Communication and Therapeutic Engagement

Facilitator - Fiona Couper

Florence Nightingale School of Nursing & Midwifery

Outcomes for the session

• To consider the nature of the Therapeutic relationships in practice

• To explore the frameworks and core conditions for engagement in practice

• To reflect on the roles that the nurse/helper plays with the patient.

• Reflect on the interventions required for effective therapeutic engagement

Nature of the therapeutic relationship

Altschul (1972) ‘Patient-nurse interaction: a study of interaction patterns in acute psychiatric wards’

• Altschul observed dyadic interactions between individual nurses and patients to explore the nature of these contacts and to see whether ‘contacts’ lead to ‘relationships’ and whether these were of value to patients

She found that:• 69% of interactions were initiated by

nurses• 41% of the patients were not

observed interacting with nurses at all

• The focus of interactions was: social conversation (42%), physical care (35%) and psychological problems (25%)

• Nurses who had high interaction rates were viewed positively by patients

• Positive attributes mentioned most frequently were: kind, cheerful, courteous, helpful, obliging, friendly, considerate, sympathetic, efficient, nice. Availability was highly valued.

• Patients greatly valued ‘interaction’ with nurses, but Altschul felt that few of these interactions developed into a ‘relationship’

• She observed highly skilled performance in the way some nurses responded to patient distress or used trivial contacts to start the patient talking

• Some nurses were able to interweave physical care with skilled interviewing

• Skilled nurses could respond to patient need – giving encouragement at the right time, staying with patients when needed.

• Altschul commented that nurses could not explain the nature of their relationships with patients describing the process as ‘common sense’

• They could not describe a theoretical basis for what they were doing

• She concluded that ‘therapeutic relationships’ were not observable in the study (might have been there but were not seen or described)

Exercise

This study is 40 years old but regarded as a seminal description of mental health nursing work.

In groups of 3-4 discuss what you have observed so far about nurse-patient relationships.

Using theory

• Theory is necessary to make sense of what we are doing

• We will consider three theoretical perspectives about therapeutic relationships:

1) Roger’s person-centred approach2) Egan’s skilled helper model3) Peplau’s interpersonal relation

theory

Therapeutic attitudes - fundamentals

Rogers, C (1965) The therapeutic relationship: recent theory and research, Australian Journal of Psychology, 17,2, 95-108

• The therapist is genuine and without front or façade

• When the therapist is experiencing a warm, positive and acceptant attitude towards what is in the client, this facilitates change

• The third essential condition of change is that the therapist is experiencing an accurate empathic understanding of the client’s private world

• Unless these attitudes are communicated, they do not exist in the world of the client and thus cannot be effective

• These are the ‘core conditions’ for a therapeutic relationship

• The aim is increased self-awareness through experiencing reflection of feelings from the nurse and acceptance of these (‘unconditional positive regard’)

• This concords with the idea in recovery that patients need to tell the story of their experience and make sense of it

• Hewitt et al (2009) describe the Rogerian approach as a ‘way of being’

• Egan’s model is a ‘way of doing’ – a problem solving approach involving partnership with the patient, again in accordance with recovery.

Egan Skilled Helper model (2002)

Egan – Skilled Helper (2002)

3 Stage model,developed in 1970s – (7th edition in 2002)1.Current scenario

2.Preferred scenario

3.Strategy:Getting there

The model helps clients to answer:– What’s going on?– What do I need or want?– What do I have to do to get what I need

or want?– How do I get results?

Current scenario (stage 1)

• What’s going on? Helping clients clarify the key issues calling for change.– 1 (A): Help clients tell their stories– 1 (B): Help clients break through

blind spots that prevent them from seeing themselves, their problem situations and their unexplored opportunities as they really are

– 1 (C): Help clients choose the right problems and/or opportunities to work on Egan (2002)

Preferred Scenario(stage 2)

• “What solutions make sense for me?” Helping clients determine outcomes– 2 (A): Help clients use their

imaginations to spell out possibilities for a better future

– 2 (B): Help clients choose realistic and challenging goals that are real solutions to the key problems and unexplored opportunities identified in part 1.

– 2 (C): Help clients find the incentives that will help them commit themselves to their change agendas

Egan (2002)

Strategy: Getting there (stage 3)

• “What do I have to do to get what I need or want?” – Helping clients develop strategies for accomplishing goals– 3 (A): Possible actions – help clients

see that there are many different ways of achieving their goals

– 3 (B): Help clients choose best-fit strategies

– 3 (C): Help clients to craft a planEgan (2002)

Summary of planning stages using Egan (2002)

Stage 1 – What’s going on?

Stage 2 – What solutions make sense for me?

Stage 3 – How do I get what I need or want?

STORY POSSIBILITIES POSSIBLE STRATEGIES

BLIND SPOTS

CHANGE AGENDA

BEST FIT

LEVERAGE COMMITMENT PLAN

Action & Ongoing Evaluation

• Action– How do I get

results?– Helping clients

implement their plans

• Ongoing evaluation– How are we doing?– Ongoing evaluation

of the helping process

(Egan, 2002)

The therapeutic relationshipin nursing

Rogers and Egan describe approaches to therapeutic relationships. Peplau attempted to describe what happens during a therapeutic nursing relationship:

• ‘the kind of person each nurse becomes makes a substantial difference to what each patient will learn as s/he is nursed throughout his/her experience with illness’

Hildegard Peplau (1952)

Peplau: four stages in the nurse-client relationship

Orientation

Identification

Exploitation

Resolution

Psychobiological Experiences

Needs

Frustration

Conflict

Anxiety

Roles in Nursing

The Nurse

Stranger

ResourcePerson

Teacher

Leader

Surrogate

Counsellor

Peplau – a literature review

• Clients perceived nurse attitude and the nature of nurse-clients interactions as being the most influential on relationship progress.

• Clients described nurses as facilitating the movement of the relationship through their availability, consistency and trustworthy actions.

• Clients described closeness, genuine liking, and trust, with the focus remaining on client needs as typical of the working phase

Stockmann (2005)

Beliefs and Values

Peplau’s approach emphasises the growth of both patient and nurse, giving importance to the phases and the roles through which they will both pass within the interpersonal process. She sees each individual as being unique with psychological, biological and social components.

Orientation

• Helping the patient to become aware of the availability of and trust in the nurses ability to participate effectively in healthcare

The nurse seeks information about the patient. The patient does not however need personal information about the nurse. Peplau suggests that if nurses do talk about personal experiences to their patients “it makes them into a sounding board for the nurses benefit”.

Identification

• Nurse facilitates expression of patients’ feelings, no rejection by nurse permits expression of illness

Exploitation

• The working phase: patient derives full value from the interpersonal relationships

Resolution

• Permits the generation and strengthening of ability to meet own need, to channel energy towards realisation of potential

Roles of the nurse in the therapeutic relationship

Orie

ntati

on Stranger

Iden

tifica

tion

Expl

oita

tion ResourceTeacherLeaderCounsellorSurrogate

Reso

lutio

n

Stranger

This would be the same role that everyone has upon meeting someone else for the first time. Strangers should not be labelled. There is a need for respect for all patients and no stereotyping.

Resource Person

Peplau sees this role as a the nurse providing information. There is a need to provide practical advice, and toi communicate this effectively

Teacher

This is where the nurse provides education and training about the patient’s ill health. This requires a relationship of trust and respect.

Leader

In this role the nurse helps the patient to take more responsibility for achieving treatment goals. Peplau supports ‘democratic nursing’, where the patient is able to negotiate and be in control of some , or all of his/her care. This requires the nurse to be flexible and prepared to consider alternatives. Autocratic leadership would offer the opposite characteristics.

Counsellor

The nurse helps the patient to understand the their current situation, by raising awareness. This is a skilled process and requires the building up of a strong interpersonal relationship. The nurse need to be a good listener, and be able to effectively use Clinical Supervision.

Surrogate

The nurse can be seen as a substitute for some one else in the patient’s past. This can be a useful experience when the patient and nurse are aware of it. It is important to remember the boundaries of a professional relationship and that a surrogate is not a replacement, it is a substitute.

John Heron’s 6 categories of intervention

AuthoritativePrescriptive: intention to direct, protect or maintain safety.Informative: intention to guide, advise or present choices.Confronting: intention to raise awareness, challenge or present new ideas.

FacilitativeCatalytic: intention to aide thinking,problem solving, reflection,creativity, or generate new ideas.Cathartic: intention to aid safe expression of emotion or affective thinking.Supportive: intention to validate, reassure, acknowledge or encourage.

John Heron-interventions

VALID

DEGENERATE

PERVERTED

Valid

This is an appropriate intervention, that takes into consideration the patients current situation. Heron states that in order to be appropriate it “is in the right category; it is the right sort of intervention within that category; its content and use of language is fitting; it is delivered in the right manner;it is delivered with good timing” (Heron 2001)

Degenerate

This is an intervention that fails in some of the criteria for a valid intervention. This is caused by lack of experience,training and awareness.

Perverted

This is an intervention that is that is deliberately cruel, and aims to hurt another.

Activity

Worksheets of scenarios using 6 categories.

References

Heron J.(2001) (5th Ed.) Helping the Client. Sage London.Peplau H.(1952) Interpersonal Relations in Nursing. London. Macmillan.Simpson. H.(1991) Peplau’s Model in Action.London. MacmillanStockmann C. (2005) A literature review of the progress of the psychiatric nurse-patient relationship as described by Peplau. Issues in Mental Health Nursing 26(9), 911 -119.

References

• Anthony WA. (1993) Recovery from mental illness: the guiding vision of the mental health system in the 1990s. Innovations and Research; 2:17-24.

• Egan, G (2002) The Skilled Helper: a problem-management and opportunity development approach to helping. 7th edition. Pacific Grove, CA: Brooks/Cole Publishing

• Stockmann C. (2005) A literature review of the progress of the psychiatric nurse-patient relationship as described by Peplau. Issues in Mental Health Nursing 26(9), 911 -119.