Psychiatric Nursing

Definition

Therapeutic nurse-patient relationship is a mutual learning experience and a corrective emotional experience for the patient. It is based on the underlying humanity of nurse and patient, with mutual respect and acceptance of ethnocultural differences.

Peplau's theory

Peplau's theory focuses on the interpersonal processes and therapeutic relationship that develops between the nurse and client. The interpersonal focus of Peplau's theory requires that the nurse attend to the interpersonal processes that occur between the nurse and client. Interpersonal process is maturing force for personality. Interpersonal processes include the nurse- client relationship, communication, pattern integration and the roles of the nurse. Psychodynamic nursing is being able to understand one's own behavior to help others identify felt difficulties and to apply principles of human relations to the problems that arise at all levels of experience. This theory stressed the importance of nurses' ability to understand own behavior to help others identify perceived difficulties.

1. Orientation:

During this phase, the individual has a felt need and seeks professional assistance. The nurse helps the individual to recognize and understand his/ her problem and determine the need for help.

2. Identification

The patient identifies with those who can help him/ her. The nurse permits exploration of feelings to aid the patient in undergoing illness as an experience that reorients feelings and strengthens positive forces in the personality and provides needed satisfaction.

3. Exploitation

During this phase, the patient attempts to derive full value from what he/ she are offered through the relationship. The nurse can project new goals to be achieved through personal effort and power shifts from the nurse to the patient as the patient delays gratification to achieve the newly formed goals.

4. Resolution

The patient gradually puts aside old goals and adopts new goals. This is a process in which the patient frees himself from identification with the nurse.

Overlapping phases in nurse- patient relationship

Peplau defines Nursing Process as a deliberate intellectual activity that guides the professional practice of nursing in providing care in an orderly, systematic manner.

Peplau explains 4 phases such as:

• Orientation: Nurse and patient come together as strangers; meeting initiated by patient who expresses a "felt need"; work together to recognize, clarify and define facts related to need.

• Identification: Patient participates in goal setting; has feeling of belonging and selectively responds to those who can meet his or her needs.

• Exploitation: Patient actively seeks and draws knowledge and expertise of those who can help.

• Resolution: Occurs after other phases are completed successfully. This leads to termination of the relationship.

In Nursing Process, the orientation phase parallels with assessment phase where both the patient and nurse are strangers; meeting initiated by patient who expresses a felt need. Conjointly, the nurse and patient work together, clarifies and gathers important information. Based on this assessment the nursing diagnoses are formulated, outcome and goal set. The interventions are planned, carried out and evaluation done based on mutually established expected behaviours.

Goals of Nurse-Patient Relationship

Goals of nurse-patient relationship as given by Travel bee Joycee in 'Intervention in Psychiatric Nursing'

1.       The nurse helps the patient to cope with the present problems.

o   The reasons for patient's hospitalization

o   Identify patient's perception of present problems

o   Collection of information from the patient himself.

o   Nurse does not try to go back to the past history from secondary sources.

2.       The nurse helps the patient to understand the problems.

o   Nurse keeps this goal through out the relationship.

3.       The nurse helps the patient to understand his active participation in an experience.

4.       The nurse assists the patient to identify emerging problems realistically.

5.       The nurse helps the patient to find out a new alternative for his or her problem.

6.       The nurse helps the patient to try out new patterns of behaviour.

7.       The nurse helps the patient to communicate.

8.       The nurse helps the patient to communicate.

9.       The nurse helps the patient to find meaning in his illness.

Types of Therapeutic relationship

Based on the goals it can be divided in to:

1.       Immediate: in this situation, the nurse and client do not know each other and the client is in immediate severe difficulty that requires the nurse to interact or intervene.

2.       Short-term: The nurse and the patient have an association with each other. Even if the nurse knows the patient, she has no responsibilities for the patient.

3.       Long-term: Nurse interacts with the patient in an effort to provide a corrective emotional experience. The nurse will be supporting the patient and giving care to the patient.

Components of nurse-patient relationship

The components of the nurse-client relationship, rapport, power, trust, respect, and intimacy, are present whenever the nurse is providing nursing services. The nurse-client relationship is therapeutic; it is based on trust, respect and intimacy with the client and requires the appropriate use of power.

1.     Rapport

Getting acquainted and establishing rapport are the primary tasks in relationship development. It implies special feelings on the part of both the client and nurse based on acceptance, warmth, friendliness, common interest, a sense of trust and a non-judgmental attitude. Establishing rapport may be accomplished by discussing non-health related topics.

2.     Power

The therapeutic nurse-client relationship is one of unequal power. Although nurses may not perceive themselves as having power in the relationship, nurses have more power than the client. The power of the nurse comes from the authority of own position in the health care system, specialized knowledge, influence with other health care providers and the client's significant others, and access to privileged information. In any professional-client relationship, there is an imbalance of power in favour of the professional, and is reinforced in health care services by the inherent vulnerability of a client needing care.

3.     Trust

To trust another, one must feel confidence in that person's experience, reliability, integrity, veracity and sincere desire to provide assistance when requested. It is the basis of therapeutic relationship. The nurse must have perfect skills that foster the development of trust-worthiness. Clients expect the nurse to have the necessary knowledge and skills and to demonstrate caring attitudes and behaviours, and so entrust their care to the nurse. Trust is critical, as the client is in a vulnerable position in the relationship. Part of trust is keeping promises to clients. If trust is breached, then it becomes very difficult to re-establish it.

4.     Respect

To show respect is to believe in the dignity and worth of an individual regardless of his or her unacceptable behaviour. Respect for the dignity and worth of the client is fundamental to the relationship. The nurse needs to know and understand the culture and other aspects of the client's individuality and to take these into account when providing care. Part of respect is being non-judgmental of the client, and seeking to discover the meaning behind certain of the client's behaviours.

The nurse can convey an attitude of respect through the following interactions:

-          Calling the person by name

-          Spending time with the individual

-          Allowing for sufficient time to answer the client questions and concerns

5.     Genuineness

The concept of genuineness refers to the nurses' ability to be open, honest and real in interactions with the client. To be 'real' is to be aware of what one is experiencing internally and express this awareness in the therapeutic relationship. When one is genuine, there will be congruence between what is felt and what is being expressed.

6.     Intimacy

Intimacy relates to the kinds of activities nurses perform for and with the client which create personal and private closeness on many levels. This does not refer to sexual intimacy. This can involve physical, emotional and spiritual elements.

Principles of nurse-patient relationship

A nurse is expected to be competent and to have the professional attributes required to manage a therapeutic relationship. The nurse-client relationship is established and maintained by the nurse through the use of professional nursing knowledge and skill, and caring attitudes and behaviours. The following are the underlying principles of professional practice:

1.        The nurse functions within the standards for nursing practice.

2.       The nurse knows the requirements of and recognizes own accountability for maintaining professional behaviour. It is the responsibility of the nurse to set and maintain the appropriate boundaries for the duration of the relationship regardless of the wishes of a client or the setting in which the relationship occurs. Nurses are responsible for the outcomes of their actions in the nurse client relationship, including outcomes that may have been unintended, but should have been foreseen.

3.       Although both the nurse and the client have needs, the therapeutic nurse-client relationship is developed for the purpose of promoting client health and well-being and not to meet the needs of the nurse.

4.       The nurse respects the individual characteristics of the client such as cultural and social identity, appearance, sexual orientation and religious affiliation, and recognizes the impact that these have on both the nurse-client relationship and the health of the client.

5.       Nurses recognize when they do not possess the necessary knowledge or skills to manage the therapeutic nurse-client relationship and seek information and assistance from other members of the health team or elsewhere.

6.       It is recognized that some client's behaviour can be abusive to nurses. It is the nurse's responsibility to understand the meaning behind the abusive behaviour and to work with the health team to develop strategies to meet the client's needs. The nurse seeks help and guidance when dealing with challenging clients.

Structuring Therapeutic Relationships

Central to the establishment of the therapeutic nurse-client relationship is the nurse's ability to use a wide range of communication strategies and effective interpersonal skills. Effective communication is an essential factor in creating and maintaining a successful relationship. Regardless of the setting and the length of interaction, the nurse acts in therapeutic ways to manage the boundaries of the relationship. This involves:

• introducing self to the client and addressing the client by preferred name and/or title;

• listening to the client without immediately giving advice or diminishing the client's feelings (The nurse listens to, understands and respects the client's values, opinions, needs, and ethno-cultural beliefs. These latter elements are integrated into the care plan, with the client's assistance. The nurse listens to the concerns of the family and significant others about the client and acts on those concerns as appropriate.);

• identifying the goals and wishes of the client and incorporating them into the plan of care;

• giving the client time and opportunity to explain self and to ask questions;

• exploring unusual comments, attitudes or behaviours of clients to discover the underlying meaning;

• showing a genuine interest in, and compassion for, the client;

• providing information to promote client choice and to enable the client to make informed decisions;

• helping clients find the best possible solution for themselves, given their personal values, beliefs, and different decision making styles (The nurse discusses the client's beliefs and wishes with them and encourages them to advocate on their own behalf or advocates for them.); and

• discussing the boundaries of confidentiality with the client including the nurse's legal responsibilities.

STAGES OF NURSE-PATIENT RELATIONSHIP

A.   Pre-interaction Phase

Pre-interaction phase begins before the nurse's first contact with the patient. Nurse's initial task is one of self exploration. In the first experience working with psychiatric patients, the nurse brings misconceptions and prejudices of the general public, in addition to feelings and fear about new situations.

Common Concerns of Psychiatric Nursing students are:

1.       afraid of being rejected by the patient

2.       anxiety due to the newness of the experience

3.       concerned about over identifying with the patient

4.       doubtful about the effectiveness of the skills or coping activity

5.       fearful of physical danger/violence

6.       suspiciousness of psychiatric patients behaviours

7.       uncertain about ability to make unique contribution

8.       vulnerable to emotionally painful experiences

9.       worried about hurting the patient psychologically

Tasks in Pre interaction phase

• obtaining available information about the patient from medical records, significant others or other health team members

• initial assessment form the available information

• explore own feelings, fantasies and feelings

• analyse professional strengths and limitations

• plan for first meeting with patient

B.   Introductory phase

During this phase the nurse and patient fist meet. One of the first primary concerns of the nurse at this phase is to find out why the patient sought help. The reasons for seeking help and whether or not it was voluntary from the basis of assessment help the nurse to focus on the patient's troubles and determine the patient's motivation for treatment.

Tasks in Introductory phase

• creating an environment for the establishment of trust and rapport

• determine why patient sought help

• determining a contract fro interventions that has details of expectations and responsibilities of both nurse and patient

• getting assessment information to build a strong patient database

• formulating nursing diagnosis, setting goals that are mutually agreeable to the nurse and patient

• developing a plan of action that is realistic for meeting the established goals

• explaining the feelings of both the patient and nurse in terms of the introductory phase

• analyze why patient is seeking psychiatric help:

  • desire for environmental change to treatment setting

  • control of psychiatric symptoms

  • for problem-solving

  • may be advised to seek medical help

The reason for seeking helps form the basis of the nursing assessment and helps the nurse in the patient's problems.

Formulating a contract

Tasks in this phase of the relationship are to establish a climate of trust, understanding and communication and formulate a contrast with the patient.  Elements of nurse-patient contract are:

• name of the individuals

• roles of nurse and patient

• responsibilities of nurse and patient

• expectations of nurse and patient

• purpose of the relationship

• meeting location and time

• conditions for termination

• confidentiality

Exploring the feelings

Both the nurse and patient may experience some degree of discomfort and nervousness in the introductory phase. The nurse may be well aware of thoughts and feelings.

1. Risk for Suicide related underlying psychopathology

Risk Factors

o   Suicidal ideas, feelings, ideation, plans, gestures, or attempts

o   Lack of future orientation

o   Feelings of worthlessness, hopelessness, or despair

o   Sleep disturbance

o   Substance use

o   Social isolation

o   Problems of depression

• Expected Outcomes

  • Patient remain free from harm and suicidal thoughts

• Interventions

  • Collect detailed information about the condition and related depressive thoughts

  • Assess the client's suicidal potential, and evaluate the level of suicide precautions at least daily

  • Ask the client if he or she has a plan for suicide. Attempt to ascertain how detailed and feasible the plan is.

  • Determine the appropriate level of suicide precautions for the client.

  • Help the client to identify negative thoughts and positive thoughts

  • Maintain especially close supervision of the client at any time there is a decrease in the number of staff, the amount of structure, or the level of stimulation

  • Observe, record, and report any changes in the client's mood

2. Disturbed Sensory Perception :Auditory related to biochemical changes in the brain as evidenced verbal expression of hearing voices

• Assessment Data

  • Hallucinations (auditory)

  • Inability to discriminate between real and unreal perceptions

  • Attention deficits

  • Inability to make decisions

  • Feelings of insecurity

• Expected Outcomes

  • Demonstrate decreased hallucinations

  • Interact with others in the external environment

  • Participate in the real environment

• Interventions

  • Avoid conveying to the client the belief that hallucinations are real.

  • Explore the content of the client's hallucinations during the initial assessment to determine what kind of stimuli the client is receiving, but do not reinforce the hallucinations as real.

  • Use concrete, specific verbal communication with the client.

  • Encourage the client to tell staff members about hallucinations.

  • If the client appears to be hallucinating, attempt to engage the client's in conversation or a concrete activity.

  • Show acceptance of the client's behavior and of the client as a person; do not joke about or judge the client's behavior.

3. Social Isolation

• Assessment Data

  • Inappropriate or inadequate emotional responses

  • Poor interpersonal relationships

  • Feeling threatened in social situations

• Expected Outcomes

  • Report increased feelings of self-worth

  • Identify strengths and assets

  • Engage in social interaction

• Interventions

  • Teach the client social skills. Describe and demonstrate specific skills, such as eye contact, attentive listening, and so forth.

  • Discuss the type of topics that are appropriate for casual social conversation, such as the weather, local events, and so forth.

  • Support any successes or responsibilities fulfilled, projects, interactions with staff members and other clients, and so forth.

4. Noncompliance

• Assessment Data

  • Exacerbation of symptoms

  • Failure to keep appointments

• Expected Outcomes

  • Identify risks of noncompliance Verbalize acceptance of illness

  • Identify risks of noncompliance

• Interventions

  • Teach the patient and the family or significant others about the patient's illness, treatment plan, medications

  • Help the patient to draw a connection between noncompliance and the exacerbation of symptoms.

  • If the patient expresses feelings of being stigmatized (ie, being observed taking medications by friends or coworkers), assist the patient to arrange dosage schedules so that he or she can take medications unobserved.

  • If the patient is experiencing distressing side effects, encourage him or her to report them rather than stopping medication entirely.

C.   Working Phase

The focus of working phase is to achieve the goals that were worked out in the nurse-patient contract. This is the time for working on solving the problems and trying out new behaviours. Most of the therapeutic work is carried out during this phase of relationship. The nurse and the patient explore stressors and promote the development of insight in the patient by6 linking perceptions and thoughts feelings and actions.

Tasks in working phase

• Maintaining the trust and support that was established during the orientation phase of relationship

• Promoting the patient's insight and perceptions of reality

• Problem solving using the model presented earlier

• Overcoming resistant behaviour on the part of the patient as the level of anxiety rises in response to discussion of painful incidents.

Working phase consists of periods of growth and resistance. As the relationship moving towards its goals, the client's behaviour changes. At this time, it is important to explore the meaning of the change in the client. Patients often display resistance during this phase, because it involves greater part of the problem-solving process. As the relationship develops, the patient begins to feel close to the nurse and responds by changing the old defenses and resisting the nurses attempt to move forward. This results in impasse or plateau in the relationship.

Therapeutic Impasses

For variety of reasons therapeutic communication can be hindered. Therapeutic impasses are blocks in the progress of nurse-patient relationship. They arise for variety of reasons, but the all crates stall in the process of nurse-patient relationship.  Impasse provokes variety of emotions in both he patient and nurse ranging from anxiety and apprehension to frustration, love, or intense anger. The commonest four impasses are discussed here: resistance, transference, counter transference and boundary violations.

Resistance

Resistance is the patent's reluctance or avoidance of verbalizing or experiencing troubling aspects of oneself. The term was first coined by Freud. Resistance is often caused by patient's unwillingness to change when the need for change is recognized. Patient usually displays resistance during the working phase of nurse-patient relationship, because greater part of problem-solving occurs during this phase.

Transference

Transference is an unconscious response in which the patient experiences feelings and attitudes toward the nurse that were originally associated with other significant figures I his or her life.

• They may be triggered by superficial similarity, such as facial features or speech, or by personality style or trait.

• These reactions are the patient's attempt to reduce anxiety.

• The nurse may be viewed as an authority figure from the past such as parent figure, or lost loved object, such as former spouse

• Transference reactions are harmful to the therapeutic relationship only if they are ignored and unexplained.

Countertransferance

It is a therapeutic impasse created by the nurse's specific emotional response to the qualities of the patient. This is inappropriate to the content and context of therapeutic nurse-patient relationship. It is transference applied to the nurse. It is natural that nurse feels warmth toward or liking for some patients more than others. The nurse also will be genuinely angry about the actions of some patient. But in countertransfernce, the nurse's responses are not justified by reality. Here nurse identify the patient with individuals from their past, and personal needs interfere with their therapeutic relationship.

Boundary Violations

Here the nurse goes beyond the boundaries of therapeutic relationship and establishes a social, economic, or personal relationship with a patient. Boundary violation is involved whenever a nurse is doing or thinking of doing something special, different or unusual for a patient.

D.   Termination of Relationship

At the beginning of the relationship, the nurse establishes with the client, family and health team an estimated period of time that the relationship will last. The health-related goals and needs of the client determine when the relationship will end. The nurse might indicate, for example, the necessity of providing care for one shift in a hospital setting or until the ulcer heals (at home in the  community), or until the client has no further need for nursing services.

As the time for terminating the relationship approaches, the nurse needs to discuss ongoing plans for meeting the client's care needs. The nurse and client may identify other necessary resources with other team members helping the client identify what would work best for him/her. In some settings, this may include discharge planning with a referral to community organizations. It may also involve a transfer to another health care provider in the same organization or from one shift to another.

Conclusion

All nurses need to work together to prevent abuse of clients and ensure safe, effective care.

Each nurse needs to:

• understand the nature of the therapeutic nurse-client relationship;

• establish and maintain the boundaries of the relationship;

• ensure that the client understands the role of the nurse and the limits of that role;

• be aware of situations that are high risk for boundary violation, for example, settings where nurse client relationships are long term or for settings where the nurse works with little supervision;

• terminate the relationship with the client in a manner that reflects an understanding of the client's needs and goals;

• practice self-reflection to achieve awareness of own professional practice and to understand the dynamics of client situations;

• ensure own personal needs are met outside client situations;

• take action to deal with personal and job-related stress;

• seek out and use resources to assist in caring for clients with challenging behaviours;

• advocate for appropriate care resources for clients;

• intervene when witnessing abuse of clients or colleagues crossing the boundaries;

• report incidents of crossing boundaries, professional misconduct and abuse in the appropriate manner; and

• advocate for the elements of a quality practice setting.

References

1. Dexter G. Psychiatric Nursing skills- A patient-Centred approach. 2^nd edn. Chapmal & Hall London. 1995.

2. Fertinash M K. & Hooldey A P. Psychiatric Mental Health Nursing. 3^rd edn. Mosbey Philadelphia, 2003.

3. Teyler MC. Eessentials of Psychiatric Nursing. 14^th edn. Mosbey London, 1994.

4. Stuart GW. Principles and Practice of Psychiatric Nursing. Harcourt Health Sciences, 2006.

5. Mohr KW. Psychiatric Mental Health Nursing 6^th edn. LWW Philadelphia, 2006.

6. Standard For The Therapeutic Nurse-Client Relationship. Nurses Association Of New Brunswick, Canada, 2000.