Chapter 1 The effective nurse
Learning outcomes
Caring
Caring is widely considered to be central to nursing theory and practice, and is frequently cited as a reason for choosing a nursing career (Jackson & Borbasi 2006). Although the word ‘caring’ is used widely in the nursing and healthcare literature, as a concept it is ill defined. It is also controversial, and there are arguments for and against nursing adopting the concept of caring as the cornerstone of the discipline. Most of these arguments are concerned with:
From a mental health perspective there are even more issues to consider in relation to nurse caring. For example, there are special issues associated with caring for consumers who are compelled (perhaps unwillingly) to accept professional care under one of the Mental Health Acts (see Ch 4 for mental health legislation). Historically, mental health nursing has been associated with custodial care and control. Godin (2000) captures the current dilemma of mental health nurses when he raises questions about the dis-ease between the caring and coercive roles that mental health nurses assume. Godin positions caring as ‘clean’ and constructs the coercive control elements of mental health nursing (a term he uses for forced treatment, community orders and so on) as ‘dirty’ (Godin 2000, p 1396). While Godin’s argument is particularly focused on clients and nurses in the community, many of the issues he raises (related to forced administration of medication, seclusion and detention) are relevant to nurses in the inpatient setting as well. The absolute vulnerability of clients who can be detained against their will and subjected to various treatments that they may vigorously and robustly resist, means that elements of the caring role such as patient advocacy are absolutely critical to skilful and compassionate mental health nursing practice.
Hope and spirituality
There is still much that we don’t know about recovery, healing and how people manage chronic health problems. Why do some people pull through a disease, while others succumb? How is it that some people seem to cope very well with even very invasive treatments, while others suffer terribly? How do some people with chronic mental illnesses function well in the community, while others are in and out of hospital in a revolving-door syndrome? We know that factors such as personality, resilience, social support, general health and access to acceptable (to the client) health services all play a crucial role in client outcomes (see Ch 2 for more on consumers, recovery and rehabilitation; Ch 9 for resilience; and Ch 24 for a discussion on instilling hope). But the importance and value of concepts such as hope, and the role it plays in the lives of clients and their families, are areas of increasing interest. Hope has particular relevance to mental health nursing practice (Cutcliffe & Koehn 2007; Koehn & Cutcliffe 2007) and there is growing recognition of the concept of hope and its relationship to health, wellbeing and recovery from illness or traumatic life events.
‘Hope’ is a taken-for-granted term and although it is seen a lot in the literature, it is seldom clearly defined. It is considered essential in handling illness and has been described as ‘the act by which the temptation to despair is actively overcome’ (Fitzgerald Miller 2007, p 13). We know it is a complex and multidimensional variable that has optimistic and anticipatory dimensions and involves looking ahead to the future. Daly, Jackson and Davidson (1999, p 43) refer to hope as ‘a positive source of power’ that individuals can find and foster. Their findings suggest that hope arises from suffering, adversity or misfortune of some sort (Daly et al 1999). After undertaking a concept analysis of hope, Stephenson (1991, p 1459) defined it as ‘a process of anticipation that involves the interaction of thinking, acting, feeling and relating, and is directed toward a future fulfillment that is personally meaningful’.
In the literature, the concept of hope is consistently associated with spirituality and the belief systems that individuals hold (Daly et al 1999). For example, Daly et al (1999, p 42) describe a theme they named as ‘having faith in the primacy of a higher power’, to capture the idea that spirituality is central to the meanings that can be drawn from major life events. Of course, spirituality does not only refer to religious issues. Goddard (1995) differentiates metaphysical spirituality, which she says focuses on the notion of God or a higher power, from existential spirituality, which relates to values, beliefs, ideologies and philosophies that provide individuals with guidance and direction throughout their lives. Furthermore, she states that spirituality is a way of understanding and making meaning of life, and is apparent in commonplace as well as unusual circumstances (Goddard 1995).
The need for research to generate knowledge and enhance understanding about hope and spirituality in relation to mental health nursing is acknowledged in the literature (Cutcliffe & Koehn 2007; Koehn & Cutcliffe 2007). However, the biomedical model values things that can be seen, measured and quantified. Though they can be felt, hope and spirituality cannot be seen, touched or smelt and cannot always be clearly articulated, and so occupy what Crawford et al (1998, p 214) term ‘an embarrassed silence’. However, if we recognise that spirituality underpins the meanings that people make of illness and other life events, and that hope is a variable that has healing potential, then we cannot ignore the importance of spirituality in practice. Indeed, Thompson (2002) reinforces the importance of recognising and responding to the spiritual care needs of clients, and calls for nurses to include spiritual care as a crucial aspect of holistic client care.
This leads us to the question: What skills do we need if we are to care for the spiritual needs of our patients and clients? The short answer is that we need to develop effective interpersonal skills. Being open to the belief systems of other people, active listening, being alert to the cues that tell us the things that matter to a person, self-awareness, spiritual awareness and reflective skills are considered crucial in the provision of spiritual care (Greasley, Chiu & Gartland 2001; Thompson 2002).
Therapeutic use of self
Therapeutic relationships are the central activity of mental health nursing. They are the foundation upon which all other activities are based. Mental health nursing is thus firstly an interpersonal process that uses self as the means of developing and sustaining nurse–client relationships. Therapeutic use of self involves using aspects of the nurse’s personality, background, life skills and knowledge to develop a connection with a person who has a mental health problem or illness. Nurses intentionally and consciously draw on ways of establishing human connectedness in encounters with clients. The process is based on a genuine interest in understanding who the client is and how they have come to be in their current situation.
The purpose of using self therapeutically is to establish a therapeutic alliance with the client. Clients in mental health services may not only be suffering from frightening symptoms or perhaps overwhelming mood changes, or out-of-control thoughts and feelings; they also suffer from alienation and isolation. Clients may be fearful of talking to others about their symptoms or difficulties because they fear being rejected and seen as ‘crazy’, or they may have had experiences of rejection because of their mental illness that make it difficult for them to form relationships. Studies of clients’ experiences of mental health services provide evidence that being understood and listened to in a thoughtful, sensitive manner confirms their humanity and provides hope for their future (Shattell et al 2006).
In the process of using self therapeutically, the nurse develops a dialogue with the client in order to understand the client’s predicament. Clients need to feel safe enough to disclose personal, difficult and distressing information. It is in the way in which the nurse can convey genuine interest, concern and desire to understand the client that a therapeutic alliance can be established. How the nurse relates, and what prior understandings she or he brings to the encounter, will affect this relationship (Foster, McAllister & O’Brien 2006; Gallop & O’Brien 2003).
Heifner (1993) used the term ‘positive connectedness’ to describe the therapeutic alliance that develops between clients and nurses in psychiatric settings. The therapeutic relationship is marked by recognition of a common humanity with the client and feelings of reciprocity that result in connectedness between the client and the nurse. A review of evidence for the necessity of therapeutic relationships when caring for people with severe mental illness indicated that people who perceived a relationship as therapeutic had better outcomes (Hewitt & Coffey 2005).
Therapeutic use of self is embedded in the theoretical frameworks of the interactionist nursing theorists Peplau, Travelbee, and Patterson & Zderad (Meleis 2007), who locate the focus of nursing in nurse–patient interactions and relationships. These theorists define health and illness as part of the human experience, and the goals of nursing as developing human potential to find meaning in the experience (Meleis 2007). They stress the importance of self as a therapeutic agent.
Empathy and therapeutic use of self
The ability to empathise with clients is positively linked with the ability to develop therapeutic relationships. Studies have consistently shown that clients value empathic nurses highly (Forchuk & Reynolds 2001; Geanellos 2002; Hewitt & Coffey 2005; O’Brien 2000, 2001; Welch 2005). Empathy is not merely a feeling of understanding and compassion for the client. Empathy, as used in the therapeutic relationship, has a number of components. First, empathy involves an attempt to understand the client’s predicament and the meanings that the client attributes to their situation. This means that the nurse makes a conscious attempt to discuss with the client their current and past experiences and the feelings and meanings that are associated with these experiences. Secondly, the nurse verbalises the understanding that she or he has developed, to the client. The understanding that the nurse has of the client’s situation will be at best tentative; we can never really know what life is like for another. However, the process of seeking to understand, and of conveying to the client the desire to understand, creates the opportunity for further exploration in a safe relationship. In addition, maintaining the stance of trying to understand rather than making assumptions averts the tendency to make judgments about clients and their behaviour. The third component of empathy is the client’s validation of the nurse’s understanding. One of the most important aspects of the development of the therapeutic relationship through empathic understanding is that the nurse can convey to the client his or her desire to understand. This level of empathic attunement allows the client to participate in identifying those aspects of their illness and healthcare experience that are problematic (see also Ch 23).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
