Umeå universitets logga

Background: Therapeutic relationships are central to psychiatric and mental health nursing, yet patients in psychiatric inpatient care (PIC) and forensic inpatient care (FIC) commonly describe nursing professionals (NPs) as unavailable and report limited interaction, boredom, and a lack of meaningful activities. Joint activities may provide opportunities for interaction and relationship building and thereby address some of these challenges. Time Together (TT) is a nursing intervention designed to create dedicated time for patients and NPs to engage in joint activities. Previous research has reported positive experiences of TT among both patients and NPs, but knowledge about its implementation, sustained engagement, and participation in everyday practice remains limited.

Aim: The overall aim of this thesis was to increase understanding of TT in PIC and FIC, with a particular focus on its relational foundations, implementation, and participation in everyday practice.

Methods: The thesis comprises four studies using qualitative and mixed methods approaches. Study I explored the meaning of participating in joint activities with patients through narrative interviews with NPs (n=14) in PIC. Data were analysed using phenomenological hermeneutics. Study II explored perspectives on implementing TT through individual, dyadic, and group interviews with mid-level leaders and implementation leads (n=11) in PIC. Data were analysed using deductive qualitative content analysis guided by the Consolidated Framework for Implementation Research (CFIR). Study III used a mixed methods design to investigate innovation deliverers’ perspectives on factors affecting implementation of TT in FIC. A CFIR-based questionnaire completed by NPs (n=23) was analysed descriptively, followed by interviews with NPs (n=9) analysed using directed content analysis. The quantitative and qualitative findings were subsequently integrated. Study IV explored how participation was negotiated and shaped within TT in FIC through participant observations and informal interviews involving NPs (n=21) and patients (n=6). Observations were conducted on 21 occasions for a total of 63 hours, and data were analysed using inductive qualitative content analysis.

Findings: Joint activities held relational meaning for NPs and were understood as a process of learning that involved navigating uncertainty, discovering aspects of the other, finding opportunities for personal growth, and meeting one another as persons beyond the formal roles of patient and NP. Findings related to TT as a structured intervention showed that its perceived advantage, adaptability, design, and the knowledge and understanding of those involved influenced its implementation. Across PIC and FIC, implementation was further shaped by organisational conditions, leadership, culture, resources, engagement among NPs, and the implementation process. Planning, follow-up, and opportunities for reflection were important, while the perceived importance of implementation determinants did not always correspond to their presence in practice. Participation in TT was negotiated between autonomy and control and shaped through relational engagement, everyday circumstances, and spatial conditions. Across the studies, the findings point to an interplay between structure and relational practice. TT can create and protect opportunities for joint activities, but structure alone does not ensure that its core component of active NP-patient interaction is realised in practice.

Conclusion: Joint activities can provide opportunities for patients and NPs to meet beyond their formal roles and develop relationships through shared everyday experiences. TT can provide a structure for creating and protecting such opportunities, but whether its core component is realised in practice depends on how the intervention is implemented and how patients and NPs engage with one another in everyday practice. The implementation and use of TT in PIC and FIC therefore require attention both to organisational conditions and to the relational practices through which opportunities for active NP-patient interaction are realised.