Mental health nurses: genuine, empowering, equitable, reliable, consistent and balanced

Background: Although the therapeutic relationship is the essence of mental health nursing practice, the formation of a therapeutic relationship between the mental health nurse and patient is a challenging process fuelled by complex environments and the people involved. Mental health nursing comprises a diverse array of positions, providing care to many diverse cohorts of people including adolescents, adults, and older persons in a number of settings which includes hospitals, community settings and forensic facilities. Given the diverse context of mental health nursing and the uniqueness of individuals involved, some therapeutic relationship constructs are likely to be more applicable to some situations than others. Aim: This thesis describes the development of a theory of therapeutic relationships in mental health nursing in different clinical settings and the attendant research questionnaire based on Q-methodology. Method: Q-methodology, a unique qualitative method which incorporates quantitative techniques to systematically assess data, provided the foundation for this research. An extant research instrument, the Mental Health Nursing Q-sort developed as part of my honours degree (Dziopa, 2006) was revised and incorporated into an on-line survey. The revised survey for my PhD, now referred to as the Psychiatric Nursing Q-sort (PNQ-sort), was piloted twice with two samples of nurses working in mental health recruited from two public hospitals in Brisbane, Australia and through a snowball technique. The final version of the PNQ-sort was completed by 87 nurses working in mental health from Australia, New Zealand, and Canada. The 87 nurses reflected on relationships from a range of mental health clinical settings (adult acute inpatient, community, child and adolescent, older persons and forensics). Analysis: Separate “by-person” factor analyses were conducted on each of the five clinical setting Q-sorts to determine different factors or relationship styles associated with each clinical setting. The nurse demographics, gender and clinical experience, associated with the factors or relationship styles were collated to assist interpretation. Results: Thirteen factors were identified across the five clinical settings representing different relationship styles. The thirteen styles were thematically categorised into six core relationship practices; Equitable, Genuine, Empowering, Balanced, Reliable and Consistent Partners. Each core relationship practice represented a unique style of interacting therapeutically with patients, adapted within different settings to meet treatment and environmental needs. Operationalization of the six unique styles was also influenced by the nurse demographics; gender and clinical experience. In the inpatient setting the nursing relationship styles were focused on meeting individualised needs. In the community, the relationship styles concentrated on encouraging or empowering the development of self and the maintenance of clear boundaries. The child and adolescent setting relationship styles were characterised by clear professional boundaries and an acceptance which facilitated the development of self. Relationship styles in the older persons’ setting emphasised respect, valuing the older person through supportive rather than empowering interactions. The forensic setting relationship styles focused on consistency in person and systems. The experience of unconditional positive regard was only identified in the child/adolescent setting and was negatively scored in the forensic setting (Consistent Partner). With regards to nurse demographics; openness to self-disclosure, intuition and the use of touch were associated with female participants. Nurses with less experience focused on genuineness/friendliness not emphasizing an awareness of the complexity of clinical boundaries and therapeutic relationship formation. Nurses with greater than 15 years of clinical experience were professionally aware within their relationships, therapeutically driven to attain individualised goals. Conclusion and Recommendation: Different therapeutic relationship belief styles are influenced by individual nurse factors, tailored to meet treatment and environmental needs. Knowledge of the different ways to form therapeutic relationships will inform education, clinical practice, and in turn recruitment and retention of mental health nurses. Future research is recommended to ascertain the beliefs of patients regarding what makes a therapeutic relationship because patient perspectives of what constitutes a therapeutic relationship will facilitate an optimal nurse-patient mix in a variety of clinical settings. In addition, further research is recommended to further assess the link between empowerment, boundary formation and clinical experience.

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