Journal of Psychiatric and Mental Health Nursing, 1999, 6, 469477

Something always comes up: nursepatient interaction in an acute psychiatric setting

M. CLEARY 1 rn bhithsc (nurs) mhithsc (nurs) & C. EDWARDS 2 rn mnurs
1

Clinical Nurse Consultant Research, and 2Clair Edwards, Operational Nurse Manager, Central Sydney Area Mental Health Service, PO Box 1, Rozelle, NSW 2039, Australia Central Sydney Area Mental Health Service, PO Box 1, Rozelle, NSW 2039, Australia

Correspondence: M. Cleary Central Sydney Area Mental Health Service PO Box 1 Rozelle NSW 2039 Australia

CLEARY M. & EDWARDS C. (1999) Journal of Psychiatric and Mental Health Nursing 6, 469477 Something always comes up: nursepatient interaction in an acute psychiatric setting In this study, 10 nurses and 10 patients were interviewed to explore factors inuencing nursepatient interactions in an acute psychiatric inpatient facility. The six themes that emerged from the nursing interviews were; environment, something always comes up, nurses attributes, patient factors, instrumental support and focus of nursing. The four themes from the patient interviews were; nurses attributes, role perceptions, clinical care, and time. These ndings have implications for clinical practice, the nurses role and nursing education. Keywords: acute inpatient care, mental health nursing, nursepatient interaction
Accepted for publication: 24 September 1999

Introduction
Mental health nursing practice is founded on interpersonal interactions with patients and the use of self is seen as an essential aspect of nursing care. Peplau explains the behaviour of the nurse as a person interacting with the patient as a person has signicant impact on the patients wellbeing and the quality and outcome of nursing care (Peplau 1992, p. 14). Quality nursepatient interaction is an important factor in positive outcomes for patients (Emrich 1989, Richmond & Roberson 1995). Nursing interactions have also been linked to patients overall satisfaction with hospital care (Meehan 1995, Richmond & Roberson 1995). The problem of psychiatric nurses interacting in a therapeutic manner has been discussed in the literature (Porter 1992, Kerr 1996, Muller & Poggenpoel 1996). There is extensive literature that provides explanations for the perceived limited quality and depth of nursepatient interaction (May 1990). Factors identied include occupational stress, organizational structure, occupational culture and bureaucratic constraints (May 1990, Porter 1992, Porter
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1993). The need to maintain ward order, to manage patients, other staff and the environment, places pressure on nursing staff who cope by utilizing a custodial model of care thereby creating barriers to effective therapeutic interaction (Porter 1992, Porter 1993, Gijbels 1995, Ryrie et al. 1998). In contrast to longer-stay wards, fewer interactions between nurses and patients in acute care was demonstrated in a study that observed the behaviour of nurses in a psychiatric hospital at 5 min intervals over a 10-day period (Tyson et al. 1995). However, Tyson et al. (1995) maintain it is the quality rather than the quantity of contact which is signicant and warn that the assumption that a lot of nurse-patient contact is benecial remains untested; some patients may prefer less contact. The assumption that interactions are both valuable and benecial has been identied by Gijbels as the starting premise for a number of studies of mental health nursing in inpatient settings (Gijbels 1995, p. 461). Heifner (1993), for example, examined the concept of connectedness in the nurse-patient relationship by inter469

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viewing eight nurses working in an acute psychiatric setting. She concluded that the nurse-patient relationship is therapeutic when connectedness occurs and therapeutic interaction has benets for both patients and staff. However, Heifners (1993) study did not explore the views of patients. Alternatively, Muller & Poggenpoels (1996) study of patients perception of interacting with mental health nurses did not include nurse interviews. In-depth interviews included both psychiatric hospital inpatients and patients being treated in an outpatient setting. Aspects of interaction identied by participants included: stereotyping, custodialism, rule enforcement, lack of intimacy, friendliness, and lack of empathy and caring (Muller & Poggenpoel 1996, p. 146). Participants also described defence mechanisms such as denial and avoidance by nurses. Muller & Poggenpoel (1996) advocate the incorporation of their study results into nurse education and practice to facilitate nursepatient interaction which promotes patient wellbeing (Muller & Poggenpoel 1996). Patients identied psychiatric nurses as being both therapeutic and helpful in a study of 100 psychiatric in-patients in a medical centre. Richmond & Roberson (1995) used a 50-item questionnaire to determine the patients perceptions of nursepatient interactions. The most appreciated nursing attribute identied was friendliness. Determining the patients perception of effectiveness of nursing actions can allow nurses to emphasize these interventions when planning patient care so that both the nurse and the patient can approach care and treatment with condence of a positive outcome (Richmond & Roberson 1995, p. 43). Patients perceptions of interaction are an important factor in assessing the quality of care (Richmond & Roberson 1995). In order to study nursepatient interactions, the perceptions of both the mental health service provider (the nurse) and the consumer (the patient) are relevant. Providers of health care are beginning to understand that patients expectations may differ from their own (Beech & Norman 1995, Richmond & Roberson 1995, Muller & Poggenpoel 1996). Recent changes in health care should lead service providers to examine these differences to enable nurses to meet consumer expectations. Increasing our understanding of consumer needs can lead to improved communication which has the potential to improve service provision (Trivedi 1996). Dismissing patients perceptions and experiences has important implications for the nursepatient relationship (McDougall 1996). McDougall (1996) highlights the importance of validating and understanding patients experiences and points out that only then is it possible to care.
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The different perceptions held by nurses and patients are identied as a major obstacle to nurse-patient relationship (Sharma & Carson 1996). Sharma & Carson (1996) investigated nurses and patients opinions about helpful aspects of inpatient care in four psychiatric admission wards. The study sample included 62 patients and 25 nursing staff who were surveyed using a helpfulness scale. In contrast to opinions of patients, nursing staff ratings were higher for all items. They recommend further qualitative studies to sensitively explore these differing perceptions before effective partnerships can be developed. The willingness of patients to share their perceptions of nursing care and offer constructive comment for improving care was identied in Beech & Normans (1995) study. Beech & Norman (1995) explored patients perceptions of nursing care using the Critical Incident Technique and a convenience sample of 24 patients from two acute wards in a large psychiatric hospital. The six themes emerging from their study were; handling violence and disturbance, communicating caring, respect, ward atmosphere, nursing numbers and nurses attributes. Overall, the number of positive comments exceeded the number of negative ones. The researchers remarked on the high value which study participants awarded communication. Nursing communication was identied as parental in style in a study that examined spontaneous nurse-patient and patientpatient interactions over a 7-week period (Emrich 1989). The study sample comprised 127 observations in an adult inpatient unit. It was thought the parental style of communication might be a result of the hierarchical hospital structure. Parental (adult-child) style interactions were more likely to be disconrming than adultadult interactions. Emrich (1989) contends that nurses providing acute care deal with both the patient and the environment in an efcient manner because of work pressure. One may speculate that this need for efciency makes nurses less sensitive to the interpersonal aspects of communication (Emrich 1989). Changes brought about by economic rationalization, deinstitutionalization, mainstreaming and the shift of the focus of care to crisis management in inpatient units has led to a shorter length of stay for patients and an increase in the level of patient acuity (Nieminen et al. 1994, Thomas 1996). The result is a changing pattern of service delivery, and nurses in acute inpatient settings are discovering that they must develop models of care which focus on the challenge of caring for the severely mentally ill with fewer resources and less time (Delaney et al. 1995). Given the rapid changes occurring in mental health nursing the importance of research which examines factors inuencing practice cannot be overstated (Porter 1992).

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Previous studies have explained how nurses interact with patients, why they interact, the effectiveness of their interaction and the role they play in the acute care setting, however, these questions need to be expanded and explored within the current dynamic environment of mental health service provision. There is consensus in the literature to date regarding the usefulness of nursepatient interaction, however, factors that facilitate or impede interaction have not been identied. Factors that impact on the manner in which nurses care for patients also require investigation. The present study set out to explore factors which facilitate and/or impede nursepatient interaction in the acute psychiatric setting from the perspective of both nurse and patient.

topics have been identied in the literature as relevant to nursepatient interaction. All interviews were audiotaped and transcribed verbatim. The analysis of the interview transcripts was guided by Burnards (1991) thematic content analysis method which has been identied as appropriate for interview transcripts. This method consists of a series of stages that includes: review of transcripts, coding transcripts and developing higher order headings (Burnard 1991). A nurse academic, independent of the study, reviewed both the data and themes and conrmed that these themes reected the content of the interviews.

Findings Method
The aim of the present study was to explore factors that facilitate and/or impede nursepatient interaction in the acute psychiatric setting. The study was conducted in a 22-bed acute psychiatric admission ward. Services are provided primarily for patients aged 1665 years. Staff scheduling, although to some extent dependent on patient numbers, is usually four nurses on morning shift, two nurses (including the Nursing Unit Manager) on day shift, four nurses on the evening shift and three nurses on night duty. The full time equivalent for nursing staff on the unit is 18.2 registered nurses. A random sample of 10 clinical nurses rostered to the study ward agreed to participate in the study. Purposeful sampling was used to obtain participants for the patient interviews. Nurses were asked to provide the researchers with the names of patients who were ready to proceed on leave or to be discharged. Ten identied patients were approached by the research team and invited to participate in the study. Semi-structured individual interviews were used to collect both sets of data. The interview guide was based on issues pertaining to nursepatient interaction derived from the literature. These included: perceptions of both the quantity and quality of the time spent interacting, factors likely to hinder interaction and factors likely to facilitate interaction. More specic interview topics for nurses included: primary nursing, prioritizing time, preparing and planning for interactions, typical interactions and the perceived value of nursepatient interaction. Specic interview topics for patients included: helpful and unhelpful nursing interactions, satisfaction with the amount of time nurses spend with them and satisfaction with the information nurses provided. Participants (nurses and patients) were also encouraged to raise issues which they considered important in terms of their inuence on interaction. These Six major themes emerged from the interviews conducted with nurses. These were: environment, something always comes up, nurses attributes, patient factors, instrumental support, and focus of nursing. The four major themes emerging from the patient interviews were: nurses attributes, role perceptions, clinical care, and time. Findings will be presented in two sections ndings from the nursing interviews followed by patient interview ndings.

Nursing interview ndings

Environment
Comments were made about physical aspects of the ward and these included the size of the unit and the provision of quiet places to sit and talk. The size of the unit was identied by some as problematic since patients could easily get lost or go unnoticed. Also unit size could, at times, create frustration for nurses checking the whereabouts of patients under close observation. Searching for patients was seen as time-consuming work which detracted from other patient centred activities.
A lot of the time . . . you nd that youve got so many people on Care Level 2 you spend . . . a lot of the shift just wandering around just trying to nd people and just giving encouragement to stay around . . .

Maintaining a safe environment was felt to be an essential aspect of care. This required nurses to keep an eye out for all patients at all times. Nurses were positive about involving patients in the ward programme and it was felt to encourage nurse patient interaction. It was apparent that when the unit was busy programme activities were the rst to be sacriced to ensure that essential work such as admissions, transfers, close observations and unit safety were maintained.
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Something always comes up

All participants spoke about the unpredictable nature of acute care inpatient facilities. This unpredictability was generally accepted as just the nature of the ward. Participants were able to outline how they prioritized their time with patients. Factors that inuenced the prioritizing of work included recency of patient admission, patient acuity, handover report and documentation. It was acknowledged that prioritization of work was not always straightforward. All participants spoke about the amount of unplanned activity. This included; admissions, discharges, transfers in, transfers out, critical incidents, assisting other staff, taking patients to urgent appointments, providing assistance and support to other wards, accompanying patients to obtain funds/personal belongings and valuables, magistrates hearings and documentation requirements. Such activities detracted from planned nursepatient interaction. The number of patients cared for each shift by individual nurses varied according to the number of nurses, patient numbers, ward needs and the number of patients requiring close observation. High numbers were perceived to result in less time being available for nursepatient interaction. Participants often expressed regret at the lack of time available to spend with individual patients.

explanation was that some nurses lack condence and again, interaction among staff was the accepted strategy for managing this especially between junior and senior colleagues.

Patient factors
It was apparent that the acuity of the illness was a factor which inuenced the nature of nursepatient interaction.
Yesterday for example, I was talking to a new client on the ward and I was there explaining [the] ward routine and the patient just screamed at me . . . I dont know what for . . . He didnt say anything he just literally screamed and I jumped . . . and then I kind of got myself together and [thought] . . . this is a fairly negative interaction . . . [Im] having with this person perhaps I cant really go any further here . . . Then I just quickly questioned him and asked if there was anything wrong, why he screamed and then he said that he didnt scream, what scream . . . so I quickly terminated the conversation and discussed . . . his observation levels . . . with him . . . and then left . . .

Nurses attributes
Nurses attributes were viewed as an inuence on nurse patient interactions. Understanding was perceived to be an essential attribute. Being nonjudgmental was also seen as an important aspect of care as a judgmental attitude could impede nursepatient interaction.
[Y]ou have to detach yourself and be a professional and . . . accept people for what they are.

Patients who were more unwell were perceived as having a greater need, and a high level of concern was expressed about the wellbeing of patients who were new to the ward. Participants felt new admissions needed a lot of encouragement, reassurance and education. These patients were also more likely to require close observation and their needs were seen to be more urgent than those of patients who were close to discharge. The latter were discussed in terms of co-ordinating tasks for example, medication, community care and paperwork. These tasks were recognized as time consuming.

A positive and fresh outlook for each shift was important. It was generally perceived by the study participants that positive staff attitudes created a positive ward atmosphere. It was evident from the interviews that there was a degree of sensitivity between colleagues. Positive, helpful, supportive interactions among nurses were perceived to inuence nursepatient interactions. Participants spoke about supporting and educating colleagues to facilitate interaction with patients. An example of having coffee with a colleague was given. The participant recognized that this would take time away from patient contact but felt it could ultimately contribute to improved care. Coffee with colleagues allowed time to ventilate and was considered to be a supportive strategy instrumental in preventing burnout. Avoidance of patients was discussed. A possible
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Instrumental support
Instrumental support was identied as a factor that inuenced interaction between nurses and patients and encompassed the units culture and the development of nursing competence and condence. The orientation of new staff provided an opportunity to set clear expectations and to promote a shared team philosophy. The value of education was acknowledged. However, it was noted that attending education sessions took time away from direct patient care. Learning also occurred through interaction with colleagues. This was perceived as a factor which could improve condence and thereby encourage nursepatient interaction. The attitude of management and senior staff was considered an important aspect of instrumental support which affected motivation and morale on the unit.

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[T]he way nursing managers or . . . supervisors, interact . . . [with] the nursing staff that actually work on the wards . . . really does make a difference, just to show they care and . . . theyre listening to . . . [our] criticisms or . . . needs.

As mentioned previously spending time with other staff, while decreasing opportunity for direct patient contact, was seen as instrumental in building team morale and positively inuencing nursepatient interaction.
[S]taff spending time with each other and just working on team morale and all that sort of stuff is really important, and that does take away from patient time but I strongly believe that the time the patients get is better because youve spent time on the staff as well.

All participants considered teamwork essential. It was perceived as a factor which could facilitate communication whilst providing support and a degree of supervision. Effective teamwork contributed to positive nursepatient interaction. Morning meetings, handovers and case reviews were identied as venues for sharing information. Reviewing clinical practice and service delivery was identied as a necessity. It was acknowledged that this took time away from patient care and at times, was a source of frustration for staff as it generated more work, and necessitated staff adapting to change. The need to balance professional development activities and patient care was also commented on.

Some found that certain aspects of their role inhibited nursepatient interaction. Examples were answering phones, writing notes, administering medication, completing nursing documentation, co-ordinating patient money, assisting with critical incidents, co-ordinating appointments and co-ordinating the activities of other professions in the multidisciplinary team. Some of these tasks were perceived as non-nursing and as such, were frustrating as well as time consuming. Being there for the patient was felt to be helpful and normalizing. Interpersonal aspects of nursing were viewed as important; nurses spoke about understanding, building relationships, developing rapport and respecting patients. Time constraints made it difcult to establish a meaningful therapeutic relationship. The short length of stay and the acute nature of the illness were seen as impeding the development of an effective therapeutic relationship and may impede effective nursepatient interactions.

Patient interview ndings

The four major themes that emerged from the patient interviews were: nurses attributes, role perceptions, clinical care and time.

Nurses attributes
In this theme participants made a number of comments concerning the attributes of the nurses. Nurses were generally perceived as being friendly, honest, understanding, empathic and easy to talk with. Participants spoke about aspects of care they liked, for example, the way the nurse called them by name, the concern reected in the nurses voice or the way nurse communicated. Nurses provided both reassurance and information and were able to x problems in an efcient manner. Most participants believed nurses were doing their best. Being available was important: [they are] always there for me which is crucial to my therapy. It was perceived that nurses were insightful and perceptive:
They sit me down and talk to me, they give me medication, only if I need it, if Im really racey and really feeling Im on edge, they give me something just to calm me down just enough. They dont drug you out. They wait for the medication to kick in and then sit down and talk to you cause its too hard for them to try to understand me when Im talking so fast and everything . . . Theyre trying to do it the right way, most people are.

Focus of nursing
Each patient was allocated a nurse who was responsible for organizing and co-ordinating their care for that particular shift. If the primary or associate nurse was on duty, it would be one of these. Nurses spoke about enjoying this model of care. They liked the practice of being involved and the individual responsibility. They felt you could get to know the patient by spending time with them and it gave the patient a nurse to whom they could direct their concerns somebody who was specically interested in their care. However, some participants believed the method of allocating primary nurses on the study unit was a factor which could impede nursepatient interaction.
[T]he way its allocated is a bit dodgy . . . we . . . look at the numbers on the board . . . [and] allocate the person to someone who hasnt got many . . . [primary patients] at the time [this nurse] . . . has never have met the patient and, you know, they . . . [may not have] any rapport with them.

Nurses perceived their role as pivotal to the functioning of the ward.

I think the nurses tend to be an anchor in the middle of things, co-ordinating what everyone else is doing.

It was not uncommon for participants to name the nurses they liked.
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[Name] . . . shes taken care of me in another hospital . . . shes brilliant. She really knows how to take care of me and patients, [name] is another one whos brilliant, whos been honest, straight forward and then comes [name] as 3rd and then [name] of course.

also spoke about the role of the nurse in orientating them to the ward. A few participants seemed to have a limited perception of the nurses role.
Physical things, you know, if youve got a heart attack . . . to assist you . . . But emotional problems, thats a Social Workers job.

Some spoke about choosing nurses based on attributes such as, age, gender and physical appearance. Particular nurses were felt to be more caring than others. At times, participants believed their symptoms had been dismissed particularly when nurses were under pressure.

Clinical care
Participants valued consistent clinical care. The primary/ associate nursing model provided a back up nurse. Most participants considered this a good system.
They always have a back up you know if someones not around . . . theyll sit down and talk to me and sort it out if the other persons . . . [is] busy.

Role perceptions
The nursing role was perceived by participants to include skills such as; promoting independence, advocating, coordinating care, counselling, solving problems, providing information with explanations and guidance, answering questions, assessment, support, helping to plan the day, communicating, interacting in a social way and providing practical assistance. A nurse who provided assistance was seen as a good nurse. Setting limits on behaviour was also viewed as part of the nursing role.
If Im too rude to them then theyll say Im not talking to you right now [name], you come back when youre more calm and I usually do or I sort myself out.

Medication and illness education were often mentioned by participants as an aspect of clinical care. Discharge planning was also considered to be part of the nurses role. One participant spoke about interaction between patients, claiming they were more likely to listen to each other than a health professional.
[I]f youve got one of your own kind and say Im a patient too and I tell someone off because theyre screaming theyve got the respect to shut up . . . its like talking to a brother . . .

This participant was asked if limit setting was a reasonable thing for the nurse to do: Yeah, of course. If Im sitting there telling her shes a [swears] Id be sending me away too, you know. You cant do that and expect to get away with it just cause youre in a loony bin. The nurses role in maintaining ward safety was discussed by some participants. It was clearly believed that defusing aggression and managing violence were part of the nursing role. Another important aspect of the nursing role was assisting participants to deal with other patients.
[Another patient] . . . had a go at me this morning again with abusive language and I just went and got the staff. I just thought thats it, its not my problem, [Ill] let you handle it and thats what they [the nurses] did . . .

However, it was generally recognized that nursepatient interaction was prioritized in response to patient needs. Acuity of illness and behaviour seemed to inuence these interactions.

Time
Participants were sympathetic to nurses and acknowledged the demands of the workplace. They believed the stafng ratios, the big workload, the responsibility and the high patient numbers contributed to fewer nursepatient interactions. Waiting time varied from a couple of minutes to half an hour. At times it appeared to the participants that the nurses were too busy to help.
Oh sometimes you just get totally ignored but sometimes theyre just saying, excuse me, wait a minute . . . I mean its all variable, it depends on the person . . . the time of day, the pressures on the ward. . . .

All patients were aware that the nurses role encompassed a need to maintain an awareness of the whereabouts of patients. Nursing observations were discussed in terms of preventing patients from absconding. For some, nursing observations assisted with feelings of security and safety. Assisting with essential activities of daily living was also expected of nurses. Examples given included making beds, assisting with showering and washing clothes. Participants
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Participants acknowledged that the nurses had other patients and responsibilities.
Theyve got a lot of other responsibilities to take care of . . . You know like today, theyre only 2 . . . 2 nurses on and there are the rest of us so basically theyve got a lot to, to do.

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Generally, participants were understanding about the time nurses spent with them. However, most said they would have liked more time.
Im pretty satised with it. Yeah, I mean they could stay longer but these are busy people too you know, theyre not just looking after one person . . . they have other people to attend to . . . the ward doesnt revolve around me . . .

One participant stated it was the patients who do not want to spend time with the nurses. Some participants felt that the ward was, at times, chaotic: and today, gosh it was like Pitt Street! It was recognized that the patient population changed frequently: 2 go, 3 come, 3 go, 5 come, you know. The ward routine was perceived as helpful. However it was generally acknowledged that the days were long and it could seem like nothings really happening.

Discussion
This study provided an opportunity for both nurses and patients to express their views on factors perceived to inuence nursepatient interaction. Both patients and nurses were positive about participating in this study and the ndings from the interviews with both patients and nurses were remarkably similar. Different perspectives on interaction may have been identied if another study ward had been included. Similarly, if the study had been conducted over a period incorporating both quiet and busy times, ndings may have varied. Aspects of the ward environment were identied as contributing to quantity and quality of nursepatient interaction. The layout of the ward often resulted in nurses spending a considerable amount of time searching for, rather than interacting with, patients. It was felt that patients could be overlooked in this environment. The ward also lacked formal interview/counselling rooms with ward alcove areas being utilized for planned therapeutic interactions. The ward programme provided some opportunity for interaction. The atmosphere of the ward was generally perceived as positive. Safety was an important aspect of the ward environment for both patients and staff. Some patients commented on safety as being, in part, attributable to the level of nursing observation. At times, patients asked nurses for help when confronted by other patients. The valuing of nursing staff who manage disturbance has been noted elsewhere (Beech & Norman 1995, Lovell 1995). Feeling safe on the unit was important for patients and the creation of a safe environment was perceived as a nursing responsibility. Nursing participants identied patient safety, patient needs, patient acuity and critical incidents as factors which

inuence nursepatient interaction. Care related to some of these factors was not always possible to plan and this unpredictability was perceived to be the nature of acute care nursing. Patient numbers, stafng levels, ward needs and administrative tasks were also identied as factors inuencing nursepatient interaction. Some aspects of patient care and ward management perceived as nonclinical nursing were identied by nurses as part of their responsibility. These tasks were viewed as pivotal to the functioning of the ward and if not performed, nursing participants believed that patient care would be compromized as a result. These activities in themselves are patient centred and if managed effectively are windows of opportunity for interaction. Anderson (1983) identies a need for mental health nurses to dene and articulate their role within the multidisciplinary team to assist in setting expectations, to promote role clarity and to facilitate planned patient care. Clarifying the role of the nurse for patients on admission and their expectations of care could also improve collaborative care. Nursing care, however, was perceived to include activities such as counselling, medication administration and education, illness education, family education, providing information, advocating, assisting with aspects of daily living, discharge planning, managing the ward environment and patient assessment. Patients identied nurses as being able to x things, that is, solve problems. This is consistent with Beech & Normans (1995) study in which it was found that patients valued nurses who assisted with problem solving. Nurses in the present study acknowledged that solving problems was part of their role but were concerned about it taking time away from planned care as it frequently occurred on an ad-hoc basis. The high turnover of patients in acute inpatient care can lead to interrupted and reactive interventions which impedes nurses ability to employ therapeutic interventions (Gijbels 1995). To ensure that planned therapeutic contact is not sacriced in the dynamic environment of an acute admission unit there is a need to encourage and formalize creativity in current work practices and methods of prioritizing care in acute inpatient settings. The ad hoc nature of acute inpatient care (Gijbels 1995) indicates a need to consider developing a model of nursing care which focuses on individual care but is more responsive to the unexpected nature of care delivery in the current acute care setting. Lepola & Vanhanen (1997) challenge nurses to develop a more therapeutic daily routine to change the lack of purpose in much of the time a patient is hospitalized. This challenge is based on their study in which they observed
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the daily activities of patients in an acute psychiatric ward. Their ndings showed that patients spend most of their time alone (Lepola & Vanhanen 1997). Patients in the present study commented about the long days. The suggestion by Tyson et al. (1995) for the development of local protocols to ensure patients are included in clinical decision making and consulted when care plans are developed or reviewed may facilitate collaborative care and decrease the meaningless and boredom identied. Nurses spoke about the large number of administrative tasks and time spent evaluating the service. Given the rapid patient turnover and the lack of secretarial support, this workload is not surprising and ultimately inuences the amount of time available for interacting with patients. The burden of clerical and administrative tasks has been identied in other studies. A survey of nursing practice in two psychiatric inner city admission wards found that over 50% of nursing time was spent in nonpatient contact (Ryrie et al. 1998). Almost a quarter of nurses time was found to involve clerical tasks in a study of psychiatric nurses interactions with patients (Tyson et al. 1995). Gijbels (1995) identied nurses as being resentful of clerical tasks. Information technology was suggested by Tyson et al. (1995) as a possibility for decreasing clerical work. Information technology has the potential to streamline the patient tracking aspects of admission, transfer, discharge and reclassication to decrease time spent on these activities by nurses. There is a need to undertake a review of the current use of clerical support given clerical duties were frequently identied as taking time from nurse patient interaction. Of importance to patients were the attributes of the nurse, that is, demonstrable caring, understanding and just being there. This nding is similar to that of other studies in which patients, when interviewed, reported as valuable personal attributes such as caring, interest, patience and friendliness (Beech & Norman 1995, Muller & Poggenpoel 1996). This would suggest that therapeutic interactions are complex interpersonal exchanges to which both nurse and patient bring their own personal characteristics, experiences and world view (Forchuk 1995, Oxley 1996). In Beech & Norman (1995) study, nurses who were available, greeted patients and made a time to see them, were perceived as caring. Nurses in the present study also valued these aspects of care. Richmond & Roberson (1995) contend the notion of service with a smile remains relevant to the nursing profession. The importance of self-awareness during nursepatient interaction cannot be understated. The attitude of the nurse/s was identied as unhelpful at times. It was felt that some nurses could have been more
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compassionate and understanding. Some patients claimed that nurses could appear abrupt when under pressure. Working in a busy, acute care psychiatric ward may render nurses less sensitive in interpersonal interactions with patients (Emrich 1989), especially those occurring on an ad hoc basis. Nurses need to be aware of both their actions and behaviours when in the presence of patients (Richmond & Roberson 1995). Nurses in this study identied a positive attitude as a prerequisite for positive interpersonal interactions with patients. Overall, patients felt that given the time constraints, nurses dealt with their needs in a reasonable manner. In general, patients were insightful about the role of nurses who they perceived to have multiple responsibilities. Patients frequently explained how busy nurses were to the interviewers and made suggestions to improve this situation including increased nursing numbers and provision of additional resources. All nurses agreed they would like to spend more time with patients and identied the lack of available time. The notion of time was consistently referred to in Gijbels (1995) study in which respondents perceived enough time would overcome their problems. In the current mental health setting with the focus on crisis care, planned interactions/interventions such as counselling may be overlooked when managing practical day to day needs. Nurses require training, education and clinical supervision to increase condence and competence in the delivery of therapeutic interventions (Long & Reid 1996, Lepola & Vanhanen 1997). Clinical supervision can assist nurses to identify and explore issues within their practice. It could also provide nurses with an opportunity to reect on their interactions with patients. Ongoing nursing education and clinical supervision are essential to assist nurses to adjust to the shorter length of patient stay and increased patient acuity in acute care settings. Organizational commitment is a necessary prerequisite for this to occur (Ryrie et al. 1998). This study explored nurse and patient perceptions of interaction in one acute admission ward in a large psychiatric hospital. Of note though is that the issues highlighted in the present study have been generally reported elsewhere. With continued hospital and community integration, decreased length of patient admissions and increased rationalization of health services it may however, be necessary to redene the focus of acute inpatient care and the goals of treatment to encompass current changes to mental health services. The changing context in which psychiatric nurses practice (Ryrie et al. 1998) may well mean that the vision that the profession holds for nurses working in acute inpatient psychiatric facilities may well need to be adapted (Gijbels 1995).

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Conclusion
Given the limitations of the study, caution is advised in generalizing the ndings to other settings. The ndings of this study indicate that there are many factors that inuence the quality and quantity of nursepatient interaction. Apart from the physical environment of the ward and the multiple demands upon nurses with competing priorities, existing methods of nursing care have been challenged by the ndings of this study and a review of nursing delivery systems could result in nurses being responsive rather than reactive to the demands of the environment. This study identied a need to review the structures that support nursing practice and optimise therapeutic interaction as an important component of patient care. In light of the changing demands in inpatient settings, a review of nursing practice is indicated. So far nursing care has been reactive. Nursing needs to be organized so that it is not just responding to the fact that something always comes up.

Acknowledgments
The authors wish to acknowledge the New South Wales Nurses Registration Board who funded this project. Additionally the authors wish to thank colleagues and patients who participated in this study. Special thanks must go to Mr Gary Rowley for his enthusiasm and project support, Mr Tom Meehan for his involvement in the design of this study, Dr Cheryl Waters for her expertise with data analysis and Ms Philippa Mazoudier and Ms Raighne Jordan for their valuable comments on the draft.

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