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The case studies are contained in 4 categories: Family (13 case studies), Fundamentals and Mental Health (14 case studies) and Medical Surgical (20 case studies). In addition the folder labeled minireviews contains PowerPoint sessions with combinations of case studies and standalone items. 

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• Attention Deficit Hyperactivity Disorder - Pediatric
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• Preeclampsia

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• Abdominal Surgery Postoperative Care
• Anorexia with Dehydration
• Catheter Related Urinary Tract Infection
• Deep Vein Thrombosis
• Dehydration Alzheimers
• Electroconvulsive Therapy
• Home Safety I
• Home Safety II
• Neuroleptic Maligant Syndrome
• Opioid Overdose
• Post Operative Atelectasis
• Post-traumatic Stress
• Pressure Injury
• Substance Use Withdrawal and Pain Control
• Suicide Prevention
• Tardive Dyskinesia
• Transfusion Reaction
• Urinary Tract infection

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• Acute Asthma
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• Breast Cancer
• Chest Pain (MI)
• Compartment Syndrome
• Deep Vein Thrombosis II
• End Stage Renal Disease and Dialysis
• Gastroesphageal Reflux
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• HIV with Opportunistic Infection
• Ketoacidosis
• Liver Failure
• Prostate Cancer
• Spine Surgery
• Tension Pneumothorax
• Thyroid Storm
• Tuberculosis

Community Based  ▾

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Mental health in nursing

A student's perspective.

Halsted, Candis DNP-PMHNP, RN; Hart, Virginia T. DNP, RN, PMHNP-BC

At Radford University School of Nursing in Radford, Va., Candis Halsted recently earned her DNP and Virginia T. Hart is an assistant professor and interim psychiatric mental health NP program coordinator.

The authors have disclosed no financial relationships related to this article.

A stigma around mental health issues within healthcare and nursing itself has created a culture of perfectionism in the workplace, and nurses struggle to live up to the expectations while pushing aside their feelings, thoughts, and needs. Inspired by one author's personal experiences, this article explores mental health issues many nurses confront today.

Inspired by one author's personal experiences, this article explores mental health issues many nurses confront today.

I DECIDED TO RETURN to school in 2015 after practicing as a nurse in various settings for 7 years. I subscribe to the adage that knowledge is power. My drive for additional education and experience was based on my desire to achieve a higher status, assume more control over my practice, and to garner more respect from other healthcare professionals. As I immersed myself in my graduate studies, however, I found my desires, self-image, and professional viewpoint had changed.

I have always endeavored to be the best student, greatest employee, and most dependable teammate. Those efforts took on a feverish intensity during periods of transition—student to nurse, nurse to working mother, mother and nurse to professional student. Good was not good enough, and my drive to be the best and greatest was an integral part of my self-worth. Unfortunately, it led to anxiety, depression, hopelessness, and isolation that negatively impacted my education, practice, and personal life.

It was not until my clinical rotations as a psychiatric-mental health NP student that I came to realize the magnitude of the situation. There I was, taking courses on trauma-informed care and giving my patients tools for building self-efficacy, self-compassion, and coping skills while simultaneously ignoring my own needs.

Having left the workplace to focus on my online studies, I was isolated, lacking confidence, feeling overwhelmed, and overcompensating for some perceived shortcoming that I could not even define. I felt hopeless and defeated. I experienced bouts of anxiety and depression so intense I lost my sense of purpose. I considered dropping out of school many times, but I gave in to the expectations of others. I forced myself to continue pushing aside my own needs, persisting despite my growing depression and anxiety.

Looking back, I had so many chances to speak up and reach out for help. I could have spoken with nurse managers, coworkers, fellow students, and faculty a hundred different ways on so many occasions. Instead, I allowed the culture of silence and my own perfectionism to rule.

At my lowest point, I made the life-altering decision to reach out for help—first to my husband, then a therapist, a fellow student, and finally my school faculty. With their assistance, some serious self-reflection, and a lot of self-help reading, I am working to address my mental illness and establish a sense of well-being.

That is not to say that I have it all figured out. I still struggle many days to keep faith in my strengths and abilities. The things I have learned and witnessed, the obstacles I have encountered and overcome, whether academic, professional, or personal, have humbled me and restored my desire to return to the love, service, and justice at the core of my professional drive and practice. I am once again prioritizing my values and making sure my actions reflect them. Among those values is the desire to work toward the unification of our profession and to advocate for policy changes that support the mental health of all nurses. Inspired by my personal experiences, this article explores mental health issues many nurses confront today.

A pervasive problem

Although mental health and suicide among nurses have emerged as areas of professional concern in recent years, little research or literature exists regarding profession-specific risk factors, prevalence of mental illness, and suicide rates. With little to no concrete statistics to draw from, the true incidence of mental illness within the nursing profession is unknown. Furthermore, little has been done to bring these problems to the attention of the general public or to acquire the recognition and support of the professional community. 1-3

What can be found are decades of research stating that nursing is psychologically demanding and can contribute to poor mental health in a variety of ways, such as depression, anxiety, secondary trauma, compassion fatigue, and burnout. 1-7 The occupational hazards of nursing can also compromise work-life balance. Add to this various individual risk factors such as genetic predisposition or history of personal trauma, as well as the fact that academic standards for the profession favor those who are exacting and high-performing. It stands to reason that nurses are in jeopardy of significantly elevated levels of stress and maladaptive coping. 5,8 When ongoing, this can lead to impaired functioning. In the professional setting, impairment has been correlated with increased risk for errors, patient harm, and clinical ineffectiveness. 9

Mental illness can be defined as clinically significant impairment in social, conceptual, and practical functioning. 9,10 Although very common, mental illness is often untreated. 11 One in five adults will have some experience with mental illness each year, but less than half will receive treatment. 11

Nursing has a hidden culture of stigma and silence regarding mental illness, which serves to minimize and overshadow those experiencing clinically significant distress. 6,12 Competition, intimidation, and bullying among nurses are pervasive across practice and in academic settings. 13,14 These behaviors can breed psychologically hazardous and hostile environments. Fear of becoming a target may result in blame, shame, self-stigmatization, isolation, and suffering in any individual with potentially undesirable characteristics in such settings, regardless of his or her mental health status. Such abuses and fear can promote conformity and negatively impact disclosure and help-seeking behaviors in stressed, distressed, and impaired individuals. 1,2,5,13

The issue is exacerbated by a lack of respect and recognition for nursing that is still present within the healthcare culture at large. The traditional hierarchy holds physicians as experts, not nurses. Even advanced practice nurses are diminished, often referred to as “mid-level providers” and “physician extenders.” 15 These attitudes undermine the autonomy and dignity of nurses, especially when they collaborate with other healthcare disciplines. 14

In addition, while healthcare entities and societies champion the rights of the patient, the need to protect the basic human dignity and professional image of nurses is often overlooked. 14 Fundamental protections and rights for nurses are being compromised every day when we are expected to tolerate long hours, interrupted (or nonexistent) breaks, heavy patient caseloads, incivility, and even violence in the workplace. Nurse unions across the country are threatening walkouts and going on strike because of the failure of hospitals to address these issues. 16,17 The situation is not helped by the fact that guiding and governing bodies for nursing practice are numerous yet, in my opinion, self-segregated.

Systemic change

Although some organizations have created emotional wellness programs, a cohesive or public effort to address systemic problems is lacking. 1-3 Until employers, boards of nursing, and nursing organizations place the same importance on the well-being of nurses and risk mitigation, nurses may continue to suffer in silence. Within the currently disjointed system, we cannot hope to make substantive changes without offering our passion and expertise as well as identifying and supporting means for promoting self-care and wellness among the thousands of practicing nurses and preprofessionals experiencing distress or symptoms of mental illness.

Pressures and barriers to mental health and help-seeking extend to the academic setting. 4-5 For professional nurses returning to school, the pressure associated with practice and professional expectations may be exacerbated by their increased need to balance a variety of personal and/or family responsibilities, deadlines, financial obligations, leisure time, and peer competitiveness. Despite these contributory risk factors, I have seen few—if any—educational programs for health and helping disciplines, such as nursing, medicine, and social work, place value on assessing students' stress and distress. In commiserative discussions with others doing graduate work in nursing, social work, occupational therapy, and physical therapy, I have yet to meet anyone who felt the faculty took action to address the genuine difficulties many of them faced in balancing their lives. In short, students (myself included) feel devalued by the lack of respect, holistic consideration, and mentorship they encounter. Academic learning environments have a great need to support improvement of the emotional well-being and psychological resiliency of students and for improving the accessibility of support, counseling, and mental health resources. 4,5

I encourage you to take a long, hard look at yourself and those around you. If you are struggling, please reach out to someone you trust and let them know you are not okay. If you are not sure that what you are experiencing is normal or cause for concern, there are many websites that provide education and information on how to identify mental health problems, as well as hotline crisis intervention services and referrals to local counseling. These websites often have articles and tips on how to improve your mental health through physical, spiritual, and psychological self-care. (See Mental health resources .)

No mental health concern is too big or too small. If you are not well, talk to a friend, family member, professional, or help hotline. If you suspect a coworker, colleague, or student needs help, please reach out. Something as simple as asking if they are okay and giving them the space and time to express their feelings can make all the difference. As Edward Everett Hale once said, “I am only one, but still I am one. I cannot do everything, but still I can do something. And because I cannot do everything, I will not refuse to do the something that I can do.” 18 We owe it to ourselves, our profession, our patients, and their families to seek help and to offer help to our fellow nurses in need.

For anyone requiring immediate crisis intervention or assistance finding a local mental health provider, the following resources are available:

• Mental Health America: 1-866-400-6428 for referrals, 1-800-273-8255 for crisis
• National Alliance on Mental Illness HelpLine 1-800-950-6264
• National Suicide Prevention Helpline 1-800-273-8255

Crisis Text Line available 24 hours a day, text “HOME” to 741741

Mental health resources

• American Psychological Association
• www.apa.org
• American Psychiatric Nurses Association (APNA)
• www.apna.org
• MentalHealth.gov
• www.mentalhealth.gov
• National Alliance on Mental Illness
• www.nami.org
• National Suicide Prevention Lifeline
• https://suicidepreventionlifeline.org
• Crisis Text Line
• www.crisistextline.org

anxiety; compassion fatigue; depression; emotional wellness; mental health; nursing; suicide prevention

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Nursing intervention in mental health: a case study in a home setting  †.

1. Introduction

2. material and methods, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Share and Cite

Oliveira, P.; Figueiredo, S.; Martinho, J.; Pires, R.; Pinto, C.B. Nursing Intervention in Mental Health: A Case Study in a Home Setting. Med. Sci. Forum 2022 , 16 , 3. https://doi.org/10.3390/msf2022016003

Oliveira P, Figueiredo S, Martinho J, Pires R, Pinto CB. Nursing Intervention in Mental Health: A Case Study in a Home Setting. Medical Sciences Forum . 2022; 16(1):3. https://doi.org/10.3390/msf2022016003

Oliveira, Palmira, Sofia Figueiredo, Júlia Martinho, Regina Pires, and Cristina Barroso Pinto. 2022. "Nursing Intervention in Mental Health: A Case Study in a Home Setting" Medical Sciences Forum 16, no. 1: 3. https://doi.org/10.3390/msf2022016003

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• Section One: Introduction
• Section Two: Learning and Teaching Resources to Support Integration of Mental Health and Addiction in Curricula
• Section Three: Faculty Teaching Modalities and Reflective Practice
• Section Four: Student Reflective Practice and Self-Care in Mental Health and Addiction Nursing Education
• Section Five: Foundational Concepts and Mental Health Skills in Mental Health and Addiction Nursing
• Section Six: Legislation, Ethics and Advocacy in Mental Health and Addiction Nursing Practice
• Section Seven: Clinical Placements and Simulations in Mental Health and Addiction Nursing Education
• Section Eight: Reference and Bibliography
• Section Nine: Appendices and Case Studies

Section Nine

Case studies, also in this section.

• Alignment between CASN/ CFMHN Entry-to-Practice Mental Health and Addiction Competencies and Sections in the Nurse Educator Mental Health and Addiction Resource
• Process Recording
• Criteria for Validation: Process Recording
• Criteria for Phase of Relationship: Process Recording
• Journaling Activity
• Safety and Comfort Plan Template
• Advocacy Groups for Mental Health in Canada
• Tips for Engaging Lived Experience
• Glossary of Terms
• Case Study 1
• Case Study 2
• Case Study 3
• Case Study 4
• Case Study 5
• Case Study 6
• Case Study 7
• Case Study 8
• Case Study 9

The case study is an effective teaching strategy that is used to facilitate learning, improve critical thinking, and enhance decision-making Sprang, (2010). Below are nine case studies that educators may employ when working with students on mental illness and addiction. The case studies provided cover major concepts contained in the RNAO Nurse Educator Mental Health and Addiction Resource.

While not exhaustive, the case studies were developed and informed by the expert panel. It is recommended that educators use the case studies and tweak or add questions as necessary to impart essential information to students. Also, educators are encouraged to modify them to suit the learning objective and mirror the region in which the studies are taking place. Potential modifications include:

• demographics (age, gender, ethnicity);
• illness and addiction, dual diagnosis or additional co-morbidities such as cardiovascular disease; and
• setting (clinical, community).

Suggested “Student questions” explore areas of learning, while “Educator elaborations” recommend ways to modify the case study. Discussion topics are a limited list of suggested themes.

When using these case studies, it is essential that this resource is referenced.

See Engaging Clients Who Use Substances BPG appendices for examples

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Article Contents

Introduction, research design and method, opening of the encounter: developing a reciprocal relationship, active listening: power sharing, vision of the future: emphasizing the positive, conclusions.

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Empowering counseling—a case study: nurse–patient encounter in a hospital

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Tarja Kettunen, Marita Poskiparta, Leena Liimatainen, Empowering counseling—a case study: nurse–patient encounter in a hospital , Health Education Research , Volume 16, Issue 2, April 2001, Pages 227–238, https://doi.org/10.1093/her/16.2.227

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This study illustrates practices that a nurse uses in order to empower patients. The emphasis is on speech formulae that encourage patients to discuss their concerns and to solicit information about impending surgery. The study is a part of a larger research project and a single case was selected for presentation in this article because it differed from the rest of the data by manifesting empowering practice. A videotaped nurse–patient health counseling session was conducted in a hospital and transcribed verbatim. The investigator interviewed the nurse and the patient after the conversation, and these interviews were transcribed as well. The encounter that is presented here as a case study is a concrete example of a counseling session during which the patient is free to discuss with the nurse. The empowering practices that the nurse employed were as follows: encouraging the patient to speak out, tactfully sounding out the patient's concerns and knowledge of impending surgery, listening to feedback, and building a positive vision of the future for the patient. We suggest that nurses should pay attention to verbal expression and forms of language. This enables them to gain self-awareness and discover new tools to work with.

In recent literature, empowerment has become an important concept of health education ( Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 ), health promotion ( Labonte, 1994 ; Tones, 1994 , 1995 ; Williams, 1995 ; McWilliam et al. , 1997 ) and health counseling ( Poskiparta et al. , 2000 ). The process of empowerment has been related more to community and organizational levels than to micro levels of practice ( van Ryn and Heaney, 1997 ) where it is constantly crucial ( Tones, 1994 ). In addition, operationalization of the concept of empowerment has been relatively vague. According to Tones ( Tones, 1994 ), empowerment is a major goal of health promotion. This article focuses on health counseling as a means of interpersonal health education practice and uses health promotion as an umbrella term.

Empowerment is as much a process as an outcome of developing the skills and perceptions of clients. It is not only something that happens but a process that is facilitated. In interpersonal health counseling, the primary goal is not to change clients' behavior and seek their compliance with the presented message but rather to raise critical awareness through learning and support, to give clients tools for making changes on their own. The aim is personal empowerment, control and choice, which means that patients become aware of changes in their knowledge and understanding, decision-making skills, enhanced self-esteem/sense of personal control, and development of various social, health and life skills ( Labonte, 1994 ; Tones 1994 ; Anderson et al. , 1995 ; Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 ; Kar et al. , 1999 ).

The basic point of departure for empowerment is taking into consideration the interactive nature of the individual and the environment: people are not completely controlled by their environment nor can they fully control their physical, social or economic circumstances ( Tones, 1994 ). Empowering health counseling is based on recognizing clients' competence, resources, explanations of action styles of coping and support networks. Client initiative, clients' realizations and clients' expressions of their opinions and interpretations are the basis on which clients can approach health issues in collaboration with professionals. They are of crucial importance for their decisions on future action ( Anderson, 1996 ). All this supports the notion that empowering health counseling is significant.

Because learning about personal health is complex, the key issue of empowering health counseling is partnership and reciprocal conversation in a confidential relationship. This means that clients not only analyze their situation but also have an opportunity to plan what to do next, and how to go on and to construct their own solutions to health issues. In this type of hospital health counseling, either patients raise the issues (i.e. determine the topics) or the nurses do so in a sensitive and non-threatening manner ( Poskiparta et al. , 2000 ). Nurses recognize and respect patients' experiences, knowledge and skills, and make their own professional knowledge and expertise available to them ( Williams, 1995 ; McWilliam, et al. , 1997 ), which are important aspects of nurse–patient relationships that are also reported by patients ( Häggman-Laitila and Åstedt-Kurki, 1994 ; Lindsey and Hartrick, 1996 ; Wiles 1997 ). The emphasis is placed on patient-driven [see ( Lindsey and Hartrick, 1996 )] health counseling, where patients' life situations are respected, patient-initiated actions are supported, and shared knowledge and deep understanding are nurtured.

The nurse's institutional task is not only to facilitate patient participation but also to promote patients' awareness of their routines and preconceptions as they are revealed to both interlocutors. This should lead to the aim of interaction, which is to activate self-reflection and re-evaluation and reorganization of patients' activities. The assumption is that new knowledge is gained in this process as a result of empirical realization and deliberation ( Feste and Anderson, 1995 ), which means that both patients and nurses have linked new knowledge to existing knowledge. Thus, patients learn to interpret and outline even familiar health problems in new ways that conform to their worldview [ cf . ( Mattus, 1994 )]. As for nurses, empowerment calls for not only sensitivity but also an ability to accurately perceive patients' messages.

From this point on, the focus is on the content of the interactive process. Tones ( Tones, 1994 ) discusses empowerment theoretically, Labonte ( Labonte, 1994 ) expresses ideas for practice in general, while Feste and Anderson ( Feste and Anderson, 1995 ) provide three empowerment tools for facilitating patients' empowering process: using questions, behavioral language and storytelling. According to them, questions maintain the process of pursuing wisdom, i.e. exploring the meaning of health problems in the context of everyday life. This kind of questioning involves broad questions that relate to one's personal philosophy and lifelong dreams. In addition, it includes practical, day-to-day issues of successfully integrating into one's personal, family, social and professional life. Behavioral language means using words such as `list', `describe', `identify', `decide', etc., in order to encourage patients to act and make choices instead of being satisfied with receiving information. Stories help to facilitate the process of self-discovery because diseases affect all areas of life and each individual's health status is unique.

Van Ryn and Heaney ( Van Ryn and Heaney, 1997 ) pay attention to interpersonal relations by suggesting concrete strategies and examples for empowering practice. In their article, they demonstrate two principles of interaction: (1) provide clients with unconditional positive regard and acceptance, and (2) facilitate client participation. Both principles include several practical strategies (Table I ).

However, the authors pay less attention to empirical findings ( Northouse, 1997 ). The present article describes some linguistic realizations of empowering practice. This article describes a nurse's empowering speech formulae during her efforts to give a patient information about an impending surgical operation and to strengthen her feelings of security by providing her with an opportunity to discuss her concerns. This study adopts a holistic approach to interaction and does not focus on isolated sentences or dialogue structure. The relationship of language and context in comprehension, as well as non-verbal communication, are also discussed.

This article describes a single case derived from qualitative data collected from a total of 38 counseling sessions in a Finnish hospital. Nurse–patient encounters were videotaped and transcribed verbatim. Interviews with the nurses and the patients after the sessions were transcribed as well. All participants volunteered to take part in the research, signed a research license and granted permission for the transcribed data to be used in publications. Nineteen nurses participated in this study. Each nurse conducted two videotaped counseling sessions with different patients. There was only one male nurse while the patient group consisted of 24 female and 14 male patients. The research material took shape as nurses volunteered in the hospital and it was found to be adequate for qualitative analysis. The length of the nurses' careers varied from 1 to 25 years. The ages of the nurses were between 24 and 50 years (mean age 36.9 years) while the patients' ages ranged from 18 to 70 years (mean age 47.9 years). The researcher did not attend the counseling sessions, which lasted from 5 to 45 min. The participating patients were experiencing diverse health problems. Various surgical problems, e.g. knee surgery, hernia operation, breast surgery, hip operation, back operation, post status of brain bleeding and post care of bypass surgery, were among the most representative. In addition to the health problems that had led to hospitalization, many patients also suffered from chronic diseases, such as hypertension, asthma, rheumatic illnesses or diabetes. Many patients also found themselves in an insecure situation when a chronic disease had suddenly been manifested or they were undergoing examinations. There were also some mothers in the group who had delivered recently and had no health problems.

The health counseling sessions were genuine counseling situations that were related to the patients' treatment. A single video camera was used, which meant that the observation of non-verbal communication was limited to examining the session as a whole, including only eye contact, smiles, laughter, tone of voice, gestures and, to some extent, facial expressions. Consequently, the emphasis of this study was examining verbal communication. Separate interviews with the nurses and the patients where both parties were encouraged to express their evaluations of the health counseling were used for partial support of the interpretations, e.g. when describing the patients' opinions about health counseling. We also checked if there were any nurses or patients who were nervous about the videotaping.

This article concentrates on videotaped data. When we examined all of the data we found many encounters that involved some empowering features from time to time, but there were none that were consistently empowering. In this article, we present a single case from the data. This particular encounter was selected because it differed from the rest of the data ( Stake, 1994 ) by manifesting empowering practice most widely. In order to study the interactive nature of communication, the coding and analysis of the videotaped data was based on principles of Conversation Analysis ( Drew and Heritage, 1998 ). The videotapes were transcribed word by word, including stammering, etc. At the same time, additional data were added to the transcriptions, such as pauses during and between turns, onset and termination of overlapping talk, intonation information, and some non-verbal communication. The following transcription symbols were used to indicate this information:

ha+ hands support speech

vo+ rising voice

vo– falling voice

[ ] at the beginning and end of overlapping speech, words enclosed

(( )) transcriber's comments, e.g. smile, laughter, body movements

(.) small but detectable pause

underlining emphasis

… omission of text

=no interval between the end of prior and start of next speech unit

°speech° speech in low volume, words enclosed

`speech'pitch change, words enclosed

The analysis was carried out on a turn-by-turn basis. The principle behind this analysis was to examine how turns were taken with regard to other participants' speech and what sequential implications each turn had for the next. After reading the transcript and watching the recording several times, we discovered a number of empowering expressions in the nurse's speech and concluded that this case was the one which best manifested empowering action in the data.

The particular case describes at the individual level information about the patient's situation, the nurse's interview after the encounter, an in-depth description of the nurse–patient conversation and the observational data derived from it. Pearson ( Pearson, 1991 ) and Patton ( Patton, 1990 ) indicate that a case study can be used, for example, for examining how different concepts emerge or change in particular contexts. However, an even more important question is what can be learned from a single case. Stake ( Stake, 1994 ) suggests that one should select a case that seems to offer an opportunity to learn and contributes to our understanding of specific phenomena. Here, a detailed single case analysis illustrates how empowerment may be practiced during health counseling and demonstrates how new working tools for empowerment can be developed on the basis of a single encounter ( Laitakari, 1998 ). The present study describes the speech of a nurse when she helped a patient to deal with anxiety and to receive information about surgery in an empowering way.

The nurse anesthetist has come to see a patient who is scheduled to have surgery the next day. The encounter involves, besides interviewing, producing a lot of information about the operation, counseling on the preparations for the surgery and advising how to manage after the surgery. The encounter takes place at a table, with the nurse and the patient facing each other. Both are women; the nurse is 50 and the patient 41 years old. The patient had had problems with her back for 10 years and was suddenly admitted to the hospital because of these problems. The patient has recently been examined and a decision has been made to operate on her the next morning. The interviewing session lasted 14 min.

At the beginning of a conversation the participants evaluate each others aims and concerns, and the communication situation as a whole, and this evaluation directs the entire discussion because the participants base their actions on it (Goffman, 1982). In a hospital, it is typical that nurses initiate a discussion ( Leino-Kilpi, 1991 ) and that is what happened in this case ( Extract 1 ). Professional dominance common in medical encounters ( Fairclough, 1992 ) is not so obvious in this conversation. After greeting the patient, the nurse refers to the goal of the discussion and individualizes it by using familiar `you' (line 1) instead of the formal, plural form of `you'. This form of address can be viewed as an act of communicating an appropriate degree of informality. It implies intimacy and mutual respect when a relationship is established ( van Ryn and Heaney, 1997 ).

1 N: Hello, Rose (.) you are going to have surgery 
 2 tomorrow…but now I would like to ask you 
 3 you well about the operation tomorrow if 
 4 there is (.) something that would influence 
 5 the preparations for your operation (.) and 
 6 then you ((ha+)) can bring things up ask well 
 7 er if something is unclear to you ((nod+)) If 
 8 you want to know anything about what's 
 9 going to happen to you tomorrow ((vo–))

((at first the nurse looks at papers on the table, while she speaks she turns her eyes to the patient and nods))

This opening was not typical of the other interviews in the data set, because in the data these encounters were usually initiated with the nurses' brief statements about the impending operation. They explained that they interviewed patients in advance in order to get information and that they could provide information to the patients as well. Nurses usually used formal, plural forms of address when speaking. When referring to the preoperative encounter, they used the plural, institutionalized form `we' [see ( Drew and Heritage, 1998 )], instead of first person singular `I', and plural `you', instead of the singular, when addressing the patient. Other nurses did not individualize their speech. On the contrary, they maintained a distance from the patients. In this particular case, a familiar mode of address reduces social distance, which is very important in health education practice [ cf . ( van Ryn and Heaney, 1997 )]. We explain our interpretations in more detail below.

The nurse uses the verb `ask' (line 2), but her remark further on (line 6–9) `then you can bring up ask well er if you were unclear about something if you want to know something about what's going to happen to you tomorrow' introduces a context for the discussion. Even though the nurse goes on to ask a question about previous operations, the interview becomes an interactive dialogue, with the patient actively participating. On her own initiative the patient discloses symptoms that she has experienced during the last few months, what happened when she needed to come to the hospital and the doctor's decision to perform surgery.

Thus, the nurse introduces the context of the discussion with her opening words [ cf . ( Peräkylä, 1995 )]. She expresses her acceptance by offering collaboration [ cf . ( van Ryn and Heaney, 1997 )] when asking questions. The verb form `would like to' (line 2) gives the discussion an air of voluntariness. The conditional form softens the notion of the necessity of the questions, and the verbal mode implies respect for the patient. At the beginning of the session (lines 1–9), the nurse combines two topics into a single long sentence, which also encourages (lines 6–9) the patient to clarify matters that are unclear to her. The nurse's words leave room for the patient's own thoughts and invites her to look for a personally meaningful way to connect the nurse's questions about the preparations (line 5) for the operation to her lack of information (lines 7–9). Encouraging statements can stimulate the patient to think in a way that is personally meaningful to her and to participate in the conversation ( van Ryn and Heaney, 1997 ; Tomm, 1988). Here, encouragement takes a form that is different from what Feste and Anderson ( Feste and Anderson, 1995 ) suggested; it is given in a more sophisticated manner. The opening words ( Extract 1 ) correspond with the goal that the nurse states later during the interview: `that the patient would receive the information she needs, what she wants to know and that she would feel safe to come, that at least those worst fears would be like forgotten. That she would feel safe'.

An encounter can threaten a patient's need for autonomy and freedom because it gives the nurse the legitimate power to request information about the patient's private life ( van Ryn and Heaney, 1997 ). Here, the nurse is mitigating her power by avoiding threatening terms and using tentative formulations (`would like to, well er, you you'), the emphasis being on the patient's needs. The opening of the interview by the nurse plays an important role in the development of the atmosphere. The act has been planned in advance but is not thoroughly thought out. In addition to conveying information, the main consideration in setting the goal for the discussion is to help the patient deal with her concerns. These are issues that have also been stressed in earlier studies ( Häggman-Laitila and Åstedt-Kurki, 1994 ; Breemhaar et al. , 1996 ; Leinonen et al. , 1996 ; Lindsey and Hartrick, 1996 ; Otte, 1996 ).

Tactful exploration: activation of reflection

Later during the interview, the patient mentions having thought about the impending surgery, which the nurse interprets as an indication of fear for the operation ( Extract 2 ). She indirectly gives the patient an opportunity to deal with her fears. The patient's words (lines 1, 3, 5 and 7) are related to the previous topic and her status during the operation and conclude the discussion. The nurse changes the subject (line 9) by praising the doctor's skill. The nurse and the patient look at each other.

1 P:mmm[think about during the day]= 
 2 N:[of] course ((nod+)) 
 3 P:=what's going to happen and (.) 
 4 N:right ((nod+)) 
 5 P:°like[that]° (.) 
 6 N:[mmm] 
 7 P:°it's[okay]° ((nod+, vo–)) 
 8 N: [that's] right (.) ((glance at papers: doctor's 
 9 name)) is is an excellent surgeon so in that 
 10 respect you can definitely (.) ((vo–)) feel 
 11 safe ((nod+)) that 
 12 P:yes of course I am 
 13 N:mmm 
 14 P: and and absolutely 110% (.) I trust that (.) 
 15 the thing is that (.) this is small case for 
 16 him but this is a horribly big thing for me…

The nurse's comment about the operating surgeon contains an allusion to fear of surgery. Instead of soothing the patient by telling her not to be afraid or asking if the patient is scared, the nurse indirectly comments on the doctor's professional skill (line 9) and emphasizes the expertise as a guarantee of success (line 10 and 11). Thus, the nurse allows the patient to save face when she leaves her to interpret her words. Her indirectness implies politeness and gives the patient options: if she does not want to deal with her fear, she may choose not to take the hint [see ( Brown and Levinson, 1987 )]. Here, politeness can also be linked to and interpreted through empowering practice, where the nurse holds the patient in high regard [ cf . ( van Ryn and Heaney, 1997 )].

The extract might have been interpreted as an example of the nurse cutting the patient off if one had not seen the videotape. Our interpretation is supported by a number of factors. First of all, the entire conversation until this extract has been tranquil and calm, the nurse has spoken and asked questions at a gentle pace, with pauses, and she has explored the patient's experiences. In this extract, the situation is similar, and she looks at the patient and nods. She speaks quite slowly, and her voice is low, friendly, and convincing ( van Ryn and Heaney, 1997 ). We can also see that the patient completes her speech by pausing (lines 3 and 5) and lowering her voice (lines 5 and 7). Therefore, after the nurse's words (lines 8–11), the patient presents her fear for discussion (lines 15 and 16) and also returns to the matter later during the interview. The extract shows how the issue has been constructed together by the nurse and the patient. The nurse raises the theme in a sensitive and non-threatening manner, and the patient continues the same topic. It also shows that the relationship is confidential enough for the patient to disclose her concerns and become aware of her own understanding, and thus contributes to empowerment. Salmon ( Salmon, 1993 ) has stressed that the main goal in the discussions between nurses and patients before surgery is not to reduce the patients' fears but to help them to deal with them.

Indirectness is a polite feature of discourse. There is `strategic indefiniteness' in indirectness that offers patients an opportunity to continue a discussion according to their own wishes ( Brown and Levinson, 1987 ). In general, nurses' empowering acts are mostly manifested in the form of questions ( Poskiparta et al. , 2000 ). In some cases, an indirect comment by a nurse, instead of a question, may encourage patients to talk about topics that they fear. Here it generates reflection in the patient. After disclosing her concerns, the patient analyzes the situation and recounts the conversation that she had with the doctor who explained the reason for her back surgery ( Extract 3 ).

Extract 3 .

1 P:this morning ((doctor's name)) said that 
 2 N:`this morning' ((surprised)) 
 3 P:this morning 
 4 N:that's recent for sure 
 4 P:yes 
 5 N:well it happened so 
 6 P: so it happened suddenly because yesterday 
 7 it became evident that (.) there was in the 
 8 X-ray ((doctor's name)) said that there was 
 9 a cause when I asked if there was anything 
 10 that caused the pain or if I was just imagining 
 11 it (.) so he said that yes there was a 
 12 genuine cause…

The amount of information given always depends on the situation and the nurse needs to continually evaluate the patient's needs: what it is that the patient knows, wants to know and how much she does want to know. This is also important because there are several persons that the patient sees before surgery ( Breemhaar et al. , 1996 ). Furthermore, nurses and doctors may deal with the same issues in their counseling. In Finland, the doctors, the surgeon and the consultant anaesthetist inform patients about the medical facts, risks, and benefits of operations. The patient also has an interview with a nurse on the surgical ward and, in addition to these encounters, there will occasionally be an encounter with a nurse anesthetist.

The nurse's empowering approach is manifested in how she raises issues or questions from time to time as if with hesitation. A pause precedes questions [`I don't have any (.) questions to ask you any more but do you—you have anything to ask from me like such things about tomorrow that worry you') ((looks at the patient))]. She asks the questions more quietly than normal and looks at the patient. According to Beck and Ragan's ( Beck and Ragan, 1992 ) study, nurses' softening words and their hesitant and tentative manner of speaking indicate discretion and tact and are aimed at not embarrassing patients. In our data, slow and hesitant speech also encourages the patients to comment more than nurses' more usual and brief question does: `Do you have any questions?'.

The nurse's tentative manner of asking questions makes it easier for the patient to start dealing with her concerns. She repeatedly pauses briefly and, in addition to the closed questions in the medical history questionnaire, she asks open-ended questions that explore the patient's experiences: `What kind of memories do you have of previous operations?' `Is there anything else you remember (.) is there something?'. Open-ended questions encourage the patient to speak and participate, e.g. in the naming and solving of a problem [ cf . ( Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 )]. In this particular case, indirectness and hesitation are polite speech formulae that help the patient to save face ( Fairclough, 1992 ). They can also serve as empowering strategies that provide unconditional positive regard and acceptance for patients.

Despite these quite extensive empowering acts, the nurse subsequently evaluated her information skills only. She indicated how difficult it was for her to decide what kind of information to give to the patient:

I wondered if I should have maintained a more professional role, I mean more facts, if the patient got all that she wanted. Because this is not really medical science, you know, that's up to the doctor. It has to happen on the patient's terms, what she wants to know. I tried to check the patient's needs several times.

The content of the session satisfied the patient as well:

I got enough information about the operation, things that occupied my mind, so I didn't, she even told me before I asked. There's nothing to find out any more. As I said to her, I'm terribly afraid but I'll go ahead with confidence.

The nurse's way of posing questions builds up interaction. With her questions she steers the discussion thematically. This is how she controls the conversation. On the other hand, it is the patient who determines the content of the discussion. Her answers are reflective and bring up new issues. When the patient speaks, the nurse supports her with various feedback (e.g. Extracts 2 and 3) `mmm, right, of course, yes, exactly' and sometimes by paraphrasing. She nods a lot, bends toward the patient and looks at her. The feedback also occasionally includes completing the patient's sentences. According to van Ryn and Heaney ( van Ryn and Heaney, 1997 ), such non-verbal cues signal acceptance and, according to Caris-Verhallen et al. ( Caris-Verhallen et al. , 1999 ), they are patient-centered. With her feedback the nurse shows that she is there to listen to the patient, that she does not want to interrupt. Her feedback encourages the patient to speak in a similar way as in the doctor–patient conversation of an alternative medical interview described by Fairclough ( Fairclough, 1992 ). The patient interprets the feedback as encouragement, goes on to discuss the matter, and indicates her intention to continue by using the expressions `What I have been wondering…', `I did that when…' and `on the other hand, it's…'. This is how the nurse supports the patient's right to speak, which is not necessarily typical of a medical conversation ( Fairclough, 1992 ). The nurse's multi-facetted listening feedback is empowering, and this can be seen here and there in the data [see also ( Poskiparta et al. , 2000 )]. In this encounter, the feedback is exceptional because it disregards the participant's status. Generally, this type of feedback is directed to the dominant person ( Hakulinen, 1989 ). In a medically oriented environment, the hospital staff are viewed as superior to patients in knowledge ( van Ryn and Heaney, 1997 ; Tones, 1994 ). In this particular case, the nurse's listening feedback manifests power sharing.

When the patient discusses the reason for her admission to the hospital, the nurse builds up a positive, healthier vision of the future through other patients' experiences ( Extract 4 ). She makes her professional knowledge and expertise available to the patient ( Williams, 1995 ; McWilliam et al. , 1997 ). This lends a touch of reality and possibly builds on the patient's strengths ( van Ryn and Heaney, 1997 ) in this situation. The nurse attempts to dispel the patient's concerns about the risks of the operation. Her tone is convincing, and her non-verbal messages also inspire confidence: she looks at the patient, reinforces her message by nodding her head and gestures with her hands. Encouraged by the nurse, the patient can have a vision of her postoperative future.

Extract 4 .

1 N:these these ((ha+)) back operations are 
 2 like such that patients in them are usually 
 3 really grateful ((nod+)) after the operation 
 4 because if the operation like succeeds and 
 5 something is found (.) then the pain will be 
 6left in the operating room (.) ((ha+)) and 
 7 in that in that this is like like different from 
 8 other operations (.) and then because the 
 9 woundpainisinthebacksomehowit's 
 10 different than in here if the wound was here 
 11 inthestomach(ha+))andit'snotthatthat 
 12bad when it is if[you]= 
 13 P:[yeah] 
 14 N:=afterthosestomachoperationsyouoften 
 15 often hear that these patients who have had 
 16their back operated are such fortunate 
 17((nod+)) cases in the sense [that]= 
 18 P:[yeah] ((nod+)) 
 19 N:= because the pain will be left in the 
 20 operating room and and that's it then 
 21 ((nod+/ha+))

The nurse encourages the patient to examine her life at some hypothetical future point of time when the operation will have succeeded. Hypothetical questions encourage patients to discuss issues that they fear [ cf . ( Peräkylä, 1995 ; Tomm, 1987 )], while a hypothetical positive situation encourages patients indirectly. In this case, discussing the past would not calm the patient but rather lead her thoughts to the incident that caused her hospitalization. The vision of the future that the nurse provides to the patient with may help relieve her. A positive example is an empowering message and displays the nurse's understanding of the patient's anxiety. This vision can tap new resources in the patient for facing the future that is suddenly uncertain [ cf . ( van Ryn and Heaney, 1997 )]. Some manifestations of this can be seen in the patient's words: `…I'm very happy that if it's going to be over (.) yes I'm ready though I feel nervous' or `…I'm going ahead with confidence…'. A skilful use of future focus by the nurse helps the patient to find new solutions to her problems [ cf . ( Tomm, 1987 )]. As Atwood ( Atwood, 1995 ) suggests, confining the clients' thoughts to their problems is not sufficient in therapy work (focus on the past). In addition, we need to assist clients to expand their outlook by re-visioning their lives (future focus).

The encounter that is presented here as a case study demonstrates empowering nursing practice in hospital. It is a concrete example of a discussion during which the official and formal nature that characterizes the role of an institutional nurse is not emphasized. It actually emphasizes partnership and reciprocal conversation [ cf . ( van Ryn and Heaney, 1997 ; Poskiparta et al. , 2000 )], with the nurse's social interaction skills at the heart of the encounter [ cf . ( Wiles, 1997 )]. The patient is free to discuss her thoughts, concerns, experiences and even fears with the nurse, and the nurse adopts an empowerment strategy in order to facilitate the patient's participation. This encounter included the following empowering practices: (1) opening the session in an encouraging and constructive manner, which improves the atmosphere, (2) tactful exploration when examining the patient's need for information and concerns for surgery, (3) active, power sharing listening, and (4) building up a positive vision of the future.

The descriptions of empowerment strategies reported by van Ryn and Heaney ( van Ryn and Heaney, 1997 ) support our findings. However, we agree with Northouse's ( Northouse, 1997 ) criticism that the reported strategies are not completely separated. In our study, empowerment was manifested through intimacy and mutual respect. The nurse's encouragement of the patient's participation and her attempt to share power signaled acceptance, and perhaps gave the patient new insights for controlling her feelings about the impending surgery. Furthermore, the perceptions of active listening feedback and questioning are consistent with our previous studies ( Poskiparta et al. , 1998 , 2000 ; Kettunen et al. , 2000 ), where we found them to be a means of activating patients' self-evaluation and self-determination. In this study, we did not find evidence for empowering stories or questions that relate to patients' personal philosophy, as mentioned by Feste and Anderson ( Feste and Anderson, 1995 ). In addition, the nurse's encouragement was more sophisticated than what Feste and Anderson suggest with their empowering tools.

Our research data consisted of only one videotaped session per patient. Thus we have no evidence about how patients' decision-making skills develop or their self-esteem improves. During the interviews we did not ask the patients' opinion on the effects of counseling and that is why the patients evaluated conversations at a quite general level. In this particular case, the patient said that an encounter was ` illuminating ' for her. She mentioned that she received enough information and again spoke about her fears but used the same words as the nurse did when she emphasized a positive vision of future (see Extract 4 , lines 5, 6, 19 and 20): `if it's a fact that the pain will be left in the operating room, if it really is possible…that there's going to be an operation and they'll do it tomorrow, then that's how it's going to be'. This could, perhaps, signify some kind of relief or new resources to face an uncertain future. During the interview it also became evident that the patient's fears had not been diminished, but she talked about them and stressed a strong reliance on the professionals and on the operation as a whole: `I believe what I'm told'. This is in line with the perspective of Salmon ( Salmon, 1993 ), who emphasized that patients' anxiety about surgery should not be seen as a problem but rather as a normal phenomenon, a sign of patients' emotional balance, of an ability to feel fear. Thus, the nurse's task is not to diminish the patient's fears but to facilitate the patient's disclosure and offer help for dealing with fear.

With caution, we can speculate on the factors behind this kind of empowering practice, which became evident during the subsequent interviews. There was no evidence that nurses' or patients' age, education or work experience influenced the format of the counseling. What makes this case different from traditional rigid counseling sessions is that the nurse had a goal that she had planned in advance and pursued flexibly. This indicates that she had reflected on the significance of this situation from the patient's perspective. In most cases, nurses approached counseling without any goal or the hospital provided a detailed agenda based on professional knowledge of diseases, their care and prevention. Then, different kinds of institutionalized health counseling packages seemed to restrict nurses' communication, and health counseling often followed the standard institutional order of phases mentioned by Drew and Heritage ( Drew and Heritage 1998 ).

This study highlights empowering opportunities that arise in actual situations and that nurses can consciously use in their work. The results of this study can be applied to other health counseling practices and we would argue that every nurse should consider how (s)he initiates discussion. The analysis of the encounter shows that a tentative discussion style gives the patient a chance to deal with her concerns and to absorb the information that she needs. Thus, the patient has an opportunity to participate more actively in the discussion from the beginning than she could in the case of filling out a questionnaire in a strict predetermined order.

Clearly there are limitations to the generalizability of these findings. For example, both interlocutors were women, and this could in part explain the nature of the conversation since the highest levels of empathic and positive behavior occur between females [see ( Coates, 1986 ; Roter and Hall, 1993 ), p. 63]. There is also some concern whether the nurse may have been subject to a performance bias because she was aware of being videotaped and possibly behaved differently. However, we think that this was limited because only two nurses discussed this type of bias in the interviews afterwards and other nurses did not even notice the camera or did so only briefly at the beginning of counseling [see also ( Caris-Verhallen et al. , 1998 )]. Techniques to enhance the credibility of the findings included data and methodological triangulation of research data ( Patton, 1990 ; Stake, 1994 ; Begley, 1996 ), and acquiring data that included both verbal and non-verbal communication from the videotaped health counseling sessions and the subsequent interviews. In addition, team analysis sessions (investigator triangulation) ensured the accuracy of data interpretation (Polit and Hunger 1995). Different expertise helped us to get more complete picture from this case and empowerment philosophy when we discussed interpretations together.

However, in the last analysis, the effect of an empowering encounter could be checked after the operation by checking the patient's perspective, e.g. her satisfaction, recovery rate, etc. Evidence from nursing and medical staff might also be offered as additional evidence. Further research from larger numbers of patients is needed and more evidence from different settings will be required for a more extensive description of empowering practice. We will continue our research, and, for example, present qualitative analysis of interaction by describing how power features and patients' taciturnity are manifested in nurse–patient counseling. In addition, we will investigate how student nurses make progress in empowering counseling.

We suggest that nurses should pay attention to verbal expression and forms of language, in addition to non-verbal messages, because then they can empower patients by opening new and important perspectives for them. Nurses' every question, remark or piece of advice leads to individualized understanding and interpretation by the patient. It is important to remember that each communication situation is a unique, dynamic and transforming process. Nurses should observe what figures of speech they use and thus gain self-awareness and discover new tools to work with. We suggest a training program where the development of health care professionals' empowering skills can occur in practical, dynamic communication situations, be videotaped and transcribed for later theoretical, conscious and instructive evaluation. Analyzing the transcripts of video or tape-recorded counseling sessions opens up the possibility of an exact evaluation of empowering skills.

In health counseling, it is important that patients are able to maintain and strengthen a positive image of themselves as communicators. Positive experiences build up patients' self-esteem and increase their confidence in their ability to influence their care. The mere opportunity to discuss one's opinions and interpretations or different health concerns with a nurse may have the effect of unlocking patients' mental resources. This article demonstrates particularly how unconditional acceptance and facilitation of participation can be used in interpersonal counseling [see ( van Ryn and Heaney, 1997 )]. The empowering practices that are presented in this article should not be regarded as rigid and formalistic, rather they should be adapted to one's personal style.

Empowering principles of interpersonal practice ( van Ryn and Heaney, 1997 )

This study was supported by the Ministry of Health and Social Affairs of Finland and by the Finnish Cultural Foundation. We are sincerely grateful to all that participated in this study.

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Mental health case studies

Driving up quality in mental health care.

Mental health care across the NHS in England is changing to improve the experiences of the people who use them. In many areas, a transformation is already under way, offering people better and earlier access as well as more personalised care, whilst building partnerships which reach beyond the NHS to create integrated and innovative approaches to mental health care and support.

Find out more through our case studies and films about how mental health care across the NHS is changing and developing to better meet people’s needs.

• Children and young people (CYP)
• Community mental health
• Crisis mental health
• Early intervention in psychosis (EIP)
• Improving access to psychological therapies (IAPT)
• Perinatal mental health
• Severe mental illness (SMI)
• Staff mental health and wellbeing
• Other mental health case studies
• Archived mental health case studies

• OJIN Homepage
• Table of Contents
• Volume 23 - 2018
• Number 2: May 2018
• Evidence Psychiatric Mental Health Interventions

Evidence for Psychiatric and Mental Health Nursing Interventions: An Update (2011 through 2015)

Dr. Bekhet is an Associate Professor at Marquette University College of Nursing in Milwaukee, WI. She received aBSN and MSN from Alexandria University in Alexandria, Egypt. She received a PhD from Case Western Reserve University (CWRU) in Cleveland, OH. Her clinical experience in psychiatric nursing is with persons having schizophrenia, bipolar disorders, obsessive-compulsive disorders, and depressive disorders. She has taught psychiatric mental health nursing to undergraduate and direct entry students. She has also advised PhD students. Dr. Bekhet’s program of research focuses on the effects of positive cognitions and resourcefulness in overcoming adversity in vulnerable populations. Her research has been funded by Sigma Theta Tau International; American Psychiatric Nursing Foundation; International Society of Psychiatric Mental Health Nurses; and Marquette University. She is a past recipient of a Midwest Nursing Research Society Mentorship Grant Award, and has received the Award for Excellence from the CWRU Nursing Alumni Association in 2011 and the Way-Klinger Young Scholar Award from Marquette University in 2012. More recently, she was awarded the 2014 research award from the International Society of Psychiatric Mental Health Nurses. Dr. Bekhet has published numerous articles and presented numerous papers and posters at regional, national, and international conferences.

Dr. Zauszniewski is the Kate Hanna Harvey Professor in Community Health Nursing, and Director of the PhD in Nursing Program at the Case Western Reserve University (CWRU), Cleveland, OH. She received a PhD and MSN from CWRU, Cleveland, OH; a MA in Counseling and Human Services from John Carroll University, Cleveland, OH; a BA in psychology from Cleveland State University, Cleveland, OH; and a diploma in nursing from St. Alexis Hospital School of Nursing, Cleveland, OH. She has practiced nursing for 42 years, including 33 years in the field of psychiatric-mental health nursing; she has experience as a staff nurse, clinical preceptor, head nurse, supervisor, patient care coordinator, nurse educator, and nurse researcher, and is board certified by the American Nurses Credentialing Center (ANCC). Her program of research focuses on the identification of factors and strategies to prevent depression and to preserve healthy functioning across the lifespan. She is best known for her research examining the development and testing of nursing interventions to teach resourcefulness skills to family caregivers. She has received research funding from the National Institutes of Nursing Research and Aging; the National Institutes of Health; Sigma Theta Tau International; the American Nurses Foundation; Midwest Nursing Research Society; and the State of Ohio Board of Regents.

Denise Matel-Anderson is a doctoral student at Marquette University College of Nursing in Milwaukee, WI. She holds an Advanced Practice Nurse Prescriber license, and is currently working on a PhD in nursing with a focus on mental health. She has three publications in mental health nursing journals. Ms. Matel-Anderson currently lectures at Carroll University, Waukesha, WI, in the undergraduate mental health nursing theory course, and serves as a nurse practitioner on the medical team at an acute mental health facility.

Jane Suresky is an Adjunct Assistant Professor at the Frances Payne Bolton School of Nursing of Case Western Reserve University (CWRU) in Cleveland, OH. She has received DNP and MSN degrees from CWRU, and a BSN degree from Cleveland State University, Cleveland, OH. Her clinical experience in psychiatric nursing covers the areas of psychobiological research, adolescent dual diagnosis, and mood disorders. She has taught psychiatric mental health nursing to undergraduate and graduate students. In addition, she has been involved in nursing research that focuses on the stress of the female family members of the severely mentally ill.

Mallory Stonehouse recently graduated with a Master of Science in Nursing degree from Marquette University in Milwaukee, WI, where she completed the adult-older adult, primary care, nurse practitioner program. She is a registered nurse at Froedtert Community Memorial Hospital in Wisconsin, where she works on the Behavioral Health Unit. Ms. Stonehouse holds a Bachelor of Arts degree in psychology.

• Figures/Tables

This state-of-the-evidence review summarizes characteristics of intervention studies published from January 2011 through December 2015, in five psychiatric nursing journals. Of the 115 intervention studies, 23 tested interventions for mental health staff, while 92 focused on interventions to promote the well-being of clients. Analysis of published intervention studies revealed 92 intervention studies from 2011 through 2015, compared with 71 from 2006 through 2010, and 77 from 2000 through 2005. This systematic review identified a somewhat lower number of studies from outside the United States; a slightly greater focus on studies of mental health professionals compared with clients; and a continued trend for testing interventions capturing more than one dimension. Though substantial progress has been made through these years, room to grow remains. In this article, the authors discuss the background and significance of tracking the progress of intervention research disseminated within the specialty journals, present the study methods used , share their findings , describe the intervention domains and nature of the studies , discuss their findings , consider the implications of these studies , and conclude that continued track of psychiatric and mental health nursing intervention research is essential.

Key Words: best practices, evidence-based practice, psychiatric nursing journals, psychiatric nursing research, published research, research dissemination, research utilization, systematic review, tradition, intervention research

Implementation science is concerned with the translation of research into practice... The past five years have seen a rapidly growing interest in the field of implementation science ( Sorensen & Kosten, 2011 ). Implementation science is concerned with the translation of research into practice; it involves the examination of the challenges and the opportunities for successful, evidence-based changes in practice ( Nilsen, 2015 ). Translating research into practice depends heavily on the dissemination of findings from intervention research to those most likely to use those findings in clinical or community settings. In contrast to implementation, dissemination involves the spread of information about an intervention, for example, through publication of the intervention in professional journals. Dissemination strategies that are actively targeted toward spreading evidence-based findings concerning an intervention may prompt future implementation in clinical practice ( Proctor et al., 2009 ).

Translating research into practice depends heavily on the dissemination of findings from intervention research... Important for psychiatric and mental health nurses, it is critical that implementation of evidence-based findings occurs across multiple settings (i.e., beyond specialty mental healthcare units) to medical settings, such as primary care areas in which mental health services are provided, and to non-specialized settings, such as criminal justice and school systems and community social service agencies, where mental healthcare is delivered (Proctor et al., 2009). However, before implementation can happen, dissemination of findings from well-designed intervention studies that can inform psychiatric and mental health nursing practice is needed.

One of the best mediums for disseminating evidence-based findings in psychiatric and mental health nursing is the professional nursing journals that are most available to practicing psychiatric and mental health nurses. Nursing journals that are specifically designed a specialty are more likely to be read by persons in the given specialty area than are other nursing research journals. Nurses in practice settings, including those at an advanced practice level, may not have access to scientific research journals or may choose not to read them if the research does not appear meaningful for their practice. The goal of this review was to describe the findings from intervention studies disseminated through publication in one of the five psychiatric and mental health nursing specialty journals published from 2011 through 2015.

Background and Significance

Through the years, more psychiatric and mental health nurse researchers have been targeting specialty journals for disseminating findings from intervention research. For example, in previous reviews of intervention studies published in the five major psychiatric and mental health specialty journals, there was a higher percentage of quantitative intervention studies conducted from 2006 through 2010 (84%) than in a similar review conducted from 2000-2005 (64%) ( Zauszniewski, Suresky, Bekhet, & Kidd, 2007 ; Zauszniewski, Bekhet, & Haberlein, 2012 ), indicating increased use of more rigorous, statistical analytic methods in published intervention research over time ( Zauszniewski et al., 2007 ; Zauszniewski et al., 2012 ).

Tracking the progress of intervention research disseminated within the specialty journals in psychiatric and mental health nursing is important for two reasons. First, it provides data to show improvements in dissemination efforts of psychiatric and mental health nurse researchers. Second, it calls attention to the importance for continued dissemination of intervention research to practicing psychiatric and mental health nurses who are in the best positions to implement the findings in practice. Therefore, the purpose of this review of the same, five, peer-reviewed psychiatric and mental health nursing journals, covering 2011 through 2015, was to determine the number and types of intervention studies within the specified review period. For consistency, the same criteria for selecting the intervention studies that were described in the previous review ( Zauszniewski et al., 2012 ) were applied: A study was determined to be an intervention study if nursing strategies, procedures, or practices were examined for effectiveness in enhancing or promoting health or preventing disability or dysfunction ( Kane, 2015 ).

Five peer-reviewed nursing journals, regarded as the most frequently read in the mental health nursing profession, were analyzed for the years 2011 through 2015. The journals included in the analysis were Archives of Psychiatric Nursing ; Issues in Mental Health Nursing ; Journal of the American Psychiatric Nurses Associatio n; Journal of Psychosocial and Mental Health Services; and Perspectives in Psychiatric Care .

Journals were reviewed for the type of intervention study (qualitative or quantitative); the study domain (biological, psychological, or social); and the number of intervention studies found within the journals. After review, the agreed upon intervention studies were extracted and individually analyzed by the co-authors.

There were 832 databased articles published from January 2011 through December 2015. However, only 115 (14%) evaluated or tested psychiatric nursing interventions. Of these 115 intervention studies, 14 tested interventions with nursing students, nine involved nurses and mental health professionals, while 92 focused on interventions to promote mental health in clients of care.

This section describes the findings from the 115 intervention studies included in the review. The 23 studies that included nursing students, nurses, and mental health professional, and the 92 that involved recipients of mental health services or care are presented in this section. First, the research settings in which the 115 studies were conducted, and descriptions of the targeted populations are described. Next, the 23 studies’ designs, purposes, and findings are discussed in detail. Third, the 92 studies that involved recipients of mental health services or care are presented using the categories of the bio-psycho-social framework. Finally, the type of data (quantitative, qualitative, or mixed) are discussed and presented in the table.

Research Settings Sixty-six of the 115 intervention studies were completed in the United States. Five studies each were done in Australia and United Kingdom. Four each were completed in Korea, China, and Turkey; three each in Norway, Canada, and Iran; and two each in Taiwan, Mexico, Sweden, France, and Netherlands. One study each was conducted in Jordan, Europe, Iceland, Pacific Islands, Thailand, Spain, Greece, and Singapore

Targeted Populations Fourteen of the 115 intervention studies involved interventions with nursing students, while nine studies focused on nurses and mental health professionals. Ninety-two of the studies examined the effect of the intervention on the client. Examples of the studies describing each of these groups are described below.

Fourteen of the 23 nursing intervention studies involved undergraduate nursing students. Nursing students . Fourteen of the 23 nursing intervention studies involved undergraduate nursing students. One study was conducted in Australia regarding consumer participation ( Happell, Moxham, & Plantain-Phung, 2011 ). In this study, researchers investigated whether education programs introducing nursing students to mental health nursing lead to more favorable attitudes towards consumer participation in the mental health setting after completing the mental health component of the nursing program. Study participants were in the first semester of the final year of the Bachelor of Nursing program. The study used a within-subject design using two points (pre-and post-educational program implementation). Results indicated that students demonstrated positive attitudes toward consumer participation even before completing the mental health component. Only marginal and non-significant changes were noted at the post-test stage. The authors concluded that the findings were not surprising given the positive scores recorded at baseline (ceiling effect) ( Happell et al., 2011 ). Another study investigated the effect of pedagogy of curriculum infusion on nursing students’ well-being and the improvement of quality of patients’ care ( Riley & Yearwood, 2012 ).

Pedagogy of curriculum infusion involves instilling the university values and mission with a focus on educating the whole person, and encouraging faculty to translate the core mission of the university into practice in the classroom. this can be accomplished through a variety of courses that provide students with opportunities for contemplation, reflective engagement, and also action through volunteerism, service, and study abroad. The ultimate goal of the study was to encourage critical thinking through reflective exercises and group discussion. Results indicated that students who have experienced the curriculum infusion showed an ability to be self-advocates when discussing their work challenges. Also, they were able to identify specific nursing actions for patient safety; to recognize the patient as a partner in care; and to demonstrate respect for patients' uniqueness, values, and desires as evidenced by case analysis and personal reflections ( Riley & Yearwood, 2012 ).

Three intervention studies explored simulation to see its impact on improving the learning experiences of the nursing students. Three intervention studies explored simulation to see its impact on improving the learning experiences of the nursing students ( Kameg, Englert, Howard, & Perozzi, 2013 ; Kidd, Knisley & Morgan, 2012 ; Masters, Kane, & Pike, 2014 ). Different simulations were used in the three studies; all of them were deemed effective. For example, the results of the study conducted by Kidd and colleagues indicated that undergraduate, mental health nurs­ing students perceived that Second Life® virtual simulation was moderately effective as an educational strategy and slightly difficult as a technical program ( Kidd et al., 2012 ). Also, second degree and traditional BSN students found that a tabletop simulation, which was developed as a patient safety activity and involved checking-in a patient admitted to a psychiatric care unit, was a good learning experience and helpful to prepare students for situations they may experience in the workplace ( Masters et al., 2014 ). The third study used a high-fidelity, patient simulation (HFPS) to assess senior level nursing student knowledge and retention of knowledge utilizing three parallel, 30-item Elsevier Health Education Systems, Inc. (HESITM) Custom Exams. Although students’ knowledge did not improve following the HFPS experiences, the findings provided evidence that HFPS may improve knowledge in students who are at risk (defined as those earning less than 850 on HESI exam). Students reported that they viewed this simulation as a positive learning experience ( Kameg et al., 2013 ).

An additional intervention study used a quasi-experimental design to explore perceptions of student nurses toward nurses who are chemically dependent, using a two-group, pretest–posttest design (prior to formal education and after receiving substance abuse education). Results indicated that the student nurses in this study had positive perceptions about nurses who are chemically dependent before the intervention; and the education program appeared to reinforce their existing attitudes. ( Boulton & Nosek, 2014 ).

Mitchell et al. ( 2013 ) investigated the impact of an addiction training program for nurses consisting of Screening, Brief Intervention, and Referral to Treatment (SBIRT), and embedded within an undergraduate nursing curriculum, on students’ abilities to apply an evidence-based screening and brief intervention ap­proach for risky alcohol and drug use in their nursing practice. Results indicated that the SBIRT program was effective in changing the undergraduate nursing students’ self-perceptions of their knowledge, skills, and effectiveness in screening and intervening for hazardous alco­hol and drug use. Furthermore, this positive perception was maintained at 30-day follow-up ( Mitchell et al., 2013 ).

Luebbert and Popkess ( 2015 ) investigated the impact of an innovative, active-learning strategy using simulated, standardized patients on suicide assessment skills in a sample of 34 junior and senior baccalaureate nursing students. Additionally, Schwindt, McNelis, and Sharp ( 2014 ) evaluated a theory-based educational program to motivate nursing students to intervene with persons having serious mental illness. Other intervention studies among nursing students focused on improving students' interpersonal relationships; communication competence; empathetic skills; and confidence in performing mental health nursing skills among nursing students ( Choi, Song, & Oh, 2015 ; Choi & Won, 2013 ; Fiedler, Breitenstein, & Delaney 2012 ; Ozcan, Bilgin, & Eracar, 2011 ; Stiberg, Holand, Ostad, & Lorem, 2012 ).

Nursing staff and mental health professionals . Interventions among the nursing staff and mental health professionals accounted for nine of the nursing intervention studies. The majority of these studies were nursing interventions to educate the nursing staff. Educational interventions included: training videos ( Irvine et al., 2012 ); a continuing education course on suicide awareness ( Tsai, Lin, Chang, Yu,& Chou, 2011 ); an education program using simulation ( Usher et al., 2014 ; Wynn, 2011 ); an educational workshop ( White, Hemingway, & Stephenson, 2014 ); training on family-centered care ( Wong, 2014 ); and the impact of the completion of a 26-week trial on nursing staff’s experience for working as a cardio-metabolic health nurse ( Happell et al., 2014 ).

Terry and Cutter ( 2013 ) used a mixed methods pilot study to evaluate the effect of education on confidence in assessing and addressing physical health needs following attendance at a module titled “Physical Health Issues in Adult Mental Health Practice.” The majority of the participants had studied at the university during the previous five years, at either the diploma or the degree level. Results showed improvement in confidence scores for all study participants following the module; participants were able to identify new knowledge and perspectives for practice change.

Results indicated that care zoning increased the nursing team’s capacity to share information and to communicate patients’ clinical needs... Finally, the study conducted by Taylor and colleagues ( 2011 ) used a pragmatic approach to increase understanding of the clinical-risks needs in acute in-patient unit settings. Each patient was classified according to three zoning levels using a traffic light system: red (high level of risk), amber (medium/moderate level of risk), and green (low level of risk). The level of risk was based on multiple factors including clinical judgment and team discussion ( Taylor et al., 2011 ). Results indicated that care zoning increased the nursing team’s capacity to share information and to communicate patients’ clinical needs, as well as to enhance their abilities to address complex clinical presentation and to seek support when needed.

Intervention Domains

Ninety-two of the studies examined the effect of an intervention for the client. In the following section, we will describe the intervention domains of these 92 articles and provided examples. Additional detail is included in the Table .

Interventions in the Biological Domain Eight interventions were in the biological domain. Study interventions included yoga, dancing, diet, medication, electroconvulsive therapy (ECT), exercise, walking, and educational intervention on metabolic syndrome. Four interventions used various kinds of exercises, including walking ( Beebe, Smith, Davis, Roman, & Burke, 2012 ); dancing ( Emory, Silva, Christopher, Edwards, & Wahl, 2011 ); yoga ( Kinser, Bourguigion, Whaley, Hauenstein, & Taylor, 2013 ); and group exercise program ( Stanton, Donohue, Garnon, & Happell, 2015 ). Diet was also used as an intervention. For example, Lindseth, Helland, and Caspers ( 2015 ) used dietary intake of a high or low tryptophan diet as an intervention. Results indicated improvement in patients’ mood, depression, and anxiety for those consuming a high tryptophan diet as compared to those who consumed a low tryptophan diet ( Lindseth et al. 2015 ). A third category within the biological domain was the use of medications as an intervention. One study tested the use of different psychotropic medications for patients diagnosed with schizophrenia ( Zhou et al., 2014 ). A second used ECT as a treatment modality and measured scores on the Montgomery Asberg (MA) Depression Rating Scale before and after the course of treatment ( Pulia, Vaidya, Jayaram, Hayat, & Reti, 2013 ). A final category was an educational program on metabolic syndrome provided to mental health counselors who performed intake assessments on patients newly admitted to two outpatient mental health facilities. ( Arms, Bostic, & Cunningham, 2014 ). Prior to the intervention, neither facility screened for metabolic syndrome at intake or referred patients with a body mass index (BMI) >25 for medical evaluation. Following the intervention, 53 of 132 patients had a documented BMI >25, and 47 of 53 patients were referred to a primary care provider for evaluation. These findings suggested that screening for metabolic syndrome and associated illnesses will increase the rate of detection of chronic conditions ( Arms et al., 2014 ).

Interventions in the Psychological Domain ...the psychological domain had the largest number of intervention studies. Compared to the other domains, the psychological domain had the largest number of intervention studies. Twenty-four of the 92 total intervention studies extracted were in the psychological domain. The intervention studies in the psychological domain included emotion, behavior, and cognition (e.g., counseling) in addition to studies that focused on behavior therapy and psychoeducational programs. Examples of psychological domains studies included: counseling regarding tobacco cessation treatment ( Battaglia, Benson, Cook, & Prochazka, 2013 ); counseling regarding sexual assault ( Lawson, Munoz-Rojas, Gutman, & Siman, 2012 ); resourcefulness training intervention for relocated older adults ( Bekhet, Zauszniewski, & Matel-Anderson, 2012 ); and resilience training and cognitive therapy in women with symptoms of depression aged 18-22 years of age ( Zamirinejad, Hojjat, Golzari, Borjali, & Akaberi, 2014 ) Please see the Table for further details.

One study utilizing an intervention from the psychological domain examined a brief, six- session, cognitive-behavioral intervention among patients with alcohol dependence and depression. The researchers used a quasi-experimental design with a control group and pretest, posttest, and follow-up assessments. Results indicated that the mean depression scores decreased significantly in both the experimental (n = 33) and control groups (n = 27) at the one-month follow-up (Week 7). However, only the experimental group showed significant differences in their mean depression scores between pre- and posttest. At Week 7, the experimental group showed significantly lower mean depression scores than the control group ( Thapinta, Skulphan, & Kittrattanapaiboon, 2014 ).

Interventions in the Social Domain The social domain considers the patients’ environment and its impact on patients’ adjustment and responses to stress. Nine studies involved use of the social domain in their interventions. The social domain considers the patients’ environment and its impact on patients’ adjustment and responses to stress. Interventions in this domain included family, friends, and social support, as well as community interactions ( Zauszniewski et al., 2012 ). One example of an intervention in the social domain involved studying the long-term impact of safe shelter and justice services on abused women’s ability to function after receiving services ( Koci, 2014 ). Another example of an intervention study in the social domain was a pilot, randomized, controlled trial study by Simpson, Quigley, Henry, and Hall ( 2014 ). In this study, the researchers evaluated the selection, training, and support of a group of peer workers recruited to provide support to service users discharged from acute psychiatric unites in London, comparing peer support with usual care ( Simpson et al., 2014 ) (see Table ). A third example in the social domain was designed to help participants successfully transfer from hospitals to the community by enhancing staff participation, creating/maintaining supportive ward milieus, and supporting managers throughout the implementation process ( Forchuk et al., 2012 ).

The study conducted by Horgan, McCarthy, and Sweeny ( 2013 ) was another example of research in the social domain. This study included designing a website for people ages 18-24 who were experiencing depressive symptoms. The website provided a forum to allow participants to offer peer support to each other; it also provided information on depression and links to other supports ( Horgan et al., 2013 ).

Combinations of the Domains Many studies used more than one domain as interventions. Many studies used more than one domain as interventions (see Figure ). Almost half (49%) of the 92 reviewed studies (n = 45) tested an intervention that included two domains. Thirty studies were psychosocial, twelve were biopsychological, and three were biosocial. In addition, six studies (7%) tested intervention with all three domains (biopsychosocial). In the following section, one study from each combination will be described. Again, additional information is provided in the Table .

Figure. Psychiatric Nursing Interventions: Examples of Domains and Their Total Numbers

Iskhandar Shah and colleagues ( 2015 ) studied and tested an intervention from the biopsychological domain using a single-group, pretest–posttest, quasi-experimental research design. Their intervention program included three daily, one-hour sessions incorporating psychoeducation and virtual-reality-based relaxation practice in a convenience sample of twenty-two people with mental disorders. Results indicated that those who completed the program had significantly lowered subjective stress, depression, and anxiety, along with increased skin temperature, perceived relaxation, and knowledge ( Iskhandar Shah et al., 2015 ).

Pedersen, Nordaunet, Martinsen, Berget, and Braastad ( 2011 ) studied an intervention from the biosocial domain. Their intervention program tested the impact of a 12-week, farm-animal-assisted intervention consisting of work and contact with dairy cattle, on levels of anxiety and depression in a sample of fourteen adults diagnosed with clinical depression. The twice-a-week program involved video recording each participant twice during the intervention. Participants were given the choice of either choosing their work tasks with animals (e.g., milking, feeding, hand feeding, moving animals) or the choice of spending their time in contact with farm animals (e.g., patting, stroking, and other non-work-related physical contact). Results indicated that levels of anxiety and depression decreased, and self-efficacy increased during the intervention. Interaction with farm animals (social) via work tasks showed a greater potential for improved mental health than merely animal contact, but only when progress in working skills (biological aspect) was achieved, indicating the role of coping experiences for a successful intervention. ( Pedersen et al., 2011 ).

The NP often accompanied the participant to medical and mental health appointments... Chandler, Roberts, and Chiodo ( 2015 ) conducted a study in the psychosocial domain that examined the feasibility and potential efficacy of implementing a four-week, empower-resilience intervention (ERI) to build resilience capacity with young adults who have identified adverse childhood experiences. The intervention included using mindfulness-based stress reduction (psychological domain) and social support with guided peer and facilitator interaction (social domain). The study randomly assigned a purposive sample of female undergraduate students between the ages of 18 and 24 years of age into two groups: intervention (n = 17) and control (n = 11), and used a pretest–posttest design to compare symptoms, health behaviors, and resilience before and after the intervention program. Results indicated that subjects in the intervention group reported greater building of strengths, reframing resilience, and creating support connections as compared with the control group ( Chandler et al., 2015 ).

Interventions in the biopsychosocial domain include all three components (biological, psychological, and social). There were six studies that included all three domains in their interventions. Hanrahan, Solomon, and Hurford ( 2014 ) used a randomized controlled design to deliver a transitional care model (TCM) intervention to patients with serious mental illness who were transferring from hospital care to home. The intervention group (n = 20) received the TCM intervention delivered by a psychiatric nurse practitioner (NP) for 90 days post hospitalization and the control group (n = 20) received the usual care. The intervention by the nurse practitioner included helping the patients adapt to the home by focusing on managing problem behaviors and physical problems, managing risk factors to prevent further cognitive or emotional decline, promoting adherence to therapies, and integrating physical and mental care approaches. The NP often accompanied the participant to medical and mental health appointments to facilitate communication, translate information to specialty providers, and advocate for the participant ( Hanrahan et al., 2014 ).

Table. Research Classifications by Domains, Design, and Type of Data Used

  Discussion

Although substantial progress is being made to develop and test interventions for persons with psychiatric and mental health challenges and their families, there remains much work to be done. Nurse scientists and practitioners share a professional obligation to persons entrusted to their care, which includes providing the highest quality care grounded in solid empirical evidence ( Willis, Beeber, Mahoney, & Sharp, 2010 ). This review yields evidence for the continued dissemination of findings from intervention studies from 2011 through 2015. To perform the analysis reported here, we employed methods that were similar to those used for amassing information from the intervention studies in two previous reviews ( Zauszniewski et al., 2007 ; Zauszniewski et al., 2012 ) in order to facilitate comparisons over time.

... the continued publication of evidence from countries outside the United States remains important... During the review period (2011-2015), 57% of the published intervention studies took place in the United States (U.S.) while 43% were conducted outside the U.S. (i.e., internationally). These percentages compare with 72% and 54% of published U.S. intervention studies and 28% and 46% published international intervention studies in the 2000-2005 and 2006-2010 reviews, respectively. The somewhat lower percentages (28% and 46%) of international intervention studies within the current time frame (2011-2015) may indicate a need for more descriptive research to identify distinguishing characteristics of international populations and important phenomena that may be amenable to intervention prior to the systematic testing of interventions. However, the continued publication of evidence from countries outside the United States remains important for developing globally relevant interventions for psychiatric nursing practice.

...there have been dramatic increases through the years in the overall number of studies that have tested interventions that tap more than one domain. Of the 115 intervention studies from 2011 through 2015 found in the five journals, nurses, student nurses, nursing staff, or other mental health professionals were the intervention recipients in 23, representing 20% of the intervention studies. This percent is higher than the 14% reported in the previous review conducted from 2006 through 2010, indicating a slightly greater focus on testing interventions in mental health care professionals in recent years. Although the interventions tested in these populations are not focused directly on outcomes for clients with mental health issues, promoting or preserving the mental health of professional caregivers most certainly affects those for whom they provide care.

Analysis of published intervention studies in the 5-year interval from 2011 through 2015 revealed an increase in the number of studies of psychiatric patients or clients in the five selected journals. For this time frame, we found 92 intervention studies in comparison with 71 from 2006 through 2010 and 77 from 2000 through 2005, which reflect 5 and 6-year intervals respectively.

We also noted fewer intervention studies where all three domains were integrated within the intervention... Moreover, there have been dramatic increases through the years in the overall number of studies that have tested interventions that tap more than one domain. For example, 33% of intervention studies from 2011 through 2015 tested psychosocial interventions, compared to 17% in the previous review (2006-2010) and 12% in the one prior to that (2000-2005). In addition, 13% of the studies from 2011 through 2015 tested biopsychological interventions compared with 4% and 5% in the previous two reviews. However, there was a slightly lower percent of biosocial intervention studies, specifically 3% in comparison with 4% from 2000-2005 and 6% from 2006-2010. We also noted fewer intervention studies where all three domains were integrated within the intervention, specifically only 6% in comparison with 17% in the previous time frame (2006-2010). Yet, our review revealed a larger percent of biopsychosocial intervention studies than from the review conducted from 2000-2005 (1%). Despite the lower number of studies that integrated all three intervention domains, there was an overall trend toward testing interventions that were not restricted only to one domain, indicating increased attention toward more holistic interventions.

... the overall trend shows a lesser focus on testing interventions within a single domain over time... There were 41 intervention studies between 2011 and 2015 that focused solely on one domain. With the exception of the biological domain (9%), interventions within the psychological (26%) and social (10%) domains were fewer than in previous reviews. For example, there has been a clear downward trend in the percent of psychological intervention studies over time with 57% from 2000-2005 to 38% from 2006-2010 and 26% in this current review. Intervention studies within the social domain decreased from 17% in 2006-2010 to 10% in this review. Studies of interventions in the biological domain have fluctuated over time from 11% in 2000-2005 down to 1% from 2005-2010 and up to 9% in the review reported here. However, the overall trend shows a lesser focus on testing interventions within a single domain over time, pointing perhaps to a growing interest in determining effective interventions that are multifaceted and target multiple factors that affect a person’s health.

Implications: Research Needed

The mind and body do not function independently of each other; therefore, when considering the focus of nursing research, we need to target both systems. Nursing has as its foundation a holistic approach to patient care. At this point in our history as we build a knowledge base, a multifaceted approach is needed when planning nursing research. This study of nursing interventions in our research has explored the biological, psychological, and social domains. Studies in the biopsychosocial domain would benefit our knowledge base and improve the criteria for more accurate, evidence-based nursing interventions.

Medicine has increasingly focused on the mental health component of medical illnesses. Nursing research would be strengthened by focusing on the possibility of medical illness and its relationship to mental illness. This nursing research approach'‹ would support our holistic philosophy of care and increase our knowledge of the whole person. It would provide the best evidence-based approach to planning treatment. In addition, it would serve to increase the sphere of psychiatric nursing beyond the psychiatric unit in health care settings.

...an increase in multicultural studies is needed to further strengthen our evidenced based practice. Finally, an increase in multicultural studies is needed to further strengthen our evidenced based practice. The individual person is complex. Identified culture provides important information as to how patients view health and illness. This information is an important component when planning our evidenced based care and should not be isolated from the patient presentation.

Tracking the progress in intervention research relevant for psychiatric and mental health nursing practice is essential to identify evidence gaps. This current, systematic review of intervention studies published in the most accessible psychiatric and mental health nursing journals for practicing nurses, educators, and researchers in the United States has revealed a somewhat lower number of studies from outside the United States; a slightly greater focus on studies of nurses, nursing students, or other mental health professionals as compared with clients who receive their care or services; and a continued trend for testing interventions that captured more than one dimension. Tracking the progress in intervention research relevant for psychiatric and mental health nursing practice is essential to identify evidence gaps. Though substantial progress has been made through the years, there is still room to grow.

Abir K. Bekhet, PhD, RN, HSMI Email: [email protected]

Jaclene A. Zauszniewski, PhD, RN-BC, FAAN Email: [email protected]

Denise M. Matel-Anderson, APNP, RN Email: [email protected]

Jane Suresky, DNP, MSN Email: [email protected]

Mallory Stonehouse, MSN, RN Email: [email protected]

Arms, T., Bostic, T., & Cunningham, P. (2014). Educational intervention to increase detection of metabolic syndrome in patients at community mental health centers. Journal of Psychosocial Nursing & Mental Health Services, 52 (9), 32-36. doi:10.3928/02793695-20140703-01

Battaglia, C., Benson, S.L., Cook, P.F., & Prochazka, A. (2013). Building a tobacco cessation telehealth care management for veterans with posttraumatic stress disorder. Journal of the American Psychiatric Nurses Association , 19 (2), 78-91. doi:10.1177/1078390313483314

Beebe, L.H., Smith, K., Davis, J., Roman, M., & Burke, R. (2012). Meet me at the crossroads: Clinical research engages practitioners, educators, students, and patients. Perspectives in Psychiatric Care, 48 (2), 76-82. doi: 10.1111%2Fj.1744-6163.2011.00306.x

Bekhet, A.K., Zauszniewski, J.A., & Matel-Anderson, D.M. (2012). Resourcefulness training intervention: Assessing critical parameters from relocated older adults’ perspectives. Issues in Mental Health Nursing, 33 (7), 430-435. doi:10.3109/01612840.2012.664802

Boulton, M.A., & Nosek, L. (2014). How do nursing students perceive substance abusing nurses? Archives of Psychiatric Nursing, 28 (1), 29-34. doi:10.1016/j.apnu.2013.10.005

Chandler, G.E., Roberts, S.J., & Chiodo, L. (2015). Resilience intervention for young adults with adverse childhood experiences. The Journal of Psychiatric Nurses Association, 21 (6), 406-416. doi:10.1177/1078390315620609

Choi, Y., Song, E., & Oh, E. (2015). Effects of teaching communication skills using a video clip on a smart phone on communication competence and emotional intelligence in nursing students. Archives of Psychiatric Nursing, 29 (2), 90-95. doi:10.1016/j.apnu.2014.11.003

Choi, Y-J., & Won, M-R. (2013). A pilot study on effects of a group program using recreational therapy to improve interpersonal relationships for undergraduate nursing students. Archives of Psychiatric Nursing, 27 (1), 54-55. doi:10.1016/j.apnu.2012.08.002

Emory, S.L., Silva, S.G., Edwards, P.B., & Wahl, L.E. (2011). Stepping to stability and fall prevention in adult psychiatric patients. Issues in Mental Health Nursing, 49 (12), 30-36 doi:10.3928/02793695-20111102-01

Fiedler, R.A., Breitenstein, S., & Delaney, K. (2012). An assessment of students’ confidence in performing psychiatric mental health nursing skills: The impact of the clinical practicum experience. Journal of the American Psychiatric Nurses Association, 18 (4), 244-250. doi:10.1177/1078390312455218

Forchuk, C., Martin, M-L., Jensen, E., Ouseley, S., Sealy, P., Beal, G., … Sharkey, S. (2012). Integrating the transitional relationship model into clinical practice. Archives in Psychiatric Nursing, 26 (5), 374-381. doi:10.1111/j.1365-2850.2012.01956.x

Hanrahan, N.P., Solomon, P., & Hurford, M.O. (2014). A pilot randomized control trial: Testing a transitional care model for acute psychiatric conditions. Journal of the American Psychiatric Nurses Association , 20 (5), 315-327. doi:10.1177/1078390314552190

Happell, B., Hodgetts, D., Stanton, R., Millar, F., Phung, C.P., & Scott, D. (2014). Lessons learned from the trial of a cardiometabolic health nurse. Perspectives in Psychiatric Care, 50 (4), 1-9. doi:10.1111/ppc.12091

Happell, B., Moxham, L., &Platania-Phung, C. (2011). The impact of mental health nursing education on undergraduate nursing students’ attitudes to consumer participation. Issues in Mental Health Nursing, 32 (2), 108-113. doi:10.3109/01612840.2010.531519

Horgan, A., McCarthy, G., & Sweeny, J. (2013). An evaluation of an online peer support forum for university students with depressive symptoms. Archives of Psychiatric Nursing, 27 (2), 54-55. doi:10.1016/j.apnu.2012.12.00

Irvine, A.B., Billow, M.B., Eberhage, M.G., Seeley, J.R., McMahon, E., & Bourgeois, M. (2012). Mental illness training for licensed staff in long-term care. Issues in Mental Health Nursing, 33 (3), 181-194. doi: 10.3109/01612840.2011.639482

Iskhandar Shah, L.B., Torres, S., Kannusamy, P., Lee Chng, C.M., He, H-G., Klainin-Yobas, P. (2015). Efficacy of the virtual reality-based stress management program on stree-related variables in people with mood disorders: The feasibility of the study. Archives of Psychiatric Nursing, 29 (1), 6-13. doi:10.1016/j.apnu.2014.09.003

Kameg, K.M., Englert, N.C., Howard, V.M., & Perozzi, K.J. (2013). Fusion of psychiatric and medical high-fidelity patient simulation scenarios: Effect on nursing student knowledge, retention of knowledge, and perception. Issues in Mental Health Nursing, 34 (12), 892-900. doi:10.3109/01612840.2013.854543

Kane, C. (2015). The 2014 Scope and Standards of Practice for psychiatric mental health nursing: Key Updates. OJIN: The Online Journal of Issues in Nursing, 20 (1), Manuscript 1. doi:10.3912/OJIN.Vol20No01Man01

Kidd, L.I., Knisley, S.J. & Morgan, K.I. (2012). Effectiveness of a Second Life® simulation as a teaching strategy for undergraduate mental health nursing students. Journal of Psychosocial & Mental Health Services, 50 (7), 3-5. doi:10.3928/02793695-20120605-04

Kinser, P.A., Bourgugnon, C. Taylor, A.G., Steeves, R. (2013). "A feeling of connectedness": Perspectives on a gentle yoga interenvention for women with major depression. Issues in Mental Health Nursing, 34 (6), 402-211. doi:10.3109/01612840.2012.762959

Kinser, P.A., Bourguigion, C., Whaley, D., Hauenstein, E., & Taylor, A.G. (2013). Feasibility, acceptability, and effects of gentle Hatha yoga for women with major depression: Findings from a randomized controlled mixed-methods study. Archives of Psychiatric Nursing, 27 (3), 137-147. doi:10.1016/j.apnu.2013.01.003

Koci, A.F., Cesario, S., Nava, A., Liu, F., Montalvo-Liendo, N., & Zahed, H. (2014). Women’s functioning following an intervention for partner violence: New knowledge for clinical practice from a 7-year study. Issues in Mental Health Nursing, 35 (10), 745-755. doi:10.3109/01612840.2014.901450

Lawson, S.L., Munoz-Rojas, D., & Siman, M.N. (2012). Changing attitudes and perceptions of Hispanic men ages 18-25 about rape and rape prevention. Issues in Mental Health Nursing, 22 (12), 864-70. doi:10.3109/01612840.2012.728279

Lindseth, G., Helland, B., & Caspers, J. (2015). The effects of dietary tryptophan on affective disorders. Archives of Psychiatric Nursing, 29 (3), 102-107. doi:10.1016/j.apnu.2014.11.008

Luebbert, R., & Popkess, A. (2015). The influence of teaching method on performance of suicide assessment in baccalaureate nursing students. The Journal of American Psychiatric Nurses Association, 21 (2), 126-133. doi:10.1177/1078390315580096

Masters, J.C., Kane, M.G., & Pike, M.E. (2014). The suitcase simulation: An effective and inexpensive psychiatric nursing teaching activity. Journal of Psychosocial Nursing, 52 (8), 39-44. doi:10.3928/02793695-20140619-01

Mitchell, A.M., Puskar, K., Hagle, H., Gotham, H.J., Talcott, K.S., Terhorst, L., … Burns, H.K. (2013). Screening, brief intervention, and referral to treatment: Overview of and student satisfaction with an undergraduate addiction training program for nurses. Journal of Psychosocial Nursing & Mental Health Services, 51 (10), 29-37. doi:10.3928/02793695-20130628-01

Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implementation Science : IS , 10 , 53. doi:10.1186/s13012-015-0242-0

Ozcan, N.D., Bilgin, H., & Eracar, N. (2011). The use of expressive methods for developing empathetic skills. Issues in Mental Health Nursing, 32 (2), 131-136. doi:10.3109/01612840.2010.534575

Pedersen, I., Nordaunet, T., Martinsen, E.W., Berget, B., & Braastad, B.O. (2011). Farm animal-assisted intervention: Relationship between work and contact with farm animals and change in depression, anxiety, and self-efficacy among persons with clinical depression. Issues in Mental Health Nursing, 32 (8), 493-500. doi:10.3109/01612840.2011.566982

Proctor, E.K., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health, 36 (1), 24-34 doi:10.1007/s10488-008-0197-4

Pulia, K., Vaidya, P., Jayaram, G., Hayat, M., & Reti, I.M. (2013). ECT treatment outcomes following performance improvement changes. Journal of Psychosocial and Mental Health Services, 51 (11), 20-25. doi:10.3928/02793695-20130628-02

Riley, J.B., & Yearwood, E.L. (2012). The effect of a pedagogy of curriculum infusion on nursing student well-being and intent to improve the quality of nursing care. Achieves in Psychiatric Nursing, 26 (5), 364-63. doi:10.1016/j.apnu.2012.06.004

Schwindt, R.G., McNelis, A.M., & Sharp, D. (2014). Evaluation of a theory-based educational program to motivate nursing students to intervene with their seriously mentally ill clients who use tobacco. Archives of Psychiatric Nursing, 28 (4), 277-283. doi:10.1016/j.apnu.2014.04.003

Simpson, A., Quigley, J., Henry, S.J., & Hall, C. (2014). Evaluating the selection, training, and support of peer support workers in the United Kingdom. Journal of Psychosocial Nursing and Mental Health Services, 52 (1), 31-40. doi:10.3928/02793695-20131126-03

Sorensen, J. L., & Kosten, T. (2011). Developing the tools of implementation science in substance use disorders treatment: applications of the consolidated framework for implementation research. Psychology of Addictive Behaviors, 25 (2), 262-268. doi:10.1037/a0022765

Stanton, R., Donohue, T., Garnon, M., & Happell, B. (2015). Participation in and satisfaction with an exercise program for inpatient mental health consumers. Perspectives in Psychiatric Care, 52 (1), 62-67. doi:10.1111/ppc.12108

Stiberg, E., Holand, U., Olstad, R., & Lorem, G. (2012). Teaching care and cooperation with relatives: Video as a learning tool in mental health work . Issues in Mental Health Nursing, 33 (8). doi:10.3109/01612840.2012.687804

Taylor. K., Guy, S., Stewart, L., Ayling, M., Miller, G., Anthony, A., … Thomas, M. (2011). Care zoning a pragmatic approach to enhance the understanding of clinical needs as it relates to clinical risks in acute in-patient unit settings. Issues in Mental Health Nursing, 32 (5), 318-326. doi:10.3109/01612840.2011.559570

Terry, J. & Cutter, J. (2013). Does education improve mental health practitioners’ confidence in meeting the physical health needs of mental health service users? A mixed method pilot study. Issues in Mental Health , 34(4), 249-255. doi:10.3109/01612840.2012.740768

Thapinta, D., Skulphan, S., & Kittrattanapaiboon, P. (2014). Brief cognitive behavioral therapy for depression among patients with alcohol dependence in Thailand. Issues in Mental Health Nursing, 35( 9), 689-693. doi:10.3109/01612840.2014.917751

Tsai, W-P., Lin, L-Y., Chang, H-C., Yu, L-S., & Chou, M-C. (2011). The effects of the gatekeeper suicide-awareness program for nursing personnel. Perspectives in Psychiatric Care, 47 (3), 117-125. doi:10.1111/j.1744-6163.2010.00278

Usher, K., Park, T., Trueman, S., Redman-MacLaren, M., Casella, E., & Woods, C. (2014). An educational program for mental health nurses and community health workers from Pacific Island countries: Results from a pilot study . Issues in Mental Health Nursing, 35 (5), 337-343. doi:10.3109%2F01612840.2013.868963

White, J., Hemingway, S., & Stephenson, J. (2014). Training mental health nurses to assess the physical health needs of mental health service users: A pre- and post-test analysis. Perspectives in Psychiatric Care, 50( 4), 243-250. doi:10.1111/ppc.12048

Willis, D.G., Beeber, L., Mahoney, J., & Sharp, D. (2010). Strategies for advancing psychiatric-mental health nursing science relevant to practice. Perspectives from the American Psychiatric Nurses Association research council co-chairs. Contemporary Nurse, 34 (2), 135-139

Wong, O.L. (2014). Contextual barriers to the successful implementation of family-centered practice in mental health care: A Hong Kong study. Archives of Psychiatric Nursing, 28 (3), 197-199. doi:10.1016/j.apnu.2014.02.001

Wynn, S.D. (2011). Improving the quality of care of veterans with diabetes. Journal of Psychosocial Nursing & Mental Health Services, 49 (2), 38-43. doi:10.3928/02793695-20110111-01

Zamirinejad, S., Hojjat, SK., Golzari, M., Borjali, A., &Akaberi, A. (2014). Effectiveness of resilience training versus cognitive therapy on reduction of depression in female Iranian college students. Issues in Mental Health Nursing, 36 (6), 480-488. doi:10.3109/01612840.2013.879628

Zauszniewski, J.A, Bekhet, A., &Haberlein, S. (2012). A decade of published evidence for psychiatric and mental health nursing interventions. OJIN: The Online Journal of Issues in Nursing, 17 (3), doi:10.3912/OJIN.Vol17No03HirshPsy01

Zauszniewski, J., Suresky M.J., Bekhet, A., & Kidd, L. (May 14, 2007). Moving from Tradition to Evidence: A Review of Psychiatric Nursing Intervention Studies . Online Journal of Issues in Nursing 12 (2) doi:10.3912/OJIN.Vol12No02HirshPsy01

Zhou, F-C., Xiang, Y-T., Wang, C-Y., Dickerson, F., Kryenbuhl, J., Ungari, G.S., … Chiu, H.F.K. (2014). Predictive value of prospective memory for remission in first-episode schizophrenia. Perspectives in Psychiatric Care, 50 (2), 102-110. doi:10.1111/ppc.12027

May 31, 2018

DOI : 10.3912/OJIN.Vol23No02Man04

https://doi.org/10.3912/OJIN.Vol23No02Man04

Citation: Bekhet, A.K., Zauszniewski, J.A., Matel-Anderson, D.M., Suresky, M.J., Stonehouse, M., (May 31, 2018) "Evidence for Psychiatric and Mental Health Nursing Interventions: An Update (2011 through 2015)" OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 2, Manuscript 4.

• Article May 31, 2018 Advancing Scholarship through Translational Research: The Role of PhD and DNP Prepared Nurses Deborah E. Trautman, PhD, RN, FAAN; Shannon Idzik, DNP, CRNP, FAANP, FAAN; Margaret Hammersla, PhD, CRNP-A; Robert Rosseter, MBA, MS
• Article May 31, 2018 Connecting Translational Nurse Scientists Across the Nation—The Nurse Scientist-Translational Research Interest Group Elizabeth Gross Cohn, RN, NP, PhD, FAAN; Donna Jo McCloskey, RN, PhD, FAAN; Christine Tassone Kovner, PhD, RN, FAAN; Rachel Schiffman, RN, PhD, FAAN; Pamela H. Mitchell, RN, PhD, FAAN
• Article May 31, 2018 Translation Research in Practice: An Introduction Marita G. Titler, PhD, RN, FAAN

Mental Health Nursing

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Case Studies

Case 5: denise.

Denise, a 19-year-old woman, has been admitted informally to an acute mental health ward; this is Denise's first admission. Denise was being treated for depression by her GP; prior to her admission Denise attempted to kill herself by cutting her wrists. Subsequently a short admission was arranged with the aim of devising a comprehensive care package.

After speaking about the circumstances leading up to her suicide attempt Denise became increasingly tearful and distressed, and started demanding to see a doctor. After being told that the doctor was on their way and would arrive in about 10 minutes, Denise became angry demanding medication to calm her down; she then proceeded to run towards the ward's doors shouting that she wanted to go home. At that moment the doctor arrived on the ward and Denise also immediately calmed down.

During the assessment process Denise disclosed that being angry if she did not get her way was not unusual for her. She also mentioned that she felt awful after these bouts of anger. She described herself as a "terrible person who was out of control" and she just wanted to die. After assessing Denise the nurse started to formulate a plan of care.

(a) What type of psychological interventions would the nurse consider implementing?

Show Answer

• Build a collaborative and therapeutic relationship based on a person-centred approach.
• Normalise an individual's experiences of mental distress.
• Take a "strengths approach".
• Maintain safety and effectively manage challenging behaviours.
• Explore the individual's capacity to change.
• Modify thought processes – identify, challenge and replace negative thoughts.
• Focus on the individual controlling and regulating their behaviour – promoting and enhancing healthy ways of coping.
• Prevent social isolation and promote social functioning.
• Focus on relapse prevention – early warning signs and self-monitoring of symptoms.
• Signpost to self-help and relevant support groups.
• Therapeutically support recovery.

(b) Currently Denise has been admitted informally to the ward. Due to Denise's impulse control difficulties this may change. On this basis what does the nurse professionally need to know when managing Denise's legal status?

• Understand and apply current legislation in a way that protects Denise.
• Act in accordance with the law, relevant ethical and regulatory frameworks, and also take into account local protocols/policies.
• Respect and uphold Denise's rights
• Know when to actively share personal information with others when the interests of safety and protection override the need for confidentiality.

(c) Denise is subsequently diagnosed with a "borderline personality disorder". What other types of personality disorders are there?

• Cluster A – paranoid, schizoid and schizotypal.
• Cluster B – antisocial (type: dissocial), borderline (type: emotionally unstable), histrionic, and narcissistic (not included in types).
• Cluster C – avoidant (type: anxious), dependent, obsessive-compulsive (type: anankastic).
• paranoid – suspicious and excessively sensitive;
• schizoid – emotional coldness, little interest in other people;
• schizotypal – odd beliefs and unusual appearance;
• borderline – instability of mood, impulsive;
• histrionic – excessive attention seeking;
• narcissistic – grandiose and arrogant;
• antisocial – disregard of self and others;
• avoidant – feelings of inadequacy;
• dependent – submissive behaviour;
• 0bsessive-compulsive – a preoccupation with orderliness.

(d) What specific psychological interventions would the nurse deliver?

• boundary setting;
• promoting healthy ways of coping;
• motivational interviewing and pre-therapy work;
• delivering specific therapeutic approaches/therapies.

(e) How could the nurse learn from their experiences of working with Denise?

• identifying and describing the experiences;
• examining the experiences in depth and teasing out the key issues;
• critically processing the issues;
• learning from the experiences by implementing future actions that improve the nurse's practice.

Denise has now been on the ward for over 6 months. Each time discharge has been arranged Denise self-harms or threatens suicide. Denise has now agreed to go to a therapeutic community, a place has been secured and Denise is now engaging in pre-therapy work.

(a) What other treatments besides a therapeutic community are recommended for individuals diagnosed with a borderline personality disorder?

• cognitive behaviour therapy – group and individual;
• behavioural approaches;
• mentalisation-based approaches;
• dialectic behaviour therapy.

(b) While working with Denise the primary nurse has found the relationship at times to be quite stressful. What are the signs of stress?

• sleep problems;
• loss of appetite;
• difficulty concentrating;
• constantly feeling anxious;
• feeling irritable and/or angry;
• having repeating thoughts;
• avoiding certain situations and/or people;
• an increased use of alcohol;
• muscle tension.

(c) What strategies could the nurse use to manage their stress?

• engage in physical activity;
• engage in something that makes them laugh;
• learn relaxation and/or deep breathing techniques;
• take control of the situation;
• seek support and talk;
• problem solve;
• eat a healthily diet;
• drink plenty of water;
• be mindful.

(d) What process should be utilised as a way to support the primary nurse to improve their practice?

Correct answer: A common method of systematically reflecting on practice is through the clinical supervision, which is a formal activity where a clinical supervisor facilitates the nurse to reflect upon their practice and identify strategies that focus on improving their practice.

Consider Chapters 20, 34 and 37.

Print Answers | « Previous Case

• NICE Guidance
• Conditions and diseases
• Mental health, behavioural and neurodevelopmental conditions

Common mental health problems: identification and pathways to care

Clinical guideline [CG123] Published: 25 May 2011

This guideline has been stood down. All of the recommendations are now covered in other NICE guidelines, or are out of date and no longer relevant to clinical practice.

For guidance on common mental health problems, see our guidelines on:

• Depression in adults
• Depression in adults with a chronic physical health problem
• Depression in children and young people
• Generalised anxiety disorder and panic disorder in adults
• Obsessive-compulsive disorder and body dysmorphic disorder
• Social anxiety disorder

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• Published: 07 August 2024

Comparison of psychopathology, purpose in life and moral courage between nursing home and hospital healthcare workers during the COVID-19 pandemic

• Iván Echeverria 1 , 2 ,
• Lucía Bonet 1 , 2 ,
• Ana Benito 1 , 3 ,
• Javier López 4 ,
• Isabel Almodóvar-Fernández 1 , 5 ,
• Marc Peraire 1 , 2 &
• Gonzalo Haro 1 , 2  

Scientific Reports volume  14 , Article number:  18305 ( 2024 ) Cite this article

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• Health occupations

The COVID-19 pandemic deeply affected healthcare workers, although the impact may have differed according to different workplace contexts. The aim of this current research was to compare the psychopathology presented by hospital versus nursing home healthcare workers during the COVID-19 pandemic and to analyse the predictive role of purpose in life and moral courage in the appearance of psychopathology. This was an observational, cross-sectional study carried out on a sample of 108 healthcare workers, 54 each from a hospital or nursing homes, who were recruited during the 5 and 6th waves of the COVID-19 pandemic in Spain. Various self-reported scales were used to assess anxiety, depression, acute/post-traumatic stress disorder, drug and alcohol abuse, burnout, purpose in life, and moral courage. Compared to the hospital healthcare workers, nursing home healthcare workers had higher scores and a higher prevalence of anxiety (74.1% vs. 42%), depression (40.7% vs. 14.8%), and post-traumatic stress disorder (55.6% vs. 25.9). In the overall sample, purpose in life was a protective factor against psychopathology (OR = 0.54) and burnout (OR = 0.48); moral courage was a protective factor against depression (OR = 0.47) and acute stress (OR = 0.45); and exposure of family/friends to SARS-CoV-2 was a risk factor for acute stress (OR = 2.24), post-traumatic stress disorder (OR = 1.33), and higher burnout depersonalisation subscale scores (OR = 1.84). In conclusion, the increased presence of psychopathology in nursing home healthcare workers may be influenced by workplace and occupational contexts, personal factors such as exposure of family/friends to SARS-CoV-2, or internal dimensions such as purpose in life and moral courage. This knowledge could be useful for understanding how a future epidemic or pandemic might affect the mental health of healthcare workers in different labour contexts.

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Introduction.

On 31 December 2019, the Wuhan Municipal Health Commission (China) reported a cluster of pneumonia cases of unknown origin that were subsequently found to be caused by SARS-CoV-2, the virus responsible for the clinical picture referred to as COVID-19 1 . By the beginning of 2020, the emergency epidemiological crisis resulting from SARS-CoV-2 had overwhelmed Spanish medical resources 2 and so healthcare workers (HCWs) had to face the situation with a lack of personal protective equipment 3 . Consequently, up to 26% of all people infected with COVID-19 in Spain during the first wave were HCWs, as compared to around 9% in Italy 4 .

Multiple studies have analysed how the COVID-19 pandemic, as well as work-related factors such as professional category, exposure to an unknown virus, high infection rates, and staff shortages resulting in increased working hours and workload, impacted the mental health of HCWs 5 , 6 , 7 . Indeed, high levels of anxiety, depression, post-traumatic stress disorder (PTSD), and burnout, a dysfunctional response to prolonged work stress characterised by the appearance of emotional exhaustion, depersonalisation, and low personal fulfilment 8 , were reported in Spain 8 , 9 and worldwide 10 , 11 . In this regard, psychopathology has also been linked to the development of burnout 5 and vice versa 12 . However, fewer studies have explored whether the workplace environment itself (i.e., hospital versus extra-hospital contexts) can affect the appearance of psychopathology and burnout in HCWs.

A relevant example of the extra-hospital context is nursing homes, where HCWs not only had to deal with long work shifts, high workloads, and an elevated risk of contagion 13 , but also suffered from the high number of resident deaths, which amounted to more than 34,000 at the beginning of 2023 14 . This implies that a quarter of all people who died from COVID-19 in Spain were nursing home residents. As a result, nursing home HCWs were at greatest risk of suffering from psychopathology during this time 15 .

In addition to the previous extrinsic factors, various studies have also analysed whether intrinsic factors, such as existential or moral dimensions, are related to the development of psychopathology and burnout in HCWs.

One of these intrinsic dimensions is purpose in life (PIL), understood as the perception each individual has that their life has a purpose and value 16 . PIL is a long-standing concept that was first defined by Viktor Frankl after World War II, and is a key dimension of meaning in life, with both these concepts, in turn, being related to resilience 17 . Although the influence of PIL on psychopathology has been studied previously, high PIL scores were associated with lower levels of anxiety, depression, acute stress, and burnout among HCWs during the COVID-19 pandemic 8 , 18 .

In this context, another relevant dimension is moral courage (MC), understood as the ability to face danger or social disapproval when one is doing what they consider to be their duty 19 . The role of MC in mental health is complex because it is closely linked to other dimensions such as moral resilience or moral distress and can both protect against and also generate psychopathology. In this sense, the pandemic may have been a key source of moral distress, defined as the dissonance caused by the gap between the moral values of an individual and the behaviour they are ultimately able to perform because of the context 20 . Indeed, high MC was associated with a higher probability of suffering psychopathology during the COVID-19 pandemic 18 .

All these findings seem to indicate that to obtain a more complete view of the psychopathology caused by the pandemic, other influencing variables such as PIL, MC, burnout, and the workplace environment must be considered. However, very few studies have compared the presence of psychopathology and burnout in hospital and nursing home HCWs during the COVID-19 pandemic and none of them considered the roles that PIL and MC may have played in their occurrence.

The objective of this current study was to compare the presence of psychopathology and burnout in hospital and nursing home HCWs during the COVID-19 pandemic and to analyse the possible effects of PIL and MC in this context. We hypothesised that: (1) psychopathology and burnout would be higher in nursing home healthcare workers than in hospital healthcare workers; (2) purpose in life would be a protective factor and moral courage a risk factor for psychopathology and burnout both in nursing home and hospital healthcare workers.

Thus, this study aimed to improve our understanding of the mental health of HCWs in nursing homes during the COVID-19 pandemic, which has been under-researched in most studies. Furthermore, we hoped that analysing PIL and MC in special contexts such as a pandemic would deepen our understanding of the nature and effect of these factors.

Material and methods

Study design.

Given the research objective and exploratory nature of this work, we conducted a cross-sectional study following the STROBE guidelines for observational studies. Therefore, we limited the inclusion and exclusion criteria so that all participating HCWs had worked during the COVID-19 pandemic and spoke Spanish. G*Power software (v3.1.9.4) was used to estimate the required sample size, considering an expected effect size of d  = 0.55, an alpha of 5%, and beta of 20% for 2 groups, with an allocation ratio of 1. Hence, we estimated that an overall sample size of 84 or 88 would be required to perform sufficiently powered Student t or Mann–Whitney U tests, respectively.

Recruitment and participants

A convenience and snowball sampling strategy were used to recruit a total of 108 participants, thus ensuring the sample size was sufficient to analyse the variables of interest. The sample comprised 54 HCWs from the Consorcio Hospitalario Provincial de Castellón, the second largest hospital in the city, and another 54 HCWs from several Spanish nursing homes. The cohort included clinical staff ( n  = 75) such as nurses, nursing assistants, and doctors as well as non-clinical staff ( n  = 33), who were mainly administrative workers ( n  = 15), although social workers and cleaning staff, among others, were also included. We considered that both clinical and non-clinical staff had been frontline workers during the COVID-19 pandemic because there had been general uncertainty about which patients were infected, a lack of personal protective equipment, and a high risk of infection among all staff in both Spanish hospitals and nursing homes. The HCW sample from the Consorcio Hospitalario Provincial de Castellón was obtained from a previous study conducted between September and November 2021 8 , while the nursing home HCW data were collected between October 2021 and January 2022, with both periods falling between the 5 and 6 th waves of the COVID-19 pandemic in Spain.

Instruments and data collection

The questionnaires were provided to the HCWs from the Consorcio Hospitalario Provincial de Castellón both in paper and electronic formats between September and November 2021, and because of their multicentric nature, to nursing home HCWs only in an electronic format between October 2021 and January 2022. No differences were expected because the same surveys were sent in both cases. To avoid duplication or fraud with the online surveys, the first and last names of the participants and their work e-mails were collected and the surveyees were assigned an anonymous identification code. This information was encrypted in a separate database which only the principal investigator had access to.

Participants were required to sign their informed consent to participation before commencing the study. All the surveys were self-administered and had been previously validated for Spanish speakers. The questionnaires and methodology were similar to those used in previous studies 8 , 18 , 21 .

First, the participants completed a sociodemographic questionnaire that asked about their age, sex, religiosity, marital status, professional category, level of responsibility/role, contract type, time working in their current role, history of physical conditions or mental health disorders, COVID-19 vaccination status, and whether they smoked and the number of cigarettes they smoked.

Second, personal and family/friend exposure to SARS-CoV-2 was assessed using a questionnaire that had been previously employed during the COVID-19 pandemic 18 . PIL was evaluated using the Purpose in Life Test, a 20-item Likert scale test that scores, from 20 to 140, the extent to which each individual considers that their life has a purpose (reliability = 0.89; adequate factorial validity) 16 . This test comprises four dimensions (perception of meaning, experience of meaning, goals and tasks, destiny-freedom dialectic) and has a cut-off point (CP) score of 113, with those exceeding this considered to have a PIL. MC was analysed using the Moral Courage Scale for Physicians (MCSP), a 9-item dichotomous scale that scores, from 0 to 9, the ability of medical personnel or healthcare professionals to face disapproval when doing what they believe is their duty (reliability = 0.74; adequate factorial validity) 22 . The MCSP does not have a CP and higher scores indicate greater MC. The Professional Moral Courage Scale (PMCS), which comprises 12 dichotomous items with a maximum score of 12 (reliability = 0.81; adequate factorial validity) 23 , was also used to analyse MC.

Third, psychopathology and burnout were assessed using various measures described below. Total scores and dichotomous variables were calculated for these scales, and the participants were divided into those who scored above the CP of each scale, thus screening positive for the psychopathology, and those who did not. Anxiety was measured using the Beck Anxiety Inventory (BAI), a 21-item Likert scale with scores ranging from 0 to 63 and a CP of 8 (reliability = 0.90; adequate factorial, discriminant and criterion validity) 24 . Depression was assessed using the Beck Depression Inventory (BDI-II), also a 21-item Likert scale with a CP of 14 (reliability = 0.89; adequate factorial, convergent, discriminant, and criterion validity) 25 . Acute stress disorder was assessed using the Acute/Post-Traumatic Stress Disorder Scale (ETEA-PT), a 15-item Likert scale based on the DSM-5 criteria for these disorders with a CP of 9. An additional ETEA-PT item that asked whether symptoms had lasted more than one month was used to assess PTSD (reliability = 0.81) 18 . Drug abuse was tested employing the Drug Abuse Screening Test-10 (DAST-10), a 10-item dicotomic scale ranging from 0 to 10 with a CP of 1 (reliability = 0.89; proven predictive validity) 26 . Finally, alcohol abuse and problems related to alcohol use were assessed with the Alcohol Use Disorders Identification Test (AUDIT), a 10-item Likert scale ranging from 0 to 40 with a CP of 6 for women and 8 for men (reliability = 0.75; adequate criterion and predictive validity) 27 . The Maslach Burnout Inventory-Human Services Survey (MBI-HSS) was used to evaluate the presence of burnout and its subdimensions. This Likert scale consists of 22 items and comprises three dimensions: personal accomplishment, emotional exhaustion, and depersonalisation (reliability = 0.71, 0.85, and 0.58, respectively) 28 . The score of each subscale is calculated by summing its items and, because of the dimensional complexity of burnout, both the overall score and the scores of one or several subdimensions have been used in the academic literature. Thus, in this current work, the presence of burnout was defined as a high level of either emotional exhaustion (CP ≥ 27) or depersonalisation (CP ≥ 10) 29 .

In addition, a three-item Likert scale was administered to ask participants about their subjective opinion of the change in their mental health since the beginning of the COVID-19 pandemic. Finally, an overall psychopathology score was calculated by summing the absolute scores of each of the psychopathology scales (BAI + BDI + ETEA/TP + DAST-10 + AUDIT).

Data analysis

First, an exploratory (normality, independence, homoscedasticity, linearity, and non-collinearity) and descriptive study was undertaken. Second, to test hypothesis 1, sociodemographic characteristics, SARS-CoV-2 exposure, PIL, MC, psychopathology, and burnout were compared between the two study groups. Quantitative variables were evaluated using Student t and Mann–Whitney U tests (when the assumptions for the application of parametric tests were or were not met, respectively). Categorical variables were compared using Pearson chi-squared test. Third, to test hypothesis 2, generalized linear models and logistic regressions were created for the dependent variables, introducing personal or family/friend exposure to SARS-CoV-2, PIL, and PMCS as predictors. MCSP was excluded from the regression analyses because of collinearity problems with PMCS. Finally, the data were modeled using the PROCESS plugin (v3.4) for SPSS 30 to study the relationships between the most prominent variables in the regression models. Missing data were eliminated pairwise in each test or analysis.

Ethical considerations

The ethical principles set out in the Declaration of Helsinki and by the Council of Europe Convention were followed and the informed consent of all participants was obtained. Moreover, data confidentiality was guaranteed according to the General Data Protection Regulation (GDPR; 2018). This study was authorised by the Institutional Review Board (ref. A-15/04/20) and the Clinical Research Ethics Committee (ref. CEI20/068).

Participant sociodemographic characteristics

Regarding the sociodemographic characteristics of the participants, the median (Me) sample age was 41 years and 85.2% ( n  = 92) of the participants were women. Significantly more nursing home HCWs (81.5%; n  = 44) than hospital HCWs (52.8%; n  = 28) self-identified as religious (χ 2  = 9.97, p  = 0.002). In terms of professional category, there were significantly more nurses (38.9%; n  = 21) in the hospital sample than in the nursing home cohort (13%; n  = 7), while there were more nursing assistants (48.1%; n  = 26) in the nursing home group compared to the hospital group (13%; n  = 7) (χ 2  = 34.39, p  < 0.001). Doctors were only present in the sample from the hospital (25.9%; n  = 14). Significantly more nursing home HCWs included in the cohort (22.2%; n  = 12) occupied a position of responsibility compared to the hospital HCWs (7.4%; n  = 4) (χ 2  = 4.69, p  = 0.03). Nursing homes stood out because significantly more HCWs (55.6%; n  = 30) had worked in their current job for 1 to 10 years when compared to the hospital HCWs (23.1%; n  = 6) (χ 2  = 9.51, p  = 0.02). Finally, there were significantly more smokers in the nursing home sample (40.7%; n  = 22) than in the hospital group (16.7%; n  = 9) (χ 2  = 7.64, p  = 0.006) (Table 1 ).

Personal and family/friend exposure to SARS-CoV-2, purpose in life, and moral courage

Table 2 shows that there was significantly greater personal and family/friend exposure to SARS-CoV-2 in the nursing home group (Me = 4; interquartile range [IQR] = 3) than in the hospital group (Me = 2; IQR = 3.25) (Mann–Whitney U = 1,831.5, p  = 0.02). Likewise, the MCSP scale score was significantly higher in the nursing home group (Me = 9; IQR = 1) than in the hospital group (Me = 8; IQR = 2) (Mann–Whitney U = 1,667.5, p  = 0.009). Surprisingly, there were no differences in PIL between the two groups.

Psychopathological and burnout variables

Regarding the psychopathology results (Table 3 ), compared to hospital HCWs, more nursing home HCWs presented anxiety (74.1%; n  = 40 vs. 42%; n  = 21) (χ 2  = 11.01, p  =  < 0.001), depression (40.7%; n  = 22 vs. 14.8%; n  = 8) (χ 2  = 9.04, p  = 0.003), acute stress (70.4%; n  = 38 vs. 25.9%; n  = 14) (χ 2  = 21.36, p  < 0.001), PTSD (55.6%; n = 25 vs. 25.9%; n  = 14) (χ 2  = 9.02, p  = 0.003), and at least one mental health disorder (85.2%; n  = 46 vs. 56.3%; n  = 27) (χ 2  = 10.45, p  = 0.001).

Likewise, compared to hospital HCWs, nursing home HCWs also had higher scores on the BAI (Me = 14.5; IQR = 15.5 vs. Me = 6; IQR = 10.2) (Mann–Whitney U = 1,911.5, p  < 0.001), BDI-II (Me = 11.5; IQR = 11.2 vs. Me = 4; IQR = 10) (Mann–Whitney U = 2,073.5, p  < 0.001), and ETEA-PT scales (Me = 14; IQR = 10.2 vs. Me = 4; IQR = 7) (Mann–Whitney U = 2,443.0, p  < 0.001), as well as for overall psychopathology score (Me = 20; IQR = 26 vs. Me = 43; IQR = 33.5) (Mann–Whitney U = 1,892.5, p  < 0.001).

Finally, from the start of the COVID-19 pandemic, compared to hospital HCWs, more nursing home HCWs had perceived a worsening in their mental health (64.8%; n  = 35 vs. 35.8%, n  = 19), while more hospital HCWs than nursing home HCWs had perceived an improvement in their mental health status (20.1%; n  = 11 vs. 3.7%; n  = 2) (χ 2  = 11.863, p  = 0.003) (Table 3 ).

Generalized linear models, logistic regressions, and psychopathology data model

There were no differences in the predictors of psychopathology when nursing home and hospital HCWs were analysed separately, except in the case of personal and family/friend exposure to SARS-CoV-2, which could predict ETEA-TP in nursing home HCWs (β = 1.94; 95% CI [1.01, 3.73]; p  = 0.04) but not in hospital HCWs. Table 4 shows the generalized linear models and logistic regressions used to predict the appearance of a psychopathology or burnout in the overall study sample.

PIL could predict the scores for the BAI (OR = 0.80; 95% CI [0.72, 0.89]; p  < 0.001), BDI (OR = 0.77; 95% CI [0.70, 0.83]; p  < 0.001), and ETEA-PT scales (OR = 0.90; 95% CI [0.85, 0.96]; p  = 0.001), as well as PTSD (OR = 0.96; 95% CI [0.93, 0.98]; p  = 0.006) and the overall psychopathology score (OR = 0.54; 95% CI [0.44, 0.68]; p  < 0.001). In addition, PIL could also predict the overall MBI-HSS score (OR = 0.48; 95% CI [0.37, 0.61]; p  < 0.001), MBI-HSS emotional exhaustion (OR = 0.66; 95% CI [0.57, 0.77]; p  < 0.001), MBI-HSS depersonalisation (OR = 0.88; 95% CI [0.82, 0.93]; p  < 0.001), and MBI-HSS personal accomplishment (OR = 1.22; 95% CI [1.13, 1.32]; p  < 0.001) burnout subscale scores.

In turn, the MCSP could predict the scores on the BDI-II (OR = 0.47; 95% CI [0.23, 0.96]; p  = 0.04) and ETEA-TP (OR = 0.45; 95% CI [0.23, 0.87]; p  = 0.001) scales. Finally, personal and family/friend exposure to SARS-CoV-2 could predict PTSD (OR = 1.33; 95% CI [1.01, 1.75]; p  = 0.03), ETEA-TP (OR = 2.24; 95% CI [1.19, 4.21]; p  = 0.01), and MBI-HSS depersonalisation burnout subscale scores (OR = 1.84; 95% CI [1.06, 3.18]; p  = 0.02).

Given that PIL predicted both psychopathology and burnout in the linear regressions, we modelled these data to learn about the mutual interactions between these variables (Fig.  1 ). Thus, a reciprocal influence was found between PIL and psychopathology (B =  − 0.31; 95% CI [− 0.56, − 0.06]; p  = 0.01; B =  − 0.35; 95% CI [− 0.48, − 0.21]; p  < 0.001), PIL and burnout (B =  − 0.45; 95% CI [− 0.70, − 0.19]; p  < 0.001; B =  − 0.35; 95% CI [− 0.47, − 0.23]; p  < 0.001), and psychopathology and burnout (B = 0.44; 95% CI [0.25, 0.64]; p  < 0.001; B = 0.39; 95% CI [0.22, 0.56]; p  < 0.001).

Explanatory model of psychopathology, burnout, and purpose in life.

To the best of our knowledge, this is the first study to compare the appearance of psychopathology and burnout during the COVID-19 pandemic in nursing home and hospital HCWs, in addition to the predictive role of PIL and MC. Consistent with our first hypothesis, the prevalence of psychopathology was higher in nursing home HCWs than in hospital HCWs, as also previously reported in another Spanish study 15 . Furthermore, nursing home staff were more likely to have reported a deterioration in their mental health since the start of the pandemic. In this sense, professional category may have been one of the main reasons for these differences in psychopathology, because the nursing home cohort had included a higher percentage of nursing assistants. In fact, some studies have suggested that nursing assistants were one of the groups most affected by the COVID-19 pandemic 7 , 15 . Another reason may have been the high mortality rate (up to 50% of the deaths in the first wave) registered in Spanish nursing homes as a result of COVID-19 15 .

Although our hypothesis of a higher prevalence of burnout among nursing home HCWs was not supported, we demonstrated that burnout and psychopathology were closely related (Fig.  1 ). In fact, previous studies have shown that burnout can increase the prevalence of psychopathology 31 and vice versa 12 . However, some extrinsic factors such as personal and family/friend exposure to SARS-CoV-2 may have also played an important role in the appearance of psychopathology and burnout during the COVID-19 pandemic. In fact, this latter risk factor could predict acute stress and PTSD, as well as higher scores on the burnout depersonalisation subscale. Regarding this finding, a previous qualitative study indicated that nursing home HCWs said that one of their main concerns was the transmission of SARS-CoV-2 to their family and friends and that this worry was more stressful to them than contracting the virus themselves 32 . This fear may have led HCWs to feel trepidation when managing residents with COVID-19, which in turn, has been linked to a higher prevalence of PTSD and increased burnout depersonalisation subscale scores 33 , perhaps in response to a dissociative defense mechanism.

In addition to the extrinsic factors mentioned above, intrinsic dimensions such as PIL predicted both the occurrence of psychopathology and burnout, although MC only predicted psychopathology, thereby partially satisfying our second hypothesis. In line with both our second hypothesis and the results of previous studies 8 , 18 , we observed that high levels of PIL were associated with lower scores for anxiety, depression, acute stress, PTSD, and burnout. These findings could be explained by the fact that PIL is framed within logotherapy and the salutogenic approach to wellbeing 34 . Thus, a high PIL would endow people with greater resilience and coherence in stressful situations, while the opposite situation would be related to a greater likelihood of developing mental health disorders 18 , 35 . Indeed, a study in nursing home staff during the COVID-19 pandemic showed that low resilience was associated with higher levels of depression 36 .

In contrast to our hypothesis, MC predicted lower depression and acute stress scores in our cohort. Although MC has often been identified as a risk factor for psychopathology because of its association with the concept of ‘moral distress’, it may also be a protective factor against suffering moral distress and, in turn, psychopathology. This ‘double-edged sword’ effect depends on the ability of individuals to act in accordance with their moral expectations 37 , with a failure in being able to do so leading to psychopathology. This phenomenon is also related to the concept of ‘moral resilience’, which refers to the ability to maintain or restore one’s integrity in response to moral adversity. Indeed, moral resilience has been shown to moderate the relationship between exposure to potentially morally distressing events and moral distress and was correlated with lower anxiety and depression in HCWs during the COVID-19 pandemic 38 .

Considering all the above, different authors have proposed several measures to improve crisis management in nursing homes, including the development of personalised action protocols for each site or coordination teams in conjunction with local healthcare services 39 . These measures could reduce the number of deaths among older adults and therefore, reduce the overwhelming work-related situations faced by HCWs that could affect their mental health 40 . The simultaneous development of resources focused on the mental health of HCWs, such as psychological support teams, peer-to-peer programmes, or coping groups, is also recommended. These measures would be useful in the prevention and management of the psychopathology developed during health emergencies 20 , 41 . In this regard, future management policies should include the systematic and regular assessment of signs of mental disorders in HCWs 9 , 40 .

Finally, several limitations to this work should be highlighted. First, this was a cross-sectional study, meaning that no inferences regarding causality can be made. Second, since a convenience and snowball sampling strategy were used, the number of people requested to participate in this study and their response rate could not be quantified. Therefore, potential non-response bias or early versus late bias could not be analysed. Furthermore, because of the urgency of the situation caused by the COVID-19 pandemic, measures to mitigate potential common methodological biases could not be implemented. Third, although the hospital sample was drawn exclusively from Castellón, the nursing home sample was recruited from different regions of Spain, leading to a small time lag between the collection of data from the two sample cohorts. Nevertheless, the incidence of COVID-19 in Spain remained broadly the same during both periods and was unlikely to have affected the outcomes. Fourth, although we wanted to address the impact of the pandemic in a naturalistic way by including non-clinical staff, since they may have had less contact with COVID-19, they could be considered non-frontline workers and thus influence the results. Nonetheless, a post hoc analysis to assess the relationship between SARS-CoV-2 exposure and professional categories found no differences between them. Finally, the main study limitation was the differences in sociodemographic characteristics between the two groups, which calls into question the comparability of the groups and role these differences may have played as a significant factor contributing to the results. However, this was an exploratory study with a small sample size compared to the large number of variables studied, thereby leading us to conduct parsimonious analyses. Notwithstanding, it would be interesting to control for these sociodemographic variables in future work in order to discriminate their possible role as confounding variables in the development of psychopathology. Nevertheless, it is still worth highlighting that the variables predicting psychopathology and burnout were almost the same in both groups.

Taken together, these limitations compromise the ability of this work to elucidate the full extent of the influence of PIL and MC on psychopathology or to recommend psychological approaches including these dimensions. Thus, future studies should consider this exploratory work and its limitations when trying to determine the usefulness of PIL and MC as targets of psychological treatments designed to prevent psychopathology.

Conclusions

The greater presence of psychopathology (anxiety, depression, and post-traumatic stress disorder) in nursing home healthcare workers during the 5 to 6th waves of the COVID-19 pandemic in Spain raises the question of its multifactorial nature and biopsychosocial factors involved in its development.

Regarding extrinsic factors, workplace environment played a central role in the lives of healthcare workers during the pandemic and factors such as professional category may have been of great relevance in the development of mental disorders. Regarding the personal sphere, personal and family/friend exposure to SARS-CoV-2 also played an important role in the appearance of psychopathology. In turn, intrinsic factors including purpose in life or moral courage buffered the effects of nosological elements mentioned above.

Thus, the interaction between the different biological, psychological and social factors specific to each individual (some of which were related to the pandemic) helped configure a latent diathesis that could be activated by a stressor such as a pandemic, ultimately leading to psychopathology. In conclusion, the present research may be useful to start to understand how a future epidemic or pandemic might affect the mental health of healthcare workers in different work contexts and the role of purpose in life and moral courage in the development of psychopathology.

Data availability

The data supporting the results of this study are available upon request from the corresponding author. The data are not publicly available because they contain information that could compromise the privacy of research participants.

Abbreviations

Alcohol Use Disorders Identification Test

Beck Anxiety Inventory

Beck Depression Inventory

Drug Abuse Screening Test-10

Acute/Post-Traumatic Stress Disorder Scale

• Healthcare workers

Maslach Burnout Inventory-Human Services Survey

• Moral courage

Moral Courage Scale for Physicians

• Purpose in life

Professional Moral Courage Scale

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Conception and design of the work: Iván Echeverria, Ana Benito & Gonzalo Haro; Acquisition: Javier López & Isabel Almodóvar-Fernández; Analysis: Iván Echeverria, Lucia Bonet & Ana Benito; Interpretation of data: Iván Echeverria, Lucia Bonet & Ana Benito; Drafting the work: Iván Echeverria, Lucia Bonet; Final approval of the version: Iván Echeverria, Lucia Bonet, Ana Benito, Javier López, Isabel Almodóvar-Fernández, Marc Peraire & Gonzalo Haro. Agreement to be accountable for all aspects of the work are appropriately investigated and resolved: Iván Echeverria, Lucia Bonet, Ana Benito, Javier López, Isabel Almodóvar-Fernández, Marc Peraire & Gonzalo Haro.

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Exploring the therapeutic relationship through the reflective practice of nurses in acute mental health units: A qualitative study

Diana tolosa‐merlos.

1 Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona Spain

Antonio R. Moreno‐Poyato

2 Department of Public Health, Mental Health and Maternal and Child Health Nursing, Nursing School, Universitat de Barcelona, L'Hospitalet de Llobregat Spain

3 IMIM (Hospital del Mar Medical Research Institute), Barcelona Spain

Francesca González‐Palau

4 Hospital Santa Maria, Salut/Gestió de Serveis Sanitaris, Lleida Spain

Alonso Pérez‐Toribio

5 Unitat de Salut Mental de l'Hospitalet, Gerència Territorial Metropolitana Sud, Institut Català de la Salut, L'Hospitalet de Llobregat Spain

Georgina Casanova‐Garrigós

6 Department and Faculty of Nursing, Universitat Rovira i Virgili, Tortosa Spain

Pilar Delgado‐Hito

7 Department of Fundamental Care and Medical‐Surgical Nursing, Nursing School, Universitat de Barcelona, L'Hospitalet de Llobregat Spain

8 GRIN‐IDIBELL (Nursing Research Group‐ Bellvitge Biomedical Research Institute), L'Hospitalet de Llobregat Spain

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Aims and objectives

To explore the therapeutic relationship through the reflective practice of nurses in acute mental health units.

In mental health units, the therapeutic relationship is especially relevant for increasing the effectiveness of nursing interventions. Reflective practice is considered an essential aspect for improving nursing care.

Action and observation stages of a participatory action research project.

Data were collected through reflective diaries designed for the guided description and reflection of practice interactions related to the therapeutic relationship and content analysis was applied. A total of 152 nurses from 18 acute mental health units participated. The COREQ guidelines were used.

The results were classified into three categories as follows: (i) Nursing attitude as a core of the therapeutic relationship. For the nurses, the attitudinal component was key in the therapeutic relationship. (ii) Nursing practices that are essential to the therapeutic relationship. Nurses identified practices such as creating a conducive environment, using an appropriate verbal approach, offering help and working together with the patient as essential for establishing a therapeutic relationship in practice. (iii) Contextual factors affecting the therapeutic relationship. The nurses considered the patient's condition, the care dynamics of the unit and its regulations, as well as the structure and environment of the unit, as contextual factors involved the establishment of an adequate therapeutic relationship in daily clinical practice.

Conclusions

This study has provided knowledge of the importance and role of the nurses' attitude in the context of the nurse–patient therapeutic relationship based on the reflections of nurses in mental health units regarding their own practice.

Relevance to clinical practice

These findings help nurses to increase awareness and develop improvement strategies based on their own knowledge and day‐to‐day difficulties. Moreover, managers can evaluate strategies that promote motivation and facilitate the involvement of nurses to improve the therapeutic relationship with patients.

What does this paper contribute to the wider global clinical community?

• An in‐depth analysis of nurses' reflections regarding the aspects that underlie the therapeutic relationship in their clinical practice enables the nurses themselves to become aware and to develop strategies for improvement based on their own knowledge.
• Understanding and confirming how the attitudinal component is a key element for nurses in the practice of the therapeutic relationship allows managers to evaluate strategies that promote motivation and facilitate the involvement of nurses to improve their practice with patients.
• The results point to the need for further studies aimed at identifying and implementing strategies that facilitate mental health nurses to incorporate and improve attitudinal skills related to establishing the nurse–patient therapeutic relationship in clinical practice.

1. INTRODUCTION

The nursing discipline is defined as a significant, therapeutic and interpersonal process that acts in conjunction with other human processes that make health possible for individuals (Peplau, 1988 ). The relationship established between nurse and patient is therapeutic, regardless of the setting in which care is provided (Stevenson & Taylor, 2020 ). However, in the mental health unit setting, the therapeutic relationship is especially relevant to increase the effectiveness of any nursing intervention (McAndrew et al., 2014 ). Reflective practice is considered an essential aspect of improving nursing care and generating knowledge (Vaughan, 2017 ). This paper aims to deepen the knowledge of the therapeutic relationship based on the reflections of nurses regarding their practice, in the context of current challenges within the mental health acute care setting.

1.1. Background

Based on Peplau's model of interpersonal relationships by ( 1988 ), which is the most widely held theory in the mental health nursing community, many authors have based their models on person‐centred mental health nursing (Barker & Buchanan‐Barker, 2010 ; O'Brien, 2001 ; Scanlon, 2006 ). All of them identify the therapeutic relationship as the foundation of nursing practice and the pillar upon which mental health nursing has been built (McAllister et al., 2019 ; Moreno‐Poyato et al., 2016 ). The proper establishment of the nurse–patient therapeutic relationship is especially relevant to increase the effectiveness of any nursing intervention in acute psychiatric units (McAndrew et al., 2014 ).

The therapeutic relationship could be defined as a human exchange (Peplau, 1988 ) that is based on effective communication that favours the possibility for a person to help another person to improve their health condition, with the objective that, through such communication, the person will be able to develop interpersonal and problem‐solving skills (Forchuk et al., 1998 ). To this end, concepts such as understanding, interest, availability, individuality, authenticity, warmth, respect and self‐knowledge are basic pillars for the nurse (Moreno‐Poyato et al., 2016 ). The literature points out that mental health nurses seem to be knowledgeable of the importance of the therapeutic relationship in inpatient units; however, the reality of clinical practice leads us to believe that theoretical knowledge is not enough to create a good bond with patients (Moreno‐Poyato et al., 2016 ). In addition, the literature points out that for nurses, the implementation of the therapeutic relationship in the current context of mental health units has suffered a strong impact related to neoliberal policies, with increased management and a risk‐centred approach (Kingston & Greenwood, 2020 ). Thus, today's environments are chaotic, and nurses are committed to therapeutic work, yet they struggle to balance it with the new demands of management (Kingston & Greenwood, 2020 ). In addition, barriers such as lack of time, communication problems (Harris & Panozzo, 2019a ), the physical structures of the units, the ratios or the cultures of care are external factors that limit the therapeutic relationship (Tolosa‐Merlos et al., 2021 ). If nurses are unable to become aware of how they respond to time pressure, frustration or unclear care policies, there is a risk that these barriers will become entrenched, new ones will be created and the patient will perceive their actions as lacking care, presence or involvement (Harris & Panozzo, 2019b ). Thus, although nurses recognise the importance of self‐awareness and knowing how to recognise how their actions can impact the therapeutic relationship and the care provided to patients, they are also aware of the need for self‐awareness (Thomson et al., 2019 ), institutions and, in general, care policies should encourage nurses to be aware of interpersonal influences, as well as the desirability of providing a safe and supportive clinical environment for these relationships (Stevenson & Taylor, 2020 ).

From the patients' point of view, in the complex environment of inpatient units, their interactions with staff are central components to their satisfaction regarding their experience with admission (Molin et al., 2021 ). When staff spend time, engage in daily activities, and recognise patients as individuals, patients seem to find it easier to be physically and emotionally closer to each other and to themselves (Eldal et al., 2019 ; Moreno‐Poyato et al., 2021 ). However, this therapeutic commitment is not always met in practice, and interventions to improve participation are few and far between and ineffective (McAllister et al., 2021 ).

Thanks to the therapeutic relationship, nurses are in a key position to lead the development of customised interventions (Molin et al., 2021 ). However, there is a significant gap in the literature regarding improving the quality of the therapeutic relationship in acute mental health units (Hartley et al., 2020 ). The nursing profession is characterised by its ability to reflect on practice to improve care and provide more person‐centred care, which is why there is a need to increase the use of evidence‐based practice (Vaughan, 2017 ). In fact, reflective practice allows practitioners to learn from their experiences (Bulman & Schutz, 2013 ; Schön, 1987 ). When nurses are given time to reflect through guided reflection questions they are able to gain valuable insight into practice (Bolg et al., 2020 ); therefore, reflective practice helps nurses integrate their emotional response and practical experience into a better understanding of the care they provide, incorporating knowledge and applying theory (Vaughan, 2017 ). Thus, although the nurse–patient therapeutic relationship has been extensively studied, no studies to date provide knowledge on the establishment of the therapeutic relationship and its implications based on the reflection on the nurses' own practice. Consequently, knowing the meaning of the therapeutic relationship together with the elements that facilitate and hinder its implementation in the complex practice of current acute mental health units can be a starting point for both nurses and managers to become aware of the needs and for the design of strategies for improvement, suited to the reality of clinical practice.

In this regard, the aim of this study was to explore the phenomenon of the therapeutic relationship through the reflective practice of nurses in acute mental health units.

2.1. Design

This study is part of a multicentre mixed methods study involving 18 acute mental health units in Catalonia (Spain) (MiRTCIME.CAT). The principal aim of the project is to improve the nurse–patient therapeutic relationship through the implementation of evidence. The project was carried out following a sequential and transformational design. Quantitative methods were used based on a single‐group quasi‐experimental design with baseline and follow‐up measurements in phases I and III of the project. In the second phase, qualitative methodology was used. In its qualitative component, participatory action research (PAR) was proposed, framed within the constructivist paradigm and following the model by Kemmis and Mctaggart ( 2008 ). A two‐cycle process consisting of four stages each was designed to carry out the PAR. Specifically, this work corresponds to the action and observation stages of the first cycle. These stages are basic in the PAR process of change and make it possible to generate relevant knowledge regarding habitual practice (Cusack et al., 2018 ). In fact, it allows nurses to understand their practices as the product of particular circumstances and thus to identify the crucial aspects on which it may be possible to transform the practices they are carrying out (Kemmis & Mctaggart, 2008 ). The study is reported in line with the Consolidated criteria for reporting qualitative research guidelines (COREQ: Tong et al., 2007 ) (File S1 ).

2.2. Participants

All the acute mental health units that were part of the Catalan Mental Health Network ( n  = 21) were informed of the study. The principal investigator presented the research project and its objectives to the management of each centre through informative sessions. Finally, 18 units agreed to participate. A nurse from each unit joined the research team and this researcher was in charge of coordinating the study at their centre and recruiting the nurses from each unit. All nurses employed in the participating units ( n  = 235) were invited to participate in the study. The inclusion criteria for the participating nurses were belonging to the permanent or interim staff and being assigned to the acute unit at the time the intervention began. The following nurses were excluded from the study: nurses who were training to obtain ‘the official qualification of mental health nurse’, staff nurses who were scheduled to be on leave or maternity leave during the intervention. Thus, a convenience sample of 195 nurses agreed to participate in PAR, of which, ultimately 152 nurses completed the action and observation stages of the first part of this study.

2.3. Data collection

During a previous meeting among the entire research team, a guide was agreed upon so that the nurses could self‐observe their clinical practice in relation to the establishment of the therapeutic relationship. The research team sent the self‐observation guide by email to each nurse, along with a reflective diary in which the nurses were asked to record the self‐observation data (File S2 ). The diary was to include the description and reflection of three types of common interactions in their usual clinical practice: (a) a standard situation of welcoming a patient for admission, (b) an interaction in which there was a pre‐agitational state that required verbal de‐escalation and (c) an interaction whereby the patient is approached individually, promoted by the nurse and in the absence of any demand on behalf of the patient. The structure of the diary, together with the instructions for completion, pursued two purposes. First, to enable nurses to reflect on their starting assumptions, to understand their practice, to understand themselves and their patients, and, finally, to understand their profession (Price, 2017 ). Second, to monitor the process of change planned for the PAR, according to the proposals of Kemmis and Mctaggart ( 2008 ). In this sense, for each interaction, the nurses had to record the description of the situation, the type of verbal and nonverbal language they had used, their reflected intervention, their emotions during the interaction and, finally, a reflection on the influence of the environment on the interaction. Once the nurses had completed the diary, they sent it to the research team by e‐mail. The data were collected between April and June 2018.

2.4. Ethical considerations

This study was approved by the Research Ethics Committees of all the participating hospitals. The nurses participated on a voluntary basis, and all participants signed an informed consent form. Nurses did not receive any compensation or incentive for participating in the study. To maintain the confidentiality and anonymity of the data obtained, each nurse received an alphanumeric code that was incorporated into their diary. The diaries were sent to a generic e‐mail of the project that was only accessible to the principal investigator of the project, subsequently, the data were stored on a computer used exclusively for this study.

2.5. Data analysis

The content analysis method was used to analyse the data (Crowe et al., 2015 ). The diaries reached the first author and were coded to preserve the anonymity and confidentiality of the participants. Under their responsibility, the entire coding and categorisation process was carried out in a consensual manner by a collaborative team that formed the backbone of the process of developing a rigorous coding system (Merriam, 2016 ). In the first stage of analysis, the text was fragmented into descriptive codes assigned exclusively according to their semantic content. In a second stage, these initial codes were grouped into more analytical subcategories, which classified the codes according to the meaning of the linguistic units and their combinations. This led to a third hierarchical stage in which, considering the semantic analysis of the previous subcategories, the codes were ranked inductively. The first and second steps were taken iteratively until a more specific understanding of the subcategories was achieved. These steps were carried out primarily by the first author and discussed and reflected upon continuously and critically within the research team. Throughout the process, the QRS NVivo 12 program was used as computer support.

2.6. Rigour

Reflexivity was continuous throughout the process. Most of the researchers were experts in mental health, with training in qualitative methodology and experience in previous similar studies. As this was a multicentre study and a very large research team, neutrality was ensured as team members adopted an open attitude towards sharing, reasoning and discussing the findings as they emerged. In addition, the team became aware of its initial onto‐epistemological positioning, which was reflected in the design of the self‐observation guide for this stage of the process. As the research progressed, team members repeatedly contrasted the experiences identified in the participants' diaries with their own opinions. They asked follow‐up questions for the generation of new knowledge without guiding the participants' responses, so that this initial positioning could not influence the subsequent analysis. Similarly, the credibility and confirmability of the data should be emphasised, given the triangulation of the researchers in the analysis process and the constant auditing of the results by the participants in subsequent groups. In relation to the transferability of the results, in the case of this study, where participation is so high and from so many centres, it ensures that the results are valid for all units.

3. FINDINGS

The diaries of 152 nurses working at 18 centres were collected and analysed. The nurses ranged in age from 22 to 62 years, with a mean age of 33.6 years (SD = 9.4). Over 70% of the nurses were female. Their experience in mental health was a mean of 7.6 years (SD = 7.5). Almost a quarter of them had the official title of mental health nurse specialist and over 25% of the nurses had a doctoral or master's degree. All facility shifts were equally represented in the sample, although 40% of the nurses had rotating shifts or served on an as‐needed basis (Table ​ (Table1 1 ).

Participants' sociodemographic and professional characteristics ( n  = 152)

Data are shown as absolute number (percentage).

Abbreviation: MH, mental health.

The nurses, by describing and reflecting on their interactions with patients, expressed what the therapeutic relationship was for them and how it was carried out in their usual clinical practice. In this sense, three main categories were identified that responded to how they gave meaning to what the therapeutic relationship represented in practice and what limitations they identified in it (Figure ​ (Figure1 1 ).

Nurses' reflections on the practice of the therapeutic relationship in acute mental health units

3.1. Nursing attitude as a core of the therapeutic relationship

After reflecting on their practice, the nurses stated that attitude was a key element in establishing a quality therapeutic relationship with patients in the units. In this regard, they identified different attitudinal components. In the first place, the nurses considered the attitude of openness to the relationship. This meant being open and available, offering time, letting the patient talk and being attentive to the person's needs.

Patients are confused when they are first admitted and need the staff to listen to them and spend time with them. I always try to use an empathetic approach and be honest from the very beginning. I think it is very important for the patient to know that they can count on me, I try to convey that I am available if they need me. (01DR101)

However, they also identified that, in order to maintain this attitude, they had to be aware of barriers such as the presence of prejudice, the unavailability of other team members, the belief that the therapeutic relationship is useless, or lying to the patient.

The first contact already gives me the feeling that there may be a personality background, a victimizing attitude, excessively correct at times, totally inadequate at others, in spite of which I stay on track and treat him with the utmost respect. (10DR101). Certain users only perform certain actions to push you to the limit. (13DR103)

Secondly, they referred to the communicative attitude as another basic element in the therapeutic relationship. In this case, the nurses considered that special attention should be paid to both their verbal and nonverbal language when interacting with patients. In this sense, they pointed out the need to establish a dialogue with the patient by means of clear and concrete messages, with an appropriate tone and without shouting, as well as showing interest in the conversation, listening attentively, without showing tiredness or boredom, and adapting their distance and physical contact to each situation.

I try to be aware of my gestures, I avoid being invasive, respecting the safety distance with the patient at all times. Regarding verbal language, I use neutral terms, a friendly and calm tone of voice. (04DR115). In a polite but firm manner, I explain to the patient his situation and the alternatives I can offer him instead of smoking. The language is clear and concise, responding directly to what he asks. Saying NO if necessary, as sometimes vague answers upset the patient even more. (04DR104)

In addition, they considered it extremely important that, as caregivers, they should adapt to the other person, that is individualise the care they provide in the context of the therapeutic relationship. This implies considering the patient's psychopathological and emotional state at any given moment, as well as the patient's age, language or culture. This often meant postponing interviews, adapting language, using sign language to communicate, agreeing on a special type of diet, or even relaxing the rules and letting the patient make a call outside the usual hours.

I try to be flexible and adapt things as much as I can to the patient and his or her characteristics. (03DR109). Sometimes the stigma in mental health appears from the self‐stigma and the treatment that the mental health professional gives to patients. Personality is lost by prioritizing the disorder, people talk about the schizophrenic, the depressive, the BPD… obviating the fact that there is a person behind it all, with a context and a manner of understanding and living their life. (05DR104)

Finally, the nurses emphasised the role of their own emotional experience of caregiving. This meant having self‐confidence, feeling they were able to help the patient and do their job well, feeling satisfied with their work and remaining calm, at ease, and relaxed with the patient during their interventions. Nurses also identified emotions that, conversely, had a negative effect on the therapeutic relationship, such as feeling fear, insecurity, tension, patient rejection, grief, helplessness and frustration when the interventions had not been resolved as expected.

To feel fulfilled in my daily work (18DR101). Calm and confident, well supported by the team. Satisfied to have successfully completed an admission. (16DR112). Then I felt helpless, as I could not find a way to reverse the situation. (12DR111)

3.2. Essential nursing actions for the therapeutic relationship

This category refers to the nurses' reflections on their actions in the context of the therapeutic relationship with patients. In their diaries, the nurses were describing and reflecting on different interventions and activities that were carried out in their usual practice and they detected certain actions that were common to all of them.

First, the nurses pointed out the importance of generating an appropriate environment to build a bond and facilitate the relationship with the patients. A calm, intimate, comfortable, unhurried environment without external stimuli or interruptions.

The room is quiet with the door closed and without any interaction from the environment…A pleasant and silent environment favors the therapeutic relationship between the professional and the patient. (04DR110)

In relation to the establishment of a good therapeutic bond, the nurses agreed that the welcome provided on admission was a fundamental intervention. This was viewed as one of the situations in which the therapeutic relationship took on a greater relevance, since this first contact was considered the key to the success of the subsequent relationship with the patient.

Without welcoming the patient when he or she enters the unit, a better quality of the patient/professional relationship cannot be achieved. (01DR113)

Secondly, the nurses felt that the verbal approach was also a relevant aspect of their practice in the context of the therapeutic relationship. For them, it was an essential step in order to be able to carry out any intervention, such as when welcoming a patient when they are admitted to the unit, the use of verbal de‐escalation techniques to ease the tension with very demanding and uncooperative patients or, on the contrary, to approach isolated patients who hardly interact with the environment, although the use of words is not always as effective as they would like it to be.

Verbal containment is one of the most relevant parts of our work. In a pre‐agitation situation, we may be able to transition a patient from pre‐agitation to calmness or from pre‐agitation to psychomotor agitation. (09DR108)

In this sense, the nurses described that the act of offering the patient their assistance was at the heart of the therapeutic relationship. They stated that this action was carried out in the context of being present, listening or through agreement with the patient by proposing alternatives to the demands and needs that they cannot meet.

As he speaks I give him my support with non‐verbal language. I take his hand and he hugs me. I offer my help. We agree that he will make an effort to eat some solid food at dinner and that I will give him a supplement (he has it prescribed if he needs it). (01DR101)

The nurses also acknowledged that interventions such as mechanical restraint were sometimes the only measure to reduce stimuli or were implemented because of patient aggressiveness, risk of escape or even medical indication. However, the nurses reflected that, although this intervention was performed relatively often, it could be seen as a failure and a deterioration in the therapeutic relationship.

(…) avoid as much as possible the adoption of measures that restrict the mobility of the people under our care, since we are aware that this produces a significant deterioration of the therapeutic relationship, adding to the patient's mistrust and suspicion (…) (07DR105)

Finally, the nurses pointed to therapeutic work as another fundamental aspect of the therapeutic relationship. This meant working with the patient on positive reinforcement and other aspects such as pharmacological adherence, identification of symptoms or awareness of the disease, explaining the objectives of admission and the importance of asking for help, respecting the patient's decisions and involving the person in their care and recovery.

The attitude is one of interest, I keep an eye on her so that she doesn't get distracted and can talk calmly. I ask her what she thinks we can do for her to explore her expectations with the admission. (07DR101)

3.3. Contextual factors affecting the therapeutic relationship

The nurses identified contextual factors that facilitated or, on the contrary, acted as barriers to the therapeutic relationship. Indeed, they described that the type of admission could already condition the therapeutic bond, with voluntary admission being a facilitator. The same is true of other factors such as knowing the patient from previous admissions, and whether the patient remembers having a good experience in those previous admissions. However, the nurses also considered elements that are intrinsic to the patient, such as language, culture or bad experiences of previous admissions, as factors limiting the establishment of the therapeutic relationship.

He is open to help and agrees to the admission (03DR110). I must admit that the fact that I know the user from previous admissions has helped the situation to unfold smoothly. (14DR106)

Similarly, the nurses identified barriers that hindered or prevented the establishment and maintenance of a good therapeutic relationship, related to both the environment and the physical structures of the units. In this sense, the structural barriers were related to the lack of adequate spaces to carry out interventions with patients with the intimacy that the nurses considered necessary. Other environmental factors were noted, such as environmental noise and tension, the unpredictability of some patients, the presence of the family or the multiple interruptions were elements that added to the difficulty of the therapeutic relationship.

That afternoon the environment allowed me to dedicate some time to the patient, since there were no emergencies, other admissions, or complicated situations in the unit that required nursing intervention, apart from the "scheduled" or "usual" activities such as the control of vital signs, medication, etc. (03DR105)

Finally, the nurses also expressed how the regulations and care dynamics of the units also conditioned the therapeutic relationship in daily clinical practice. Thus, unit regulations were recurrently brought up by the nurses as a major barrier, due to the numerous limitations and prohibitions.

I explain the rules of the unit: no cell phones, no smoking, no entering other rooms, no belts, no glass objects, etc. and the established schedules… (10DR104)

Nonetheless, the greatest source of difficulties was the care dynamics at the unit, ranging from lack of time, high workload, administrative tasks, staff rotations or the night shift.

Even so, there are barriers that hinder the therapeutic relationship. Sometimes, our language is influenced by the tension in the unit, the lack of time, excessive administrative tasks, etc.… (01DR101)

4. DISCUSSION

This study aimed to explore the phenomenon of the therapeutic relationship from the reflective practice of nurses in acute mental health units. The nurses highlighted that attitude was the core aspect of the therapeutic relationship after reflecting on their practice. Similarly, they also reflected on the actions that were customary in the habitual interventions carried out in the context of the therapeutic relationship, identifying the most common barriers encountered in practice. Finally, the nurses reflected on those aspects of the context of care that conditioned the therapeutic relationship in the clinical practice of acute mental health units.

These findings offer knowledge about relational competence, a competency of professional nursing that is highly relevant in mental health (D'Antonio et al., 2014 ). This competence is directly linked to participation in practice and incorporates not only knowledge and skills, but also attitudes and professionalism that involve applying evidence and learning to practice (Casey et al., 2017 ; Moreno‐Poyato, Casanova‐Garrigos, et al., 2021 ). Specifically, the attitudinal component highlighted in the results and its importance in the context of the nurse–patient therapeutic relationship has been described from a theoretical perspective by authors such as Peplau or Orlando (Forchuk, 1991 ), Travelbee ( 1971 ) and Watson (Turkel et al., 2018 ). Similarly, the empirical literature has collected multiple studies that study the importance of nurses' attitudes towards more general aspects of mental health, such as stigma (Young & Calloway, 2021 ), recovery (Gyamfi et al., 2020 ), coercion (Doedens et al., 2020 ; Laukkanen et al., 2019 ) or severe mental disorder (Economou et al., 2019 ). However, there is hardly any empirical evidence that explicitly shows the relevance and identifies the specific attitudinal skills of nurses in the context of the practice of the therapeutic relationship. Thus, it is likely that the fact that the nurses were able to reflect on their practice made them more aware of the importance of attitude in the context of the therapeutic relationship (Harris & Panozzo, 2019a ), as they were able to respond to the real challenge of establishing an adequate therapeutic relationship in their day‐to‐day work in the acute mental health units (Choperena et al., 2019 ). Moreover, the attitudinal capacity identified by the nurses encompassed aspects already empirically recognised in the context of the therapeutic relationship, such as availability, communication and individualisation (Delaney & Johnson, 2014 ; Harris & Panozzo, 2019b ; McAllister et al., 2019 ; Moreno‐Poyato et al., 2016 ). However, the nurses also highlighted other aspects that have been less empirically studied, such as the importance of self‐confidence and self‐assurance, both in a positive way in order to be able to establish an appropriate therapeutic relationship, (Roche et al., 2011 ; Van Sant and Patterson, 2013 ) as well as negatively, in the form of limitation (O'Connor & Glover, 2017 ; Van Sant and Patterson, ). These results confirm the relevance of Peplau and Orlando's theoretical approaches and the use of the nurse's awareness as a fundamental part of the nursing relationship (Forchuk, 1991 ; Thomson et al., 2019 ).

The results indicate that by reflecting on their practice, the nurses were able to identify those skills (practices) that are essential for the development of the therapeutic relationship and which were transversal to any intervention. The nurses emphasised the importance of generating an adequate environment for the relationship, considering the environment not only as an element of context typical of many acute care units, but also as an element that is essential for the development of the therapeutic relationship (Kingston & Greenwood, 2020 ), also considering that it was their responsibility to be able to build the space where the relationship could take place (McAllister et al., 2021 ; Raphael et al., 2021 ). As in other studies, nurses also identified skills such as verbal engagement, offering help or working with the patient as basic practices for the development of effective interventions in the context of the relationship with their patients (Harris & Panozzo, 2019a ; McAllister et al., 2019 ; Molin et al., 2018 ). Furthermore, in relation to specific interventions, reflection on practice allowed nurses to identify and become aware of nursing admission assessment and mechanical restraint as two common interventions in mental health units that were particularly influential in the therapeutic relationship with the patients. In this sense, for the nurses, welcoming the patient on admission was considered an essential intervention determining a large part of the success in building the therapeutic relationship with the patients (Forchuk et al., 1998 ; Peplau, 1997 ). However, the use of mechanical restraint compromised the therapeutic relationship and the patient's trust (Kinner et al., 2017 ), although they understood that, even if this measure was undesirable, at times it was necessary (Doedens et al., 2020 ).

In addition, the nurses reflected on the contextual factors that directly affected the therapeutic relationship with the patients. In this sense, the nurses paid attention to patient aspects such as voluntariness or involuntariness regarding admission (Moreno‐Poyato, El Abidi, et al., 2021 ) or being previously acquainted with each other from previous admissions and the experience of the relationship (Van Sant and Patterson, 2013 ). The nurses also emphasised the role of the environmental and structural conditions of the units (Staniszewska et al., 2019 ), as well as the regulations and the dynamics of care that were automatically generated in the intense day‐to‐day routine of the units (Adler, 2020 ; Kingston & Greenwood, 2020 ).

4.1. Strengths and limitations

This study has several strengths and limitations. First, it should be noted that this project faced major challenges from a methodological point of view as well as during its execution. Initially, a research group had to be formed with representation of the institutions to assess the feasibility of the project. Next, a balanced team of researchers, consisting of methodologists and clinicians had to be assembled to ensure that the different stages of the research project could be completed. The team had to be formed in several initial working sessions and, subsequently, there was a process of constant mentoring by the principal investigator to the rest of the team. In addition, a considerable volume of data had to be managed. For management and storage, a secure on‐line space was created, guarded and accessed only by the principal investigator of the project. All data were collected electronically to facilitate the circuit. In relation to the analysis, a team was set up under the responsibility of a researcher. This team had to work in a collaborative and consensual manner. Regarding more specific limitations, it should be mentioned that the nurses' reflections in the diaries could be subject to the Hawthorne effect and their responses may have been biased by social desirability. In this sense, the research team insisted on the importance of honesty in the nurses' responses and on the team's handling of the confidentiality of the data. Secondly, another limitation inherent to the use of diaries is related to memory bias and the stress associated with reflective practice. In relation to this, the team recommended specific instructions, both verbally and through the guide provided to the nurses, to prevent this from occurring. Furthermore, the representativeness of the participating nurses and the number of diaries obtained should be highlighted as strengths of the study. These facts enable the findings of this study to be transferred to similar contexts.

5. CONCLUSIONS

The present study contributes to the understanding of the phenomenon of the therapeutic nurse–patient relationship by reflecting on the actual practice of nurses in acute mental health units. The attitudinal component is at the heart of the therapeutic relationship, and, in this sense, it is fundamental for nurses to believe in themselves and their attitude to communicate, adapt and open up to the relationship with the patient. In addition, there are actions that are essential for nurses to establish a TR in practice such as creating a conducive environment, using an appropriate verbal approach, offering help and working together with the patient. Finally, nurses should consider the patient's conditions, the dynamics of care and regulations of the unit, as well as the structure and environment of the unit, as contextual factors to be able to establish an adequate TR with patients in daily clinical practice.

6. RELEVANCE TO CLINICAL PRACTICE

These findings have important implications. The study findings demonstrate that participatory methods stimulate nurses' reflection, motivation and critical thinking. By learning from the reflection of the nurses themselves about the aspects that underlie the therapeutic relationship in their clinical practice, this enables the nurses themselves to become aware and to develop strategies for improvement based on their own knowledge. Moreover, the individual reflection involved in these first stages of a participatory process provides the nurses with an intrinsic knowledge of how they approach the therapeutic relationship and shows that the attitudinal component is basic for them. In this sense, understanding and confirming how the attitudinal component is a key element for nurses in the practice of the therapeutic relationship allows managers to evaluate strategies that promote motivation and facilitate the involvement of nurses in improving their practice with patients. Moreover, these results point to the need to conduct mixed or qualitative studies aimed at exploring the aspects that facilitate the motivation, empowerment and attitudinal training of nurses in greater depth, rather than studies that only seek improvements in the theoretical knowledge of the therapeutic relationship.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

AUTHOR CONTRIBUTIONS

Study design: ARMP and PDH; Data collection: APT, FGP and GCG; Data analysis team: DTM; Final report draft: DTM, ARMP and PDH; Supervision the process of data collection and analysis and provide support and feedback during all study phases: ARMP; Contribution of the manuscript, and read and approved the final manuscript: All authors.

Supporting information

Acknowledgements.

We would like to acknowledge all the participants of MiRTCIME.CAT project.

Tolosa‐Merlos, D. , Moreno‐Poyato, A. R. , González‐Palau, F. , Pérez‐Toribio, A. , Casanova‐Garrigós, G. , & Delgado‐Hito, P. ; MiRTCIME.CAT Working Group (2023). Exploring the therapeutic relationship through the reflective practice of nurses in acute mental health units: A qualitative study . Journal of Clinical Nursing , 32 , 253–263. 10.1111/jocn.16223 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

College of Nurses of Barcelona (PR‐218/2017)

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Study finds large gaps in mental health care for people with chronic pain

Millions of people with chronic pain fall into gaps in the mental health care system when it comes to treating symptoms of anxiety and depression, according to new research from the Comprehensive Center for Pain & Addiction.

A new University of Arizona Health Sciences study found that adults with chronic pain are more likely to experience symptoms of anxiety and depression than people without chronic pain, yet they access mental health care at lower rates and are less likely to have their mental health needs met in treatment. 

In 2021, approximately 51.6 million U.S. adults experienced chronic pain, according to the Centers for Disease Control and Prevention. The study showed that while people living with chronic pain represent 20.4% of the U.S. adult population, they make up an estimated 55.5% of U.S. adults with clinically significant anxiety and depression symptoms. 

“People living with chronic pain may form a distinct population with special mental health care needs,” said lead author Jennifer S. De La Rosa, PhD , strategy director for the U of A Health Sciences Comprehensive Center for Pain & Addiction , which funded the study. “Improving outcomes for people with chronic pain will include connecting more people to mental health care, as well as increasing the availability of mental health care that is responsive to their needs.” 

Jennifer De La Rosa, PhD, is the strategy director for the University of Arizona Health Sciences Comprehensive Center for Pain & Addiction and an assistant research professor at the College of Medicine – Tucson’s Department of Family and Community Medicine.

Photo by Noelle Haro-Gomez, U of A Health Sciences Office of Communications

The paper, “The unmet mental health needs of U.S. adults living with chronic pain,” was recently published in the journal PAIN .

This study builds on previous Comprehensive Center for Pain & Addiction research that found 1 in 20 U.S. adults have a combination of chronic pain and symptoms of anxiety or depression, and adults living with chronic pain are approximately five times more likely to have untreated symptoms of anxiety or depression compared to those not living with chronic pain.

The new study examined the degree to which people with chronic pain and mental health symptoms accessed and benefitted from mental health treatment. The research team analyzed data from 31,997 people who participated in the National Health Interview Survey, which has been identified as the best single source for the surveillance of chronic pain.

Researchers identified chronic pain-associated disparities in three areas: the need for mental health treatment; the use of mental health treatment; and the success of treating anxiety and depression symptoms when mental health treatment was used.

They found that 43.2% of U.S. adults living with chronic pain – approximately 21.5 million people – had a mental health need. By comparison, mental health care needs were identified in only 17.4% of U.S. adults who do not have chronic pain.

Among all U.S. adults with mental health treatment needs, chronic pain was associated with a 40.3% reduction in the odds of using mental health treatment.

“For those with chronic pain, the narrative about what needs to be done to address mental health is qualitatively different than for those who don’t have chronic pain,” said De La Rosa, who is an assistant research professor in the  U of A College of Medicine – Tucson’s Department of Family and Community Medicine . “Improving health care for people with chronic pain includes not only connecting people to care, but also addressing a disproportionate failure to achieve relief, even in the context of caregiving."

Researchers found that when mental health treatment is used, U.S. adults with chronic pain are more than twice as likely as others to experience continuing anxiety or depression symptoms.  

The study team found that only 44.4% of people with chronic pain, an estimated 9.5 million people, used mental health services and had their anxiety and depression symptoms adequately treated compared with 71.5% of those without chronic pain. When mental health treatment was used, U.S. adults with chronic pain are more than twice as likely as others to experience continuing anxiety or depression symptoms. 

People living with chronic pain represent 20.4% of the U.S. adult population, yet they make up an estimated 55.5% of U.S. adults with clinically significant anxiety and depression symptoms.

“There are many possible reasons an individual with chronic pain might have suboptimal mental health experiences, including the accessibility of care and the feasibility of attending appointments,” De La Rosa said. “Additionally, few mental health providers are trained in chronic pain, so only a small percentage of people living with chronic pain are likely receiving mental health treatment that is designed to address their needs. By further examining the role chronic pain plays in our national mental health crisis, we have a potentially transformative scientific and policy opportunity to build the United States health care system’s capacity to address co-occurring chronic pain and mental health challenges.”

“This study identified a significant gap in meeting the mental health needs of people who live with chronic pain,” said senior author  Todd Vanderah, PhD , director of the Comprehensive Center for Pain & Addiction, Regents Professor and head of the  Department of Pharmacology  in the U of A College of Medicine – Tucson and a BIO5 Institute member. “Our goal at the Comprehensive Center for Pain & Addiction is to use this information to reimagine and transform health care for chronic pain. By recognizing and treating the co-occurrence of anxiety and depression symptoms and chronic pain, we can empower millions of people affected by pain to thrive.”

Other co-authors from the Comprehensive Center for Pain & Addiction include Medical Director Mohab Ibrahim, MD, PhD , professor of  anesthesiology  at the College of Medicine – Tucson and director of the  Chronic Pain Management Clinic ; Policy Director Beth E. Meyerson, PhD, MDIV , professor of family and community medicine at the College of Medicine – Tucson; and members Alicia M. Allen, PhD , associate professor of family and community medicine at the College of Medicine – Tucson; Kyle Suhr, PhD , associate professor of psychiatry at the College of Medicine – Tucson; and  Benjamin R. Brady, DrPH . Other co-authors are doctoral student  Katherine E. Herder and  Jessica S. Wallace , a program evaluator in the College of Medicine – Tucson’s Department of Family and Community Medicine.

Jennifer S. De La Rosa, PhD     Assistant Research Professor, Department of Family and Community Medicine, College of Medicine – Tucson Strategy Director, Comprehensive Center for Pain & Addiction

Todd Vanderah, PhD Director, U of A Health Sciences Comprehensive Center for Pain & Addiction Regents Professor and Head, Department of Pharmacology, College of Medicine – Tucson Professor, Department of Anesthesiology, College of Medicine – Tucson Professor, Department of Neurology, College of Medicine – Tucson Member, BIO5 Institute

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Study shows millions of people live with co-occuring chronic pain and mental health symptoms

Phil Villarreal Uof A Health Sciences Office of Communications 520-403-1986, [email protected]

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Aug. 12, 2024

VCU School of Nursing duo secures funding for revision of maternal mental health screening tool

They are refining the language and elements of the Edinburgh Postnatal Depression Scale to make it more inclusive and less stigmatizing.

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By Caitlin Hanbury School of Nursing

A researcher and the interim dean of Virginia Commonwealth University’s  School of Nursing  have received $50,000 to support their revision of a notable screening tool for maternal mental health: the Edinburgh Postnatal Depression Scale.

The EPDS, a questionnaire that was developed in Scotland in the 1980s, has been a cornerstone worldwide in assessing perinatal mental health, with translations into over 60 languages. But research by  Sara Moyer , Ph.D., a clinical research coordinator and recent doctoral graduate at the School of Nursing, as well as feedback from expectant and new mothers highlighted the need for revisions to ensure that the tool more accurately resonates with American populations.

Moyer and her mentor,  Patricia Kinser , Ph.D., professor and interim dean of the School of Nursing, are leading  EPDS-US , an initiative to revise the tool for cultural and linguistic relevance. The effort aims to make the screening process more inclusive and less stigmatizing, ultimately encouraging a more open dialogue about mental health. It focuses on a more respectful and trauma-informed approach, adapting the tool’s language to reduce the feelings of shame and confusion reported by American users of the original EPDS.

Their work captured the attention of Sage Therapeutics, a biopharmaceutical company developing therapies for better brain health. It has awarded $50,000 to the EPDS-US team to conduct a nationwide evaluation of its updated tool. The team will gather input from a diverse group of participants across the U.S., as well as explore potential interest elsewhere in North America.

“The funding from Sage Therapeutics is critical for our next steps,” Moyer said. “It allows us to reach a broader audience and gather valuable feedback to ensure the EPDS-US meets the needs of all users.”

Moyer, whose career began in neonatal intensive care nursing, has long been attuned to the profound stressors faced by new parents. Her experiences in the field, combined with her personal journey as a mother, fueled her interest in advancing better tools to address perinatal mental health.

“Through my work as a nurse and researcher, I’ve seen firsthand how the original EPDS, despite its global impact, sometimes falls short in addressing the specific experiences of U.S. populations,” Moyer said. “Many patients have shared that the language used in the tool can be confusing, judgmental or misaligned with their realities. I believed that by updating the language, we could better support parents and improve conversations around mental health during and after pregnancy.”

Moyer, who continues to work in NICU care, centered her doctoral research on the challenges families face during early parenthood. Her conversations with pregnant and postpartum individuals revealed that existing mental health screening tools are too systematic and can contribute to missed diagnoses, inadequate follow-up and insufficient interactions with providers. Additionally, EPDS results may fail to clearly indicate the need for support, which can limit opportunities to assist those who are struggling but may not need extensive intervention.

Motivated by the insights and observations of her research subjects, Moyer set out to revise the language of the EPDS and test its efficacy. In addition to the updated language, the EPDS-US revision incorporates the “Additional Experiences Checklist,” an addendum that broadens the tool’s focus beyond postpartum depression to include a wider range of perinatal mental health experiences. The checklist is intended to facilitate more comprehensive and supportive clinical conversations about overall well-being and various stressors that new parents might encounter.

Moyer hopes that with a more respectful and inclusive screening process, stigma surrounding mental health will decline, with more new parents getting connected to resources as needed.

“Improving the EPDS-US is just one part of a larger effort to overhaul how we approach perinatal mental health,” Moyer said. “Our goal is to make a meaningful difference in how we support new mothers and parents, ensuring they feel respected and heard throughout their mental health journeys.”

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