Conclusion And Recommendations * Corresponding author AbstractAlthough a therapeutic relationship is essential to psychiatric/mental health nursing practice, its use is problematic because the nursing attributes contributing to a therapeutic relationship are elusive. A review of the literature in the field of psychiatric/mental health nursing was conducted to conceptualize constructs contributing to the development of a therapeutic relationship in advanced practice psychiatric/mental health nursing.A typology of nine general attributes were identified which have practical implications for psychiatric/mental health nursing education and practice. Recommendations include the application of a typology of constructs upon which psychiatric/mental health nurse curricula, in-service education, and reflective practice can be based. Introduction/ BackgroundThe establishment of a quality nurse-patient relationship is considered important in most nursing situations (1). However, in psychiatric/mental health nursing, the interpersonal interaction is the core of practice (2,3) making the therapeutic relationship a fundamental element of mental health care (4).
Indeed, the therapeutic relationship employed in mental health care has been associated with therapeutic outcomes across a range of clinical settings and patient populations (5). Ironically, despite the therapeutic relationship being vital to treatment outcomes, the formation of a quality therapeutic relationship between the psychiatric/mental health nurse and patient is not an instinctive occurrence and requires great skill to be established (6). Berg and Hallberg (7) found that caring for people with mental illness ‘demands an intensified presence, not allowing one to glide away, close the door or just disappear’ (p. 329).
The daily work demand requires psychiatric/mental health nurses have the capacity to handle continually new and unpredictable experiences (7).This endeavour is made more difficult because in some situations psychiatric/mental health nurses are faced with the paradox of providing therapeutic care in conjunction with involuntary treatment (8) and detainment (9). In short, psychiatric/mental health nurses require specialized skills in order to develop and maintain therapeutic relationships with patients. The specialized skills required by psychiatric/mental health nurses to develop therapeutic relationships are elusive (10). Weissmark and Giacomo (11) concluded in their discussion of measuring therapeutic relationships, that although global rating methods can use items such as “warmth” and “judgementalness’ to distinguish good from poor relationships, these terms do not specify what the therapist does to establish a therapeutic relationship.As long as these interpersonal attributes remain vague, opportunities for high level practice and research will be lost.
The purpose of this paper is to review the research literature in psychiatric/mental health nursing to develop a typology of the components that constitute one of the main tools of psychiatric/mental health nursing; that of the therapeutic relationship with a patient. This typology will constitute the beginning of the operationalization of specialist behaviors and skills required in building an effective nurse-patient relationship, which will enable the development of behavioural criteria to enhance advanced psychiatric/mental health nursing practice, research and education.Literature ReviewA search was conducted through the electronic search engines MEDLINE, CINAHL, PSYC INFO and WEB OF SCIENCE. The keywords used were therapeutic relationship, therapeutic alliance, working alliance, nurse patient relationship, nurse patient interaction, mental health, mental illness and psychiatry. Research literature between the years 1996 to 2008 was accessed because this period marks the publication of almost all articles on evidence-based practice (12). Peer reviewed studies which referred to and described nurse attributes in their findings were included.
The literature review yielded 31 research studies. These studies were heterogeneous in that the sampling, data collection, analysis and research focus of the studies all differed.The investigators found that a therapeutic relationship in advanced psychiatric/mental health nursing could be deconstructed into nine main constructs: conveying understanding and empathy, accepting individuality, providing support, being there/ being available, being genuine, promoting equality, demonstrating respect, maintaining clear boundaries and having self awareness. Figure 1 provides the attributes contributing to these constructs.
Figure 1: Attributes and Constructs Contributing to a Therapeutic Relationship in Psychiatric/Mental Health Nursing Understanding and EmpathyUnderstanding is a vital element in the development of a therapeutic relationship in mental health nursing. Both patients (2,13) and nurses (3) value the ability of mental health nurses to convey understanding.Conveying understanding is important as it instils patients with a sense of importance (14). Feeling important is significant to the lives of people who live in a society, which often stigmatizes them because of their mental illness (15). Notably when the nurse knows and understands the patient, the nurse assists patients to understand themselves (16), empowering them to influence their treatment (13).
Consequently knowing the patient promotes individualized care (6). Active listening is considered to be one of the core elements of understanding (15,17). To fully apply listening to convey understand the psychiatric/mental health nurse must not only hear the patient but also be attending and attentive.Accordingly, Johannson and Eklund (13) determined when psychiatric/mental health nurses gave proper attention and appeared interested, patients felt understood.
Needless to say interpersonal and communication techniques such as summarizing, clarifying, reflecting, and providing eye contact are considered essential to understand and relate to the patient (15). In addition to the skill of listening to understand the patient accurately, the psychiatric/mental health nurse must appreciate the unique communication, problems and situation of the patient (13,16). To truly understand the uniqueness of each situation psychiatric/mental health nurse must go beyond what is expected of most other health professionals to attain an in-depth personal knowledge of the patient (15).As noted by Geanellos (18) rather than simply containing “testing” and “acting out” behaviour, the psychiatric/mental health nurse must look beyond the obvious and strive to understand and ascribe meaning to the behaviour. The in-depth knowledge required to develop this level of understanding requires time and skill to understand (15). Importantly, the patient’s unique personal experience is worthy of the deepest respect.
The psychiatric/mental health nurse is required to treat the patient’s personal experiences as a gift brought to the relationship (10). The expression of thoughts and feelings should be encouraged without blaming, judging or belittling (18). As found by Shattell et al. 15), the way the psychiatric/mental health nurse responds when the patient divulges “terrible” information can either promote or impede the relationship.
When psychiatric/mental health nurses in their study had developed skills to be able to respond without shock or revulsion, the patient felt a sense of understanding in addition to feeling normalized as a human being (15). Non-judgemental attitudes are critical to this process (2). Essentially by relating to the patient as a person, the psychiatric/mental health nurse enables the patient to feel understood (15). To encourage this type of understanding the psychiatric/mental health nurse must interact foremost as a human being (17), talking to the patient as a neighbour or friend rather than a counsellor or expert (15).In addition the sharing of common experiences, such as similar backgrounds and mutual adversities has also been found to help the patient to connect with the psychiatric/mental health nurse and feel understood (14). In psychiatric/mental health nursing, certain situational expectations and communication barriers make understanding an involved process.
For instance Hem and Heggen (19) were astonished by the way the psychiatric/mental health nurse in their study maintained empathy for the patient. When subjected to fierce personal attacks, the psychiatric/mental health nurse retained the desire and ability to understand the patient. Involvedness is also required when patients expect nursing staff to understand the patient even when they are unable to express their needs verbally (7,20).Furthermore Johansson and Eklund (13) found that understanding was an involved process for “younger” psychiatric/mental health nurses who had to defeat barriers to communicate with patients who were uncomfortable disclosing their problems with “younger staff”.
Seemingly, in different situations, individuals will require different levels of involvedness and skill to practice understanding. Individuality Individualized care is mediated through knowing the patient (6). To obtain this knowledge the psychiatric/mental health nurse must see patients as individual people with lives beyond their mental illness. Seeing people as individuals with lives beyond their mental illness is imperative to make patients feel valued (21) and respected (22).
