INTRODUCTION

Since moving out of the institutional setting whichwas its exclusive site of practice for over 100 yearst h e re has been little re s e a rch into the practice ofmental health nursing in New Zealand. Thechange in location and focus of nursing educationf rom the hospital with its medically and pro c e d u r-ally oriented curriculum to the generalist nursingfocus of the polytechnic has also occurred in theabsence of substantial re s e a rch into the practiceof mental health nursing.

This study is a preliminary investigation intomental health nurses’ perceptions of theirpractice. The study used two focus group inter-views to gain data which were analysed forthemes using a three-stage inductive process.The interpersonal relationship was found to be

central to the practice of the participants. Thetheme of the nurse–patient realtionship and thesubthemes of involvement, individualising care,and minimising visibility describe a dynamicprocess in which the nursing relationship is con-stantly negotiated.

BACKGROUND

Understanding the knowledge that underliesnursing practice has been identified as a ‘highpriority for the future of psychiatric nursing as aspecialty area of nursing practice’ (McElro y, 1990,p.1). This concern has been echoed in the NewZealand context by Ryan (1997). The limitedamount of re s e a rch into mental health nursingpractice in New Zealand means that mentalhealth nurses are currently unable to art i c u l a t e ,f rom a re s e a rch basis, the knowledge underlyingtheir practice. In considering the future of mentalhealth nursing, Sanggaran (1993) identified twokey roles of nurses: carrying out medical tre a t-ment and the psychotherapeutic role. Sangarr a n

Australian and New Zealand Journal of Mental Health Nursing (1999) 8, 153–161

FE AT U R E ART I C L E FA 1 4 8 E N

Negotiating the relationship: Mentalhealth nurses’ perceptions of their practice

Anthony J. O’BrienDepartment of Psychiatry and Behavioural Science, University of Auckland, Auckland, New Zealand

ABSTRACT: This exploratory descriptive study used focus groups to investigateexperienced mental health nurses’ perceptions of expertise in relation to theirpractice. Two focus group discussions were conducted, one comprising four nursesworking in inpatient care and the other with five nurses working in community care.The nurse–patient relationship was the central theme for both groups. Three sub-themes were identified and are discussed. They are involvement, individualisingcare, and minimising visibility. The significance of these themes for the articulationof mental health nursing practice is discussed.K E Y W O R D S : individualising care, involvement, nurse–patient r e l a t i o n s h i p ,qualitative research, visibility.

C o rre s p o n d e n c e : Anthony J. O’Brien, Department ofP s y c h i a t ry and Behavioural Science, University ofAuckland, Private Bag 92019, Auckland, New Zealand.

Anthony J. O’Brien RGN, RPN, BA.Accepted March 1999.

a rgues that recent changes in the social context ofmental health care, such as deinstitutionalisationand the emergence of the generic ‘compre h e n-sive’ nurse have challenged mental health nursingidentity and continuity. It would appear that thedistinct identity sought by Sangarran must bebased on the therapeutic relationship which is atthe heart of mental health nursing.

Benner (1984) found that nurses practisingwith a high level of expertise frequently gobeyond their theoretical understandings anddevelop practical knowledge which can notalways be explained by formal theories. Benner’swork has been influential in New Zealand nursing(Price, 1995). The concept of ‘expertise’ is widelyused. However, Price felt that there was need toevaluate the applicability of Benner’s work for therealities of nursing in New Zealand.

The current study sought to identify the per-spectives of experienced practitioners, as exper-tise is considered to develop with experience. Byexploring and describing the perceptions ofexperienced practitioners it is expected thatthemes will emerge which can be furt h e rre s e a rched to continue the task of articulating thepractice of mental health nursing in New Zealand.The purpose of the study was to document experi-enced mental health nurses’ perceptions of exper-tise in relation to their practice.

METHODOLOGY

A constructionist view of the research processwas adopted (Guba & Lincoln, 1994). Within theconstructivist view, inquiry is regarded as a socialactivity in which understandings emerge dialog-ically. Reality is considered to exist as ‘multiple,sometimes conflicting mental constructions ofeveryday life experiences that are situation andcontext dependent’ (Ford-Gilboe, Campbell, &Berman, 1995, p. 16). It was assumed that the‘reality’ of nurses’ perceptions of their practicewas variable within and across individual nurses,and did not represent a unified set of ideas thatcould be elucidated without a process of inter-action. The social position of the researcher as amental health nurse provided a common per-spective between researcher and participants.

Commonality of perspective is considered toenhance the quality of constructionist inquiry(Guba & Lincoln, 1994).

FOCUS GROUPS AND NURSINGRESEARCH

Focus groups were originally developed as amarket re s e a rch tool (Morgan, 1988). Morerecently the potential utility of focus groups inhealth and nursing research has been recognised(Basch, 1987; Kingry, Tiedje, & Friedman, 1990)and they have been used in a variety of nursingresearch studies. Happell (1996) has describedthe potential usefulness of focus groups in mentalhealth nursing re s e a rch. Krueger (cited inK i n g ry, Tiedje, & Friedman, 1990) describesfocus groups as ‘a carefully planned discussiondesigned to obtain perceptions on a defined areaof interest…’. Focus groups generate observa-tions, contradictions, explanations and elabora-tions which illuminate the phenomena beingstudied (Kitzinger, 1994).

The use of focus groups to inquire into per-ceptions is consistent with the constructionistassumption that ‘…what we take to be objectiveknowledge and truth is the result of perspective.Knowledge and truth are created, not discoveredby mind’ (Schwandt, 1994). In constructionistresearch the researcher is part of the process ofthe construction of knowledge. Focus groupsproceed through a dialectical process leading toarticulation of individual perspectives and iden-tification of areas of consensus and difference.The researcher is involved in this process andcontributes to the development of truth andknowledge within the group.

ETHICAL CONSIDERATIONS

Ethical approval for this study was obtained sep-arately from the host institute and the local healtha u t h o r i t y. Ethical concerns identified wereinformed consent, privacy, confidentiality andsoundness of research. Participants were givenan initial briefing about the nature and conductof the research, and issues of voluntary partici-pation, the right to withdraw, privacy and confi-

154 A. J. O’BRIEN

dentiality were discussed. An information sheetin which these issues were explained was alsoprovided. Participants were asked to sign a formconsenting to their participation.

METHODS

Sampling

An initial purposive sample of five was obtainedby placing an advertisement in a staff newsletterexplaining the nature of the research and askinginterested individuals to contact the researcherfor further details. Other participants wererecruited by snowballing. An eventual sample ofnine participants was obtained.

ParticipantsParticipants comprised two groups of mentalhealth nurses, one of nurses employed in com-munity mental health, and the other of nursesemployed in inpatient care. All were pakeha1 andwere currently practising as either RegisteredPsychiatric or Comprehensive nurses. All exceptone2 met the research criteria of ‘experienced’ byhaving two or more years’ full time experience inmental health nursing. The length of experienceranged from one to 20 years, with a mean of tenyears. The characteristics of each group areshown in Table 1.

Data collectionData were collected in the form of audiotapedfocus group discussions, later typed to providewritten transcripts, and field notes. Participantswere asked to respond to the question: ‘What doyou consider to be expert mental health nursingpractice?’ by discussing their perceptions inrelation to their own practice. Consistent with the

recommendations of Morgan (1988) andKitzinger (1994) participants were encouraged totalk amongst themselves rather than to respondindividually to the interviewer. Moderator inter-vention through the use of probes and clarifyingquestions was aimed at encouraging interactionbetween participants.

AnalysisAnalysis of the transcripts involved an inductivep rocess and was carried out in three stages.Transcripts were first read individually by theresearcher, the research supervisor, and a col-league with clinical experience in mental healthnursing. Margin notes were made to identifythemes, and numerical codes used to denotepassages of text in which themes occurred (Morse& Field, 1995). At subsequent meetings all threereaders discussed and compared their readingsof the transcripts. Agreement was reached aboutthemes which were apparent.

The initial findings were then discussed withas many of the research participants as couldmake themselves available (n = 5). There waslittle dissent as to the initial findings, and no substantial changes were made following this discussion.

RESULTS

The nurse–patient relationship was central to thepractice of both groups. For both groups therewas a sense of negotiating, maintaining and re-

M E N TAL HEALTH NURSES’ PERCEPTIONS OF PRACTICE 1 5 5

1 The term pakeha refers to members of the European pop-ulation of New Zealand (Orange, 1987).

2 This participant was included in the study as the result of anoversight in the process of scrutinising the consent forms onwhich participants’ details were recorded.

TABLE 1: Characteristics of focus group participants

Category of registration Years of experience Gender

Registered Psychiatric Registered Comprehensive Nurse Nurse M F

Group One. Community-based nurses (n=5) 2 3 Range = 1–18

Mean = 10 2 3Group Two. Inpatient 2 2 Range = 5–20

nurses (n=4) Mean = 13 2 2

negotiating the relationship. This was highly con-textual, situational and dynamic and can only bedescribed as a process rather than a fixed phe-nomenon. Three subthemes relating to thenurse–patient relationship are discussed in detailbelow. These subthemes are overlapping andsometimes contradictory, underlining the com-plexity of clinical practice.

InvolvementInvolvement emerged as a process in which thenurse seeks to negotiate a relationship with herclients. With time and experience involvementtakes on fundamental personal meanings for bothnurse and client, suggesting that a narro wconcept of involvement in a therapeutic rela-tionship is not adequate to describe the relation-ship as it develops over time.

Both groups of nurses spoke of a sense ofinvolvement with clients which went beyond theimmediate focus of the situation. This wasexpressed as ‘being there for the client’, and being‘totally committed to actually listening and sup-porting and helping that person’. Involvementcan be seen in interactions which are overtlycasual but which nevertheless are suffused withmeaning and significance for the nurse:

But you’re not just going and having a cup oftea, I mean you sit down and you know, catchup with each other and sort of connect to whereyou are at the moment, have a cup of tea, andthen you might get into talking about somespecific type of thing…[it’s ] . . . p a rt of theprocess.

In situations where one purpose of a visit is togive medication, this is seen as secondary toinvolvement in the relationship:

But I make it part of my practice to sit downwith the person first and try to talk to them andthen say, then bring in the injection later. It’s gotto come as the secondary thing to the…, youknow, the primary thing is that I was going thereto see the person...

The theme of involvement also showed up asa recognition of constraints which limited thepossibilities of the nurse–patient relationship.One community-based nurse used the metaphor

of ‘being invited’ to refer to the process of nego-tiating involvement when visiting a client athome. This nurse was acutely aware of theconflict involved in maintaining therapeuticinvolvement under conditions of legal constraint:

And even if they’re a person who’s under a CTO3

I’m still an invited guest into their home…It’sbeing invited, you know, all those pleasantriesand niceties which allow the person to see, yes,ok, well this is my castle and you’re an invitedguest.

In this situation it was particularly important toensure that the legally mandated nature of thenurse’s involvement did not translate into aninvasion of the client’s person.

While the involvement of nurse and patient isusually seen in the context of a therapeutic rela-tionship, one nurse related an experience whichsuggests that this ‘therapeutic’ involvement doesnot fully describe the involvement that occurs inlong term relationships between nurse and client.The nurse had been filmed incidentally as partof a television news story (not part of his nursingrole) which had been seen by the client:

...one of the guys came in on Monday and said‘Oh look, I, the TV was on the other night andI saw you on that, and I said, ‘Oh that’s my nurse’.And I thought what a funny thing, I have thisrelationship with this guy that I’m his nurse. Andits just a funny situation, so, you’re part of theirlives, you know?

Involvement occurs in both the specificconcrete circumstances of current relationships,and as an enduring commitment to individualsover time. Participants discussed their involve-ment with clients over many admissions tohospital and with several members of the samefamily. The sense of involvement went beyondthe specific therapeutic goals of a single rela-tionship, or the goals of a single episode of care.

I’ve watched it myself, I’ve seen people comeinto the units that I knew many, many years ago.

156 A. J. O’BRIEN

3 A Compulsory Treatment Order (CTO) under Section 28 ofthe Mental Health (Compulsory Assessment and Tre a t m e n t )Act (1992). A CTO can be either an Inpatient Order (Section29) or a Community Treatment Order (Section 30), both ofwhich provide for compulsory tre a t m e n t .

And I’ve looked at them and I’ve wondered, Ithought: it’s a tough life.

This statement was made in the context of a dis-cussion about the long term nature of someclients’ illnesses, and the long term nature of therelationship between nurse and client. Anotherparticipant related an anecdote indicating thatlong term involvement is reciprocal:

I know people that have come in that I’ve knownmany years ago…you have a relationship withthem that dates a long time, you know, a verylong time ago…Sometimes they relate to youstraightaway…you mightn’t have seen them foryears…I’ve had that happen to me two or threetimes…I’ve hardly said a word to them, and theyknow who I am, they know my name and theystart talking as if we, we haven’t had that gap ofyears and years.

For the nurses in this study, nursing relation-ships are characterised by involvement which isprimary to other aspects of nursing care, such asassessment, giving medication and initiatingadmission to hospital. This involvement is bothsituational, in that it is apparent in individualepisodes of care, and enduring, in that it extendsbeyond and connects individual episodes overlong periods of time. Enduring involvement wasperceived by nurses in this study as reciprocal.Involvement is sought by nurses as they negoti-ate relationships with clients, and results inperson to person engagement which is meaning-ful in itself, rather than a means to a therapeuticend.

Individualising careIn their discussions of their practice, the nursesin this study made many references to the impor-tance of identifying the individual needs of clientsand responding in ways that recognised clients’individuality. There were differences betweenthe two groups in how this subtheme was realisedin practice. Inpatient nurses spoke of the poten-tial for unit rules to prevent the individualisationof care, and the skill of ‘bending the rules’ as partof the practice of experienced nurses. ‘Bendingthe rules’ was also mentioned by community-based nurses. For this group the subtheme ofindividualising care also showed up in their

emphasis on responding to individual needs inprioritising their daily work.

Inpatient nurses spoke of varying the institu-tional rules based on their assessments of indi-vidual clients’ needs.

You’ve got to look at the purpose behind [therules]. The rule and why it was put there. A bitlike the intention of the law, you know, the wayi t ’s not just the word of the law, but the intention.

The ability to interpret rules was seen asrelated to experience, with more experiencednurses seen as being able to ‘bend the rules’ inthe interests of individual clients than less experi-enced nurses.

I think when you’re more experienced you’reable to realise which risks are worth taking.

Community-based nurses also saw bendingthe rules to meet individuals’ needs as an impor-tant part of their practice. A policy of not visitingclients at their place of work was seen as arbi-t r a ry and restrictive if it was not what the clientw a n t e d :

And we don’t accept the practice of not visitingpeople in their workplace. But I visited peopleon Saturday mornings…outside their place ofwork…Because it suited that person…So to methat’s perfectly OK, if the consent is given by theperson.

Defining boundaries was an important aspectof responding to individual differences for com-munity-based nurses:

You know some people — you will go in and chatabout their family and sit down and have a cupof tea; with another person you might go andvisit and you’d never get that close, you’d be verycareful about your boundaries, you know, you’refurther apart.

As with involvement, the need to individu-alise care was perceived as an organising princi-ple of nursing care. It was reflected in nursingdecisions and activities and in interpretations ofrules. Where involvement appears as a pro c e s sof negotiating a relationship, the subtheme ofindividualising care recognises the need torespond to individual diff e rences within the re l a-t i o n s h i p .

M E N TAL HEALTH NURSES’ PERCEPTIONS OF PRACTICE 1 5 7

Minimising visibilityNurses in both groups spoke of strategies theyemployed to minimise the visibility of theirinvolvement with clients. For both groups therewas sense in which their involvement was eithernot wanted or brought with it a feeling ofbreaking interpersonal or social boundaries. Yetthe imperative of care necessitated that nursesnegotiated involvement even where there wasambivalence or resistance to their involvement.The strategy of minimising visibility is the meansby which the nurses in this study negotiated theirinvolvement while recognising and respectingthe client’s interpersonal boundaries and thesocial boundaries which surround mental illness.

For the inpatient nurses a clinical professionalrole was seen as a potential barrier to their rela-tionships with their clients. Minimising the visi-bility of that role meant that they became morehuman and accessible to their clients:

…it’s actually breaking down the role barriers,you know the nurse–patient role, and you wantto relate as an equal human, you know, just likea friend or whatever…You try and break downthose barriers by getting on the same level asthe patient…

There was sense of contradiction arising fromthe recognition that minimising the professionalrole by ‘being natural’ with clients entailed therisk of overstepping boundaries:

If we’ve overstepped the boundary, having theability to perform damage control really quickly.It saves your bacon.

For the community-based nurses the skill ofminimising visibility showed up in ways that werequite striking. The minimising of the professionalin favour of a personal approach was seen asvaluable in establishing and maintaining a rela-tionship. The community-based nurses showedan acute awareness of the issue of visibility anddescribed some of the strategies used to reducethe visibility of their intervention. Maintaining anawareness of being in the client’s home is part ofthis process. In the community-based nurse’spractice described previously by the metaphor of‘being invited’, the nurse described a strategy ofnon-intrusiveness in order to gain acceptance.

One nurse talked of ‘hiding the skill’, a con-scious strategy of minimising the visibility ofnursing skills while maintaining an awareness ofthe need to assess and deal with pro b l e m s .Assessment was referred to as an unobtrusiveprocess that occurred in the context of ordinaryinteractions:

You’re doing it all the time aren’t you? Everytime you see a client you’re making an assess-ment even though you might not actually beasking them, you know, how are you sleeping,w h a t ’s your appetite like, what’ve you beendoing…Even if you don’t actually ask questionsyou’re assessing somebody.

When intervention occurs in the client’s homethe need to be non-intrusive is accentuated. Inthe following excerpt the nurse describes aconcrete example of visibility and its meaning forthe client.

With one person on a CTO…I’ve just discov-ered over the last few months that it makes herfeel a lot more comfortable if I don’t carry theblack box, you know, our briefcases look likesewing machine cases. And you know that wasa real issue for her because every time I rockedup to her house, she felt like all the power wasin the black box, so now I carry everything sep-arately.

For the client the black box was a signifier ofpower. This visible symbol of the nurse’s practiceheld meanings for the client which went farbeyond its utility for the nurse. This interactiontook place in the publicly visible space aroundthe client’s home, and demonstrates that visibil-ity issues are accentuated when care is providedin the client’s home rather than within the pro-fessional space of the hospital or clinic. It isnotable that the client did not request that thenurse stop visiting, just that the visibility of herpractice was reduced by removing its principalsymbol.

Sensitivity to how clients perceive the nurse’spresence and involvement leads to the adoptionof practices of reducing the visibility of theirinvolvement. These are not always welcomed byclients who, perhaps aware of the nurse’s sensi-tivity to her visibility, may have their own reasons

158 A. J. O’BRIEN

for thwarting the nurse’s attempts to reduce vis-ibility.

…I looked after one person who insisted onalways having her injection on the verandah.And I always felt absolutely terrible about that,you know, and I’d say, look, don’t you want itinside, and she’d say, no, I don’t care if the neigh-bours see this.

Minimising visibility is a practical skill whichrecognises the effect of intrusiveness on thenurse–patient relationship, and the dynamics ofpower involved. The nurses in this studydescribed negotiating their relationships withclients by reducing the visibility of their involve-ment, and by attempting to minimise the extentto which mental illness results in an experienceof intrusion.

DISCUSSION

The nurse–patient relationship was central to thepractice of the nurses in this study. The sub-themes of involvement, individualisng care andminimising visibility describe practices which areimplicit in the process of negotiating and main-taining this relationship. There is significantoverlap between these subthemes.

Involvement is negotiated in specific interac-tions and long term relationships. It is an expres-sion of nurses’ commitment to clients whichextends beyond the demands of particular situa-tions and is primary to empirical and legallymandated interventions such as assessment,giving medication and enacting legislated roles.Mental health nursing is considered by the nursesin this study to be a practice in the moral senseof a set of activities designed to promote the good,rather than merely efficiently ‘meet the needs’ ofclients (Bishop & Scudder, 1990).

The significance of involvement arising from‘ordinary’ interactions has been discussed by Fry(1998) whose depiction bears similarities to thatof the nurse whose perception was presentedearlier.

Mental health nursing connects with clients byactively sharing experiences with them, such asplanning a programme of care and implement-

ing it, having a cup of tea and discussing things,providing information, administering medica-tion and participating in leisure activities (Fry,1998, p. 30).

The effect on the therapeutic relationship ofnurses’ participation in the involuntary admissionprocess has been the subject of an investigationby Street and Walsh (1994). It seems likely thatthe primacy nurses accord involvement creates acontext for conflict when the nurse is legally, andperhaps ethically, obliged to act in contraventionof the client’s explicit wishes. The practice ofmaintaining a therapeutic relationship is partic-ularly problematic when the nurse’s involvementis to some extent legally mandated. This createsan environment for an experience of intrusion,invasion and coercion. The apparent contradic-tion of this practice makes one nurse’s comment,‘it’s a real skill’, seem quite ironic.

Individualised care is a theme of much nursingliterature, and is considered to be a ‘cherishedvalue in nursing’ (Radwin, 1996, p.1142).Peplau’s psychodynamic theory of nursing soughtto explain how nursing functioned in identifyingthe personal needs of individuals and in solicit-ing the individual client’s collaboration in solvingmutually defined problems (Peplau, 1952/1988).The value placed on individualised care wasevident in talking to the nurses involved in thisstudy. Rules were seen as necessary in someinstances, but frequently as inimical to the idealof individualised care. The need to individualisecare meant identifying individual client’s bound-aries and being sensitive to their changing inter-personal needs. The ability to adapt practices tomeet individual client’s needs was seen as some-thing which develops with experience.

The need to minimise the visibility of nursingintervention was identified by both groups. Anovertly ‘professional’ manner was considered tolimit the ability to establish rapport and interacteffectively. Participants described various strate-gies used to reduce visibility, including adoptionof an unobtrusive personal manner of interaction,and avoiding the use of specific signifiers ofpower. Brown (1995) has suggested ‘conversa-tional interviewing’ as an appropriate model fornursing assessment, and this seems consistent

M E N TAL HEALTH NURSES’ PERCEPTIONS OF PRACTICE 1 5 9

with the practice of nurses in this study who per-ceived an informal approach as important in theirinteractions with clients.

P a rticularly for community-based nurses,whose practice occurs in clients’ homes in thecommunity, the issue of visibility is compoundedby stigma surrounding mental illness and byclients’ understandable wish for privacy. In theexample of the client who asked the nurse not tocarry her briefcase, a highly visible signifier of herrole, the public context in which this occurredwas undoubtedly a factor.

It was apparent in this study that both inpa-tient and community-based nurses manipulatethe visibility of their practice where limited visi-bility might facilitate a more effective employ-ment of their skills. There are implications of thispractice for the articulation of mental healthnursing practice. If these invisible aspects ofpractice are not made explicit to others, it is likelythat perceptions of nursing will be shaped by itsmore visible practices, rather than by practicesrendered invisible. This has occurred in the areaof nursing assessment, where the legislated roleof Duly Authorised Officer (DAO)4 has appro-priated the nursing skills of assessment withoutacknowledging them as nursing skills (Street &Walsh, 1998).

The sense of contradiction arising from theconflict between maintaining a professional rela-tionship and yet finding that an overtly profes-sional role conflicts with maintaining atherapeutic relationship is consistent with thetheme of contradiction described by Handy(1991) and Prebble (1996), and requires furtherinvestigation.

CONCLUSION

This re s e a rch has documented experiencedmental health nurses’ perceptions of their

practice. The findings are based on two inter-views with a small number of nurses, but suggestthat there is much to be gained from the quali-tative approach used, and that there are com-plexities to mental health nursing practice thatneed further research.

The theme of the nurse–patient re l a t i o n s h i pand the subthemes of involvement, individualis-ing care, and minimising visibility, re p resent prac-tical knowledge which is embedded in thee v e ryday nursing practice of experienced nurses.These tentative findings provide support forB e n n e r’s (1984) view that the practical knowledgeof experienced clinicians extends their theore t i c a lunderstandings and can be articulated thro u g hqualitative re s e a rch. Further elaboration ofmental health nursing’s practical knowledge is nec-e s s a ry in order to articulate the contribution ofmental health nursing to mental health care .

ACKNOWLEDGEMENTS

I would like to acknowledge the assistance ofLouise Rummel and Sharon Rydon fro mManukau Institute of Technology for assistancein the development of this paper, and theManukau Institute of Technology for there s e a rch grant which made this re s e a rc hpossible.

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