involvement with patients and the potential of sexualisation of the nurse-patient relationship, particularly in mental health (May, ). Nursing encouraged the. disorders cannot be healed through therapeutic that development of a positive alliance (therapeutic re- of mental health nursing is more clearly defined. Keywords. Nurse-client relationship, Mental health, Emotional disorders, Therapeutic relationship Knowledge of Interpersonal and Development Theory .
Methods Integrative review process An integrative review is a research strategy involving the review, synthesis, and critique of extant literature. In addition, the reference lists of potential papers retrieved were examined to identify any further material that met the inclusion criteria. Both versions of British and American spellings were used to construct the search strategy as to reflect a systematic and comprehensive approach.
The concept of therapeutic interpersonal relationships is not confined to any specific time period or type of peer-reviewed publication, and so no limitations were placed on these parameters to ensure a broad and diverse scope of knowledge. Papers that focused on pediatrics and adolescence were also excluded as this review focused on adult patient—staff interaction. In addition, papers involving student cohorts were also excluded as were papers that reported solely on satisfaction surveys.
- Therapeutic Relationship of Nurses in Mental Health-A Review
Data evaluation The search strategy initially identified papers after removal of duplicates Figure 1. For Foucault, however, power is not something that can be held by certain groups or individuals, nor is it exclusive to intentional action.
Power is essentially a positive force which permeates all levels of society and people are always simultaneously undergoing and exercising this power. People are disciplined by discourses that work as normalising structures which guide people to understand the world and their bodies in certain ways Foucault and Sheridan In order for a relationship to be therapeutic, though, it must function as more than an everyday relationship.
It is a relationship in which the patient feels accepted as a person of worth, free to engage in self-expression without fear of rejection. The popularity of the therapeutic relationship in mental health nursing has not meant it is easily defined, however. A literature review on what makes good quality therapeutic relationship identified nine overlapping constructs within the nurse-patient therapeutic relationship See image 1which require a complex interplay of skills dependent on the needs of both nurse and patient at a given time Dziopa and Ahern Judicious use of power is implicated as one mechanism through which the development of a good quality therapeutic relationship is achieved, although the possibility of nurses abusing said power is also duly noted.
The impact of power on the therapeutic relationship has been alluded to Dziopa and Ahern ; Wilkinson and Miers However, a review of the literature within this area may shed increasing insights into whether a relationship exists.
This literature review, Inspired by my curiosity from practice, defines power as bi-directional, as something that can be used negatively in coercion, compulsion, force and threat and positively through empowerment and legitimate authority or leadership.
It also acknowledges that power can be overt as in restraint or seclusionor subtle as in persuasion, approval and observation. This literature review aims to highlight common themes in academic literature, and areas where more research is needed answering the question: How does current primary research, with relevance to mental health nursing, explore issues of power within the therapeutic relationship? There is potential for findings to help guide practice enabling nurses to be aware of the benefits and drawbacks of different facets of power and their use within the therapeutic relationship.
It is also possible that the evidence found may confirm or deny whether these concepts are related. Methodology The research question was developed during the process of preliminary searching around the concept of power and the therapeutic relationship. This allowed me to gain a sense of what published research existed on my chosen topic, leading to the development of a question that could be answered by the research available without becoming over or under saturated aiming for between 10 and 20 articles Aveyard As power can be conceptualised in different ways Scottwhich may result in the exploration of different perspectives, it is important to use the appropriate terms associated with those perspectives in order to find a breadth of literature.
Some synonyms of power have been mentioned in the introduction — yet preliminary searching revealed more. Authority represents the legitimate use of power while Control, coercion, restraint and restriction represent more invasive uses of power Scott In addition, Agency and empowerment could be seen as positive elements of power whereas influence and leverage are more subtle forms of power Wilkinson and Miers These synonyms of power were utilised as unique search terms in my preliminary search strategy.
Observations from preliminary searching demonstrated a dearth of specifically nursing literature within this topic indicating my search strategy would need to be broad. A systematic approach was adopted for the primary search strategy in order to gain a sense of the literature that already exists on this subject.
Four separate search sectors were developed to ensure specificity to nursing, mental health, power and the therapeutic relationship respectively.
These search sectors were combined using the Boolean logic AND so all results returned were relevant to all the search sectors Boagy et al. Within the search sectors, additional search operators were used informed by literature specific to performing a literature search Aveyard ; Boagy et al. The extent that the search was restricted by the generic search sectors was then considered. The following databases were accessed as considered the most relevant to nursing psychiatry and sociology: It was then necessary to develop inclusion and exclusion criteria Table 1 in order to define the scope of the review Aveyard and answer the research question: Inclusion and exclusion criteria Only articles exploring power and its synonyms and the interpersonal relationship were included.
Only articles that were relevant to nursing were included. This included articles that were interdisciplinary in nature but excluded articles that were exclusive to other professions such as physicians.
Articles examining control and restraint as an intervention were excluded. Only primary research was included. Only research published after was included. Only research available in English was included. Research from all specialities of mental health was included. Research from all countries was included.
Therapeutic Relationship of Nurses in Mental Health-A Review | Open Access Journals
As it is possible that searching through online databases alone may not find all relevant research, snowball sampling was used to accent this initial approach Aveyard When the full texts of the final articles were read, 9 did not meet inclusion criteria, leaving 10 Although similarities between findings were apparent from an early stage and fit into themes, to aid in presentation of the findings, articles were instead split into themes according to the approach used to gather data, rather than their findings.
Critical analyses of each article took place using a research appraisal framework by Caldwell et al.
Critical appraisal of the articles were presented in the appropriate themes and the impact of each article was considered and synthesized for discussion. The following articles result in a fairly narrow conceptualisation of power as coercion, which, despite being often measured on a continuum, does not allow for positive conceptualisations of power.
Also, a variety of measures are used to describe the therapeutic relationship resulting in some conceptual discrepancies within this area too. They recognise that introductions with consumers had to be negotiated through case managers which may result in social desirability bias. It is noted, however, that case managers utilised almost exclusively low-end coercive strategies, such as verbal guidance Neale and Rosenheck Higher perceived coercion was also related to shorter service contacts with a small effect size; more years spent in services with a medium effect size and negative service evaluation with medium to large effect size.
Sheehan and Burnsfrom a complimentary perspective, seek to test a hypothesized association between the therapeutic relationship and the experience of coercion. A cross sectional cohort study was conducted for a consecutive sample of admissions to five acute hospitals in Oxford, England. How the population used in this study differs from a UK population is noted with consequences for generalizability.
Furthermore, Theodoridou et al. Furthermore, involuntary admission, history of involuntary admission diagnosis of schizophrenia were all associated with higher AES scores. These three articles present corroborating evidence to demonstrate that higher ratings of the therapeutic relationship are linked to lower perceptions of coercion in inpatient psychiatric populations across England Sheehan and Burns and Switzerland Theodoridou et al.
The researchers show that coercion was significantly related to external motivation and that external motivation was partially related to lower therapeutic alliance. While none of these studies sought to examine the therapeutic relationship, relationships with professionals emerge as an important concept from their results. The following qualitative articles should help expand on the reductionist nature of quantitative research, enhancing understanding of how the variables of power and the Therapeutic relationship relate to each other in certain situations, as understood by service users, giving some sense of the complexity of this relationship.
Participants were recruited, using staff as gatekeepers, from two newly formed ACT teams in Copenhagen, Denmark. Themes were revalidated through agreement among other researchers and participants. Lack of active participation in treatment processes and a poor alliance with case managers; not being recognised as an autonomous person and crossing the line and intruding on privacy, were recognised by Thogersen et al.
On the other hand, a collaborative and mutually trusting relationship with case managers; commitment, perseverance and availability and a recognition of the need for social support and assistance with everyday activities were experiences that counteract perceptions of coercion. The study also demonstrates that different services invoke different experiences that relate to perceptions of coercion.
Namely, ACT was considered coercive in that it was intimidating and overwhelming, whereas experiences of coercion in other services were related to lack of autonomy, lack of alliance with staff and lack of influence on treatment. They define the concept of empowerment, relating it to concepts of advocacy, service user involvement and participation, stating that user participation allows transcendence of the power hierarchy inherent in psychiatry.
The population is selected from two inpatient units in Norway, each with different acuity, but similar in relation to the services offered. The three main themes included possibilities and presuppositions for participation, influence of the system on the empowerment process, and collaboration along a continuum of power between empowerment and powerlessness.
The Therapeutic Relationship and Issues of Power in Mental Health Nursing
Interesting to note for this review is that, in the possibilities and presuppositions theme, participants spoke about real acknowledgement, rather than acknowledgement as a formal claim. They acknowledge that, while participants found it difficult to engage with the concept of power, two overarching themes emerged.
First that patients feel the need for a shifting balance of power that moves over time and is dynamic according to circumstances. Within this theme it is also suggested that threats of coercion and neglect disable patients.
Second, patients saw a trusting relationship as vital in their care. Trusting relationships are portrayed as going beyond the recognised expertise gained through training and experience, to include attributes and behaviours of patients as well as staff. The value of a personal touch was also stressed through aspects of kindness, hopefulness, friendliness, conversations about shared interests and personal disclosure from staff.
There was contradictory evidence from some participants who suggest that they thought patient views should take precedence over scientific evidence and that relying on scientific knowledge was disempowering for patients.
Limit setting is frequently used in forensic settings and it focuses upon setting boundaries in the therapeutic relationship and limiting or preventing disruptive behaviour.
First, limit-setting is valued by patients as it sets boundaries around what are acceptable or unacceptable behaviours, promoting safety structure and control in the unit. This is also proposed as development of a therapeutic milieu. Experiences of humiliation and disrespect contribute to coercive experiences, whereas experiences of limit-setting in a caring way did not damage the relationship or lead to negative outcomes.
Thirdly, the authoritative, rather than authoritarian style of limit setting suggests that, from a patient perspective, an authoritarian style is experienced as intimidating, aggressive and disrespectful and damages the therapeutic relationship. Conversely an authoritative style involves the nurse being knowledgeable about the patient and setting limits in a fair, consistent and respectful manner.
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