A literature review of the progress of the psychiatric nurse-patient relationship as described by Peplau

Knowledge is limited with regard to the progress of the nurse and patient through the phases of the psychiatric nurse-patient relationship (PNPR). Relationship progress is indicative of patient progress in the healing and recovery process. Hildegard Peplau described the phases of the therapeutic relationship in her Interpersonal Relations Theory (IRT). This review of literature describes the state of nursing science using IRT as the theoretical framework. Research conducted on the progress of the PNPR has generated evidence of the relevance of IRT to clinical practice, the importance of the PNPR to the patients themselves, and the importance of nursing knowledge regarding the progress of the orientation phase of the PNPR to patient care. However, all studies were done in Canada, and additional studies are needed. Knowledge of the relationship established between psychiatric nurses and patients is essential to the nursing process in psychiatric mental health settings.     

A LITERATURE REVIEW OF THE PROGRESS OF THE PSYCHIATRIC NURSE-PATIENT RELATIONSHIP AS DESCRIBED BY PEPLAU

Knowledge is limited with regard to the progress of the nurse and patient through the phases of the psychiatric nurse-patient relationship (PNPR). Relationship progress is indicative of patient progress in the healing and recovery process. Hildegard Peplau described the phases of the therapeutic relationship in her Interpersonal Relations Theory (IRT). This review of literature describes the state of nursing science using IRT as the theoretical framework. Research conducted on the progress of the PNPR has generated evidence of the relevance of IRT to clinical practice, the importance of the PNPR to the patients themselves, and the importance of nursing knowledge regarding the progress of the orientation phase of the PNPR to patient care. However, all studies were done in Canada, and additional studies are needed. Knowledge of the relationship established between psychiatric nurses and patients is essential to the nursing process in psychiatric mental health settings.     

Awareness of self and expanding consciousness: using nursing theories to prepare nurse-therapists

Psychotherapy is an accepted role of the advanced practice psychiatric nurse. Nursing theorists, notably Hildegard Peplau and Margaret Newman, offer guidance on the psychological and professional development of the nurse. This paper examines Newman's theory of health as expanding consciousness and the concept of awareness of self in Peplau's theory, and suggests that psychiatric advanced practice nursing programs consider the need for nurses to develop self-knowledge to facilitate the nurse-patient relationship and to improve outcomes of patient care in psychotherapy.     

Nurse bait: strategies hospitalized patients use to entice nurses within the context of the interpersonal relationship

Patients on medical-surgical and psychiatric inpatient units long for more and deeper connections with nurses. Patients' dependence on the nursing staff, as well as their perceived powerlessness, creates a situation where patients believe they have to actively find ways to seek needed nursing care. This paper will describe active strategies used by medical-surgical patients to entice nurses within the context of the nurse-patient relationship; strategies designed to mitigate vulnerability and increase interpersonal connection. Implications for nursing practice and for Peplau 's Theory of Interpersonal Relations will be presented.     

The interface of anthropology and nursing guiding culturally competent care in psychiatric nursing

Nurses and all health care providers are called on to involve patients and families in health care decision-making and to accommodate culturally diverse populations. This article describes the Interface of Anthropology and Nursing Model (IAN), which is derived from the works of Kleinman and Peplau, classical theorists from anthropology and nursing, respectively. This model provides a framework for nurses to uncover cultural information through the elicitation, analysis, transfer, restructure, and feedback of explanatory models within the interpersonal nurse-patient relationship. Such integration of theory enhances a holistic nursing practice incorporating good communication, mutual decision making, and fostering patient agency.     

Something special: forensic psychiatric nursing

In this paper the claims that forensic psychiatric nursing has achieved the status of a specialist area of nursing are refuted. An examination of the literature demonstrates that specialist knowledge and skills have not been documented. It is suggested that three requirements are necessary if forensic psychiatric nurses wish to achieve specialty status. Forensic nurses have to consolidate their role in the containment and care of patients, they have to return to the nurse-patient relationship as the foundation of psychiatric nursing practice, then, within that relationship, nurses must expand their practice to include dealing with offence issues.     

"Towering genius disdains a beaten path" Abraham Lincoln

We see nursing leadership existing at all levels in nursing...all nurses leading. Nurse executives within academic health environments across Canada will be influencing health policy directions and dialogue within the profession nationally. They will be contributing to the development of a national agenda for nursing practice, education, research and leadership. These nurse executives will lead in a way that makes an invigorating impact on human service in health care environments and they will be dedicated to preparing the nursing leaders of tomorrow. The Academy of Canadian Executive Nurses will connect with the Office of Nursing Policy, Canadian Nurses Association, Canadian Association of University Schools of Nursing, Association of Canadian Academic Health Care Organizations and others to develop position papers regarding key issues such as patient safety, health human resource planning and leadership in the Canadian health care system. Our definition of professional nursing practice, fully integrated with education and research, will be advanced through these endeavours. The end result of a strong individual and collective voice will be improved patient outcomes supported by professional nursing practice in positive practice environments. This paper is intended to stimulate dialogue among nursing leaders in Canada, dislodge us from a long and traditional path, and place us firmly in a new millennium of leadership for the profession and practice of nursing, a style of leadership that is needed, wanted and supported by nurses and the clients we serve. It is the responsibility of those of us who lead in academic health science centres to be courageous for the students we support, the puactitioners we lead and the renewal of the profession. We are the testing ground for nursing research, and need to be the source of innovation for nursing practice. It is incumbent on us to leap forward to engage a new vision of the professional practice of nursing with a reconfigured work design and work environment compatible with the new economy, workplace and workforce.     

Promoting leadership and management in Australian general practice nursing: what will it take?

Aim This paper outlines the current state of Australian practice nursing, describes the context of general practice and establishes the importance of promoting leadership and management in this setting. Background Australian general practice nurses have emerged as key stakeholders in primary health care. However, their role in leadership and management has been largely invisible. The reasons for this are multifactorial, including the delay to establish a strong professional organization, their negative power relationships with general medical practitioners, limited nursing leadership and poorly defined roles. To date, the impetus for practice nurse growth has been largely external to the nursing profession. Growth has been driven by the increasing burden of chronic disease and workforce shortages. This has further weakened the control of nurse leaders over the development of the specialty. Conclusions The Australian practice nurse role is at a crossroads. While the practice nurse role is a viable force to improve health outcomes, the growing strength of the practice nurse challenges traditional professional roles and practice patterns. Implications for nursing management There is an urgent need to develop practice nurse leaders and managers to not only embrace the challenges of Australian general practice from an operational perspective, but also undertake a clinical leadership role. As clinical leaders, these nurses will need to develop a culture that not only optimizes health outcomes but also advances the status of the nursing profession.     

Responding to health care reform by addressing the institute of medicine report on the future of nursing

The current health care environment has heightened the importance of achieving positive patient outcomes and excellent customer satisfaction. To remain competitive, health care organizations must adapt quickly to changing regulatory requirements, quality improvement initiatives, and customer expectations. To ensure nursing practice at the Saint Clare's Health System in Northwest New Jersey is at the forefront of leading change, the nursing staff has embraced the Institute of Medicine report The Future of Nursing: Leading Change. The empowered nursing team has applied Benner's Novice to Expert model and McCauley's Careful Nursing Theory as the foundation for nursing practice. The ability to apply evidence-based nursing research and cultivate professional development at the bedside has resulted in retention of expert nurses at the bedside. Engaging the nursing team has resulted in increased patient satisfaction and improved clinical outcomes. Advanced practice nurses play an important role to mentor the nursing staff and promote an interdisciplinary, collaborative relationship between all health care disciplines and community support programs. Nurses are recognized for their accomplishments and encouraged to obtain specialty certification, advanced degrees, and earn state and national recognition through professional organizations. The professional nurses at the Saint Clare's Health System are prepared to work in whatever environment the new normal creates.     

Dilemmas and directions for psychiatric nursing in the 1990s

Problems with the recruitment of nurses to the specialty area of psychiatric nursing have stimulated much debate and discussion in the field. This article explores dimensions of psychiatric nursing education, science, and practice and their impact on the future of this specialty area of nursing. It proposes that the present task is to define more precisely the continuum of psychiatric mental health nursing both to differentiate between psychosocial (mental health) and psychiatric (mental illness) components of the role and balance the priority that psychiatric nurses give to each in educational curricula, research agendas, and practice settings.     

Releasing the therapeutic potential of the psychiatric nurse: a human relations perspective of the nurse-patient relationship

In psychiatry mental health nurses form the largest professional discipline providing care on an everyday basis for sustained periods. Mental health nurses therefore are in a pivotal position to establish valued therapeutic alliances. In practice, however, a disproportionate amount of nursing time is taken up by administration, time spent talking to patients is minimal and when interactions do occur they remain notionally therapeutic and often are not theoretically informed. This noted paucity of therapeutic contact is antithetical to the aspirations of service users who increasingly are asking for a more skilled approach to the talking-listening that occurs in the therapeutic encounter. It is hypothesized by the present authors that an object-relations perspective of the nurse-patient relationship could release the largely untapped therapeutic potential of the psychiatric nurse by (1) bridging the gap between theory and practice and (2) providing a professional identity from within which nurses can begin to 'get to know' and understand the predicament of the patient with severe mental illness.     

Enhancing psychiatric nursing practice: role of an advanced practice nurse.

In response to demands for alternative health models that deliver cost-effective quality care, one large Midwestern medical center implemented a change in their nursing practice model. The change involved the introduction of unit-based nursing leadership teams that included advanced practice nurses (APNs). This article reports the findings from an investigation that employed a case study design to evaluate the process and outcomes of integrating an APN on a psychiatric unit with experienced nurses. Data collection methods included a nursing survey (n = 34), interviews with nine randomly selected nurses, and two multidisciplinary open forums. Consistent with the staff nurses' survey ratings of important advanced practice role functions, responses from the nursing interviews and open forums suggested nurses' professional development to be the most positive outcome. Role confusion was identified as a negative outcome. Recommendations for improved integration and use of APNs in today's psychiatric health environments were identified.     

Exploring evidence of the therapeutic relationship in forensic psychiatric nursing

While the body of nursing research in forensic psychiatry is growing rapidly, the therapeutic nurse-patient relationship in secure hospitals needs to be further examined. This paper reports on a research project that found two representations of the nurse-patient relationship in two male acute secure inpatient units. One representation was formed by the data collected from the unit nurses in semistructured interviews. The nurses valued the relationship and described their practice as therapeutic, however, evidence from the interviews would suggest that the nurses operate from a social frame of reference. Examination of the nurses 'entries in patients' case files formed the other representation. Through their documentation practices, nursing was represented as being oriented to custodial care. While neither representation can capture the clinical reality, these findings are relevant to forensic psychiatric nurses as their entries are a historical record through which their practice will become known to others, and in some cases, judged by others.     

Nursing in quality space: technologies governing experiences of care

This paper challenges contemporary portrayals in the nursing literature of the spaces within which care of patients in hospital settings is conducted. Within the wider discourse of fiscal restraint on health care spending, professional nursing has cast its disciplined eyes on details of the nurse-patient relationship for the ostensible purpose of repairing that which is treated as individual failings of nurses to practise in ways prescribed by nursing theories. Set aside in this approach to the so-called 'problems' of nursing practice has been an examination of the conditions within which nurses come in contact with patients, and a critical recognition that such contacts represent skilled accomplishments of social action. In this paper, these conditions are treated as resources available to both nurses and patients to generate accounts for the nurse's presence as well as the nurse's absence. Examples from an ethnographic study of nursing practice are used to illustrate how the spaces operating between nurses and patients are not empty voids but are social spaces through which particular meanings about nursing care can be conveyed.     

Differentiated practice: The evolution of professional nursing

Differentiated practice identifies and uses three distinct nursing roles to create a comprehensive nursing care delivery system that meets client needs across the health care continuum. Clearly defined associate degree in nursing, bachelor's of science in nursing, and master's science in nursing competencies present career opportunities for professional nurses at the bedside providing, integrating, or managing client care as well as options in management, education, and regulation. An evolutionary paradigm shift required of all nurses is the awareness that each nurse is not the whole of nursing, but rather each nurse contributes to the whole of nursing. A nursing community comprised of differentiated roles that are mutually valued and well integrated will position nursing as a powerful force in meeting the diversity and complexity of health care needs in contemporary society.     

Trust: a critical element in critical care nursing

All nurses, regardless of specialty, should strive to develop a trusting relationship with their patients. This relationship paves the way for obtaining the accurate and pertinent information necessary to form correct nursing diagnoses. In a critical care unit, this accuracy and trust is essential caused by the intensity of the environment. Support systems are weakened with family members being separated and allowed to visit for only short periods of time. Family members may see a loved one as never seen before, appearing absolutely helpless. A trusting relationship with the critical care nurse could help reinforce and strengthen the weakened support system. Professional nurses spend the greatest amount of time with consumers of health care. This situation places them in a position to influence life-styles. Seeking further assistance or following advice may depend on the quality of the nurse-patient relationship. Specifically for critical care and long-term situations, trusting relationships may make a long, intensive illness less traumatic. Trust built in the critical care area may provide the basis for positive nurse-patient relationships developing throughout the hospitalization and during future interactions with professional nurses.     

Health-promoting nursing practice: the demise of the nursing process?

Health promotion is gaining widespread recognition throughout the world as the most efficacious practice in achieving health for all In Canada, the philosophy of health promotion is driving both federal and provincial health initiatives Such a philosophy is derived from a human science paradigm and is in direct opposition to the natural science paradigm from which the biomedical approach to health care emerged There now exists a tension between these contrasting paradigms as health care shifts to embrace a health-promotion perspective The nursing process is based in the natural science paradigm and on a biomedical approach to health care In order for nurses to embrace health promotion fully, they must move away from the philosophy of the natural sciences and adopt a human science perspective Such a shift requires a radical transformation in nursing practice as nurses move away from the'top-down'approach of the nursing process and adopt a'bottom-up'approach to health-promoting nursing practice The purpose of this paper is to compare and contrast the nursing process with the principles of health promotion, and to challenge our use of the nursing process in current nursing practice In particular, a framework for health-promoting nursing practice will be provided     

Control and restraint in contemporary psychiatric nursing: some ethical considerations

Nursing theories which have evolved from mental health-psychiatric nursing have focused on the individual nurse-client relationship Other nursing theories generally focus on the individual as client Therefore, nurses working with families may have difficulty in applying these frameworks to their practice Nursing theories need to be expanded to include families, groups and communities more explicitly The well established theory of Hildegard Peplau, which previous studies have found to be the theory most frequently used by psychiatric nurses, and the family systems nursing theory of Wright and Leahey share a complementary focus Both theories form part of the interpersonal paradigm of nursing, both view nursing from an interactional perspective, rather than focusing on individuals Use of a combined theoretical approach offers several advantages The approach explicitly considers both the individual and the family The combination provides grounding for family work in an articulated nursing theory     

Psychiatric mental health nursing: challenge and change

. We invited Dr Peplau to provide a personal reflection on the recent history of psychiatric nursing and her thoughts on immediate challenges facing the profession. The paper is an individual scholar's commentary on the way that psychiatry has waxed and waned over the years, in relation to nursing. This historical review discovers and reports a challenge to current practice. Dr Peplau describes a professional shift that is pulling nurses toward the subordinate role observed earlier this century. The paper draws attention to how contemporary practice can be positively influenced, e.g., by giving a structure to the allocation and conduct of nurse–patient time.