BACKGROUND: Building therapeutic relationships and social presence are challenging in digital services and maybe even more difficult in written services. Despite these difficulties, in-person care may not be feasible or accessible in all situations.
OBJECTIVE: This study aims to categorize crisis counselors\' efforts to build rapport in written conversations by using deidentified conversation transcripts from the text and chat arms of the National Child Abuse Hotline. Using these categories, we identify the common characteristics of successful conversations. We defined success as conversations where help-seekers reported the hotline was a good way to seek help and that they were a lot more hopeful, a lot more informed, a lot more prepared to address the situation, and experiencing less stress, as reported by help-seekers.
METHODS: The sample consisted of transcripts from 314 purposely selected conversations from of the 1153 text and chat conversations during July 2020. Hotline users answered a preconversation survey (ie, demographics) and a postconversation survey (ie, their perceptions of the conversation). We used qualitative content analysis to process the conversations.
RESULTS: Active listening skills, including asking questions, paraphrasing, reflecting feelings, and interpreting situations, were commonly used by counselors. Validation, unconditional positive regard, and evaluation-based language, such as praise and apologies, were also often used. Compared with less successful conversations, successful conversations tended to include fewer statements that attend to the emotional dynamics. There were qualitative differences in how the counselors applied these approaches. Generally, crisis counselors in positive conversations tended to be more specific and tailor their comments to the situation.
CONCLUSIONS: Building therapeutic relationships and social presence are essential to digital interventions involving mental health professionals. Prior research demonstrates that they can be challenging to develop in written conversations. Our work demonstrates characteristics associated with successful conversations that could be adopted in other written help-seeking interventions.

Self-harm is becoming increasingly common in student populations. Brief psychological therapies might be helpful for those who have recently self-harmed. The current paper reports on an evaluation of a brief psychotherapy service delivered via remote means, namely University-Community Outpatient Psychotherapy Engagement (U-COPE). The service combines elements of psychodynamic interpersonal and cognitive analytic therapy to help students who present with self-harm related difficulties. The primary aim was to understand students\' and practitioners\' experiences of a remote psychotherapy service. Semi-structured interviews were conducted with a total of nine participants (seven students and two practitioners). Interview data were analysed using thematic analysis. Analyses of the interviews across the stakeholders revealed three overarching themes: \'Accessibility\'; \'Therapeutic experiences\'; and \'Spaces and places of therapy\'. Students appreciated the rapid access to intervention, especially as student services are typically characterised by long waiting lists. Despite the brief nature of the intervention, many students reported feeling a sense of control over the direction and pace of the therapeutic sessions, which is an important consideration for those who self-harm. The findings suggest that U-COPE may be helpful to students with difficulties related to self-harm. Further investigation of this brief intervention is warranted in order to ascertain whether U-COPE has a long-term impact on difficulties and distress-related behaviours.

The global COVID-19 pandemic presented not only challenges for services but also opportunities for reflection and change. This study aimed to understand young people, parents/carers, and professionals\' experiences of remote provision across a voluntary sector organization to inform the nature of future delivery. Reflections from professionals (n = 7), young people (n = 7), and parents/carers (n = 2) were collected through semi-structured interviews and focus groups. Data were thematically analysed. Five overarching themes were identified: \'Accessibility\', \'Remote therapeutic experiences\', \'Translating to online\', \'Spaces of comfort/discomfort\', and \'Moving towards hybrid provision\'. The COVID-19 pandemic changed service provision, notably with accelerated digitalisation. Although the service became more accessible, the digitalisation of services impacted the relational experiences for young people. Nevertheless, online provision was described as a \'steppingstone\', allowing young people to engage in online therapy or group programmes before transferring to in-person provision. Although remote provision can lead to improvements in young people\'s mental health, this format was not suitable for all. When considering future models of provision, assessing needs, preferences, and access to private space and hardware are all important considerations when deciding which format to use to achieve the best possible outcomes.

To explore how the expression of positive emotions during the interaction between patients and providers can cultivate the patient-provider relationship.
We conducted a realist review guided by the Realist and Meta-narrative Evidence Syntheses: Evolving Standards.
We systematically searched CINAHL, MEDLINE, PsychINFO and Scopus from inception to March 2019. Study selection and data extraction were performed blinded in pairs. From 3146 abstracts blinded in pairs, 15 papers were included and analysed. From each included paper, we extracted contexts, mechanisms and outcomes that were relevant to answer our research questions, creating a configuration between these elements (CMO configuration).
Our findings suggest that in the contexts of person orientation and positive outlook, patient-provider relationships improve by communication conveying and eliciting positive emotions. We found six underlying mechanisms for this that form either direct or indirect pathways between the context and the outcome.

WHAT IS KNOWN ON THE SUBJECT?: Psychiatric treatment is commonly seen as not treating the whole person, but as using technical fixes for symptoms. Both in treatment and when reading their medical files, lay people often feel personally disrespected. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We suggest that some practitioners are aware of their patients as humans: They respect the service user\'s understandings and relationships, including the one between patient and practitioner. Two mechanisms for bonding and building mutual respect (translation and contextualization) are described. WHAT ARE THE IMPLICATIONS FOR MENTAL HEALTH NURSING?: Every intervention emerges from an encounter, and therefore, talk cannot merely be instrumental but must also be an exchange. Translation means that the service user understands the provider, and vice versa. Contextualization means that patients and practitioners interact not only in those roles, but as people with a broader history and network of relationships. Neither technical nor personal understandings are privileged, but used flexibly and as needed.

Stigmatization of patients exists in nursing and results in less than optimal nursing care and poor patient outcomes. It is also a violation of our code of ethics. In order to eliminate stigmatization from nursing practice, it is necessary to understand how it develops. Two possible theoretical pathways are proposed to explain the development of stigmatization in nursing. These pathways are informed by a conceptual understanding of stigma and theories of professional socialization, professional formation, symbolic interactionism, and social cognitive theory. Re-labeling and role-taking and moral disengagement are proposed as two possible processes that may lead to stigmatization of patients. Both proposed pathways have implications on professional socialization, formation, and the development of professional identity. Devoting attention to and reframing normative behavioral expectations, eliminating labeling, developing empathy, focusing on relationships, and cultivating ethical comportment and moral maturity during nursing formation may reduce the stigmatization of patients by nurses.

WHAT IS KNOWN ON THE SUBJECT?: There are insufficient nurses to meet current demand for mental health care. This is an international concern. Within England, the impact of staff shortages on the quality of patient care in forensic high secure settings has been highlighted by the national regulatory body for hospitals. Forensic hospital nursing is a distinct specialism within mental health. Forensic nurses must negotiate the therapeutic, ethical and practical challenges of caring for high-risk patients in a locked environment. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: There has been no previous study to ask frontline high secure forensic nurses, union representatives, senior nurses and workforce leads about what factors may be affecting recruitment and retention in their setting. As well as the specialized and challenging nature of the work, participants identified that workforce sustainability was affected by unequal working terms and conditions, the hospital locations and wider national factors, such as changes to how nurse training was funded. They also identified that some strategies that were employed to address workforce shortages, such as day-to-day movement of staff within the hospital and incentive packages for new recruits could be demotivating for established staff. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Forensic high secure nursing workforce strategies should include training, development and career pathways that are specific to the specialism and extend beyond preceptorship for newly qualified staff. There should be clear and equitable employment terms and conditions with remuneration packages that are consistent within and between organizations. Hospital managers should address the effect that movement of staff between wards may have on nurses\' morale, therapeutic relationships and safety culture. ABSTRACT: Introduction There has been no previous study of stakeholders\' views on recruitment and retention concerns in high secure forensic settings. Aim To identify factors affecting recruitment and retention in high secure hospitals, from the perspectives of stakeholders with experience in forensic mental health nursing. Method Framework analysis of data from fifteen interviews and three focus groups with frontline nurses, nurse leaders, recruitment leads and union representatives from three high secure hospitals in England. Results Six themes emerged from the data: (a) the unique nature of high secure nursing; (b) the impact of short staffing; (c) wider factors affecting the high secure nursing workforce; (d) the location; (e) staff being on different terms and conditions of work; (f) recruitment strategies. Discussion Multiple factors are likely to simultaneously affect high secure hospital recruitment and retention. Findings on the unique nature of high secure work reflect previous qualitative research. The themes of location, working terms and condition and recruitment strategies have not been previously identified in forensic nursing research. Implications for practice Employers should ensure that employment terms and conditions are equitable and consistent. Furthermore, hospital managers should address the effect that movement of staff between wards may have on morale and therapeutic relationships.

Therapeutic relationships are fundamental in aphasia rehabilitation, influencing patient experience and outcomes. While we have good understandings of the components of therapeutic relationships, there has been little exploration of how and why therapists construct and enact relationships as they do. Sociological theories may help develop nuanced understanding of the values, assumptions and structures that influence practice, and may facilitate critical reflexivity on practice.
To explore the potential for theoretical approaches from outside speech-language therapy to enable a deeper understanding of the nature and enactment of therapeutic relationships in aphasia rehabilitation.
An explanatory single case study of one speech-language therapist-patient dyad in an in-patient stroke rehabilitation setting. Data included observations of five interactions, two interviews with the client and three interviews with the speech-language therapist. Analysis was guided by analytical pluralism that applied aspects of three sociological theories to guide data analysis and make visible the contextual factors that surround, shape and permeate the enactment of therapeutic relationships.
The analysis of this dyad made visible individual, interactional and broader structural features that illustrate the dynamic processes that practitioners and patients undertake to enact therapeutic relationships. Clinical practice could be viewed as a performance with each person continually negotiating how they convey different impressions to others, which shapes what work is valued and foregrounded. The patient and therapist took up or were placed in different positions within the interactions, each with associated expectations and rights, which influenced what types of relationships could, or were likely to, develop. Organizational, rehabilitation and individual practitioner structures assigned rules and boundaries that shaped how the therapist developed and enacted the therapeutic relationship. Whilst the therapist had some agency in her work and could resist the different influencing factors, such resistance was constrained because these structures had become highly internalized and routinized and was not always visible to the therapist.
While therapists commonly value therapeutic relationships, social and structural factors consciously and unconsciously influence their ability to prioritize relational work. Sociological theories can provide new lenses on our practice that can assist therapists to be critically reflexive about practice, and to enact changes to how they work to enhance therapeutic relationships with clients. What this paper adds What is already known on the subject Therapeutic relationships are critical in aphasia rehabilitation. We have a good understanding of the different components of therapeutic relationships and how relationships are perceived by patients and practitioners. What this paper adds to existing knowledge This study is novel in its use of sociological lenses to explore contexts and complexities inherent in building and maintaining therapeutic relationships. These are often invisible to the practitioner but can have a significant impact on how relational work is enacted and what forms of relationship are possible. What are the potential or actual clinical implications of this work? This study will support clinicians to critically reflect on how they enact therapeutic relationships and may enhance awareness of the often-hidden factors which influence the ways in which they work.

UNASSIGNED: Communication between patients and clinicians influences the development of therapeutic relationships. Communication is disrupted when the patient has communication impairments after stroke. However, how these communication disruptions influence therapeutic relationships is not well-understood. This qualitative metasynthesis explores the perspectives of people with communication impairment to understand how interpersonal communication influences therapeutic relationships.
UNASSIGNED: Four databases were searched for qualitative studies which discussed how communication influenced therapeutic relationships from the perspectives of people with aphasia, dysarthria or apraxia of speech. Additional papers were identified through citation searching and subject experts. Nineteen eligible papers were included and analysed using thematic analysis.
UNASSIGNED: Four themes were constructed from the analysis: (1) Relationships provide the foundation for rehabilitation; (2) Different relational possibilities arise from \"reading\" the clinician; (3) Creating therapeutic relationships through validating interactions and connections; and (4) Creating therapeutic disconnections through invalidating, exclusionary interactions.
UNASSIGNED: A therapeutic relationship develops, at least in part, in response to the clinician\'s communication and how this is received and experienced by the patient. Understanding the characteristics of relationship-fostering communication and knowing how communication influences relationships can help clinicians critically reflect on their communication and better develop therapeutic relationships with people with communication impairment.IMPLICATIONS FOR REHABILITATIONPractitioner-patient communication can facilitate therapeutic relationships or create therapeutic disconnections.Communication patterns that are commonly evident when a patient has communication impairments can impede therapeutic relationships.Clinicians need to attend to how their communication is received and how it influences people\'s sense of self.Communication partner training should address the existential and relational needs of people with communication impairment after stroke.

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.