Maintaining Therapeutic Relationship - Essay Example

Running head: Maintaining Therapeutic Relationship Maintaining Therapeutic Relationship By __________________ MaintainingTherapeutic Relationship A therapeutic relationship refers to an unusual mixture of overlapping, complex, and contradictory dimensions shaped by nurse in the favour of his patient. In its paradoxical way, it is unlike any other kind of relationship, especially because it attends to many types of relationships in the form of patient that may be simultaneously applied at an unconscious level. These multiple dimensions are what a nurse therapist is available to participate in but also to try to understand and heal with a patient. A patient and nurse are both "working" in some way or the other, though their respective jobs may be different. The nurse feels and ponders the relationships or patterns that are going on, usually ones that are modeled on family experiences or other blueprints from the past. From the psychotherapeutic perspective, a patient has those kinds of relationships with a nurse at a so-called unconscious level. (Sedgwick, 2001, p. 60) The ability to create and maintain treatment boundaries within the nurse-client relationship is one of the most important competencies required by psychiatric mental health nurses. However simple this declaration, in practice, boundary work is anything but straightforward. The familiarity and trust that develops between a nurse and a client, coupled with the seductive pull of helping, the complexity of the client's treatment needs, and a general lack of understanding of boundary theory, can threaten the integrity of the relationship and ultimately lead to boundary violations (Taylor & Yonge, 2003, p. 55) Ironically, through engaging a client in a professional caring relationship the essence of psychiatric mental health nursing nurses are at risk of overstepping their professional boundaries. Similar to the walls around one's house, or the fence around one's yard, metaphorically, boundaries mark the parameters of the professional relationship. In their simplest form, boundaries are the limits that allow a client and nurse to engage in a therapeutic relationship (Baron, 2001). It is through the creation and maintenance of therapeutic boundaries that a safe relational space is created, whereby the client and the therapist are able to explore treatment issues from a position of neutrality. The nurse's accountabilities in the nurse-client relationship is limited to the standards i.e., Therapeutic communication, Client-centred care, Maintaining boundaries and client protection from abuse etc. Therapeutic Communication Therapeutic communication is the initial stage in which nurses use communication skills and strategies to maintain nurse-client relationship. Communication within relationships, for both major and mundane events, is cumulative in establishing a relationship culture that provides a shared meaning for both individuals in the dyad. In a therapeutic context, that relationship culture could be seen as a source of strength and stability that has been developed from many years of shared experiences. Relationship could be in any form whether a husband-wife or son-father. A couple interventions, then, could capitalize on that shared relationship culture as a basis for an exploration of relationship distress and the implementation of behavior change. The tendency of an individual to forgive his or her family member for making a hurtful comment is related to high levels of satisfaction with the relationship and low levels of perceived frequency and proclivity of hurtful statements. (Harvey & Venzel, 2002, p. 81) It is the responsibility of a nurse to analyze this aspect of the patient and get results from the interaction. It demonstrates that the tendency to forgive family members for most of the patients indicates maintenance and enhancement of close relationships. A nurse has to keep a close eye upon such interactions of family affairs and should respond to the customer with patience and accordingly. She has to provide her utmost support to the patient in every manner. This is done in the following ways: The client likes to be addressed by his/her name, so the nurse must remember the client name. The nurse takes care of the client by giving him appropriate time, opportunity and ability to explain himself/herself, meanwhile she at the utmost listens to the client thereby understanding his feelings and intentions. A nurse has to keep in mind about the patient's verbal and non-verbal communication style and should act accordingly, she has to update herself to that extent in which she is able to grasp the cognitive status of patient's psychology. A nurse should reflect on interactions with a client and the health care team, while investing time and effort to continually improve communication skills; and Discussing, throughout the relationship, ongoing plans for meeting the client's care needs after the termination of the nurse-client relationship (for example, discharge planning with the client and/or referral to community organizations). (Thera, 2006) Some patients have a vivid and lively capacity to bring relevant material into analysis, through both their verbal and non-verbal communications. Nurses when in supervisions have often observed that if what a patient says is not understood it will frequently be repeated two, three, or even four times in a session, in many different ways. Such attempts to communicate (even in the unfavourable circumstances in which a nurse has difficulty understanding the patient) are remarkable. Such patients seem to try to make the material more and more easy to understand with very little resentment about the failure of the nurse. They are particularly likely to communicate what they feel and think about the nurse, and, as others have noticed, their understanding of the nurse's problems is often vivid and precise. They seem to have much tolerance for the nurse's weakness and to have a great capacity to live and to look for object relations. Other patients, particularly schizoid ones, of course, are much more easily discouraged and quickly withdraw when they feel snubbed or not understood. Even so, nurse have noticed that regressed patients belonging to this group often have an amazing capacity for communicating their needs and observations, particularly by non-verbal means although when non-verbal means predominate does not mean to imply that the patient is silent and unable to use words. It is rather that their language sometimes sounds as if they are in a dream. Such language is common with schizophrenic patients and it takes some time to learn. It exemplifies such contention that careful consideration of even the most disturbed psychotic behaviour can be rewarded by finding that it communicates something meaningful. Client-centred care Client centred care can be illustrated by the relationship between those concepts that make patient believe that the nurse is always there for interaction in a health/ illness situation and this as a human being (nursing client) is an integral part of his or her socio-cultural context environment and who is in some sort of transition or is anticipating a transition (transition); the nurse-patient interactions are organised around some purpose (nursing process), and the nurse uses some actions (nursing therapeutics) to enhance or facilitate health. The principal therapeutic function of a nurse is to help the patient put into words and conscious thoughts the unconscious feelings and wishful fantasies which preoccupy him. In this way the patient's repetitions of early object relations and the omnipotent defences built up in the infantile period can be modified. Gradually, the patient can tolerate more feelings (and particularly the anxiety they provoke), recognize conflicts, and become able to think about them. (Rosenfeld, 1987, p. 31) Even the most disturbed and tricky patients, whose pathology may cause them time and time again to defend themselves against anxiety by distorting and undermining the analytic process, not only seek to communicate their predicament but also have a considerable capacity for co-operating with the therapeutic endeavour, if nurse can recognize it. Maintaining boundaries with the patients The client's may feel the room/hospital like an informal environment in which to provide care is just to make the boundary between professional and social relationships less clear. It may be tempting to do more for a client who lacks the usual social supports. For example, it may be convenient for the nurse to perform some non-nursing activities for the client, such as picking up groceries on the way to a visit. Such behaviours can change the boundaries of the therapeutic relationship and make the limits of the relationship unclear. (Thera, 2006a) Acceptable Behaviours Self disclosure Feedback from clients (Positive or Negative) Accepting gifts from clients Giving gifts to clients Providing nursing services to family, friends or acquaintances Unacceptable Behaviours Emotional/verbal abuse Sarcasm Retaliation Threatening behaviour Manipulation Teasing Ignoring client's preferences Swearing Cultural slurs Rude or inappropriate tone or voice Physical Abuse Hitting, pushing or handling the patient in a rough manner Sexual Abuse Avoiding the patient Financial Abuse Differentiate patient on the basis of cultural or religious aspects (Thera, 2006a) Nursing for disabled People Nurses often administer treatments underestimating the disabled client's abilities and vulnerability. While consider some of the moral responsibilities of a nurse researcher-particularly one working in a multidisciplinary team, contractually accountable to both a funding body (a charity) and a medical faculty, but professionally accountable to her own professional body, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) has suggested some ways of handling the ethical questions which arise. (Hunt, 1994, p. 68) A primary ethical problem for nurse researchers working with people with disabilities is that while they may appear able to give informed consent (and one should never presuppose that they cannot) their comprehension is in some cases questionable. At the same time excluding people with disabilities from research may do them a disservice by failing to obtain potential nursing knowledge. People with disabilities, who are incontinent or confined to a wheelchair, have particular and realistic concerns about forming and maintaining relationships, both with their able-bodied and disabled peers. As one might expect, the self-awareness and sexual interest of people with disabilities often increases during adolescence, often in their late teens. It is now recognised that some sexuality research provides limited results. Investigative, but non-prescriptive research might arguably be considered unethical if no recommendations are provided as a result. One should never lose sight of the fact that ultimately health care research is about bringing benefits to people. Some research (therapeutic research) obviously aims to be of direct benefit to the research subject. In other kinds of research (non-therapeutic) the aim is to advance scientific knowledge, but here too it should be envisaged as benefiting a client group as a whole, even if it is not expected to give direct benefit to the research subjects. (Hunt, 1994, p. 86) There is a pressing need to ensure that clients, particularly people with physical disabilities and learning difficulties, fully comprehend the nature, extent and time of their expected involvement in a research programme. People with disabilities should not be coerced into participation by researchers. The primary interest of some researchers may be professional development or securing suitable programmes of study in which to obtain a higher qualification. Competency to consent may be regarded in terms of three integral components: free choice, knowledge and understanding, and competency to decide. Some patients with learning difficulties are often capable of making decisions about daily care but may have difficulty in understanding details about operations, treatments and research involvement. Total incompetence should never be presupposed, and is only found in the profoundly mentally handicapped person. Gunn points out 'that there is no legal decision that a person who is mentally handicapped is necessarily incapable of making treatment or care decisions'. It has to be admitted that 'competence' is itself a rather vague concept. Measures of competence may vary according to the institution where the research is being undertaken. Some institutions use psychological testing, others use educational attainment as indicators of cognitive function. How often do we allocate decision making to carers or relatives with a certain disregard for the individual feelings, contributions and expectations of disabled people themselves In modern practice there is often an underlying tension between two different understandings of 'nourishing' the patient. First, nourishing as an intrinsic part of giving care, which falls within the realm of nursing. Second, nourishing as a biological and technical process, a life-sustaining treatment under the control of the medical or nutrition team (from which the nurse may be excluded). These situations are seldom straightforward. On the admission of a patient with a severe stroke, or one who is unconscious and unable to communicate, the decision to feed or hydrate may in fact be made by the doctor. Other members of the health care team and the family may not be consulted, or not consulted adequately. The initiation of medical treatment in an old person with a severe stroke or dementia may be seen with hindsight to be inappropriate and to represent a missed opportunity to allow dying to occur with the dignity and integrity of everyone intact. The early rescue of patients from an illness from which there is no hope of meaningful recovery may well cause distress to the patient and relatives. Nurses have a special advisory role in dealing with such situations. Nasogastric feeding may, under some clinical circumstances, be used to feed patients. Modern fine-bore tubes and pumps which ensure controlled delivery of the feed, together with manufactured feeds designed to meet a wide variety of metabolic and absorptive conditions, have eliminated many of the common complications and distress associated with tube-feeding in the past. Such advances still have not completely eliminated fears and anxieties about 'force-feeding'. To the patient the use of nasogastric tubes may be seen as an assault or an invasion rather than as a form of medical treatment or nourishment. The distress and upset which may be caused to the patient by tube-feeding should not be dismissed, and has been taken into account in many cases. In the alert patient it entails the loss of control over the choice of food and timing of meals. The very presence of the tube is a visible sign of a loss of appetite and an underlying pathology, and this has its impact on the patient's self-image. Furthermore, the long-term use of nasogastric feeding necessitates regular blood tests to check that the patient's biochemistry and haematology are satisfactory. Given the risks, tube-feeding ethically requires that the patient be monitored. But the long-term benefits to a dying person of the blood tests may be in doubt. Where possible, nursing care should encourage patients to express their feelings about tube-feeding. If such feelings become too painful then artificial feeding may be rejected. A difficult ethical issue is under what conditions the patient may exercise the right to reject such feeding. If restraint is needed to prevent the patient from According to law, the therapeutic privilege is a well-recognized exception to the objectives standards of disclosure, which excuses the withholding of information where disclosure would be unhealthful to the patient. This privilege is applicable only if disclosure of the information would complicate or hinder treatment, cause such emotional distress as to preclude a rational decision, or cause psychological harm to the patients. The laws set out consent requirements for certain procedures, for example it is often recommended for physicians to inform the patients of alternative treatments for breast cancer and the law sets out specific requirements regarding informed consent for a hysterectomy. A battery theory of liability should be reserved for those circumstances when a patient gives consent to perform one type of treatment and the provider performs another, as in this situation the requisite element of deliberate intent to deviate from the consent given is present. However, when the patient consents to certain treatment and that treatment is performed but an undisclosed inherent complications with a low probability occurs, the provider has not deviated from the consent but rather may have failed to disclose all the pertinent information to obtain the consent, so the claim should be one of negligence and not battery. The scope of the providers duty to disclose choices regarding proposed therapies and the dangers involved in each is measured by the amount of information a patient needs to make an informed choice. All information materials to a patient's decision should be given. Material information is information the provider knows or should know would be regarded as significant by reasonable person in the patient's position when deciding to accept or reject the proposed treatment. To be material, a fact must also be one that is not commonly be appreciated, for example, if a patient declines a risk free test or a treatment, the provider has an additional duty to advice about all material risks that a reasonable person would want to be told before deciding not to undergo the procedure or test (Cady, 2003:196). References Sedgwick David, (2001). An Introduction to Jungian Psychotherapy: The Therapeutic Relationship: Brunner-Routledge. Place of Publication: Hove, England. Harvey H., John & Wenzel Amy. (2002). A Clinician's Guide to Maintaining and Enhancing Close Relationships: Lawrence Erlbaum Associates. Place of Publication: Mahwah, NJ. Taylor Peternelj A, Cindy & Yonge Olive. (2003). Exploring Boundaries in the Nurse-Client Relationship: Professional Roles and Responsibilities in Perspectives in Psychiatric Care. Volume: 39. Issue: 2. Rosenfeld Herbert, (1987). Impasse and Interpretation: Therapeutic and Anti-Therapeutic Factors in the Psycho-Analytic Treatment of Psychotic, Borderline, and Neurotic Patients: Tavistock Routledge. Place of Publication: London. Mckenna Hugh, (1997). Nursing Theories and Models: Routledge. Place of Publication: London. Cady F. Rebecca, (2003) The Advanced Practice Nurse's Legal Handbook: Lippincott Hunt Geoffrey, (1994). Ethical Issues in Nursing: Routledge. Place of Publication: New York. Baron, S. (2001). Boundaries in professional relationships in Journal of the American Psychiatric Nurses Association, 7(1), 32-34. Thera, 2006 accessed from Thera, 2006a, accessed from Read More