This aspect of social relatedness, which often passes unnoticed, is exaggerated in therapy because of the inevitably imbalanced power relationship (Szasz. Journals A Guide to ' W Power imbalances and Therapy Karla Kennedy Boyd, are different from them, and the power dynamics of the therapeutic relationship. Van Mens-Verhulst questions traditional therapeutic practice and the image of. difficult to maintain a therapeutic relationship if any of these are violated. Power. There is an inherent power imbalance, in favour of the speech or hearing.
Does a power imbalance exist and what if the relationship deteriorates? Advise your manager that you are dating, if you are keeping the relationship a secret, ask yourself why? You see a rather unusual case and take a photo to send on to a consultant you know in Sydney who may be able to provide some further advice for treatment. You take the photo on your personal phone and send the image to him via email.
- Nursing and Midwifery Council of New South Wales
Did you obtain an informed consent from the patient? Is this a medical record? What are the regulations around the storage of medical records?
What if the image goes public? What do you do with the clinical advice given to you by the consultant? What if your phone is lost or accessed and the image distributed widely? What of you send it to the wrong email?
If you are required to send photos for clinical advice speak to your employer regarding a safe way to do this and for the consultation to be part of the medical record. Do not take photos for reasons other than seeking professional clinical advice. A good friend of yours is having a baby and has asked you to be their midwife. Straight away you should advise them that you are flattered but it would not be in both your best interests. There is a clear conflict here. Can you be objective in determining care?
Will they tell you everything you need to know to provide adequate care, for example they might not disclose some information due to embarrassment i. Are you the right person in relation to skill and complexity of the case?
What if something goes wrong and there is a poor outcome? Will your friendship survive? It is best to be a support in this case and allow another midwife to objectively provide care. In rural and small communities this is very difficult as is the case of colleagues having babies. It is paramount that all strategies are in place to manage these situations as professionally and objectively as possible.
You are at a barbecue with a group of friends and one friend starts discussing a health issue they have. They ask what you think of the condition and whether you can recommend any advice. What if your advice is wrong, not evidence based, challenged by others at the BBQ or you are intoxicated with alcohol and give them incomplete advice?
What if they follow your advice and something goes wrong? Politely advise that as you're not on duty, you won't be answering their inquiry but give them a way to get the advice they need, like who to see and when.
You are in the local coffee shop and overhear some people concerned and talking about the health of an acquaintance you play netball with. You are working a shift at the hospital and your acquaintance walks into another department and you're not involved in their care. Cutcliffe and Happell argue that these examples are tied to the use of invisible power through the dominant discourse of bio-psychiatry. However, this article paints an exclusively negative picture which taken alone may overemphasize the prevalence of the use of invisible power in current mental health practice.
In contrast, Gardner reports on a preliminary theory of how mental health nurses establish therapeutic relationships and maintain professional boundaries. Similar to Laugharne et al. This is demonstrated to be particularly important in order to counteract the previous negative experiences many mental health clients have had in services before, supporting results suggesting that previous experiences of coercion might result in a higher likelihood of perceiving coercion in future Laugharne et al.
The quality of their relationships emerged as the central way in which professionals influenced patients, highlighting the need for trust within these relationships to be built over time.
Honesty, curiosity, fairness, empathy, consistency and reliability were considered important to demonstrate within the therapeutic relationship, which in turn promoted engagement from patients. Providing something outside of patient expectations, such as going for coffee, or helping with practical tasks, helped to create reciprocal obligations, similar to findings by Laugharne et al.
This was seen as an inferior approach to others as, although it is a useful way of ensuring patient safety, it also had the potential to undermine relationships. In fact, the very context of having the Mental Health Act to fall back on can be experienced as coercive in itself. Strengths and limitations of study As a novice researcher at undergraduate level, this review is hindered by inexperience and limitations placed by financial and time restrictions Aveyard Publication bias may be an issue for this review as literature was only found on electronic databases which could be improved if efforts were made to search for grey literature Polit and Beck Single author reviews might also increase the potential for subjectivity and bias, although I have consulted with my dissertation tutor, which will hopefully have helped limit my own biases where evident.
I have also acknowledged my own views at the beginning of this research so that it would be evident to others if my own views did influence the results.
The Therapeutic Relationship and Issues of Power in Mental Health Nursing
In contrast, I consider the broad approach to this research a strength, as it demonstrates the complexity of power relations instead of focusing on a single area. Recommendations may be found as relevant to other professions working in settings alongside nurses but may also lack specificity to nursing. Discussion Power is a complex phenomenon that may need to be broken down into other elements in order to be better understood and researched.
This review was able to observe some of the current trends in research relevant to mental health nursing as to the way in which power is conceptualised.
The findings of this review mainly converge upon 4 areas: Legitimate use of power by professionals, the adverse impact of coercion, force and neglect, how are balance and reciprocity important to both power and the therapeutic relationship, and the influence of the system upon these perceptions.
Mental health nurses are clearly in a position of power in comparison to service users and this review proposes that this is not inherently bad. There are examples of where professionals use their power legitimately and this is beneficial.
This relies upon having a good Therapeutic relationship. However, the potential for coercion if this power is misused is apparent and perceptions of coercion are related to poor evaluations of the therapeutic relationship.
Professionals should be aware that balance and reciprocity may be important concepts when thinking about building relationships in the context of unbalanced power relations and might also want to acknowledge that structural and environmental factors can influence how patients perceive actions as either legitimate or coercive.
There were only three articles exclusive to nursing Gardner ; Maguire et al. The extent to which nurses can accurately reflect on and engage with the concept of power, when it has been indicated as something which they are uncomfortable discussing Cutcliffe and Happellis highlighted by the lack of articles exclusive to nursing and the language used to signify power within those articles, such as leverage Gardner and limit setting Maguire et al.
It has been noted elsewhere that there is a dearth of nursing literature regarding coercion which is surprising considering that nurses are involved, directly and indirectly, in many coercive interventions Galon and Wineman Although this review is exclusive to nursing, it was difficult to find exclusively nursing-related literature. This is an important limitation as the unique culture of the UK may provide unique challenges and perspectives.
Future research in the UK, including nurses in the process, would enable more specific recommendations to UK nurses in various settings and may highlight areas of power explicitly relevant to nursing. Interestingly, the only centre where nurses order coercive measures more frequently than physicians was the United Kingdom Raboch et al.
The need for nurses to be involved in research about coercion in the UK, when they are the ones most frequently ordering it, is evident. However, as results in this review appear to conform across cultures and are supported by an article of international approach Cutcliffe and Happellsome implications of this review should not be discounted From a UK perspective.
Recommendations and implications for practice and research Despite consensus in this review that many relationships might exist between power and the therapeutic relationship, further research is needed due to the quality of the current quantitative research and the tendency to focus on a single element of power: In regard to the relationship between perceived coercion and evaluations of the therapeutic relationship, longitudinal studies may help determine whether this is a causal relationship and experimental studies may be appropriate if an intervention specifically targeted at building a therapeutic relationship can be developed.
Studies should continue to use face to face interviews to collect data for surveys as, although this is more time consuming, it results in a more complete data set and higher response rate.
Directions in research to date appear to be interdisciplinary, reflecting the increasing interdisciplinary nature of mental health care. However, an increased nursing emphasis needs to be applied to research in order to relate findings specifically to nursing. The current research is difficult to generalise to UK culture and more research is needed in order to assess whether these findings can be generalizable across cultures, and whether unique cultures have unique differences.
However, the homogenous nature of high income countries mean it would be more reasonable to generalise the findings of this review to the UK than to developing economies who do not have such a developed mental health workforce. Ethnographic studies involving participant observation may also be helpful in future in order to see if there is a difference between attitudes as gathered by interviews, and actions as seen through observation Gobo Future research needs to make efforts to attempt to gain the views of individuals who for various reasons did not want to participate in current research.
This will obviously pose practical and ethical challenges, although involving service users as part of the research team may provide new perspectives due to the potential for people to change their responses in relation to who is asking the questions.
This also highlights the importance of increased nursing involvement in these research teams, which are currently overrepresented by medical staff. Nurses may benefit from acknowledging power as a relevant concept within their practice, which appears to be strongly related to evaluations of the quality of the therapeutic relationship. Power may be an uncomfortable topic to reflect on as it may be seen as equating to coercion, but not all power is perceived as coercive and may be perceived legitimately.
Relationships are clearly indicated as a factor in which perceptions of power may change. Some of the important aspects in these relationships to ensure they are empowering and not coercive are fairness, reciprocity, authenticity and a personal touch.
Sharing of power involves the sharing of information and needs to be balanced appropriately throughout the relationship in order to avoid feelings of either coercion or neglect.
The need to reflect upon power has been demonstrated and there is potential for ab use of power to damage the therapeutic relationship. Coercion is also remembered by service users and impacts their perceptions of future encounters within services. The coercive context of mental health services may make service users more sensitive to issues of power and more prone to perceptions of coercion — and the threat of coercion through the mental health act itself may cause formation of therapeutic relationships to be more difficult.
It may not be a coincidence that mental health nurses ascribe such value to the therapeutic relationship if you consider how difficult it is to build relationships in a culture where coercion is so prevalent. The influence of the system should not be ignored when thinking about power and current models of practice should be evaluated to determine their benefits and disadvantages in relation to the power relationships they can produce and, in turn, the effect this has on building trusting therapeutic relationships.
In particular, the allocation of time should be considered as an important aspect of whether our relationships with service users are coercive or therapeutic. Doing a literature review in health and social care: Measures of the therapeutic relationship in severe psychotic illness: Int J Soc Psychiatry 52 3: The politics of caring.
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European Psychiatry 18 5: Therapeutic limit setting in an assertive community treatment program. Psychiatr Serv 51 4: The Australian and New Zealand journal of mental health nursing 8 4: Approaches for dealing with missing data in health care studies. Interpersonal relations in nursing: Essentials of nursing research: Findings From Ten European Countries. Psychiatric Services 61 Developing therapeutic one-to-one relationships. Royal Collage of Nursing. Trust, Deals and Authority: Community Mental Health Journal 50 8: A concept analysis of empowerment: Journal of Advanced Nursing 29 3: Frontiers in Psychology 3: Perceived coercion and the therapeutic relationship: Psychiatr Serv 62 5: The impact of coercion on services from the perspective of mental health care consumers with co-occurring disorders.
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