MASTER OF ARTS IN NURSING Major in Clinical Instruction

The Effectiveness of Therapeutic Relationship Provided by the Psychiatric Nurse in Contrast with the Psychiatrist

As Perceived by Schizophrenic Patients

~ A thesis proposal~

In partial fulfilment of the requirements for the subject Philosophical and Theoretical Foundations of Nursing (MAN 101)

Mr. Jordan Albert J. Cruz, RN

Mr. Chito L. Pagsanghan, RN, MAN MAN 101 Professor

October 17, 2010

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INTRODUCTION

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 (2,3

) 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).

In health care research, the patient-healthcare professional relationship as perceived by

the patient is considered important. It is the interaction that is toward enhancing the client's

well-being, and the client may be an individual, a family, a group or a community. The patient

will experience better health when all their needs are fully considered in the relationship.

Ironically, despite the therapeutic relationship being vital to treatment outcomes, the

formation of a quality therapeutic relationship between the psychiatric/mental health nurse &

the psychiatrist 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). 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 (8). Weissmark and Giacomo (

9) concluded in their

discussion of measuring therapeutic relationships, that although global rating methods can

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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.

STATEMENT OF THE PROBLEM

The researcher conducted this study on the responses of schizophrenic patients to the

therapeutic relationship rendered by their psychiatric nurse and their psychiatrist in psychiatric

care home setting.

Specifically, the following questions guided the investigation:

1. What is the profile of the schizophrenic patients according to:

a. Age

b. Sex

c. Civil Status

d. Educational Attainment

e. Number of Years Diagnosed as Schizophrenic

2. What extent do Schizophrenics experience with regard to:

a. Beliefs

b. Feelings

c. Relationships

as provided by the psychiatrist and psych nurse?

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3. Is there a significant relationship between experiences of Schizophrenics in terms of

beliefs, feelings, and relationship as provided by the psych nurse and psychiatrist and

the Demographic Profile?

4. Is there a significant difference between the mean perception of Schizophrenics

concerning their beliefs, feeling, and relationship with :

a. Psychiatrist

b. Psychiatric Nurse

CONCEPTUAL FRAMEWORK

This study extrapolated on determining the relationship of schizophrenic patients in

terms of beliefs, feelings, and relationship as provided by the psych nurse and psychiatrist

considering the client‟s age, sex, civil status, educational attainment, and number of years

diagnosed as schizophrenics. This also projects the difference of the average perception of

Schizophrenics concerning their belief, feeling, and relationship with their psychiatrist and

psychiatric nurse.

Therapeutic Relationship Experience of Schizophrenic Patients in terms of

their: 1. Beliefs 2. Feelings 3. Relationship

As provided by:

Demographic Profile of Schizophrenic Patients

a. Age b. Sex c. Civil Status d. Educational Attainment e. Number of years diagnosed as

Schizophrenic

Psychiatrist

Psychiatric Nurse

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THEORETICAL BASIS – HILDEGARD PEPLAU‟S INTERPERSONAL RELATIONS THEORY

Peplau's theory implies the health care provider's importance in the patient's social

network. Peplau proposes that the relationship between the patient and the primary

healthcare-provider (PHCP) is the basis of therapeutic practice and that every aspect of a

patient's care centers around that relationship (Howk et al., 1998). A positive relationship

between the patient and the PCHP is vital to achieving a positive outcome. This study

conceptualizes the influence of the relationship between schizophrenic clients and their PHCP

as one of the most important factors in determining the prognosis of their illness. In a

therapeutic relationship, the PCHP and a mentally-ill patient come together, identify a problem,

and develop a strategy to overcome that problem (Peplau 1952, 1988).

During all phases of the therapeutic relationship, communication is essential.

Communication requires honesty and self-scrutiny on the part of the PHCP and the patient.

During interactions with the patient, PCHPs must diligently analyze their own behavior and

assess what their behavior is communicating to the patient. PHCPs need to understand that

their own behavior can facilitate or deter positive health behaviors by the patient.

Peplau‟s theory focuses on “Psychological Mothering” that includes accepting patient

unconditionally, recognition of the patient‟s readiness for growth, and the shift of power in

the relationship to the patient. This theory will help the researcher to organize and establish

the foundation of his/her basis of therapeutic relationship to mentally-ill patients.

With scheme, nursing researchers follow the major assumption that patient‟s problems

were within the person‟s phenomena and were dealt inside the nurse-patient interaction

studies.

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Her theory is based on reality. It could be tested and observed using pure examination,

especially from psychiatric healthcare providers to their patients.

METHODS

Research Design

This study was carried out through a quantitative research design that a descriptive

correlational method of inquiry is used. The researcher compared the relationship between

experiences of Schizophrenics in terms of beliefs, feelings, and relationship as provided by the

psychiatric nurse and psychiatrist and the client‟s demographic profile.

A descriptive-comparative study was also used by the researcher to determine the

dissimilarity between the mean perception of Schizophrenics concerning their beliefs, feeling,

and relationship with their psychiatric nurse and their psychiatrist.

Respondents of the Study

The sample consisted of 100% of schizophrenics that totalled to 35 patients. Only

patients admitted in this year, 2010, were included in the study.

At intake, the patient‟s average age was 33 6.6 years; 60% were males and 40% were

females.

Setting

The setting of the study was in 2 psychiatric care home facilities in eastern Manila,

namely: Holy Spirit Psychiatric and Custodial Care Home and Grace Halfway Home with a

minimum of 20 patients each.

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Measures

The tool used was the Helping Alliance Questionnaire, Patient Version developed by

Luborsky et. Al (1996). Participants were instructed to respond to a questionnaire on ways

they may feel or behave in relation to another person, their therapist. They were requested to

consider carefully their relationship with their therapist, and then mark each statement

according to how strongly they agree or disagree. The tool measured the extent

Schizophrenics experience with regard to their beliefs, feelings, relationships as provided by

their psychiatrist and their psych nurse.

The Alliance Questionnaire, Patient Version is a widely used 19-item questionnaire that

measures the strength of the patient-therapist therapeutic alliance. It is divided into 3 sections:

(1) Belief s with 6 questions, (2) Feelings with 5 questions, and (3) Relationship with 8

question. Each item is rated on a 6-point Likert scale (1 = I strongly feel it is not true, 6 = I

strongly feel it is true).

DATA ANALYSIS

Quantitative and correlational analysis was used to explore the question of whether

there was evidence difference between the mean perception of Schizophrenics concerning

their beliefs, feeling, and relationship with their therapist, the psychiatric nurse and the

psychiatrist.

Using a top-down approach in which we began with a set of criteria based on

Peplau‟s work for evidence of the existence of a therapeutic relationship, the analysis focused

on the interaction between interviewer and participant reflective of the content of that

interaction (Gubrium & Holstein, 1994). The conversations could be characterized as

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“institutionalized” rather than ordinary, everyday conversation in the sense that they were

systematically scheduled and occurred between a health care professional and resident in an

institutional setting (Heritage, 1987).

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REFERENCES

1. Forchuk C, Reynolds W. Clients' reflections on relationships with nurses: comparison form Canadian and Scotland. Journal of Psychiatric and Mental Health Nursing. 2001;8:45-51. (s)

2. Cleary M, Edwards C. 'Something always comes up': nurse-patient interaction in an acute psychiatric setting. Journal of Psychiatric and Mental Health Nursing. 1999;6:469-477. (s)

3. Cleary M, Edwards C, Meehan T. Factors influencing nurse patient interaction in the acute psychiatric setting: an exploratory investigation. Australian and New Zealand Journal of Mental Health Nursing. 1999;8:109-116. (s)

4. McGuire R, McCabe R, Priebe S. Theoretical frameworks for understanding and investigating the therapeutic relationship in psychiatry. Social Psychiatry Psychiatric Epidemiology. 2001;36:557-564. (s)

5. McCabe R, Priebe S. The therapeutic relationship in the treatment of severe mental illness. A review of methods and findings International Journal of Social Psychiatry. 2004;50(2):115-128. (s)

6. Moyle W. Nurse-patient relationship: a dichotomy of expectations. International Journal of Mental Health Nursing. 2003;12:103-109. (s)

7. Berg A, Hallberg IR. Psychiatric nurses' lived experiences of working with inpatient care on a general team psychiatric ward. Journal of Psychiatric and Mental Health Nursing. 2000;7:323-333. (s)

8. Welch M. Pivotal moments in the therapeutic relationship. International Journal of Mental Health Nursing. 2005;14:161-165. (s)

9. Weissmark MS, Giacomo DA. Measuring therapeutic interaction: Research and clinical applications. Psychiatry. 1995;58(2):173. (s)

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APPENDIX Sociodemographic Questionnaire Date and Time: ________________________________________________________________ Name of Patient (Optional):______________________________________________________ Name of Health Care Provider (Optional):___________________________________________ Name of Hospital/Institution: _____________________________________________________ Age

o Below 20 years old

o Between 21 and 30 years old

o Between 31 and 40 years old

o Between 41 and 50 years old

o Between 50 and 60 years old

o 60 years old and above

Sex

o Male

o Female

Civil Status

o Single

o Married

o Separated

o Widow/er

Educational Attainment

o Elementary Undergraduate

o Elementary Graduate

o Highschool Undergraduate

o Highschool Graduate

o College Undergraduate

o College Graduate

o Masteral Undergraduate

o Masteral Graduate

Number of Years Diagnosed with

Schizophrenia

o Less than a year

o 1 to 2 years

o 2 to 3 years

o 3 to 4 years

o 4 to 5 years

o More than 5 years

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Helping Alliance Questionnaire, Patient Version

Instructions: These are ways that a person may feel or behave in relation to another person, their therapist. Consider carefully your relationship with your therapist and then mark each statement according to how strongly you agree or disagree. Please mark every one.

Helping Alliance Questionnaire 1

SD 2 D

3 SD

4 SA

5 A

6 SA

Beliefs

1. At times I trust the therapist's judgment [B]

2. I believe we have similar ideas about the nature of my problems. [B]

3. The procedures used in my therapy are well suited to my needs. [B]

4. The therapist relates to me in ways that speed up the progress of the therapy. [B]

5. The therapist appears to be experienced in helping people. [B]

6. I believe the therapist likes me as a person. [B]

Feelings

7. I feel I can depend upon the therapist. [F]

8. I feel the therapist understands me. [F]

9. I feel the therapist wants me to achieve my goals. [F]

10. I feel I am working together with the therapist in a joint effort. [F]

11. I want very much to work out my problems with my therapist. [F]

Relationship

12. I generally respect the therapist's views about me. [R]

13. I like the therapist as a person. [R]

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14. In most sessions, the therapist and I find a way to work on my problems together. [R]

15. A good relationship has formed with my therapist. [R]

16. The therapist and I have meaningful exchanges. [R]

17. The therapist and I have profitable exchanges. [R]

18. From time to time, we both talk about the same important events in my past [R]

19. At times the therapist seems eager to interact with me [R]