Patients’ experiences of Daily Talks: a patient-driven intervention in inpatient mental healthcare

Abstract Background Recovery is known to be enhanced by meaningful interactions between patients and mental health staff. However, nurses may become distanced from patients, and patients may spend most of their time in inpatient mental health care alone. Aims This study aimed to explore how patients experience the intervention Daily Talks, a patient-driven innovation intended to enhance meaningful interactions between patients and staff. Methods Fourteen in-depth interviews were performed with patients who participated in Daily Talks. The interviews were analysed using reflexive thematic analysis. Results The results of the participants’ experiences of Daily Talks are presented in four themes: 1.Interpersonal and active interaction where individual factors matter 2.A patient-controlled space 3.A multi-use intervention and 4.A part of the daily healthcare structure. Participants stated that Daily Talks improved the relationship between patients and their nursing staff, and they stressed the importance of patients having control over both time and content in the Daily Talks. Daily Talks was used to vent emotions and thoughts, handle situations and create strategies, and become part of a helpful structure. Conclusions The results support the value of Daily Talks, indicating that Daily Talks may facilitate helpful structures and meaningful relationships between patients and nursing staff.


Introduction
Many people recover from mental health challenges, and medical treatment is only one of several routes toward recovery (Slade & Longden, 2015). People who recover may live a life with a mental health challenge and can still at the same time build a satisfying and meaningful life, irrespective of ongoing or recurring symptoms or problems (Andresen et al., 2003;Bracken et al., 2012). Recovery is known to be enhanced by helpful relationships between patients and mental health staff (Anthony & Mizock, 2013;Borge & Fagermoen, 2008;Borg & Kristiansen, 2004;Catty et al., 2011;De Leeuw et al., 2012;Howgego et al., 2003). Such relationships are characterised by trust and time spent together, compassion, understanding and a belief in recovery (Horgan et al, 2021;Ljungberg et al., 2015;Wand et al., 2022). Empathy is a central component in mental health nursing and involves nurses being more present and trying to understand the perspective of people with mental health experiences and (Gerace et al., 2018). Another aspect of therapeutic relationships is when mental health staff skilfully go beyond some of the boundaries of their professional role, for example, by sharing personal information about themselves, which may restore both the professional and the patient as persons . Operationalising the concept of recovery in practice has proven to be challenging (Le Boutillier et al., 2011, Waldemar et al., 2016, where several studies highlight the lack of collaboration, communication, and engagement between patients and staff in mental health inpatient settings (Waldemar et al., 2016).
Research about everyday life in mental health inpatient care is sparse (Molin et al., 2016). Although the therapeutic relationship between patients and staff is repeatedly highlighted as helpful for patients, patients may spend most of the time in mental health inpatient care alone, without engaging in meaningful activity, perhaps feeling lonely (Folke et al., 2018;Gunasekara et al., 2014). Nursing staff may be stressed and heavily burdened with other tasks, for example, administration, and they become distanced from patients and distracted from a more therapeutic nursing role (Goulter et al., 2015;Wand et al., 2022). Although the formation of interpersonal therapeutic relationships with patients is seen as a core task for mental health nurses (Cutcliffe et al., 2015), the task of nursing staff may, from a more biomedical perspective, be restricted to checking on patients and administering medication (Goulter et al., 2015).
This study presents and explores "Daily Talks", a patientdriven intervention with the overall aim of providing a structure for meaningful interaction between mental health staff and patients as well as enhancing patients their recovery (Steinsaphir, 2017). The intervention was implemented in 2017 and although Daily Talks is now used in several mental healthcare facilities in Sweden, no research has yet been conducted on how patients experienced the intervention and how they made use of the opportunity for Daily Talks. The aim of this study was therefore to explore how patients in inpatient mental healthcare experienced the intervention Daily Talks.

Design
This was a qualitative study where semi-structured interviews were analysed with reflexive thematic analysis (Braun & Clarke, 2006Clarke & Braun, 2017). The study is reported according to the COnsolidated criteria for REporting Qualitative research (COREQ) checklist (Tong et al., 2007) (supplement 1). Ethical approval was granted by The Regional Ethical Review Board of Stockholm (Ref. 2019-03849 with amendment ref. 2020-04604). All participants gave their consent for their data to be used in the research.

Intervention
Daily Talks (described in Textbox 1) was developed and implemented in practice in 2017 by ÅS, who at the time was employed as User Involvement Coordinator (UCI) at a mental health service in a major city in Sweden. The employment of UCIs is a regional initiative within mental health care, the position as UCI requires lived experience of being a patient in mental health inpatient care. As a part of the job, the UCIs invite patients to discussion forums. A recurring topic that patients addressed was that they expressed a lack of one-to-one talks with their nursing staff, and the need for a transparent structure that enabled them to talk to their nursing staff on a daily basis, instead of patients having to ask for it. To address this, ÅS designed and implemented the intervention Daily Talks, with input from patients and healthcare staff.

Participants
Participants were recruited from patients admitted to the pilot ward where Daily Talks had been in use since 2018. The pilot ward is a psychiatric inpatient acute care ward for adults, where patients have access to health care professionals for treatment planning, care and medication. Further, activities are offered such as outdoor walks, arts, physical activities and relaxation, these activities are usually lead by occupational therapist, physiotherapist and Peer Support workers. Inclusion criteria were age >18 years, and that they could speak and understand Swedish enough to be able to participate in an interview). Fourteen interviews (10 women, 4 men, 22-62 years old) were conducted from October 2020 to February 2021 by MR, a female registered nurse with training in qualitative interview technique and analysis.

Procedures
Patients admitted to the ward were approached by staff for participation in the study, and the study was also introduced at recurring patient forums on the ward. An interview guide was used with open questions about participants' experiences of Daily Talks, such as "How would you describe Daily Talks?" and "Can you describe a situation where a Daily Talk was useful to you?". Follow-up questions such as "Can you tell me more about that?" were used as probes. Interviews were audio-recorded and transcribed shortly after each interview and all authors read the transcripts to refine the interview guide along the way. Interviews lasted from 18 to 44 minutes (mean length: 29 minutes).

Analysis
Transcripts from the interviews were analysed using reflexive thematic analysis according to Braun and Clark (2006). All authors read through the transcripts to familiarise themselves with the content. Three authors (MM, MR, ÅS) then coded transcripts using the comment function in Microsoft Word. In line with the explorative aim, the analysis did not build on pre-existing theory or use any sensitising concepts and the coding was therefore inductive with open codes. Codes with corresponding quotes were exported with a Textbox 1. Description of daily talks. Daily Talks aim to increase patient participation and enhance the structure of the care provided using only existing budget and skill set. The intervention is not intended to be a form of therapy but offers a structure to enhance interaction between patients and nursing staff. Daily Talks was first pilot tested at a pilot ward and thereafter implemented in all mental health inpatient wards at a Swedish hospital in 2017. The pilot ward was an acute care ward with voluntary and involuntary admission where persons with mental health challenges and can be admitted for inpatient care during an acute phase. When Daily Talks was implemented, the staff was instructed that all patients at the ward should be offered to sit down and talk with someone in their team each day (either nurse or mental aid). The talks were restricted to be 30 minutes long at most and the time for the talk should be set in advance. It is up to the patient to choose what to talk about in the Daily Talks. Internal evaluation of the pilot test showed that during a four-week period, 70-100% of patients were offered Daily Talks and each day, 35-40% of those that were offered a Daily Talk accepted. The Daily Talks often took about 15 minutes and staff said that it was possible to find time for Daily Talks and that the structure with offering Daily Talks was helpful and made it easier to prioritise talking to patients (Steinsaphir, 2017) Word Macro (Fredborg, 2007) to Microsoft Excel where similar codes were grouped together. MM systematically coded all transcripts, and we randomly selected five transcripts that MR and ÅS also coded. Codes were compared at weekly meetings, where the content was discussed, and initial themes were generated. All authors then reviewed the preliminary themes for internal consistency and validity in relation to the entire data set and they then provided suggestions on how the themes could be revised to better represent the content in the interviews. MM revised the coding for all transcripts when needed. The final interview was analysed when the themes had been formed and the content did not add any new information to the themes, which supports the credibility of the results.

The research team
Researchers need to improve the relevance of research to patients (Chalmers & Glasziou, 2009) and this is why our research team includes clinical, academic and lived expertise, in form of both formal experience as researchers, healthcare workers and other academic professions (see affiliations), and also lived experiences of being a patient in mental healthcare. In line with Bellingham et al. (2021), we believe such inclusion is central for improving the quality and relevance of research priorities, outcomes, and knowledge translation, as well as for achieving health service reform. The team co-created all of the different aspects of the research process, from study design to analysis and write-up. However, we were mindful of that certain experiences may affect our suitability to engage in certain roles in the research process, for example, ÅS, as an initiator of the Daily Talks, and employed at the hospital, did not conduct the interviews. All authors also engaged in a process where we reflected upon what personal or professional experiences we have, that may affect our interpretation of the data. This was a three-step process where we first wrote down our thoughts individually, which we then shared with each other and finally discussed.

Findings
Participants' experiences of Daily Talks are presented in four themes: 1. Interpersonal and active interaction where individual factors matter 2. A patient-controlled space 3. A multi-use intervention and 4. A part of the daily healthcare structure.
Some of the themes have sub-themes which are presented in Table 1. The findings are illustrated by quotes from participants (in italics). Quotes are edited to enhance understanding, and deleted words and sentences are marked with [ … ].
Interpersonal and active interaction where individual factors matter Participants described that it could be difficult to interact with nursing staff at the ward from time to time, but that Daily Talks contributed to a more interpersonal and active interaction between patients and nursing staff. Daily Talks was described to improve the relationship between them, especially when sharing experiences, and that it made them feel seen. Participants expressed that the intervention improved the relationship between patients and nursing staff as they got to know each other beyond their roles as "staff" or "patient".
We get to know each other beyond the diagnosis and why you are here. And it becomes a little more than a patient and a doctor, or a patient and a nurse. It is more like a meeting between two people (Participant #5) Some participants increased their trust in the staff and got a better understanding of their work and perceived that the nursing staff got to know them beyond their diagnosis. The respondents also brought up the positive effect of nursing staff going beyond professional responses to also sharing personal information with them, such as their hobbies, as such responses helped participants feel safe and understood.
One participant reflected on how the staff might think about patients after getting to know them more in the Daily Talks when they had learned about their interests, such as singing and painting: And … then it kind of becomes more, well, how is it going with the singing? Did you draw anything today?
Following up on that, she expressed that the staff treated her differently after the Daily Talks.
[ … ] and then I know, aha, they remember me. I'm not just like patient number three in the second room on the left. (Participant #5) The improved relationship between patients and staff that followed the Daily Talks was described as useful when seeking the staff's attention in other situations, as they found it easier to perceive when nursing staff were preoccupied and therefore chose to ask at a better time to have their undisturbed attention. Advantages and disadvantages of talking to the same person. It was expressed that the quality and effect of Daily Talks was considered dependent upon which of the nursing staff participants you were talking to and the importance of talking to a person whose personality they felt drawn to. Participants described that in some cases they felt worse after the talk than they did before if the behaviour of the nursing staff made the conversation feel contrived.
There are some that are more … they force something upon you that you feel is difficult. And then, then it feels difficult. And then it also feels awkward afterwards, because you feel that you were so pressured, in some way. (Participant #2) Some participants expressed a wish to have the talks with the same person every time, as it could sometimes be perceived as draining to open up to several people. However, the benefits of talking to a different nurse or mental aide each time were also commented upon as it led to patients forming a relationship with more people.
I think that it is important to talk to different people [ … ] because the experience is different every time. It would be repetitive to meet the same person over and over again (Participant #4) A patient-controlled space Participants repeatedly brought up the importance of Daily Talks being a space controlled by the patients, including aspects of both time and content. Participants expressed how it was important for them to ensure that they received this time only for themselves and that they could decide what to talk about, although deciding which topics to talk about was sometimes described as difficult.
Control over time. Daily Talks as a guaranteed time set aside for just one patient was described as important and helpful: You have an opportunity to talk to the staff in peace and quiet. That there is time set aside strictly for, for me, so to speak, during these 30 minutes. (Participant #3) Participants described it as an asset to be able to schedule the Daily Talks in advance, to further ensure that they got their time. The importance of having the power to decide when to have the talks and when to stop was expressed by the respondents. They described the possibility to say no to Daily Talks if they did not want to or did not have anything new to discuss as important. Some of them also expressed concerns abouta worry of not receiving their guaranteed time, and feelings of being overlooked or forgotten, if their Daily Talk was not offered.
Control over content. Having control over the content of the conversation was another aspect that many participants mentioned. Participants described Daily Talks as unconstrained, lacking an agenda and a space to talk about what they felt like at that moment. One participant described how controlling the content of Daily Talks could lead to patients feeling like they are in control of their own healthcare and health.
I still think it is very important for patients to feel that they are heard properly. That they are the ones who are like … in control of their own … healthcare. And that they are not just leaving it to someone else, that it is someone else's to take care of, but that it is they who … themselves must make sure that they feel better. (Participant #4) Participants also brought up topics not related to their own health and care and appreciated that they were able to talk about how they felt, not only about topics linked to their hospitalisation. It was described how the staff could guide the conversation at times, for example with leading questions, and this was described as helpful. One participant said that it could be difficult to set the agenda all by yourself and said: It is good to be guided with a few leading questions so that you dare to talk about certain things. (Participant #2) It was described that when the Daily Talks became a dialogue between two people, the nursing staff's answers gave the impression that they had been listening carefully. Some participants said that they preferred the conversational nature of the Daily Talks over therapy, as their experience was that therapists followed an already set protocol of questions and answers.
A multi-use intervention Participants presented different ways that they used the Daily Talks and we therefore describe it as a multi-use intervention. Daily Talks was used to vent thoughts and emotions, handle situations that appeared during the hospital stay and find life strategies for when they were able to return home.
A forum for venting emotions and thoughts. Talking to another person helped the patients to feel better. Participants described how Daily Talks was used to vent emotions and thoughts, connected to for example life situations, past experiences, family members or thoughts about their hospitalisation. The professional confidentiality helped the participants to feel safe when talking about their experiences, and they described how it was easier to talk about certain topics with staff than with family members. Furthermore, participants described how the Daily Talks intervention enabled them to better access deep and heavy emotions.
Although you may not always dare to admit it to yourself either and then it can be of some help with this conversation, to sort of tease out, that you get to focus on what is difficult. (Participant #2) Some participants expressed that they tend to hide their emotions and that the intervention helped them drop this façade and express how they really felt.
A forum for handling situations on the ward. Some patients described how Daily Talks worked as a forum to discuss situations that may arise during their time on the ward, such as difficulties with sleeping when the person in the next bed is snoring, opinions about food or issues with other nursing staff.
There are always things that you want to talk about, that popup. It can be anything from medication to your neighbour's snoring (participant #2) A forum for creating strategies. During the Daily Talks, patients would use their time to discuss how to manage life situations and find strategies to prevent undesirable behaviour in the future. One participant described getting help on how to handle unwanted behaviour during her manic periods: I have talked about how I behave in my manic and depressive periods. Unwanted behaviours of mine that I find hard because it affects other people. Take my financial situation, I waste money and order things without thinking about whether or not I can pay for them and my poor husband has to deal with that. I was given tips on how to deal with that. (Participant #8) Some respondents described how the talks were used to plan for short-term leave from the hospital and one participant recalled a Daily Talk where the nursing staff had helped him realise the risk of going on leave over Christmas, as they feared a substance abuse relapse during that period.
We discussed whether it may be better for me to stay here, and I did, and that was a very good decision. At home, things got out of hand, and if I would have been there, I would have been part of it. (Participant #12) A part of the daily healthcare structure Participants described how Daily Talks was one of many different recurring activities offered on the ward; all in all, it created a structure for the day. They pointed out how these recurring activities created meaningful breaks in which to reflect. One participant also expressed that talking to nursing staff daily had always been a part of mental health inpatient care. Now, you put a name to it ( … ) And it's just this, that you sit down and talk to someone about … yes, problems or about anything, I think it has been in care all along. It's just that it's now got a name. (Participant #6) A way to notice personalpersonal progress. Besides helping to create a structure for the day, the Daily Talks also helped create structure in the participants' own process toward recovery, making them aware of their own process. Participants described how they initially discussed more serious subjects, but that the conversations grew lighter the better they felt, or, that the further into their treatment they got, the easier it became to open up.
Participants also believed that Daily Talks accelerated their recovery and added a qualitative aspect to the recovery process, compared to experiences at other mental health inpatient care units without the intervention.
Because I believe that your recovery is not only accelerated but that it becomes a little more, if I may put it that way, qualitative. Precisely because there will be more immeasurable values that may exist. It's not like everything can be measured, in tables and numbers, and medicines and blood samples … it sort of becomes an extra dimension of humanity in everything that I think is very, very appreciated. (Participant #5)

Discussion
The current study explored patients' experiences of Daily Talks in inpatient mental health care. Although Daily Talks is used in several mental health care facilities in Sweden, it has been relatively unknown how the intervention unfolds in clinical practice and how it may be perceived by patients. Participants described that Daily Talks improved the relationship between patients and the nursing staff and they stressed their importance and that them as patients gained control over both time and content in the Daily Talks. Our findings show that Daily Talks was a valued part of inpatient care, that patients used it to vent emotions and thoughts, handle situations and create strategies, and that the Daily Talks became part of a helpful structure.
Daily Talks allowed staff to show empathy and understanding and to get to know the perspective of the patients, which is a central part of mental health nursing (Gerace et al., 2018;Wand et al., 2022). Daily Talks appears to have deconstructed both patients and nursing staff from their roles, enabling helpful relationships that have repeatedly been identified as a core ingredient in recovery (Bacha et al., 2020;Borg & Kristiansen, 2004;Lindvig et al., 2020;Ljungberg et al., 2015;Sch€ on et al., 2009).) Earlier studies highlight that professionals who "go beyond" their professional roles are helpful in a patient's recovery process (Borg & Kristiansen, 2004;Jackson & Stevenson, 2000; and participants mentioned it as helpful when nursing staff participated in the Daily Talk as fellow human beings, sharing their own personal reflections. Relatively simple gestures such as a feeling of being familiar or friendly, or sharing a laugh, have, in previous studies, been found to be valued by patients (Molin et al., 2016),) and these sentiments are echoed in our intervention.
A recent review exploring nurses' therapeutic potential within mental health suggests that their expertise is underutilised and that nurses can build therapeutic connections, and positive and trusting relationships with patients utilising their personal lived experience (Hurley et al., 2022). Daily Talks as an intervention seems to emphasise the important work nursing staff may conduct through informal humanto-human connection (Wand et al., 2022). Many of the participants based their experience on a handful of Daily Talks and still described how they got to know the staff beyond their role as professionals, and that staff got to know who they were beyond their role as patients. Interestingly, this stands in contrast to earlier research that states that relationships need to be long-term to be helpful (Ljungberg et al., 2015). Our findings are in line with previous research stating that patients want to be recognised for recognized with their personal stories (Gunasekara et al., 2014), what this study adds, is an example of an intervention to help achieve this. The results also indicate that the common challenge of staff being occupied with other things than patient interaction (Goulter et al., 2015;Wand et al., 2022, Waldemar et al., 2016 is possible to address by relatively simple changes to the everyday structure at the ward. Our findings imply that facilitating the facilitation of a movement toward a more person-centred centred approach is possible without adding specific training and incurring extra costs; it can also be put into effect and within a short time frame.

Implications for practice
Nursing staff are often burdened by administrative tasks (Folke et al., 2018;Goulter et al., 2015) and we propose that Daily Talks be used as a useful tool that helps nurses and mental aides prioritise direct care, and thereby make use of existing resources in a more effective way. Participants in the present study expressed the importance of keeping the patient-driven elements of Daily Talks and letting the patient control the length and the content of the Daily Talks. This does not imply that members of staff are passive partners in the talks. On the contrary, patients expressed that they want their staff to play an active role in the Daily Talks and provide answers, not based on a protocol but as human beings. We propose that it is important to keep the structure of the intervention when Daily Talks is implemented in practice and make sure that staff understand that the structure is the intervention. Some participants wanted to be able to choose specific staff members for their Daily Talks, while others saw advantages in talking to different people. Earlier research has shown that patients may experience safe and helpful relationships with some specific nurses or mental aides (Bacha et al., 2020) and we want to encourage users of Daily Talks to let these relationships develop. Based on this, we recommend a flexible approach regarding the match of patients and staff in the Daily Talks.

Implications for future research
This was an exploratory study and some of the themes described in the findings present complex processes. Future studies on Daily Talks could further explore the processes that patients go through during the Daily Talks, and we propose a study design with repeated interviews during a patient's stay at a ward to better capture these processes. Further studies could explore potential barriers to participation, and it is important to explore the perspective of nursing staff who participate in Daily Talks to fully understand how the intervention unfolds in clinical practice. Some participants in the present study said that they preferred the Daily Talks to therapy and that it would also be interesting to expand the understanding of how mental health nurses perceive their role in mental health inpatient care and more specifically how they use these talks in mental health nursing. The potential impact that could be assessed in an extensive evaluation of the effects of Daily Talks is the overall experience of care, improved relationships between patients and nursing staff, patients' sense of control over their care and patients' willingness to seek help again if needed. However, the effects of Daily Talks that participants described are not easily quantifiable, for example, is that Daily Talks adds a qualitative aspect to the recovery process. We, therefore, propose expanding the qualitative evaluation of Daily Talks in order to assess the effects of the interventions.

Strengths and limitations
This is, to our knowledge, the first study of how the intervention Daily Talks unfolds in practice. The exploratory design allowed us to explore how Daily Talks were perceived by patients using it. A strength is the depth of the interviews, showing that patients use Daily Talks in different ways. A limitation in the present study is recruitment at a single ward, which restricted the age span and type of diagnoses among participants. The results are likely to be transferable to other patients with affective diagnoses, but more research is needed to explore how patients with severe mental illness (e.g. psychosis) experience Daily Talks. The age span of participants ranged from 22-62 and we do not know how younger or older patients would experience Daily Talks.

Conclusions
Our findings support the value of Daily Talks, indicating that Daily Talks may facilitate helpful relationships between patients and nursing staff in what appears to be a manageable way for mental health inpatient care and thereby enhance recovery for patients in inpatient mental healthcare.