mental health case study nursing

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Effective nurse–patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance

Samantha hartley.

a Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre, University of Manchester, Manchester M139PL, United Kingdom

b Pennine Care NHS Foundation Trust, Ashton-under-Lyne OL6 7SR, United Kingdom

Jessica Raphael

Karina lovell.

c Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M139PL, United Kingdom

Katherine Berry

Therapeutic alliance is a core part of the nursing role and key to the attainment of positive outcomes for people utilising mental health care services. However, these relationships are sometimes difficult to develop and sustain, and nursing staff would arguably benefit from evidence-based support to foster more positive relationships.

We aimed to collate and critique papers reporting on interventions targeted at improving the nurse–patient therapeutic alliance in mental health care settings.

Systematic literature review.

Data sources

The online databases of Excerpta Medica database (Embase), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched, eligible full text paper references lists reviewed for additional works and a forward citation search conducted.

Review methods

Original journal articles in English language were included where they reported on interventions targeting the nurse–patient therapeutic relationship and included a measure of alliance. Data were extracted using a pre-determined extraction form and inter-rater reliability evaluations were conducted. Information pertaining to design, participants, interventions and findings was collated. The papers were subject to quality assessment.

Relatively few eligible papers ( n  = 8) were identified, highlighting the limitations of the evidence base in this area. A range of interventions were tested, drawing on diverse theoretical and procedural underpinnings. Only half of the studies reported statistically significant results and were largely weak in methodological quality.

Conclusions

The evidence base for methods to support nursing staff to develop and maintain good therapeutic relationships is poor, despite this being a key aspect of the nursing role and a major contributor to positive outcomes for service users. We reflect on why this might be and make specific recommendations for the development of a stronger evidence base, with the hope that this paper serves as a catalyst for a renewed research agenda into interventions that support good therapeutic relationships that serve both staff and patients.

What is already known about the topic?

• • The therapeutic relationship between nursing staff and patients in mental health care is key to positive outcomes.
• • Therapeutic alliance is a multi-faceted concept that is valued by patients while being difficult for staff to develop.

What this paper adds

• • Interventions targeting the therapeutic alliance were identified; including training, psychological formulation, reflective groups, consultation and shared activity.
• • The review showed that none of these is as yet confirmed effective and that the methodological quality of the evidence base at present is predominantly poor.

1. Introduction

Nursing staff are the core of the caring profession and central to their role is the development of effective relationships with the individuals they support ( Hoeve et al., 2014 ; Zugai et al., 2015 ). In the United Kingdom, engaging meaningfully with patients (rather than ‘doing to’) runs through the principles of the nursing profession ( Royal College of Nursing, 2010 ); while in the United States, the interpersonal relationship is seen as foundational to a person-centred, recovery-oriented approach within mental health nursing ( Kane, 2015 ). Internationally, the alliance features heavily in the remit of European and Australasian nursing associations, who highlight the need for human connection and the ability to demonstrate effective therapeutic relationships ( Australian College of Mental Health Nurses, 2018 ; World Health Organisation, 2003 ).

The nursing relationship has been conceptualised as ‘a significant therapeutic interpersonal process [that] functions co‐operatively with other human processes that make health possible for individuals and communities’ ( Peplau, 1988 , p. 16). This therapeutic alliance—the relationship connecting professional and service user—is between one human and another, with a uniqueness of each dyad ( Forchuk, 1995 ), which therefore requires renewed efforts at each new pairing. Nurses see the development of the alliance as requiring a convergence of interpersonal professional skills with personal life experience ( Scanlon, 2006 ) and clients view it as life-sustaining in its ability to foster collaboration and a sense of being understood ( O'Brien, 2001 ). The concept has recently enjoyed a renewed focus, with an emphasis on consumer-models that encourage personal recovery assisted by therapeutic alliance ( Zugai et al., 2015 ).

Therapeutic alliance has the greatest impact on treatment outcomes for those with mental health difficulties, over and above the specific mode or model of intervention that is provided ( Duncan et al., 2010 ; Martin et al., 2000 ; Messer and Wampold, 2002 ; Priebe and McCabe, 2006 ; Wampold, 2001 ). Emerging initially within the psychoanalytic discipline and later generalised to multiple therapeutic contexts, the concept of alliance has been defined as an agreement on goals, tasks and a therapeutic bond between therapist and client ( Bordin, 1979 ). The phenomena can be measured using various tools from both the perspective of the professional and service user, with important differences between the two ( Bachelor and Salamé, 2000 ; Fitzpatrick et al., 2005 ). In an age of increasingly remote therapeutic interactions, the alliance and concomitants of it are still seen as intrinsic to change, whether therapy is facilitated by phone ( Mulligan et al., 2014 ), online dialogue ( Cook and Doyle, 2002 ) or even fully-automated chat-bot ( Fitzpatrick et al., 2017 ).

Traditionally, research has focused on understanding and improving the alliance between therapist and client; as part of one-to-one, psychotherapeutic interventions ( Lambert and Barley, 2001 ; Martin et al., 2000 ). In contrast to these direct therapy roles, there are also staff members who adopt a care coordination role or act as a key worker; assessing, engaging and organising care with individuals ( Burns, 2004 ; Simpson, 2005 ; Thurston, 2003 ). All of these roles inevitably involve the building and maintenance of an effective alliance and therefore research has shifted to include definitions and exploration of the relationship as built within these guises ( Farrelly et al., 2014 ; Kirsh and Tate, 2006 ), where it remains correlated with outcomes ( Cruz and Pincus, 2002 ; Howgego et al., 2003 ) and is developed in a range of settings.

As part of secondary care community services, nursing staff coordinate care and deliver brief therapies, which despite (or possibly because of) their short-term nature require the adept building of alliance. People supported by secondary care services are those experiencing severe mental health difficulties, often in the context of challenging relational and social circumstances. Here, nurses strive to develop mutuality, reciprocity, synchrony, and sense of belonging with their clients ( Spiers and Wood, 2010 ) and clients value being known and related to as a person rather than service-recipient ( Shattell et al., 2007 ), requiring a skilful use of the self ( O'Brien, 2000 ). Service users value therapeutic relationships with care coordinators in community settings, and view these as central to recovery; over and above the role of specific care plans ( Simpson et al., 2016 ). These complex processes are rendered difficult for staff members by burnout, struggles building engagement with patients and ineffective team-working ( Koekkoek et al., 2011 ; Singh, 2000 ), with the nature of organisational structures and roles limiting the care that nurses can provide ( Simpson, 2005 ).

The therapeutic role of nursing staff in mental health care is especially pertinent in settings such as inpatient wards, where patients interact with nurses for the largest proportion of time and the relationship with them is cited as key to therapeutic progression ( Hopkins et al., 2009 ; McAndrew et al., 2014 ), with a perceived interplay between therapeutic relationships and the quality of care ( Coffey et al., 2019 ) . Engagement in these challenging contexts requires a balance of approaches, the development of personalised understanding and use of the self to facilitate recovery-oriented growth of the patient ( McAllister et al., 2019 ). However, how these specific competencies can be developed is not fully elucidated in the literature or supported by service structures. The alliance can be impeded by individual and organisational factors that leave it unseen and stifled in practice ( Pazargadi et al., 2015 ), with nurses left to negotiate contradictory and challenging relational minefields ( Cleary et al., 2012 ).

Despite the potential value and best efforts, attempts to develop strong nursing alliance in mental health care can be hampered by challenging settings where its development is impeded ( McAndrew et al., 2014 ). Moreover, interactions between nursing staff and patients are often not supported or guided by the psychological theory of relationships; there is a substantial theory-practice gap ( Cameron et al., 2005 ) that might leave both staff and service users vulnerable to relational difficulties and the consequent impact on wellbeing and outcomes. It seems that services, patients and staff place value on the therapeutic alliance, its core attributes have been explored and conceptualised, and yet theoretically-driven, evidenced systems that support its development and maintenance are lacking. With this deficiency in targeted support, staff members increasingly report feeling burnt-out as a result of managing complex and emotionally difficult relationships ( Holmqvist, and Jeanneau, 2006 ; Nathan et al., 2007 ). This could lead to compassion sometimes waning when it is needed most ( Lombardo, and Eyre, 2011 ; Ray et al., 2013 ) and staff retention proving extremely difficult, with subsequent strategic priorities to improve this in both the United Kingdom and internationally ( Andrews, and Wan, 2009 ; European Commission, 2014 ; NHS, 2019 ; Parliament of Australia, 2002 ).

There has been some tentative progress in supporting effective relationships, with indications that clinical supervision can protect against staff burnout ( Edwards et al., 2006 ) and psychologically-informed case discussions can enhance positive feelings towards service users and reduce staff self-blame ( Berry et al., 2009 ). Team-based training to develop staff skills using psychological models can even improve patient engagement with the service ( Caruso et al., 2013 ). However, there is no comprehensive, critical summary of interventions that have specifically targeted the element of treatment that we know is essential; the therapeutic alliance, for the group who potentially has the capacity and context to deliver compassionate, caring relationships; nurses.

In conducting this review, we systematically collated and critiqued studies reporting on interventions targeting the therapeutic relationship between nursing staff and service users in mental health settings. We aimed to answer some key questions; what intervention methods have been tested, in what clinical contexts and with which groups, what outcome measures were utilised, what effects were demonstrated and what was the quality of the methods used.

3.1. Protocol and registration

The review protocol was pre-registered and is available online within the international prospective register of systematic reviews (PROSPERO) under the registration number CRD42018111022.

3.2. Criteria for inclusion

Papers were considered eligible for inclusion if they: were published as an original, peer-reviewed journal article; written in English; included an intervention aimed to improve the therapeutic relationship between nursing staff and user/s of psychiatric or mental health services; included analysis of the impact of the intervention utilising a standardised measure of alliance. The review includes studies from any mental health service context (such as community, inpatient), client groups of any age, with any mental health diagnosis or need and interventions targeted at the relationship with either qualified or non-qualified nursing staff. Where the staff group incorporated other disciplines, these findings were still eligible if that included nurses in the overall sample.

3.3. Search methods

The current review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( Moher et al., 2009 ). Search terms were generated through review of empirical and opinion pieces regarding alliance and systematic review papers of alliance (for example, Elvins, and Green, 2008 ; Flückiger et al., 2012 ; Horvath, and Luborsky, 1993 ; Priebe, and McCabe, 2006 ; Zaitsoff et al., 2015 ), scoping literature searches and consultation with experts in the field. A systematic search of Excerpta Medica database (Embase), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases was conducted on 05/07/18 and then updated on 04/04/19 using the following search strings: (nurse* OR nursing OR staff) AND (alliance OR relationship*) AND (mental OR psychiatry*) AND (improve* OR interven* OR change OR support). The reference lists of eligible papers were also consulted for any additional studies and a forward citation search undertaken.

3.4. Data collection and analysis

All potentially eligible records were imported into Endnote reference management software package (Version 8) and duplicate references identified and deleted. One reviewer screened titles and abstracts for relevance, using the inclusion criteria set out above and alongside regular discussion with the research team. Another independent reviewer blindly assessed 50% (randomly selected) of the full texts against the inclusion criteria demonstrating 88% agreement, with any remaining disagreements resolved through discussion with the project team, resulting in full agreement. Data extraction was guided by a pre-specified data extraction sheet detailing key features of the study: sample, setting, design, intervention, outcome measure, analysis, effect size, limitations. Authors were contacted where effect size data was not available in the original paper. The review used a narrative synthesis approach, whereby an attempt was made to go beyond a description of the studies to explore relationships within and between them ( Popay et al., 2006 ).

3.5. Assessment of methodological quality

In order to evaluate the methodological rigour of the studies included and therefore to inform the critical synthesis of the findings produced and subsequent recommendations, the papers were assessed using a standardised quality tool. There is a distinct lack of assessment tools that fulfil both the need to be demonstrably reliable and valid and also appropriate for use with a range of study designs. Based on a previous review of quality assessment tools ( Deeks et al., 2003 ), the Effective Public Health Practice Project tool ( Effective Public Health Practice Project, 1998 ) was selected as one that could offer valid ( Thomas et al., 2004 ), reliable ( Armijo-Olivo et al., 2012 ) and flexible appraisal of varying study designs. All of the eligible papers were assessed for quality by the first author and blind second-rated, with 86% agreement demonstrated. Initial ratings from the first author were reviewed collaboratively with the second rater and a decision was made to retain these scores.

4.1. Flow of records

The flow of records through the review process can be seen in Fig. 1 , in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines ( Moher et al., 2009 ). The search resulted in a total of eight papers which met inclusion criteria. These are summarised in Table 1 .

Flow of records

Summary of papers and quality ratings.

4.2. Methodological quality

Table 1 provides the overall quality rating for each paper, based on the constituent ratings of the Effective Public Health Practice Project tool and its guideline procedure. Full details of the ratings are available from the first author. As is evident, six of the eight studies were rated as weak methodologically. Berry et al. (2016) was the only study that met ‘strong’ design criteria, while Moreno-Poyato et al. (2018) was deemed moderate. The studies were predominantly down-rated due to lack of randomised designs, blinding, confounder control and full reporting of retention information.

4.3. Participant and settings

The eligible papers included interventions delivered in a range of settings (inpatient and community services, acute, rehabilitation), in a number of different countries (United Kingdom, Australia, Sweden, Spain, Netherlands) for individuals with a range of conditions under the umbrella of severe mental health problems, including psychosis and difficulties associated with a diagnosis of personality disorder. As per the inclusion criteria, all studies targeted the relationship between mental health nursing staff and service users, although there were a range of additional criteria. The range of settings and participants is reflective of the variety of roles and services within which the therapeutic alliance is fostered.

4.4. Interventions

The interventions varied in scope, focus and theoretical underpinning. Berry et al. (2012 , 2016 ) drew on psychological formulation (allied mainly to a cognitive behavioural model) to foster understanding of drivers for patients’ behaviour and clinical presentation within staff group workshops. Carpenter et al. (2007) offered group training in psycho-social interventions that included focus on specific models and also core values of therapeutic engagement. Kellett et al. (2019) utilised a consultancy model provided to pairs of staff members and service users, with cognitive analytic therapy as the underlying approach. Molin et al. (2018) focused on the structure of ward timetables, creating space for time spent together between nursing staff and patients, providing opportunity for joint activities and meaningful engagement. The authors involved staff on each ward in the precise implementation structure to provide a good fit to routine ward activities and preferences. Moreno-Poyato et al. (2018) utilised a participatory action research approach whereby the nurses involved in the study generated intervention elements in a bid to reach best practice, which ultimately involved daily interactions with individual patients, reflective groups for staff and study of scientific texts as selected by staff. Stringer et al. (2015) adopted a broad-based collaborative care programme that consisted of elements including understanding (via timeline work), structural changes (teams, treatment plans), specific interventions (problem solving) and psycho-education. The primary focus of Byrne and Deane's (2011) intervention was to improve medication adherence, with the alliance targeted as a mediating variable, involving modifying clinician beliefs about non-adherent patients that can pose barriers to the relationship and support for adherence.

4.5. Outcome measurement

The majority of the studies ( Berry et al., 2012 , 2016 ; Byrne and Deane, 2011 ; Kellett et al., 2019 ; Moreno-Poyato et al., 2018 ) utilised the Working Alliance Inventory (WAI; Horvath and Greenberg, 1989 ) as the primary alliance outcome, reflecting its prominence in the literature, although only Berry et al. (2016) and Kellett et al. (2019) used both the patient- and clinician-rated version, with the rest opting for the latter only. Others ( Molin et al., 2018 ; Stringer et al., 2015 ) used the Caring Professional Scale ( Swanson, 2000 ), as rated by service users and the scale to asses therapeutic relationships (STAR; McGuire-Snieckus et al., 2007 ), respectively. Carpenter et al. (2007) relied on a non-validated but user-defined outcome scale ( Barnes et al., 2000 ), which included numerous items relevant to the alliance; including involvement, listening and understanding.

Four of the eight included studies reported no statistically significant difference as a result of the intervention in terms of assessed therapeutic alliance ( Berry et al., 2012 , 2016 ; Molin et al., 2018 ; Stringer et al., 2015 ). Molin et al. (2018) did not provide data to facilitate a more nuanced interpretation. Berry et al. (2016) findings are intriguing as staff-rated alliance was better for the control than intervention group (similar to Berry et al., 2012 ), whereas client-rated alliance delivered a large effect size in favour of the intervention, which was presumably then diluted by a more rigorous analysis method in their strongly rated study. Stringer et al. (2015) showed a small effect in favour of the intervention group at nine months, although crucially, both groups declined in reported alliance through the course of the intervention period, leaving the findings difficult to interpret and confounded by a weak study design.

Carpenter et al. (2007) did not report longitudinal statistical improvement but did find a difference between the intervention and control groups in terms of user-rated involvement with staff, although sufficient data was not available to comment on the size of this effect and the weak study quality rating detracts from the significance. Byrne and Deane (2011) reported a statistically significant change in Working Alliance Inventory scores between baseline and six months following the alliance intervention with a medium effect size, although no improvement at 12 month follow-up and concerns raised by the weak study quality rating. Moreno-Poyato et al. (2018) demonstrated a significant difference in post-intervention alliance scores between the active and comparison group, with a median difference of 7 scale points, and large effect size. This study was one of only two in the review to score better than a weak rating in terms of quality assessment, placing more weight on the potential effectiveness of their collaboratively developed intervention. Kellett et al. (2019) demonstrated statistically significant change and a large effect size improvement for client-rated alliance in their case series study, but not for staff-rated alliance or for their larger ( n  = 12 staff-client pairings) pre-post service evaluation. The weak study rating also means that these findings should be interpreted with caution, despite the encouraging ratings from service-user perspectives.

5. Discussion

We set out to collate and synthesise information pertaining to interventions that aim to support effective therapeutic alliance between nursing staff and users of mental health services, which has been shown to be central to positive outcomes in both psychotherapy and broader engagement contexts ( Cruz and Pincus, 2002 ; Duncan et al., 2010 ; Howgego et al., 2003 ; Martin et al., 2000 ; Messer and Wampold, 2002 ; Priebe and McCabe, 2006 ). The central finding of note, in the authors’ view, is the dearth of studies in this area. It seems surprising that an element of care that is so intrinsic to both patient progress and clinician role does not have a robust evidence base on which to draw in order to provide effective foundations for its development and maintenance. It might be that this has emerged from an assumption of alliance building and maintenance as an implicit ability rather than a skill to be honed and scaffolded, or of the difficulty in addressing a complex issue with a readily-evaluated design.

The evaluated interventions adopted a range of methods, including psychosocial approaches ( Berry et al., 2012 , 2016 ; Carpenter et al., 2007 ; Kellett et al., 2019 ), those targeting specific clinician attitudes ( Byrne and Deane, 2011 ) and those derived from action research, where the intervention content was collaboratively developed with staff in an attempt to bridge the gap between current and best practice ( Moreno-Poyato et al., 2018 ). The lack of a coherent, shared theoretical underpinning might contribute to the deficiency of robust research and consistent evidence base. The interventions largely consisted of group-based programmes, whereas the relationship that is predominantly measured is a dyadic one between one nurse and one service user; this discrepancy might be contributing to lack of consistent positive change. Kellett et al. (2019) did demonstrate change when the dyadic relationship was specifically targeted and measured as such in the context of a dynamic consultation approach rather than workshop-based training. It is also not entirely clear what level of public (staff and/ or service user) involvement there was in the development of the intervention packages, which might have enhanced the feasibility, acceptability and ultimately, impact ( Brett et al., 2014 ).

Data gathered by the current review do not permit recommendations in terms of effective interventions and their theoretical underpinnings. The evolution of the concept of the therapeutic alliance, from one of dyadic and confined psychotherapeutic engagement to one that often spans relationships within complex team structures, with multiple professionals at once and in varying roles outside of the narrow remit of formal therapy no doubt contribute to the difficulty in developing interventions that are sufficiently targeted yet appropriately flexible. Given the nuanced conceptualisation of the core elements of therapeutic relationships between different settings ( Cleary et al., 2012 ; McAllister et al., 2019 ; O'Brien, 2000 ; Pazargadi et al., 2015 ; Shattell et al., 2007 ; Spiers and Wood, 2010 ), it might be that the development of an alliance intervention needs to draw from both theoretical understanding, alongside setting-based contextual needs, which will need to be explored and supported in situ.

As the methodological quality assessment indicates, the studies were predominantly under-controlled, with a lack of randomised designs and matched comparison groups or controls. This limits conclusions that can be drawn even from those studies where positive outcomes were identified. The relatively small samples sizes might also have limited statistical power to detect differences, and those studies that showed promise in terms of effect sizes will need to be replicated with more adequate samples and appropriate statistical control. Few studies checked the validity of their intervention with any kind of fidelity tool ( Santacroce et al., 2004 ). It is therefore also possible that negative outcomes were due to a dilution of or divergence from the intervention protocol, rather than necessarily an intrinsic limitation of the active elements. The lack of statistical control also highlights difficulties central to the issue of intervention design and evaluation in this field. As the alliance is conceptualised as a reciprocally developed, genuine human connection, then how can this be reliably supported and measured between different pairs of individuals, where the goals, needs and definition of the relationship will be inherently idiosyncratic? The current review therefore also points to the need for a range of evaluation methods, alongside the development of controlled trials, which can adequately capture the key elements of the alliance both in terms of supporting its development and evaluating its progress.

Most studies chose to measure outcome using the working alliance inventory. Although fairly ubiquitous, this might be somewhat problematic. The Working Alliance Inventory is a tool designed for use in the context of therapy that does not fully converge with the nature of a nurse–patient relationship, which might often be more accurately conceptualised as a therapeutic key worker role, where therapeutic conversations might be had in the context of a broader care-coordination or care-planning role ( Burns, 2004 ; Simpson, 2005 ; Thurston, 2003 ). Thus, the relationship of interest and its quality might not be accurately evaluated by the use of Working Alliance Inventory. In terms of the source of the ratings, two studies that reported mixed findings ( Kellett et al., 2019 ; Berry et al., 2016 ) demonstrated larger effect sizes for the client perspective as compared to the staff member. This underscores the importance of considering multiple sources but also the need to elaborate on the best method for determining good relational outcomes, especially since client-rated alliance is the better predictor of therapeutic progress ( Bachelor, 1991 ; Fitzpatrick et al., 2005 )

5.1. Strengths and limitations of the review

We aimed to provide a comprehensive and critical summary of current evidence pertaining to intervention to support nursing staff in their therapeutic relationships with people utilising mental health services. The systematic, thorough nature of the review offers a contribution to an important area of literature hitherto unreported. The small sample of studies is reflective of the field as it stands while also limiting the utility of the review and it will be important to repeat the process as the evidence based develops, incorporating more nuanced analysis of the findings and methods and robust meta-analysis or meta-synthesis, where the nature of the interventions delivered and their qualitative impact could be more fully explored. Our decision to include both qualified and non-qualified staff interventions, and to include studies whose sample include nurses alongside other staff groups was pragmatic in nature to ensure any relevant intervention was highlighted, particularly in a limited evidence base. However, future work might wish to consider how to delineate samples more precisely and thus provide evidence best-suited to the target discipline. This review has focused on interventions that specifically target the therapeutic alliance as a core aspect of effective mental health care. It is acknowledged that the alliance is part of the approach of other modality-specific therapies, such as cognitive behavioural therapy, dialectical behaviour therapy or cognitive analytic therapy ( Bennettet al., 2006 ; Bedics et al., 2015 ; Gilbert, and Leahy, 2007 ). Therefore, synthesising findings from modality-specific intervention research, where the alliance might be evaluated as a mechanism of change, with the current, more focused conceptualisation might be warranted.

5.2. Clinical implications and recommendations for future work

The nature of the evidence base as it stands renders it difficult to make clear clinical recommendations in terms of how nursing staff should be best supported to develop and maintain effective therapeutic relationships with the individuals they work with in the settings they operate. There is some indication that interventions targeting clinician attitudes and reflective capacity, relational understanding and dynamic interactions might be helpful, although further work is needed. There is also a relative absence of service user and clinical staff involvement in the development of the reported interventions, which might limit their acceptability and feasibility. This paper, therefore, should serve as an impetus to develop a clear trajectory of research endeavours that build on the current findings and creates a more robust body of work incorporating the following key elements: i) intervention based on strong theoretical underpinnings and service user and clinician involvement; ii) methodologically sound studies; iii) assessment of fidelity to the intervention model; iv) targeting and evaluation of the alliance aligned with its conceptualisation as a dyadic, mutual, professional relationship outside the specific bounds of psychotherapy.

Conflict of interest

Dr Samantha Hartley is funded by a National Institute for Health Research (NIHR) Integrated Clinical Academic Clinical Lectureship for this research project. This paper presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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Article Contents

Introduction, research design and method, opening of the encounter: developing a reciprocal relationship, active listening: power sharing, vision of the future: emphasizing the positive, conclusions.

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Empowering counseling—a case study: nurse–patient encounter in a hospital

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Tarja Kettunen, Marita Poskiparta, Leena Liimatainen, Empowering counseling—a case study: nurse–patient encounter in a hospital , Health Education Research , Volume 16, Issue 2, April 2001, Pages 227–238, https://doi.org/10.1093/her/16.2.227

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This study illustrates practices that a nurse uses in order to empower patients. The emphasis is on speech formulae that encourage patients to discuss their concerns and to solicit information about impending surgery. The study is a part of a larger research project and a single case was selected for presentation in this article because it differed from the rest of the data by manifesting empowering practice. A videotaped nurse–patient health counseling session was conducted in a hospital and transcribed verbatim. The investigator interviewed the nurse and the patient after the conversation, and these interviews were transcribed as well. The encounter that is presented here as a case study is a concrete example of a counseling session during which the patient is free to discuss with the nurse. The empowering practices that the nurse employed were as follows: encouraging the patient to speak out, tactfully sounding out the patient's concerns and knowledge of impending surgery, listening to feedback, and building a positive vision of the future for the patient. We suggest that nurses should pay attention to verbal expression and forms of language. This enables them to gain self-awareness and discover new tools to work with.

In recent literature, empowerment has become an important concept of health education ( Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 ), health promotion ( Labonte, 1994 ; Tones, 1994 , 1995 ; Williams, 1995 ; McWilliam et al. , 1997 ) and health counseling ( Poskiparta et al. , 2000 ). The process of empowerment has been related more to community and organizational levels than to micro levels of practice ( van Ryn and Heaney, 1997 ) where it is constantly crucial ( Tones, 1994 ). In addition, operationalization of the concept of empowerment has been relatively vague. According to Tones ( Tones, 1994 ), empowerment is a major goal of health promotion. This article focuses on health counseling as a means of interpersonal health education practice and uses health promotion as an umbrella term.

Empowerment is as much a process as an outcome of developing the skills and perceptions of clients. It is not only something that happens but a process that is facilitated. In interpersonal health counseling, the primary goal is not to change clients' behavior and seek their compliance with the presented message but rather to raise critical awareness through learning and support, to give clients tools for making changes on their own. The aim is personal empowerment, control and choice, which means that patients become aware of changes in their knowledge and understanding, decision-making skills, enhanced self-esteem/sense of personal control, and development of various social, health and life skills ( Labonte, 1994 ; Tones 1994 ; Anderson et al. , 1995 ; Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 ; Kar et al. , 1999 ).

The basic point of departure for empowerment is taking into consideration the interactive nature of the individual and the environment: people are not completely controlled by their environment nor can they fully control their physical, social or economic circumstances ( Tones, 1994 ). Empowering health counseling is based on recognizing clients' competence, resources, explanations of action styles of coping and support networks. Client initiative, clients' realizations and clients' expressions of their opinions and interpretations are the basis on which clients can approach health issues in collaboration with professionals. They are of crucial importance for their decisions on future action ( Anderson, 1996 ). All this supports the notion that empowering health counseling is significant.

Because learning about personal health is complex, the key issue of empowering health counseling is partnership and reciprocal conversation in a confidential relationship. This means that clients not only analyze their situation but also have an opportunity to plan what to do next, and how to go on and to construct their own solutions to health issues. In this type of hospital health counseling, either patients raise the issues (i.e. determine the topics) or the nurses do so in a sensitive and non-threatening manner ( Poskiparta et al. , 2000 ). Nurses recognize and respect patients' experiences, knowledge and skills, and make their own professional knowledge and expertise available to them ( Williams, 1995 ; McWilliam, et al. , 1997 ), which are important aspects of nurse–patient relationships that are also reported by patients ( Häggman-Laitila and Åstedt-Kurki, 1994 ; Lindsey and Hartrick, 1996 ; Wiles 1997 ). The emphasis is placed on patient-driven [see ( Lindsey and Hartrick, 1996 )] health counseling, where patients' life situations are respected, patient-initiated actions are supported, and shared knowledge and deep understanding are nurtured.

The nurse's institutional task is not only to facilitate patient participation but also to promote patients' awareness of their routines and preconceptions as they are revealed to both interlocutors. This should lead to the aim of interaction, which is to activate self-reflection and re-evaluation and reorganization of patients' activities. The assumption is that new knowledge is gained in this process as a result of empirical realization and deliberation ( Feste and Anderson, 1995 ), which means that both patients and nurses have linked new knowledge to existing knowledge. Thus, patients learn to interpret and outline even familiar health problems in new ways that conform to their worldview [ cf . ( Mattus, 1994 )]. As for nurses, empowerment calls for not only sensitivity but also an ability to accurately perceive patients' messages.

From this point on, the focus is on the content of the interactive process. Tones ( Tones, 1994 ) discusses empowerment theoretically, Labonte ( Labonte, 1994 ) expresses ideas for practice in general, while Feste and Anderson ( Feste and Anderson, 1995 ) provide three empowerment tools for facilitating patients' empowering process: using questions, behavioral language and storytelling. According to them, questions maintain the process of pursuing wisdom, i.e. exploring the meaning of health problems in the context of everyday life. This kind of questioning involves broad questions that relate to one's personal philosophy and lifelong dreams. In addition, it includes practical, day-to-day issues of successfully integrating into one's personal, family, social and professional life. Behavioral language means using words such as `list', `describe', `identify', `decide', etc., in order to encourage patients to act and make choices instead of being satisfied with receiving information. Stories help to facilitate the process of self-discovery because diseases affect all areas of life and each individual's health status is unique.

Van Ryn and Heaney ( Van Ryn and Heaney, 1997 ) pay attention to interpersonal relations by suggesting concrete strategies and examples for empowering practice. In their article, they demonstrate two principles of interaction: (1) provide clients with unconditional positive regard and acceptance, and (2) facilitate client participation. Both principles include several practical strategies (Table I ).

However, the authors pay less attention to empirical findings ( Northouse, 1997 ). The present article describes some linguistic realizations of empowering practice. This article describes a nurse's empowering speech formulae during her efforts to give a patient information about an impending surgical operation and to strengthen her feelings of security by providing her with an opportunity to discuss her concerns. This study adopts a holistic approach to interaction and does not focus on isolated sentences or dialogue structure. The relationship of language and context in comprehension, as well as non-verbal communication, are also discussed.

This article describes a single case derived from qualitative data collected from a total of 38 counseling sessions in a Finnish hospital. Nurse–patient encounters were videotaped and transcribed verbatim. Interviews with the nurses and the patients after the sessions were transcribed as well. All participants volunteered to take part in the research, signed a research license and granted permission for the transcribed data to be used in publications. Nineteen nurses participated in this study. Each nurse conducted two videotaped counseling sessions with different patients. There was only one male nurse while the patient group consisted of 24 female and 14 male patients. The research material took shape as nurses volunteered in the hospital and it was found to be adequate for qualitative analysis. The length of the nurses' careers varied from 1 to 25 years. The ages of the nurses were between 24 and 50 years (mean age 36.9 years) while the patients' ages ranged from 18 to 70 years (mean age 47.9 years). The researcher did not attend the counseling sessions, which lasted from 5 to 45 min. The participating patients were experiencing diverse health problems. Various surgical problems, e.g. knee surgery, hernia operation, breast surgery, hip operation, back operation, post status of brain bleeding and post care of bypass surgery, were among the most representative. In addition to the health problems that had led to hospitalization, many patients also suffered from chronic diseases, such as hypertension, asthma, rheumatic illnesses or diabetes. Many patients also found themselves in an insecure situation when a chronic disease had suddenly been manifested or they were undergoing examinations. There were also some mothers in the group who had delivered recently and had no health problems.

The health counseling sessions were genuine counseling situations that were related to the patients' treatment. A single video camera was used, which meant that the observation of non-verbal communication was limited to examining the session as a whole, including only eye contact, smiles, laughter, tone of voice, gestures and, to some extent, facial expressions. Consequently, the emphasis of this study was examining verbal communication. Separate interviews with the nurses and the patients where both parties were encouraged to express their evaluations of the health counseling were used for partial support of the interpretations, e.g. when describing the patients' opinions about health counseling. We also checked if there were any nurses or patients who were nervous about the videotaping.

This article concentrates on videotaped data. When we examined all of the data we found many encounters that involved some empowering features from time to time, but there were none that were consistently empowering. In this article, we present a single case from the data. This particular encounter was selected because it differed from the rest of the data ( Stake, 1994 ) by manifesting empowering practice most widely. In order to study the interactive nature of communication, the coding and analysis of the videotaped data was based on principles of Conversation Analysis ( Drew and Heritage, 1998 ). The videotapes were transcribed word by word, including stammering, etc. At the same time, additional data were added to the transcriptions, such as pauses during and between turns, onset and termination of overlapping talk, intonation information, and some non-verbal communication. The following transcription symbols were used to indicate this information:

ha+ hands support speech

vo+ rising voice

vo– falling voice

[ ] at the beginning and end of overlapping speech, words enclosed

(( )) transcriber's comments, e.g. smile, laughter, body movements

(.) small but detectable pause

underlining emphasis

… omission of text

=no interval between the end of prior and start of next speech unit

°speech° speech in low volume, words enclosed

`speech'pitch change, words enclosed

The analysis was carried out on a turn-by-turn basis. The principle behind this analysis was to examine how turns were taken with regard to other participants' speech and what sequential implications each turn had for the next. After reading the transcript and watching the recording several times, we discovered a number of empowering expressions in the nurse's speech and concluded that this case was the one which best manifested empowering action in the data.

The particular case describes at the individual level information about the patient's situation, the nurse's interview after the encounter, an in-depth description of the nurse–patient conversation and the observational data derived from it. Pearson ( Pearson, 1991 ) and Patton ( Patton, 1990 ) indicate that a case study can be used, for example, for examining how different concepts emerge or change in particular contexts. However, an even more important question is what can be learned from a single case. Stake ( Stake, 1994 ) suggests that one should select a case that seems to offer an opportunity to learn and contributes to our understanding of specific phenomena. Here, a detailed single case analysis illustrates how empowerment may be practiced during health counseling and demonstrates how new working tools for empowerment can be developed on the basis of a single encounter ( Laitakari, 1998 ). The present study describes the speech of a nurse when she helped a patient to deal with anxiety and to receive information about surgery in an empowering way.

The nurse anesthetist has come to see a patient who is scheduled to have surgery the next day. The encounter involves, besides interviewing, producing a lot of information about the operation, counseling on the preparations for the surgery and advising how to manage after the surgery. The encounter takes place at a table, with the nurse and the patient facing each other. Both are women; the nurse is 50 and the patient 41 years old. The patient had had problems with her back for 10 years and was suddenly admitted to the hospital because of these problems. The patient has recently been examined and a decision has been made to operate on her the next morning. The interviewing session lasted 14 min.

At the beginning of a conversation the participants evaluate each others aims and concerns, and the communication situation as a whole, and this evaluation directs the entire discussion because the participants base their actions on it (Goffman, 1982). In a hospital, it is typical that nurses initiate a discussion ( Leino-Kilpi, 1991 ) and that is what happened in this case ( Extract 1 ). Professional dominance common in medical encounters ( Fairclough, 1992 ) is not so obvious in this conversation. After greeting the patient, the nurse refers to the goal of the discussion and individualizes it by using familiar `you' (line 1) instead of the formal, plural form of `you'. This form of address can be viewed as an act of communicating an appropriate degree of informality. It implies intimacy and mutual respect when a relationship is established ( van Ryn and Heaney, 1997 ).

1 N: Hello, Rose (.) you are going to have surgery 
 2 tomorrow…but now I would like to ask you 
 3 you well about the operation tomorrow if 
 4 there is (.) something that would influence 
 5 the preparations for your operation (.) and 
 6 then you ((ha+)) can bring things up ask well 
 7 er if something is unclear to you ((nod+)) If 
 8 you want to know anything about what's 
 9 going to happen to you tomorrow ((vo–))

((at first the nurse looks at papers on the table, while she speaks she turns her eyes to the patient and nods))

This opening was not typical of the other interviews in the data set, because in the data these encounters were usually initiated with the nurses' brief statements about the impending operation. They explained that they interviewed patients in advance in order to get information and that they could provide information to the patients as well. Nurses usually used formal, plural forms of address when speaking. When referring to the preoperative encounter, they used the plural, institutionalized form `we' [see ( Drew and Heritage, 1998 )], instead of first person singular `I', and plural `you', instead of the singular, when addressing the patient. Other nurses did not individualize their speech. On the contrary, they maintained a distance from the patients. In this particular case, a familiar mode of address reduces social distance, which is very important in health education practice [ cf . ( van Ryn and Heaney, 1997 )]. We explain our interpretations in more detail below.

The nurse uses the verb `ask' (line 2), but her remark further on (line 6–9) `then you can bring up ask well er if you were unclear about something if you want to know something about what's going to happen to you tomorrow' introduces a context for the discussion. Even though the nurse goes on to ask a question about previous operations, the interview becomes an interactive dialogue, with the patient actively participating. On her own initiative the patient discloses symptoms that she has experienced during the last few months, what happened when she needed to come to the hospital and the doctor's decision to perform surgery.

Thus, the nurse introduces the context of the discussion with her opening words [ cf . ( Peräkylä, 1995 )]. She expresses her acceptance by offering collaboration [ cf . ( van Ryn and Heaney, 1997 )] when asking questions. The verb form `would like to' (line 2) gives the discussion an air of voluntariness. The conditional form softens the notion of the necessity of the questions, and the verbal mode implies respect for the patient. At the beginning of the session (lines 1–9), the nurse combines two topics into a single long sentence, which also encourages (lines 6–9) the patient to clarify matters that are unclear to her. The nurse's words leave room for the patient's own thoughts and invites her to look for a personally meaningful way to connect the nurse's questions about the preparations (line 5) for the operation to her lack of information (lines 7–9). Encouraging statements can stimulate the patient to think in a way that is personally meaningful to her and to participate in the conversation ( van Ryn and Heaney, 1997 ; Tomm, 1988). Here, encouragement takes a form that is different from what Feste and Anderson ( Feste and Anderson, 1995 ) suggested; it is given in a more sophisticated manner. The opening words ( Extract 1 ) correspond with the goal that the nurse states later during the interview: `that the patient would receive the information she needs, what she wants to know and that she would feel safe to come, that at least those worst fears would be like forgotten. That she would feel safe'.

An encounter can threaten a patient's need for autonomy and freedom because it gives the nurse the legitimate power to request information about the patient's private life ( van Ryn and Heaney, 1997 ). Here, the nurse is mitigating her power by avoiding threatening terms and using tentative formulations (`would like to, well er, you you'), the emphasis being on the patient's needs. The opening of the interview by the nurse plays an important role in the development of the atmosphere. The act has been planned in advance but is not thoroughly thought out. In addition to conveying information, the main consideration in setting the goal for the discussion is to help the patient deal with her concerns. These are issues that have also been stressed in earlier studies ( Häggman-Laitila and Åstedt-Kurki, 1994 ; Breemhaar et al. , 1996 ; Leinonen et al. , 1996 ; Lindsey and Hartrick, 1996 ; Otte, 1996 ).

Tactful exploration: activation of reflection

Later during the interview, the patient mentions having thought about the impending surgery, which the nurse interprets as an indication of fear for the operation ( Extract 2 ). She indirectly gives the patient an opportunity to deal with her fears. The patient's words (lines 1, 3, 5 and 7) are related to the previous topic and her status during the operation and conclude the discussion. The nurse changes the subject (line 9) by praising the doctor's skill. The nurse and the patient look at each other.

1 P:mmm[think about during the day]= 
 2 N:[of] course ((nod+)) 
 3 P:=what's going to happen and (.) 
 4 N:right ((nod+)) 
 5 P:°like[that]° (.) 
 6 N:[mmm] 
 7 P:°it's[okay]° ((nod+, vo–)) 
 8 N: [that's] right (.) ((glance at papers: doctor's 
 9 name)) is is an excellent surgeon so in that 
 10 respect you can definitely (.) ((vo–)) feel 
 11 safe ((nod+)) that 
 12 P:yes of course I am 
 13 N:mmm 
 14 P: and and absolutely 110% (.) I trust that (.) 
 15 the thing is that (.) this is small case for 
 16 him but this is a horribly big thing for me…

The nurse's comment about the operating surgeon contains an allusion to fear of surgery. Instead of soothing the patient by telling her not to be afraid or asking if the patient is scared, the nurse indirectly comments on the doctor's professional skill (line 9) and emphasizes the expertise as a guarantee of success (line 10 and 11). Thus, the nurse allows the patient to save face when she leaves her to interpret her words. Her indirectness implies politeness and gives the patient options: if she does not want to deal with her fear, she may choose not to take the hint [see ( Brown and Levinson, 1987 )]. Here, politeness can also be linked to and interpreted through empowering practice, where the nurse holds the patient in high regard [ cf . ( van Ryn and Heaney, 1997 )].

The extract might have been interpreted as an example of the nurse cutting the patient off if one had not seen the videotape. Our interpretation is supported by a number of factors. First of all, the entire conversation until this extract has been tranquil and calm, the nurse has spoken and asked questions at a gentle pace, with pauses, and she has explored the patient's experiences. In this extract, the situation is similar, and she looks at the patient and nods. She speaks quite slowly, and her voice is low, friendly, and convincing ( van Ryn and Heaney, 1997 ). We can also see that the patient completes her speech by pausing (lines 3 and 5) and lowering her voice (lines 5 and 7). Therefore, after the nurse's words (lines 8–11), the patient presents her fear for discussion (lines 15 and 16) and also returns to the matter later during the interview. The extract shows how the issue has been constructed together by the nurse and the patient. The nurse raises the theme in a sensitive and non-threatening manner, and the patient continues the same topic. It also shows that the relationship is confidential enough for the patient to disclose her concerns and become aware of her own understanding, and thus contributes to empowerment. Salmon ( Salmon, 1993 ) has stressed that the main goal in the discussions between nurses and patients before surgery is not to reduce the patients' fears but to help them to deal with them.

Indirectness is a polite feature of discourse. There is `strategic indefiniteness' in indirectness that offers patients an opportunity to continue a discussion according to their own wishes ( Brown and Levinson, 1987 ). In general, nurses' empowering acts are mostly manifested in the form of questions ( Poskiparta et al. , 2000 ). In some cases, an indirect comment by a nurse, instead of a question, may encourage patients to talk about topics that they fear. Here it generates reflection in the patient. After disclosing her concerns, the patient analyzes the situation and recounts the conversation that she had with the doctor who explained the reason for her back surgery ( Extract 3 ).

Extract 3 .

1 P:this morning ((doctor's name)) said that 
 2 N:`this morning' ((surprised)) 
 3 P:this morning 
 4 N:that's recent for sure 
 4 P:yes 
 5 N:well it happened so 
 6 P: so it happened suddenly because yesterday 
 7 it became evident that (.) there was in the 
 8 X-ray ((doctor's name)) said that there was 
 9 a cause when I asked if there was anything 
 10 that caused the pain or if I was just imagining 
 11 it (.) so he said that yes there was a 
 12 genuine cause…

The amount of information given always depends on the situation and the nurse needs to continually evaluate the patient's needs: what it is that the patient knows, wants to know and how much she does want to know. This is also important because there are several persons that the patient sees before surgery ( Breemhaar et al. , 1996 ). Furthermore, nurses and doctors may deal with the same issues in their counseling. In Finland, the doctors, the surgeon and the consultant anaesthetist inform patients about the medical facts, risks, and benefits of operations. The patient also has an interview with a nurse on the surgical ward and, in addition to these encounters, there will occasionally be an encounter with a nurse anesthetist.

The nurse's empowering approach is manifested in how she raises issues or questions from time to time as if with hesitation. A pause precedes questions [`I don't have any (.) questions to ask you any more but do you—you have anything to ask from me like such things about tomorrow that worry you') ((looks at the patient))]. She asks the questions more quietly than normal and looks at the patient. According to Beck and Ragan's ( Beck and Ragan, 1992 ) study, nurses' softening words and their hesitant and tentative manner of speaking indicate discretion and tact and are aimed at not embarrassing patients. In our data, slow and hesitant speech also encourages the patients to comment more than nurses' more usual and brief question does: `Do you have any questions?'.

The nurse's tentative manner of asking questions makes it easier for the patient to start dealing with her concerns. She repeatedly pauses briefly and, in addition to the closed questions in the medical history questionnaire, she asks open-ended questions that explore the patient's experiences: `What kind of memories do you have of previous operations?' `Is there anything else you remember (.) is there something?'. Open-ended questions encourage the patient to speak and participate, e.g. in the naming and solving of a problem [ cf . ( Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 )]. In this particular case, indirectness and hesitation are polite speech formulae that help the patient to save face ( Fairclough, 1992 ). They can also serve as empowering strategies that provide unconditional positive regard and acceptance for patients.

Despite these quite extensive empowering acts, the nurse subsequently evaluated her information skills only. She indicated how difficult it was for her to decide what kind of information to give to the patient:

I wondered if I should have maintained a more professional role, I mean more facts, if the patient got all that she wanted. Because this is not really medical science, you know, that's up to the doctor. It has to happen on the patient's terms, what she wants to know. I tried to check the patient's needs several times.

The content of the session satisfied the patient as well:

I got enough information about the operation, things that occupied my mind, so I didn't, she even told me before I asked. There's nothing to find out any more. As I said to her, I'm terribly afraid but I'll go ahead with confidence.

The nurse's way of posing questions builds up interaction. With her questions she steers the discussion thematically. This is how she controls the conversation. On the other hand, it is the patient who determines the content of the discussion. Her answers are reflective and bring up new issues. When the patient speaks, the nurse supports her with various feedback (e.g. Extracts 2 and 3) `mmm, right, of course, yes, exactly' and sometimes by paraphrasing. She nods a lot, bends toward the patient and looks at her. The feedback also occasionally includes completing the patient's sentences. According to van Ryn and Heaney ( van Ryn and Heaney, 1997 ), such non-verbal cues signal acceptance and, according to Caris-Verhallen et al. ( Caris-Verhallen et al. , 1999 ), they are patient-centered. With her feedback the nurse shows that she is there to listen to the patient, that she does not want to interrupt. Her feedback encourages the patient to speak in a similar way as in the doctor–patient conversation of an alternative medical interview described by Fairclough ( Fairclough, 1992 ). The patient interprets the feedback as encouragement, goes on to discuss the matter, and indicates her intention to continue by using the expressions `What I have been wondering…', `I did that when…' and `on the other hand, it's…'. This is how the nurse supports the patient's right to speak, which is not necessarily typical of a medical conversation ( Fairclough, 1992 ). The nurse's multi-facetted listening feedback is empowering, and this can be seen here and there in the data [see also ( Poskiparta et al. , 2000 )]. In this encounter, the feedback is exceptional because it disregards the participant's status. Generally, this type of feedback is directed to the dominant person ( Hakulinen, 1989 ). In a medically oriented environment, the hospital staff are viewed as superior to patients in knowledge ( van Ryn and Heaney, 1997 ; Tones, 1994 ). In this particular case, the nurse's listening feedback manifests power sharing.

When the patient discusses the reason for her admission to the hospital, the nurse builds up a positive, healthier vision of the future through other patients' experiences ( Extract 4 ). She makes her professional knowledge and expertise available to the patient ( Williams, 1995 ; McWilliam et al. , 1997 ). This lends a touch of reality and possibly builds on the patient's strengths ( van Ryn and Heaney, 1997 ) in this situation. The nurse attempts to dispel the patient's concerns about the risks of the operation. Her tone is convincing, and her non-verbal messages also inspire confidence: she looks at the patient, reinforces her message by nodding her head and gestures with her hands. Encouraged by the nurse, the patient can have a vision of her postoperative future.

Extract 4 .

1 N:these these ((ha+)) back operations are 
 2 like such that patients in them are usually 
 3 really grateful ((nod+)) after the operation 
 4 because if the operation like succeeds and 
 5 something is found (.) then the pain will be 
 6left in the operating room (.) ((ha+)) and 
 7 in that in that this is like like different from 
 8 other operations (.) and then because the 
 9 woundpainisinthebacksomehowit's 
 10 different than in here if the wound was here 
 11 inthestomach(ha+))andit'snotthatthat 
 12bad when it is if[you]= 
 13 P:[yeah] 
 14 N:=afterthosestomachoperationsyouoften 
 15 often hear that these patients who have had 
 16their back operated are such fortunate 
 17((nod+)) cases in the sense [that]= 
 18 P:[yeah] ((nod+)) 
 19 N:= because the pain will be left in the 
 20 operating room and and that's it then 
 21 ((nod+/ha+))

The nurse encourages the patient to examine her life at some hypothetical future point of time when the operation will have succeeded. Hypothetical questions encourage patients to discuss issues that they fear [ cf . ( Peräkylä, 1995 ; Tomm, 1987 )], while a hypothetical positive situation encourages patients indirectly. In this case, discussing the past would not calm the patient but rather lead her thoughts to the incident that caused her hospitalization. The vision of the future that the nurse provides to the patient with may help relieve her. A positive example is an empowering message and displays the nurse's understanding of the patient's anxiety. This vision can tap new resources in the patient for facing the future that is suddenly uncertain [ cf . ( van Ryn and Heaney, 1997 )]. Some manifestations of this can be seen in the patient's words: `…I'm very happy that if it's going to be over (.) yes I'm ready though I feel nervous' or `…I'm going ahead with confidence…'. A skilful use of future focus by the nurse helps the patient to find new solutions to her problems [ cf . ( Tomm, 1987 )]. As Atwood ( Atwood, 1995 ) suggests, confining the clients' thoughts to their problems is not sufficient in therapy work (focus on the past). In addition, we need to assist clients to expand their outlook by re-visioning their lives (future focus).

The encounter that is presented here as a case study demonstrates empowering nursing practice in hospital. It is a concrete example of a discussion during which the official and formal nature that characterizes the role of an institutional nurse is not emphasized. It actually emphasizes partnership and reciprocal conversation [ cf . ( van Ryn and Heaney, 1997 ; Poskiparta et al. , 2000 )], with the nurse's social interaction skills at the heart of the encounter [ cf . ( Wiles, 1997 )]. The patient is free to discuss her thoughts, concerns, experiences and even fears with the nurse, and the nurse adopts an empowerment strategy in order to facilitate the patient's participation. This encounter included the following empowering practices: (1) opening the session in an encouraging and constructive manner, which improves the atmosphere, (2) tactful exploration when examining the patient's need for information and concerns for surgery, (3) active, power sharing listening, and (4) building up a positive vision of the future.

The descriptions of empowerment strategies reported by van Ryn and Heaney ( van Ryn and Heaney, 1997 ) support our findings. However, we agree with Northouse's ( Northouse, 1997 ) criticism that the reported strategies are not completely separated. In our study, empowerment was manifested through intimacy and mutual respect. The nurse's encouragement of the patient's participation and her attempt to share power signaled acceptance, and perhaps gave the patient new insights for controlling her feelings about the impending surgery. Furthermore, the perceptions of active listening feedback and questioning are consistent with our previous studies ( Poskiparta et al. , 1998 , 2000 ; Kettunen et al. , 2000 ), where we found them to be a means of activating patients' self-evaluation and self-determination. In this study, we did not find evidence for empowering stories or questions that relate to patients' personal philosophy, as mentioned by Feste and Anderson ( Feste and Anderson, 1995 ). In addition, the nurse's encouragement was more sophisticated than what Feste and Anderson suggest with their empowering tools.

Our research data consisted of only one videotaped session per patient. Thus we have no evidence about how patients' decision-making skills develop or their self-esteem improves. During the interviews we did not ask the patients' opinion on the effects of counseling and that is why the patients evaluated conversations at a quite general level. In this particular case, the patient said that an encounter was ` illuminating ' for her. She mentioned that she received enough information and again spoke about her fears but used the same words as the nurse did when she emphasized a positive vision of future (see Extract 4 , lines 5, 6, 19 and 20): `if it's a fact that the pain will be left in the operating room, if it really is possible…that there's going to be an operation and they'll do it tomorrow, then that's how it's going to be'. This could, perhaps, signify some kind of relief or new resources to face an uncertain future. During the interview it also became evident that the patient's fears had not been diminished, but she talked about them and stressed a strong reliance on the professionals and on the operation as a whole: `I believe what I'm told'. This is in line with the perspective of Salmon ( Salmon, 1993 ), who emphasized that patients' anxiety about surgery should not be seen as a problem but rather as a normal phenomenon, a sign of patients' emotional balance, of an ability to feel fear. Thus, the nurse's task is not to diminish the patient's fears but to facilitate the patient's disclosure and offer help for dealing with fear.

With caution, we can speculate on the factors behind this kind of empowering practice, which became evident during the subsequent interviews. There was no evidence that nurses' or patients' age, education or work experience influenced the format of the counseling. What makes this case different from traditional rigid counseling sessions is that the nurse had a goal that she had planned in advance and pursued flexibly. This indicates that she had reflected on the significance of this situation from the patient's perspective. In most cases, nurses approached counseling without any goal or the hospital provided a detailed agenda based on professional knowledge of diseases, their care and prevention. Then, different kinds of institutionalized health counseling packages seemed to restrict nurses' communication, and health counseling often followed the standard institutional order of phases mentioned by Drew and Heritage ( Drew and Heritage 1998 ).

This study highlights empowering opportunities that arise in actual situations and that nurses can consciously use in their work. The results of this study can be applied to other health counseling practices and we would argue that every nurse should consider how (s)he initiates discussion. The analysis of the encounter shows that a tentative discussion style gives the patient a chance to deal with her concerns and to absorb the information that she needs. Thus, the patient has an opportunity to participate more actively in the discussion from the beginning than she could in the case of filling out a questionnaire in a strict predetermined order.

Clearly there are limitations to the generalizability of these findings. For example, both interlocutors were women, and this could in part explain the nature of the conversation since the highest levels of empathic and positive behavior occur between females [see ( Coates, 1986 ; Roter and Hall, 1993 ), p. 63]. There is also some concern whether the nurse may have been subject to a performance bias because she was aware of being videotaped and possibly behaved differently. However, we think that this was limited because only two nurses discussed this type of bias in the interviews afterwards and other nurses did not even notice the camera or did so only briefly at the beginning of counseling [see also ( Caris-Verhallen et al. , 1998 )]. Techniques to enhance the credibility of the findings included data and methodological triangulation of research data ( Patton, 1990 ; Stake, 1994 ; Begley, 1996 ), and acquiring data that included both verbal and non-verbal communication from the videotaped health counseling sessions and the subsequent interviews. In addition, team analysis sessions (investigator triangulation) ensured the accuracy of data interpretation (Polit and Hunger 1995). Different expertise helped us to get more complete picture from this case and empowerment philosophy when we discussed interpretations together.

However, in the last analysis, the effect of an empowering encounter could be checked after the operation by checking the patient's perspective, e.g. her satisfaction, recovery rate, etc. Evidence from nursing and medical staff might also be offered as additional evidence. Further research from larger numbers of patients is needed and more evidence from different settings will be required for a more extensive description of empowering practice. We will continue our research, and, for example, present qualitative analysis of interaction by describing how power features and patients' taciturnity are manifested in nurse–patient counseling. In addition, we will investigate how student nurses make progress in empowering counseling.

We suggest that nurses should pay attention to verbal expression and forms of language, in addition to non-verbal messages, because then they can empower patients by opening new and important perspectives for them. Nurses' every question, remark or piece of advice leads to individualized understanding and interpretation by the patient. It is important to remember that each communication situation is a unique, dynamic and transforming process. Nurses should observe what figures of speech they use and thus gain self-awareness and discover new tools to work with. We suggest a training program where the development of health care professionals' empowering skills can occur in practical, dynamic communication situations, be videotaped and transcribed for later theoretical, conscious and instructive evaluation. Analyzing the transcripts of video or tape-recorded counseling sessions opens up the possibility of an exact evaluation of empowering skills.

In health counseling, it is important that patients are able to maintain and strengthen a positive image of themselves as communicators. Positive experiences build up patients' self-esteem and increase their confidence in their ability to influence their care. The mere opportunity to discuss one's opinions and interpretations or different health concerns with a nurse may have the effect of unlocking patients' mental resources. This article demonstrates particularly how unconditional acceptance and facilitation of participation can be used in interpersonal counseling [see ( van Ryn and Heaney, 1997 )]. The empowering practices that are presented in this article should not be regarded as rigid and formalistic, rather they should be adapted to one's personal style.

Empowering principles of interpersonal practice ( van Ryn and Heaney, 1997 )

This study was supported by the Ministry of Health and Social Affairs of Finland and by the Finnish Cultural Foundation. We are sincerely grateful to all that participated in this study.

Anderson, J. M. ( 1996 ) Empowering patients: issues and strategies. Social Science and Medicine , 43 , 697 –705.

Anderson, R. M., Funnell, M. M., Butler, P. M., Arnold, M. S., Fitzgerald, J. T. and Feste, C. C. ( 1995 ) Patient empowerment. Results of randomized controlled trial. Diabetes Care , 18 , 943 –949.

Atwood, J. D. ( 1995 ) A social constructionist approach to counseling the single parent family. Journal of Family Psychotherapy , 6 , 1 –32.

Beck, C. S. and Ragan, S. L. ( 1992 ) Negotiating interpersonal and medical talk: frame shifts in the gynaecologic exam. Journal of Language and Social Psychology , 11 , 47 –61.

Begley, C. M. ( 1996 ) Using triangulation in nursing research. Journal of Advanced Nursing , 24 , 122 –128.

Breemhaar, B., van den Born, H. W. and Mullen, P. D. ( 1996 ) Inadequacies of surgical patient education. Patient Education and Counseling , 28 , 31 –44.

Brown, P. and Levinson, S. C. (1987) Politeness. Some Universals in Language Usage. Cambridge University Press, Cambridge.

Caris-Verhallen, W. M. C. M., Kerkstra, A., van der Heijden, P. G. M. and Bensing, J. M. ( 1998 ) Nurse–elderly patient communication in home care and institutional care: an explorative study. International Journal of Nursing Studies , 35 , 95 –108.

Caris-Verhallen, W. M. C. M., Kerkstra, A. and Bensing, J. M. ( 1999 ) Non-verbal behaviour in nurse–elderly patient communication. Journal of Advanced Nursing , 29 , 808 –818.

Coates, J. (1986) Women , Men and Language. A Sociolinguistic Account of Sex Differences in Language. Longman, New York.

Drew, P. and Heritage, J. (1998) Analyzing talk at work: an introduction. In Drew, P. and Heritage, J. (eds), Talk at Work. Interaction in Institutional Settings. Cambridge University Press, Cambridge, pp. 3–65.

Fairclough, N. (1992) Discourse and Social Change. Polity Press, Cambridge, pp. 134–168.

Feste, C. and Anderson, R. M. ( 1995 ) Empowerment: from philosophy to practice. Patient Education and Counseling , 26 , 139 –144.

Goffman, E. (1967/1982) Interaction Ritual. Doubleday, New York, pp. 5–45.

Hakulinen, A. (1989) Keskustelun luonnehtimisesta konteksti- ja funktionaalisten tekijöiden nojalla. [Characterizing the conversation according to contextual and functional factors]. In Hakulinen, A. (eds), Kieli 4 Suomalaisen Keskustelun Keinoja I. Helsingin Yliopiston Suomen Kielen Laitos, Helsinki, pp. 41–72.

Häggman-Laitila, A. and Åstedt-Kurki, P. ( 1994 ) What is expected of nurse–client interaction and how these expectations are realized in Finnish health care. International Journal of Nursing Studies , 31 , 253 –261.

Kar, S. B., Pascual, C. A. and Chickering, K. L. ( 1999 ) Empowerment of women for health promotion: a meta-analysis. Social Science and Medicine , 49 , 1431 –1460.

Kettunen, T., Poskiparta M. and Liimatainen, L. (2000) Communicator styles of hospital patients during nurse–patient counseling. Patient Education and Counseling , in press.

Labonte, R. ( 1994 ) Health promotion and empowerment: reflections on professional practice. Health education quarterly , 21 , 253 –268.

Laitakari, J. ( 1998 ) How to develop one's counseling—demonstration of the use of single-case studies as a practical tool for evaluating the outcomes of counseling. Patient Education and Counseling , 33 , S39 –S46.

Leino-Kilpi, H. ( 1991 ) Good nursing care—the relationship between client and nurse. Hoitotiede , 3 , 200 –206.

Leinonen, T., Leino-Kilpi, H. and Katajisto, J. ( 1996 ) The quality of intraoperative nursing care: the patient's perspective. Journal of Advanced Nursing , 24 , 843 –852.

Lindsey, E. and Hartrick, G. ( 1996 ) Health-promoting nursing practice: the demise of the nursing process? Journal of Advanced Nursing , 23 , 106 –112.

Mattus, M.-R. (1994) Interview as intervention: strategies to empower families of children with disabilities. In Leskinen, M. (ed.), Family in Focus. New Perspectives on Early Childhood Special Education. Jyväskylä Studies in Education, Psychology and Social Research 108. Jyväskylä University Printing House, Jyväskylä, pp. 87–107.

McWilliam, C. L., Stewart, M., Brown, J. B., McNair, S., Desai K., Patterson, M. L., Del Maestro, N. and Pittman, B. J. ( 1997 ) Creating empowering meaning: an interactive process of promoting health with chronically ill older Canadians. Health Promotion International , 12 , 111 –123.

Northouse P. G. 1997 . Effective helping relationships: the role of power and control. Health Education and Behavior , 24 , 703 –706.

Otte, D. I. ( 1996 ) Patients' perspectives and experiences of day case surgery. Journal of Advanced Nursing , 23 1226 –1237.

Patton, M. G. (1990) Qualitative Evaluation and Research Methods. Sage, Newbury Park, CA, pp. 388–390.

Pearson, P. ( 1991 ) Clients' perceptions: the use of case studies in developing theory. Journal of Advanced Nursing , 16 , 521 –528.

Peräkylä, A. (1995) AIDS Counselling. Institutional Interaction and Clinical Practice . Cambridge University Press, Cambridge.

Polit, D. F. and Hungler, B. P. (1995) Nursing Research. Principles and Methods. Lippincott, Philadelphia, PA.

Poskiparta, M., Kettunen, T. and Liimatainen, L. ( 1998 ) Reflective questions in health counseling. Qualitative Health Research , 8 , 682 –693.

Poskiparta, M., Kettunen, T. and Liimatainen, L. ( 2000 ) Questioning and advising in health counseling. Results from a study of Finnish nurse counselors. Health Education Journal , 95 , 47 –67.

Roter, D. L. and Hall, J. A. (1993) Doctors Talking with Patients/Patients Talking with Doctors . Greenwood, Westport, CT.

van Ryn, M. and Heaney, C. A. ( 1997 ) Developing effective helping relationships in health education practice. Health Education and Behavior , 24 , 683 –702.

Salmon, P. ( 1993 ) The reduction of anxiety in surgical patients: an important nursing task or the medicalization of preparatory worry? International Journal of Nursing Studies , 30 , 323 –330.

Stake, R. E. (1994) Case studies. In Denzin, N. K. and Lincoln, Y. S. (eds), Handbook of Qualitative Research. Sage, Newbury Park, CA, pp. 236–247.

Tomm, K. ( 1987 ) Interventive interviewing: part II. Reflexive questioning as a means to enable self-healing. Family Process , 26 , 197 –183.

Tones, K. (1994) Health promotion, empowerment and action competence. In Jensen B. B and Schnack, K. (eds), Action and Action Competence as Key Concepts in Critical Pedagogy. Studies in Educational Theory and Curriculum . Royal Danish School of Educational Studies, vol. 12, pp. 163–183.

Tones, K. ( 1995 ) Editorial. Health Education Research , 10 , i –v.

Wiles, R. ( 1997 ) Empowering practice nurses in the follow-up of patients with established heart disease: lessons from patients' experiences. Journal of Advanced Nursing , 26 , 729 –735.

Williams, J. ( 1995 ) Education for empowerment: implications for professional development and training in health promotion. Health Education Journal , 54 , 37 –47.

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• Section One: Introduction
• Section Two: Learning and Teaching Resources to Support Integration of Mental Health and Addiction in Curricula
• Section Three: Faculty Teaching Modalities and Reflective Practice
• Section Four: Student Reflective Practice and Self-Care in Mental Health and Addiction Nursing Education
• Section Five: Foundational Concepts and Mental Health Skills in Mental Health and Addiction Nursing
• Section Six: Legislation, Ethics and Advocacy in Mental Health and Addiction Nursing Practice
• Section Seven: Clinical Placements and Simulations in Mental Health and Addiction Nursing Education
• Section Eight: Reference and Bibliography
• Section Nine: Appendices and Case Studies

Section Nine

Case studies, also in this section.

• Alignment between CASN/ CFMHN Entry-to-Practice Mental Health and Addiction Competencies and Sections in the Nurse Educator Mental Health and Addiction Resource
• Process Recording
• Criteria for Validation: Process Recording
• Criteria for Phase of Relationship: Process Recording
• Journaling Activity
• Safety and Comfort Plan Template
• Advocacy Groups for Mental Health in Canada
• Tips for Engaging Lived Experience
• Glossary of Terms
• Case Study 1
• Case Study 2
• Case Study 3
• Case Study 4
• Case Study 5
• Case Study 6
• Case Study 7
• Case Study 8
• Case Study 9

The case study is an effective teaching strategy that is used to facilitate learning, improve critical thinking, and enhance decision-making Sprang, (2010). Below are nine case studies that educators may employ when working with students on mental illness and addiction. The case studies provided cover major concepts contained in the RNAO Nurse Educator Mental Health and Addiction Resource.

While not exhaustive, the case studies were developed and informed by the expert panel. It is recommended that educators use the case studies and tweak or add questions as necessary to impart essential information to students. Also, educators are encouraged to modify them to suit the learning objective and mirror the region in which the studies are taking place. Potential modifications include:

• demographics (age, gender, ethnicity);
• illness and addiction, dual diagnosis or additional co-morbidities such as cardiovascular disease; and
• setting (clinical, community).

Suggested “Student questions” explore areas of learning, while “Educator elaborations” recommend ways to modify the case study. Discussion topics are a limited list of suggested themes.

When using these case studies, it is essential that this resource is referenced.

See Engaging Clients Who Use Substances BPG appendices for examples

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• NLN Certification
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Henry and Ertha Williams

Julia morales and lucy grey, millie larsen.

• Developing Interprofessional Education and Practice in Oral Health
• Importance of Oral-Systemic Health in Older Adults
• Performing Oral Health Assessments on Aging Patients
• Oral Health for the Older Adult Living in the Community
• Elder Abuse in the United States
• Geriatric Syndromes
• Mental Health Needs of Older Adults
• Student-Led Geriatric Nursing Conference: Evidence in Practice
• Teaching Oral Health Care for Older Adults
• Using Case Study Betsy to Understand Down's Syndrome & Dementia
• Using Cinema to Enhance Teaching Issues Related to Older Adults
• Using the Monologue of Doris Smith to Understand Situational Decision-Making
• Caring for the Caregiver
• Caring for the Older Adult at Risk for Falling
• Coordinating and Managing Care During Transitions Among Care Settings
• End-of-Life Decision Making for Older Adults: Competent and Compassionate Care
• Myths of Aging
• Using Continuing Care Retirement Communities to Enhance a Better Understanding of Older Adults
• ACE.S Knowledge Domains
• ACE.S Essential Nursing Actions
• ACE.S Framework
• ACE.S Development & History
• ACE.S Additional Resources
• ACE.S Video Library

ACE.S Unfolding Cases

An unfolding case is one that evolves over time in a manner that is unpredictable to the learner. New situations develop and are revealed with each encounter. Every ACE unfolding case uses the highly regarded unfolding case model developed for Advancing Care Excellence for Seniors (ACE.S) . Each case includes the following:

• A first-person monologue that introduces the family and the complex problems they are facing.
• Simulation scenarios designed to help students practice assessing function and expectations of their patient(s), with links to appropriate evidence-based assessment tools. Suggestions for debriefing are included.
• An innovative final assignment that asks students to finish the story .
• Instructor toolkits with suggestions on how to use the various components of the unfolding cases and incorporate them into the curriculum.

These unfolding cases combine the power of storytelling with the experiential nature of simulation scenarios. They are intended to create a robust, meaningful experience for students, one that provides a simulated experience of continuity of care and that will help them integrate the Essential Knowledge Domains and Nursing Actions into their practice of nursing. We hope you will give them a try! Standardized/Simulated patients are recommended for all ACE simulations. If you are not already familiar with the Association for Standardized Patient Educators Standards of Best Practice, we encourage you to review them.

Learn more about unfolding cases by visiting the  How to Use an Unfolding Case  page.

Sherman "Red" Yoder

Nln leadership development program for simulation educators project mapping the ace.s unfolding cases to the aacn essentials.

Project Disclaimer: Simulation leadership projects are a requirement for the Leadership Development Program for Simulation Educators. All projects are then placed within SIRC for the benefit of the nursing education community. Inclusion of this specific project does not constitute an endorsement by the NLN of the AACN Essentials.

Unfolding Cases with Older Adults from Other ACE Programs

Butch sampson (ace.v), eugene shaw (ace.v), ertha williams (ace.z), george palo (ace.z), judy and karen jones (ace.z), mike walker (ace+).

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State Resources

National Resources

Nursing Organizations

• MNWC Initiatives

Maryland Nursing Workforce Center

• NextGen NCLEX

Faculty Case Studies

The purpose of this project was to develop a repository of NextGen NCLEX case studies that can be accessed by all faculty members in Maryland.

Detailed information about how faculty members can use these case students is in this PowerPoint document .

The case studies are in a Word document and can be modified by faculty members as they determine. 

NOTE: The answers to the questions found in the NextGen NCLEX Test Bank  are only available in these faculty case studies. When students take the Test Bank questions, they will not get feedback on correct answers. Students and faculty should review test results and correct answers together.

The case studies are contained in 4 categories: Family (13 case studies), Fundamentals and Mental Health (14 case studies) and Medical Surgical (20 case studies). In addition the folder labeled minireviews contains PowerPoint sessions with combinations of case studies and standalone items. 

Family  ▾

• Attention Deficit Hyperactivity Disorder - Pediatric
• Ectopic Pregnancy
• Febrile Seizures
• Gestational Diabetes
• Intimate Partner Violence
• Neonatal Jaundice
• Neonatal Respiratory Distress Syndrome
• Pediatric Hypoglycemia
• Pediatric Anaphylaxis
• Pediatric Diarrhea and Dehydration
• Pediatric Intussusception
• Pediatric Sickle Cell
• Postpartum Hemmorhage
• Poststreptococcal Glomerulonephritis Pediatric
• Preeclampsia

Fundamentals and Mental Health  ▾

• Abdominal Surgery Postoperative Care
• Anorexia with Dehydration
• Catheter Related Urinary Tract Infection
• Deep Vein Thrombosis
• Dehydration Alzheimers
• Electroconvulsive Therapy
• Home Safety I
• Home Safety II
• Neuroleptic Maligant Syndrome
• Opioid Overdose
• Post Operative Atelectasis
• Post-traumatic Stress
• Pressure Injury
• Substance Use Withdrawal and Pain Control
• Suicide Prevention
• Tardive Dyskinesia
• Transfusion Reaction
• Urinary Tract infection

Medical Surgical  ▾

• Acute Asthma
• Acute Respiratory Distress
• Breast Cancer
• Chest Pain (MI)
• Compartment Syndrome
• Deep Vein Thrombosis II
• End Stage Renal Disease and Dialysis
• Gastroesphageal Reflux
• Heart Failure
• HIV with Opportunistic Infection
• Ketoacidosis
• Liver Failure
• Prostate Cancer
• Spine Surgery
• Tension Pneumothorax
• Thyroid Storm
• Tuberculosis

Community Based  ▾

Mini Review  ▾

• Comprehensive Review
• Fundamentals
• Maternal Newborn Review
• Medical Surgical Nursing
• Mental Health Review
• Mini Review Faculty Summaries
• Mini Review Training for Website
• Mini Reviews Student Worksheets
• Pediatric Review

Mental Health and Psychiatric Nursing

The field of mental health often seems a little unfamiliar or mysterious, making it hard to imagine what the experience will be like or what nurses do in this area. This is an overview of the history of mental illness, advances in treatment, current issues in mental health, and the role of the psychiatric nurse .

Table of Contents

Mental health, mental illness, diagnostic and statistical manual of mental disorders, ancient times, period of enlightenment and creation of mental institutions, sigmund freud and treatment of mental disorders, development of psychopharmacology, mental illness in the 21st century, psychiatric nursing practice, mental health and mental illness.

Mental health and mental illness are difficult to define precisely. The culture of any society strongly influences its beliefs and values, and this in turn affects how that society defines health and illness.

No single universal definition of mental health exists. Generally, a person’s behavior can provide clues to his or her mental health.

• In most cases, mental health is a state of emotional, psychological, and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability.
• Factors influencing a person’s mental health can be categorized as individual, interpersonal, and social/cultural.
• Individual , or personal, factors include a person’s biologic make up, autonomy and independence, self-esteem , capacity for growth, vitality, ability to find meaning in life, emotional resilience or hardiness, sense of belonging, reality orientation, and coping or stress management abilities.
• Interpersonal , or relationship, factors include effective communication, ability to help others, intimacy, and a balance of separateness and connectedness.
• Social/cultural , or environmental, factors include a sense of community, access to adequate resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive, yet realistic, view of one’s world.

The American Psychiatric Association (APA, 2000) defines a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and is associated with present distress or with a significantly increased risk of suffering death , pain , disability, or an important loss of freedom.

• General criteria to diagnose mental disorders include dissatisfaction with one’s characteristics, abilities, and accomplishments; ineffective or unsatisfying relationships; dissatisfaction with one’s place in the world; ineffective coping with life events; and lack of personal growth.
• Factors contributing to mental illness also can be viewed within individual, interpersonal, and social/cultural categories.
• Individual factors include biologic make up, intolerable or unrealistic worries or fears, inability to distinguish reality from fantasy, intolerance of life’s uncertainties, a sense of disharmony in life, and a loss of meaning in one’s life.
• Interpersonal factors include ineffective communication, excessive dependency on or withdrawal from relationships, no sense of belonging, inadequate social support, and loss of emotional control.
• Social/cultural factors include lack of resources, violence, homelessness, poverty, an unwarranted negative view of the world, and discrimination.

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR)  is a taxonomy published by the APA.

• The DSM-IV-TR describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research.
• The DSM-IV-TR has three purposes:
• To provide a standardized nomenclature and language for all mental health professionals.
• To present defining characteristics or symptoms that differentiate specific diagnoses.
• To assist in identifying the underlying causes of disorders.
• The multiaxial classification system that involves assessment on several axes, or domains of information, allows the practitioner to identify all the factors that relate to a person’s condition.
• Axis I is for identifying all major psychiatric disorders except mental retardation and personality disorders .
• Axis II is for reporting mental retardation and personality disorders as well as prominent maladaptive personality features and defense mechanisms .
• Axis III is for reporting current medical conditions that are potentially relevant to understanding or managing the person’s mental disorder as well as medical conditions that might contribute to understanding the person.
• Axis IV for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders.
• Axis V presents a Global Assessment of Functioning, which rates the person’s overall psychological functioning on a scale of 0 to 100; this represents the clinician’s assessment of the person’s current level of functioning.

Historical Perspectives of the Treatment of Mental Illness

• People of ancient times believed that any sickness indicated displeasure of the gods and in fact was punishment for sins and wrongdoing.
• Those with mental disorders were viewed as either divine or demonic, depending on their behavior.
• Later, Aristotle attempted to relate mental disorders to physical disorders and developed his theory that the amounts of blood , water, and yellow and black bile in the body controlled the emotions.
• These four substances, or humors, corresponded with happiness, calmness, anger, and sadness; imbalances of the four humors were believed to cause mental disorders, so treatment was aimed at restoring balance through bloodletting, starving, and purging.
• In early Christian times, all diseases were again blamed on demons, and the mentally ill were viewed as possessed; priests perform exorcism to to rid evil spirits.
• During the Renaissance, people with mental illness were distinguished from criminals in England; those considered harmless were allowed to wander the countryside and or live in rural communities, but the more “dangerous lunatics” were thrown in prison, chained, and starved.
• In 1547, the Hospital of St. Mary of Bethlehem was officially declared a hospital for the insane, the first of its kind; by 1775, visitors at the institution were charged a fee for the privilege of viewing and ridiculing the intimates, who were seen as animals, less than human.
• In the 1790s, a period of enlightenment concerning persons with mental illness began.
• Phillipe Pinel in France and William Tukes in England formulated the concept of asylum as a safe refuge or haven offering protection at institutions where people had been whipped, beaten, or starved just because they were mentally ill (Gollaher, 1995).
• In the United States, Dorothea Dix (1802-1887) began a crusade to reform the treatment of mental illness after a visit to Tukes’ institution in England; she was instrumental in opening 32 state hospitals that offered asylum to the suffering.
• The period of scientific study and treatment of mental disorders began with Sigmund Freud (1856-1939) and others, such as Emil Kraeplin (1856-1926) and Eugene Bleuler (1857-1939).
• With these men, the study of psychiatry and the diagnosis and treatment of mental illness started in earnest.
• Freud challenged society to view human beings objectively; he studied the mind, its disorders, and their treatment as no one had before.
• Kraeplin began classifying mental disorders according to their symptoms, and Bleuler coined the term schizophrenia .
• A great leap in the treatment of mental illness began in about 1950 with the development of psychotropic drugs, or drugs used to treat mental illness.
• Chlorpromazine (Thorazine) an antipsychotic drug, and lithium, an antimanic agent, were the first drugs to be developed.
• Over the following 10 years, monoamine oxidase inhibitor antidepressants, haloperidol (Haldol), an antipsychotic; tricyclic antidepressants ; and antianxiety agents, called benzodiazepines , were introduced.

The National Institute of Mental Health (NIMH) estimates that more than 26% of Americans aged 18 years and older have a diagnosable mental disorder- approximately 57.7 million persons each year (2006).

• Furthermore, mental illness or serious emotional disturbances impair daily activities for an estimated 10 million adults and 4 million children and adolescents.
• Mental disorders are the leading cause of disability in the United States and Canada for persons 15 to 44 years of age.
• Homelessness is a major problem in the United States today; the National Resource and Training Center on Homelessness and Mental Illness (2006) estimates that one-third of adult homeless persons have a serious mental illness and that more than one half also have substance abuse problems.
• In 1993, the federal government created and funded Access to Community Care and Effective Services and Support (ACCESS) to begin to address the needs of people with mental illness who were homeless either all or part of the time.
• In 1873, Linda Richards graduated from the New England Hospital for Women and Children in Boston; she went on to improve nursing care in psychiatric hospitals and organized educational programs in state mental hospitals in Illinois.
• Richards is called the first American psychiatric nurse; she believed that “the mentally sick should be at least as well cared for as the physically sick” (Doona, 1984).
• The first training of nurses to work with persons with mental illness was in 1882 at McLean Hospital in Belmont, Massachusetts.
• The care was primarily custodial and focused on nutrition , hygiene, and activity.
• The role of psychiatric nurses expanded as somatic therapies for the treatment of mental disorders were developed.
• Treatments such as insulin shock therapy (1935), psychosurgery (1936), and electroconvulsive therapy (1937) required nurses to use their medical- surgical skills more extensively.
• The first psychiatric nursing textbook, Nursing Mental Diseases by Harriet Bailey was published in 1920; in 1913, John Hopkins was the first school of nursing to include a course in psychiatric nursing in its curriculum.
• In 1973, the division of psychiatric and mental health practice of the American Nurses Association (ANA) developed standards of care, which it revised in 1982, 1994, and 2000.
• Standards of care are authoritative statements by professional organizations that describe the responsibilities for which nurses are accountable.
• The goal of self-awareness is to know oneself so that ones’ values, attitudes, and beliefs are not projected to the client, interfering with nursing care; self-awareness does not mean having to change one’s values and beliefs unless one desires to do so.

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Mental Health Nursing

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Case Studies

Case 3: john.

John, a 26-year-old man, presented at the local A & E department and has now been referred to the mental health liaison team after drinking a large amount of alcohol and taking 100 paracetamol tablets. He woke up the next morning surprised that he was alive but also concerned about his actions. On this basis he asked his next-door neighbour to take him to hospital.

Over the last year John has been experiencing symptoms of anxiety; John describes himself as a constant worrier but recently he has felt "more panicky", to the point that he finds it more and more difficult to engage in everyday activities such as talking to other people. The impact of these distressing symptoms is that John has now been off sick from work for the last three months.

John indicates that he now has significant difficulty in controlling his "worrying", he constantly feels restless and irritable, is physically tense, has difficulty concentrating on everyday tasks, and has difficulty sleeping. John also mentions that to help him sleep he has been drinking four to five cans of strong lager every night.

(a) How would the mental health nurse build a therapeutic relationship with John?

Show Answer

• selecting the right words to use;
• knowing when to talk and when to be silent;
• using the right verbal and non-verbal responses;
• adapting non-verbal communication to suit the situation.
• an active listener;
• genuinely interested;
• accepting the person;
• caring and compassionate.

(b) How should the nurse mange the risk element when building a therapeutic relationship with John?

• considering John's perspective;
• balancing the "rules" against this perspective;
• preserving the person-centred element of this perspective;
• fully representing this perspective in the decision-making process.

(c) How would the nurse formally describe John's drinking?

Correct answer: Alcohol use is usually described in terms of safe limits: 21 units of alcohol per week for men and 14 units for women (a unit of alcohol is approximately a small glass of wine or half a pint of beer). In John's case his alcohol use can be described as harmful drinking, which in men is consuming over 50 units weekly.

(d) What negative impact could John's alcohol intake have upon his health?

• disturbances of consciousness and perception;
• damage to John's health and social functioning;
• physical and psychological withdrawal;
• hallucinations and delusions;
• memory and cognitive impairments.

(e) What other symptoms of anxiety might John be experiencing?

• increased vigilance;
• hyperactivity;
• palpitations;
• abdominal discomfort and nausea;
• hot flushes;
• outbursts of anger;
• ruminating thoughts and compulsions.

(f) What types of psychological interventions would the nurse consider delivering, bearing in mind John's alcohol consumption?

• build a collaborative and therapeutic relationship;
• motivational and brief intervention work;
• guided self-help ;
• breathing and relaxation exercises;
• identifying, challenging and replacing negative thoughts;
• harm reduction;
• coping strategy work;
• health promotion;
• contingency approaches – using incentives to change behaviour.

John is progressing well; he feels that he has recovered and has now returned to work; subsequently John has been discharged from the community mental health nurse's case load.

(a) What potential conflict could there possibly be between John's and the nurse's understanding of recovery, and what would be the best way forward?

• promoting wellbeing;
• maximising opportunity;
• empowering individuals to take control;
• facilitating and supporting the individual in finding meaning and purpose.

(b) John returning to work can be viewed as a factor that positively influences the recovery process. What other factors are there?

• positive and sustainable relationships;
• meaningful activity;
• resilience;
• personal growth;
• a healthy living environment;
• a supportive social network.

(c) How should the nurse use their experiences of working with John in their journey towards being a clinical expert?

Correct answer: Key to being an expert is the use of reflection; this process enables the nurse to develop their self-awareness to a level where they are able to clearly identify their strengths and also the areas that they need to develop further. It is important to recognise that knowledge accrued through the reflective process is useful knowledge especially as it is experience-based knowledge. Like scientific knowledge this form of knowledge should not be used in isolation; rather it should be used to complement scientific knowledge in a way that anchors both forms of knowledge to the nurse's ongoing practice experiences.

Consider Chapters 27 and 38.

Print Answers | « Previous Case | Next Case »

• NICE Guidance
• Conditions and diseases
• Mental health, behavioural and neurodevelopmental conditions

Common mental health problems: identification and pathways to care

Clinical guideline [CG123] Published: 25 May 2011

This guideline has been stood down. All of the recommendations are now covered in other NICE guidelines, or are out of date and no longer relevant to clinical practice.

For guidance on common mental health problems, see our guidelines on:

• Depression in adults
• Depression in adults with a chronic physical health problem
• Depression in children and young people
• Generalised anxiety disorder and panic disorder in adults
• Obsessive-compulsive disorder and body dysmorphic disorder
• Social anxiety disorder

Suburbanization Problems in the USSR : the Case of Moscow

• Référence bibliographique

Gornostayeva Galina A. Suburbanization Problems in the USSR : the Case of Moscow . In: Espace, populations, sociétés , 1991-2. Les franges périurbaines Peri-urban fringes. pp. 349-357.

DOI : https://doi.org/10.3406/espos.1991.1474

www.persee.fr/doc/espos_0755-7809_1991_num_9_2_1474

• RIS (ProCite, Endnote, ...)

Résumé (fre)

La suburbanisation n'existe pas en URSS au sens des phénomènes décrits dans les villes occidentales. Cependant on observe certains transferts limités d'activités industrielles exigeantes en espace ou polluantes, voire même de centres de recherches, vers les zones suburbaines ou des villes-satellites. Mais ces déconcentrations répondent à une logique de planification administrative. En outre, les Moscovites hésitent à aller habiter dans ces centres d'emploi, de crainte de perdre les privilèges liés à l'autorisation d'habiter Moscou (la propiska) et du fait des communications insuffisantes avec la capitale. Le taux de croissance de la population moscovite reste supérieur à celui du reste de l'oblast. Par contre le développement de datchas de seconde résidence est très important dans l'oblast de Moscou, en particulier aux alentours des stations de chemin de fer. L'abolition du système de propiska pourrait transformer les datchas les plus proches de Moscou en résidences principales.

Résumé (eng)

The suburbanisation does not exist as such in the USSR with the meaning one has of the phenomena in Western cities. Though one may notice some limited transfers of industrial activities demanding a lot of space or polluting ones, even research centres, towards the suburban areas or satellite-towns. But these déconcentrations correspond to an administrative planification logics. Moreover the Muscovites hesitate before going and living in these employment centres, because they are afraid of loosing the privileges linked with the authorisation to live in Moscow (the propiska) and because of insufficient communications with the capital. The growth rate of the Muscovite population remains higher than this of the remainder of the oblast. To the contrary developing of datchas for second residences is very high in the Moscow oblast, especially in the vicinity of a railway station. The abolishment of the «propiska» system might transform the datchas nearer to Moscow into main residences.

• Economic structure [link]
• Suburbanization of activities [link]
• Suburbanization of population [link]
• Conclusions [link]
• Literature [link]

Liste des illustrations

• Table 1. Employment structure, % [link]
• Table 2. Annual rate of population increase, % [link]
• Fig. 1. Spatial distribution of country-cottages and gardening associations in the Moscow region [link]

Texte intégral

Galina A. GORNOSTAYEVA

Moscow University

Suburbanization Problems

in the USSR :

the Case of Moscow

Suburbanization processes typical to cities in Western Europe, the USA and other countries are not observed in the USSR or they are distorted to such an extent that they may not be compared with existing standards. This states the question how Soviet cities-succeeded in escaping this stage of urban development. In order to answer this question, we should first summarize the main aspects of Western suburbanization.

Firstly, it is well known that the urbanization processes are linked to structural changes in the economy. Thus the transition from the stage of concentration to this of suburbanization is associated with industrialization, and the transition to the third stage - déconcentration - is related with the rapid growth of employment in the non-industrial sphere. Secondly, a suburbanization of economic activities can be distinguished. It applies in the first place to the building and iron- working industry, transports, engineering and chemical works. These are polluting and requiring extensive areas. This suburbanization of industry is caused by the following factors: rising demand for land from firms ; worsening of transport

tions in the inner cities ; demand for lower land costs and taxation levels in suburbs ; rapid growth of road transports; state policies regulating the growth of large cities ; migration of the labour force to the suburban zones. Scientific and educational activities are also transferred from the centre to the suburbs.

The third important aspect of suburbanization applies to the population. In the suburbs two opposite flows of population meet ; one is centripetal, coming from non- metropolitan regions, the other is centrifugal, coming from the central city. The reasons for the migration to the suburbs are as follows : declining living standards in large cities (overcrowding, slow housing renewal, environmental problems, etc.); growth of motorization of the population, development of communications (telephone, telex, fax, computer) ; intensifying decentralization of working places ; lower land prices in the suburbs ; state support for the intensification of real estate development in the suburbs. The above-mentioned factors and reasons for suburbanization are altered in the Soviet cities. Let us explore them, by taking for example the largest one - Moscow.

Economic structure

The employment structure in the USSR reveals sharp differences from those in developed urbanized countries. The USSR is characterized by a high share of employment in agriculture, industry, construction and a low share in the non-industrial sphere (tab. 1).

A correlation analysis of the percentage of urban population and employment in the different spheres of economic activity reveals that the share of urban population in the USSR is higher than in countries with the same percentage of persons employed in agriculture.

TABLE 1. EMPLOYMENT STRUCTURE,

Source: personal calculations.

The urbanization processes in the Moscow Capital Region (MCR) are more intensive than in other regions of the USSR. Structural changes are more obvious here : the share of employment in the non-industrial sphere increases more substantially and the percentage of persons employed in industry and agriculture is lower than in the whole country. However the MCR cannot therefore be compared with a metropolitan region in a Western country. Although Moscow is the most advanced agglomeration in the USSR, it lags is far behind the major world cities in terms of development and it is at the very start of the post- industrial stage of its structural and urban transformation.

The structural «anomaly» of the USSR as a whole and of the MCR in particular is explained by the enforced process of industrialization (starting from the thirties) at the expense of the peasantry (thus, there is not only a booming industrial employment in cities, but also worsening living and working conditions in villages and forced collectivization having triggered off the massive rural emigration). As a result, the share of urban population in the USSR is higher than expected, based on changes in the economic structure. While urbanization in the developed countries was due, among

other causes, to an increasing labour efficiency in agriculture, this remained quite low in the USSR. Therefore the employment share in agriculture is overstated in comparison with countries with a similar percentage of urban population, and even this considerable part of the labour force is unable to feed the whole population of the country.

The share of agricultural employment in the mcr increased from 7,4 % to 7,6 °7o between 1980 and 1985 (as a result of Moscow attractiveness and the better living standards in its surrounding villages), whereas it continued to decline in other parts of the Central region. The population growth in villages adjacent to Moscow is especially intensive, though labour efficiency in localities near Moscow is higher than in the other oblasts. In spite of this, Moscow oblast provides only 61 % of milk, 34 °/o of potatoes, 45 % of vegetables and 23 % of meat needed by the population in Moscow city and oblast (Argumen- ty i facty, 1988, N50, p. 3). The structural anomaly is not only related to processes in agricultural sphere but also in industrial sector. As a result of the low economic mobility of socialist firms and of the absence of market relations, the industrial development was extensive,

without significant increases of the labour

productivity.

Thus the employment transfer from the

agricultural to the industrial sector, their

extensive development and their low labour

productivity are intrinsically related with the political definition of productiorfrela- tions and course of structural economic transformation.

Suburbanization of activities

Moscow and Moscow oblast show divergent economic structures and changes (tab. 1). In Moscow the employment share in the non-industrial sphere in Moscow is growing more rapidly, whereas the share of industrial employment is decreasing. In Moscow oblast the part of transport and communication infrastructure, retail trade, administration, housing (presently less developed than in Moscow) is increasing. Some stages in the transformation of activities in the mcr's settlements may be pointed out here. The stage of industrialization and reconstruction after World War II is characterized by the swift industrial development and the active restructuration of the Moscow and Moscow oblast economy. New industries have been built (motor-car and aircraft assembly, machine-tool industry, organic synthesis, etc.), around Moscow research and production potential. Nevertheless, this restructuration is extensive, since traditional industries don't curtail production. It favours the heavy concentration of modern functions in Moscow. There is no transfer of firms outside Moscow. Suburbanization of industrial activities did not occur because of the state owning the means of production and of thé socialist form of production relations. When research and technological progress are slowing down, these firms become inefficient and spatially immobile. The period 1956-1970 is marked by an intensive development of the region scientific sphere and by the rise of « satellite » urban policy. The new centres were specialized in modern branches of machinery and research-engineering activities and were undoubtedly very attractive for the population. Therefore towns like Dubna were growing rapidly. While the aim was to redirect part of Moscow population

growth, they display a quite specific relation with the capital. For instance, Muscovites working in Pushchino cannot reach their job every day because they lack transport facilities. Nevertheless, they don't wish to move and register their passports in the city in which they actually work, since they would have to give up their Moscow registration and then lose all Moscow privileges (see further). These new centres are isolated from information sources in Moscow. Poor telephone communications, lack of computers and telex systems hamper contacts and teamwork with colleagues in the city. It seems that material resources for experimental work in research centres are not sufficient to compensate for lack of information and communications. At the same time, poor transport links with Moscow and the other towns of Moscow oblast isolate the scientists from the higher standard of culture in the centre and from a well developed social infrastructure. An original home-work relation can be observed in Dubna: the Muscovites get the second registration of passports and live there in hostel apartments during 4 or 5 working days, during the weekends they go back to Moscow, where their families are living. The change of functions in Moscow oblast towns is still going on. Inside the towns of the first circle adjacent to Moscow, the share of employment in the non-industrial sectors and transport is growing. Inside the towns of the second circle (suburban zone) these changes lead to an increasing potential of non-industrial, industrial and construction functions. Finally, in the outlying parts of the region the further grovth of construction and industrial functions is observed and the organization potential is intensifying in some towns. The mcr towns display a crawling concen-

tration of the regional most important functions and their extension outside the boundaries of Moscow to the towns of the suburban zone. But the déconcentration of functions in the mcr is not only of natural- economic character. It also results from the state urban policy. Déconcentration is not related to the search for more advantageous sites for firms and institutions as regards to economic or social relations (the availability of cheaper labour force or more comfortable living conditions, etc.), nor is it sustained by the expansion of transport and communication facilities. Thus, this déconcentration is independent from curtailment of any function in central Moscow, whose potential is still growing, and it is also completely inadequate regarding the continuing concentration of population (see below). All this, together with the slow economic and territorial mobility of firms, is an obstacle to the economic restructuration of the region, and to the reorientation of Moscow and its suburbs to non-industrial activities and to progressive scientific and informational work. The mass labour-consuming functions still remain in Moscow and its suburbs, but they are inevitably cut off from modern types of activities.

The idea of alleviating Moscow's development appeared from the very beginning of its rapid growth, since the excessive concentration of population and employment led (as in the other major world cities) to environmental discomfort, worsening of transport, strip-holding of land and other congestion signs. In market economies, the firms react to alterations of economic or social conditions by their mobility: some

of them close, other relocate in more convenient places. In the USSR, the problem of firm transfer (unhealthy or unprofitable firms) becomes unsolvable because of the special type of production relations. Economic and territorial passivity of firms is apparent in the difficulties of erecting industrial buildings and dismantling machinery and equipment, in the low turnover of the means of production. The same problem exist regarding the labour force. Firms transferred to the suburban towns of Moscow oblast are encountering great difficulties in recruiting staff in sufficient numbers and of required skill. The local labour force is rather weak, while the Moscow workers wouldn't leave the capital to follow their firm, because they are afraid of being deprived of passport registration in Moscow. From the social point of view, giving up a Moscow registration is more significant to people than losing their job. The processes going on in the mcr are therefore not quite comparable with those in the Western world. The market economy is more «lively» and replacement of functions has the character of territorial waves. Some functions disappear while new ones emerge. In the mcr, the waves are replaced by stratification. New functions do not replace the old ones, but joining them. At the same time, this process of relative déconcentration of functions overpass the process of stable concentration of population. In the mcr, the modern branches are gravitated closely to Moscow, where skilled workers are retained by their registration advantages. Suburban towns have to be satisfied with commuters or specialists from the outlying regions of the USSR.

Suburbanization of population

The urbanization structure of the region is characterized by the predominance of its main centre - Moscow. The share of the capital in the total Moscow oblast population was as follows: in 1929 - 44,3 Vo, in 1939 - 51,6 %, in 1959 - 54,9 %, in 1979 -54,5 Vo, in 1985 - 57,3 % (Moscow Capital Region, p. 137.). Within the agglomeration, the share of Moscow is still higher, in 1959 it was 75,5 % and in 1985

- 67,3 % (ibid., p. 141), whereas in the highly developed capital regions of the world the agglomeration counts one half or less of the total population and of the economic potential, the second half being concentrated in the suburbs (Gritsay, p. 71). Moreover, the growth rate of Moscow population is higher than that of Moscow oblast (tab . 2).

TABLE 2. ANNUAL RATE OF POPULATION INCREASE,

Migrations are of great importance to the mcr. The internal migration of rural population to the cities is rather substantial, and the immigration flow from the rest of the USSR is not compensated by the decrease of rural population in the mcr. The nearer a town to Moscow, the larger the migration share in its total population increase.

The dynamics of population in the mcr has a specific character. In agglomerations of the developed countries the principle of the «broken glass» summarizes the suburbanization process. When, for some reasons, the centre loses its attractiveness the urban population moves to suburbs in search of higher living standard. In Moscow agglomeration the principle of the «overfilled glass» is operating. People wanting to live in Moscow cannot enter the city and are forced to settle near it. In Moscow immigration undoubtedly prevails over emigration, confirming the extreme territorial differentiation in conditions, level and way of life. As a rule, commuting is oriented from suburbs to Moscow (600 thousand persons come to Moscow and only 200 thousand leave it), but it accounts only for 12-15 % cf the total employment in Moscow's economy. Moreover, these commuters are not Muscovites but potential new inhabitants of the capital (striving for passport registration and domicile in Moscow).

Moscow became the most attractive place for living and an intensive flow of ruined rural residents as well as residents from other regions of the country were rushing -to Moscow. These processes were generated not only by the inception of the country structural economic transformation,

but also by the policy of special privileges for Moscow. These privileges came into being after the establishment of a centralized distribution system. Such a system involves the assignment of a priority level of foodstuffs and manufactured goods to each territory. Moscow was awarded the highest priority level. From the very beginning, better living standards and higher income for certain population categories were established there. In the thirties the artificial differentiation in living standards was confirmed by imposing restrictions to passport registration in the capital, and also by the division of administrative bodies into Moscow and Moscow oblast authorities. In the period 1925-30 dozens of new large firms were located in Moscow, but housing was insufficient at that time. Therefore, a great number of migrants from every corner of the country came to get a job in Moscow and settled in cottages in the nearby countryside. Soon, these settlements in the nearby countryside. Soon, these settlements turned into urban ones. For example, towns like Mytishchi and Luberstsy developed rapidly, and even Muscovites moved there when the railways were electrified. This was clearly the outset of a suburbanization process, but it stopped as soon as the restrictions on passport registration in Moscow were imposed and the social barrier between Moscow and Moscow oblast was established. In the period 1930-40, new industrial developments were banned from Moscow and firms drawn towards the city were located on the outskirts thus causing a rapid growth of the old and new towns. Although the development of cottages as second residence near Moscow started even before the revolution, since the en-

vironmental degradation of Moscow was practically completed at that time, they became the main resorts of those years. They had flourished in the districts with privileged natural conditions and convenient transport services (not further than 2 km from a railway station). In the period 1930-40, this sprawl of leisure housing carried on - cottage settlements expanded into an entire belt of scattered one- storeyed buildings. But at the same time, urban multi-storeyed housing also increased and after World War II these multi- storeyed buildings were found in the cottage settlements of the leisure zone. In the period 1950-60 a network of gardening associations was established. In those

years the most convenient land near Moscow had already been built on. The gardening plots allotted to the Muscovites were located in the remote parts of the mcr, outside the suburban zone, and very frequently they were on improper territories. Because of their remoteness, the difficulties in cultivation and building, the lack of infrastructure, these plots cannot become effective leisure resorts. More frequently Muscovites use them for fruit and vegetable growing.

The desire of the Muscovites for having a second residence in the suburbs can be interpreted as an unfulfilled suburbanization tendency. This desire has the same, mainly environmental, causes as suburbaniza-

tion in Western countries. The cottages within the reach of Moscow's traffic and having access to appropriate infrastructure and amenities, might become the principal residence of Muscovites if passport registration is abolished. The restrictions of passport registration in Moscow fixed in the thirties were devised as an administrative solution against the effects of Moscow's unique attractiveness and not as a means of eliminating the attractiveness itself. For this reason, Moscow became even more attractive, like a forbidden fruit. The consequences were both the concentration of the upper strata of society in the city and the extensive development of industry, resulting in a growing shortage of unskilled labour.

The shortage of regular workers in Moscow is sometimes explained by the increasing number of working places. An adequate planning of the «limiters» (1) system is then put forward as the solution for controlling the growth of Moscow is found in (Glushkova, 1988, p. 43). To be frank, about twenty industrial units and more than one hundred scientific institutions were already created in the seventies alone, in spite of the industrial building ban in Moscow, only a few firms moved outside the city in return. New industrial units easily find staff, since they offer new machinery, relatively good working conditions and higher wages. New scientific and administrative institutions are in a similar position. But the situation is totally different in the old industrial units, with rundown equipment and a high level of manual tasks. Those units suffer from a staff shortage. Moreover, as in any other city, there is a social mobility in Moscow, in most cases improving - from manual up to mental, from unskilled up to highly skilled work. Furthermore, the prestige of a higher education (university) is overestimated in Moscow, whereas the prestige of the manual professions has declined as a result of the stagnation of reinvestments in industry, the high share of manual labour (40 %), and also favouritism and

crowding in the administrative staffs. The attractiveness of an upper class position is therefore overestimated, and social mobility activated. Since Moscow cannot admit free «immigrants» the lower strata of the social structure are vacant and there appears a shortage of unskilled labour force. The lower strata of the social structure were filled in with « limiters ». Available employment in Moscow was not the cause of an organized immigration flow, but represented the only possible way to register the passport there. Roughly half of these people drawn into Moscow's economy left their jobs. «Limiters» get the right to register their passports in Moscow and take up their residence in new houses when their contract expires. They usually quit their job as soon as possible in search of better working conditions (Glushkova, 1988, p. 42). The nature of unskilled work in Moscow and the associated working conditions are so unattractive that it is nearly impossible to find Muscovites willing to perform them.

The institution of passport registration raised many problems. Thus the « limiters » are recruited in social groups not needing most of the advantages of a large city, their psychology and value system differ sharply from native Muscovites. The direct environment of the hostels where «limiters » live, has a pronounced criminal character. Fictitious marriage in order to register the passport in Moscow has become a widespread practice.

Moscow's environmental problems can hardly be solved as long as passport registration exists. The population is literally locked up within the city boundaries. Notwithstanding the environmental stresses, the Moscow privileges prevent the Muscovites from leaving the city. The urban districts not saturated with harmful industrial units are the most prestigious. The social and economic causes of Moscow's extensive growth reveal that its problems are a reflection of the ones facing the USSR. The concentration of economic, social and management functions in Mos-

cow in Soviet times materializes the strong centralism of the particraty and weighs down on the city's development. Low labour efficiency in agriculture and sheer desolation of villages on the one hand, rapid but extensive industrialisation together with forced increasing social attraction of Moscow, confirmed by the restrictions on passport registration, on the other hand, were the key factors of the mcr's polarization during decades. Together with objective factors found in other large cities of the world, subjective factors related to the Soviet political and economic system influence Moscow's growth.

The objective factors are as follows: the diversity of employment in the capital, the emergence of new types of occupations, the concentration of high-skilled and creative labour, the higher living standards, the large educational and cultural opportunities.

The subjective factors are the higher supply level of foodstuff and manufactured goods different than in other regions (the existence of meat-rationing system in many regions of the country and its absence in Moscow establishes a significant threshold not only in terms of supply but also in the outlook of the population); the lack of communications and individual motorized transport (in the rsfsr one counts 47 cars per 1000 urban inhabitants against 560 in the USA) (Argumenty i facty, 1988, N47, p. 2); the craving for joining the upper social classes and for accessing neighbourhoods with a high quality of life; unjustified promotion of upward social mobility releasing «the ground floors» of Moscow's economy; continued growth of employment due to the extensive economic development and the low economic and territorial mobility of firms. Today, the hierarchy of priorities for selecting a residence within the mcr and the whole country is as follows. Food supply comes first. The supply of manufactured

goods, the opportunities to obtain better and larger living quarters and to accede to a prestigious employment with a wage increase, social promotion, well developed consumer services come next. And only at the end of the scale appears the opportunity to fulfil cultural needs and education. Thus, there is a process of «pseudo- urbanization» characteristic of the Soviet economic and social system, superimposed on the process of «natural» urbanization. By natural urbanization we mean the process related to economic development and to the natural difference between rural and urban ways of life. The specificity, the structural changes and the hierarchy of city functions shape the migration flows conditioned by natural urbanization. «Pseudo-urbanization» points to «the scum» of the process, that may complete the economic and socially conditioned urbanization. The «pseudo-urbanization» is generated by a disproportionate development of the country's economic structure (hypertrophie share of industry; economic and political reforms have triggered off a massive flow of the peasantry towards the cities, related not with the rising but with the lowering of labour efficiency in agriculture, with impoverishment of the countryside and hence with the urge towards the centres of relative well-being), and by the territorial inequalities in standards of living, artificially created and maintained by the institution of passports and registration.

The suburbanization of population cannot be observed in the MCR. The centripetal tendencies mentioned above resulted in rapid growth of Moscow and its suburbs, as well as in some stagnation of its periphery. Thus Moscow agglomeration is now in the first stage of development, the stage of «crawling» concentration where centrifugal forces are very weak. This situation will last as long as the barrier in terms of standards of living exists between Moscow and Moscow oblast.

Conclusions

This study has reaffirmed the general lack of suburbanization in the Soviet cities. Some signs of suburbanization like the

transfer of some activities from Moscow to the suburbs, the concentration of population in towns and villages near the central

city and commuting, differ significantly pie and firms will emancipate, only if the from the Western cities. The process of ur- existing political and economic system in banization will take its normal course, peo- the USSR is dismantled.

Argumenty i facty, 1988, N47, p. 2 Argumenty i facty, 1988, N50, p. 3

GLUSHKOVA V.G. Questions of Interrelated Settlement in Moscow and the Moscow Region, Problems of Geography, vol. 131, Moscow, 1988, pp. 40-56.

GRITSAY O.V. Western Europe : Regional Contrasts at the New Stage of Scientific-Technological Progress, Moscow, 1988, 148 p.

Moscow in Figures. 1980, Moscow, 1981, 220 p. Moscow in Figures. 1985, Moscow, 1986, 240 p.

National Economy of Moscow Oblast. 1981-1985, Moscow, 1986, 271 p.

National Economy of the ussr. 1985, Moscow, 1986, 421 p. Yearbook of Labour Statistics. 1987, Geneva, 1987, 960 p.

Moscow Capital Region: Territorial Structure and Natural Environment, Moscow, 1988, 321 p.

(1) Limiters are unskilled workers, hired in an organised way by Moscow firms; after working there for several years of working they get the right to register

their passports and to take up their residence in Moscow.

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Out of the Centre

Savvino-storozhevsky monastery and museum.

Zvenigorod's most famous sight is the Savvino-Storozhevsky Monastery, which was founded in 1398 by the monk Savva from the Troitse-Sergieva Lavra, at the invitation and with the support of Prince Yury Dmitrievich of Zvenigorod. Savva was later canonised as St Sabbas (Savva) of Storozhev. The monastery late flourished under the reign of Tsar Alexis, who chose the monastery as his family church and often went on pilgrimage there and made lots of donations to it. Most of the monastery’s buildings date from this time. The monastery is heavily fortified with thick walls and six towers, the most impressive of which is the Krasny Tower which also serves as the eastern entrance. The monastery was closed in 1918 and only reopened in 1995. In 1998 Patriarch Alexius II took part in a service to return the relics of St Sabbas to the monastery. Today the monastery has the status of a stauropegic monastery, which is second in status to a lavra. In addition to being a working monastery, it also holds the Zvenigorod Historical, Architectural and Art Museum.

Belfry and Neighbouring Churches

Located near the main entrance is the monastery's belfry which is perhaps the calling card of the monastery due to its uniqueness. It was built in the 1650s and the St Sergius of Radonezh’s Church was opened on the middle tier in the mid-17th century, although it was originally dedicated to the Trinity. The belfry's 35-tonne Great Bladgovestny Bell fell in 1941 and was only restored and returned in 2003. Attached to the belfry is a large refectory and the Transfiguration Church, both of which were built on the orders of Tsar Alexis in the 1650s.  

To the left of the belfry is another, smaller, refectory which is attached to the Trinity Gate-Church, which was also constructed in the 1650s on the orders of Tsar Alexis who made it his own family church. The church is elaborately decorated with colourful trims and underneath the archway is a beautiful 19th century fresco.

Nativity of Virgin Mary Cathedral

The Nativity of Virgin Mary Cathedral is the oldest building in the monastery and among the oldest buildings in the Moscow Region. It was built between 1404 and 1405 during the lifetime of St Sabbas and using the funds of Prince Yury of Zvenigorod. The white-stone cathedral is a standard four-pillar design with a single golden dome. After the death of St Sabbas he was interred in the cathedral and a new altar dedicated to him was added.

Under the reign of Tsar Alexis the cathedral was decorated with frescoes by Stepan Ryazanets, some of which remain today. Tsar Alexis also presented the cathedral with a five-tier iconostasis, the top row of icons have been preserved.

Tsaritsa's Chambers

The Nativity of Virgin Mary Cathedral is located between the Tsaritsa's Chambers of the left and the Palace of Tsar Alexis on the right. The Tsaritsa's Chambers were built in the mid-17th century for the wife of Tsar Alexey - Tsaritsa Maria Ilinichna Miloskavskaya. The design of the building is influenced by the ancient Russian architectural style. Is prettier than the Tsar's chambers opposite, being red in colour with elaborately decorated window frames and entrance.

At present the Tsaritsa's Chambers houses the Zvenigorod Historical, Architectural and Art Museum. Among its displays is an accurate recreation of the interior of a noble lady's chambers including furniture, decorations and a decorated tiled oven, and an exhibition on the history of Zvenigorod and the monastery.

Palace of Tsar Alexis

The Palace of Tsar Alexis was built in the 1650s and is now one of the best surviving examples of non-religious architecture of that era. It was built especially for Tsar Alexis who often visited the monastery on religious pilgrimages. Its most striking feature is its pretty row of nine chimney spouts which resemble towers.

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The Unique Burial of a Child of Early Scythian Time at the Cemetery of Saryg-Bulun (Tuva)

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Pages:  379-406

In 1988, the Tuvan Archaeological Expedition (led by M. E. Kilunovskaya and V. A. Semenov) discovered a unique burial of the early Iron Age at Saryg-Bulun in Central Tuva. There are two burial mounds of the Aldy-Bel culture dated by 7th century BC. Within the barrows, which adjoined one another, forming a figure-of-eight, there were discovered 7 burials, from which a representative collection of artifacts was recovered. Burial 5 was the most unique, it was found in a coffin made of a larch trunk, with a tightly closed lid. Due to the preservative properties of larch and lack of air access, the coffin contained a well-preserved mummy of a child with an accompanying set of grave goods. The interred individual retained the skin on his face and had a leather headdress painted with red pigment and a coat, sewn from jerboa fur. The coat was belted with a leather belt with bronze ornaments and buckles. Besides that, a leather quiver with arrows with the shafts decorated with painted ornaments, fully preserved battle pick and a bow were buried in the coffin. Unexpectedly, the full-genomic analysis, showed that the individual was female. This fact opens a new aspect in the study of the social history of the Scythian society and perhaps brings us back to the myth of the Amazons, discussed by Herodotus. Of course, this discovery is unique in its preservation for the Scythian culture of Tuva and requires careful study and conservation.

Keywords: Tuva, Early Iron Age, early Scythian period, Aldy-Bel culture, barrow, burial in the coffin, mummy, full genome sequencing, aDNA

Information about authors: Marina Kilunovskaya (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Vladimir Semenov (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Varvara Busova  (Moscow, Russian Federation).  (Saint Petersburg, Russian Federation). Institute for the History of Material Culture of the Russian Academy of Sciences.  Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail:  [email protected] Kharis Mustafin  (Moscow, Russian Federation). Candidate of Technical Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Irina Alborova  (Moscow, Russian Federation). Candidate of Biological Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Alina Matzvai  (Moscow, Russian Federation). Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected]

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Gagarin Cup Preview: Atlant vs. Salavat Yulaev

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Gagarin cup (khl) finals:  atlant moscow oblast vs. salavat yulaev ufa.

Much like the Elitserien Finals, we have a bit of an offense vs. defense match-up in this league Final.  While Ufa let their star top line of Alexander Radulov, Patrick Thoresen and Igor Grigorenko loose on the KHL's Western Conference, Mytischi played a more conservative style, relying on veterans such as former NHLers Jan Bulis, Oleg Petrov, and Jaroslav Obsut.  Just reaching the Finals is a testament to Atlant's disciplined style of play, as they had to knock off much more high profile teams from Yaroslavl and St. Petersburg to do so.  But while they did finish 8th in the league in points, they haven't seen the likes of Ufa, who finished 2nd. 

This series will be a challenge for the underdog, because unlike some of the other KHL teams, Ufa's top players are generally younger and in their prime.  Only Proshkin amongst regular blueliners is over 30, with the work being shared by Kirill Koltsov (28), Andrei Kuteikin (26), Miroslav Blatak (28), Maxim Kondratiev (28) and Dmitri Kalinin (30).  Oleg Tverdovsky hasn't played a lot in the playoffs to date.  Up front, while led by a fairly young top line (24-27), Ufa does have a lot of veterans in support roles:  Vyacheslav Kozlov , Viktor Kozlov , Vladimir Antipov, Sergei Zinovyev and Petr Schastlivy are all over 30.  In fact, the names of all their forwards are familiar to international and NHL fans:  Robert Nilsson , Alexander Svitov, Oleg Saprykin and Jakub Klepis round out the group, all former NHL players.

For Atlant, their veteran roster, with only one of their top six D under the age of 30 (and no top forwards under 30, either), this might be their one shot at a championship.  The team has never won either a Russian Superleague title or the Gagarin Cup, and for players like former NHLer Oleg Petrov, this is probably the last shot at the KHL's top prize.  The team got three extra days rest by winning their Conference Final in six games, and they probably needed to use it.  Atlant does have younger regulars on their roster, but they generally only play a few shifts per game, if that. 

The low event style of game for Atlant probably suits them well, but I don't know how they can manage to keep up against Ufa's speed, skill, and depth.  There is no advantage to be seen in goal, with Erik Ersberg and Konstantin Barulin posting almost identical numbers, and even in terms of recent playoff experience Ufa has them beat.  Luckily for Atlant, Ufa isn't that far away from the Moscow region, so travel shouldn't play a major role. 

I'm predicting that Ufa, winners of the last Superleague title back in 2008, will become the second team to win the Gagarin Cup, and will prevail in five games.  They have a seriously well built team that would honestly compete in the NHL.  They represent the potential of the league, while Atlant represents closer to the reality, as a team full of players who played themselves out of the NHL. 

• Atlant @ Ufa, Friday Apr 8 (3:00 PM CET/10:00 PM EST)
• Atlant @ Ufa, Sunday Apr 10 (1:00 PM CET/8:00 AM EST)
• Ufa @ Atlant, Tuesday Apr 12 (5:30 PM CET/12:30 PM EST)
• Ufa @ Atlant, Thursday Apr 14 (5:30 PM CET/12:30 PM EST)

Games 5-7 are as yet unscheduled, but every second day is the KHL standard, so expect Game 5 to be on Saturday, like an early start. 

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