Collaborative efforts in treatment plans, physical and emotional presence provided by nurses, and coordination of care are known to contribute to positive patient outcomes in mental health care settings. The application of such interventions can be particularly challenging with the schizophrenia population (Easter et al., 2016; Pitkanen et al., 2008). Barriers to therapeutic relationships are inherent in the treatment setting. These barriers can contribute to time pressure; limited length of stay; and policies, procedures, and communication issues related to schizophrenia that include alteration in thought process and behavior, and nurses' perceptions of barriers (Farrelly et al., 2015; Helene Hem et al., 2008; Shattell et al., 2014).
All the above can make it difficult to develop therapeutic relationships with patients in general, but what has been acknowledged less is that nurses may not be aware of how their responses to these constraints create additional barriers to developing therapeutic relationships (Harris & Panozzo, 2019a). For example, a nurse who is preoccupied with completing tasks in a timely manner may not realize he or she is perceived by the patient as uninterested. Literature also suggests that even when nurses are aware of how their actions hinder the therapeutic relationship, they may not be clear on how to remedy this, engage collaboratively, or what the goals of interaction should be (Andvig & Biong, 2014; Foster & Isobel, 2018). Andvig and Biong (2014) and Foster and Isobel (2018) suggested that nurses may not feel confident in the best ways to interact with patients, particularly when attempting to make sense of disparate priorities in outcomes between health care institutions and patients' own verbalized priorities. In addition, Kornhaber et al. (2016), in their review of adult nurse–patient relationships, suggested that although nurses are aware of the necessity to engage in a nurse–patient relationship, the techniques to make the relationship therapeutic may be unknown or assumed to exist within the relationship without additional effort required by the nurse.
Research into what facilitates effective therapeutic relationships in mental health nursing is sparse, leaving nurses who are grappling with these issues with little guidance (Farrelly et al., 2015; Hewitt & Coffey, 2005). A recent review of literature on therapeutic relationships and the schizophrenia population found that only a minority of studies included nurses in the samples (Harris & Panozzo, 2019b). Gabrielsson et al. (2016) suggested that if nurses encounter barriers they cannot surmount, they are at risk of withdrawing from patients.
The current pilot study is in response to the dearth of research on therapeutic relationships and the schizophrenia population, designed to generate information on how psychiatric nurses define the nurse–patient relationship and identify activities they understand as therapeutic within the relationship. This study represents an initial step in a program of research that can ground the development of resources for practicing nurses to successfully implement collaborative and therapeutic interpersonal interventions to assist individuals with schizophrenia. The results of the pilot survey can be used to refine and further develop the survey for use in larger scale studies to provide more generalizable findings that can be used to design effective educational interventions for psychiatric nurses to optimize therapeutic relationships with patients with schizophrenia.
In addition to initial assessment of construct validity of the survey and assessment of usefulness and clarity of qualitative items, preliminary data will be examined in the following areas: (a) What factors impact perspectives of psychiatric nurses regarding therapeutic relationships with the schizophrenia population?; (b) How do psychiatric nurses define the nurse–patient relationship and therapeutic relationship?; and (c) What factors facilitate nurses' relationships with the schizophrenia population and what resources can better prepare them?
Although the sample is small and this is a pilot study, the findings have merit as indicators of areas to probe further or more deeply in a revised survey.
Current approaches to enhance nurse–patient relationships in psychiatry recognize the importance of grounding models in empirical findings (Delaney et al., 2017). Kornhaber et al. (2016), in their review of nurse–patient relationships, also emphasized the importance of nursing-specific research regarding therapeutic relationships. They note that nurses are aware of the necessity to engage in a nurse–patient relationship but that they may not differentiate between nurse–patient relationship and therapeutic relationship. Lack of differentiation can occur if nurses are not aware that therapeutic interaction is intentional and based on theory and evidence. Techniques to make the relationship therapeutic may be unknown or believed to be automatically occurring within the relationship itself. The active attempt to identify and implement evidence-based therapeutic techniques purposefully should be explored.
A recent integrative review of the literature found little empirical work had been focused on nurses and individuals with schizophrenia; the main focus has been on therapists and providers (Harris & Panozzo, 2019b). Several themes were identified in the review; however, only a minority of the studies included nurses in the samples. The review identified that patient and provider ratings of relationships were based on different and incongruent factors. For example, in a study by Ruchlewska et al. (2016), it was noted that patients rated quality of relationships based on their own life needs versus those of providers who rated the relationship based on medical indices, such as symptom severity and medication adherence. In addition, patients with acute and severe symptoms rated their relationships higher than their providers. A study by Kvrgic et al. (2013) noted that patients who experienced high levels of self-stigma rated their relationships significantly lower than their providers. Due to the under-representation of nurses in the samples, it is difficult to apply these findings to psychiatric nurses' relationships with patients with schizophrenia.
Additional factors limit usefulness of existing research for psychiatric nurses. The conceptualization of therapeutic relationships is difficult and there are numerous issues with reliable and valid assessment (Ardito & Rabellino, 2011; Elvins & Green, 2008; Farrelly et al., 2015). Harris and Panozzo (2019b) found that a variety of instruments were used in recent studies that focused on therapeutic relationships between mental health care providers and patients with schizophrenia; these included the Working Alliance Inventory (WAI), Scale to Assess Therapeutic Relationship (STAR), Helping Alliance Scale (HAS), and California Therapeutic Alliance Scales (CALPAS). There is substantial variability across scales. Some contain different patient and provider versions, some have subscales. The conceptual grounding of the scales varies and most instruments that exist were developed by and used for other mental health professions, not nursing (Harris & Panozzo, 2019b).
Piloting a survey that elicits practicing nurses' perceptions and understandings of the nurse–patient relationship is a first step in development of a reliable survey that can generate knowledge integral to more effectively facilitating therapeutic interaction between nurses and patients in psychiatry.
A pilot study of a developed survey (mixed method) was performed to elicit nurses' perceptions of the concept of therapeutic alliance with patients with schizophrenia and to use the data collected to begin to build a body of information about practicing mental health nurses' understandings of therapeutic relationships. Data collection occurred from March to June 2018. Online survey administration was used to maintain anonymity of participants and to make participation more accessible and convenient by using Qualtrics™.
Due to lack of instruments, as noted above, that focus on psychiatric nurses and therapeutic relationships with the schizophrenia population, a survey was developed by the researchers. Careful consideration was taken in developing a survey to explore nurses' perceptions of therapeutic alliance with the schizophrenia population. The instrument piloted consists of seven demographic items, four qualitative items, and 16 quantitative items scored on a Likert scale with seven answer choices: 1 = never, 2 = rarely, 3 = occasionally, 4 = sometimes, 5 = often, 6 = very often, 7 = always (Figure A, available in the online version of this article).
The 16 Likert scale items and the four qualitative items were developed as follows. Themes derived from an integrative review of literature on therapeutic relationships in psychiatric treatment settings (Harris & Panozzo, 2019b) were compared with the researchers' own extensive experience working and teaching in psychiatric nursing. The items were developed to elicit attitudes and perceptions related to each of these concepts. Whenever possible, more than one survey item was developed to address a concept, resulting in 16 items. The items were grouped conceptually by psychiatric nurses' perceptions on the following in relation to the schizophrenia population:
- comfort level;
- mutual goals;
- ability to understand patients' needs;
- minimalization of communication;
- comfort level with communication and respect;
- challenges and interactions;
- stigma and outcomes;
- therapeutic alliance and compliance;
- training and knowledge;
- the need for family support and impact on outcomes;
- leisure and socialization; and
- boundaries and expectations.
Stems were made clear and as short as possible with positive language. Four qualitative items were developed to provide an opportunity for participants to explain the significance and their understanding of the nurse–patient relationship in comparison to the therapeutic relationship, the specific ways therapeutic relationships are promoted in their practice, and to elicit ideas or suggestions for training and education that can better prepare them to engage in effective therapeutic alliance with patients (Figure A).
Minimizing Instrument Bias
Items were reviewed carefully by the researchers to eliminate double-barreled, halo effect, load, double-negative, and questions with complex vocabulary to reduce potential for instrument bias (Rubenfeld, 2004). The survey was pre-tested by two psychiatric nurses who provided feedback on clarity, readability, and redundancy. No recommendations were provided to the researchers after the pre-testing occurred.
Approval for the survey study was received by the researchers' university Institutional Review Board. Convenience snowball sampling was used. Participants were recruited by the researchers through email, social media (Facebook®), and at one psychiatric nursing conference. Inclusion criteria for participation were: currently hold a licensed practical nurse (LPN) or RN certification, including advanced practice nurses (APNs) who are not nurse practitioners (NPs) (non-prescribing roles); be between the ages of 21 and 65 years; currently practice in mental health nursing as staff or faculty; have at least 1-year experience in psychiatric nursing; and have cared for patients with schizophrenia within the past 5 years. The inclusion criteria were selected to allow for representation of the population that currently work, have recently worked with, manage those, or teach in settings in relation to patients with schizophrenia. The practitioner role was excluded due to additional education and training relative to working with patients. NPs may see high volumes of patients but spend less time with each patient than staff nurses working in a clinical setting. The Health Resources and Services Administration's (HRSA) 2018 National Survey of Registered Nurses (not practitioners) who work in psychiatric-related settings, including inpatient, outpatient, and substance use and counseling, comprised 208,213 nurses. The most recent data from the National Sample Survey of Nurse Practitioners noted 13,057 psychiatric NPs practiced nationally as of 2012 (HRSA Health Workforce, 2012). The American Association of Nurse Practitioners (2020) reported a prevalence of >290,000 NPs in the United States, with only 1.8% (approximately 5,220) in the psychiatric/mental health field. Due to the prevalence of psychiatric RNs in comparison to psychiatric NPs, non-practitioner participants were of focus for the sample. Faculty may teach in a clinical role up to 12 hours in a day, which is why they were included in the sample. The length of exposure to patients and need to therapeutically communicate with patients throughout that duration is of interest. LPNs and RNs were included because LPNs often work in psychiatric settings and are exposed to patients with schizophrenia. Potential participants were given an informational flyer about the study listing inclusion criteria and inviting participation if eligible. Participants were able to access the online survey through a link provided on the informational flyer.
The survey was offered through Qualtrics. Informed consent was obtained on the initial page of the survey. Data were collected through the software platform and stored there until analysis. Only the primary and secondary investigators (G.P., B.H.) and statistician viewed the data. Data were collected over a 3-month period.
Quantitative Analysis. A major goal of data analysis was to perform initial assessment of construct validity of the 16-item Likert scale section of the survey. Common factor analysis was used to determine how the 16 items load onto four factors conceptually determined to be related to therapeutic alliance: (1) understands the patient's needs, (2) attitudes toward patients, (3) treatment plan goals, and (4) communication. Two survey items, #9 (“I am fearful of patient escalation”) and #10 (“The positive symptoms of schizophrenia make it challenging to interact with patients”), were reverse coded in preparation for factor analysis, which was then executed. SPSS version 25 was used to run this analysis, looking for values >0.4 to provide a threshold to demonstrate if a particular item loaded onto one of the factors.
Chi-square was used to explore possible associations between each demographic item and each of the 16 Likert-scaled items on the survey. Chi-square, a nonparametric test, was used due to the small sample size and inability to meet assumptions of parametric tests of association for purpose. A significance of association was tested for at p values of 0.01, 0.05, and 0.10 due to the small sample size. The Kruskal-Wallis equality of populations rank test was used to analyze for significant findings in terms of education, age, degree seeking, current setting, and current role. The Mann-Whitney U test was used to analyze for significant findings/comparison in terms of APRN/clinical nurse specialist (CNS), RN-BC, and gender.
Qualitative Analysis. Content analysis to identify themes and patterns was performed by the researchers on the four qualitative items. A table was created to organize analysis into meaning unit, condensed meaning unit, code, category, and themes. All response rates and answer choices were cross checked with Qualtrics. Predominant themes, as well as the frequency of themes, were reported.
Approximately one half of participants were between ages 41 and 55 years. Most participants were female (n = 43) versus male (n = 7). Forty-one percent of participants had a master's degree, with more than one half of participants working as staff nurses in inpatient settings. Twenty-one percent of participants were board certified in psychiatric and mental health nursing (Table 1).
Demographic and Background Characteristics of Survey Participants (N = 51)
All but one of the 16 items loaded onto the four factors listed above with loadings ≥0.4. One item, #5 (“I minimize communication with patients with schizophrenia”), did not load. On review, it is clear that although the item was intended to elicit responses about attitudes toward care, because the content focused on behavior, participants may have interpreted it in a manner not anticipated by the researchers.
The Kruskal-Wallis equality of populations rank test did not reveal significant findings (in terms of education, age, degree seeking, current setting, current role) nor did the Mann-Whitney U test (in terms of APRN/CNS, RN-BC, and gender). Significant findings from chi-square analysis are noted in Table 2 for selected measures. Four of the 16 Likert scale items showed associations with demographic items at or approaching significance. The most significant associations with specific demographic/background characteristics were:
- Item #1: I feel comfortable working with patients with schizophrenia (significant association with APRN role).
- Item #3: I understand the needs of patients with schizophrenia (significant association with current practice setting and the participant being degree seeking).
- Item #6: I am comfortable communicating with patients with schizophrenia (significant association with possession of RN-BC certification in psychiatric and mental health nursing).
- Item #9: I am fearful of patient escalation (significant association with current setting).
Results of Chi-Square Analysis for Selected Measures
Four qualitative items were included in the survey and overall themes and illustrative quotes are provided in Table 3 and Table 4. When participants were asked to reflect on what the nurse–patient relationship means to them, it was noted that trust and communication, empathy, as well as collaboration were the most common themes. The themes highlight a sense of a mutual relationship that involves trust to be able to work together effectively. When participants were asked how they promote therapeutic relationships, patient focused care, goals and achievement, self-awareness and trust, therapeutic communication, and respect/safety/reduction of stigma were themes. The themes highlight a combination of self-behaviors and awareness as well as those directed toward patients. To better prepare and develop therapeutic relationships with the schizophrenia population, participants noted that professional organizations could assist in education or training and continuing education informally and formally are important. Topics of interest for further education and training include fostering professional growth and interactive experiences. Interestingly, despite the elements of the therapeutic relationship and the nurse–patient relationship as noted in the themes above, not all participants answered the item to identify the difference between nurse–patient relationship and therapeutic relationship. Fifty-six percent of participants responded to this item and of those responses, 13% did not differentiate between therapeutic relationship and nurse–patient relationship, 6% thought the terms were synonymous, and 10% thought the terms were different. Those who did not differentiate between therapeutic relationship and nurse–patient relationship could have viewed the terms as synonymous, which is why they did not make a separation. The nurse–patient relationship was noted to be patient care or treatment focused, hands on, superficial, and noted a power imbalance. Therapeutic relationship was noted to involve elements of collaboration, respect, and trust. Participants also aligned therapeutic relationship with attending and assessment behaviors, trust and reciprocity, and knowledge and skills.
Overall Themes in Item 23: What is the Difference Between the Nurse–Patient Relationship and Therapeutic Relationship?
Common factor analysis of the 16 Likert scale items showed adequate loadings of 15 items onto four factors identified by the researchers as conceptual components of the concept of therapeutic nurse–patient relationship with patients with schizophrenia, which provides preliminary evidence for the validity of the scaled items of the survey. Given the relatively small sample size, any results of factor analysis need to be interpreted with caution. However, the 15 items that loaded adequately will be retained as items in the next iteration of the survey.
Statistically significant associations were found between level of training/expertise specific to mental health (APN-CNS or RN-BC) and comfort level working/communicating with patients with schizophrenia (37% of the sample). Although this finding may suggest that level of training/expertise is a facilitative factor for therapeutic relationship, the underlying basis of this association is unclear. Others have found that increased education or training in interaction with individuals with schizophrenia increases comfort and confidence in interaction with such persons (McCabe et al., 2016; van Meijel et al., 2009). Increase in education or training would not explain the association between comfort and RN-BC found here as the latter does not require specific formal training. Confidence may increase comfort and it may also be increased by other factors besides formal education, such as workshops and conference attendance.
Another potential factor for increased confidence may be years of experience working with individuals with schizophrenia in a care setting. Going forward, inquiring about years of experience will be one of the changes made to the survey. More than 30% of the sample were faculty or administrators, leaving open questions as to how much direct care these participants had and if other role-related factors contributed to comfort and confidence. In addition, LPNs did not participate in the study but they practice in psychiatric facilities with individuals with schizophrenia. Expanding the sampling technique to obtain accessibility to LPNs would assist in a better representation of the population of nurses working with individuals with schizophrenia and potentially provide more information to discriminate between education and expertise as factors that increase confidence, as well as whether there is a connection between years of practice experience and confidence. LPNs may not have responded due to lack of interest in research and survey studies and time constraints. The staff mix of RNs and LPNs requires more attention and there is little collaboration between the groups regarding education and practice (Butcher & MacKinnon, 2015). Enhancing the relationships could improve collaborative research. Phillips and Neumeier (2018) noted that few LPNs access scholarly nursing journals and research studies in comparison to RNs, which could further explain lack of interest in not only consuming research but participating in it.
The qualitative items provide preliminary insight into how nurses perceive and understand therapeutic relationships. Many participants did not consistently distinguish between therapeutic relationship and nurse–patient relationship, although the qualitative data show that among those who did differentiate, different descriptors and priorities were found. Confusion between these and other related terms among nurses and mental health care professionals has been identified in previous research (Andvig & Biong, 2014; Foster & Isobel, 2018). More education is required on the definitions of these relationships, differences, and how to engage in them. However, it cannot be ruled out that the wording of questions in this pilot survey influenced participants' understanding of what the qualitative items were asking.
The sample size of the study was small (N = 51), but offered a range of various practice settings, educational levels, and current roles in nursing, despite lack of LPN participation. Data collected on years in practice and participation in informal professional education would have increased interpretability. Sample size limited statistical options for assessing associations between demographic characteristics and survey items. The sample size also limited the confidence that can be placed in the factor analysis. The use of snowball/convenience sampling may have contributed to skewing of the demographic variable of level of formal education. Obtaining a larger sample through use of state nursing associations, or other entities with large and diverse membership, would decrease the chance of the sample skewing toward certain levels of education or other demographic variables. Missing data are a concern for the four qualitative items. The questions as they were worded could have led several participants to choose not to answer. Participants most motivated or interested in the content may have been those who answered the items, possibly creating a bias in the qualitative findings.
Survey Modification and Future Research
Several modifications of the survey are indicated based on findings. First, a demographic item will be added to obtain information on the number of years participants have had experience working with the schizophrenia population. Participants will also be asked to estimate the number of hours of informal education or training they received. Consideration will be given to the development of items that can focus on other factors that increase confidence and comfort with the schizophrenia population, such as asking what specific factors participants attribute to their level of confidence and comfort.
Findings suggest that Item #23, which asked participants to differentiate between nurse–patient and therapeutic relationship, be modified to add a statement making clear that some people understand the two to have differences and ask participants to identify these differences. Response rate for this item was approximately 50%, much lower than for other items, indicating at the very least disinclination to answer, perhaps due to confusion as to what the question was asking. A more effective approach to address participant confusion may be to use an item that asks participants to list characteristics, or choose from a list of characteristics for each, which may generate more useful data.
Sampling strategies to obtain a larger sample will be employed. Sampling will also be aimed at increasing LPN participation and limiting participation to non-provider, psychiatric nurses working in clinical settings versus academic-based. Surveying RNs and LPNs on items related to therapeutic relationships and theory could be insightful on what additional training may be required based on data analysis comparing responses of the two groups. An increase in theory-based psychiatric nursing training and course work could be added to LPN programs, if the next survey reveals a need.
Implications for Practice
Being aware of factors that influence comfort levels when working with the schizophrenia population is important. Nurses should also consider how informal training/certification or formal education specific to mental health may increase comfort as well as ability to interact effectively with persons. Conversely, the significance of comfort in this study directs attention to factors that can decrease comfort in interactions with individuals with schizophrenia.
Most participants did not decipher between nurse–patient relationship and therapeutic relationship or thought the terms were synonymous. Conceptual confusion can hamper efforts by nurses, and those educators in contact with them, to communicate clearly and effectively about therapeutic relationship. Nurse managers and educators should review ongoing education and in-services provided on therapeutic relationships, with attention to terms used and the definitions associated with them (Kornhaber et al., 2016).
Nursing research and education exist to enhance what nurses can do to help their patients recover. The exploratory pilot study yielded preliminary findings related to therapeutic relationships between nurses and individuals with schizophrenia that can assist practicing nurses and educators in this area. Further study is needed to confirm, explain, and expand these findings to increase support for relationship in the practice area. As discussed at the beginning of the article, contemporary practice contexts can create barriers to nurses' therapeutic engagement with their patients, which stands in contrast to patients' documented desires to engage therapeutically with their nurses. Much work is needed to examine barriers and their effects and to develop effective strategies to address them. A growing community of nurse researchers studying therapeutic relationships among psychiatric nurses and patients can allow educators and practicing nurses to maximize the therapeutic potential of relationships between nurses and patients.
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Demographic and Background Characteristics of Survey Participants (N = 51)
| 20 to 30||5 (9.8)|
| 31 to 40||13 (25.5)|
| 41 to 55||24 (47.1)|
| ≥56||9 (17.7)|
| Female||43 (13.7)|
| Male||7 (84.3)|
| Unknown||1 (2)|
| High school||7 (13.7)|
| Associate's degree||6 (11.8)|
| Bachelor's degree||13 (25.5)|
| Master's degree||21 (41.2)|
| DNP||3 (5.9)|
| PhD||1 (2)|
|RN-BC (psychiatric–mental health)|
| No||40 (78.4)|
| Yes||11 (21.6)|
| No||43 (84.3)|
| Yes||8 (15.7)|
| Staff nurse||30 (58.8)|
| Faculty||9 (17.7)|
| Administrator/manager||8 (15.7)|
| Other||4 (7.8)|
| Inpatient||27 (52.94)|
| College/university||9 (17.65)|
| Community/clinic||7 (13.73)|
| Outpatient||5 (9.8)|
| Residential||2 (3.92)|
| Other||1 (1.96)|
| DNP||3 (5.88)|
| Nurse practitioner||2 (3.92)|
| MS/MA||2 (3.92)|
| PhD||1 (1.96)|
| Other||3 (5.88)|
| Not currently seeking degree||40 (78.43)|
Results of Chi-Square Analysis for Selected Measures
|Age||Gender||Educational Level||RN-BC||APRN||Current Role||Current Setting||Degree Seeking|
|1: I feel comfortable working with patients with schizophrenia.||1.98||0.7||20.13**||11.64**||5.26*||6.49||9.12||20.65**|
|3: I understand the needs of patients with schizophrenia.||8.39||6.47**||13.21||0.78||1.24||8.95||20.47**||19.87**|
|6: I am comfortable communicating with patients with schizophrenia.||5.88||0.64||25.61**||4.76*||4.11||8.65||7.33||34.27***|
|9: I am fearful of patient escalation.||4.47||6.8**||10.82||6.75**||2.48||5.69||19.82**||30.3***|
|Theme||Item 21a||Item 25b||Item 27c|
|Foster Professional Growth||X|
|Goals and Achievement||X|
|Self-Awareness and Trust||X|
|Respect, Safety, and Reduce Stigma||X|
|Trust and Communication||X|
|Communication and Respect||X|
Overall Themes in Item 23: What is the Difference Between the Nurse–Patient Relationship and Therapeutic Relationship?
|Nurse–Patient Relationship Themes||Therapeutic Relationship Themes||Quotes Demonstrating Perspectives on the Two Types of Relationships|
Collaboration and Trust
Attending and Assessment
Trust and Reciprocal
Knowledge and Skills||Not deciphering the two terms or only addressing one of the two terms (13 participants):
“The therapeutic relationship focuses on communication, education, and encouraging helpful behaviors.”
Noting the terms are synonymous (6 participants):
“I'm not sure I consciously make a distinction. I would use the terms interchangeably.”
Identifying a difference in terms (10 participants):
“Therapeutic relationship is a supportive interaction that helps the well-being of patients. It's based on trust, respect, interest, and empathy. It is a kind of psychotherapy. But nurse–patient relationship should be there for all the phases of therapeutic communication (i.e., from pre-interaction till termination phase).”|