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.

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I employed classical grounded theory methodology to formulate a theory of establishing therapeutic relationships in the context of public health nursing practice. Targeting Essence: Pragmatic Variation of the Therapeutic Relationship emerged as the theoretical model that elucidates how public health nurses develop therapeutic rapport with vulnerable and potentially stigmatized clients, specifically lower income lone-parent mothers. Data sources consisted of interview transcripts and dyadic observations. Public health nurses and lower income lone-parent mothers were the primary participants. During analysis, other sources for data were sought to achieve saturation of conceptual categories and theoretical integration. Targeting Essence: Pragmatic Variation of the Therapeutic Relationship is a six-stage process that evolved from theoretical interpretive analysis of the participants general pattern of relating. Public health nurses strategically modify the therapeutic relationship during their efforts to ascertain main concerns of mothers within the constraints of contemporary practice. Lower income lone-parent mothers with heightened sensitivities enact interactional behaviours to discern the intent of public health nurses. The studys focused context elicited a nuanced explanation of the dynamic process that builds on the fundamentals of communication. Targeting Essence: Pragmatic Variation of the Therapeutic Relationship has the potential to enhance relational practice capacity, to advance nursing communication training curricula, and, ultimately, to promote maternal/child health and well-being.

The relationship expected to occur between a therapist and his or her clients is a fiduciary relationship, a relationship of special trust. Professional boundaries ensure that the needs of clients remain primary. However, boundary transgressions are inevitable. Unfortunately, boundary transgressions have the potential of exploiting clients. Most of what is known about boundary transgressions comes from the perspective of professionals. The literature reiterates the importance of educating the lay public about the dangers of boundary transgressions. This study experimentally examined what effect education specific to boundary transgressions has on the lay public's level of acceptance of boundary transgressions, as opposed to what effect general information about personal/family therapy has on the lay public'­s level of acceptance of boundary transgressions. Two hundred students from a southeastern university participated and read either general information pertaining to personal/family therapy, or specific information pertaining to boundary transgressions, prior to rating their level of acceptance of therapists transgressing boundaries with their clients. Independent sample t-tests determined there were statistical differences in mean ratings of acceptance of boundary transgressions between the groups. However, because the mean scores between the two groups were not much different, the results suggest that the lay public could benefit from a more comprehensive explanation of boundary transgressions. / Master of Science

Yes / Objectives: To explore experienced physiotherapists’ attitudes, beliefs and experiences regarding their personal role in contributing to effective therapeutic relationships when working with people with chronic musculoskeletal pain. Design: Descriptive qualitative design using semi-structured interviews. Setting: Within physiotherapy departments in two National Health Service acute secondary care trusts in the North West of England. Participants: Six experienced physiotherapists working with people with chronic musculoskeletal pain. Data Analysis: Thematic coding analysis of transcribed interview recordings Main outcomes: Four overarching themes emerged from the data: Listening to the person; a caring understanding of the person’s situation; engaging the person and coming together; and moving forwards. Results: Participants emphasized the importance of building effective therapeutic relationships when working with people with chronic pain, seeking to create these by engaging with the person, to promote a strong collaborative partnership. Participants highlighted the themes of listening to the person’s story and showing a caring understanding of their situation through empathy and belief with validation. The final theme of moving forward emphasized how positive therapeutic relationships aid the rehabilitation process in enabling people to make positive changes in their lives. Conclusions: A clearer understanding of how physiotherapists engender positive therapeutic relationships has the potential to improve training and service development priorities for physiotherapists working in the area of chronic musculoskeletal pain. Future studies should seek to further define the core dimensions impacting therapeutic relationships, from the perspectives of both physiotherapists and people with chronic musculoskeletal pain. / Health Education Yorkshire and the Humber

This thesis comprises three main sections: a literature review, research report, and a critical appraisal of the research process. The literature reviewed is the existing research relating to trust as a construct. An attempt is made to clarify the conceptual confusion that exists in the area, by suggesting a comprehensive definition of what is meant by the term trust for the purposes of both the current study and future research. The importance of trust in relation to mental health and therapeutic relationships is discussed. Current measures of the construct are critically examined, and the ‘scientist’ versus ‘humanist’ divide is explored. It is concluded that a new multidimensional trust measure is required to further research efforts in the area. The aim of the research project was to develop a trust measure to form a part of a larger endeavour to operationalise the concept of mental health via key set of basic human emotions and responses. The research reported in Section 2 consists of a Pilot Test, Main Study, and follow up validation study of a new multidimensional measure of trust. Three bases of trust were hypothesised and tested. These were: self trust, interpersonal trust, and environmental trust (that is, trust in wider social, cultural, or political context). A new measure was constructed and validity tested using an inductive approach, and the relationship between trust and trait anxiety was also examined. The results supported the hypothesis that trust is a multidimensional construct, and demonstrated a strong relationship between trust and trait anxiety. It is hoped that this work will rekindle research interest in this important area. The final section is the researcher’s critical appraisal of the research process based on her personal research diary. It is a reflective piece that examines the impact of the research on the researcher (and vice versa) and the critical events in the research process.

This narrative inquiry explores therapeutic relationships in the practice of recreation therapy. Narratives were generated in Recreation Therapy’s self-reflective case review process at Sunnybrook Health Sciences Centre—a process developed to support team engagement in reflections on their therapeutic relationships. In total, three self-reflective case reviews were explored, and for each case review, four layers of analysis occurred. The first two layers used narrative analysis to restory reflections of the case review leader (layer one) and then reflections within the recreation therapy team (layer two). The third and fourth layers used analysis of narrative to explore theoretical ideas from person-centred care emerging inductively in the text (layer three), and then to restory the previous narratives using a relational theory lens (layer four). Exploration revealed the self-reflective case review process also strengthens therapeutic relationships within the recreation therapy team. In the recreation therapists’ narratives we hear relational notions of connection, disconnection, reconnection, mutuality, mutual empathy, authenticity, vulnerability, and support. This study engaged recreation therapists in an act of critical pedagogy as they engaged in critical self-reflection by exploring across layers of narrative that story their therapeutic relationships. The self-reflective case review process creates opportunity for the recreation therapy team to recognize, identify and name their experiences within therapeutic relationships, and to find their voices in the medical context of a hospital setting. When engaging in self-reflective processes, recreation therapy moves further away from treating individuals as objects, shifting practice toward connection and mutuality in therapeutic relationships.

This narrative inquiry explores therapeutic relationships in the practice of recreation therapy. Narratives were generated in Recreation Therapy’s self-reflective case review process at Sunnybrook Health Sciences Centre—a process developed to support team engagement in reflections on their therapeutic relationships. In total, three self-reflective case reviews were explored, and for each case review, four layers of analysis occurred. The first two layers used narrative analysis to restory reflections of the case review leader (layer one) and then reflections within the recreation therapy team (layer two). The third and fourth layers used analysis of narrative to explore theoretical ideas from person-centred care emerging inductively in the text (layer three), and then to restory the previous narratives using a relational theory lens (layer four). Exploration revealed the self-reflective case review process also strengthens therapeutic relationships within the recreation therapy team. In the recreation therapists’ narratives we hear relational notions of connection, disconnection, reconnection, mutuality, mutual empathy, authenticity, vulnerability, and support. This study engaged recreation therapists in an act of critical pedagogy as they engaged in critical self-reflection by exploring across layers of narrative that story their therapeutic relationships. The self-reflective case review process creates opportunity for the recreation therapy team to recognize, identify and name their experiences within therapeutic relationships, and to find their voices in the medical context of a hospital setting. When engaging in self-reflective processes, recreation therapy moves further away from treating individuals as objects, shifting practice toward connection and mutuality in therapeutic relationships.

Therapeutic relationships were explored using participatory action research in recreation therapy at Sunnybrook Health Sciences Centre (SHSC). The 22 recreation therapists at SHSC comprised the research team and were actively involved throughout the research process; they determined the research questions, the research process, and engaged in data collection and data analysis. This study explored how recreation therapists understood their therapeutic relationships, how different waves of influences were negotiated and philosophies of care that emerged in their therapeutic relationships. At first glance, therapeutic relationships were understood as meaningful connections and shared experiences that developed over time between a recreation therapist and individual receiving care. Later on, therapeutic relationships emerged as a complex process with welcoming, continuing and closing phases. Positive therapeutic relationships were defined by qualities such as caring, trust, respect, and non-judgment for everyone involved. Therapeutic relationships were also influenced by the organizational context, unit specific cultures, family, and staff members and recreation therapists continually negotiated the expectations, power and boundaries of these influences within their therapeutic relationships. The recreation therapists also discussed the different roles, they and the individuals receiving care could engage in during their therapeutic relationships ranging from the traditional, contemporary or controversial. Findings revealed that recreation therapists’ practices were predominantly influenced by person-centered care philosophies, although the biomedical model and relationship-centred care philosophies were also apparent. The practice of being in the moment emerged as a means of enhancing therapeutic relationships, whereas self-reflective practice assisted the recreation therapists to negotiate different waves of influence on their therapeutic relationships.