Therapeutic Relationship in Nursing - Essay Example

Therapeutic Relationship in Nursing An Essay for the Journal Perspectives in Psychiatric Care Submission PROBLEM: This essay focuses on the following topics: role of the nurse as a counselor; the various theoretical principles of counseling theory to meet the individual needs of clients; systematic approach to counseling as the basis for therapeutic communication; major counseling techniques to enhance therapeutic counseling communication skills; and ethical and professional issues inherent in the counseling practice. METHODS: A literature review of the abovementioned topics. CONCLUSIONS: One of the areas that nurses should focus on in order to build successful therapeutic relationships is therapeutic communication. There are a number of therapeutic communication techniques available, but one thing is certain, active listening strongly fosters positive therapeutic relationship. Key words: therapeutic relationship, therapeutic communication, counseling, nurse, postmodern, cognitive behavioral, humanistic, psychodynamic A therapeutic relationship is an organized, systematized, goal-directed process of communication between a patient and a nurse with the intention of planning and executing care for the client and his/her family and other significant others. This essay focuses on the following topics: role of the nurse as a counselor; the various theoretical principles of counseling theory to meet the individual needs of clients; systematic approach to counseling as the basis for therapeutic communication; major counseling techniques to enhance therapeutic counseling communication skills; and ethical and professional issues inherent in the counseling practice. Role of the Nurse as a Counselor When working as a counselor, a nurse helps patients with the identification and resolution of problems. The counselor helps patient action by assisting patients in making their own choices or decisions. Counseling is performed to help patients enhance their coping mechanism. Holistic counseling is generally effective, for it deals with the person’s cognitive, spiritual, psychological, and emotional issues (Dossey & Keegan, 2008). The role of the counselor is usually fulfilled by the nurse who mediates with patients suffering from chronic illnesses and clients who are grief-stricken. Taking into consideration the distinctive role of the nurse in a hospital setting, the task of nursing is to help the patient. The nurse gives the physical and emotional wellbeing and security of the patient (Forster, 2001). The patient views the nurse as the bringer of comfort or relief. The most important aspect is the capacity of the nurse to make sense of the patient’s behaviors. The nurse should express compassion that generates ideas about the needs and sentiments of the patient (Forster, 2001). Patients are confused and fearful for themselves. A nurse must have within him/herself a profound spiritual expertise; s/he will be capable of coping with the crushing difficulties of misery and pain, and which will challenge him/her day by day. First and foremost nurse must obtain assistance in counseling for personal support for themselves, for it aids them in times of difficulties and stress which is brought about the specific nature of their work and obligation (Nugent & Vitale, 2013). In the hospital, the patient is the most essential individual. The obligation of the nurse is to help the patient in the hospital. Counselor offers thoughtful response and understanding, intervenes in the patient’s conflicts and bewilderment, and simultaneously acknowledges his/her emotional responses so that s/he not merely selects more effective ways to attain his/her sensible objectives, but also has adequate control, determination, and confidence to pursue those goals (Nugent & Vitale, 2013). Nurse counselor requires profound, thorough communication, which steadily becomes a deep, passionate form of sharing. The nurse performs psychological counseling for patients’ personal development and growth by cultivating freedom within the patient, enhancing his/her relationships, and finding his/her purpose in life or the meaning of his/her existing (Videbeck, 2011). Objectives of counseling is not to resolve a single specific issue, but to help the person grow or develop so that s/he can deal with the current issues and with future problems in a highly effective way. Hence, the patient becomes more able to cope with new problems in the most effective way (Dossey & Keegan, 2008). Counselor helps patients improve from a feeling of worthlessness to a feeling of self-respect, reluctance to eagerness, immaturity to maturity, and incompetence to competence, and counselor gets rid of the barriers that impede full recovery and personal growth. Theoretical Principles of Counseling Theory The therapeutic relationship has more usually been related to the processes of psychological counseling, but it is very adjustable or open to holistic nursing. Therapeutic relationships, as agued by MacDonald, enable the patient and the nurse to gain relief or fulfillment. The client feels important, valued, and supported, and the nurse gains purpose and value in his/her task (Austin & Boyd, 2010). An important fact is that clients may not listen to their doctors, nurses, and other healthcare providers except if they themselves feel valued. Dissatisfaction with healthcare providers can force clients to dodge treatment, misconstrue important information, experience more complications, and require longer recovery period (Jones et al., 2012). The therapeutic relationship is regarded as “the cornerstone of psychiatric nursing” (Dossey & Keegan, 2008, 372). Nevertheless, therapeutic relationship has no definite or conclusive definition, and those who perform it confront several problems defining it. In Welch’s (2005) research, six veteran psychiatric nurses emphasized that the major attributes of therapeutic relationship are uniqueness, self-disclosure, empathy, meaning and purpose. Other researchers also explored the views of psychiatric nurses of what comprises a therapeutic relationship. They found out that it is hard to assess the degree of positive outcome related to therapeutic relationship (Shives, 2008). Moreover, the capacity to build and sustain a therapeutic relationship is reliant, to a certain extent, on the nurse’s interpersonal abilities and the patient’s life experiences. Similarly, numerous psychotherapists regard the therapeutic relationship essential to treatment. Zuroff and Blatt (2006) investigated patients experiencing depressive symptoms and found out that a good therapeutic relationship between the nurse and patient contributed greatly to the outcome of the therapy. Some researchers also discovered that the specific therapy method applied, like cognitive behavioral therapy, for instance, had no connection to the existence of positive therapeutic outcome. If an effective therapeutic relationship is already built early in the therapy this was a determinant of better treatment outcome, alleviation in symptoms, and general wellbeing (Boyd, 2008). In view of this, it is vital to talk about major counseling theories pertaining to therapeutic relationship. Even though holistic nurses may not have knowledge or proficiency in various counseling methods, it is purposeful for them to possess a fundamental knowledge of major psychological frameworks that have shaped perspectives of counseling and therapy. Even though traditional psychology, which explores the subconscious and usually wicked desires of human beings, has been defined as psychoanalytical, the 20th-century humanistic approach carried with the idea that trust, caring, and appreciation for human intricacy are essential in psychology. The individual is seen in a holistic way, and human perfection and ingenuity are considered valuable (Elder et al., 2012). The unique part of humanistic psychology is the idea that humans are not only regulated or determined by their environments or subconscious, but are individuals of self-determination who have the capacity to develop and actualize their abilities. Holistic nurses may choose which theoretical principles they think are most appropriate to use in their practice context and in their own personal lives (O’Carroll & Park, 2007). A school of counseling and therapy is a cluster of various theories that are related to one another with regard to specific key features that differentiate them from theories in other schools of counseling and therapy. Perhaps the three major schools informing or guiding individual or specific counseling and psychotherapy method are the cognitive-behavior, humanistic, and psychodynamic school. The postmodern school, which is the fourth on, holds several more current theoretical frameworks. A. The Postmodern School The postmodern treatments are largely influenced by the perspective of social constructionism, stating that how individuals create, interpret, and process information about their surroundings, their world, and themselves is crucial to their being. Instead of theorizing improvement as a dismissal of and withdrawal from the past, postmodernism uses the past for the benefit of the present (Geldard & Geldard, 2011). The emotional experiences of individuals hinge on the labels that they assign to these emotions. How individuals view their relationships influences how they understand the response or behavior of other people and how they deal with them. Individual behavior arises from these cognitive mechanisms and is thus vulnerable or likely to change (Geldard & Geldard, 2011). A counseling and therapy approach commonly known under the postmodern school is the ‘solution-focused therapy’. This approach states that causation theories are not relevant to the effort to attain objectives and resolve issues. The counselor is tasked to direct the dialogues or conversation toward the patient’s objectives and recognizing their problems (Horsfall et al., 2001). Particular forms of questioning and application of language are exercised to promote ingenuity and flexible analysis or interpretation of the important issues. B. The Cognitive Behavior School Conventional behavior therapy concentrates largely on modifying recognizable behaviors through creating and executing various or rewarding outcomes. The cognitive behavior theory expands behavior treatment to include the impact of the way individuals ‘think’ to constructing, maintaining, and altering their problems (Norman & Ryrie, 2013). Counselors within the cognitive behavior setting evaluate patients and afterward intercede to encourage them to alter or modify particular behaviors and thoughts that reinforce and perpetuate their problems. Aaron Beck introduced the cognitive therapy. According to this counseling approach, patients become disturbed or anxious because their information processing system is defective, which, consequently, make them prone to jump to unnecessary, baseless conclusions (Jones et al., 2012). Therapy involves teaching patients how to determine the veracity of their thoughts by methods like actual experiments and Socratic questioning. C. The Humanistic School The humanistic approach is derived from humanism, a belief and values system that focuses on the more positive attributes of human beings and capabilities of individuals to develop and enhance their human abilities. Humanistic counselors focus on improving patients’ capabilities to experience their emotions and behave and think in accordance to their fundamental propensities to portray themselves as distinctive or unique individuals (Elder et al., 2012). Two counseling and therapeutic approaches are widealy associated with the humanistic school—person-centered therapy and gestalt therapy. Person-centered therapy, which was introduced by Carl Rogers, puts remarkable emphasis on the importance of subjective experience and the way patients can become detached or isolated from their humanistic experiencing by means of interacting with the assessments of others and handling them as though their own. This therapeutic approach highlights a relationship typified by sincere respect, compassion, and empathy (Elder et al., 2012). On the other hand, Fritz Perls developed the Gestalt therapy. Individuals become anxious, irrational, and obsessed by becoming detached to their senses and inhibiting their ability to make stable or healty relationships with their surroundings. Therapy stresses enhancing the awareness and strength of patients through frustration, compassion, experiments, and consciousness methods (Jones et al., 2012). D. The Psychodynamic School The concept of psychodynamic implies the transmission of mental or cognitive energy between the various stages and mechanisms of awareness within individuals’ minds. Psychodynamic methods stress the significance of ‘unconscious’ effects on how individuals function (Austin & Boyd, 2010). Therapy tries to enhance the capabilities of patients to use a higher level of consciousness over their decisions and their lives as a whole. Dream interpretation or analysis can be a therapy’s crucial component. The two most widely known psychodynamic methods are classical psychoanalysis and analytical therapy (Geldard & Geldard, 2011). Sigmund Freud introduced classical psychoanalysis. It emphasizes unconscious elements associated with infantile sexuality in the growth of neurosis (Jones et al., 2012). The psychoanalytic method, or ‘psychoanalysis’, which could take several years, stresses the conduct of transference, wherein patients see their counselors as restorations or reawakening of major personalities from their childhood years, and dream interpretations. On the other hand, analytical therapy, as introduced by Carl Jung, categorizes the unconscious into the collective and personal, the former being a storeroom of primitive images and general epitomes (Norman & Ryrie, 2013). Therapy involves transference analysis, dream interpretation, and vigorous imagination. Jung was specifically focused on working with patients in the latter portion of life (Egan, 2013). Systematic Approach to Therapeutic Communication The relationship between the nurse and the patient is mainly mediated by nonverbal and verbal communication. Relationships, similar to communication, are individualized situations and are reciprocally created through which the professional nurse-patient relationship is receptive, sensitive, and accommodating. The nurse-patient relationship is believed to be of value for patient involvement in nursing care. A systematic model of therapeutic communication involves the application of ‘broad openings, clarification, reflection, confrontation, informing, verification, self-disclosure, silence, directing, questioning, and summarizing’ (Basavanthappa, 2007, 171). The communication’s content and emotional elements are generally demonstrated in an exchange. The patient’s capacity to identify emotions and discern whether behavior is functional or dysfunctional embodies therapeutic growth to the nurse. When an emotion has been identified, the nurse afterward employ a paraphrasing or translating method to assist the patient in concentrating on this emotion, resolve misunderstandings and modify the consequent dysfunctional or misleading behavior (Peplau, 1952). In this manner, patients become skilled at new interpersonal abilities and learn to assess their emptions and convey or show them in a functional, adaptive way. The message’s content part is also essential because it allows the patient to replicate or identify and experience from his/her perspective. The nurse recognizes commonalities in issues or problems of the patient and cultivates an understanding of the distinctiveness of the patient’s condition (Sullivan, 1968). Listening, or concentrating on all the actions, responses, and behaviors manifested by a patient, is the groundwork of therapeutic communication. Listening demands effort in a form of attention or concentration that performs the following (Nugent & Vitale, 2013, 132): 1. Minimizes distractions. 2. Conveys objectivity. 3. Is not evaluative in terms of agreeing or disagreeing with the communicator. 4. Focuses on the client’s behavior. 5. Uses feedback objectively. Listening is a dynamic practice that concentrates compassionate, impartial attention on the patient. Listening to another individual involves deciphering the emotions and the content conveyed in the message. To individualize techniques for the patient, the nurse observes similarity and dissimilarity between non-verbal and verbal communication and afterward confirms such observations with the patient (Peplau, 1952). The nurse thoroughly waits or observes for the patient’s communication of inner factors that could impede the concentration required for the process of therapeutic communication. The nurse, as well, is affected by inner factors and could be tired, absent-minded, and so on. These sorts of factors can hamper the nurse-client relationship and must be assessed and altered if need to sustain a compassionate and objective setting favorable to the communication process (Videbeck, 2011). A primary objective of therapeutic communication is to employ a systematic technique to facilitate the patient’s self-disclosure and allow adaptive modifications. Ultimately, an individual’s culture shapes the expression of emotion; every culture has certain formal nonverbal and verbal medium of communication. Where an Asian may hide emotions, a Westerner may willingly and openly communicate happiness, anger, or sorrow. Communication is an important component of any culture and the nurse should thus gain knowledge of how a particular culture makes use of it. Cultural factors, like territorial rights, physical contact, and view of time, also affect communication (Shives, 2008). A culture’s communication practices influence communication of emotions, ideas, choices, and communication techniques. Major Counseling Techniques to Enhance Therapeutic Counseling Communication Skills The nurse can employ different techniques or models of therapeutic communication to interrelate with patients. The selection of technique relies on the purpose of the interaction and the patient’s capacity to communicate orally. In general, the nurse chooses methods that foster the interaction and improve communication between the nurse and the patient. Therapeutic relationship between the nurse and the patient necessitates mutual respect, compassion, empathy, trust, and acceptance (Forster, 2001). Furthermore, the patient should feel that the nurse is sincere and truly cares and concerned about his/her issues. A secure and accommodating environment encourages the nurse to accept and give importance to the external and internal experience of the patient, promote collective decision making, produce important clinical information, and create an individualized care plan (Horsfall et al., 2001). The major therapeutic communication techniques that a nurse may choose from are the following (Antai-Otong, 2008, 57): Active listening Negotiation Assertiveness Questioning Clarification Reflection Conflict resolution Self-disclosure Confrontation Silence Focusing Summarizing Giving or imparting information Verbalizing the implied Humor Therapeutic communication techniques provide both the neophyte and veteran nurse a pool of methods, like negotiation, conflict resolution, assertiveness, and active listening to build a conducive, positive work environment and relationship. As a group, these techniques promote self-respect and consideration for others, and offer a strong basis to foster and mediate patient-oriented health care (O’Carroll & Park, 2007). In the evolving health care system, it is essential for nurses to foster and employ assertive communication techniques as a way to promote professional and personal growth, ensure secure work environments, cultivate holistic and quality nursing care, and building strong, productive relationships with patients, personnel, and different stakeholders. Ethical and Professional Issues Inherent in Counseling Practices Ethical and professional issues are indispensable in counseling practice. Ethnic, racial, and social populations require psychiatric health services less often and when needed or asked, the services tend to be poor in quality and outcome. Despite of potential risks for mental and emotional disorder among various racial and ethnic populations, support systems contribute to the mitigation of risks. There are settings and situations that raise ethical issues and potential legal consequences. Competence is the most evident ethical duty of the professional, for incompetence significantly raises the possibility of harm or injury to a patient and profoundly reduces the capacity to help (Videbeck, 2011). There are ten basic values of counseling practice, namely, (1) valuing human dignity and individual rights; (2) ensuring patient’s safety; (3) guaranteeing the strength of nurse-patient relationships; (4) improving the level of professional expertise, knowledge, and competence; (5) mitigating personal misery and pain; (6) cultivating a sense of self that is relevant and helpful to the individual(s) involved; (7) enhancing personal competence; (8) strengthening relationships between individuals; (9) understanding and respecting the diversity of human culture and experience; and (10) pursuing just and sufficient delivery of counseling services (Elder et al., 2012; Dossey & Keegan, 2008). Ethical decisions that are solidly informed by several of these values without any conflict from others could be considered as soundly well-built. Nevertheless, professionals will come across situations wherein it is not possible to reunite all the relevant values and selecting between values may be needed. A judgment or decision does not automatically become unprincipled or unethical simply because it is controversial or other professionals would have arrived at different assumptions in the same situations (Boyd, 2008). The duty of the professional is to take into consideration all the important factors or situations with as much focus as is judiciously possible and to be properly responsible or answerable for choices made. Conclusions In summary, the nurse’s counseling role can be divided into several categories, namely, mentor, manager, socializing agent, maternal surrogate, and so on. Psychiatric mental health nurses, irrespective of their obligations or tasks, have a single particular goal—to create and maintain a positive, helpful therapeutic relationship with their patients. They can select from a large number of theories to help them achieve these goals. There are four major counseling and psychotherapy schools of thought, namely, postmodern, humanistic, cognitive behavioral, and psychodynamic. These theories can be applied not only in creating and maintain therapeutic relationship, but also in resolving issues or conflicts like those caused by ethical problems. One of the areas that nurses should focus on in order to build successful therapeutic relationships is therapeutic communication. There are a number of therapeutic communication techniques available, but one thing is certain, active listening strongly fosters positive therapeutic relationship. Moreover, a systematic approach to therapeutic communication has much potential and benefits. Nevertheless, in conducting these tasks, nurses and other professionals are obliged to take into consideration ethical and professional issues that are inherent to their field. References Antai-Otong, D. (2008). 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