What Makes a Quality Therapeutic Relationship in Psychiatric/Mental Health Nursing: A Review of the Research Literature

摘要

Although 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/ Background The 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 ([23]) 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 Review A 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. Th