NT3 – The Management of Therapeutic Challenges
The following assignment aims to identify, explore and discuss the therapeutic goals of working with a patient I have encountered during past clinical practice, and the challenges associated in meeting the goals and needs of the patient; this will be achieved through reflection and the consideration of the behaviour of the patient, the responses of the nursing team, and a plethora of other factors inherent within the healthcare service itself. This is important, as Shafer (1997) highlights that although the field of mental health nursing is an “exciting” arena in which to work, it also presents nurses with a wealth of challenges. The interpersonal exchanges and communication processes that occurred between the nursing team and the patient will be analysed, with the hope of recognising interactions and interventions which were effective, as well as identifying those which were ineffective (Caris-Verhallen et al, 1999). This is significant, as Miller (2002) reports that good communication facilitates the development of good interpersonal relationships, and is also considered to be a critical factor in the growth of a “positive nurse-patient relationship” (McCabe, 2004).
The seminal work of Peplau (1952) asserts the importance of an effective and successful ‘therapeutic relationship’ between nurse and patient in the delivery of holistic, high quality, patient-centred care; accrediting this interpersonal phenomenon with the ability to improve outcomes for both nurse and patient. Such relationships between patients and those caring for them can be argued to provide the “backbone upon which all other care is delivered” (Forchuk, 2002); and significantly, Graham (2001), Hewitt and Coffey (2005), Lauder et al (2002) and Welch (2005) all concur that the therapeutic relationship forms the “cornerstone” of good nursing practice. The establishment of such a relationship is a “pivotal factor in the treatment and recovery of patients” (Ramjan, 2004); and is, according to Davis and Lysaker (2007), Hewitt and Coffey (2005), Horvath and Symonds (1991) and Martin et al (2000) highly conducive to the improvement of outcomes for patients.
It cannot be denied that amongst much of the nursing literature the ‘therapeutic relationship’ between nurse and patient is widely acknowledged to form the foundation of all nursing care, and that its successful development is of crucial benefit to both parties in that relationship (Akerjordet and Severinsson, 2004; Cowin et al, 2003; Forchuk, 2002; Graham, 2001; Hagerty and Patusky, 2003; Hewitt and Coffey, 2005; Lauder et al, 2002; Peplau, 1952; Ramjan, 2004; Stuart and Sundeen, 1995; Welch, 2005; Wilson and Kneisl, 1996). However, it is also interesting to note that according to Peternelj-Taylor and Johnson (1995, p. 16) the fundamental working practices of healthcare professionals, and the healthcare environment itself “are ‘ripe’ for potential problems regarding therapeutic relationships”; indeed, it must be acknowledged that the development of an effective and functional therapeutic relationship can present both parties with a range of significant challenges (Hertzberg, 1990; Ramjan, 2004; Suikkala and Leino-Kilpi, 2001; Weiss and Delia, 2007). Furthermore, Davis and Lysaker (2007), Evans (2001), Frank and Gunderson (1990), Hagerty and Patusky (2003), Hewitt and Coffey (2005), Langley and Klopper (2005) and Rushton et al (2007) all assert that that the development of a therapeutic nurse-patient relationship is often a problematic and time-consuming process.
Before proceeding further, it may be beneficial to consider the patient and the scenario upon which I am going to base the subsequent discussion. In order to conform to the code of conduct as outlined by the Nursing and Midwifery Council (2004), and also to maintain the confidentiality of the patient in question, throughout this essay they will be referred to as ‘Jemaine’. I first met Jemaine during his second admission to an acute inpatient mental health ward, where I was placed as a student nurse; I worked closely with Jemaine throughout the duration of his admission.
Jemaine is a 23-year-old man, who has been unemployed since leaving school at the age of 16. His first contact with mental health services was at the age of 19, when he was admitted to an acute inpatient ward under Section 2 of the Mental Health Act (1983) following a rapid deterioration in his mental state, and evidence of psychosis and disturbed behaviour; this was later amended to Section 3 of the act, for treatment. Following the commencement of a regime of anti-psychotic medication and the benefits of a therapeutic environment his mental state appeared to improve and he was discharged from the ward, with after-care and regular input from the ‘assertive community treatment team’; which suggests that Jemaine may have demonstrated challenging behaviour and poor engagement with services (Evans, 2001). He then continued to reside with his widowed mother, his main carer; making good and sustained progress for a number of years; eventually enrolling at the local college to study GCSEs and also regularly attending a vocational support group.
However, in recent months following the sudden death of his grandfather he had shown inconsistency with regard to taking his prescribed medication, expressed paranoid and delusional thoughts, and had missed several appointments with his community nurse. This, in turn, may have been instrumental to the “rising levels of anxiety” among his healthcare team (Llewelyn, 2002, p.128). His mother reported to his community nurse that Jemaine had not attended college at all over the past fortnight, and also stated that she believed he had been smoking cannabis; she added that his behaviour was becoming increasingly difficult to manage and cope with. It appeared that the stress and bereavement induced by the loss of his grandfather, the most significant male role-model to Jemaine after his father died when he was a young child, had led to a progressive deterioration in his mental state (Eysenck and Flanagan, 2001). Gross (2001) supports this notion, suggesting that the stress experienced by Jemaine is also likely to increase his susceptibility to a relapse of illness.
Following a Mental Health Act (1983) assessment Jemaine was re-admitted to hospital under Section 3 of the act, as he was unwilling to accept an informal admission. The presentation and behaviour exhibited by Jemaine on admission immediately presented a number of challenges for the nursing team and myself, particularly with regard to the development of a therapeutic relationship. It may be worth noting that according to Graham (2001), Hewitt and Coffey (2005) and Langley and Klopper (2005) patients suffering with mental health problems often experience difficulty in forming and maintaining relationships, as a direct result of their illness; this notion is reiterated by Shafer (1997, p.204) emphasising that the “isolation” and social exclusion of patients with mental health problems has the potential to perpetuate a lack of interpersonal skills, and can consequently contribute to a “history of poor interpersonal relationships”, and a realm of “potential problems in the therapeutic nurse–client relationship”. This has obvious implications for all mental health nurses, and demands sensitivity and consideration.
Upon meeting Jemaine, it became clear that there were a number of factors with a vast potential for the augmentation of therapeutic challenges. As Jemaine was not willing to accept an informal admission to hospital, he was clearly being held against his will. His persecutory delusions and paranoid beliefs had appeared to heighten in intensity following his detainment in hospital, and then expanded in complexity to incorporate a number of members of the multidisciplinary healthcare team as people he perceived to have betrayed him and pose a threat to his well-being and safety (Rushton et al, 2007). When attempting the leave to hospital, and upon confronting staff about his detainment Jemaine appeared to become increasingly frustrated, aggressive and hostile when told of the limitations and restrictions imposed on him by his Section 3 (Mental Health Act, 1983) status. He appeared unwilling to accept that he was unwell, and repeatedly denied experiencing any abnormal phenomenon, appearing to firmly attribute his entire situation and presentation to being the victim of a conspiracy whereby genetic material was being stolen from his body by government agents, in order to create a clone.
The therapeutic goals of working with Jemaine included the maintaining of his safety and that of those around him at all times, and also to challenge his persecutory delusional beliefs and paranoid thoughts; the intended aim was for Jemaine to go through an appropriate grieving process for the loss of his grandfather and also to experience an overall reduction in his psychotic symptoms, with a view to being discharged back into the care of his mother and the assertive community treatment team. Whilst Jemaine was an inpatient the opportunity was also taken to attempt to engage him in meaningful and therapeutic activities with the intention of improving his rapport with both staff and the healthcare service itself (Evans, 2001); it was hoped that this would reduce his feelings of frustration whilst in hospital and reduce the level of risk posed by his hostile and aggressive behaviours (Star Wards, 2006).
Despite the initial efforts of the staff team and myself, the lack of insight displayed by Jemaine into his illness and situation presented a considerable barrier to the success of many therapeutic interventions (Davis and Lysaker, 2007); this was especially challenging, as patients cannot overcome their problems without first being able to identify and understand them (Egan, 1994). Consequently, it was also difficult in involve and include Jemaine in collaborative approaches to the delivery of his care, due to his poor engagement, poor insight and repeated “denial of illness” (Davis and Lysaker, 2007). Additionally, McQueen (2000) highlights that while collaborative practice between healthcare professionals and their patients is increasingly regarded the focus of care delivery, “some patients may not want this”; suggesting that it is beneficial for nurses to “ascertain to what extent patients want to participate in their care”. This missed opportunity to empower Jemaine through the invitation to actively participate in the decision-making processes of his own care, may have allowed Jemaine to “gain a critical understanding” of his problems, had he engaged more with staff in such collaborative efforts (Cutcliffe, 1997); such empowerment may have helped Jemaine to feel he had more control (Gibson, 1991), perpetuated feelings of hope, increased his motivation (Langley and Klopper, 2005; Miller, 1989) and also improved his experience as a patient (Downie et al, 1990).
When working with Jemaine I made a conscious effort during our interactions to paraphrase the information that Jemaine disclosed; according to Antai-Otong (1999a), Antai-Otong (1999b) and Bush (2001) this may have helped to reduce the occurrence of misunderstanding and miscommunication between Jemaine and myself, enabling the progression of comprehensive communication between us. This may have also satisfied Jemaine that I understood his situation (Sloan, 1999). I also attempted to employ ‘phatic conversation’ during our interactions, such language, often considered akin to small talk or casual chat is “used in free, aimless, social intercourse” (Malinowski, 1922), the purpose of which is to establish sociability and find commonality between both interacting parties, and additionally to maintain and regulate interpersonal relationships (Burnard, 2003). I feel that this worked well during our interactions, as Jemaine and myself are both of a similar background in terms of religion, culture, gender, social class, and in particular, age (Deering and Cody, 2002; Miller 2002); this may account for the numerous options and opportunities for initiating interactions, dialogue and rapport between Jemaine and myself, and also for the apparent ease in finding shared interests and experiences between ourselves. It is also interesting to note, that McQueen (2000) states that on some occasions, nurses may find that a “good rapport may be formed without undue effort”, however it is also important to distinguish between the development of a good rapport and the development of a good therapeutic relationship.
Significantly though, the commonalities that were quickly identified between Jemaine and myself were not enough to foster the development of trust at a comparable rate within our therapeutic relationship (Llewelyn, 2002). The importance of trust within the therapeutic relationship is emphasised by Hagerty and Patusky (2003), stating that its emergence within the nurse-patient relationship can create a climate in which patients disclose accurate and reliable information, and actively collaborate with healthcare professionals in order to achieve shared goals; furthermore, Rushton et al (2007) argue that “trust must be present in each encounter with patients”, if care is to be delivered to the highest possible standard, and the optimum patient outcomes achieved.
Trust is a crucial component of all effective therapeutic relationships (Davis and Lysaker, 2007; McQueen, 2000), and yet, it must also be acknowledged that when experiencing “conditions of great vulnerability”, for example “critical illness” our willingness and ability to trust others can become “especially fragile” (Rushton et al, 2007). This is particularly relevant to my encounters and working with Jemaine, as his suspiciousness, paranoid thoughts, and persecutory delusions all appeared to be counter-productive and inhibitory factors with regard to the development of mutual trust between us; throughout the duration of my initial meeting with Jemaine he remained guarded and suspicious, and became increasingly aggressive towards hospital staff (Brown, 1997; Langley and Klopper, 2005). Importantly, Rushton et al (2007) emphasise that as individuals, our ability to trust is “influenced” by our “perceptions” and “beliefs”; suggesting that the paranoid and suspicious thoughts, and persecutory beliefs experienced by Jemaine had huge potential to jeopardise the success of therapeutic interventions due to his strong sense of betrayal by the nursing staff (Davis and Lysaker, 2007; McQueen, 2000). This is crucial, as Rushton et al (2007) assert that “betrayal diminishes the capacity for trust”; and furthermore, if trust does not develop within the therapeutic nurse-patient relationship then “scepticism and mistrust may prevail” (Langley and Klopper, 2005).
Jemaine continued to exhibit psychotic symptoms, with increasing levels of distress and arousal. He also consistently and persistently refused all offers of his prescribed anti-psychotic medication; such non-concordance with treatment is, according to Hagerty and Patusky (2003), a likely cause of frustration among nursing staff as nurses may expect their patients to possess a desire to recover from illness, and in turn, may expect concordance and compliance with their treatment, including any prescribed medication. Indeed, I feel that this was a source of much frustration to the healthcare team and myself, due to our shared and objective stance that Jemaine was in urgent need of anti-psychotic medication, primarily for his own benefit (Wilson and Kneisl, 1996), but also to maintain the safety of others (Stuart and Sundeen, 1995). Davis and Lysaker (2007) argue that Jemaine may have been more readily open to and accepting of treatment, including pharmacological approaches, had an effective therapeutic relationship existed between a member of the healthcare team and Jemaine; reporting that the development of therapeutic relationships in practice is “broadly linked with treatment adherence” and “adherence to medication”.