Orientation:
- In the beginning of the therapeutic relationship, the nurse and client are strangers to each other, yet each individual has preconceptions of what to expect – based on previous relationships, experiences, attitudes and beliefs
- The parameters of the relationship are established (e.g., place of meeting, length, frequency, role or service offered, confidentiality, duration of relationship)
- The client and nurse begin to learn to trust and know each other as partners in the relationship
- Trust, respect, honesty and effective communication are key principles in establishing a relationship
Working Phase:
- The working or middle phase of the relationship is where nursing interventions frequently take place
- Problems and issues are identified and plans to address these are put into action. Positive changes may alternate with resistance and/or lack of change
- It is important for the nurse to validate thoughts, feelings and behaviours
- The nurse assists the client to explore thoughts (e.g. views of self, others, environment, and problem solving), feelings (e.g. grief, anger, mistrust, sadness), and behaviours (e.g. promiscuity, aggression, withdrawal, hyperactivity)
- The content to be explored is chosen by the client although the nurse facilitates the process
- The nurse continues his/her assessment throughout all phases of the relationship
- New problems and needs may emerge as the nurse-client relationship develops and as earlier identified issues are addressed
- The nurse advocates for the client to ensure that the client’s perspectives and priorities are reflected in the plan of care
Resolution Phase:
- The resolution or ending phase is the final stage of the nurse-client relationship
- After the client’s problems or issues are addressed, the relationship needs to be completed before it can be terminated
- The ending of the nurse-client relationship is based on mutual understanding and a celebration of goals that have been met
- Both the nurse and the client experience growth
- Termination may be met with ambivalence
- The nurse and the client must recognize that loss may accompany the ending of a relationship
- Both should share feelings related to the ending of the therapeutic relationship
- Validating plans for the future may be a useful strategy
- Increased autonomy of both the client and the nurse is observed in this phase
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International Journal of Nursing Studies
Summary of papers and quality ratings.
Berry et al., 2012 | Pre-post intervention, no control group | Adult low secure psychiatric inpatient unit, NHS, UK. Nursing staff employed at least three months, 10 h contact with patients per week, including day shifts. | 25 baseline (60% mental health nurses); 13 with both intervention and follow up measures | Three hour workshop by clinical psychologist, eliciting psychological factors to understand patients. | WAI-short form Staff report | No significant change in WAI. Rated as helpful, relevant by attendees. Low take-up (42% of baseline). | 0.28 (not in favour of intervention) | A Selection 2B Design 2C Confounders 3D Blinding 3E Data 1F Withdrawal 3 GLOBAL Weak |
Berry et al., 2016 | Single-blind cluster RCT. Intervention plus TAU versus TAU alone | Adult psychiatric rehabilitation units, UK NHS and private. Nursing staff on units, at least three months experience, including day shifts. | 85 baseline (42% mental health nurses), 74 at follow up. | 24 1 h sessions per unit over six months. Facilitated by clinical psychologist. Formulation-based with written report and care planning. | WAI- short form (staff and patient report), completed in relation to key worker | Intention to treat analysis controlling for clustering. T-tests showed no significant difference for staff or patient reported outcomes. 87% completed follow up. | 0.45 staff (not in favour of intervention) 0.92 patient | A Selection 2B Design 1C Confounders 1D Blinding 2E Data 1F Withdrawal 2 GLOBAL Strong |
Byrne and Deane, 2011 | Pre and post, no control group | Adult community services for severe mental illness, Australia. Workers (including nurses), at least 12 month experience, therapeutic relationship at least 12 months. | 46 clinicians (‘mostly nurses’) | Three day workshop on medication alliance training, clinician attitudes addressed. Six and 12- month follow up. | WAI- short form, clinician rated only. | 72% remained until completion. Significant change in WAI between baseline and six mth. | 0.53 | A Selection 2B Design 2C Confounders 3D Blinding 3E Data 1F Withdrawal 2 GLOBAL Weak |
Carpenter et al., 2007 | Quasi-experimental design. Results compared between training cohort and cohort from another setting, also pre-post course evaluation. | Staff training context with follow up of outcomes with patients in community, mostly with psychotic disorders, NHS, UK. | 36 trainees (60% nursing) | Training in psycho-social interventions | Non-validated measure of relationships between service user and trainee, service-user rated. | No significant differences between time 1 and 2 (6 months). Some differences between those in training cohort and those not. | Insufficient data to report. | A Selection 2B Design 2C Confounders 3D Blinding 3E Data 3F Withdrawal 3 GLOBAL Weak |
Kellett et al., 2019 | Two nested studies: pre-post one group design with three sites (1) and case series (2) | Secondary Care Community Mental Health NHS-based services (UK) | 58 staff-patient dyads in study 1, five dyads in case series (study 2). Hard to engage clients not receiving individual therapy. | Cognitive analytic consultancy delivered by accredited practitioners to staff-patient dyads. Five sessions (typically lasting 1 h) | Working alliance inventory: staff and patient long form in study 1 (NB only one site used this with n = 12) and short form (Staff and patient versions) in study 2. | No significant difference in study 1. Client-rated WAI improved significantly between intervention and follow-up (large effects size). No significant difference for staff- rated. | Study 1client = 0.22 and staff = 0.23Study 2(case series) client = 1.11 staff = 0.29 | A Selection 2B Design 2C Confounders 3D Blinding 3E Data 1F Withdrawal 3 GLOBAL Weak |
Molin et al., 2018 | Pre-post visual display of findings, no control group. | Three adult psychiatric clinics in three hospitals in Sweden. | 50 staff members across three ‘systems’. 70% nurses in training or registered nurses. | ‘Time together’ intervention, focusing on protected time for shared activities between staff and patients. | Caring professional scale completed by patients | No reported effects on quality of interactions. Statistics not reported. | Insufficient data to report. | A Selection 2B Design 2C Confounders 3D Blinding 3E Data 1F Withdrawal 3 GLOBAL Weak |
Moreno-Poyato et al., 2018 | Participatory action research. Quasi-experimental pre-post design. | Adult acute psychiatric hospital, Barcelona, two sites | 26 nurses, four dropped out Permanent staff, at least 21 h per week. | Ten months. Individual interactions, reflective groups, scientific texts. | WAI-short form, clinician-rated | Significant difference between groups post-intervention Wilcoxon signed rank | 1.14 | A Selection 2B Design 2C Confounders 1D Blinding 3E Data 1F Withdrawal 2 GLOBAL Moderate |
Stringer et al., 2015 | Comparative multiple case study design | Adult borderline personality disorder services, community. Netherlands. Caseloads of nurses approached in random order. | Ten nurses for experimental condition and five from the control condition. | Collaborative care programme versus care as usual. Allocated by patient, not nurse. | STAR- scale to assess therapeutic relationships | No significant effect of intervention. | 0.13 at time 2 (nine months) | A Selection 3B Design 2C Confounders 3D Blinding 3E Data 1F Withdrawal 3 GLOBAL Weak |