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Engagement is a fundamental aspect of patient care that impacts patient recovery, promotes a culture of safety, and also influences patient and staff satisfaction. There are many factors which contribute to patient engagement. One factor is the culture and ideology of the unit or practice area that guides the direction of patient care. In an attempt to create safe environments and manage potential conflict, units which are highly focused on risk management often rely on interventions that are designed to control. Often these types of interventions create or exacerbate barriers to engagement. However, units which embrace patient centered care and recovery principles, provide the necessary resources, training, and education for staff on ways to avoid conflict and how to diffuse difficult situations without resorting to interventions designed to control. Additionally, important to an environment that promotes engagement is the ability of nursing leadership to recruit well educated nurses along with the provision of safe and adequate nurse to patient ratios. In order to promote engagement, unit staff are encouraged to remain outside of the nurses’ station to be present with the patients. Staff should not be given administrative assignments which distract from patient care. Also influencing engagement is the physical design of the unit space. Closed units create a divided atmosphere of “us and them” making it more difficult for patients to have access to staff. A more open nursing station design concept allows for staff to be more accessible and approachable for patient needs. The following selection of literature explores:

  • The meaning of engagement and how it promotes recovery.
  • The process involved establishing and maintaining a relationship based on engagement.
  • The factors that influence engagement within Mental health inpatient settings.

Capturing the Interpersonal Process of Psychiatric Nurses: A Model for Engagement
Kathleen R. Delaney, Mona Shattell, Mary E. Johnson (2017) Capturing the Interpersonal Process of Psychiatric Nurses: A Model for Engagement. Archives of Psychiatric Nursing, Volume 31, Issue 6, Pages 634-640,

“This paper presents a model of engagement that clarifies the skills necessary to support the engagement process. The model draws on Peplau’s Theory of Interpersonal Relations, patients’ ideas on healing elements of psychiatric hospitalization, and research on inpatient therapeutic relationships. The model describes six stages of engagement: 1) CENTER YOURSELF- clearing the mind to establish stillness in order to develop the capacity for connection. 2) SEND INTENT/HERE TO LISTEN- make it clear to the patient that the therapist is ready to listen. 3) ESTABLISH EMPATHIC BRIDGE- This is a twofold process. First the nurse increases awareness of the patient’s mood, and then imagines what it is like to be in the patient’s shoes. 4) ATTUNEMENT- The nurse attempts to imagine the patient’s mental state and identifies the meaning behind the patient’s behavior. 5) DECODE – Understanding the patient’s story and clarifying what the patient is telling you. 6) CRAFTING A RESPONSE: Identifying the needed response. Either listening and validating, problem solving or identifying an immediate need to be met.”

Conceptualizing nurse-patient therapeutic engagement on acute mental health wards: An integrative review
Sarah McAllister, Glenn Robert, Vicki Tsianakas, Niall McCrae (2019) Conceptualizing nurse-patient therapeutic engagement on acute mental health wards: An integrative review. International Journal of Nursing Studies, 93, 106-118. ISSN 0020-7489

“A systematic integrative review of the literature was conducted to conceptualize engagement and use the COM-B/TDF theoretical framework to explore factors which influence engagement within acute mental health inpatient settings. Specifically, to explore the components of engagement according to the experiences and perspectives of patient and nurses, and to devise a conceptual model of engagement.

Principle 1: understanding the person and their experiences
This construct describes how the nurse, along with the patient, understands the meaning of the patient’s lived experience of illness.  It was important that nurses did not dismiss the patient’s own reality due to their illness but rather acknowledged and validated the patient’s symptoms.

Principle 2: facilitating growth
This construct describes how the nurse assists patients in learn new coping skills as well as preparing for discharge. This is a facilitative role in which the nurse recognizes that the patient knows the path to wellness. The nurse must respect the patient’s decisions.

Principle 3: therapeutic use of self
This is accomplished not only by the verbal interactions but also the non-verbal interactions, such as sitting with the patient. To use oneself as a therapeutic tool it is necessary for the nurse to act not only as a health professional, but also as a fellow human being

Principle 4: choosing the right approach
This construct describes how the nurse uses a variety of engagement skills based on the needs of the patient. The nurse can use either formal or informal sessions to meet with their patients, however, patients preferred shorter, informal interactions which were regularly available

Principle 5: authoritative vs. emotional containment
Nurses use physical containment to control patients when the nurse perceives the unit as unsafe. However physical containment should be used as a last resort and is considered non-therapeutic. Emotional containment on the other hand, is considered an entirely therapeutic act where nurses contain either their own, or the patient’s own, distressing emotions. Effective emotional containment requires the nurse to self-reflect as well as allow patients the time and space to discuss their experiences.”

Relationship between the nursing practice environment and the therapeutic relationship in acute mental health units: A cross-sectional study.
Roviralta-Vilella, M., Moreno-Poyato, A. R., Rodríguez-Nogueira, Ó., Duran-Jordà, X., Roldán-Merino, J. F., & MiRTCIME.CAT Working Group (2019). Relationship between the nursing practice environment and the therapeutic relationship in acute mental health units: A cross-sectional study. International journal of mental health nursing, 28(6), 1338–1346.

“This article describes a cross-sectional design study in which data was collected online from nurses in 18 mental health units to determine whether the therapeutic relationship is influenced by the practice environment and/or the individual nurse’s characteristics. Results showed that nurses who take part in shared leadership decisions, have positive collegial relationships with physicians, and supportive relationships with their leadership were able to develop stronger relationships with patients than those who do not. A lack of staffing and the addition of administrative tasks negatively affected the time nurses could spend with their patients. Philosophies of care and workplace training have the most significant positive impact on the therapeutic relationship, followed by the length of experience and academic qualifications of the nurse. “

The association between empathy and the nurse-patient therapeutic relationship in mental health units: a cross-sectional study
Moreno-Poyato, A. R., Rodríguez-Nogueira, Ó., & MiRTCIME.CAT working group (2021). The association between empathy and the nurse-patient therapeutic relationship in mental health units: a cross-sectional study. Journal of psychiatric and mental health nursing, 28(3), 335–343.

“The aim of this study was to examine whether the dimensions of empathy influence the nurse–patient therapeutic relationship within mental health units. A cross-sectional design was used to measure the therapeutic alliance and the different dimensions of empathy. Data was collected via an online form completed by 198 nurses working at 18 mental health units. The dimensions of empathy include perspective taking, empathic concern, personal distress and fantasy. Except for personal distress, which had a negative impact, all dimensions of empathy were found to have a positive implication on the therapeutic relationship. Understanding the patient’s perception was the most essential aspect of a therapeutic relationship which creates trust leading to a stronger nurse patient bond. Empathic concerns mobilize the nurse’s desire to help the consumer to progress from the orientation phase to the working phase of the therapeutic relationship. The affective components of empathy are associated with a greater empathic concern, helping the nurse and consumer establish agreement regarding goals and tasks. However, there can be a disagreement, creating personal distress within the nurse. This distress is related to the nurse’s subconsciously maintaining an emotional distance in order to avoid personal suffering. The nurse’s level of experience significantly impacts empathy and therefore the therapeutic relationship, improving the joint establishment of goals with patients. Multiple factors were identified which either facilitated or impeded the nurse’s ability to engage with patients. Namely, the culture of the organization and how it embraced engagement, the nurse’s personal resources and ability to engage with the patient, the patient’s resources and response to the nurse, the infrastructure of the unit, and a sense of safety shared by the patient and nurse.”

Nurses’ influence on consumers’ experience of safety in acute mental health units: A qualitative study
Cutler, N, Sim, J, Halcomb, E, Moxham, L, Stephens, M. (2020) Nurses’ influence on consumers’ experience of safety in acute mental health units: A qualitative study. Journal of Clininical Nursing; 29: 4379– 4386.

“This is a qualitative descriptive study using semi-structured interviews of fifteen consumers to determine what safety meant for them during their acute mental health unit admissions. Three sub-themes were identified which described how nurses influence how consumers experience safety in acute units, namely by the nurse’s availability, responsiveness, and caring towards the consumer. Availability was demonstrated by the Nurses as being physically present in the common areas and spending time with the consumers. On the other hand, consumers felt unsafe when the nurses were “hidden” in the nurse’s station or had so many demands they were “too busy” to be with their patients. Being responsive was shown by the nurses by listening to the consumers and making efforts to assist them with their needs and offering support. Finally Caring was demonstrated through the nurses’ expressions of empathy and kindness directed toward the consumer. The authors acknowledge that most of nursing efforts are to assess the unit for low-frequency, high-impact risks, such as suicide, self-harm and violence, while much less time is allotted to common risks for consumers, such as sexual vulnerability and social isolation. The authors recommend efforts should be focused on enhancing safety and instilling a culture of safety, rather than focused on risk.”

The therapeutic role of mental health nurses in psychiatric intensive care: A mixed-methods investigation in an inner-city mental health service
McAllister, S, McCrae, N. (2017) The therapeutic role of mental health nurses in psychiatric intensive care: A mixed-methods investigation in an inner-city mental health service. Journal of psychiatric and mental health nursing; 24: 491– 502.

“This article describes a research study that uses a mixed-methods investigation with a structured measurement tool and qualitative interviews conducted with four practitioners and six patients. The researchers found a disparity between nurses’ and patients’ desired frequency and type of therapeutic engagement. Nurses preferred longer and more formal interactions, whereas patients desired brief but consistently accessible contact. The authors concluded that nurses should not focus on the amount of time spent with the patient; rather, the focus should be on the content, emphasizing frequency, empathy and therapeutic purpose.”

How do PICU nurses spend their time? A pilot study
Haw C., Kotterbova E. (2016) How do PICU nurses spend their time? A pilot study. Journal of psychiatric Intensive Care 12 (1) 19-26

“This article describes a research study in which nurses were observed while they worked. Each activity was timed and assigned to one of seven main categories. Nurses only spent 30% of the time in direct patient care with 12% of this time involving medication administration. Nurses spent only 1% of their time in individual 1:1 sessions with their patients. The authors concluded that nurses need to spend more therapeutic time with their patients.”

A modified grounded theory study of how psychiatric nurses work with suicidal people.
Cutcliffe, J. R., Stevenson, C. Jackson S., Smith P., (2006) A modified grounded theory study of how psychiatric nurses work with suicidal people. International Journal of Nursing Studies (7) 791-802.

“This article describes a research study to examine the effects of nursing interventions on patients who have recently attempted suicide. The authors believe that nursing care in psychiatric units is often associated with the mechanical process of observations and wanted to determine what nursing interventions, if any, were helpful to patients who experienced suicidal thoughts. The authors conducted semi-structured interviews on twenty patients who had recently attempted suicide and analyzed the data using modified grounded theory. Results indicate that patients with suicidal thoughts have become “disconnected from humanity” and the nursing interventions “re-connects the patient back to humanity.” The authors describe depressed patients as having unresolved psychosocial issues which are perceived by the patient as overwhelming. These persons feel that no one can understand their problems and eventually come to believe that they are a burden on others. As a result, they withdraw from others and have the perception that their life has no value and no one cares about them. They become “disconnected from humanity.”

The nurse helps the patient “reconnect back to humanity” through establishing a warm, supportive, nonjudgmental relationship based on acceptance. The most important aspect of the nursing interventions is demonstrating care and concern about the patient. One of the most important interventions to demonstrate care is just being with the patient. The nurse spending time with the patient demonstrates they care about the patient and will not abandon them. This caring relationship inspires the development of hope. Through this relationship, the patient discovers that they can connect with another human. The nurse acts as an ambassador in reconnecting the patient with humanity.”

Failure of the Capacity for self-soothing in women who have a history of abuse and self-harm.

Gallop, R. (2002) Failure of the Capacity for self-soothing in women who have a history of abuse and self-harm. Journal of the American Psychiatric Nurses Association, 8, 20-26

“The article reviews the purpose of self-harming behavior. It describes the development of the person’s sense of self (according to Winnicott) and the effects that trauma can have on it. The author discusses the neurobiological impact of trauma. The abuse survivor experiences intense emotions as a result of the abuse and how they often exhibit panic, anxiety, dissociation, and somatization. The author describes how emotional pain is experienced as worse than physical pain and the abuse survivor’s only coping skill is to self-injure. The article describes the adverse consequences of using containment procedures, such as observations. The authors state, “If the focus of nursing care is to stop the self-injury then the self-injury becomes the battleground.” (Page 25). The author describes that the patient’s impulse to self-injure may lead the nurse to use forced medication or restraints. This recapitulates the trauma. Finally, the author describes the nurse’s role in helping the patient cope with the physiologic and emotional symptoms caused by the abuse, emphasizing the importance of engagement when working with those who self-injure, as well as demonstrating that the nurse understands how real the emotional and physical pain the patient experiences is”.

The bulldozer and the ballet dancer: aspects of nurses’ caring approaches in acute psychiatric intensive care

Björkdahl, A., Palmstierna, T., & Hansebo, G. (2010). The bulldozer and the balletdancer: aspects of nurses’ caring approaches in acute psychiatric intensive care. Journal of psychiatric and mental health nursing, 17(6), 510–518.

“This article describes two nurses’ approaches in the care of patients on inpatient psychiatric unit. The first is the ballet dancer approach described as attempting to cultivate a sense of safety, trust and closeness through spending time with the patients and sending the message that they are accepted and the nurse is there to care for them. On the other hand, when the unit would feel unsafe the nurses would use the bull dozer approach. This approach was designed to control the patient in order to provide protection to others on the unit. The authors describe that when approaching patients in a controlling manner, the patients can view this as being potentially harming and uncaring, which impacts the nurse-patient relationship. They also describe that if the staff must use controlling interventions, they should be done in a caring manner to demonstrate that the staff care about the patient and are concerned with their wellbeing, which can reduce the potential harm of the controlling intervention to the staff-patient relationship.”