The Effects of a Participatory Intervention in Mental Health Units on Nurses' Perceptions of the Practice Environment: A Mixed Methods Study.

BACKGROUND: The practice environment influences the quality of care and the nursing outcomes achieved in their workplaces. OBJECTIVE: To examine the perception of the clinical practice environment among nurses working in mental health units in the context of their participation in an action research study aimed at improving the nurse-patient relationship. METHOD: An explanatory sequential mixed methods study was designed. The data were collected in three phases in 18 mental health units (n = 95 nurses). Quantitative data were collected through the Practice Environment Scale of the Nursing Work Index, and qualitative data were collected through reflective diaries and focus groups in the context of participatory action research. RESULTS: The nurses' assessment of their practice environment shifted from positive to negative. Nurse manager leadership was the aspect that worsened the most. In addition, the perception of their participation in the affairs of the center and nursing foundations for quality of care decreased. The nurses considered it essential to be able to influence decision-making bodies and that the institution should promote a model of care that upholds the therapeutic relationship in actual clinical practice. CONCLUSIONS: Nurses perceived that they should be involved in organizational decisions and required more presence and understanding from managers. Furthermore, nurses stated that institutions should promote nursing foundations for quality of care. This study contributes to understanding how nurses in mental health units perceive their work environment and how it affects the improvement of the nurse-patient relationship in clinical practice.

Examining the association between evidence-based practice and the nurse-patient therapeutic relationship in mental health units: A cross-sectional study.

AIMS: To examine the relationship between the dimensions of evidence-based practice and the therapeutic relationship and to predict the quality of the therapeutic relationship from these dimensions among nurses working in mental health units. DESIGN: A cross-sectional design. METHODS: Data were collected between February-April 2018 via an online form completed by nurses working at 18 mental health units. Multiple linear regressions were used to examine the relationship between the dimensions of evidence-based practice and therapeutic relationship. Questionnaires were completed by 198 nurses. RESULTS: Higher levels of evidence-based practice were a significant predictor of a higher-quality therapeutic relationship (ß: 2.276; 95% CI: 1.30-3.25). The evidence-based practice factor which most influenced an improved therapeutic relationship was the nurses' attitude (ß: 2.047; 95% CI: 0.88-3.21). The therapeutic relationship dimension which was most conditioned by evidence-based practice dimensions was agreement on tasks, which was most favourable with a better attitude (ß: 0.625; 95% CI: 0.09-1.16) and greater knowledge and skills for evidence-based practice (ß: 0.500; 95% CI: 0.08-0.93). CONCLUSION: In mental health settings, the therapeutic nurse-patient relationship is positively enhanced by evidenced-based practice and the nurse's level of experience, with a great influence on shared decision-making. IMPACT: This research sought to examine the relationship between the evidence-based practice and the therapeutic relationship in mental health nursing. This study demonstrates that an improved attitude and knowledge of evidence-based practices of mental health nurses increases shared decision-making with patients, which is a basic requirement for person-centred care. Because the therapeutic relationship is considered the backbone of nursing practice in mental health units, this research will have an impact on both mental health nurses and mental health unit managers.

The impact of a participatory intervention on the therapeutic relationship in mental health nurses: A multicentre study.

AIMS: To evaluate the effects of an intervention aimed at improving the therapeutic relationship, using the participatory-action research method, in terms of improving the quality of the nurse-patient therapeutic relationship. DESIGN: A single-group pre-post research design. METHODS: Quantitative data were collected between January 2018 and June 2019 using an online form completed by nurses from 18 mental health units (N = 95). Data were collected before and after the intervention, which consisted of the design, implementation and evaluation of strategies to improve the therapeutic relationship through participatory-action research involving nurses. The Working Alliance Inventory-Short, Interpersonal Reactivity Index, Evidence-Based Practice Questionnaire and Practice Environment Scale of the Nursing Work Index were used. The Wilcoxon rank-sum test was used together with the Spearman's correlation coefficient. Two multiple linear regressions models were constructed. RESULTS: Overall, the intervention improved the nurse-patient therapeutic relationship. In addition, the results revealed that, above all, the improvement in evidence-based practice along with a decrease in nurses' personal distress were the factors associated with the improvement of the nurse-patient therapeutic relationship. CONCLUSION: In mental health units, the therapeutic nurse-patient relationship can be improved through participatory interventions that include the implementation of evidence-based practices. IMPACT: This research examined the effects of an intervention aimed at improving the therapeutic relationship among nurses working at mental health units using participatory action research. The results show that the therapeutic relationship can be improved through participatory methods where evidence-based practice is implemented and enhanced among nurses, since a better therapeutic relationship along with reduced staff discomfort are determining factors that influence the quality of the therapeutic relationship. Institutional managers should promote participatory group interventions to enable nurses to develop evidence-based aspects of the therapeutic relationship together with expanding personal aspects and self-knowledge.

Psychometric properties of instruments measuring quality and satisfaction in mental health: A systematic review.

AIM: To identify the methodological quality of each study and analyse the psychometric properties of instruments measuring quality and satisfaction with care from the perspective of mental health patients and professionals. BACKGROUND: In recent years, interest in rigorously assessing quality of care in mental health and nursing has increased. Health professionals and researchers should select the most adequate instrument based on knowledge of its measurement properties. REVIEW DESIGN: A psychometric review was conducted of the instruments from the perspectives of both patients and professionals according to the COnsensus-based Standards for the selection of health Measurement INstruments panel (COSMIN). DATA SOURCES: Articles published from January 2005 - September 2016 were identified in a search of MEDLINE, CINAHL, and SCOPUS. We included studies in English, Spanish, and Portuguese. REVIEW METHODS: Inclusion criteria were applied to all articles validated and reviewed by a second independent reviewer. The analysis included the use of the COSMIN checklist and the Terwee quality criteria. RESULTS: In the 34 studies selected, a total of 22 instruments which measure quality and satisfaction with care provided, according to patients and/or professionals, were identified. Most are instruments with sound, contemporary theoretical foundations. They vary to the extent to which they have been used in empirical studies and with respect to evaluation of their validity and reliability, although five instruments stand out as yielding good-excellent values in quality criteria. CONCLUSION: The present psychometric review found that five of the instruments met valid psychometric criteria. In light of the current economic situation, future reviews should include analysis of the usefulness of instruments based on cost-effectiveness, acceptability, and educational impact.

Implementation of evidence on the nurse-patient relationship in psychiatric wards through a mixed method design: study protocol.

BACKGROUND: Psychiatric nurses are aware of the importance of the therapeutic relationship in psychiatric units. Nevertheless, a review of the scientific evidence indicates that theoretical knowledge alone is insufficient to establish an adequate therapeutic alliance. Therefore, strategies are required to promote changes to enhance the establishment of the working relationship. The aims of the study are to generate changes in how nurses establish the therapeutic relationship in acute psychiatric units, based on participative action research and to evaluate the effectiveness of the implementation of evidence through this method. METHODS/DESIGN: The study will use a mixed method design. Qualitative methodology, through participative action research, will be employed to implement scientific evidence on the therapeutic relationship. A quasi-experimental, one-group, pre-test/post-test design will also be used to quantitatively measure the effectiveness of the implementation of the evidence. Participants will consist of nurses and patients from two psychiatric units in Barcelona. Nurses will be selected by theoretical sampling, and patients assigned to each nurses will be selected by consecutive sampling. Qualitative data will be gathered through discussion groups and field diaries. Quantitative data will be collected through the Working Alliance Inventory and the Interpersonal Reactivity Index. Qualitative data will be analysed through the technique of content analysis and quantitative data through descriptive and inferential statistics. DISCUSSION: This study will help to understand the process of change in a nursing team working in an inpatient psychiatric ward and will allow nurses to generate knowledge, identify difficulties, and establish strategies to implement change, as well as to assess whether the quality of the care they provide shows a qualitative improvement.

The Therapeutic Relationship in Inpatient Psychiatric Care: A Narrative Review of the Perspective of Nurses and Patients.

PURPOSE: To study the significance of 'therapeutic relationship' between nurses and patients within the context of a psychiatric hospital. METHOD: Narrative literature review. Content analysis. FINDINGS: The significance of the therapeutic relationship is quite similar for both nurses and patients in psychiatric hospital units. Nevertheless, several factors may separate the two positions: the time available for the relationship, the negative perceptions on the part of both parties, and the insecurity of the setting. PRACTICE IMPLICATIONS: Increased knowledge and understanding of the significance of the therapeutic relationship from the perspective of nurses and patients would allow the strengthening of areas of mutual interest.

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

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

Impact of the 'reserved therapeutic space' nursing intervention on patient health outcomes: An intervention study in acute mental health units.

AIMS: To evaluate the effectiveness of the 'reserved therapeutic space' intervention for improving the nurse-patient therapeutic relationship in acute mental health units in Spain. DESIGN: Multicentre intervention study with control group. METHODS: The study will be carried out in 12 mental health units. The 'reserved therapeutic space' intervention to be tested has been co-designed and validated by both nurses and patients. The quality of the therapeutic relationship, the care received and perceived coercion among patients will be assessed. An estimated 131 patients per group are expected to participate. Funding was granted by the Instituto de Salud Carlos III. Co-financed by the European Union (European Regional Development Fund (ERDF) (PI21/00605)) and College of Nurses of Barcelona (PR-487/2021). The proposal was approved by all the Research Ethics Committees of participating centres. RESULTS: This project will lead to changes in clinical practice, transforming the current models of organization and care management in mental health hospitalization units. No patient or public contribution.

Transcultural adaptation and assessment of psychometric properties of the Spanish version of the Scale for the Evaluation of Staff-Patient Interactions in Progress Notes.

PURPOSE: To adapt the Scale for the Evaluation of Staff Patient Interactions in Progress Notes to Spanish and to test the psychometric properties. DESIGN AND METHODS: The study was conducted in two phases: (1) Adaptation of the instrument to Spanish following the Standards for Educational and Psychological Testing. (2) Psychometric study in a sample of mental health nurses. FINDINGS: The Cronbach's alpha values were 0.97 for the total scale and 0.83 to 0.81 for each dimension. The inter-rater reliability values were between 0.94 and 0.97. PRACTICE IMPLICATIONS: The scale is a reliable tool for assessing nurses' clinical notes in relation to the quality of nurse-patient interactions.

Spanish mental health nurses' experiences of mechanical restraint: A qualitative descriptive study.

WHAT IS KNOWN ON THE SUBJECT?: Mechanical restraint is a common practice in mental healthcare settings in Spain, despite controversy. Mechanical restraint is perceived as a negative experience for nurses and service users. Mechanical restraint damages the nurse-patient therapeutic relationship, which is essential in providing quality care and promoting recovery. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The negative experiences of service users and mental health nurses arising from use of mechanical restraint affects both parties involved and results in trauma. Using mechanical restraint can provoke a moral injury in mental health nurses which can negatively impact on the establishment of trust within the therapeutic nurse-patient relationship. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses must be aware of the negative effects that mechanical restraint use has on both their practice and their day-to-day lives. Post-mechanical restraint debriefing is required to repair the damage to the trust aspect of the nurse-patient relationship. Involving service users in co-producing a debriefing framework may be a way to rebuild trust through constructive dialogue. ABSTRACT: INTRODUCTION: Mechanical restraint is an intervention that causes harm to service users and nurses, yet continues to be used in many countries, including Spain. However, there is a lack of research exploring Spanish mental health nurses' experiences of using mechanical restraint. AIM: To describe the experiences of mental health nurses who have used mechanical restraint in practice. METHODS: A qualitative descriptive methodology was used and a purposive sample of 10 Spanish mental health nurses were interviewed about their experiences of using mechanical restraint. Thematic analysis was then employed to analyse interview data. RESULTS: Participants' experiences of using mechanical restraint were mostly negative. Three main themes arose from the analysis of interview transcripts, (i) symmetrical trauma, (ii) moral injury and (iii) broken trust. DISCUSSION: The use of restrictive practices, which can be perceived as counter-therapeutic, exposes nurses to risks such as moral injury and service users to broken trust in the therapeutic nurse patient relationship. Avoiding empathy in order to use mechanical restraint is counterproductive, in the understanding that empathy is key to reducing this intervention. IMPLICATIONS FOR PRACTICE: Reducing or eliminating use of mechanical restraints should be a policy and practice priority due to the symmetrical harms it causes both nurses and service users. The trust aspect of the therapeutic nurse-patient relationship is a significant casualty when mechanical restraint is used, therefore involving service users in co-production of post-mechanical restraint debriefing can be an avenue for restoring this trust through dialogue.

Relationship between nurses' use of verbal de-escalation and mechanical restraint in acute inpatient mental health care: a retrospective study.

Although the use of verbal de-escalation in nursing has been shown to be an effective tool for controlling agitation and avoiding mechanical restraint, there is scarce evidence supporting the use of de-escalation by nurses and factors related to the patients who ultimately receive mechanical restraint. This retrospective study sought to examine the relationship between the use of verbal de-escalation by nurses and the clinical profile of patients who had received mechanical restraint at an acute mental health unit. This study analysed the records of patients who had received mechanical restraint between the years 2012 and 2019. A bivariate analysis was initially performed, followed by multiple logistic regression analysis. A total of 493 episodes of restraint were recorded. Of these, in almost 40% of cases, no prior use of verbal de-escalation was noted. The factors associated with the use of verbal de-escalation by nurses were patients with a history of restraint episodes and patients who previously had been administered medication. Furthermore, episodes of mechanical restraint that occurred later during the admission were also associated with the use of de-escalation. These findings confirm the relevance of early nurse interventions. Consequently, it is important to establish an adequate therapeutic relationship from the start of hospitalization to facilitate getting to know the patient and to enable the timely use of verbal de-escalation, thus avoiding the use of mechanical restraint.

Relationship between the nursing practice environment and the therapeutic relationship in acute mental health units: A cross-sectional study.

The therapeutic relationship constitutes the central axis of mental health nursing. The clinical practice environment has been empirically related to the quality of care. However, the relationship between the two constructs is unknown in the setting of mental health units. We aimed to examine whether the practice environment and nurses' characteristics influence the therapeutic relationship in mental health units. Through a cross-sectional design, data were collected via an online form completed by nurses in 18 mental health units. Linear regression was used to examine the relationship between the clinical practice environment and the therapeutic relationship. Questionnaires were completed by 198 participants. The mean age was 33.8 (SD 9.1) years, 71.7% were women, and only 20.2% had a specialist qualification in mental health. The therapeutic relationship was better when there was a more favourable practice environment (B: 3.111; 95% CI: 1.46-4.75). The most influential environment-related factor was the nursing foundations for quality of care (B: 2.124; 95% CI: 0.17-4.07). The factors associated with a high-quality therapeutic relationship were a more favourable practice environment and the presence of more foundations for quality nursing care, coupled with higher academic attainment and longer nursing experience. Institutions should take into account the importance of the nursing practice environment in mental health units. Aspects related to the quality of nursing foundations, such as training, the use of nursing language and taxonomy, and the existence of a common nursing philosophy, are influential for a high-quality therapeutic relationship.

Improving the therapeutic relationship in inpatient psychiatric care: Assessment of the therapeutic alliance and empathy after implementing evidence-based practices resulting from participatory action research.

PURPOSE: To examine how evidence about the therapeutic alliance gleaned from participatory action project affected the level of this alliance and the degree of empathy of psychiatric nurses. DESIGN AND METHODS: Quasi-experimental study in two psychiatric units. In one group, evidence-based practices that affected the therapeutic alliance were implemented; in the comparison group, there was no such intervention. FINDINGS: The nurses from the intervention group improved their degree of empathy and factors such as agreement on objectives and tasks with the patient. PRACTICE IMPLICATIONS: The results confirm the possibility of measuring and improving the therapeutic relationship in psychiatric care.