“Easy But Not Simple”—Nursing Students’ Descriptions of the Process of Care in a Psychiatric Context

Abstract

The nurse-patient interaction is the cornerstone of psychiatric care, yet the concept “mental health nursing” is difficult to describe. This article aims to address this problem through the experiences of nursing students. Online journals from 14 nursing students were analyzed using qualitative content analysis, resulting in three categories: Trusting the Trusting Relationship, Voicing the Unspoken Needs, and Balancing the Dynamics of Doing and Being. This study demonstrates that providing nursing care based on trusting relationships is not a demanding task, but it takes place in a complex environment that has a tendency to make easy things complicated.

Full text

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This is an Accepted Manuscript of an article published by Taylor &
Francis: Looi, G. M. E., Sävenstedt, S., & Engström, Å. (2016). “Easy but
not simple”—nursing students’ descriptions of the process of care in a
psychiatric context. Issues in Mental Health Nursing, 37(1), 34-42,
available online: https://doi.org/10.3109/01612840.2015.1085607

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Easy but not simple –
Nursing students’ descriptions of the process of
care in a psychiatric context
Running title:
The process of care in a psychiatric context
Authors:
Ejneborn Looi, Git-Marie, RPN, RN, MSc
Sävenstedt, Stefan, RN, PhD, Professor
Engström, Åsa, RN, CCN, MSc, PhD, Associate Professor
Department of Health Sciences, Luleå University of Technology, Luleå, Sweden
Corresponding author:
Git-Marie Ejneborn-Looi
Department of Health Sciences, Luleå University of Technology, 971 87 Luleå,
Sweden
E-mail: git-marie.ejneborn.looi@ltu.se
Phone: +46703281236
Fax: +46920491399

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Abstract
The nurse-patient interaction is the cornerstone of psychiatric care, yet the
concept “mental health nursing” is difficult to describe. This paper aims to
address this problem through the experiences of nursing students. Online
journals from 14 nursing students were analyzed using qualitative content
analysis, resulting in three categories: “Trusting the trusting relationship”,
“Voicing the unspoken needs” and “Balancing the dynamics of doing and
being”. The study demonstrates that providing nursing care based on
trusting relationships is not a demanding task, but it takes place in a
complex environment with a tendency to make easy things complicated.
Key words: the process of care, mental health nursing, relationship, need
assessment, interventions

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Both researchers and clinicians struggle to articulate the content of nursing
practice in psychiatric mental health care. This paper aims to address this
challenge through nursing students’ descriptions of their work with
patients in different types of psychiatric care settings. Their work in this
paper will be called “the process of care” and includes building
relationships, assessing needs and abilities, and implementing interventions
(actions including a conscious approach).
The nursing process traditionally starts with an assessment (data
collection). It continues with planning, implementation of the chosen
nursing intervention, and evaluation (Yura & Walsh, 1988). Others add
making a diagnosis to the process (Carnevali, 1983; Gordon, 2002). In
these descriptions of the nursing process, the nurse-patient relationship is
seldom included or may simply be taken for granted. In contrast,
Halldorsdottir (2008) argues that the nurse-patient relationship is the most
fundamental aspect of professional nursing. If the relationship reaches what
Halldorsdottir calls “a life-giving nurse-patient relationship”, it can
significantly empower the patient and increase his or her feelings of health
and well-being, summarized as empowerment (Halldorsdottir, 2008).
From their literature review, Cleary, Hunt, Horsfall and Deacon (2012)
describe that the nurse-patient interaction continues to be the cornerstone
of psychiatric inpatient care, and mental health nursing, often described as
an empowering process, distinctly stresses the nurse-patient relationship as
an essential factor (Barker & Buchanan-Barker, 2010; Lakeman, 2012;
Svedberg, 2011). However, according to Looi and Hellzén (2006),
insecurity about how nurses are expected to act in a nurse-patient
relationship results in different approaches that are strongly influenced by
each nurse’s personal view of what the “right” caring approach entails.
Barker and Buchanan-Barker (2008; 2011) consider that that the concept

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“mental health nursing” is still a myth, i.e. many professionals believe in it
and value it highly, yet describing and defining the concept is difficult and
quite vague.
The nursing students who participated in this study formulate and reflect
on the process of care in online journals, e.g. what they are doing, how
they do it, and why they do it. According to Dewey (1938), when a
theory has been tried out in practice, reflecting upon the experience is a
good opportunity to develop knowledge. Using reflective journals as a
pedagogic tool for nursing students during their clinical placement offers
positive experiences (Kok & Chabeli, 2002; Landeen, Byrne, & Brown,
1995). It is also known that a good patient-student relationship can benefit
both the patient’s health and the student’s learning process (Suikkala &
Leino-Kilpi, 2001; 2005). However, using nursing students’ experiences
recorded in reflective online journals doesn’t seem to be common, and it
appears that the process of care, from establishing relationships to the
implementation of an intervention, has not yet been described from their
perspectives.
The students in this study were included due to their successful work with
patients with changeling behavior. The aim of this study is to investigate
the process of care by describing these nursing students’ reasoning and
experiences related to creating relationships, conducting needs assessments,
and choosing interventions in psychiatric care.

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METHOD
This study applies a qualitative design and has an abductive approach,
which can be suitable for renewing patterns and acquiring a deeper
understanding of caring (Eriksson & Lindström, 1997). The data is based
on nursing students’ descriptions of their work in different psychiatric
inpatient settings as recorded in reflective online journals.
Context
The psychiatric nursing care course took place during the second year of a
three-year university course to become a registered nurse in Sweden. The
nursing students previously had about 10 weeks’ experience of nursing
practice within somatic care. The full-time course was 5 weeks in
duration, and practical skills and theoretical knowledge were combined,
practised and examined. Workplace training was conducted in different
areas of psychiatry: forensic psychiatry (5), municipal psychiatry (2),
addiction unit (1), emergency psychiatry (3), and general psychiatry (3).
The patients for whom the students cared suffered mostly from different
types of schizophrenia, severe depression, neuropsychiatric diagnoses, and
self-harming behaviours. Most were admitted involuntarily.
The nursing students’ assignment was to work with a patient and attempt
to establish a relationship, identify needs, and plan, perform, and evaluate
the chosen interventions. The students continuously documented their
work in reflective online journals; those chosen for this study contained
approximately 5,000–15,000 words each. The students reflected on and
argued for their assessments and choices, and they received feedback from
a lecturer a couple of times during the course.

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Participants
Seventeen (17) former students (16 women and one man) who had
succeeded in establishing relationships with patients known to be
“challenging” were selected and asked if they were interested in
participating in the study. The requests were sent by post, and students
could respond either by post or email. A lack of a response was interpreted
as a no. Fourteen (14) students, all female, agreed to participate, two did
not respond, and one letter was returned because it had been sent to the
wrong address.
Analysis
The analysis commenced by reading the nursing students’ journals. The
text that described aspects of the care process was sorted into three content
areas (cf. Graneheim & Lundman, 2004): relationships, needs and
interventions. Next, the texts from each content area were divided into
meaning units and were assigned a numerical code so that each meaning
unit could be traced back to each journal. Then, each content area was
analyzed separately, first by reading the text to understand what each
content area was about in more detail, and then to categorize the meaning
units step-wise (cf. Graneheim & Lundman, 2004) to find out what the
students did, how they did it, and for what reason. This process was
discussed and reflected upon by the authors until six sub-categories were
formulated in the three content areas that formed the three final categories
(Table 1).
Methodological considerations
The lectors’ feedback to the nursing students could have affected the
content of the journals and therefore the results. The authors remained
aware of this possibility as they reviewed journals, and only those that

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received minimal feedback were selected. The feedback was also included
in the initial stages of analysis; this allowed the co-authors to assess the
relationship between the nursing students’ descriptions and the lector’s
feedback, thus reducing the risk that lector would influence the direction
students took. Another risk was that students might have embellished their
work, as they are in a dependent position and will be assessed by the
lector. However, the lector had a continuing dialogue with the supervisor
and clinical lecturer in which they confirmed the descriptions; the risk
seemed mostly to be that they had toned down their own significance and
contributions.
Ethical considerations
Ethical approval was granted by the regional Ethics Committee in Umea
(2010-4-31M), which was also informed of the original design (2012-315-
32M) and approved alterations to it.

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RESULTS and DISCUSSION
The results were developed from journals written by nursing students who
had successfully managed to create a trusting relationship with patients
who were recognized as “challenging” and who, working with the
patient, had begun a positive health process. The results are shown from
three content areas, categories and sub-categories (Table 1), and together
they form “the process of care”. This involves working with the patient
on different areas (relationships, needs, interventions). The process is not
linear; the nursing students could move back and forth between the
different areas, depending on external and internal factors and renewed
assessments. The same intervention could, in some cases, have the goal of
creating relationships and, in other cases, be chosen with the aim of
satisfying an individual need. However, a trustworthy relationship was
seen as vital to achieving a high quality of nursing care.
------------------------------------- INSERT TABLE 1 ABOUT HERE -------------------------------
Result: Trusting the trusting relationship
The nursing students made a case for a secure and trusting relationship as a
precondition for identifying the patients’ real needs and resources. In
regard to trust, the patients felt secure with the nursing students and had
sufficient confidence to be able to express their thoughts and experiences
about their current situation. Without a trusting relationship, there was a
clear risk of misinterpretation and of needs being overlooked or patients
attributing needs they did not have. All of the nursing students described
that a trusting relationship was a precondition for helping patients feel that
the students were involved in their care.

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How to support a trusting relationship
By being easily approachable and showing that they had time and an
interest in the patients, the students created opportunities for interactions.
Being confirmatory and showing genuine interest in the patient as an
individual was the most frequently described condition for creating
relationships. Students demonstrated their interest by listening, trying to
understand, and being present in the patient’s pain and suffering, thereby
strengthening the relationship. They also found that it was just as
important to be approachable and to listen when the patient was well and
described his or her interests, wishes and other issues that were important
for the patient to raise. Another important aspect that illustrated their
acknowledgment of patients was that many students described feeling and
clearly showing a sincere and genuine happiness about patients’
improvements and successes.
The nursing students also offered to talk about their own interests and
experiences and to answer patients’ questions. This meant that a feeling of
mutuality could increase if patients and students were close in age or had
similar interests, such as the same tastes in music or sports. Defending a
patient’s integrity and showing respect were described as necessary
prerequisites. These could be achieved in many ways, but in general, the
nursing students considered that it was important to approach the patient
when the patient wanted to be approached and to always ask about the
patient’s preferences. Doing so also strengthened the patient’s autonomy
by encouraging him or her to make as many decisions as possible and trust
his or her own ability.
The staff were totally impressed that I have been able to create such a
good relationship with him in such a short time. By really just being,

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I try not to stress him but allow him to decide what our meeting will
be like. (Student 9)
Honesty was also an important factor in creating relationships. The
students described being careful to make only promises that they were sure
they could keep. They were also clear about why they were on the ward
and how long they would be there so that patients wouldn’t feel let down
and abandoned. In addition, the nursing students used different kinds of
“tools” to encourage building the relationship; for example, they could
choose to introduce various documents that gave them a reason to follow
up with a patient.
Through the sleep diary, it became easier to create a safe and trusting
relationship when the patient had a reason to sit down with me and
talk about his own self-assessment. The sleep diary itself was not
important, but it was a good thing to have when he took the
initiative to talk to me about it, but in fact we always got on to other
matters. (Student 1)
The nursing students used different conversation techniques. The majority
described using open-ended questions and active listening, while some
said they spoke with a lower pitch or a softer voice. They also reflected on
their body language; for example, they sat down to signal that they had
time and were interested in what the patient had to say. Inviting patients
to play games or engage in conversations where they had opportunities to
demonstrate their knowledge were other measures that the students found
strengthened their relationships with the patients.

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How to know if it is a trusting relationship
The nursing students clearly described knowing when a trusting
relationship had advanced. They described small, subtle signs such as
smiles and eye contact and more tangible ones, such as the patient turning
to them for companionship or help with a variety of things.
Patients might shake students’ hands or give them a hug, as well as
cooperating in their own care and treatment. The nursing students
considered that these meant a more-trustworthy relationship had been
created.
My patient asked me if it was my last day tomorrow, and then he
wondered if I could give him the injection. So this morning the
patient asked for the injection on his own initiative. The other staff
were surprised that he came and asked for his injection (he was
usually given a forced injection). (Student 6)
What obstacles are encountered in building relationships
The nursing students also identified several obstacles to building
relationships. For instance, they were well aware of the risk that their
prejudices could affect the conditions for creating a relationship, and
several students described hearing reports about patients who had been
labelled as “hopeless” or aggressive”. A strategy that emerged from several
students was that they wanted to get to know patients before they started
to read about their diagnoses and past histories so the information
wouldn’t influence them. Several students also described being afraid of
certain patients initially but quickly changing their opinions, while others
were fearful of doing something “wrong” and therefore hesitated to make
contact with a patient.

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She felt so alone and lacking support as she sat in the room with the
doctor’s, nurse’s, daughter’s and my eyes on her. I wanted to move
closer and show by touch that she was safe, but I didn’t dare. No one
else made an attempt to do it either, and I think I got scared of being
a bit too forward. I still regret it … (student 10)
In some cases, the students described how a patient’s personality or
symptoms could complicate creating relationships. They described that
some patients didn’t want their company, and then the only response was
to accept their wishes; however, it could also be a question of the patient
being deeply depressed or paranoid.
The nursing students also discussed the risk of harming the relationship by
carrying out treatments that patients didn’t wish to receive. However, this
meant that the relationship could also be strengthened if students managed
to perform their duties in a way that was beneficial for and agreeable to
the patient.
Maybe she’s scared of injections and this might result in our first
meeting not turning out that positively. But, at the same time, if she
is scared, I can try keeping her fear at bay with calmness and
carefulness. (Student 5)
Discussion: Trusting the trusting relationship
In many cases, the nursing students managed in a short time to achieve a
trustworthy relationship with admittedly “challenging” patients where the
staff had “failed”, which was surprising for both staff and nursing students.
To understand the nursing students’ success, we looked at what they were
doing and the approach they were using, but we also considered the
situations that the students had compared to the nurses (and whether those
conditions could be applied organization-wide). One possible reason

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could be that the patients perceived the students as more trustworthy and
less threatening because they didn’t have the same authority as the nurses.
Students identified trust as the most important quality in the relationship.
However, according to Hem, Heggen and Ruyter (2008), achieving a
trusting relationship between the nurse and the patient is challenging.
Hem et al. argue the need for trusting relationships in psychiatric care, but
achieving them requires radical change. This kind of improvement is not
realized by increasing staff or raising pay; it requires a change in the
professional nursing role that includes developing effective countercultural
skills. This, in turn, calls for professional development in practice,
education and research (Hem et al., 2008). The nursing students had a
clear mission – to learn how to create a trusting relationship with the
patient, and in that learning process they consciously reflected and
evaluated not only their own actions and approaches but also the responses
of patients in order to develop their skills in relationship-building. It is
well known that reflection and self-reflection are important factors for
nursing students’ progress in personal and practical skills (Cameron &
Mitchell, 1993; Kelly, Hager, & Gallagher, 2014). However, reflection
alone is not enough, according to Dewey’s holistic theory of knowing.
Reflection and action must be combined and are interdependent in the
same way theory and practice are (Hartman, 2003). Taken together,
theory, practise and reflection might have given the students a set of tools
to develop skills to be able to think “outside the box” of traditional care
on the ward, which might be compared to Hem et al.’s (2008)
descriptions of countercultural competence and be one of several
explanations for the students high level of success in creating trusting
relationships.
Another difference was related to the nurses’ many responsibilities and
lack of time compared to the nursing students, who needed to care for

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only one patient at a time. In a review (Cleary et al., 2012) about nurse-
patient interaction, the authors write that showing interest in the patient
and what they call an integrated triad including listening, understanding,
and responding were critical factors from the patients’ perspectives. These
results about what patients want align well with the students’ descriptions
of their work in this study.
However, if the nurse listens but does not try to understand and respond
to the patient, listening could have the opposite effect and cause the
patient to feel rejected (Hem & Heggen, 2004). According to Hem and
Heggen, a nurse’s rejection of a patient can have two causes, internal
factors (for example, unclear roles and responsibilities; cf. Hem et al.,
2008) and external factors such as inadequate staffing (e.g. not enough
time for the patient). A study by Shattell, Andes and Thomas (2008) found
that if the nurse-to-patient ratio is very low, nurses describe having to be
task-oriented and unable to focus on each patient’s needs. We cannot
know about the staff ratio on the different wards, but based on the nursing
students’ experiences and actual research, if we agree that the nurse-
patient relationship is important for the quality of care, then providing
nurses with adequate working conditions regarding both internal and
external factors is critical.

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Result: Voicing the unspoken needs
The nursing students described different ways of gathering information
about a patient in order to make an assessment of his or her individual
needs, and then being able to choose the appropriate measures. The most
common and frequent description was that, while they were talking to
patients and listening to try to understand their overall situations, students
were also cognizant of the need to attempt to identify patients’ different
resources and abilities. They also talked with staff and, when appropriate,
with relatives of the patients. Reading medical journals and patients’ self-
assessments was also included in gathering information.
How can different behaviours be understood
In addition to the usual data collection as described above, needs
assessments included identifying and interpreting different signs. The
students were very receptive and tried to understand patients’ different
signals and behaviours. For example, in cases where the patients had been
delusional or deeply depressed, the students believed that it was important
to try to understand what the different behaviours meant since the patients
were unable to express their own needs.
Because he doesn’t have an insight into his illness, I can’t ask him
what the problem is or what he wants. His only problem is that he’s
locked up in totally the wrong place, but during observations and
conversations with him, I have the feeling that he is in need of
security, trust and participation. He’s a man who believes that his
surroundings are poisoning him, and he doesn’t trust anyone.
(Student 6)

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In other cases, the students were told that behaviours were linked to the
clinical picture, such as when it was difficult to get the patient’s attention
and he or she was withdrawn. However, the students were of the opinion
that withdrawal could have a number of causes and purposes. By this, they
meant that some patients withdrew because they had a pointless and dull
existence, whilst others felt abandoned and felt no affinity with the staff.
In other cases, the students interpreted a patient’s distancing himself or
herself as a coping strategy. Therefore, they considered it important to
learn to read how the patient felt and make new assessments daily to
identify an individual balance between closeness and distance in order to
show respect for the patient without abandoning him or her.
Students also met patients who displayed threatening behaviours, but they
interpreted these more as expressions of the patient’s illness and feeling
frustrated.
I know that he can scare both patients and staff with his behaviour,
which is an expression for him feeling ill; he is often misunderstood,
and he has expressed his gratitude because I have dared to meet him
and suppressed the process. (Student 5)
A nursing student described that staff said she should watch out for a
“chronically aggressive woman”, but instead, she saw a woman with a
chaotic life situation and in despair who felt mistrusted and wrongly
judged. Often, students interpreted a patient’s behaviour more positively
and saw opportunities for the patient’s development; they experienced
rigid rules as often making it more difficult to make individual assessments
of a patient’s needs.

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Staff forbade a young girl with an eating disorder to heat up food
after 8 p.m. because there’d be too much noise. I wonder about the
reasoning then; I would be happy no matter what time of day a
patient with anorexia nervosa wants to eat. (Student 10)
The students also saw numerous small signs they considered extremely
important to take into consideration.
It is difficult to explain, but she gets so happy when she has her hair
plaited and feels pretty. If she had totally given up hope, she
wouldn’t have cared at all, I believe. Deep inside there is a spark of
life that needs to be reawakened. (Student 1)
The students felt it was obvious to prioritize patients who felt unwell and
saw different behaviours as signals that they would try to respond to. They
found it difficult to understand how staff could reach the opposite
assessment and take an opposing action.
Strongly disputing a decision to leave a hyperventilating, crying,
anxiety-ridden young girl whose upbringing has been insecure (and
who’s experienced so many things I don’t even want to think about)
alone so as not to give her unnecessary attention … I think that her
way of saying that she doesn’t feel well is just by sitting in the
corridor. What kind of pain do we then cause her by ignoring her?
Are we not there to pay attention to the patients? A girl who’s been
fighting her whole life for somebody’s attention and not even when
she is genuinely feeling bad does she get the attention … (Student
10)

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The nursing students also thought that behaviours they interpreted as
positive signs could, in the staff’s assessment, be used instead against the
patient; students felt these signs could be significant, for example, for a
diagnosis or for the patient being discharged.
“It can’t be true that she’s so depressed because she sits on the sofa
and sometimes smiles.” It’s great that she can smile! But that doesn’t
tell the whole truth about how people feel. (Student 5)
How can a patient’s needs be assessed
The nursing students identified a number of patient needs, some very
specific but most more abstract in nature. The students were of the
opinion that the need for increased self-esteem could express itself through
the patient not demanding anything or having no confidence in his or her
abilities. Some nursing students connected low self-esteem to a patient’s
unkempt appearance, arguing that this could indicate the patient believed
he or she was unworthy of being clean and looking nice. Because many
patients had experienced a number of failures in life, the students reasoned
that the care often focused on the patient’s shortcomings and problems.
I noted that he was looking for some kind of praise or
acknowledgement. Then afterwards I thought about this as he gets a
lot of negative comments because he’s filthy, his clothes are dirty or
his sheets are soiled with snuff. He doesn’t get many positive
comments. (Student 13)
The students felt that many needs were connected, and if they were
successful in satisfying one need, this could contribute to reinforcing other
needs, and hope was a normal positive “side effect”. The need for
increased hopefulness was identified in essentially all patients. The students
argued that many patients described having no belief in the future; they

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had no energy to fight because “there is no point” and felt that their
existence was pointless. The nursing students argued that patients had a
need for increased participation and empowerment based on that they
rarely participated in decisions concerning their care. The students also
thought that the patients often had insufficient knowledge and
information about their own illness and treatment and lacked coping
strategies for different symptoms such as anxiety, uneasiness, and
restlessness, which the students considered as decreasing patients’ feelings
of empowerment and control over their situation.
Motivation and the need to take the initiative were other common
assessments. Nevertheless, most of the students were very careful when
distinguishing these needs. One student described that it was important to
meet the patient’s need to strengthen his or her sense of initiative “… for
him to get started and do all the things he is motivated to do and that he thinks are
fun and that makes him feel good”. Students also argued that, when they saw
that a patient had received adequate support, he or she was successful in
carrying out different activities; they felt this indicated that the patient had
the will and motivation but lacked the power and ability to get started.
They inferred that, if motivation was lacking, patients might have had the
ability to begin and carry out an activity but lacked the desire and interest
to do so.
It’s not possible to design interventions that motivate the patient to
achieve our goals. It’s important to work out the goals together; we
have listened to what the patient wants to achieve and that the
patient feels involved and motivated to achieve these goals.
Otherwise, we’ll never reach these goals, and it’s also good because
they aren’t the patient’s goals. (Student 1)

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Trust and confidence were also frequently occurring needs identified by
the students. They were of the opinion that lack of trust could be
manifested by patients not saying how they really felt or being fearful
about eating food or taking their medication. A patient could also
experience the environment as unsafe and frightening. In other cases,
examinations and treatments could be sources of insecurity or the fear that
they wouldn’t have a secure existence when they were discharged.
Discussion: Voicing the unspoken needs
In this study, the nursing students often saw signs and conducted
assessments different from those of staff. This could be for a number of
reasons, and one that is obvious is the students’ lack of experience
compared to most of the nurses. Another is that the students appear to
have focused on patients’ abilities and had a more salutogenic perspective
compared to the nurses, whose perspective could have been more
pathogenic (cf. Jormfeldt, 2011; Svedberg, 2011). Jormfeldt (2011) argues
that promoting health is important in supporting the patient’s self-esteem
and empowerment. Empowerment appears to be the most important
intervention in health promotion from both the patient and staff
perspective (Svedberg, Hansson, & Svensson, 2009). The nursing students’
descriptions are similar to what Svedberg et al. call an empowerment
approach, and this is described additionally when students attempt to
improve relationships with patients and implement interventions.
Furthermore, when they assess a patient, they often identify a need for
enhanced empowerment and improved self-esteem. Research results show
that while low self-esteem should be seen as a risk factor, improved self-
esteem can have a protective function in both physical and mental health
care (Mann, Hosman, Schaalma, & de Vries, 2004).

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In nursing theories, experience is defined as an important factor for the
quality of care (Benner, 2001; Haldordottir, 2008), but most of the
students had no psychiatric care experience. However, in the psychiatric
context, it sometimes appears that many years of experience can be a
impediment because experienced nurses can be less sensitive in regard to
patients’ needs and may have a more symptom-oriented approach
(Hellzén, Kristiansen, & Norbergh, 2003). In another study, Hellzén
(2004) found that the main factor in regard to how much time a nurse
spent with a patient depended on whether the nurse liked the patient or
not. The students’ lack of experience could have exerted a positive effect,
in the sense that they did not know patients or have much knowledge
about their psychiatric diagnoses. Instead, they have as their assignment
the clear instruction to focus on understanding patients’ needs. Another
possible difficulty for staff as opposed to students is that staff have to deal
with the caring culture, and a common staff approach can lead to a
personal conflict between a focus on relationships with one’s colleagues
versus a patient’s situation and needs (Enarsson, Sandman, & Hellzén,
2008; Looi, Gabrielsson, Sävenstedt, & Zingmark, 2014). Some students
were also critical about the staff’s assessments and argued that some rules
and treatments could have been harmful to patients. The students’ critical
reflections conform to patients’ experiences (Looi, Engström, &
Sävenstedt, 2015).
A third difference between the registered nurses and the nursing students
involved responsibilities. Sometimes patients are assessed as violent, and
assessing the potential for violence is an important task for nurses so that
preventive interventions can be implemented (Björkdahl, Olsson, &
Palmstierna, 2006). The nursing students had no responsibilities in regard
to this kind of task, but when a student met a patient who was considered
aggressive, the student often interpreted the aggressive behaviour

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differently, and the patient did not express any aggressive behaviours
towards the nursing student. Carlsson, Dahlberg, Ekebergh and Dahlberg
(2006) argue that it is possible to prevent violent encounters with
“authentic personal” and “undisguised” care, approaches similar to what
the nursing students described.
Thus, it seems like the nursing students’ basis for assessments was
understanding and respect for each patient’s own story, “positive”
understanding of patients’ behaviours, and a focus on their capabilities.
Students’ lack of experience can, to some extent, be compensated by not
having been influenced by the caring culture within the institution/ward.
The nursing students had no preconceived opinions and didn’t have to
take the caring culture into account, which might have helped them to
see needs from the patient’s perspective (cf. Looi et al., 2014).

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Result: Balancing the dynamics of doing and being
The nursing students carried out different types of interventions to meet
individual needs and take advantage of patients’ abilities and resources.
Their descriptions of planning and carrying out interventions described an
approach and an action. It was important that both were included and
visible in the interventions.
What to do, how to do it, and how to be
The nursing students demonstrated that it wasn’t possible to decide on a
specific action in order to address a specific need; rather, different types of
actions were used to address the same needs and vice versa. Conversely,
several approaches were described for more specific needs. For example,
the students were deliberate about listening to and acknowledging the
patients and their abilities to strengthen their self-esteem and intrinsic
value. It was also about providing them with the space and opportunity to
give something back to the nursing students, which was seen as important
for strengthening patients’ self-esteem. Examples of steps taken to
strengthen self-esteem, motivation, and hopefulness include letting
patients teach the students something they were good at, like playing an
instrument, needlework, or a sport.
I’ll let the patient teach me to play a song on the piano; this can
improve his self-esteem when he feels that he is really good at
something and has skills that he can share with others, but also the
feeling of other’s appreciation when he shares his skills and plays
beautifully on the piano. (Student 1)
Sometimes the tables were turned, and a nursing student taught the
patient something, for example, to play a game or make jewellery. The
nursing students could also take excursions with patients, going for coffee

25
or visiting the library with the aim of motivating the patient, breaking the
isolation, and promoting hopefulness. Further steps that the nursing
students mentioned for promoting hope and self-esteem were showing
interest in some of the items patients had created, for example, paintings
and poems. This could also entail the student helping the patient to plait
her hair or put on makeup or giving a massage. Some measures were
clearly connected to tangible needs like hygiene, nutrition or sleep, but
the students added factors that could also satisfy other, more abstract
needs.
After showering I saw that she had very dry skin, so I carefully
rubbed cream onto her, and her husband said that she likes to have a
massage so I took the opportunity to carefully massage the lotion onto
her legs, also with the aim to increase blood circulation, considering
her immobilization, as well as to increase well-being and self-esteem.
(Student 5)
Conversations and walks were frequently occurring measures described by
the nursing students, but in some cases the students chose unique measures
to satisfy individual needs.
Yesterday a male opiate addict and I were taking the drainpipe away
from the sink to clean it. We had fun together, and he enjoyed
having something to do despite the fact that it was a pretty disgusting
task. Otherwise, he only walked around nervously waiting for his
medication. (Student 7)
Rearranging the furniture in a patient’s room was a measure aimed to
create a sense of safety for a paranoid patient who didn’t dare to be in the
room. Teaching the patient different coping strategies to handle worry,
anger, and anxiety was also a common measure aimed at strengthening the

26
patient’s feeling of control and empowerment and thereby contributing to
a sense of security.
The approaches that the nursing students described to encourage
participation and empowerment might include the patient being able to
choose between different activities and decide both the design and time of
the activity, with the aim of encouraging and respecting the patient’s
autonomy and participation in decision-making. The students could also
choose some unusual approaches to traditional steps, for example, not only
giving information but also satisfying abstract needs.
The schedule that he now has is a piece of A4 with times and it
doesn’t work. I thought that you could draw a clock on the
whiteboard in his room and at every specific time, he can write what
he will do during the day. Then he will get the visual part with the
clock and through that it might be easier for him to remember, and
besides, if he writes it down himself he needs to think what he will
do and to memorize it and to write down the information himself
too. The combination of several senses, I believe, will make it easier
for him to remember the things he needs to do, which in turn will
increase his self-esteem and empowerment. (Student 9)
To strengthen the patient’s ability for initiative, the student could “push”
the patient in an encouraging and supportive way both verbally and
physically, for example, by laying out things the patient needed and
guiding the patient step by step or gradually handing over the
responsibility for different tasks to the patient. They described it as
important for them to ensure that the demands on the patients were at a
reasonable level so they would feel competent and not experience failure.
Some steps could also be connected to satisfying many abstract needs at
the same time.

27
The conversation that was created around the sleep diary makes him
feel that someone has time for him, listening to him, and really takes
him seriously, which also strengthens his participation and self-
esteem; self-esteem is also strengthened by him feeling that he can
manage the task; also, his ability to take the initiative is strengthened
when he has the responsibility to take initiative to fill in his sleep
diary on a daily basis. (Student 1)
The nursing students were generally given the freedom to try out different
interventions, but in some cases, they were forced to break the ward’s
rules to show that they took the patient’s suffering seriously and could
take measures to strengthen the patient and help him or her to feel secure
or to encourage a sense of well-being.
Discussion: Balancing the dynamics of doing and being
The nursing students carried out many interventions with the patients;
some of the activities were common ones in a psychiatric ward, such as
talking and going for a walk. However, the nursing students were always
aware of the patients’ needs for planning and working together
collaboratively towards a mutual goal that aligned well with the patient’s
wishes about how care should be conducted (Looi et al., 2015). Aiming to
individualize the intervention, they made evaluations continuously and
were open to altering the intervention and their own approach. Most of
the interventions began with the patient’s abilities or focused on support
or developing the patient’s skills. This way of working is in agreement
with Svedberg’s (2011) model of the process-oriented health promotion
intervention in mental health care; alliance, empowerment, and educational
and practical support are essential concepts of this model.

28
Most of the patients that the students worked with have experienced
coercive measures. A significant difference between the student and the
staff was that the students didn’t have access to coercive measures that
could possibly have a vital significance in the whole process. In planning
and implementing interventions, the students based their decisions on the
patient’s individual needs instead of focusing on correcting behaviours and
solving problems using coercive measures, which can be common
strategies, especially if the nursing staff is under pressure (Looi et al., 2014)
or lack knowledge and hope about the patient’s recovery (Ashcraft &
Anthony, 2008).
The lack of coercive measures may have contributed to the students
having to use alternatives; thus, they developed their repertoire of care
based on mutual cooperation with the patient instead of confrontation (cf.
Ashcraft & Anthony, 2008). This could have contributed to their
successful results in stimulating positive health processes.
Conclusion
One may wonder whether students are the best choice of participants to
answer the research question. In this case, the sample was a few students
who managed surprisingly well with their work with patients with
challenging behaviour. Because they were students they had good
prerequists such as time and opportunity to prioritize a patient. They had
no access to coercive measures which might have created security for the
patient. The students did not know the workplace and were not part of
the regular staff group which meant that they had no knowledge of or
needed to relate to the current health care culture. Students have limited
professional experiences and are therefore not the best choice to describe
the experience of caring for patients in a psychiatric ward, but they have

29
other conditions which can be suitable based on their unique work
situation.
The expression “simple but not easy” is sometimes used to describe a
basically uncomplicated task that still requires considerable effort to
accomplish. The results of this study, however, suggest a situation that can
be characterized as “easy but not simple”. Providing high-quality nursing
care based on trusting relationships is basically not a demanding task, but it
takes place in a complex environment with a tendency to make easy
things complicated.
Clinical implications and further research
The description of the process of care in this paper is not supposed to be
seen as a manual to follow step by step. Rather, it is a framework for those
who work from a nursing perspective where relationships, needs and
interventions are key elements in the planning and design of patient care.
The results show the importance of the nurses has knowledge of,
understand and prioritise the relationship-building in order to lay the
foundations for nursing quality work. This means that the patient nursing
relationship should have plenty of space and priority in nursing education.
As further research it would be interesting to have the patients' perspective
based on the factors they value on the basis of particularly good care
experiences with students as carers.
Declaration of interest: The authors report no conflicts of interest. The
authors alone are responsible for the content and writing of the paper.

30
REFERENCES
Ashcraft, L., & Anthony, W. (2008). Eliminating seclusion and restraint in
recovery-oriented crisis services. Psychiatric Services, 59(10), 1198-1202.
Barker, P., & Buchanan-Barker, P. (2008). Mental health in an age of
celebrity: The courage to care. Medical Humanities, 34(2), 110-114.
Barker, P., & Buchanan-Barker, P. (2010). The tidal model of mental
health recovery and reclamation: Application in acute care settings. Issues
in Mental Health Nursing, 31(3), 171-180.
Barker, P., & Buchanan‐Barker, P. (2011). Myth of mental health nursing
and the challenge of recovery. International Journal of Mental Health Nursing,
20(5), 337-344.
Benner, P. E. (2001). From novice to expert: Excellence and power in clinical
nursing practice. (Commemorative ed.). Upper Saddle River, NJ: Prentice
Hall.
Björkdahl, A., Olsson, D., & Palmstierna, T. (2006). Nurses' short-term
prediction of violence in acute psychiatric intensive care. Acta Psychiatrica
Scandinavica, 113(3), 224-229.
Cameron, B. L., & Mitchell, A. M. (1993). Reflective peer journals:
Developing authentic nurses. Journal of Advanced Nursing, 18(2), 290-297.
Carlsson, G., Dahlberg, K., Ekebergh, M., & Dahlberg, H. (2006).
Patients longing for authentic personal care: A phenomenological study of
violent encounters in psychiatric settings. Issues in Mental Health Nursing,
27(3), 287-305.
Carnevali, D.L. (1983). Nursing care planning: Diagnosis and management.
(3rd ed.) London: Lippincott.

31
Cleary, M., Hunt, G. E., Horsfall, J., & Deacon, M. (2012). Nurse-patient
interaction in acute adult inpatient mental health units: A review and
synthesis of qualitative studies. Issues in Mental Health Nursing, 33(2), 66-
79.
Dewey, J. (1938). Experience and education. New York: Macmillan.
Enarsson, P., Sandman, P., & Hellzén, O. (2008). “Being good or evil”:
Applying a common staff approach when caring for patients with
psychiatric disease. International Journal of Qualitative Studies on Health and
Well-being, 3(4), 219-229.
Eriksson, K., & Lindström, U. A. (1997). Abduction – A way to deeper
understanding of the world of caring. Scandinavian Journal of Caring
Sciences, 11(4), 195-198.
Gordon, M. (2002). Manual of nursing diagnosis: including all diagnostic
categories approved by the North American Nursing Diagnosis Association. (10.
ed.) St. Louis, Mo.: Mosby.
Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in
nursing research: Concepts, procedures and measures to achieve
trustworthiness. Nurse Education Today, 24(2), 105-112.
Halldorsdottir, S. (2008). The dynamics of the nurse-patient relationship:
Introduction of a synthesized theory from the patient's perspective.
Scandinavian Journal of Caring Sciences, 22(4), 643-652.
Hartman, S. (2003). Läraren från Oil city – inför det nyväckta intresset för
John Dewey [The teacher from Oil City - faced with the resurgence of
the John Dewey]. In S. G. Hartman, K. Roth & N. Rönnström John
Dewey: om reflektivt lärande i skola och samhälle [John Dewey: on
reflective learning in school and society]. Stockholm: HLS Förlag.

32
Hellzen, O. (2004). Nurses' personal statements about factors that
influence their decisions about the time they spend with residents with
long-term mental illness living in psychiatric group dwellings. Scandinavian
Journal of Caring Sciences, 18(3), 257-263.
Hellzén, O., Kristiansen, L., & Norbergh, K. G. (2003). Nurses' attitudes
towards older residents with long-term schizophrenia. Journal of Advanced
Nursing, 43(6), 616-622.
Hem, M. H., & Heggen, K. (2004). Rejection – A neglected
phenomenon in psychiatric nursing. Journal of Psychiatric and Mental Health
Nursing, 11(1), 55-63.
Hem, M. H., Heggen, K., & Ruyter, K. W. (2008). Creating trust in an
acute psychiatric ward. Nursing Ethics, 15(6), 777-788.
Jormfeldt, H. (2011). Supporting positive dimensions of health, challenges
in mental health care. International Journal of Qualitative Studies on Health
and Well-being, 6(2).
Kelly, M. A., Hager, P., & Gallagher, R. (2014). What matters most?
Students’ rankings of simulation components that contribute to clinical
judgment. Journal of Nursing Education, 53(2), 97-101.
Kok, J., & Chabeli, M. M. (2002). Reflective journal writing: How it
promotes reflective thinking in clinical nursing education: A students'
perspective. Curationis, 25(3), 35-42.
Lakeman, R. (2012). What is good mental health nursing? A survey of
Irish nurses. Archives of Psychiatric Nursing, 26(3), 225-231.
Landeen, J., Byrne, C., & Brown, B. (1995). Exploring the lived
experiences of psychiatric nursing students through self-reflective journals.
Journal of Advanced Nursing, 21(5), 878-885.

33
Looi, G. E., Engström, Å., & Sävenstedt, S. (2015). A self-destructive
care: Self-reports of people who experienced coercive measures and their
suggestions for alternatives. Issues in Mental Health Nursing, 36(2), 96-103.
Looi, G. E., Gabrielsson, S., Sävenstedt, S., & Zingmark, K. (2014).
Solving the staff's problem or meeting the patients' needs: Staff members'
reasoning about choice of action in challenging situations in psychiatric
inpatient care. Issues in Mental Health Nursing, 35(6), 470-479.
Looi, G. E., & Hellzén, O. (2006). Nurses' perception of the relationship
between themselves and the long-term psychiatric client – An interview
study. Primary Care and Community Psychiatry, 11(4), 185-192.
Mann, M., Hosman, C. M. H., Schaalma, H. P. & de Vries, N. K.,
(2004). Self-esteem in a broad-spectrum approach for mental health
promotion. Health Education Research, 19(4), 357-372.
Shattell, M. M., Andes, M., & Thomas, S. P. (2008). How patients and
nurses experience the acute care psychiatric environment. Nursing Inquiry,
15(3), 242-250.
Suikkala, A., & Leino-Kilpi, H. (2001). Nursing student-patient
relationship: A review of the literature from 1984 to 1998. Journal of
Advanced Nursing, 33(1), 42-50.
Suikkala, A., & Leino-Kilpi, H. (2005). Nursing student-patient
relationship: Experiences of students and patients. Nurse Education Today,
25(5), 344-354.
Svedberg, P. (2011). In what direction should we go to promote health in
mental health care? International Journal of Qualitative Studies on Health and
Well-being, 6(2).

34
Svedberg, P., Hansson, L., & Svensson, B. (2009). The attitudes of
patients and staff towards aspects of health promotion interventions in
mental health services in Sweden. Health Promotion International, 24(3),
269-276.
Yura, H. & Walsh, M.B. (1988). The nursing process: Assessing, planning,
implementing, evaluating. (5th ed.). Norwalk: Appleton & Lange.