The therapeutic relationship is the central focus of nursing work in mental health (Peplau, 1992, 1997). However, there is currently little research that has examined influences on the nurses’ capacity to effectively engage in this relationship. This study investigated the impact of nurse, patient and work environment factors on the willingness and ability of nurses to engage in therapeutic relationships. This attribute of the nurse, identified as therapeutic commitment, is essential for an effective therapeutic relationship (Lauder, et al., 2000; Rogers, 1957), which has been identified by users of mental health services as the foundation of their care (Forchuk & Reynolds, 2001). The therapeutic relationship is central to nursing in mental health and has been linked to improved patient outcomes (Horvath, 2005). Environmental factors hypothesised to impact the nurse’s therapeutic commitment included leadership, collegial nurse-doctor relationships, participation in hospital affairs, the foundations of quality nursing, clinical supervision, staffing, skill mix and patient turnover (Aiken, et al., 2008; Duffield, et al., 2009a; Estabrooks, et al., 2002; Kramer & Schmalenberg, 2004; Lake & Friese, 2006; McGillis-Hall & Doran, 2004; Needleman, et al., 2002; Proctor, 1986). These factors, together with measures of the nurse’s qualifications and experience, were assembled into an hypothesised model, based on an earlier framework that included the nurse’s perception of support, adequacy and legitimacy in their role along with their therapeutic commitment (Lauder, et al., 2000; Shaw, et al., 1978). Data were collected from 76 nurses across six mental health wards in general acute hospitals in New South Wales. A nurse survey collected the identified factors using the Practice Environment Scale of the Nursing Work Index (Lake, 2002), the Mental Health Problems Perception Questionnaire (Lauder, et al., 2000), and other questions. A ward profile was used to collect staffing, skill mix and patient movement data. Partial least squares path modelling was applied to the model in order to identify the most influential relationships. The most significant factors in the model were the foundations for quality care, nurse experience, participation in hospital affairs and clinical supervision. Services should enhance the support provided to clinical nurses in mental health through improved access to preceptorship, continued education and clinical supervision. In addition, the therapeutic commitment of nurses in mental health can be increased through improved continuity of care, access to career development opportunities such as the involvement of mental health nurses in the governance of the hospital, and improved responsiveness of administration to the needs of nurses in mental health. Engagement in these supportive activities should be enacted through structured mechanisms that both facilitate involvement and encourage evaluation. This study provides a basis on which to modify the operation of mental health services in general hospitals in order to improve the nursing work environment.

The therapeutic relationship is the central focus of nursing work in mental health (Peplau, 1992, 1997). However, there is currently little research that has examined influences on the nurses’ capacity to effectively engage in this relationship. This study investigated the impact of nurse, patient and work environment factors on the willingness and ability of nurses to engage in therapeutic relationships. This attribute of the nurse, identified as therapeutic commitment, is essential for an effective therapeutic relationship (Lauder, et al., 2000; Rogers, 1957), which has been identified by users of mental health services as the foundation of their care (Forchuk & Reynolds, 2001). The therapeutic relationship is central to nursing in mental health and has been linked to improved patient outcomes (Horvath, 2005). Environmental factors hypothesised to impact the nurse’s therapeutic commitment included leadership, collegial nurse-doctor relationships, participation in hospital affairs, the foundations of quality nursing, clinical supervision, staffing, skill mix and patient turnover (Aiken, et al., 2008; Duffield, et al., 2009a; Estabrooks, et al., 2002; Kramer & Schmalenberg, 2004; Lake & Friese, 2006; McGillis-Hall & Doran, 2004; Needleman, et al., 2002; Proctor, 1986). These factors, together with measures of the nurse’s qualifications and experience, were assembled into an hypothesised model, based on an earlier framework that included the nurse’s perception of support, adequacy and legitimacy in their role along with their therapeutic commitment (Lauder, et al., 2000; Shaw, et al., 1978). Data were collected from 76 nurses across six mental health wards in general acute hospitals in New South Wales. A nurse survey collected the identified factors using the Practice Environment Scale of the Nursing Work Index (Lake, 2002), the Mental Health Problems Perception Questionnaire (Lauder, et al., 2000), and other questions. A ward profile was used to collect staffing, skill mix and patient movement data. Partial least squares path modelling was applied to the model in order to identify the most influential relationships. The most significant factors in the model were the foundations for quality care, nurse experience, participation in hospital affairs and clinical supervision. Services should enhance the support provided to clinical nurses in mental health through improved access to preceptorship, continued education and clinical supervision. In addition, the therapeutic commitment of nurses in mental health can be increased through improved continuity of care, access to career development opportunities such as the involvement of mental health nurses in the governance of the hospital, and improved responsiveness of administration to the needs of nurses in mental health. Engagement in these supportive activities should be enacted through structured mechanisms that both facilitate involvement and encourage evaluation. This study provides a basis on which to modify the operation of mental health services in general hospitals in order to improve the nursing work environment.

The purpose of this research was to explore the process used by mental health nurses working with adolescents to ameliorate the experience of moral distress. Using grounded theory methodology, a substantive theory was developed to explain the process. All the incidents that lead to the experience of moral distress were related to safety and resulted in the nurse asking themselves the question, “Is this the best I can do?” Engaging in dialogue was the primary means nurses used to work through the experience of moral distress. Engaging in dialogue was an ongoing process and nurses sought out dialogue with a variety of people as they tried to make sense of their experience. Participants identified qualities of dialogue that were helpful or unhelpful as they sought to resolve their moral distress. Participants who had a positive experience of dialogue were able to answer the question, and continue working with adolescents with a renewed focus on the therapeutic relationship. Participants who have a negative experience of dialogue are unable to answer the question and either leave the unit or agency, or talk about leaving. / Graduate

The aim of this study was to describe the process and practices that informed fever therapy treatment at the Ontario Hospital, Toronto, and to describe the work of mental health nurses providing fever therapy at the Ontario Hospital, Toronto from 1941 to 1950. For almost a decade (1941 to 1950) the Ontario Hospital, Toronto operated a fever therapy unit for the treatment of neurosyphilis, an advanced stage of syphilis. This unit, the only one of its kind in Ontario, used specially designed cabinets to elevate patient temperatures in an attempt to kill the bacterium known to cause neurosyphilis. These treatments, lasting 8 to 10 hours, was taxing on patients, both mentally and physically, and often left the patient in a compromised medical state. The fever unit at the Ontario Hospital, Toronto was managed entirely by mental health nurses with next to no oversight from physicians, even in times of adverse medical reaction. This image of the mental health nurse as a highly skilled and competent practitioner is not one that has been historically assigned to this area of nursing. This thesis contributes to the history of mental health nursing in Ontario and nursing overall.

ABSTRACT A descriptive correlation study design, directed within the conceptual framework of Kanter’s (1977, 1993) Structural Theory of Organizational Behavior, examined mental health nurses’ perceptions of empowerment and job satisfaction. Empowering work settings are both necessary and critical since nurses need to be empowered to fulfill their role within the standards espoused by the nursing profession and to meet the challenges of a dynamic and evolving healthcare system that is flooded with service delivery demands. Empowerment within the workplace can result in job satisfaction which is essential given that empowerment and job satisfaction can lead to positive outcomes such as, quality patient care and professional autonomy. Furthermore, nurses’ job satisfaction has a significant effect on patients’ satisfaction with nursing care and overall patients’ satisfaction with their hospital care. Mental health nurses’ views regarding empowerment and job satisfaction are underrepresented in the literature. The purpose of this research was to describe the nurses’ perceptions of these variables and to further shed light on their perspectives. Fifty-five mental health nurses who were employed within an acute in-patient mental health program were recruited for the study. Four questionnaires, Conditions of Work Effectiveness, Job Activities Scale, Organizational Relationship Scale and the McCloskey/Mueller Satisfaction Scale were employed to determine nurses’ perceptions of the variables of empowerment and job satisfaction. A validation index was included to measure global empowerment. To test the first hypothesis, multiple linear regression was undertaken to determine the productive relationship of formal and informal power on perceptions of job empowerment. A Spearman’s rank-order correlation was used to assess the second hypothesis with regard to the magnitude of the relationship between empowerment and job satisfaction variables. P-values less than 0.05 were considered statistically significant. The hypotheses were as postulated, mental health nurses’ perceptions of formal and informal power were related to their perceptions of workplace empowerment, with formal power being more significant. Moreover, empowerment and job satisfaction were positively correlated. Similar to other research settings which were highlighted within the literature review, mental health nurses were moderately empowered and moderately satisfied within their work setting. Utilizing Kanter’s (1977, 1993) Structural Theory of Organizational Behavior as a guide can assist administrators in creating empowering work environments that can facilitate job satisfaction for mental health nurses. The presence of empowering and satisfying work conditions are vital within the specialty of mental health nursing if nursing care of the mentally ill patient is to be maximized and nurses are to reach their professional goal of providing quality patient care. Limitations to this research include the small sample size and the convenience sample methodology. Recommendations for further research involve surveying mental health nurses from other hospital sites and incorporating a qualitative viewpoint.

ABSTRACT A descriptive correlation study design, directed within the conceptual framework of Kanter’s (1977, 1993) Structural Theory of Organizational Behavior, examined mental health nurses’ perceptions of empowerment and job satisfaction. Empowering work settings are both necessary and critical since nurses need to be empowered to fulfill their role within the standards espoused by the nursing profession and to meet the challenges of a dynamic and evolving healthcare system that is flooded with service delivery demands. Empowerment within the workplace can result in job satisfaction which is essential given that empowerment and job satisfaction can lead to positive outcomes such as, quality patient care and professional autonomy. Furthermore, nurses’ job satisfaction has a significant effect on patients’ satisfaction with nursing care and overall patients’ satisfaction with their hospital care. Mental health nurses’ views regarding empowerment and job satisfaction are underrepresented in the literature. The purpose of this research was to describe the nurses’ perceptions of these variables and to further shed light on their perspectives. Fifty-five mental health nurses who were employed within an acute in-patient mental health program were recruited for the study. Four questionnaires, Conditions of Work Effectiveness, Job Activities Scale, Organizational Relationship Scale and the McCloskey/Mueller Satisfaction Scale were employed to determine nurses’ perceptions of the variables of empowerment and job satisfaction. A validation index was included to measure global empowerment. To test the first hypothesis, multiple linear regression was undertaken to determine the productive relationship of formal and informal power on perceptions of job empowerment. A Spearman’s rank-order correlation was used to assess the second hypothesis with regard to the magnitude of the relationship between empowerment and job satisfaction variables. P-values less than 0.05 were considered statistically significant. The hypotheses were as postulated, mental health nurses’ perceptions of formal and informal power were related to their perceptions of workplace empowerment, with formal power being more significant. Moreover, empowerment and job satisfaction were positively correlated. Similar to other research settings which were highlighted within the literature review, mental health nurses were moderately empowered and moderately satisfied within their work setting. Utilizing Kanter’s (1977, 1993) Structural Theory of Organizational Behavior as a guide can assist administrators in creating empowering work environments that can facilitate job satisfaction for mental health nurses. The presence of empowering and satisfying work conditions are vital within the specialty of mental health nursing if nursing care of the mentally ill patient is to be maximized and nurses are to reach their professional goal of providing quality patient care. Limitations to this research include the small sample size and the convenience sample methodology. Recommendations for further research involve surveying mental health nurses from other hospital sites and incorporating a qualitative viewpoint.

Magister Curationis - MCur / Research reported that it is very challenging for mental health care users to quit smoking and the risk of relapsing after quitting is high. However, tobacco dependence treatment is possible and potentially lifesaving for people. The delivery of tobacco dependence treatment by nurses is influenced by a variety of factors, including lack of knowledge and skills, limited professional leadership, and smoking within the profession. There is a strong link between mental illness and smoking-related diseases, including cancer, respiratory diseases and heart diseases that are linked with depression. There is a high incidence of cancer in people with bipolar mood disorder and schizophrenia due to smoking. In spite of this, smoking is regarded as part of the culture of psychiatric institutions and tobacco is seen as “necessary self- medication for the mentally ill”.

Magister Curationis - MCur / Research reported that it is very challenging for mental health care users to quit smoking and the risk of relapsing after quitting is high. However, tobacco dependence treatment is possible and potentially lifesaving for people. The delivery of tobacco dependence treatment by nurses is influenced by a variety of factors, including lack of knowledge and skills, limited professional leadership, and smoking within the profession. There is a strong link between mental illness and smoking-related diseases, including cancer, respiratory diseases and heart diseases that are linked with depression. There is a high incidence of cancer in people with bipolar mood disorder and schizophrenia due to smoking. In spite of this, smoking is regarded as part of the culture of psychiatric institutions and tobacco is seen as “necessary self- medication for the mentally ill”. Historically, cigarettes have been used for behavioural reinforcement within the psychiatric setting. Mental health nurses also have the highest rate of smoking behaviour, which is coupled with permissive attitudes towards smoking among Mental health care users. It is also reported that nurses lack knowledge regarding the interaction of tobacco dependence with treatment of mental disorders. Nurses are also regarded as role models and therefore, nurses’ beliefs and attitudes regarding the smoking behaviour of mental health care users have an influence on any smoking cessation interventions. The psychiatric institution where the researcher was employed had recently implemented a smoke-free policy in the wards. The aim of this study was to investigate the knowledge, attitude and practices of mental health nurses related to tobacco dependence among MHCUs in a psychiatric institution in the Western Cape. The researcher used a descriptive survey design to carry out this study at a selected government-funded tertiary psychiatric hospital in theWestern Cape, South Africa. The target population comprised all mental health nurses permanently employed at this institution (169) and all-inclusive sampling was used. Data was analysed using SPSS Statistics version 24. The findings of the study reveal mental health nurses had good knowledge on tobacco dependence among MHCUs and that they had positive attitudes regarding the need to combat tobacco dependence among MHCUs. This is revealed through their knowledge on the dangers of smoking to MHCUs. The quality of training influences knowledge, which in turn cultivates a positive attitude regarding the need to combat tobacco and smoking addiction among MHCUs. There is also difference between the attitudes of non-smokers and those of smokers regarding the treatment of nicotine and tobacco dependence in MHCUs. For instance, mental health nurses who smoke perceive smoking as a necessary element for creating relationships with their patients, and therefore they tend to have a relaxed attitude towards treating smoking addiction among patients. Those who do not smoke tend to perceive combating nicotine dependence as essential. A recommendation is that some form of training for mental health nurses is needed to cultivate positive attitudes towards strategies meant to curb smoking addiction.

The present thesis was carried out in part fulfilment of the Doctorate in Clinical Psychology at the University of Edinburgh. It is presented in portfolio format, comprising of two individual papers although a total thesis abstract provides an overview of the entire thesis. The first paper is a systematic review of existing empirical research. It explores the predictive validity of risk assessment tools for imminent (short-term) violence and aggression in forensic psychiatric settings. The second paper is an empirical study exploring how frontline nursing staff both predict and emotionally cope with experiencing violence and aggression in a high-security setting. Paper one was prepared for Aggression and Violent Behavior and paper two for The International Journal of Forensic Mental Health; so, follow their respective author guidelines. Mental health, and forensic mental health nurses have been identified as being at particular risk of experiencing patient perpetrated violence and aggression (PPVA). There is relatively little research investigating how nursing staff predict and cope with more immediate, imminent inpatient violence and aggression, specifically within secure (forensic) settings. Negative outcomes of PPVA are widely accepted and demonstrated within empirical literature, including increased anxiety and stress for staff, fractures to the therapeutic relationship between patients and staff, and difficulties with staff retention and absenteeism for the organization. Due to the extensive negative outcomes associated with PPVA, a wealth of research has focused on developing the area of violence risk assessment. Despite this, there remains limited understanding regarding the utility of existing risk assessment tools for predicting and assessing violence risk over brief time frames (i.e. days to weeks). Therefore, a systematic review was conducted to explore the predictive validity of violence risk assessment tools for imminent, short-term risk in inpatient forensic psychiatric settings. Findings demonstrated that multiple tools had decent predictive validity, however quality scores were impacted by small sample sizes. The Dynamic Appraisal of Situational Aggression- Inpatient Version was the most effective tool with the highest mean quality score. The main limitations were the small number of studies assessing some of the included tools and the level of ambiguity between studies regarding the definition of imminent, short-term violence. Developing a shared understanding of what constitutes short-term risk and improving the number and quality of studies on the largely neglected tools, should therefore be research priorities. How nurses actually recognize and predict inpatient violence and aggression in forensic psychiatric settings, and how they emotionally cope with the aftermath, are poorly explored and understood processes. A social constructivist grounded theory approach was used to analyze the transcripts from 12 interviews with frontline nursing staff from an inpatient high-security setting. A model was constructed integrating nurses' beliefs and assumptions about subtypes of violence, their efforts to use observation skills in order to aid risk prediction, and their resultant emotional experiences following PPVA. Nurses emotional coping seemed to be affected by several factors relating to the culture of the organization and the accessibility of support. Seemingly, knowing the patient helped nurses to better identify underlying needs leading to violent behavior. This understanding helped nurses to implement targeted, needs-led interventions to address these unmet needs, and so reduce recurrent and cyclical violence. Recommendations are made to build upon, and utilize nursing skills in risk prediction and management, and to help better support the emotional impact of experiencing PPVA within forensic psychiatric settings.

Thesis (MPH.) --University of Limpopo, 2018 / Background: Employee morale is a critical factor in any organization either be locally and or globally and Botswana is no exception. Mental health nurses have been considered professionals that assist people to regain a sense of coherence over what is occurring to them - be it a result of trauma or some other form of mental distress. Good morale among staff on inpatient psychiatric wards is an important requirement for the maintenance of strong therapeutic alliances and positive patient experiences, and for the successful implementation of initiatives to improve service delivery. The aim of the study was to determine the factors influencing nursing staff morale at S’brana Psychiatric Hospital (SPH) in Botswana. Methods: A quantitative, cross sectional study was conducted on 147 respondents. Self-administered questionnaire was used for data collection and it was closed ended. Data was collected at S’brana Psychiatric Hospital (SPH) and stratified random sampling technique was used to select nurses according to their categories. Data were analyzed through SPSS Software v21.0. Results: The results revealed that the majority of the nurses were aged between 26 - 30 years and most of them were females compared to males. It is evident from the results that, there was strong association between number of years and nursing position (χ2(15) = 72.34, p = .000). Also, there was positive correlation between respondents highest qualification in nursing and training received to do the job well (r = .312, n = 147 and p = .000.). Multiple regression analysis showed a statistically significant, F(3, 143) = 46.69, p = .000, and accounted for 70.3% of the variance. Conclusion: This study has revealed that nurses’ morale in SPH can be affected by a number of factors irrespective of their age, work experience, nursing position and ward they work in. The consequences of low staff morale are detrimental to health professionals (nurses) and patients, therefore, it is important for healthcare managers to address the shortcomings in order to counteract the negative effects of low staff morale