relationships. Human relationships can be argued to be the primary motivational force in life [ 25 ]. It is not surprising therefore that relationships while in hospital play an important role in shaping patient experiences. Service users' descriptions of their experiences were largely centred on their relationships with staff or other patients. The importance of relationships cannot be underestimated, with increasing evidence that building and maintaining a strong therapeutic relationship can be an agent for change in itself and leads to positive client and treatment outcomes [ 2627 ].
While each of the themes relating to relationships, depending of the quality of interaction, could affect the relationship in a positive or negative way, coercion was always experienced negatively and had a negative impact on relationships. Communication was the theme most central to the perception of relationships and an essential ingredient of the patient experience. How a relationship was experienced related to the nature and quality of the communication.
Leach [ 26 ] recognises the impact that a clinician's behaviour and communication style can have on practitioner-client relationships. He discusses aspects of staff engagement that elicit good communication, trust and rapport with patients, many of which can be said to be of importance to the service users interviewed.
Both studies highlight the importance of staff being approachable, non-judgemental, engaging, empathic, respectful of clients' wishes and needs, and the formation of a collaborative relationship.
The largely positive relationships of service users in this study with other patients, and staff who had personal experience of mental illness may be indicative of the value of collaboration, self-disclosure by both parties in developing relationships [ 28 ].
Both safety and trust were important in influencing the patient experience and the consequences of positive therapeutic relationships in hospital. The issue of safety was key to how relationships were experienced in hospital. With one of the functions of hospital being that of a place of safety, service users defined safety both in terms of safety from themselves and safety from others. The need for social input and the link between social isolation and suicide highlights this importance of safety for those at risk of harm [ 29 ].
However, much of the discussion with service users centred on a lack of safety on wards. The role of violence within the mental health system is a largely under researched subject [ 30 ].
With the adoption of zero tolerance policies across hospital departments, much of the focus has been on patient perpetrated violence. Although this remains a concern of patients, in this study it was clear from these interviews, and those of Kumar et al. Service users described restraint techniques as a violent act perpetrated by staff towards patients, and service users described resulting injuries.
The practice of restraint is under close scrutiny in the UK following a number of high profile deaths e. David Bennett case [ 31 ]. While the use of restraint may be a necessary force in controlling violent outbursts on wards, service users described no other techniques being used in the lead up to restraint to dissipate the situation. Furthermore, for some service users, staff were instrumental in provoking situations that made violence more likely.
Participants described staff winding them up and playing games, a practice that was also found in a study on violence and abuse against social workers [ 32 ]. Essex [ 33 ] warns that the words and manner of staff can prevent or induce aggression or confrontation. A further indication of a lack of safety on acute wards was the widespread report of fear by service users. Both women and men felt particularly vulnerable on male dominated wards. The vulnerability of women on mixed sex acute wards has been previously reported [ 34 ] and single sex wards are now government policy [ 35 ], but the vulnerability of men on male dominated wards is an area as yet unexplored.
It is argued that single sex wards may reduce fear and risk of assault for some women but can result in non-therapeutic environments for male patients, and are argued by some researchers to be an inadequate solution to what women really want from mental health services [ 3637 ]. Despite reports of fear, it did not always lead to a negative experience of hospital. The role of staff in maintaining a sense of safety for patients was stressed. An experience of safety was maintained, despite fearful situations arising, when staff demonstrated professionalism in their job and were able to control and contain situations preventing them escalating and affecting other patients.
Another consequence of a positive therapeutic relationship was the experience of trust. Trust can exist between individuals and in a system or institution [ 38 ]. The trust spoken about by participants was solely interpersonal trust as a result of relationships in hospital. Trust is the basis of positive social interaction and is necessary for daily life [ 39 ], it has even been argued that the practice of medicine is impossible without the trust of patients [ 40 ]. For the doctor-patient relationship, trust affects willingness to seek care, reveal sensitive information, submit to treatment, and follow physician's recommendations, and may also affect behaviours and outcomes [ 4142 ].
In common with conceptualisations of trust in staff-patient relationships [ 4344 ], participants expressed the value of being able to talk through experiences with staff and ask questions, involvement in decision making, and having a sense of emotional equality.
Participants expressed a marked disparity in the assignment of trust to different people in hospital. Trust was frequently attributed to other service users and although intimated, mistrust of other patients was never actually articulated.
In contrast, there was an emphasis on reported mistrust of staff, and even when a patient put the well-being of other patients on the ward at risk, the staff were assigned responsibility for their ability to contain or bring the situation under control.
With risk and trust being closely related [ 45 ], it is an unexpected finding that service users who present risk on wards, are not identified as untrustworthy. This may however be indicative of the greater risk that staff are perceived to present to patients. Interviewees give a further reason for the attribution of trust to staff in the description of trusted staff as professionals.
Trust as an expectation about the future behaviour of a person [ 46 ], may be expected of staff as professionals about whom there is a level of expectation.
Therapeutic alliance in mental health nursing: an evolutionary concept analysis.
Staff that fail to fulfil their patients' expectations of professionalism may be deemed untrustworthy. The yearly census of mental health services for inpatients undertaken by the Healthcare Commission has backed up research studies in highlighting higher rates of admission and detention for patients from Black groups with higher levels of seclusion once detained [ 47 ]. Service users interviewed here describe discrimination in mental health services attributed to racism, but also the more subtle yet discriminatory impact of a lack of cultural awareness.
Like white interviewees, the experience of black and ethnic minority interviewees was also largely defined by the relationships they had experienced in hospital. Cultural awareness is seen as an important factor in developing therapeutic relationships, and argued by Hardy and Laszloffy [ 48 ] to be crucial.
Since culture is a lens through which a person views the world, it plays a critical role in mental health [ 49 ]. Culture defines what is normal and abnormal, the causes of problems, and the appropriate ways to help a person who is disturbed.
Service users described a lack of cultural awareness by staff resulting in their expressions of illness, and perception of aetiology, being ignored or misinterpreted. However, it was service users from white backgrounds who highlighted racism towards ethnic minorities within psychiatric hospitals. Such attitudes and practices are argued to be a result of both institutional racism in the NHS [ 3150 ] but may also be inherent in the procedures, practice, and policy governing service delivery [ 5152 ].
For people from black and minority ethnic groups, then, their social identity may be used to prevent more positive therapeutic relations being formed between themselves and mental health professionals.
Despite the emphasis on the role of the therapeutic relationship in patients' experiences, the role of medication and treatment was also recognised. Participants were accepting of medication as an important, if not vital, component in the treatment of mental illness. However, its potentially coercive overuse and use without consent led to negative experiences.
Participants stress the importance of communication in continuing consultation with both service user and family. Participants identified that the main barrier to the formation of a therapeutic relationship was the experience of coercion. Relationships that were perceived as coercive were always described as negative and resulted in negative patient experiences.
Coercion comprises objective coercion and perceived coercion. Objective coercion implies the deprivation of liberty, the use of seclusion, restraint and forced medication.
Perceived or subjective coercion refers to the patient's experience of being coerced. The inherently coercive nature of the English Mental Health Act [ 53 ], makes coercion particularly relevant to detained patients. Reports of restriction of freedom and compulsion to receive treatment by participants who had been detained confirm this association between compulsory admission and experience of coercion reported by other authors [ 5455 ]. In the present study, objectively coercive experiences, such as a reduction in freedom as direct result of detention, were not attributed to the legislation itself but to the purveyors of the coercion.
Furthermore, enactment of the legislation in which a sense of safety was instilled by the staff performing the sectioning and experienced in a positive manner by the service user suggests that coercion is not necessarily a function of the Mental Health Act, but of the relationship with the staff enforcing aspects of it. The use of coercion in relationships between staff and service users is not limited to detained patients [ 5354 ].
Both participants who had been detained and those staying voluntarily reported experiences of perceived coercion. In this study, threats of force were the most widely reported form of subjective coercion. Threats have been shown to be positively associated with patients' perceptions of coercion [ 55 ].
Therapeutic Relationship of Nurses in Mental Health-A Review
Subjective coercion was most commonly experienced by voluntary patients when they were threatened with sectioning. Szasz [ 56 ] refers to this practice when characterising voluntary hospitalisation as "an acknowledged practice of medical fraud" in part because "a person is forced to sign in In this study participants saw subjective coercion as an inherent, but unacceptable, part of being an inpatient.
Their survival under such conditions is described as 'following the rules' and 'playing the game'. Coercive practices were used both to maintain control of patients, for instance through the use of restraint and seclusion, but also resulted from staff being in a position of power. Inherent in the staff role of maintaining control is a level of power over patients. It is this power imbalance in institutions that leads to abuses and unethical use of coercion [ 57 ].
Service users describe several instances in which staff misuse their power to hurt or humiliate patients. Such temptations and abuses are documented throughout the care industry [ 59 ]. Freedom and environment represent the only two physical themes that were identified as affecting the patient experience. Unhygienic environments with a lack of outside space contributed to a perception of hospitals as prisons.
More recently, Bowers et al. The deleterious effects of the hospital environment on psychiatric patients was identified nearly 30 years ago by Goffman [ 61 ]. Increasing attention is being paid in the design and building of new psychiatric hospitals to the role of the environment in both establishing a safe and therapeutic milieu but along side this the role of social, educational and therapeutic interaction with skilled staff has also been highlighted [ 60 ].
Conclusion Previous interviews with service users have highlighted both the role of both the environment and relationships in the patient experience [ 6263 ].
Service users in this study identified the central role of relationships in the patient experience, and their accounts clarify the important elements of relationships and how they inform patient experiences. The user-led approach of this study impacts on all aspects of the research.
It results in an understanding of service users' experiences of hospital which differs in content and emphasis from other previously undertaken academic and clinician led studies in this area. The implications of this research are twofold: Secondly, the value of user research lies not only in empowerment of people with mental illness but also in expanding the evidence base derived from psychiatric and health services research. Competing interests The authors declare that they have no competing interests.
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Papers that focused on pediatrics and adolescence were also excluded as this review focused on adult patient—staff interaction. In addition, papers involving student cohorts were also excluded as were papers that reported solely on satisfaction surveys. Data evaluation The search strategy initially identified papers after removal of duplicates Figure 1. The authors RK and KW independently identified 37 potential papers for inclusion based on titles and abstracts.
The authors RK, KW, and JD independently appraised the 37 identified papers based on the inclusion and exclusion criteria. Disagreements that arose were resolved by debate and consensus. Thirty studies were subsequently excluded, leaving a total of seven.