Research and Study Skills: Interpersonal Skills to build a therapeutic relationship in mental health nursing

by darthgirlie (student)

University Degree Subjects allied to Medicine

Research Methods and Study Skills

SID: 1113769

Contents

Introduction

In mental health nursing, effective communication and excellent interpersonal skills is the backbone of all aspects of patient care (Bach and Grant, 2010, p9; Dougherty and Lister, 2008, p54). The National Institute of Clinical Excellence (NICE, 2011, p2-4) recognise that communication is a part of clinical excellence, stating that interpersonal skills, the way professions practice and interact with service users about their treatment and care, is essential in shared decision-making and promoting independence. The Department of Health (DoH, 2010, p13) and the Royal College of Nursing (RCN, 2012) agree, stating that shared decision making should be the norm in clinical practice and nurses should put people at the centre of their own care, supporting them to make informed decisions. This idea is also emphasised in the Nursing and Midwifery Council Code (NMC, 2008); that a healthcare professional should acknowledge and respect that people can and will contribute to their own care and wellbeing, with the right support. The NMC (2008, p3) also states that professionals should listen to service users and respond to their concerns and preferences. This implies that communication is a reciprocal process that involves the interchange of both verbal and non-verbal messages to express feelings, information, ideas and knowledge (Dougherty and Lister, 2008, p54).

The purpose of this essay is to review and critically analyse the literature and research in regards to my topic. This process has made me think of encounters in practice. In my previous clinical placement I went to an acute admission ward (NMC, 2008, p3).Simpson (2009, p404) identifies the development of a supportive nurse-patient relationship with people in acute distress is an important goal for nurses working in acute care. This process, along with my clinical placement experience, highlighted how challenging it can be to form therapeutic relationships with people suffering multiple and often complex presentations of distress (Simpson, 2009, p404). This made me consider how interpersonal skills and communication skills interact within this context. This experience has led me to investigate the evidence base behind the use of interpersonal skills to help build a therapeutic relationship with clients suffering with mental health problems.

Literature Searching

Good literature searching skills are important for healthcare professionals so they can find and critically evaluate relevant pieces of research. Using this they can compile the best available evidence to care for service users (Fulton and Krainovich-Miller, 2010, p61; NMC, 2008, p6). This is fundamental for registered practitioners because they are accountable for their actions and omissions (RCN 2012; Aveyard and Sharp, 2009, p10; NMC, 2008, p1).

To assist in articulating my clinical question, I used the Patient, Intervention, Compare and Outcome (PICO) model by Richardson at al. (1995) (Lewis et al. 2011;Fulton and Krainovich-Miller, 2010, p62; Godshall, 2009, pp 197-199). Huang, Lin and Fushman (2006) state that it is essential for a clinical question to have well-articulated PICO elements. This helps the researcher to make evidence-based decisions and find high-quality evidence. It also allows healthcare professionals to structure clinical questions and find patient-specific information (Huang, Lin and Fushman, 2006). Furthermore, the PICO model supports concepts such as patient-centred care (RCN, 2012; DoH, 2011, p16) and treating patients as individuals (NMC, 2008, p3).

I used a key word search in ‘Google’, searching ‘Communication’ and it brought up 204,000,000 results. This highlighted the breath and ambiguities in the subject topic. O’ Dochartaigh (2007, p1) states that students’ heavy reliance on online sources means that they miss high quality academic sources elsewhere.

Using the databases, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medical Literature Analysis and Retrieval System Online (MEDLINE), I utilised the use of CINAHL Headings and Medical Subject Headings (MeSH) to search different components of my clinical question. I used these databases because they consisted of more than 750 nursing and allied health journals and more than 600,000 full text articles, making them a key resource (Anglia Ruskin University, 2011a).

During my literature search to find quantitative studies relevant to the subject was problematic. Papastarrou, Efstathiou and Charalambous (2010) agree, stating that there is an abundance of studies using a qualitative approach with the aim of gaining subjective insight into therapeutic relationships. Furthermore, this helps explains why systematic reviews of literature and random controlled trials are considered to the source of the best quality, scientific evidence (Godshall, 2009, p16-17). Looking at quantitative studies made me consider the topic and the usefulness of having loads of statistical data. This consideration and the literature searching process informed my decision, to include a lot more qualitative pieces of research in my literature review.

To find contemporary literature discussing interpersonal skills explicitly was challenging. Considering the fact that pre-registration nursing students are assessed using the interpersonal skills profile (Anglia Ruskin University, 2011b, see Appendix A) and NMC Cluster skills, which includes ‘Care, Communication and Compassion’ (2010 p80; Bach and Grant, 2010, p10), it was problematic to find text books published within the last 10 years discussing the subject in detail.

Whilst it is important for healthcare professionals to keep their skills and knowledge up-to-date to ensure safe practice (Anglia Ruskin University, 2011b, see Appendix A section 2; NMC, 2008, p6), this implies that literature should be contemporary. I initially started my literature search only looking at evidence published within the last ten years and although I have used these in the literature review, it requires interpretation to apply it to interpersonal skills. Several pieces of key evidence, looking the topic in detail were published in the 1990s and it was these documents that informed the decision to extend the date restriction to cover literature published within the last twenty years and include the best available evidence. In my opinion this highlights a gap in the current evidence base because changes in society and technology could have had an impact on the interpersonal processes and how professionals form therapeutic relationships. This is not discussed explicitly in reference to interpersonal skills in much of the literature published within the last 10 years.

What are Interpersonal Skills and how to they relate with Communication Skills?

This is a preview of the whole essay

What are Interpersonal Skills and how to they relate with Communication Skills?

The literature is unclear and ambiguous about how communication and interpersonal skills overlap with each other. Upon interpretation, the two skills are linked very closely: Whilst communication skills are the portrayal of a message verbal and/or non-verbally, interpersonal skills are the techniques used by a healthcare professional to develop a therapeutic relationship (Oxford Dictionary, 2007, p547; Dougherty and Lister, 2008, p54). An interpersonally skilled professional is having the knowledge and experience to help relieve a distress, by looking at client’s personal attributes and circumstances to know what communication technique to use (Anglia Ruskin University, 2011b, see Appendix A, section 10; Morrisey and Callaghan, 2011, p1; Burnard, 1996 p45). In other words, in order to create a meaningful therapeutic relationship, Reynolds (2009, p313) states that in mental healthcare, professionals needs to sensitively observe patients and interpret those observations to base their own interpersonal actions.

According to Bach and Grant (2010, p13), well-practised communication techniques are ineffective if the idea of the interpersonal connection goes unacknowledged. To put it simply, ‘Good interpersonal skills are what each mental health nurse needs to make nursing happen’ (Morrisey, and Callaghan, 2011, p1).Yet there is little nursing research discussing interpersonal skills, whereas there is copious amounts investigating the use of communication (Bach and Grant, 2010, p13; Jones, 2007). This has made me consider whether you can effectively communicate, assess a client with a mental health problem, without the use of interpersonal skills. Simpson (1991, p1) agrees stating without a therapeutic relationship, the dynamics of assessing a patient’s needs, feelings, attitudes and beliefs in a holistic and empowering way would be ineffective (Simpson, 1991, p1).

Peplau’s Theory of Interpersonal Relations

Peplaus’s Model of Interpersonal Relations (1952 cited in Forchuck, 1994) is designed to assist nurses in the understanding of a successful and nurturing nurse-patient relationship. The theory of interpersonal nursing is a four stage model which incorporates the patient experience and supporting a service user through the dynamics of their health, rather than a patient’s internal pathology (Hrabe, 2005; Simpson, 1991, p3). It starts with the orientation of the caring environment for example, in an acute setting showing a patient where their room is and helps ease anxiety about being in a new situation (Simpson, 1991, p10-11).

Forchuck (1994) investigated using a quantitative approach, the orientation phase in nurse-patient dyads. A quantitative study is the scientific approach to nursing research. The main aim is to collect numerical data to test relationships, differences and cause and effect interactions between variables (LoBiondo and Haber, 2010, p584; Getliffe, 1999 p112). Forchuck (1994) set out to test a number of hypotheses and to research them to demonstrate cause and effect. The researcher reported that variables being measured that would directly affect the nurse-client relationhship. These consisted of preconceptions of the nurse and client; positive interpersonal relationships and anxiety levels. After statistical analysis, they found that client’s preconceptions of the nurse were significantly predictive, according to p-value of statistical significance (Godshall, 2009, p80-81). Whereas the nurse’s preconceptions of the client were the most predictive value (Forchuck, 1994), however, this was unreliable according the p-value of statistical significance (Godshall, 2009, p80-81).

Forchuck’s research (1994) gives insight into the nurse-client relationship and how the public may view nurses. Taking into account that the research highlighted the client’s preconceptions of the nurse as a confounding factor in the interpersonal relations, this adds emphasis to a nurse’s non-verbal communication and acting in a professional manner.

Forming a Therapeutic Relationship

Mobile technology has developed significantly over the last ten years and has been increasingly utilised in monitoring health outcomes and delivery of health intervention. Therefore, mobile phones are important in encouraging nurse-client communication and therapeutic relationship (Blake, 2008). Hazelwood (2008) agrees, stating that the use of mobile phone text messaging was a useful communication tool. A nurse and client exchanging in text messaging conversations contributed and encouraged self- expression and self-reflection from clients, which facilitated a more trustworthy therapeutic relationship. According to Hazelwood (2008), alongside therapy and other nursing interventions to care for people suffering with mental health problems, text messaging helps clients open up to new treatment possibilities and can assist with clients’ lack of confidence to talk about their issues.

Hart (2010) disagrees, however, declaring that “text messaging is the antithesis of interpersonal relationships” and the purpose of a therapeutic relationship is to interact with one another. According to Hart (2010) text messaging undermines Peplau’s theory of interpersonal relations (1952 cited in Forchuck, 1994) because interpersonal skill requires a two way communication between nurse and client, as well as immediate response of non-verbal an individual communicates. This can only be provided by face-to-face interaction (Hart, 2010). In my opinion, although Hart (2010) provides a reasoned argument of the disadvantages of the use of text messaging, as a nurse you should respect the way an individual chooses to communicate.

Coatsworth-Puspoky, Forchuk & Ward-Griffin (2006) conducted a study to collect qualitative data to find out the client’s perspective of the nursing process. This means they used a discovery-orientated approach, to focus on how nurses’ social interaction is interpreted, understood and experienced by the service user (Barroso, 2010, p86). Coatsworth-Puspoky, Forchuk & Ward-Griffin (2006) used semi- structured interviews and an ethnographic design to collect data, from both an inpatient and community setting, in more interactive and less controlled way to uncover details about therapeutic relationships. This is one of the advantages of qualitative research during the data collection process; it allows the researcher to rely on insights found whilst, for example, interviewing participants to guide the course of further data collection (Wallace, 2008, p125).

There is little dispute that the therapeutic relationship between nurse and client is pivotal to high quality care (Hurley and Linsley, 2006). Gilburt, Rose and Slade (2008) found similar results to Coatsworth-Puspoky, Forchuk & Ward-Griffin (2006), looking more specifically at the importance of relationships when caring for people with acute mental health problems. The design method was also comparable, as they used semi- structured interviews to collect qualitative data. The sample of participants for this study consisted of 19 service users who had been admitted to an acute ward in England. The process of sampling was conducted on a volunteer basis, to empower participants and take into account the power imbalance involved in the research process (Gilburt, Rose and Slade, 2008). Sampling is the term given to the process of selecting participants that represent the population of interest, such as people suffering with mental health problems, which enables the researcher to make valid interpretations and generalisations (Haber, 2010, p585; Wallace, 2008, p538).

The results of both studies found similar themes. Clients that were acutely unwell sought a nurse who was sincere, caring, approachable, trustworthy, a good listener and smiled to provide a sense of safety and reassurance (Anglia Ruskin University, 2011b, see Appendix A, section 23; Gilburt, Rose and Slade, 2008; Coatsworth-Puspoky, Forchuk & Ward-Griffin, 2006). Simpson (1991, p6) states that in Peplau’s theory (1952 cited in Forchuck, 1994) that a prerequisite to a successful caring relationship is a nurse to be warm and skilled at what she does. Papastarrou Efstathiou and Charalambous (2010) agree, in regards to their research, they found that service users highly regard a nurse who is competent and capable in doing nursing tasks. This idea was reiterated this in Gilburt, Rose and Slade’s study (2008), stating that listening in a way that was open, non-judgmental and not patronising was rated highest by service users. This demonstrated that the nurses valued and respected them and as a consequence were more willing and able to accept advice and information (Gilburt, Rose and Slade, 2008).

There were also differences in results from the two studies, despite in the similar methodology. Gilburt, Rose and Slade (2008) reported about service users’ experiences being sectioned under the Mental Health Act (2007). Clients mentioned lack of freedom and how this led some experiences feeling like they were being coerced. This often had a negative effect on therapeutic relationships being formed because it was perceived to be a lack of listening and understanding from the nursing staff. According to Peplau’s ideas of Interpersonal Relations (1952 cited in Forchuck, 1994), illness is a learning experience which is a two-way process, the nurse learns from the client and client learns from the nurses, which leads to them both developing and maturing as people. This process of maturation requires a significant understanding of the interpersonal process (Anglia Ruskin University, 2011b, see Appendix A, section 13, 24 and 35; Simpson, 1991, p2 and p8). This made me consider, whether you can form a therapeutic relationship without listening and showing a service user understanding.

In contrast to the positive relationships describe Gilburt, Rose and Slade (2008) and Coatsworth-Puspoky, Forchuk & Ward-Griffin, 2006, clients stated that a dissatisfying relationship consisted of a power and control imbalance; coercion, mistrust, using medical terminology to label clients; being ignored and a focus only pathology of an illness (Gilburt, Rose and Slade, 2008;Coatsworth-Puspoky, Forchuk & Ward-Griffin, 2006).

These two studies emphasises the need for good interpersonal skills because the communication skills involved in these interactions was effective at portraying a particular message. It is the use of interpersonal skills, for example self-awareness (Anglia Ruskin University, 2011b, see Appendix A, section 7), that determined whether client perceived the relationship as a positive or negative outcome. Simpson (1991, p2) agrees with this, stating that according to Peplau’s theory of Interpersonal Nursing (1952 cited in Forchuck, 1994)in order for a therapeutic relationship to progress, a nurse needs to have a clear understanding of dynamics of interpersonal communication. Reynolds (2009, p314) supports this idea commenting that it the gaps in development of intellectual and interpersonal competencies that lead to unhealthy social interaction and poor health outcomes, such as the obstacles described in both studies by Coatsworth-Puspoky, Forchuk & Ward-Griffin (2006) and Gilburt, Rose & Slade (2008).

Salzmann-Erikson and Eriksson (2005) supports Reynolds (2009, p314) with their study investigating the use of therapeutic touch with people suffering psychosis. Service users stated that if the therapeutic relationship was good, therapeutic touch was perceived as warm and compassionate, creating a sense of security. Whilst the researchers found that if the therapeutic relationship was underdeveloped, the behaviour emphasised feelings of inferiority and oppression.

This study highlighted the importance of considering the ethical implications of conducting a piece of research. Ethics is the discipline asking how morally justifiable a person actions are (Sommers- Flanagan and Sommers-Flanagan, 2007, p4). This is important for clinical practice because as nurses we must protect individuals in our care from harm and act as an advocate (NMC, 2008, p 2-3) Salzmann-Erikson and Eriksson (2005) reported that basic ethical guidelines such informed consent and right to withdraw were upheld in the duration of the study. However, the researchers were asking vulnerable participants to discuss feelings of inferiority and oppression. It is debatable whether this could be considered as deliberate harm and therefore unethical research to investigate. Barker and Buchanan-Barker (2009, p13) discuss how one of the fundamental things about being caring is to ‘Do No Harm’ and whether if we do cause psychological or physical pain, is it beneficial to a service user. This idea emphasises the use of interpersonal skills to make a decision about using therapeutic touch.

Simpson (2009, p404) states that to create a helping relationship that nurtures the recovery of a patient, it is important to develop a therapeutic caring environment. Alexander’s research (2006) aimed to discover the impact of rules in a therapeutic care environment by collecting qualitative data and comparing two acute psychiatric wards and how this impacts nurse–patient relationships. The researcher found that it is important to have therapeutic context for rule enforcement, negotiation with patients about contents of rules and the rationale for their existence could lead to higher levels of therapeutic engagement. This idea can be applied to ideas of treating patients as individuals and recognising that patient’s contribution to their own care (NMC, 2008, p3).

Alexander (2006) suggests in his research that patients should be given a clear set of rules as a part of the admissions process. This would relate to the orientation phase of Peplau’s theory of interpersonal relations (1952 cited in Forchuck, 1994). According to Simpson (1991, p10-11) the orientation phase is about easing anxiety and creating a safe environment. Upon interpretation Alexander’s suggestion in his research (2006) would help implement this; however healthcare professionals need to be aware about appearing too authoritative. Forchuck (1994) suggests service users’ perspective of a nurse will impact on the therapeutic relationship formed and other research suggests that a nurse should concentrate on appearing sincere, caring, approachable (Gilburt, Rose and Slade, 2008; Coatsworth-Puspoky, Forchuk & Ward-Griffin, 2006).

Peplau’s theory (1952 cited in Forchuck, 1994) perceived the positive outcomes of care for patients were the result of as a developing, trusting relationship (Simpson, 1991, p2). However according to Hem, Heggen and Ruyter (2008) there is a higher prevalence of distrust with acutely unwell patients. They collected empirical evidence, using observation and transcribed interview as a data collection method, to analyse how this could be improved for service users. Sullivan-Bolyai and Bova, (2010, p269) state that data should be collected in an objective and systematic way. However, this piece of research does not discuss explicitly how they collected their data; the report just mentions the data collection method. This led me to consider the reliability and validity of data collecting. The key factors in Hem, Heggen and Ruyter’s research (2008) were service users’ felt like there were inferior to the nursing staff. This was emphasised by the control imbalance and clear evidence of personal security alarms and keys, creating a distrustful therapeutic relationship. This relates back to Peplau’s theory of interpersonal relations (1952 cited in Forchuck, 1994), stating that a therapeutic relationship is two way and reciprocal (Simpson 1991, p2). In Hem, Heggen and Ruyter’s research (2008) because it was perceived that nurses did not trust the clients; the clients in turn did not trust them.

According to Peplau’s theory of interpersonal relations (1952 cited in Forchuck, 1994), trust is a very important factor in the Identification phase because it aids in open and honest communication from both nurse and client. There is an assumption that if this is not achieved the helping relationship cannot progress to the next stage, exploitation, where service users make use of the available resources (Simpson 1991, p11-12). This made me consider whether a distrustful therapeutic relationship can aid recovery.

Conclusion

To conclude, the purpose of this essay was to review and critically analyse the literature investigating the evidence base behind the use of interpersonal skills to help build a therapeutic relationship with clients suffering with mental health problems. This is important for healthcare professionals the best available evidence to care for service users and to inform decisions for which they are accountable.

The current evidence base for interpersonal skills is limited by literature which was published over ten years. This outlines a gap in the evidence base because changes in society and technology could have had an impact on the interpersonal processes and how professionals form therapeutic relationships, which has yet to be researched fully. This has significance for mental health professionals because interpersonal actions are based on sensitively observing patients and as evidence based practitioners these decisions need to be based on research and literature.

Specifically the aim of my argument was to support the idea that well-practised communication techniques are ineffective if the idea of the interpersonal connection goes unacknowledged. The research defines what service users’ value in a therapeutic relationship and helps healthcare professionals in the understanding of a successful and nurturing nurse-patient relationship.

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