Nursig Research: Individual Nursing Therapy

Nursing practice is becoming increasingly complex and diverse, and many changes have been noted by authors in psychiatric mental health nursing in recent years (Jones, 2003). Increasingly, mental health services are taking place in the community rather than in inpatient settings. 


Nursing Therapy


As a result, contact time between nurses and clients has become limited. In discussing individual nursing therapy and nursing interventions on a one-to-one basis, one must move beyond the traditional parameters of individual therapy as first de-scribed by Peplau and consider brief psychotherapy and crisis intervention, case management, and even family interventions as crucial aspects of the nurse-client relationships. To-day, with the emphasis on psychobiology in the cause and treatment of mental illness, the importance and relevance of individual nursing therapy is in question (Kraus, 2000; McCabe, S., 2002; Raingruber, 2003).
The cornerstone of psychiatric mental health nursing today is the therapeutic relationship. Peplau defined the therapeutic nurse-client relationship as the interpersonal process between professional nurse and the client (Peplau, H. E., 1952). In this process the nurse needs to establish trust, strive to-ward mutually established goals of the relationship, and focus the movement of the interpersonal process toward growth for the client (Gelazis & Coombe-Moore, 1993). Peplau described the nurse as the basic tool or resource for the betterment of the client. Researchers have studied various aspects of Peplau’s theory, including the phases of the nurse-client relationship (Forchuk, 1995), the various roles of the nurse studied by Morrison (1992) and concepts and constructs identified as important to nurses by Peplau (O’Toole & Welt, 1989). Forchuk et al., (2000) studied Peplau’s theory and clarifies many aspects of the theory, including the assumptions, basic definitions, and relationships between the concepts. Future researchers need to continue the study of Peplau’s interpersonal paradigm, for it is a rich source of knowledge about the therapeutic individual nurse-patient relationship and the inter-personal process as it is used and is relevant today. Other nurse theorists based their own ideas and frameworks on Peplau’s nurse-client relationship theory (Orlando, 1961; Travel bee, 1972). Theorists, such as King, have communication and interpersonal process as central to the theory (King, 1992). Some have studied aspects of therapeutic process, such as empathy (Evans, G., Wilt, Alli-good, & O’Neil, 1998). Individual one-to-one nurse-client relationships continue to be highly important in psychiatric mental-health nursing. Much of nursing, both inpatient and outpatient, involves the nurse’s ability to engage the client in interpersonal interactions. In recent years, however, as care is more profit-driven, the nurse-client relationship has undergone some changes. The fact that the client has much shorter contact with the nurse in inpatient settings due to short hospital stays means that the phases of the nurse-client relationship, which in the past had more time to develop, now must solidify within brief periods of time. Sometimes there are only a few days available and at times only hours for contact between nurse and patients (Vaughn, Webster, Orahood, &Young, 1995). The relevance of individual nursing therapy has been called into question by those who claim that giving the appropriate medication to the mentally ill person is the most important feature of care, thereby calling forth serious discussion of how psychiatric nurse clinical specialists should use their time (Raingruber, 2003). Complex mental illness seems to require more than a medical approach with medication. The recent success of dialectical behavioral therapy, DBT, with patients having this disorder suggests that more complex treatments are in order which blend various paradigms in treatment of mental illness (Perseius et al., 2003).
Brief therapies or short-term psychotherapies are time limited, have limited goals, and generally cost less than longer forms of therapy. Psychiatric nurses and particularly psychiatric nurse clinical specialists are well suited and prepared to use a brief psychotherapy model because their education and clinical experience prepares them well to use this form of therapy (Shires & Tappan, 1992). Brief therapy usually lasts for six to twelve sessions, but for clients with chronic problems the sessions may be spaced over a 3 to 6-month period (Wells, R., & Gionnetti, 1990). Visits tend to be shorter and may be from 15 to 30 minutes (Budman & Gurman, 1988). In brief therapy the therapist is usually quite active and can use techniques such as homework assignments to extend treatment (Shires & Tappan). Frequently therapeutic experiences occur in the community setting (Budman & Gurman). Nurses are usually knowledgeable regarding community resources and may work for community based agencies.
The psychiatric mental-health nurse practicing in the community setting deals with chronically mentally ill clients both in long term therapeutic relationships and in crisis situations. In this setting communication skills are even more important because trust needs to be established in a relatively short period of time. The nurse applying crisis intervention uses her assessment skills to the utmost and builds trust to have clients confide important information. For example, if the client is suicidal, trust is a highly important element to buy time for the client so that emergency services can be sent (Wheeler, 1993). Another use of crisis intervention in individual nursing therapy is by the triage nurse in community mental-health nursing, who frequently deals with suicidal clients or clients who may be dangerous or threatening to others due to exacerbation of psychiatric symptoms (Wheeler, 1993). The nurse not only must communicate therapeutically with clients, but also with distraught families. The principles of individual therapy as outlined by Peplau must therefore be expanded to include family members and clients, all of whom may be in crisis at the time of contact (Gilliss, 1991). Some work has been done in this area, but nurse researchers need to continue to systematically study how the interpersonal process can be expanded to include family and others and how this process is therapeutic.
The psychiatric mental-health nurse is part of the community mental-health system and is able to help coordinate care of clients through the use of case management. Often the criticism of the care of the chronically mentally ill in the community is that care is fragmented and uncoordinated (Anthony, W. A., Cohen, Farkas, & Cohen, 2000). Research has shown that care-management services may be available to clients in the community, but that clients rarely take advantage of such services due to lack of knowledge or other reasons (Parson, 1999). Some researchers pointed out that case management can be the key to adjusting to the community for the chronically mentally ill because it provides a link for the client to the support services he or she needs (Forchuk & Brown, 1989). Forchuk recommends that an essential component of a case-management model is the establishment of a one-to-one relationship, which can be the basis for continued long term care in the community. Thus Peplau’s theory comes into play through its use in case management. The Peplau case-management model provides a framework for delivering nursing care and comprehensive care for the chronically mentally ill client (Forchuk & Brown).

In the demanding environment in which psychiatric mental-health nursing takes place today, the nurse must use basic skills in new applications. The individual therapy that nurses use is based on Peplau’s interpersonal framework. This theory is still relevant and can be used in various forms of individual therapy, which include brief psychotherapy, crisis intervention, and case management. All of these frequently occur in community settings. Nurse researchers need to study the therapeutic process in various settings and time frames to establish the effectiveness of the nurse’s interactions and interventions. The interpersonal framework and theory itself also would benefit from continued study and research, particularly because of the extreme emphasis today on the psychobiological aspects in the care of the mentally ill.


EmoticonEmoticon