Therapeutic relationship - the core of milieu therapy - what does nursing documentation contain?

Background and purpose: There is agreement that therapeutic relationships should form a main foundation in mental health care. Still, there is lack of research on how this is documented. Method: We conducted a qualitative and descriptive analysis of daily nursing documentation. The study investigated how staff in an acute psychiatry hospital ward documented staff-patient interactions and attunement. The data were drawn from 14 patient records where 363 report extracts documented staffs' description of patient experiences. Findings: 94% described uncomfortable experiences while 6% were positive experiences. Two main categories of reported approaches to patient experiences were identified: No description of attunement and Description of attempts of attunement. Only 25% of the report extracts described attempts of attunement. Most of the approaches were observation-and action -oriented without any emphasis on patient experience and mutual interaction. Conclusion: Further research on nursing documentation may include staff's attunement and patients' participation in report writing.