WHAT IS KNOWN ON THE SUBJECT?: Psychiatric and/or mental health nurses are struggling to measure the outcomes of the nurse-patient relationship. Collecting nurse-sensitive patient outcomes is a strategy to provide outcomes of a nurse-patient relationship from patients\' perspectives. Because there was no validated scale, the Mental Health Nurse-Sensitive Patient Outcome-Scale (six-point Likert-scale) was recently developed and psychometrically evaluated. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study using the Mental Health Nurse-Sensitive Patient Outcome-scale to measure nurse-sensitive patient outcomes of the nurse-patient relationship in psychiatric hospitals. Moderate to good average scores for the MH-NURSE-POS total (4.42) and domains scores (≥4.09). are observed. Especially outcomes related to \'motivation\' to follow and stay committed to the treatment received high average scores (≥4.60). Our results are consistent with the patient-reported effect(s) of relation-based nursing in qualitative research. The scores generate evidence to support the outcomes of the nurse-patient relationship and implicates that further investment in (re)defining and elaborating nurse-patient relationships in mental healthcare is meaningful and justified. More comparative patient-reported data can determine how nurse-sensitive patient outcomes are affected by the patient, nurse, and context. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Demonstrating patient-reported outcomes of the nurse-patient relationship can be important to enhance the therapeutic alliance between nurses and patients, organize responsive nursing care, and create nursing visibility in mental healthcare. Further nursing staff training on interpersonal competencies, such as self-awareness and cultural sensitivity, can be pivotal to achieving the patient-reported outcomes for inpatients with mental health problems.
UNASSIGNED: INTRODUCTION: Identifying patient-reported outcomes of the nurse-patient relationship is a priority in inpatient mental healthcare to guide clinical decision-making and quality improvement initiatives. Moreover, demonstrating nurse-sensitive patient outcomes can be a strategy to avoid further erosion of the specialism of psychiatric and/or mental health nursing.
OBJECTIVE: To measure nurse-sensitive patient outcomes of the nurse-patient relationship.
METHODS: In a multicentred cross-sectional study, 296 inpatients admitted to five psychiatric hospitals completed the recently developed and validated Mental Health Nurse-Sensitive Patient Outcome-Scale (MH-NURSE-POS). The MH-NURSE-POS consists of 21 items (six-point Likert-scale) in four domains: \'growth\', \'expression\', \'control\', and \'motivation\'.
RESULTS: Participants displayed moderate to good average scores for the MH-NURSE-POS total (4.42) and domain scores (≥4.09). Especially outcomes related to \'motivation\' to follow and stay committed to the treatment received high average scores (≥4.60).
CONCLUSIONS: The results demonstrate that patients perceive the nurse-patient relationship and the care given by psychiatric and/or mental health nurses as contributing to their treatment.
UNASSIGNED: Patient-reported outcomes can guide nurses and managers to provide and organize nursing care and to build a nurse-patient relationship that has a positive impact on these outcomes. Additionally, outcomes can create nursing visibility as a profession in- and outside mental healthcare.

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

For undergraduate nursing students, an integral mode of learning is their clinical placements. Learning within the clinical setting is influenced by factors such as the facilitators, peers, unit, or department the student is placed on. What is not known is the role of a social context that is grounded in Self-Determination Theory and how this influences the development of therapeutic relationship skills among undergraduate nursing students. The aim of this study was to examine the role of autonomy support in the professional learning of undergraduate nursing students. This study employed a two-group pre-test and post-test design, with undergraduate nursing students placed in either an autonomy-supportive group or a comparison group in an Australian context. Therapeutic relationship skills were assessed at the beginning and end of their compulsory mental health clinical placement. Participants were 210 (n = 210) Australian undergraduate nursing students. Using a tertile split, 140 students were placed into one of two groups based on their perception of autonomy support at the post-test time point. Pre- and post-test therapeutic relationship data were collected for both groups. A repeated measures analysis of variance was used to examine whether engagement in different clinical placements would illicit significant differences in therapeutic relationship skills. Undergraduate nursing students who were engaged in the autonomy-supportive setting had significantly higher scores associated with the therapeutic relationship subscales: Positive Collaboration and Positive Clinical Input. The importance of the social context is underscored, which is strongly influenced by the educational leader, typically referred to as a nurse facilitator.

OBJECTIVE: To explore how nurses influence the perceptions and experience of safety among consumers who have been admitted to an acute mental health unit.
BACKGROUND: Safety is a priority in acute mental health inpatient units, yet consumers do not always experience acute units as safe. Despite being primary stakeholders, little is known about what safety means for consumers in acute mental health units.
METHODS: A qualitative descriptive study informed by naturalistic enquiry was conducted and is reported using the COREQ checklist.
METHODS: Fifteen consumers with experience of mental illness participated in semi-structured individual interviews. These interviews explored what safety meant for them during their acute mental health unit admissions. Thematic analysis was used to analyse the data.
RESULTS: The theme Influence of Nurses reflected that the way nurses engaged in acute mental health units had a profound impact on participants\' sense of safety. Three sub-themes emerged as follows: (a) Availability: \"It\'s about nurses spending time with you\"; (b) Being responsive: \"They would listen if you had a concern\"; and (c) Caring: \"Little acts of kindness.\"
CONCLUSIONS: These findings challenge the dominant discourse around safety in mental health organisations, in which nursing practice is often oriented towards the management of risk, rather than the promotion of safety. The findings demonstrate that, through their clinical practice, nurses can enhance consumers\' feelings of safety in the acute mental health unit.
CONCLUSIONS: Nurses play a key role in providing care within acute mental health units. It is vital that the behaviours and actions nurses can enact in order to promote feelings of safety among consumers in this setting are enabled at individual, unit and organisational levels.

WHAT IS KNOWN ON THE SUBJECT?: Empathy is one of the main attributes for establishing the nurse-patient therapeutic relationship. Davis (1983) identified four components on an empathic response: perspective taking, fantasy, empathetic concern and personal distress. It is essential to deepen our knowledge on the influence of the dimensions of empathy for the construction and development of the therapeutic alliance during the different phases of the therapeutic relationship. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: A significant association exists between the dimensions of empathy and the construction and development of the therapeutic alliance during the different phases of the therapeutic relationship between nurses and patients in mental health units. This study shows that the nurses\' perspective on the patient\'s situation improves the bond, and therefore, this skill is especially useful in the first phase or orientation phase of the therapeutic relationship. However, for the second phase or working phase of the therapeutic relationship, a greater empathic concern among nurses, together with less personal distress, improves collaborative goal setting with patients. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is important for mental health nurses to be aware of the importance of personal self-awareness and the emotional management of empathy for the construction and development of therapeutic relationships of quality with patients. Knowledge of the relationship between each of the dimensions of empathy in the different stages of the therapeutic relationship is useful for the design of educational programmes, by including training on empathic strategies. ABSTRACT: Introduction Empathy and its dimensions (perspective taking, empathic concern, personal distress and fantasy) are essential for establishing the nurse-patient therapeutic relationship. It is important to know how this influences the construction and development of the therapeutic alliance during the different phases of the therapeutic relationship. Aim To examine whether the dimensions of empathy influence the nurse-patient therapeutic relationship within mental health units. Method A cross-sectional design was used to collect data to measure the therapeutic alliance and the different dimensions of empathy via an online form completed by nurses working at 18 mental health units. Linear regressions were used in the analysis. Results A total of 198 participants completed the questionnaires. Nurses established a greater therapeutic alliance with patients when they were able to adopt their patient\'s perspective and experience concern. Discussion Nurses\' perspective taking is an influential factor impacting the nurse-patient bond in the orientation phase, whereas experiencing greater concern and decreased emotional distress were associated with improved therapeutic alliance in the working phase. Implications for practice These findings may help gain awareness among nurses of the importance of empathy in the nurse-patient relationships, as well as inform educational programmes, by including training in empathic strategies and emotional management.

Involving mental health service users in planning and reviewing their care can help personalised care focused on recovery, with the aim of developing goals specific to the individual and designed to maximise achievements and social integration. We aimed to ascertain the views of service users, carers and staff in acute inpatient wards on factors that facilitated or acted as barriers to collaborative, recovery-focused care.
A cross-national comparative mixed-methods study involving 19 mental health wards in six service provider sites in England and Wales. This included a survey using established standardised measures of service users (n = 301) and staff (n = 290) and embedded case studies involving interviews with staff, service users and carers (n = 76). Quantitative and qualitative data were analysed within and across sites using descriptive and inferential statistics, and framework method.
For service users, when recovery-oriented focus was high, the quality of care was rated highly, as was the quality of therapeutic relationships. For staff, there was a moderate correlation between recovery orientation and quality of therapeutic relationships, with considerable variability. Staff members rated the quality of therapeutic relationships higher than service users did. Staff accounts of routine collaboration contrasted with a more mixed picture in service user accounts. Definitions and understandings of recovery varied, as did views of hospital care in promoting recovery. Managing risk was a central issue for staff, and service users were aware of measures taken to keep them safe, although their involvement in discussions was less apparent.
There is positive practice within acute inpatient wards, with evidence of commitment to safe, respectful, compassionate care. Recovery ideas were evident but there remained ambivalence on their relevance to inpatient care. Service users were aware of efforts taken to keep them safe, but despite measures described by staff, they did not feel routinely involved in care planning or risk management decisions. Research on increasing therapeutic contact time, shared decision making in risk assessment and using recovery focused tools could further promote personalised and recovery-focused care planning. This paper arises from a larger study published by National Institute for Health Research (Simpson A, et al, Health Serv Deliv Res 5(26), 2017).

UNASSIGNED: Analysis of co-production in mental health and specifically Recovery Colleges has not previously considered the impact on clinicians and their clinical practice. Co-production as a concept is open to multiple interpretations. Core components of co-produced work are as follows: a focus on assets, mutuality, peer support and the use of a facilitative approach. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Senior clinicians who have chosen to become Practitioner Trainers describe the experience of collaboration with service users in an educational rather than clinical context. Working together in this educational environment led to some shifts in their perceptions of professional power and authority, in some cases leading to personal disclosures about their mental health. This study suggests the mechanisms by which co-production may transform professional practice: being in an educational rather than clinical context, the experience of being supported, the challenge of negotiating multiple roles (including that of being a colleague to someone with mental health needs) and experiencing a gradual shift of role emphasis as co-trainer relationships develop. The practical challenge of holding a simultaneous role as clinician for and co-trainer with Peer Trainers has been articulated, with the caveat that mental health support may be a feature of collegiate as well as clinical roles. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Being a Practitioner Trainer could be a professionally transformative experience. Ground rules for how to support colleagues\' mental health needs should be established and refined during co-produced working. Negotiating personal disclosure and professional role identity must be explored further in both co-production research and practice.
UNASSIGNED: Introduction Co-production between service users and clinicians is a desirable element of recovery-oriented practice in mental health, but the effect of co-production on clinicians has not been explored thoroughly. Aim To explore the meaning of co-production for clinicians based on their experience of co-production in a Recovery College. Method Thematic analysis of eight semi-structured interviews with clinicians who have co-produced and co-delivered workshops with a Recovery College Peer Trainer. Results The \"meaning of co-production\" had four themes: definitions, power dynamics, negotiating roles and influence on practice. Clinicians\' experience of co-production meant a reassessment of their expert role and power. They said that this altered their clinical practice, particularly the language they used and the personal information they shared. Discussion Role negotiation between Practitioner and Peer Trainers is an iterative process, whereby clinicians may revise their perspectives on personal disclosure, professional identity and collegiate support. The Peer and Practitioner Trainer relationship is characterized by reciprocity and mutuality, and there is some evidence that Practitioner involvement in a co-produced activity has the potential to transform service user and provider relationships beyond the Recovery College setting. Implications for practice Engaging in co-produced educational workshops can alter clinicians\' perspectives on roles, power and clinical expertise. Findings from this case study must be tested against research on other Recovery Colleges.

OBJECTIVE: To describe what and why nurses self-disclose to patients in mental health care.
BACKGROUND: Self-disclosure is common, but controversial and difficult to delineate. Extant research suggests that self-disclosure might have several potentially beneficial effects on therapeutic alliance and treatment outcome for patients in mental health care, but results are often mixed and limited by definitional inconsistencies.
METHODS: Multi-site study with purposive sampling and source triangulation.
METHODS: Qualitative descriptive study including data from 16 nurses taking part in participant observation, individual interviews and focus group interviews.
RESULTS: Separate analyses resulted in four themes addressing the research question of what nurses self-disclose, and one main theme and four subthemes addressing why nurses self-disclose. The content of self-disclosure was captured in the four themes: Immediate family, Interests and activities, Life experiences and Identity. In addition, results showed that disclosures were common among the nurses. Self-disclosure\'s potential to transform the nurse-patient relationship, making it more open, honest, close, reciprocal and equal, was the overarching reason why nurses shared personal information. The nurses also chose to self-disclose to share existential and everyday sentiments, to give real-life advice, because it felt natural and responsive to patients\' question to do so.
CONCLUSIONS: Nurse self-disclosure is common and cover a variety of personal information. Nurses have several reasons for choosing to self-disclose, most of which are connected to improving the nurse-patient relationship.
CONCLUSIONS: Self-disclosure controversy can make it difficult for nurses to know whether they should share personal information or not. Insights into the diversity of and reasons for nurse self-disclosure can help with deliberations on self-disclosure.

OBJECTIVE: The aim of this study was to understand the context of the inpatient setting for the treatment of anorexia nervosa and the implications for the therapeutic alliance between nurses and consumers.
BACKGROUND: The nature of the therapeutic alliance is dependent on the contextual factors that influence interactions. The inpatient setting for the treatment of anorexia nervosa is one such setting where the therapeutic alliance is operative, yet challenging and poorly understood.
METHODS: A two-phase explanatory sequential design was employed. Descriptive statistics from phase one informed phase two interviews. Phase two data were analysed through thematic analysis.
METHODS: A convenience sample of nurses and consumers were recruited from six wards, in five hospitals. Phase one involved the completion of a survey (N = 128) that measured the strength of the therapeutic alliance, as well as other elements of ward context. Phase two interviews (N = 54) were focused on the therapeutic alliance between nurses and consumers and the implications of the inpatient setting. Data collection occurred between May 2014 - February 2015.
RESULTS: Anorexia nervosa as an illness carries destructive implications for the quality of the therapeutic alliance. Nurses\' intimate position in the inpatient setting and interpersonal capacity is influential in overcoming the obstacles that impede the therapeutic alliance.
CONCLUSIONS: Nurses\' capacity for developing therapeutic alliances is in part dependent on a supportive ward organization and the adequacy of resources to permit meaningful interactions with consumers with anorexia nervosa. Understanding the contextual factors specific to the inpatient setting enhances nurses\' ability to develop therapeutic alliances.

OBJECTIVE: To develop a greater understanding of the nature of the inpatient therapeutic alliance between nurses and consumers with Anorexia Nervosa (AN).
BACKGROUND: Consumers with AN value interpersonal relationships with nurses, finding these relationships meaningful and therapeutic. It is established that the therapeutic alliance enhances outcomes for consumers with AN. However, establishing the therapeutic alliance in the inpatient setting is considered challenging.
METHODS: This study employed a two-phase mixed-method explanatory sequential design. An initial quantitative survey, phase one, was followed by the collection and analysis of qualitative data, phase two.
METHODS: Phase one employed validated survey instruments, measuring the perceived degree of therapeutic alliance and elements of ward milieu. Phase two involved semi-structured interviews that focused on therapeutic relationships between nurses and consumers, with specific exploration of the results from phase one. Data collection commenced May 2014 and concluded February 2015.
RESULTS: The therapeutic alliance involved interpersonal engagement and a balanced application of authority. In a therapeutic alliance, nurses cared for consumers with interpersonal finesse, whilst maintaining clear distinction between the consumer as an individual and AN as an illness. Nurses also developed a therapeutic alliance by occupying their position of power with consistent yet individualised expectations and by maintaining appropriate professional boundaries.
CONCLUSIONS: The therapeutic alliance between nurses and consumers with AN is not developed through negotiation of equal partners. Rather, the therapeutic alliance is dependent on nurses\' capacity to maintain their position of power, whilst demonstrating their trustworthiness to the consumer. In trusting nurses, consumers felt safer in investing in a new concept of well-being.
CONCLUSIONS: By understanding the nature of the therapeutic alliance as it is described in this study, nurses have an enhanced capacity to develop effective therapeutic alliances with consumers. A maternalistic nursing style emerged as a viable approach.