An Interpretation of Nurse–Patient Relationships in Inpatient Psychiatry
transference, and script, together with the methods of inquiry, attunement and involvement add to the framework of a therapeutic relationship. The integrating of .. psychiatric and mental health nursing, certified Clinical Transactional Analyst. aspects of countertransference and to identify their impact on a therapeutic relationship. 2. To gain a Term frequently used to denigrate nurses regarding their reactions to . A dysfunctional pattern of living, which emerges from repeated. and the influence of transference and countertransference on boundary blurring. 5. . The therapeutic relationship between nurse and client differs from both a .. patterns of behavior and emotional reactions that orig- inated in relation to.
Nine PMH nurses and six patients were enrolled in the study, and their participation was not discussed with their peers or treatment teams. All participants gave informed consent, and all were free to withdraw from the study at any time. I reconfirmed consent at each meeting and ensured that participants knew that I was not formally connected with their clinical decision-making teams or their nursing supervisors. Unit managers were not informed about the participation of any particular nurse.
During nonparticipant observation, those who were present on the unit were informed that the researcher would be present and observing study participants and that no observation data relating to study nonparticipants would be recorded or used unless their specific consent was given. Data Collection Conversations took place over a month period.
Approximately 40 hours of nonparticipant observation also took place. Patients were interviewed while in the hospital, and nurses were interviewed during or immediately after their work shifts. I conducted semistructured interviews in a formal, quiet interview room in or near the inpatient unit.
I followed the interview guide, and at the same time, I attempted to establish rapport with each participant to encourage a free flow of ideas. I used a form of iterative questioning whereby I relied on earlier information to suggest and create new lines of questioning. With patient-participants, I ended the interview if I sensed that the patient was seeking a therapeutic encounter rather than engaging in a research interview. In our first meetings, I asked patients the following: Data consisted of texts transcribed from participant accounts as well as data from nonparticipant observations and journal notes.
To be credible, my analysis needed to be a fitting representation of a my conversations with participants and b the meanings that emerged from my experiences and those of the study participants Shenton, To enhance credibility, I actively reviewed the accounts of the patients and nurses before I conducted the secondary interviews, so that I could focus my attention on emerging themes and questions for discussion that arose from their previous accounts.
I engaged in reflective writing, which helped me to clarify my own perspective on my research experiences. As is always the case in hermeneutic phenomenology, my interpretation must be understood by readers to be speculative, imperfect, and incomplete. Other than exceeding the number of interviews necessary for saturation suggested by Morse and Guest et al. The focus of this article is the theme of mindful approach Oxford University Press, In this case, a mindful approach represented the experiences of PMH nurses who recognized that patients were experiencing intense psychological distress and potential behavioral volatility and who adopted a consciously strategic approach to achieving a therapeutic connection.
It is often, what does that mean for you? I identified three subthemes in the theme of a mindful approach: The theme of a mindful approach is illuminated in the following accounts of nurses and patients, who are identified by pseudonyms. Frontline PMH nurses and patients frequently engaged each other in moments of patient distress, and this distress sometimes led to conflict.
I understood conflict between the nurse and the patient as expressions of differences that needed to be reconciled before patient and nurse could work relationally. I employed the metaphor of the frontline to signify these experiences.
A frontline is a place where parties first engage. It can be a place of courage and confrontation, but above all, a frontline is a place of possibilities, where each party meets the other and conflicts eventually dissipate. In the following anecdote, a nurse recounts a frontline experience: I went in to relate to him. I sat where we were eye to eye.
I can get to know you better and you can get to know me too, so we can work. Patients sometimes expressed anger overtly, in both words and actions. The nurse in the following situation described an encounter in which the patient seemed likely to act out. In the face of an escalated risk of physical harm, Nurse Joy attempted to engage the patient by openly communicating care and concern. Her response was framed by her understanding that the patient needed to vent his feelings safely, her language was patient-centered, and she did not attempt to situate herself in a position of power.
Where I get a chance to have a little more rapport. I have to find a window, that quiet moment or pause: The nurse in the following exchange looked for an opening, but that moment was difficult to find: There was no break in the conversation for me to get in. It was unleashed anger continually. How you know that a conversation is going to go anywhere or get anywhere positive is if there is an opportunity to speak and if they have stopped and listened for a moment.
But you know you are getting in there. Nurse Diane The following experience highlights different qualities of frontline encounters. Nurse Samantha recounted an experience in which a patient surprised her with his threatening actions: I had my chair in the doorway and he came over the chair to get out of the room because he thought somebody was coming to kill him. I knew that he had this fear of people coming to kill him.
He came to the point where he recognized me. I was able to redirect him and do some reality orientation. This patient experienced hallucinations and delusions and acted out a scenario that the nurse only partially understood.
Patients gave accounts of conflict with nurses. At the time of our conversations, Marie still did not comprehend the experience, and she had made little progress in working with her nurse in a more engaged manner. Nurses reported that they continued to situate their searches for a place and time of engagement even when they themselves were experiencing anxiety and fear: Nurse Diane Furthermore, Nurse Samantha seemed to understand that she needed to think through her responses in a frontline encounter: There is always something going on in the back of my head.
Even though Samantha valued the emergence of any possibility of common ground, she continually reviewed her approach: A value such as personal safety came into the foreground and Samantha would question the route she was taking. Nurse Hilary gave an account of a different reaction.
She had been confronted by an angry patient and she responded in a manner that she later regretted: This patient has a propensity for. I forget what I said to her. I thought afterwards I could have handled it differently. This exchange revealed the challenge of enacting a mindful approach. I thought, just let her say it. She worked hard to uncover the possibility of a more engaged relationship in the future.
I could kill you. So there are those conflicts, right? Upon later reflection, Nurse Lydia recognized that her response did not conform to her own professional standards; she understood that in the social matrix of nursing practice, nurses do not always act in their own defense: You have to say, this is a person who is ill; this is not a personal attack. Nurse Tim, who viewed much of his relational work as psychodynamic psychotherapy, understood that when patients uncover thoughts and feelings previously hidden, they often experience anxiety: In another account, Nurse Colleen also used language that illustrated the movement of nurse and patient in this shared relational space: These nurses understood the frontline as an experience filled with motion, at once a place of possible convergence and a place of disjuncture that participants constantly approached, held their positions in, retreated, and encircled.
Each highlighted a moment when the frontline shifted, and confrontation and explanation appeared to be replaced by a more comfortable connection. I used the term common ground to highlight this kind of relationship, where each person is more at ease with the other and the patient feels less of an object.
Transference in the nurse-patient relationship.
Patient Laura stated, When I talked to my nurse. We were engaging and we were on the same page. She was listening to me, and she gave me an intelligent answer back. Patient Elsie reported the value of this kind of exchange: He invited the patient to consider different truths and attempted to help the patient to understand a confusing experience.
He had this thing that was important to him and he had a chain on it. He takes out this old pocket watch that he had.
So obviously there was that commonality that I can see how much his grandfather meant to him and right away made that little bit of extra connect, people connection. Charles illustrated how he explored his own intentions and motivations; he later articulated to me that he knew that his perspective was only one constituent of shared understanding. The notion of place seems to be particularly present in these experiences: How could nurses and patients create shared understanding when their worldviews appeared to be so different?
Perhaps the answer lies in the overarching theme of mindful approaches. In this inquiry, the accounts of nurses and patients appeared to suggest that frontline encounters were often filled with tension and defensiveness.
It makes sense then that nurses and patients, having experienced the frontline encounters, would wish to uncover and inhabit a more shared, intersubjective space. Each would be able to understand the other and, without losing the identities of patient and nurse, create an encounter that more closely resembles a person-to-person connection.
It may be that nurses and patients who inhabit common ground are beginning to cocreate a new and more shared perspective, thereby setting the stage for a new relationship. Nurse Charles recounted the following: The patient, having satisfied himself that Charles was safe and trustworthy, approached him with curiosity, and the relationship changed. Nurse Joy gave an account of a relationship in which a shift occurred despite struggles to engage and ongoing conflict: There was a young fellow; he had a hard go of it.
So with patience I slowly got through to him. Both nurses and patients seemed to notice this relational shift. I am less tearful when I spill my guts and a bit more comfortable. I have control, so maybe I can talk to her. Before, what we talked about was always my suggestion, whereas once he started to feel a little bit better and we were able to link better to each other, I was able to ask him more.
I remember a picture on his windowsill. Do you get to visit him often? How do you feel after these visits? It looks like you have family gatherings—what is that like for you? Should they let their defenses down or should they put them back up? Patient Marie described how she experienced this kind of vulnerability as being on a pathway to recovery: At one point, I observed a nurse and a patient operating within this space of shifting vulnerability. A sad and angry patient expressed puzzlement at a question the nurse posed, and then his eyes filled with tears.
In the ensuing conversation, the patient recounted specific aspects of his story that were clearly uncomfortable and anxiety-provoking and that had not previously been a focus of their conversation. At the end of the conversation, the nurse understood the patient in a different way; he had both articulated and argued for his vision of his future, and the nurse considered the experience to signify a change in their relationship. Within each of the subthemes of frontline, common ground, and shift, patient-participant accounts highlighted changes in openness to engagement, willingness to share uncomfortable experiences, and visions of the future.
Patient experiences with unknowing and defensiveness inhabited the subtheme of frontline. The importance of being viewed as a person and not an object inhabited the subtheme of common ground. The subtheme of shift highlighted the significance to the patient of a safe connection where his or her perspective could be fully articulated and given meaning.
In contrast, nurse-participant accounts across all themes highlighted the importance of being alert to changes in patient experience and committed to achieving shared understanding. The care face is the place where PMH nurses are directly engaged with patients for aims that are unique to nursing practice Barker et al.
In this inquiry, the frontline was one example of the care face. For example, a patient may react in a therapeutically antagonistic manner, expressing excessive dependency or angry, bitter, or contemptuous feelings towards a particular nurse or group of staff.
Transference in the nurse-patient relationship.
Thus, discomfort arises in both parties. The patient may be uncomfortable in expressing these feelings in such a negative manner, and the nurse will usually dislike being the object of such expression.
In cases of transference, the relationship does not usually need to be terminated e. The nurse should work with the patient in sorting out the past from the present, and assist the patient into identifying the transference and reassign a new and more appropriate meaning to the current nurse-patient relationship. In addition, if the patient is having a problem with the nurse due to transference, the patient often has or will have problems with other people in their lives who represent individuals in past conflicts.
The goal is to guide the patient to independence by teaching them to assume responsibility for their own behaviors, feelings, and thoughts, and to assign the correct meanings to relationships based on present circumstances instead of the past. Helping the patient work through the transference is beneficial in two important ways: Countertransference Countertransference involves the same principles, except the direction of the transference is reversed.
For example, a patient who displays childlike dependency toward a nurse may evoke a parental attitude from that nurse, depending on the meaning that he or she assigns to the relationship with the patient, and if past conflicts are significant to the present situation. Nurses may be completely unaware or only minimally aware of the countertransference as it is occurring.
Interventions Interventions for countertransference involve identification, observation, and feedback by other nurses and staff members. Once again, the relationship usually should not be terminated in the presence of countertransference. Rather, the nurse or staff member experiencing the countertransference should be supportively assisted by other staff members to identify his or her feelings and behaviors and recognize the occurence of the phenomenon.
The therapeutic relationship can often be improved by offering the nurse or other staff member feedback about the progression of the relationship. It may be helpful to have evaluative sessions with the nurse or staff member after their encounters with the patient, in which both they and other staff members who are observing the interactions discuss and compare the exhibited behaviors in the relationship.
Importantly, a staff member who is helped to identify their own countertransference in dealing with a particular patient might be able to recognize and manage this on their own when they encounter other patients later on who evoke similiar personal reactions.
It is important to recognize the effects of transference and countertransference on the patient and the staff. The phenomena also can affect the entire therapeutic environment if not managed properly, as the rest of the therapeutic community of patients and staff may perceive the relationship in a positive or negative manner.
Facilitating staff awareness and education regarding these phenomena is essential to help ensure the quality of therapy and to preserve the integrity of the therapeutic, nurse-patient relationship. Transference and countertransference in nursing. Foundations of Clinical Psychiatry.
Essentials of Psychiatric Nursing,14th ed.