In the given scenario, patient Mrs Mary Brown Taylor is an elderly lady who was admitted to the hospital with issues of acute depression, mild malnutrition, dehydration, deprivation of sleep and loss of affect which causes her difficulty in managing herself. Mrs Taylor lived alone with no one to talk to. Her relatives or siblings were all far away in nursing homes or they had died. During the admission, it was found that her sleep and appetite improved significantly and also led to an increased level of effect and ability to carry out self-care activities. Mrs Taylor wishes to go back home with an apt plan of discharge, by the nurse. This essay will entail a discussion on the role of building a strong therapeutic as well as trustworthy relationship between a nurse and the mental health patient.
Role of developing therapeutic and trustworthy relationship in mental health care: Therapeutic relationship is defined as a relationship which focuses on the needs of the patient and the patient’s need act as a guiding force for nurse’ action. Therapeutic relationship building is a major aspect of nursing care. As per the NMBA standards of Nursing Standard 2 (NMBA, 2016), "A nurse engages in therapeutic and professional relationships". This is a many-fold statement which elaborates into the nurse' duty to establish effective communication with the patient; have respect for their culture, origin, age, values and belief system, to provide support to patients for making effective health care decisions, respect their autonomy, foster culture of safety and learning. Building a therapeutic relationship is a cornerstone of providing patient-centred care and a recovery-oriented approach (Barker, 2017; Hartley et al., 2020).
The mental health nursing is synchronously used with a therapeutic interpersonal process between two individuals, requiring unique efforts. It is a conjunction of interpersonal professional skill and personal life experience for gaining positive healthcare outcomes (Totura et al., 2018). Therapeutic relationship also forms the basis of the legal and ethical care practices nursing practice in mental health settings. Mental health nursing care includes proficiencies which relate with the Australian laws and policies, “such as, living will, decision-making capacity, strict adherence to Health services protection act and guardianship.” In this scenario, it is seen that Mrs Taylor wishes to go home, and her decision is respected despite of the reluctancy of the health care workers in the team who cared for her, regarding her decision.
While providing care to the mentally ill patient is important that their autonomy is respected. It is essential because it helps in building a therapeutic and trustworthy relationship between the caregiver and the individual who requires care. This act is regulated by the Quality Care Commission and states that, “Providers must make sure that they take into account people's capacity and ability to consent, and that either they, or a person lawfully acting on their behalf, must be involved in the planning, management and review of their care and treatment.
Providers must make sure that decisions are made by those with the legal authority or responsibility to do so, but they must work within the requirements of the Mental Capacity Act 2005, which includes the duty to consult others such as carers, families and/or advocates where appropriate (Quality Care Commission, n.d.).” However, the mental health care nurse must comprehend the vitality of the association between mental health and the present state the individual has presented with (Little, 2013). According to research done by Waweru et al., (2020), "Health workers are more likely to fall into traditional hierarchical practice behavior when there is lack of effective supportive supervision and mentorship" and Epstein, (2014), because of the increase in the burden on the healthcare staff it has become difficult for the nurses to provide adequate time to the patients in a mental health set up.
The mental health nurse also requires and strength to effectively communicate with the patient and to provide better care. Health workers must be trained and supervised when they are communicating with the patients. The nurses are not been given a distinct training in their academic years for developing a therapeutic relationship, but is a skill which is developed with experience. Therefore, emphasis should be laid on improvising the nursing skills in the clinical setting concerning the abilities of the nurse to inculcate feelings of empathy; respect; cultural competency and mind-fullness while treating the patients with mental health issues.
Another significant component of therapeutic care is active participation. By encouraging person to actively participate in their care lead to improved healthcare outcomes (Kim et al, 2018). The participation of caregivers or immediate family members is also beneficial in providing support and improving the care of the person. It improves the experience of the person as well as supports in achieving his or her overall well-being. Person-centred care offers a challenge for the healthcare workers to appreciate a paradigm shift in the processing of the delivery of healthcare. The shift occurs in the way the person is seen as a whole and not as an individual problem or issue the person has been presented with. It forms the basis of providing holistic care and improving the person's quality of life rather than focusing only on the health conditions.
It also focuses on the management of the disabilities of the person and improvising the care plan as per the new inputs with the person's and the care giver's experience with the treatment or care being provided (Waweru et al, 2019). The healthcare professional who is providing person-centred care also prioritizes the schedules according to the schedule of the person. This is important especially if the person is suffering from a long-term illness or is an older adult.
Healthcare professional must understand that the condition and the challenges faced by the person who is already suffering from an ailment or disease. It is also the responsibility of the healthcare worker to let the person decide the timing and the date of visit comfortable for the person. The person must understand all the risks, procedures, side-effects as well as the benefits of all the actions taken in providing the care and consents with it.
According to NMC, (2018), Standard states that, “work in partnership with service users, caregivers, groups, communities and organizations. They must manage risk, and promote health and wellbeing while aiming to empower choices that promote self-care and safety. Also, support and promote the health, wellbeing, rights and dignity of people, groups, communities and populations. These include people whose lives are affected by depression, sleeping disorders or primarily any other mental health illness.
Nurses must act on their understanding of how these conditions influence public health." Therefore, the patient must be educated about the health condition they are suffering from and also provide support in learning the progression of treatment. It has known to increase the compliance of the individual to the treatment protocol. Building a therapeutic relationship with the patient also helps in reducing the burden on the healthcare system by increasing the ownership of care by the patients. It reduces the period of hospitalization as well as the cost incurred by the healthcare system (Fisher, 2017; Frank, 2018).
The discharge plan for Mrs Taylor must include adherence to medical management and regular presence in routine follow-ups. Mrs Taylor should be advised to meet new people and get out of the house for some time during the day for a walk and she must maintain an exercise routine and have fixed meals. This would reduce her depression and reduce the anxiety; exercising will help her to sleep well. NMBA, In standard 5, statement 2 states: "together constructs nursing practice plans until contingencies, options, goals, procedures, outcomes and timeframes are agreed with the relevant persons." Therapeutic coalition with the patient has a positive impact on the outcomes as seen in this case scenario.
During the admission, it was found that her sleep and appetite improved significantly and also led to an increased level of effect and ability to carry out self-care activities. Therapeutic coalition starts with goal setting and working in collaboration with the patient, improves compliance with the goals, improves medication adherence and accomplishes psychoanalytical discipline. The therapeutic role of mental health nursing staff is extremely important in settings such as inpatient wards, where there is a continuous or a prolonged interaction of the patient with nurses which leads to the development of therapeutic and trustworthy relationship between them (Hopkins, Loeb, & Fick, 2009; McAndrew, Chambers, Nolan, Thomas, & Watts, 2014), and better healthcare outcomes are anticipated, as in case of Mrs Taylor.
Barker, P. (2017). Psychiatric and mental health nursing: The craft of caring. United States of America. CRC Press.
Care Quality Commission, (n.d.). The Independent Regulator of Health and Social Care in England. Retrieved from https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-9-person-centred-care
Epstein, R. M. (2014). Realizing Engel's biopsychosocial vision: resilience, compassion, and quality of care. The International Journal of Psychiatry in Medicine, 47(4), 275-287.
Fisher, M. (2017). Professional standards for nursing practice: How do they shape contemporary rehabilitation nursing practice?. Journal of the Australasian Rehabilitation Nurses Association, 20(1), 4.
Frank, L. (2013). Person-centered care, autonomy, and the definition of health. The American Journal of Bioethics, 13(8), 59-61.
Hartley, S., Raphael, J., Lovell, K., & Berry, K. (2020). Effective nurse–patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance. International Journal of Nursing Studies, 102, 103490.
Kim, K. K., Khodyakov, D., Marie, K., Taras, H., Meeker, D., Campos, H. O., & Ohno-Machado, L. (2018). A novel stakeholder engagement approach for patient-centered outcomes research. Medical care, 56(10 Suppl 1), S41.
Little, M. (2013). A better grounding for person-centered medicine? The American Journal of Bioethics, 13(8), 40-42.
NMBA (2016). Registered nurses STANDARDS FOR PRACTICE. Retrieved from file:///C:/Users/nidhi/Downloads/Nursing-and-Midwifery-Board---Standard---Registered-nurse-standards-for-practice---1-June-2016%20(1).PDF
NMC, (2018). Standards for competence for registered nurses. Retrieved from https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-competence-for-registered-nurses.pdf
Totura, C. M. W., Fields, S. A., & Karver, M. S. (2018). The role of the therapeutic relationship in psychopharmacological treatment outcomes: a meta-analytic review. Psychiatric Services, 69(1), 41-47.
Waweru, E., Sarkar, N. D., Ssengooba, F., Gruénais, M. E., Broerse, J., & Criel, B. (2019). Stakeholder perceptions on patient-centered care at primary health care level in rural eastern Uganda: A qualitative inquiry. PLOS ONE, 14(8), e0221649.
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