Psychiatric nurse's perceptions of their interactions with people who hear voices: A qualitative systematic review and thematic analysis

Accessible Summary What is known on the subject? There is no qualitative systematic review of nurses' perceptions of their interactions with people hearing voices. There are some studies exploring the interventions provided by community psychiatric nurses to people hearing voices; these give a sense of what interactions may contain. What the paper adds to the existing knowledge? Nurses across both community and inpatient mental healthcare settings feel uncertain about how to interact with people hearing voices, sometimes feeling like they can do little to help. Their interactions are affected by the workplace culture, education and training and concern for their own safety. Nurses rely on a therapeutic relationship for all interactions. What are the implications for practice? This is an under investigated area of mental healthcare. None the less this qualitative systematic review highlights that nurses are unclear about how to interact with service users hearing voices with the resultant outcome that service users in great distress may only be receiving minimal benefit from their interactions with the nurses caring for them. Abstract Aims and Objectives The aim of this qualitative systematic review and thematic analysis was to identify and synthesize results from studies that explored psychiatric nurses' perceptions of their interactions with service users experiencing auditory hallucinations (hearing voices). Method Qualitative systematic review and thematic analysis. Results Five studies that met the inclusion criteria were identified. Nurses reported that they felt uncertain about what to do for service users hearing voices, struggled to have interactions with voice hearers, but greatly valued the therapeutic relationship with service users. Nurses also reported that they required more education and training on how to interact effectively with people hearing voices. Finally, various workplace challenges were identified as an important factor mediating nurse interaction with service users hearing voices. Discussion Existing evidence shows that nurses lack clarity about how they can interact effectively and in a way that helps service users who are hearing voices. Significant barriers that they must overcome in order to be more certain of their role in caring for people hearing voices are difficult to engage service users and workplace challenges that were not conducive to helpful interactions and conversations. Implications for Practice Nurses caring for people hearing voices require more and better education and training with a view to them becoming more confident and competent when interacting with this service user group. Furthermore, healthy workplace cultures and maintaining a safe environment are necessary for effective caring interactions with people hearing voices.


| INTRODUC TI ON
Auditory hallucinations (hearing voices) are described as a perceptual involuntary experience that occur without an appropriate external stimuli, (David, 2004;Longden et al., 2011). A recent metaanalysis concluded that up to one in ten individuals report hearing voices, and that the prevalence of hearing voices across the lifespan decreases with age, ranging from a prevalence in children and adolescents of between 12.7% and 12.4%, reducing in adulthood to 5.8%, and reducing again to a prevalence of 4.5% in elderly people (Maijer et al., 2018). Hearing voices can occur in a range of psychiatric disorders such as schizophrenia, post-traumatic stress disorder (PTSD) and emotional unstable personality disorder (Laroi et al., 2012). Research has shown that 25% of people that reported hearing voices met the relevant criteria for a psychotic disorder diagnosis (Leed-Smith & Barkus, 2013).
There are four ways in which hearing voices occur. These include persistent commanding/commenting hallucinations, voices of the individual's own thoughts, non-verbal hallucinations and broadcasting auditory hallucinations (Wang & Xu, 2013). Voice hearing hallucinations are heterogenous; they can vary from first, second and third person commentary, from transient utterances of a simple sound to single words or full conversations with familiar and unfamiliar voices. They can be complimentary and pleasant, but usually they are unpleasant and insulting (Laroi et al., 2012). These voices can be distressing and threatening towards the individuals that hear them (Nayani & David, 1996), causing disruption in all aspects of their life; socially, occupationally and psychologically (Hayward et al., 2017;Ruddle et al., 2011). It has been reported by Larøi et al. (2019) that a significant cohort of people reports hearing voices with a negative content.
While guidelines outline that people hearing voices should be offered cognitive behaviour therapy for psychosis (CBTp; NICE 2014).
CBTp is a talking therapy designed to help people experiencing psychosis to gain better coping strategies for their mental health difficulties (Health Service Executive 2021). Yet these CBTp services are rarely provided to people suffering from psychosis (Royal College of Psychiatrists, 2018), with funding and a lack of expert practitioners blocking the provision of what is considered a resource-intensive therapy. In the meantime, informal conversations by practitioners such as psychiatric nurses can be valuable and potentially beneficial (Bogen-Johnston et al., 2019). However, little is known about these interactions, despite the importance of the nurse-service user relationship (Delaney 2018).
According to Coffey and Hewitt (2008), service users hearing voices revealed that they desired more direct engagement with their Community Mental Health Nurses (CMHNs), such as exploring the meaning behind the voices they were hearing. Other evidence also suggests that service users place great value on healthcare providers discussing the voices they hear with them (Coffey et al., 2004;Place et al., 2011;Romme & Esher, 1989;Romme & Morris, 2007). With research indicating that service users welcome nurses engaging with them about their voice hearing experiences, it is important to understand the nuances of these interactions for clinical practice.
Psychiatric nurses represent the largest health professional group across mental healthcare services internationally (Jones & Coffey, 2012). Nurses are the key frontline care providers in most mental healthcare facilities; they are with service users 24 h a day in some care settings and have countless interactions with service users on a daily basis (Niu et al., 2019). In light of this, there is a growing interest in clarifying the exact contribution of nursing care towards the service users' recovery and health (Morris et al., 2014).
The purpose of this review will be to explore the evidence on how nurses perceive the interactions they have with service users hearing voices.
training on how to interact effectively with people hearing voices. Finally, various workplace challenges were identified as an important factor mediating nurse interaction with service users hearing voices.
Discussion: Existing evidence shows that nurses lack clarity about how they can interact effectively and in a way that helps service users who are hearing voices. Significant barriers that they must overcome in order to be more certain of their role in caring for people hearing voices are difficult to engage service users and workplace challenges that were not conducive to helpful interactions and conversations. Implications for Practice: Nurses caring for people hearing voices require more and better education and training with a view to them becoming more confident and competent when interacting with this service user group. Furthermore, healthy workplace cultures and maintaining a safe environment are necessary for effective caring interactions with people hearing voices.

K E Y W O R D S
auditory hallucinations, hearing voices, nurse interactions, health and wellbeing.

| QUE S TION
"What are the reported psychiatric nurses' perceptions of their interactions with people who hear voices?"

| AIMS
The aim was to identify and synthesize results from studies that explored nurses' perceptions of their interactions with mental healthcare service users hearing voices, and discuss how nurses could optimize their responses to service users hearing voices.

| ME THODOLOGY
This paper reports a qualitative systematic review of studies that explore nurses' perceptions of their interactions with service users experiencing auditory hallucinations. In what is a newly emerging approach to healthcare research, the qualitative systematic review aims to present a comprehensive grasp on the experiences or perceptions of research participants (Stern et al., 2014). Much the same as the more traditional systematic review, a qualitative systematic review intends to produce a high quality and meticulous review of the best available evidence (Aromataris & Pearson, 2014). As qualitative systematic review techniques are still evolving and developing, there are minimal resources available to guide researchers through review process (Butler et al., 2016). However, the Centre for Review and Dissemination's (CRD) (2009) document on systematic reviews was used for guidance to strength the methodological underpinning of this review, aiming to develop a high standard systematic review with supporting methods.
Relevant published literature were searched. The Critical Appraisal Skills Programme (CASP) tool was utilized to assess the quality of the included studies (Long et al., 2020). The CASP tool is considered to be a user friendly choice for beginner researchers, and is endorsed by Cochrane and the World Health Organisation in for use in qualitative synthesis (Hannes & Bennette, 2017). The CASP tool was also originally developed for use within health-related research (Long et al., 2020), proving to be an appropriate choice for this systematic review.
The quality assessment was completed before the synthesis of data as recommended by the CRD (2009). The results of the review were analysed using thematic analysis. The reporting of this systematic review was guided by the standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement.

| Inclusion and exclusion criteria
The inclusion and exclusion criteria were as follows: • Non-qualitative studies.
• Studies not in the English language.

| Screening
A total of 29 records were identified before screening. Seventeen papers were excluded after screening as they did not focus on nurses' perceptions of their interactions with people hearing voices. One conference paper, one dissertation and one book were also removed, as were four duplicates. Five papers met the inclusion criteria. The reference lists of the five papers were screened but no further papers were identified. Please see Figure 1.

| Thematic analysis
One method suggested for the synthesis of qualitative data is thematic analysis (CRD 2009). Braun and Clarke's (2006) thematic analysis was the method used to synthesize the results in the five selected papers. Braun and Clarke's (2006) approach was utilized as it offers a robust and manageable method for those new to qualitative research (Braun & Clarke, 2006). There were six phases to this method and these were completed manually, to keep the researchers as close and immersed in the data as possible. In phase one, two authors (AMC & DP) read the papers numerous times to gain an in-depth familiarity with the content of each paper. At this stage, notes were made of possible themes which could be revisited at a later stage, as patterns across papers were sought. Phase two involved the generation of initial codes from the data; this was done independently by the same two authors.
Coding is essential as it involves grouping meaningful data into groups (Tuckett, 2005). In phase three, the different individual codes were placed into broader themes, ultimately creating an overarching theme.
Themes continued to be refined and reviewed in phase four by the two reviewers with any disagreement resolved by discussion, and if needed consultation by a third author (CW). In phase five, themes were defined, Braun and Clarke (2006) describe this as "determining the essence of the theme." Phase six is the final phase of the thematic analysis, and this involved the commencement of this paper.

| Overview of studies
Study characteristics are outlined in Table 1

| Quality appraisal
The CASP (2020) checklist was used to quality appraise the five papers, see Table 2. Overall the CASP checklists identified a high standard of research in all the reviewed papers, demonstrating strengths such as adequate reflexivity, consideration for the relationships between participants and researchers and justified study design and methodologies.
Ratings of "yes," "no," and "can't tell" were used to signal whether the ten items on the tool were exhibited (CASP 2020). The CASP checklists were carried out independently by two reviewers (AM and DP). When disputes arose, they were resolved through discussion to reach consensus.

F I G U R E 1 PRISMA flow chart
Full text articles accessed for eligibility (n = 5) Studies included in review (n = 5)

Screening
Included Table 3 provides details on which papers contributed to which themes.

Difficult to engage
It appears that nurses faced a challenge when initiating an interaction with service users who were hearing voices. While most nurses showed a willingness to engage with the service user and sit down and have a conversation with them surrounding their voice hearing, they also perceived having this interaction as a challenging task. One nurse participant in Bogen-Johnston et al. (2019) paper reported that using our engagement skills and that to try and tease out what is going on. But cert, even with some that I see, I've been seeing for two or three years, they don't like to talk about it even though we can sense they're hearing voices from their looking away or responding.
The notion that nursing staff must "tease out" details and discus- they're just really… loud, they experience them as loud, and you notice that when you're trying to talk to them… 'oh you're hearing voices?' and you try and engage them in some sort of distraction and… coping strategies or something. And you can't quite get… you can't quite get to them because they're in that stage where they can't… I guess they need medication and it's difficult to help them then.
In this case, the voices themselves proved to be an obstructive factor for nurses looking to interact with service users hearing voices, delaying and perhaps preventing a potentially useful and comforting interaction for the service user.

Therapeutic relationship
The importance of the therapeutic relationship with service users hearing voices was another prominent theme. Developing a trusting relationship, where the service user felt comfortable in sharing their thoughts and emotions regarding their voices during an interaction with nurses was perceived as essential (White et al., 2019), "building rapport and a relationship…if somebody has a good rapport with you, […] they're much more willing to share their vulnerabilities." This short extract articulates that without a good working alliance with service users, they may not share their true thoughts or experiences, such as their voice hearing. Developing a good rapport with serve users was deemed an essential undertaking for the delivery of op-

| DISCUSS ION
This review has found that nurses greatly value therapeutic relationships, mirroring what has been written previously, with some authors going as far as to describe the therapeutic relationship as the "cornerstone" of mental health practice (Delaney et al., 2017;McAllister et al., 2014). Active listening, showing empathy and understanding the service users unique experience are all essential to the development of a therapeutic relationship, which in turn is pivotal to recovery orientated mental health care (Gerace et al., 2018;McAllister et al., 2019). The aforementioned traits were also some of the most desirable qualities of psychiatric nurses articulated by service users (Horgan et al., 2020), This review also found that nurses' engagement with service users hearing voices must be understood within the challenging context of managerial demands (Kingston & Greenwood, 2020) and an unpredictable environment (Cleary, 2012). Nurses across the five selected studies spoke of being unable to interact effectively with some service users due to their perceived distrust and paranoia, meaning some service users missed out on the helpful interactions fostered by the therapeutic relationship with nurses. Farooq et al.
(2020) agree with this, suggesting that nurses will face challenges when they encounter service users that are not willing to engage with them. Nurses also said that that some service users were unwilling to sit and interact with them. They may have been suspicious of nurses due to their mental illness, or perhaps embarrassed at disclosing their voice hearing experience, not an unusual observation (Henderson et al., 2020). It has also been said by Molin et al. (2016) that the obstruction or absence of such interactions with nursing staff can reinforce the perception of a stigmatizing environment and unclear content of care. Missing out on these potentially beneficial interactions and subsequent working relationship may be damaging to people hearing voices.
Evidence to-date suggests that nurses are struggling with therapeutic engagement (McAllister & McCrae, 2017;McKeown, 2015), due to non-engagement and more wide-ranging issues such as time constraints which limit the amount of time nurses can spend interacting with service users (Harris and Panozzo, 2019) and an increase in administration (Seed et al., 2010;Ward & Cowman, 2007). As a result nurses may use custodial methods of care to maintain safety and to manage service users that present with challenging behaviour, custodial methods of care can then become a barrier to effective engagement (Cutcliffe et al., 2015;McAllister et al., 2021). The evidence suggests that there are potential solutions to these difficulties. According to McKeown et al.
(2019), adequate staff levels can reduce the use of custodial methods of care. Some studies have also examined the utility of protected engagement time (Edwards, 2008;Thomson & Hamilton, 2012), but with little success (McCrae, 2014). There is a universal acceptance that therapeutic engagement should be a priority, but there remains no practical or theoretically sound solution to facilitate it successfully and consistently. Thus, a solution is urgently required, as the efficacy of psychiatric nursing is dependent on nurse and service user engagement (Browne & Cashin, 2012, McKeown et al., 2017. It has long been suggested that nursing has been dominated by a medical approach to care (Roberts et al., 2009). However, psychiatric nursing has undergone a radical transformation in the recent past catapulting the profession to high levels of professionalism and autonomy with advancements including the introduction of degree level education, the development of more advanced and specialized roles within practice (ONMSD, 2012), and nurses being authorized to prescribe medication (Maier, 2019), within their scope of practice. Despite the progress of the profession and the opportunity for growing autonomy in emerging roles, the studies included in this review generated some insights into how nurses believe they did not have the appropriate or adequate skill set required to care for people hearing voices. Nurses are essential to the provision of high-quality care for people experiencing mental health issues; therefore, high levels of competency are pivotal to this (Happell et al., 2019). In an exploratory mixed method study to identify nursing skills competencies, Cusack et al. (2017) cited that participants reported that the opportunity for education and training was essential. In this review, White et al.'s (2019) declaration that none of the participants believed that they had suitable knowledge and skills to care for people hearing voices highlights the importance of more nurse preparation in this area.
A study by England (2007) revealed that psychiatric nurses' understanding and assessments of voice hearing were limited, aligning this to inadequate clinical experience and knowledge of the voice hearing experience. Innovative educational tools such as voice simulation exercises may assist in improving knowledge and understanding in this area as they provide complex but risk-free learning to aid the comprehension, knowledge and competency of nursing students (Orr et al., 2013). More importantly, research demonstrates that implemented simulated learning within nursing curricula is associated with increased clinical skills and competence (Alinier et al., 2006).
However, two recent papers suggest that after undergraduate nurse training, nurses still felt underprepared and desired further training (White et al., 2019, Bogen-Johnston et al., 2019. This shows that there is a need to develop and form appropriate tools for learning that will enable psychiatric nurses to grow their scope of practice. Psychiatric nurses make up the largest cohort of professionals in the mental healthcare workforce. Therefore, there is an explicit advantage in guaranteeing that these nurses have a robust set of therapeutic skills directed towards meeting the needs of service users and their distress (Horgan et al., 2020).
In terms of uncertainty, participants felt they were not equipped with the adequate training and education to feel confident and assured when caring for people hearing voices. Cusack et al. (2017) maintain that due to the restructuring of mental health policy to a more recovery focus, psychiatric nurses' roles require clarification.
Bladon (2018) concurs, articulating that psychiatric nursing has undergone radical change since its emergence in the last century.
A lack of coherence and vague descriptions of the precise role of psychiatric nurses is afflicting the profession, with a specific definition of their role remaining elusive (McAllister & McCrae, 2017).
Compounded by a stark contrast between a dominant biomedical model and the desired recovery-based parameters that nurses are trying to work by (Myklebust et al., 2018), psychiatric nurses may be adrift somewhere in between. Psychiatric nurses in a recent study described intertwining biological, sociological and psychological roles based on service user needs (Hurley & Lakeman, 2021). Perhaps if the core role and skills of psychiatric nursing were identified, appropriate education would then be created and made available (Grant, 2006), thus reducing nurse's experience of such self-doubt and uncertainty.
Another aspect of psychiatric nursing that may increase clinical capability and capacity to provide meaningful interactions is a healthy workplace culture. A workplace culture reflects its values, beliefs and norms. It is essential that staff have mutual values and beliefs as they work together in order to achieve a set of shared goals (Kurjenluoma et al., 2017). An unhealthy or unsupportive workplace culture can have an impact on employee empowerment, interdisciplinary relations, the use of evidence-based practice and the alignment with the organizational strategic direction (Moss et al.2017).
This review reported an unsupportive and judgemental workplace for nurses. Aschebrock et al. (2003) reported a similar hesitation by nurses to utilize certain approaches for hearing voices specifically due to the fear of ridicule by other professionals. This type of feared reaction has been described as "horizontal violence." Horizontal violence involves nonphysical intergroup conflict that is expressed in overt and covert hostile behaviours (Bloom, 2019).
Furthermore, Randle (2003) relates that downgrading another person's work can have an effect both self-esteem and job satisfaction.
Another theme that emerged from this review that threatens the performance of healthcare organizations was the perceived risk to the personal safety of nursing staff while caring for people that hear voices. Nurses are in close and constant contact with service users; this results in countless interactions; thus, nurses are at risk of encountering incidents of violence (Niu et al., 2019), moreso then other healthcare providers (Arnetz et al., 2014).
Psychiatric nurses experiencing violence or a threat of physical violence against them can result in negative outcomes for both themselves and the healthcare organization they are employed by.
Understandably, nurses can experience physical injuries, but they can also face psychological consequences, including fear, anxiety, guilt, and shame and an increased intent to leave the organization (Stevenson et al., 2015), as well as low morale and reduced quality of care (Campbell et al., 2011).
Participants in this review voiced feeling fear and apprehensiveness when providing interventions for people hearing voices. In a recent studying exploring the experiences of newly qualified nurses beginning their career in mental health units in South Africa, participants also described feeling fearful when faced with the realities of a psychiatric unit (Mabala et al., 2019). It has been suggested by Happell et al. (2019) that overcoming fear and anxiety is undeniably necessary when it comes to the provision of high-quality care for people experiencing mental health issues. Considering both the negative impacts on nursing staff and patient care, it is crucial that healthcare leaders act to prevent these incidents of violence, reducing the fear and anxiety that is experienced by psychiatric nurses.
To achieve this, healthcare organizations need to provide adequate staff, training and assistive devices to reduce these incidents (Niu et al., 2019).

| S TRENG TH S AND LIMITATI ON S
While ascertaining the nursing perspective can be considered a strength of this paper, it is important to note that this may not be consistent with the service user focused evidence, so therefore findings should be interpreted with a degree of caution. To complete the thematic analysis, the approach by Braun and Clarke (2006) was used. This is a new way of completing systematic review thematic analysis and may require future studies to solidify its reliability as an approach. This review focused solely on qualitative papers, a future review may wish to broaden the search to include research from other types of studies.

| CON CLUS ION
Psychiatric nurses perceive several barriers to interacting with service users hearing voices, including a perceived lack of adequate education and skills, workplace challenges and an uncertainty of how to help this cohort of people. Nurses also reported that it was difficult to engage with people hearing voices; however, they were acutely aware of the importance and benefit of establishing and maintaining a therapeutic relationship with voice hearers. Further systematic reviews are needed from the service user perspective, and more primary research is needed into the area generally.

| IMPLI C ATI ON S FOR PR AC TI CE
There are a number of implications for mental health nursing prac-

DATA AVA I L A B I L I T Y S TAT E M E N T
Data availability is not applicable to this article as no new data were created or analysed in this study.