ROLES OF THE NURSE IN A THERAPEUTIC RELATIONSHIP
As when working with clients in any other nursing setting, the psychiatric nurse uses various roles to provide needed care to the client. The nurse understands the importance of assuming the appropriate role for the work that he or she is doing with the client.
The teacher role is inherent in most aspects of client care. During the working phase of the nurse–client relationship, the nurse may teach the client new methods of coping and solving problems. He or she may instruct about themedication regimen and available community resources. To be a good teacher, the nurse must feel confident about the knowledge he or she has and must know the limita-tions of that knowledge base. The nurse should be familiar with the resources in the health-care setting and commu-nity and on the Internet, which can provide needed infor-mation for clients. The nurse must be honest about what information he or she can provide and when and where to refer clients for further information. This behavior and honesty build trust in clients.
The primary caregiving role in mental health settings is the implementation of the therapeutic relationship to build trust, explore feelings, assist the client in problem-solving, and help the client meet psychosocial needs. If the client also requires physical nursing care, the nurse may need to explain to the client the need for touch while per-forming physical care. Some clients may confuse physical care with intimacy and sexual interest, which can erode the therapeutic relationship. The nurse must consider the relationship boundaries and parameters that have been established and must repeat the goals that were established together at the beginning of the relationship.
In the advocate role, the nurse informs the client and then supports him or her in whatever decision he or she makes (Edd, Fox, & Burns, 2005). In psychiatric–mental health nursing, advocacy is a bit different from medical-surgical set-tings because of the nature of the client’s illness. For example, the nurse cannot support a client’s decision to hurt himself or herself or another person. Advocacy is the process of acting on the client’s behalf when he or she cannot do so. This includes ensuring privacy and dignity, promoting informed consent, preventing unnecessary examinations and proce-dures, accessing needed services and benefits, and ensuringsafety from abuse and exploitation by a health professional or authority figure. For example, if a physician begins to exam-ine a client without closing the curtains and the nurse steps in and properly drapes the client and closes the curtains, the nurse has just acted as the client’s advocate.
Being an advocate has risks. In the previous example, the physician may be embarrassed and angry and make a comment to the nurse. The nurse needs to stay focused on the appropriateness of his or her behavior and not be intimidated.
The role of advocate also requires the nurse to be obser-vant of other health-care professionals. At times, staff mem-bers may be reluctant to see what is happening or become involved when a colleague violates the boundaries of a pro-fessional relationship. Nurses must take action by talking to the colleague or a supervisor when they observe boundary violations. State nurse practice acts include the nurse’s legal responsibility to report boundary violations and unethical conduct on the part of other health-care providers.
There is debate about the role of nurse as advocate. There are times when the nurse does not advocate for the client’s autonomy or right to self-determination, such as by supporting involuntary hospitalization for a suicidal client. At these times, acting in the client’s best interest (keeping the client safe) is in direct opposition to the cli-ent’s wishes. Some critics view this as paternalism and interference with the true role of advocacy. In addition, they do not see advocacy as a role exclusive to nursing but also relevant to the domains of physicians, social workers, and other health-care professionals.
When a client exhibits child-like behavior or when a nurse is required to provide personal care such as feeding or bathing, the nurse may be tempted to assume the parental role as evidenced in choice of words and nonverbal com-munication. The nurse may begin to sound authoritative with an attitude of “I know what’s best for you.” Often, the client responds by acting more child-like and stubborn. Neither party realizes they have fallen from adult–adult communication to parent–child communication. It is easy for the client to view the nurse in such circumstances as a parent surrogate. In such situations, the nurse must be clear and firm and set limits or reiterate the previously set limits. By retaining an open, easygoing, nonjudgmental attitude, the nurse can continue to nurture the client while establishing boundaries. The nurse must ensure the rela-tionship remains therapeutic and does not become social or intimate.