talking more logically and to be more in control of his thoughts.They spoke
about how he was coping since leaving the unit. He seemed to be coping
quite well on an independent level, other than still feeling a little paranoid.
On my following visit, Stuart complained of not sleeping very well. I asked
why and he replied that he thought the pope was talking about him on the TV,
plotting against him, and didn’t want to take any sedatives, as he believed
they were addictive. He seemed paranoid and tired. The student-nurse
spoke about how he should try and relax in the evening. They discussed
some activities Stuart could try such as, having a bath with aromatherapy oils,
drawing, listening to some relaxing music, or evening reading. Stuart seemed
satisfied by the advice the student-nurse had offered him. Before leaving the
Stuarts home, he requested that on his next meeting he would like to go
shopping for some relaxation tapes. This I felt was a positive sign towards
our therapeutic engagement and for Stuart’s health, that he was putting trust
in my advice on relaxation techniques He even appeared a little more at ease
in my presence.
During my next meeting I was running a little late, so I phoned Stuart to
ask him if he could meet me in his shopping area café. He seemed fine about
this, so we both met where we arranged. Stuart was very keen to find some
relaxation tapes and seemed to be handling it very well being in an area
where it was congested by people. It seemed as tough his mind was more
focused on good thoughts i.e finding some relaxation tapes to help him relax
rather than bad thoughts. I felt Stuart come across as more relaxed in
his own environment, such as home and also around certain
presences of people he trusted. A week later after trying relaxation
techniques Stuart was more relaxed.
This confirmed to me that mine and Stuart’s therapeutic relationship had
flourished a little with him opening up gradually about his interests. He told me
he wanted to get back playing for his old darts team, as he believed this
would be good for him socially. During my next visit I was accompanied my
another CPN nurse, who obviously was far more experienced then myself.
The reason for this was because the team had received a worrying phone call
from Stuart saying he felt suicidal (NSF,1999). As we entered Stuarts flat
there was a smell of alcohol and he confessed to drinking a lot in the last
week to escape his fears of the pope plotting against him. This made me think
that the quality of time we were spending was not enough for Stuart to not
open up to me about any psychological concerns, i.e his paranoid thoughts.
Whist building a therapeutic relationship with Stuart there were some nursing
theories applied:
Carl Roger’s person centred conselling
This consists of three core conditions; Unconditional positive regard,
empathy and congruence.
Unconditional positive regard is how the counsellor accepts a client
unconditionally and also in a non-judgemental way. This gives the client
the chance to discern their thoughts and feelings, in a optimistic or
pessimistic approach.
Empathic understanding, the counsellor has an awareness of
the patient’s, feelings. According to Forchuk (1991), the ability to empathise
with the patient and self-understanding are necessary requisites of the nurse
as the therapist. (Forchuk 1991, in stuart and sundeen 2004).
Congruence is when the counsellor shows genuiness towards the patient.
The counsellor should not show an aloof professional facade. There is no
feeling of authority from the counsellor (D,Mearns,2004).
Analysis of model
Person-centred counselling helps individuals achieve personal
goals and come to terms with a explicit event or crisis they are going trough.
This method is based on the theory of talking therapy and is
also non-directive move. The therapist encourages the patient to show
their feelings. Listening and mirroring back what the patient discloses, this
guides the patient to learn and understand their feelings for themselves. This
may also help the patient to decide what kind of changes they would like to
make.
l thought this technique has been criticized by some for its lack of structure
and set method. However it has proved to be a hugely effective and popular
treatment. One criticism as that delivering the core conditions is what all good
therapists do anyway. The core conditions are not the only way to achieve a
quality relationship. Rogers technique also appears to be a little schematic,
and ignores the patients individuality. It’s like applying a method, rather then
really listening to the actual patient, i.e. paraphrases which have been
implemented.
.
Hildagard Peplau‘s development stages of the nurse-client realionship
Peplau’s(1952) Developmental Stages of the Nurse-Client Relationship
include the following phases, which are: the Orientation Phase, working
Phase, and the Resolution Phase.
This phase of the relationship is when the nurse and patient first meet, and is
known as the orientation phase. This is a time when the patient and nurse
come to know each other as people and each other’s
expectations and roles are understood(Peplau,1952). On the authors and
Stuart’s first meeting I asked Stuart to tell me about himself, so I could
understand how he was feeling, I also stated to him that it was his time to talk
about anything that was unsettling or important to him. I felt Stuart was
opening up a little, but was not showing much trust towards me. This can be
difficult when a patient has had an extensive experience as inpatient on a
ward (Forchuk, c. 1992).MIND (1992) states the importance of the patients
being fully informed of the type of psychological approach taken in their care
process. So I found it important that Stuart understood the intention of the
relationship. Ritter (1989) states that that it’s essential that the psychiatric
nurses are clear about the distinction between being a psycho-therapist and
behaving in a psychotherapeutic way. I was aware of this with my relationship
with Stuart. The working phase incorporates the identification and
exploitation sub-phases and the relationship may fluctuate back and forth as
new problems are identified (Peplau,H. 1952) As Stuart started open up
about his concerns, he explained that sometimes he did not like being on his
own in his flat. So I enquired why this is? And Stuart replied saying he feels
vulnerable and anxious that someone might try and attack him on behalf of
the Pope. Burnard (1999) has observed that by exposing themselves to active
listening and the experience of empathy with supervisory relationship, nurses
may find it easier to enact similar therapeutic exchanges with their patients.
(Burnard, 1999 in Barker 1999). The Resolution Phase involves the gradual
freeing from identification with helping persons, and the generation and
strengthening of the ability to stand alone, eventually leading to the mutual
termination of the relationship. (Peplau,1952). On the student-nurse’s and
Stuarts final therapeutic intervention and on my final day of my clinical
placement. Looking back on mine and Stuarts growing intervention it went
well, as Stuart was always on time for his appointment with me, and always
seemed to be enjoying the interaction. During this session the student-nurse
discussed termination of their sessions. During this session the student-nurse
assisted Stuart in coping with the termination of the intervention. The student-
nurse spent this session introducing Stuart to another student-nurse, who was
to engage with him and take over from the author.
Analysis of model
Peplau (1952) thinks the nurse–patient relationship has traditionally been
viewed as the essence of nursing practice. She disputes that the ideals of
such a relationship occurs effortlessly in nursing practice.
Looking at Peplau model, it was useful in getting to know the patient as a
whole and understanding their perspectives in life. The phases helped to give
me a framework in mapping out how mine and Stuart’s relationship
progressed, I.e. especially in the working phase, this helped me to gain a
better insights into his thoughts.
Phill Barker’s tidal model
The tidal model was developed by Professor Phil Barker. In
2000 the Tidal Model was first implemented in Newcastle Upon Tyne, UK in
an acute admission ward. The principles of the Model are broken into ten
commitments: to Value the patients voice, respect their language, show
genuine curiosity into what the the person's telling you. Learn from the person
you are helping, expose personal wisdom, be transparent, remember the
person's story contains valuable information as to what works and what
doesn’t, craft the step beyond – this can assist the person (s) to toil together
to construct an positive reception of what needs to be done. Grant the gift of
time (Barker P 2007).
When valuing Stuart’s voice, this gave me an insight into his
world and where he was coming from, i.e. what he was suffering within the
internal and external environment. This was a significant tool to me and
Stuart within his recovery process, especially when his care plans were
formulated.
I found respecting his language, encouraged Stuart to be open
about his thoughts and feelings he was experiencing. This I feel helped
him to be expressive regarding his feelings and thoughts.
Peplau believed that language influences thought, thought that influences
action, and that thought and action together evoke feelings in relation to a
situation or context. (Peplau 1969 in Barker,P2003 ).
Presenting genuine curiosity was an unrealistic quality that I
lacked sometimes, especially when he was suffering from certain
delusions I couldn’t understand what Stuart was experiencing.
Giving the gift of time was one of the most important necessities of the
recovery model to mine and Stuart’s relationship, as this helped create a
whole environment of trust and helped the therapeutic relationship to flourish.
Giving the gift of time, I found coming towards the end of my placement, I felt
as a student-nurse I had not accomplished a whole meaningful therapeutic
relationship with Stuart. The reason for this I felt was the limited time I had to
Interact with Stuart I only seen Stuart five times in total.
Within the limited time I had with Student on a therapeutic level, I found this to
challenging towards our relationship, especially as I was placed on a
community based team where I would only interact with Stuart once a week
by fixed appointment. This I feel had an effect on Stuart’s trust which being
the core of our relationship was very important to me to gain. Eriksson’s
states that through the formation of bonds with parents or carer’s over time,
the patient comes to believe in her/himself as a worthy of help, should
difficulties arise (E, Erikson 1950 ). Another definition posited by Lynn-
McHale and Deatrick (2000) focused on trust between families and health
Care providers. They defined trust as: ‘…a process, consisting of
varying levels, that evolves over time and is based on mutual
intention, reciprocity and expectations’ (p. 217). I felt I needed more time to
create a persona of trust, looking at a study which was carried out at
Inverness University it found the nurse-patient relationship in a hospital
establishment is lost during discharge. They found it takes several weeks to
form new working relationships with community staff. I found this to be the
case, as when the relationship began it was very closed off on Stuart’s behalf
but as it slowly developed he was gradually opening up to me about his
concerns and also his enjoyments out of life. I deeply feel if I had a little longer
time with Stuart the relationship would have become more complete.
Analysis of Model
Prof Phil Barker believed that in order for the practitioner to begin the process
of engagement using the Tidal Model, the following needs to be accepted:
that recovery is possible, that change is inevitable - nothing lasts, that
ultimately, people know what is best for them, that the person possess all the
resources. They need to begin the recovery journey, that the person is the
teacher and the helpers are the pupils, and that the helper needs to be
creatively curious, to learn what needs to be done to help the person.
In a study by Brooks, the results showed in the year 2005, of the introduction
of the Tidal Model, the total number of serious untoward incidents such as
physical assaults, violence and harassment, decreased by 57% in
Birmingham Hospital. City Hospital (G. BROOKS rmn (2005). I also found
this to be effective in my relationship with Stuart. Such as when valuing the
voice of the patient, this helped me to understand Stuart’s world, also develop
genuine curiosity, this established trust in mine and Stuart’s relationship.
Using this mmodel it also provided a practice framework for the exploration of
the patient's need for nursing and the provision of individually tailored care.
Conclusion
During the last three decades, numerous theories have been generated
with multiple and varying orientations various tools and techniques help
identify suitable usage. A number of nursing models relating to
therapeutic engagement has been introduced within Stuarts care.
Whilst they engender considerable debate there are similarities in the
them all. These models focused on how the nurse can manipulate the
environment to benefit the patient. Within the therapeutic intervention
with Stuart and after conducting a literature search. I generated an
initial list of possible theories and models. The tidal model appeared to be the
more appropriate model, as it had use in analysis and evaluation. The tidal
model used concepts (i.e., words representing reality that enhance our ability
to communicate in familiar ways). Other therapeutic models use concepts in
unfamiliar ways or introduce new concepts about nursing and nursing care.
These are practical issues, which are put into practice and come from the
theory. The theories are interrelated, defined, and presented to explain
everything. I found that the models can create a level of Discrimination
because they have a fixed view of what the client is like. They lack flexibility.
They also attempt to prescribe what the nurse can do. For example, the
theory can determine whether a nurse is acting as a nurse or a substitute
psychiatrist. To clarify some therapeutic techniques deployed in some other
traditions depend on the nurses willingness to 'hold back', mentally
formulate hypotheses about the client, or conceal their own
personal reactions behind a consistent professional face, there is a
real challenge in applying these techniques. So to conclude my experience,
the theory does not always mach the practice. In mine and Stuart’s case I
found time was the key facet in our therapeutic interaction.
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