Therapeutic Relationship in Mental Health Nursing - Essay Example

?Therapeutic Relationship in Mental Health Nursing: A Concept Analysis Introduction The use of therapeutic relationship skills is considered as a crucial component of modern mental health nursing practice. It is observed that patients value being attended to by a person that they perceive as someone who shows genuine concern for their welfare. However, the question remains whether a genuine caring attitude towards others is an innate or acquired human quality (Forster 2001). The Registered Nurses Association of Ontario (2002) defined therapeutic relationship as an interpersonal process between the patient and nurse characterized by a purposeful, goal directed relationship aimed at promoting the welfare and well-being of the patient. In a mental health setting, establishing a therapeutic relationship with the patient makes it easier to provide interventions and initiating two-way communication with the patient. Assumptions Mental health nurses hold a set of beliefs or values that guide them in their work. First, mental health is considered as a specialized area of nursing practice, education, and research (Videbeck 2010). Mental health nursing is an essential component of the mental help profession, making use of various nursing, psychosocial, and neurobiological theories, as well as research evidence towards the development of general, patient-centred mental health interventions (International Society of Psychiatric Mental Health Nurses 2011). Second, the mental health nursing practice places importance on the promotion of mental health and interventions focused on the prevention, treatment, and management of mental disorders. Moreover, a successful therapeutic relation between patient and nurse is founded on trust and mutual respect. Establishing a therapeutic relationship with a patient is an important step towards removing the stigma and discrimination commonly associated with mental illness (Videbeck 2010). Third, the mental health nursing profession acknowledges the essential role of research in the development of improved mental health care approaches and interventions. Fourth, the promotion of mental health goes beyond the doors of a mental institution by encouraging society to take action and take part in shaping health and organizational policy. This can be realized by fostering collaboration between individuals, families, communities, populations and social agencies (Videbeck 2010). Mental health nurses advocate a holistic approach, equal access to culturally competent care, protection of human rights, and safe, conducive work environments. Moreover, the mental health profession promotes reflective ethical practice, continuous learning, and the establishment of a moral and visionary nursing leadership that adheres to the Code of Ethics for Registered Nurses (Videbeck 2010). Goals of Concept Analysis Rodgers (1989) acknowledged the importance of the development and clarification of the nursing knowledge base. Concepts are essential components required to perform specific tasks, and any ambiguity that exists on a concept, whether by definition or attribute, would affect its effectiveness in addressing a particular situation. This is the reason why concept analysis is commonly utilized to ensure that important concepts possess a definite degree of clarity. However, the method of concept analysis in the field of nursing is not fully understood by nurses. This is due to the fact that most nurse scholars fail to fully examine the philosophical foundations and results of concept analysis. Most nurses therefore have no clear idea how the methods of concept analysis works Meleis (2007) described the goal of concept analysis as a method of advancing a specific concept to a higher level of development. Specifically, concept analysis is performed to determine how a concept may be used in research, clinical practice, instrument development, and theory testing. The most common methods utilized are: Wilson’s Method of Concept Analysis, an 11-step technique for clarification and conceptual communication; simultaneous concept analysis strategy; and hybrid method. Concept analysis is comprised of the following steps: (1) identification of concept to be analysed; (2) identification of alternative terms and common uses of the concept; (3) selection of realm for data collection; (4) enumeration of concept attributes; (5) recognition of references, antecedents, and consequences of the concept; (6) identification of related concepts; and (7) selection of a model case of the concept (Rodgers 1989). Review of Related Literature and Studies Definitions A therapeutic relationship is described as a nurse-client interaction based on trust, caring, and compassion. The primary objective of establishing a therapeutic relationship is advancing the client’s well being by enforcing positive patient behaviour, encouraging interaction with the environment, and improving a patient’s wellness and level of self-actualization (Forster 2001). Patel and Jakopac (2011) illustrated the difference between a social relationship and a therapeutic relationship. Social relationships are created for the benefit of every party involved in the relationship and the interaction is more subjective in nature. In contrast, therapeutic relationships exist mainly for the benefit of the client. Mental health nurses maintain a relationship which is guided by a code of ethics and enables clients to take an active role in goal setting and treatment decisions. The existence of a therapeutic relationship allows the provision of emotional, psychological, and learning interventions which can provide a significant impact on how a patient and his or her family would cope in the face of a mental health problem. Moreover, the relationship itself is considered as an indispensable part of therapy. A harmonious relationship is appreciated by clients since most have poor social support and unstable relationships. Therefore extending kindness and showing compassion to a client adds to the therapeutic quality of such a relationship (Forster 2001). However, several factors may hinder mental health nurses from creating a therapeutic relationship with a client. First, some mental conditions such as schizophrenia are neurochemical in nature, making counselling or psychotherapy ineffective. Second, patient factors such as negative attitudes, experiences, and the severity of psychological condition may erect barriers which make it difficult to reach out to the client (Forster 2001). Third, shortcomings in the side of the institution include: insufficient number of staff, shortage of specialist services, limited resources, leadership issues, and changes in policy. In addition, institutions may impose restrictions on how clients and therapists are selected. Also, some facilities are constrained to enforce safety while sacrificing a certain degree of personal freedom (Forster 2001). The mental health nursing profession practice follows a set of standards which guide them in the provision of appropriate mental health services and interventions. The first standard emphasized on the provision of exceptional professional care founded on the establishment of a therapeutic relationship between the client and patient. Therefore, a mental health nurse is expected to exhibit a significant level of competence to gain a client’s trust, which is the basic foundation of a therapeutic relationship. Defining Criteria Respect. It is described as the act of regarding another person’s beliefs, feelings, and thoughts at the same level as one’s own. In a therapeutic relationship, mental health nurses are required to honour a patient’s right to self-determination, even if it is in contrast with one’s perspective or belief. In addition, nurses are encouraged to discuss with the patient any potential issue regarding a patient’s action or decision in a constructive manner without putting the patient on the spot (Knapp 2007). Legal. Mental health nurses are required to adhere to ethical and legal guidelines that govern a therapeutic relationship. This includes guidelines regarding confidentiality, reporting of crimes, and social contact (Knapp 2007). Confidentiality. In a mental health care setting, maintaining patient confidentiality is a crucial aspect in maintaining a therapeutic relationship. Confidentiality covers information regarding a patient’s current state of physical and mental health, and treatment. Should there be a need to discuss patient information with another health care practitioner, the patient’s identity is not to be disclosed unless required (Knapp 2007). Scope of practice. Mental health nurses are only allowed to provide services wherein they have received appropriate training, certification, and licensure. As such, nurses are limited to utilize mainstream and medically-accepted treatments, even when clients insist on using alternative methods (Knapp 2007). Nonjudgmental attitude. Though it is human nature to develop opinions and perceptions about other people, mental health nurses should refrain from getting their personal biases in the way. Nurses should maintain a neutral viewpoint in respect to a patient’s gender, age, race, sexual orientation, ideology, social class, educational attainment, political affiliation, culture, and religious beliefs (Knapp 2007). Positive regard. One of the goals of a therapeutic relationship is to empower clients towards growth and change. However, there are times when clients fail to meet certain goal or experience a relapse in behaviour. Mental health nurses should engage the client in a constructive discussion wherein a patient’s strengths and accomplishment are accentuated, at the same time reviewing past efforts to identify hindrances and difficulties. The goal of the activity is to empower the client to try again and identify alternative approaches (Knapp 2007). Personal contact. Mental health nurses are encouraged to keep their personal and professional lives separate. This is to ensure that a sense of professionalism and objectivity is maintained when dealing with clients (Knapp 2007). Boundaries. In a therapeutic relationship, the client is still the centre of everything. Thus, self-disclosure by mental health nurses should be kept at a minimum. In addition, it should be made clear to the client that professionally, nurses may interact with them based on the required services or treatments set at a schedule agreed upon. Any contact outside the therapeutic setting should be avoided (Knapp 2007). Self-disclosure. In a therapeutic relationship, self-disclosure may come in two forms: personal and professional. Professional disclosure includes giving out information regarding one’s professional attainments such as trainings, certifications, or credentials. On the other hand, patients may be hinted regarding a nurse’s personal attributes by observations regarding gender, age, race, ethnicity, grooming, attire, mannerisms, demeanour, physicality, and language (Knapp 2007). Advice. Mental health nurses may provide advice to clients based on their knowledge and experience. Using reputable information resources, nurses can also provide referrals to reinforce a therapeutic relationship (Knapp 2007). Involvement. In a therapeutic relationship, a mental health nurse’s role is to guide the client in towards the realisation of specific goals while making sure that the client accomplishes most of the tasks required. In collaboration with the patient, goals are set and feedback and encouragement is given to promote the client’s personal growth and movement towards independence (Knapp 2007). Goal. Goal-setting in a therapeutic setting involves collaborating with the client in identifying mutually accepted goals. In addition, goals should be consistent with the client’s cultural, social, and religious norms (Knapp 2007). Topic of conversation. In a therapeutic relationship, topics are focused more on the accomplishment of goals set with the client. When engaged in a conversation with a patient, a mental health nurse should keep the discussion on track and topics should be in relation to the patient as much as possible (Knapp 2007). Rescinding the ego. Despite being collaborative in nature, a therapeutic relationship should be maintained with a certain level of objectivity. A mental health nurse should keep in mind that client self-determination is a primary goal (Knapp 2007). Antecedents In the mental health profession, an antecedent is described as an incident or event that initiates the existence of a therapeutic relationship. A therapeutic relationship may be brought about by a number of antecedents which include: the environment; communication process; and preconceptions of patient, carers, and mental health professionals. To facilitate the development of therapeutic relationships, the physical and interpersonal environment should be taken into consideration since environmental factors influence the success of failure of communication. Hence, once communication is established, a therapeutic relationship can start to develop (Cutcliffe & McKenna 2005). Another antecedent to therapeutic relationship is the presence of stereotypes and perceptions which may promote or hinder attempts to reach out to the patient. For example, a nurse who had experienced being a victim of a crime might have difficulty reaching out to a patient convicted of a serious crime (Cutcliffe & McKenna 2005). An important step in creating a therapeutic relationship is establishing an initial social relationship with the patient. This way, both the nurse and patient would have the chance to get to know each other first and share a connection or friendly bond before moving forward towards a therapeutic relationship with a patient. As both the nurse and patient progress towards creating a therapeutic relationship, lessons are learned by both parties and this creates a learning environment crucial to improving the level of care being provided to the patient (Cutcliffe & McKenna 2005). Consequences On the other hand, a consequence is defined as the result or outcome of maintaining a therapeutic relationship. The experiences in terms of learning, personal growth, and development, as well as having increased awareness of one’s strengths and weaknesses help mental health nurses in improving their competencies. On the patient’s end, positive outcomes from a therapeutic relationship enable them to become involved in their own process of self-discovery and to be able to understand and cope with their condition (Cutcliffe & McKenna 2005). Implications to Mental Health Nursing Dziopa and Ahern (2009) argued that despite the importance of creating and maintaining a therapeutic relationship between the mental health nurse and the client, there is a need to determine contributory attributes to mental health nursing. Therefore, the authors examined relevant literature in order to identify possible factors of therapeutic relationship in a mental health setting. A total of nine general attributes were identified in the review: (1) understanding and empathy; (2) individuality; (3) providing support; (4) being there / being available; (5) being genuine; (6) promoting equality; (7) demonstrating respect; (8) demonstrating clear boundaries; and (9) demonstrating self-awareness. Understanding and empathy. Mental health nurses should not only hear a patient but also give proper attention and show interest in what a patient has to say. By demonstrating attention and interest, a patient feels understood and important. This is crucial in empowering a patient, considering the stigma placed by society on individuals suffering from mental health illness. Mental health nurses are encouraged to reach out, know more about their patient, and strive to be non-judgmental as they communicate with a patient (Dziopa & Ahern 2009). Individuality. Once a nurse gets to know their patient more, it is easier to tailor-fit their approaches as they provide care for a patient. Nurses should see their patients as individuals who also need to be valued and respected. This helps in breaking barriers and dispelling stereotypes which are common among mental health patients. In addition, nurses should see themselves as a person who supports a patient in their attempt to manage their lives despite their current mental condition (Dziopa & Ahern 2009). Providing support. A therapeutic relationship will flourish only if the patient is in a supportive environment where they will feel safe and comfortable. It is suggested that nurses should perform gestures showing support such as: giving suggestions and feedback; showing concern in one’s voice; reassuring patients; and accompanying a patient in therapeutic activities. In the case of vulnerable patients, nurse should take on a nurturing and protective role (Dziopa & Ahern 2009). Being there / being available. Mental health nurses should be willing to allocate time to their patient. Patients appreciate nurses who take the time to listen and those who are ready to help them when they need it. Initially, nurses may find it draining to be there for the patients in a supportive and consistent manner. However, once they learn how to manage their time effectively for each patient, the burden is lessened significantly (Dziopa & Ahern 2009). Being genuine. Nurses are encouraged to be in friendly terms with their patient to facilitate the provision of necessary care. A friendly relationship is enforced by the use of humour, self-disclosure, and honesty. Patients should see nurses as more than just a provider of care and as a real person just like them. However, a conflict exists between the level of closeness a nurse has with a patient and maintaining professionalism in the workplace. To circumvent this, mental health nurses should be aware of the balance of being real person with their patients and being professional in their line of work (Dziopa & Ahern 2009). Promoting equality. Mental health nurses in a therapeutic relationship with a patient unintentionally places them in a position of power since the relationship is considered asymmetric. However, if used properly, a mental health nurse may be able to use this to influence the success of a therapeutic relationship. This may be done by ensuring diet and medication compliance, as well as protecting vulnerable patients (Dziopa & Ahern 2009). In contrast, mental health nurses may be tempted to abuse the situation by denying assistance, becoming unavailable to the patient, improper imposition of rules, rude and condescending behaviour, and perceiving one’s self as superior to the patient. In order to avoid this, the relationship should be viewed by both parties as mutually beneficial. Control or power should shift back and forth between nurse and patient depending on the situation (Dziopa & Ahern 2009). Demonstrating respect. Mental health nurses should make patient feel respected and valued. In order to attain this, nurses should be able to: practice active listening; show accessibility, consistency, and fairness; and acknowledge the patient’s inherent faults, weaknesses, and problems (Dziopa & Ahern 2009). Demonstrating clear boundaries. A therapeutic relationship is maintained by the use of boundaries. These boundaries protect both the nurse and the patient by setting limitations which ensure that the existing level of relationship does not degrade. Knowing how far one can go benefits a patient by avoiding embarrassing behaviour and maintaining a feeling of safety and protection. On the other hand, nurses will be able to perform their duties within the scope of their practice and maintain a level of professionalism (Dziopa & Ahern 2009). Demonstrating self-awareness. Nurses are encouraged to be self-aware as they perform their work. Being self-aware may be done through reflection, better clinical skills, and helping improve strained relationships. Mental health nurses should learn not to let their personalities affect how they interact with their patients. In time, nurses will be able to improve on their interpersonal skills (Dziopa & Ahern 2009). Conclusion As with any type of human relationships, there should be a minimum of two parties involved to initiate and maintain interaction. Though it may share some similarities with social relationships, a therapeutic relationship is unbalanced and focuses on one party – the client. Mental health practitioners are encouraged to initiate and maintain a therapeutic relationship since it facilitates the provision of services and treatment to clients. However, in a mental health setting, a number of hindrances could prevent mental health nurses from initiating or maintaining a therapeutic relationship with a client. These hindrances could be personal, coming from the client, or from the environment. In order for an intervention to succeed, these challenges should be addressed with the client’s welfare and well-being as a priority. The following recommendations are therefore forwarded: (1) the importance of therapeutic relationships should be inculcated into the minds of mental health nursing students in the university; (2) mental health nurses should always be reminded on therapeutic relationship guidelines and techniques; and (3) the mental health profession should include therapeutic relationship as a topic for continuing education studies. References Cutcliffe, JR & McKenna, HP (2005), The essential concepts of nursing: building blocks for practice, Elsevier, London. Dziopa, F & Ahern, K (2009), What makes a quality therapeutic relationship in psychiatric / mental health nursing: A review of research literature. Internet Journal of Advanced Nursing Practice, 10(1), pp. 7. Forster, S (2001), The role of the mental health nurse, Nelson-Thornes, Cheltenham, UK. International Society of Psychiatric Mental Health Nurses (2011), Psychiatric mental health nursing scope & standards, viewed 29 April 2011, http://www.ispn-psych.org/docs/standards/scope-standards-draft.pdf Knapp, H (2007), Therapeutic communication: Developing professional skills, Sage Publications, Thousand Oaks, CA. Meleis, AI (2007), Theoretical nursing: development and progress. Lippincott, Williams & Wilkins, Philadelphia, PA. Patel, SC & Jakopac, JA (2011), Manual of psychiatric nursing skills, Jones & Bartlett, London. Registered Nurses Association of Ontario (2002), Establishing therapeutic relationships, Registered Nurses Association of Ontario, Toronto, Ontario. Rodgers, BL (1989), Concepts, analysis, and the development of nursing knowledge: The evolutionary cycle. Journal of Advanced Nursing, 14, pp.330-335. Videbeck, SL (2010), Psychiatric-mental health nursing, Lippincott, Williams & Wilkins, Baltimore, MD. Read More