The caring encounter between patient and nurse within a mental health and psychiatric care context – as described by nurses working in an emergency polyclinic

Mental health care in Finland, especially psychiatric emergency care, has undergone great changes from having been free-standing and in 2015 moving to the emergency polyclinics [1]. Concern was raised in public debates about how patients with mental ill-health would be treated in this new emergency polyclinic environment and what new challenges this would entail. Other issues that were brought to the fore in connection with this change were: what is a caring encounter with patients with mental ill-health, what takes place in the encounter and what are the hurdles and challenges?


Introduction
Mental health care in Finland, especially psychiatric emergency care, has undergone great changes from having been free-standing and in 2015 moving to the emergency polyclinics [1]. Concern was raised in public debates about how patients with mental ill-health would be treated in this new emergency polyclinic environment and what new challenges this would entail. Other issues that were brought to the fore in connection with this change were: what is a caring encounter with patients with mental ill-health, what takes place in the encounter and what are the hurdles and challenges?
Treatment and knowledge of how we approach individuals with mental ill-health has greatly improved during the last twenty years, but there is still room for development. Even a fleeting or short encounter may be significant for patients and pave the way for trust and communion [2]. This qualitative study aims to examine the caring communion between patients and nurses within a mental health caring context.

Background
Mental ill-health is a great concern in society and within public health in the Nordic countries today. Mental ill-health is a concept that is used for different mental disorders. These include for example mental illnesses, depression, different panic and anxiety disorders, abnormal psychic reactions, sleeping difficulties, eating disorders, sexual disorders, behavioural and personality disorders as well as addictions. The human being who suffers from mental ill-health experiences a decrease in the ability for action, quality of life deteriorates, which in turn can lead to suffering and anxiety. In addition, people with mental ill-health are reported to be stigmatized [3].
The 1980s' experienced great progress within psychiatric care [4]. The international psychiatric diagnostic handbook was published; projects for developing health care for patients with schizophrenia were initiated and succeeded in reducing the number of suicides; the development of training in psychotherapy began; and new drugs for depression appeared on the market [4]. According to the National Institute for Health and Welfare in Finland [5], mental health care services refer to such activities that prevent, alleviate and treat psychic disorders and their consequences. Mental health promotion is also included in mental health care. The services include supervision, counseling, and, depending on the patient's need for psychosocial support in situations of crisis and examination, treatment and rehabilitation of individuals suffering from psychic disorders.
Deficiencies in encounters with patients are common. The nurse needs to be aware of patients' vulnerability in their life situations and take this into account in the care. A meaningful encounter can awaken feelings in both patients and nurses [6]. A true caring encounter has the potential for communion between nurses and patients [7][8][9]. The characteristics that express communion include sharing, listening, instilling hope, responsiveness, touching, affirming, encouragement, showing empathy, giving advice, providing comfort and support [10].
A caring encounter presupposes an invitation of the patient by the nurse through openness where the nurse builds a bridge between himor herself to the patient [11]. The encounter can be seen as an invitation to communion where the nurse encounters patients in a way that makes them feel welcome and invited to participate in a caring communion [12,13]. By being present, the nurse invites the patient to the encounter [7]. The encounter can take place through a conversation with the patient or simply through being present in the moment. Patients often feel that they do not receive enough time for discussing with nurses [14]. A caring act can only be caring if the encounter between nurse and patient is characterized by positive interactions, intentions and attitudes [10] Thus, the caring act can be caring, for instance, when the nurse is actively engaged in the patients' lives through understanding and true presence in conversation and shows interest in their experiences. Patients experience communion when they can share their burdens with the nurse. Trust is crucial in the encounter [15]. The encounter reflects a nurse's attitudes and approach toward patients with mental ill-health and whether the nurse is able to create a sense of trust in patients [14]. An important factor contributing to the patients being able to open up and feel trust in the encounter was the environment in which the encounter took place. In addition, Björkdahl [11] indicates that the environment and the nurse's education are important aspects that affect the encounter. The nurse is responsible for creating an encounter with patients that is characterized by trust and openness, but nurses should also act as "guardians" and make sure the care is safe. The encounter develops through warmth and trust.
The first invitation to an encounter is often non-verbal and represents a platform for the creation of an encounter. The nurse should not view the patient as a passive participant in the encounter, but as someone who can influence its content [11]. In the first encounter, the nurse encourages interaction with the patient. This is similar to research by Johansson, Skärsäter and Danielsson [16] who indicate that the encounter is the fundamental category in the art of caring. This art can be seen as nurses' potential to use their own creativity to create a meaningful contact with patients [17]. This meaningful caring encounter may include understanding, open conversation, insight, strength and solutions. At best, the encounter is an expression of solidarity and closeness where patients can come into contact with themselves owing to that the nurse receives them with openness, offers support and is flexible. Nurses' affirmation of their own vulnerability is a condition for the possibility of entering the encounter with the patient to create trust [18]. The communion between the nurse and the patient in the encounter is characterized by their meeting each other on the same level [8]. Both are active in the encounter and the nurse shows understanding and instills hope in the patient. The longer the caring relation lasts the more the patient can see the signs that the nurse genuinely cares about and knows the patient. Patients experience they have good contact with the nurses when they work together for the fulfillment of the same goal set up by the patient [8]. The patient desires to be seen and understood; therefore, it is important that the nurse is present in the encounter [9]. Not only does the encounter make patients aware of their suffering but also enables reconciliation [9,19].
As earlier research suggests, the caring communion and trust in the encounter is crucial for the patient [7][8][9][12][13]18] because it may affect the quality of life [10]. Therefore, this study sees it as relevant and meaningful to further explore this area.

Aims
This study aims to explore, from a caring science perspective, what constitutes and creates a caring encounter between the patient and the nurse within a mental health and psychiatric care context.

Theoretical framework
Caritative theory is part of the caring science tradition [20,21]. According to the ontological perspective of caring science, health is understood as a "becoming", which implies a movement towards a deeper wholeness and holiness. A movement occurs, when the human being's inner health potential is touched and this may be seen in the different dimensions of health. The dimension "doing" implies what the human being does for his or her health, "being" means the endeavour to achieve balance and harmony, and "becoming" pertains to a deeper level of integration and feeling of wholeness [20][21][22].
According to Eriksson [23], caring is understood as a natural human behaviour which implies cleansing and nourishing, and spontaneous and unconditional love. All human beings are believed to be natural caregivers and natural basic caring is expressed through tending, playing and learning in a spirit of love, faith and hope. The characteristics of tending are warmth, closeness, respect, honesty and touch; playing is an expression of exercise, testing, creativity and imagination, and desires. Learning implies sharing. Caring attains its distinctive character through the caring communion [24]. A caring communion cannot be taken for granted but presupposes a conscious effort to be with the other. By being involved in the suffering of the patient, by being a co-actor in the drama of suffering, as it were, the nurse can support the patient and thereby create a caring communion in the encounter [25]. The act of caring contains particular caring elements that invite deep communion. The human being longs to be loved and to love and can find this through communion [25]. In the encounter, nurses emerge from their own world and offer themselves to patients. The encounter demands of nurses genuine concern for and attention to patients because when love becomes evident the human being can heal. This form of caring love that exists in a caring relation can be explained as a sense of connection and the nurse's willingness to be there for patients and help them [26]. The caring communion is seen as the source of strength and meaning in caring [21].

Methodological aspects
The study is inspired by a hermeneutical approach according to Gadamer [27]. The material consists of interviews with nurses working in an emergency polyclinic regarding their experiences of interacting with patients in mental ill-health in order to create a caring encounter. The texts were interpreted through hermeneutical reading [28].

Data material, data collection and ethical considerations
The data material consists of interviews with nurses working in an emergency polyclinic and their experiences of interacting with patients with mental ill-health and creating a caring encounter with these. The interview data was gathered in five face-to-face interviews, with a total of five participants (three females and two males). The age of the participants varied between 25 and 50. All of the participants came from a similar urban background and had a similar socioeconomic as well as ethnic background. The inclusion criteria were that all participants should work as nurses or mental health care nurses at an emergency polyclinic and that they should have worked within mental health care a few years. Another inclusion criterion was that the participants should be specifically trained for working within mental health care. Three of the participants had worked the majority of their active years at a psychiatric emergency. Two participants had long experience of psychiatric non-institutional care or treatment of out-patients as well as of institutional care or treatment of in-patients. One of the researchers contacted a large emergency polyclinic within the city of Helsinki where the participants were recruited. Those who accepted the invitation received oral detailed information about the study and were given brief information about the main topic of the interview. The participants were informed both orally and in writing about the study purpose, confidentiality and withdrawal of consent. Each interview lasted for about 30-60 minutes, and all the interviews were digitally taped and transcribed. Permission to conduct the study was granted by the ethical committee at the head organization were the data was conducted. The study follows The Finnish National Advisory Board on Research Ethics [29].

Hermeneutical reading of texts
The aim in hermeneutical reading [30] is to uncover the inner essence of the substance that rises up in the text in order to open up for a deeper understanding. The readers' ethical approach to the text is the basis of hermeneutical reading, which assumes that the reader sees texts as an opportunity for new understanding and that the reader is prepared to challenge his or her pre-understanding. Openness and creativity is required from the reader to reveal meanings in the depths of the text [28].
The texts from the interviews were read several times with openness in order to find (underlying) themes that led to new questions that were asked to the texts so that the substance in these could be uncovered. The whole of the text was reflected against the parts and meaningful units were created from the features that emerged from the texts. A continuously moving process between understanding and interpretation, between the parts and the whole, was obtained in order to uncover the substance beyond the present. Finally, the reading resulted in five main themes.

Results
The hermeneutical reading resulted in five main themes: Recognition of the patient through love and compassion as essential for the caring encounter, The patients' first impression as decisive for the caring encounter, The personality of the nurse as the key for establishing trust in communion, The uniqueness of the encounter as a demand for openness and The room as a basis for the encounter and for safeguarding the patient's integrity and vulnerability. These main themes are further described in the following.

Recognition of the patient through love and compassion as essential for the caring encounter
A caring encounter can be created when patients feel they are heard and understood. Nurses then show a genuine willingness to help through love and compassion, even though the situation sometimes requires that the nurse must use restraint or not give patients what they want. A caring encounter can also be created when the nurse helps patients understand what they need so that that they feel that the nursing staff has heard and understood them even if they do things against the patients' will. Then it is important to talk things through so that the patients do not feel overlooked. The patient has in the good caring encounter been treated and helped in a way that leaves a positive and respectful echo, even if the nurse had been forced to limit the patient's wishes and subject the patient to restraint. The nurse has then shown that the patients' wishes have been heard and understood but the nurse has still carefully motivated why he or she cannot give them what they want. It is important that also next-of-kin are being heard and allowed to express their thoughts and concern about the situation.
The interplay is successful when the effect on patients is that they feel they have had a good experience of the encounter and the treatment and that they have been heard and perhaps in some way understood, and that they have received an answer or some kind of help for their problems. One should not expect that the emergency polyclinic patients should be fully satisfied because we must sometimes disappoint them when we cannot fulfill all their wishes, but the interplay is successful when patients leave with a sense that someone has understood his or her problems. A good encounter is hence about the patient's experience after the encounter. (Interview person d) It is important that nurses are responsive to what the patient says and do not draw conclusions based on their own prejudices or preconceived ideas. In addition, it is important that the nurse remains in the encounter to listen and see the patient despite lack of time. It is also important that patients feel they have the space and permission to show very difficult thoughts and feelings. Being listened to and having someone else see one's suffering is crucial.
It is not easy but one should strive to listen to what patients are actually saying, and not listen to what I think they are saying. Therefore, one has to pause in the moment and see the patient. Of course, this is difficult when there is no time to lose, but one should still stop, take it step by step, because the needs of the patient can be something entirely different than what I had in mind. (Interview person c) Long waiting hours can prove difficult because patients can feel that their needs and distress are not taken seriously. Patients can then become frustrated, worried or aggressive. When the nurse finally has time to encounter the patient the patient may already be upset.

The patients' first impression as decisive for the caring encounter
First impressions are meaningful and decisive because they set the tone for the encounter. This tone or experience later acts as a foundation that influences subsequent encounters and conversations between patient and nurse. It is important to know that the encounter takes place directly and the patient quickly has an idea of the care and the nurses.
The encounter begins immediately as the patient enters the entrance hall where a nurse is present and introduces him or herself, tells the patient where we are and what will happen next. If the patient is asked to wait we examine whether the patient's health is such that it is at all possible for the patient to wait, and, if required, we try to find a calmer place where he or she can wait… (Interview person b) Patients need information so that they feel important, seen and cared for. Nurses should always greet patients when they arrive at the emergency polyclinic. They should also inform patients if things are busy in the consulting room and let patients know that they may have to wait for a while, but that the goal is to have patients see the doctor as soon as possible.
The emergency polyclinic is often the first place where patients with mental problems seek help or are admitted. Coming to the emergency polyclinic can be difficult for patients (if they feel ashamed of their mental ill-being). Patients may tense up when they seek help and feel alone and like a failure. Therefore, the first encounter at the emergency clinic is crucial. Offering a first brief encounter despite lack of time is important. Informing patients make them feel important, seen and feel that they have come to the right place.
Of course one seeks to always go and say hello to new patients. One also has to decide which of the patients to take care of first, even though one is busy and it is a hectic working environment, because there may be different patients with different needs at the emergency polyclinic. (Interview person e) The personality of the nurse as the key for establishing trust in communion The personality of the nurse is key and a tool for creating trust in communion in the encounter with the patient. The nurse's showing respect and recognizing the dignity of the patient is essential for a successful encounter based on trust to take place. Those who work within mental health care, specifically in emergency polyclinics, cannot hide (for instance, behind technical or care measures because nurses themselves and their personalities represent tools in the encounter with patients). This is because nurses must use their own personality in their encounter with patients. Each event and encounter is unique. It is important to make time for an encounter, that is, so that one does not rush through it and encounters the human being in a careless manner and make the situation more of an interview than a human encounter.
Respect for the patient is emphasized in emergency mental care. Patients come here from different places and with different means of transport, but it crucial that they do not experience that they are being belittled or depreciated but that they are treated with dignity regardless of circumstances. (Interview person e) Patients enter the acute situation in emergency mental health care and their feelings may differ considerably from normal situations. An otherwise calm and rational human being may in a situation of acute crisis behave very differently. Nurses must therefore through their behaviour try to calm down the patients they encounter. They should show respect for patients and for the reasons they have sought help, and treat them in a human way. Nurses can, through their personality and way of being instill hope in patients that things will improve. This requires willingness and courage, however. By instilling hope and being there and sharing the patients' problems, nurses show their compassion and concern whereupon trust may emerge. Here the personality of the nurse is crucial. By creating trust in the encounter a caring relation in which both nurse and patient feel they have succeeded can then be achieved.
If one obtains trust in the care both nurse and patient have a good feeling about the encounter, and the patient feels safe to return to this place in another emergency situation. (Interview person a)

The uniqueness of the encounter as a demand for openness
Each encounter with a patient is unique and should be based on what the patient expresses, the patient's need, not on the nurse's preconceived ideas. One cannot follow the same pattern with all patients. The nurse must not exploit the patient in the encounter or enter the encounter with preconceived ideas. One cannot in advance know how patients feel and what they need. Thus, openness in the encounter is required as care should be based on patients' needs.
I always ask patients, and ask them to tell me why they have come here to the emergency polyclinic… this is how the interview begins… and then we figure out how we can help. Naturally, there are issues regarding medication, nourishment and open contact etc. that we ask about, but I always ask the patient what he or she wants and how we can help here at the clinic. (Interview person c) Sometimes the encounter must be brief because of the patient's condition. The nurse cannot and does not want to burden the patient as the patient may be in a very frail condition. In this case a brief encounter is preferable. The nurse uses short sentences and in this way creates a sense of safety and trust. Especially patients who are psychotic and disoriented can benefit from a brief encounter. The goal should be to attain a caring communion through cooperation. Having to wait may also be therapeutic for these patients, and even if they criticize being forced to wait for a long time, it is sometimes precisely this form of care that is practiced. Nurses must be attentive to patients and not automatically believe they know what the patients need. It is not possible to prepare for an encounter in advance. Each encounter is thus a blank page and one should therefore enter it with openness and without expectations. The non-verbal communication is important in the encounter because it immediately signals whether one is present in the encounter or not.
The first encounter is important, because it largely dictates how the encounter will end. We have had a lot of training regarding non-verbal body language and how much communication takes place through facial expressions. (Interview person d)

The room as a basis for the encounter and for safeguarding the patient's integrity and vulnerability
The environment and the room create conditions for a caring encounter with the patient. Calm surroundings, for instance a separate waiting-room, are important in a mental health care context. Patients with mental ill-health are often vulnerable and can, due to the waiting, be tired or frustrated and then it may be difficult to enter into the encounter with the nurse. When the encounter can take place in peace and quiet one can create a trust that becomes the foundation for an encounter. It is not always possible to arrange an optimum room, but the nurse can, if possible, try to arrange a separate room or a room that is somehow screened off from other patients. In this way, the conditions are improved for a safe and successful encounter where the patient's integrity and vulnerability may be safeguarded. The communication should take place on the patient's terms, that is, the nurse must listen to the patient and by those means respect the patient's integrity. Honesty, for instance, that the nurse does not promise something that cannot be fulfilled is crucial in the encounter. The nurse should be objective and inform the patient about available alternatives. Nurses should also explain why they provide the care they do so that the patient does not feel disparaged or ignored. In this way, the patient's experience of integrity and vulnerability can be safeguarded. To respect the patient's integrity the nurse must maintain the patient's dignity which may have been destroyed because of the suffering. The nurse's task is therefore to in the suffering and hopelessness instill a sense of hope in the patient. Consequently, this means that the nurse is willing to share the suffering with the patient and show the patient new prospects and possibilities. Nurses should convey that patients are important to them and will not be abandoned. Nurses can instill a sense of hope also by considering, inventing and arranging different forms of care so that patients do not feel they have sought help at the polyclinic in vain.
The encounter must be matter-of-fact and professional. When a patient arrives, we take him or her to a calm place for a discussion. We should not do this in the corridor so that someone else may overhear us… It is also important that we reserve sufficient time and one should not check one's watch or in other ways indicate that there is lack of time. The patient should not be made to feel that you as a nurse is pressed for time. (Interview person d) The quality of the treatment of the patient is primarily highlighted when the nurse is forced to restrain patients or when their wishes are not fulfilled. Then it does not so much matter what one says or does but how it is done. Because patients with mental ill-health often carry a vulnerability that is very fragile their trust can be smashed in a matter of seconds in case the human being's integrity is violated in the encounter, and to which the following extract bears witness: The patient had finally agreed to care and was willing to get help at the emergency polyclinic… and we went together with the doctor to see the patient. By the way, the place where we encountered the patient was ludicrous, a follow-up room where another patient was present… but the doctor decided that we should talk to the patient there. And this doctor began by grabbing the patient's hat and took it off from the patient's head, whereupon the whole situation came to nothing and the patient rushed out of there swearing… (Interview person e)

Discussion
The results of this study showed that the caring encounter within a mental health and psychiatric care context demands patient centering [8] and recognition of the patient through love and compassion. Patients feel that good care has to do with the nurse being there for patients, supporting, seeing and understanding them for what they are [6]. The caring relation requires trust and openness where the nurse is constantly present and responsive to the patients' needs. Responses from patients often revel that they do not feel heard or seen for who they are [6]. Patients who feel ill-treated often blame themselves and feel that they have not been able to describe their suffering [12]. If patients are not recognized, seen or heard, they may suffer from care [31], which means additional suffering [17]. Patients being seen and understood as the human beings they truly are means experiencing the solidarity and meaning that they long for [32]. The encounter between the suffering human being and the nurse represents the room where the patient can experience comfort and feel joy [19]. Caring encounters requires patient centering, seeing and hearing the patient, that the patient is the main focus. It is important that patients feel that the nurse has time and wants to listen to them, giving space for all their experiences and feelings because stress in the encounter prevents patients from opening up. Nurses should take their time to encounter, observe and give patients time to relate their problems, take them seriously and ask questions. According to reports [14], patients are aware of if nurses are authoritarian and of often being treated in a disparaging way. Especially those patients who initially have been isolated or force-fed medication feel that they have not been able to trust nurses and therefore did not want to enter the encounter. The patients also stated that the nurses were not active in creating encounters and were unavailable. The present study has also shown that nurses through a caring encounter can safeguard patients' integrity and dignity so that they are not disparaged, degraded or ridiculed but feel they are being heard. This may mean that nurses have carefully explained to patients so that they understand why the nurses choose a particular kind of care.
A caring encounter is fundamentally successful interplay between nurse and patient characterized by a good experience that remains with the patient as well as with the nurse after the encounter. A good encounter is also significant for nurses as they may for themselves assess whether the encounter has been a good one by observing whether a positive feeling remains from it, even if they discussed other than positive matters with the patient in the encounter.
This study has demonstrated that the first impression is decisive for the encounter. The encounter begins when the patient enters through the door. An emergency polyclinic where patients with mental ill-health come to seek help is often a hectic, restless and quickly changing workplace. For patients who feel they have been treated well, this experience is highly significant for whether they feel they have received good care or not. If the nurse is in a hurry or gives patients an experience in which they feel they have been treated in a careless manner in some respects, this has a negative impact on how they feel they have received care. Patients always compare subsequent care to this first impression that has left traces and that can create a lasting mood in patients that influence their understanding of future encounters in a negative way; the encounter does not just take place with patients but also with their next-of-kin. Patients may have trust issues if they have previously sought help but found that they have not been treated in a dignified way. Then it is even more important that the nurse approaches the patient extra tactfully so that new hope and trust can be built. Nurses must then be there for patients and show that they will not abandon them.
This study also shows that the uniqueness of the encounter demands openness [11] from nurses. The encounter should be based on what the patient expresses, on the patient's needs, not on the nurse's preconceived ideas. This is similar to research [18] that indicates that in the communion the nurse should be sensitive to the patient's experiences and not take the encounter for granted. The present study also demonstrates that one cannot follow the same pattern with all patients. In other words, one cannot know in advance how the patient feels and what the patient needs. This is why the encounter requires openness; something unexpected that happens can prove to be essential in the encounter.
This study shows that the environment is important and creates conditions for a caring encounter [11,33]. The environment and the room should offer the patient peace and quiet. When there is time and space for the encounter a communion may develop and the interplay is successful works. Through the encounter and the conversation, the nurse can together with the patient work towards fulfilling the goal. Nurses can then demonstrate that they want what is best for the patient. This is when nurses encounter patients as fellow beings, they do not appear from above and dominate patients through abuse of power but encounter the human being with openness and on the same level the patients find themselves. The patient's dignity may thereby prevail.
The present study has shown that the creation of a caring communion is dependent upon the nurse's personality and professionalism [11]. Everything originates in how the patient has been treated by the nurse in a true, calm and professional way, so that trust has emerged. Nurses should encounter the human being as a whole and show that they wish the other well. This form of caring love that exists in a caring relation can be explained as a sense of connection and the nurse's will to be there for and help the patient [26]. This is love as the foundation for the caring communion in the encounter because it shows the nurse's willingness to care [25]. Research shows that if nurses are too distant patients may not open up [8]. Gjengedal et al. [18] also indicate that nurses are required to give of themselves in the encounter and show their personality. By doing this, patients may experience that they have received a unique invitation to the encounter. Patients feel recognized and accepted in their own world of experience. Nordby et al. [7] raise the issue that a true caring encounter carries the possibility of communion.
According to Innes et al. [34], nurses who have only vague knowledge about mental ill-being risk having old-fashioned thoughts and views on the encounter with patients. Piippo and Aaltonen [35], too, emphasize that patients can feel that nurses have prejudices and negative attitudes against them or their illness. These prejudices may prevent the patients to enter the encounter because they feel they lack faith in the nurse. Other research [14] describes how patients often feel abandoned with their experiences and that their feelings are sidelined in favour of other matters, which lead to experiences of loneliness and not being invited to the encounter in which they could have participated and experienced communion. The encounter is vital for patients because they can find meaning in life through it [31]. Through limit-situations, where patients are forced to come into contact with their suffering, reconciliation can take place. The human being needs another human being to cope with unbearable suffering in the darkness of the understanding of life in a limit-situation to a bearable suffering [31]. Patients with mental ill-health often carry feelings of shame and inadequacy because of their illness [13,15]. When patients feel that there is no space to talk about their experiences or feelings, they withdraw, which can lead to a sense of profound loneliness. Being encountered in love and care and thereby through the encounter being able to experience communion is found to be healing.
Do nurses today have the courage, willingness and preparedness to encounter the patient? Research reveals that deficiencies in the encounter may be due to that trust is absent [15] or that patients feel that the nurse is not present, or does not recognize the vulnerability of the patient. The most tragic scenario is perhaps when nurses do not take the patient's vulnerability seriously or use it so that the patient feels ridiculed or minimized. Studies have also shown that the conditions for being able to enter into a caring encounter with patients where trust is key is that nurses are anchored in themselves and give of themselves [9] and also have sufficient knowledge and confidence in themselves [34] as well as affirm their own vulnerability [18]. Affirming one's own vulnerability as a nurse can be compared to being present in the encounter with the patient, having the courage to be oneself, which simultaneously means being able to be close to oneself [9] through having affirmed and reconciled with oneself. When nurses feel their own vulnerability they can recognize and identify the patient's vulnerability. This ability to see and encounter the other's vulnerability is missing if nurses have not first recognized their own. Nurses can, once they have become aware of their own vulnerability, recognize something familiar in the other's vulnerability in suffering which make nurses show their own vulnerability, and open up and thereby being able to truly invite and encounter patients on the level at which the patients find themselves. When nurses have acknowledged their own vulnerability they show true willingness and interest to enter into the encounter and receive, learn to know and help the patient. If nurses dare to show their own vulnerability, patients dare to confront their own vulnerability and share it with the nurses without shame. In a true caring encounter the nurse's and the patient's vulnerabilities meet, and from two fragile threads a stronger thread has been created both in the nurse and in the patient. Both have thus received something new through the encounter. This enables them both to experience the encounter to be good and strengthening. These results are similar to those of Nilsson et al. [6] who indicate that both nurse and patient can have positive experiences through a meaningful encounter. Research also shows that the encounter not only makes patients aware of their suffering but also enables reconciliation [9,19]. This study thus suggests that vulnerability is understood as the guiding star in the caring encounter between the patient and the nurse within a mental health care context. Every day is different in an emergency polyclinic, the speed is high and caring contacts brief. Nurses must be able to handle feelings of chaos and uncertainty, and be able to make swift decisions, for instance, regarding which patient is first in need of care. Regarding psychiatric patients this may be difficult to see because mental ill-health is abstract and, for instance, anxiety does not always show on the outside. How is it possible to evaluate whose suffering is most difficult? This is a great responsibility for nurses and many times ethical dilemmas occur. In turn, this may sometimes lead to psychological exhaustion. To constantly go from encounter to encounter as a nurse within a mental health care context can be stressful. Feelings of inadequacy may emerge in the nurse as a result of lack of resources and the fact that in an emergency polyclinic it is not always possible to offer patients what they want. Experience of working in psychiatric care help nurses cope with feelings of inadequacy. A supportive work community and supportive nurse leaders are important for coping within a mental health and psychiatric care context, as is continuous supervision. Sharing experiences from encounters within the emergency polyclinic with colleagues is a form of support. Maintaining professionalism and one's own health is fundamental. The work is performed through encounters with patients where one's own self is the tool. Difficult encounters with patients may preferably involve two or three nurses and a doctor. By viewing each encounter with the patients as a unique challenge and to strive for its success may be a way of coping in this caring context. For nurses, it is rewarding to feel that the patient was left with a good feeling, that is, caring was successful. Being passionate about their work may contribute to nurses finding a meaning in it which in turn can give them strength. It is possible to improve the quality of encounters in health care and to better cope as a nurse if the work team discusses encounters with patients by bringing out different cases among the staff and talk about what could have been done in a more optimal way.

Strengths and limitations
One limitation to this study might be the limited number of participants (only five). However, the strength of this study lies in that the participants were willing to share their views in face-to-face interviews regarding interacting with patients with mental ill-health and establishing caring encounters with these. The interviews gave rich data and each interview lasted up to 60 minutes.

Conclusions
This study uncovers love and communion as the bases for the caring encounter between the patient and the nurse within a mental health and psychiatric care context. The caring encounter may represent a source of strength and meaning for the patient. This study also indicates that vulnerability as a phenomenon plays a fundamental role in the caring encounter between the patient and the nurse in a mental health and psychiatric context. Future research should focus on how to further explore this area regarding vulnerability within a mental health and