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 clients age, sex, civil status, educational attainment, and n umber 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.

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

Therapeutic Relationship Experience of Schizophrenic Patients in terms of their: 1. Beliefs 2. Feelings 3. Relationship As provided by: Psychiatrist Psychiatric Nurse

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THEORETICAL BASIS HILDEGARD PEPLAUS 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. Peplaus theory focuses on Psychological Mothering that includes accepting patient unconditionally, recognition of the patients 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 patients problems were within the persons 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 clients 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 patients average age was 33 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. 6.6 years; 60% were males and 40% were

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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 Peplaus 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;7:323333. (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 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 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

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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. 1 SD 2 D 3 4 SD SA 5 A 6 SA

Helping Alliance Questionnaire Beliefs

1. 2.

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

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. 8. 9. 10.

I feel I can depend upon the therapist. [F] I feel the therapist understands me. [F] I feel the therapist wants me to achieve my goals. [F]

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]