Phases of Therapeutic relationship Implementation among the Queen Alia Heart Center Nurses

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Ala'a AL-A'araj Ahmad AL- Omari Correspondence: Ahmad Kamel AL-Omari Instructor & Faculty Member, Royal Medical Services College for Allied Health Professions, Department of Nursing Jordanian Royal Medical Services PO box. 36033 , Alhashmy Aljanoubi , Amman , Jordan 11120 Telephone: 00962772080776 Email: ahmadalomari85@hotmail.com

Introduction
Achieving a relationship of mutual trust and respect between the nurse and the patient requires the ability to communicate a sincere interest in the patient (1). The therapeutic relationship is purposeful and goal oriented, which creates a beneficial outcome for the patient (2+3), unlike the social relationship, where there may not be a specific purpose or direction (11+12). In fact, for interventions to be successful with clients in all nursing specialties, it is crucial to build a therapeutic relationship. So, crucial phases are involved in establishing a therapeutic nurse-patient relationship and the communication within it which serves as the underpinning for treatment and success (2+4+10).

The concept of therapeutic relationship is used in many disciplines and is recognized as one of the important concepts in nursing (2+3+4+6+9). In the practice, the therapeutic relationship can be described in terms of four sequential phases, each characterized by identifiable tasks and skills, and theses phases are: preinteraction phase, introduction phase, working phase, and termination phase (2+4+5). So, the therapeutic relationship must progress through the stages in succession because each builds on the one before. In fact, even though most healthcare professionals, including nurses, know the phases and its skills very well, they have trouble applying them to their behaviors, particularly in hospitals where there are a huge number of patients in comparison with small number of nurses assigned to the patients (3+5+6+7+8).

This gap between the therapeutic relationship perception and the therapeutic relationship practice directs us toward this study (5+11+12). So, the purpose of this study is to assess the current practices and problems that are encountered regarding the implementation of therapeutic relationship phases among registered nurses at Queen Alia Heart Center.

Methodology
The descriptive design was used for this study. A convenience sample of 200 registered nurses was selected from both genders with different experiences, who were working in the wards and units of the Queen Alia Heart Center (Table 1).


Table 1: The characteristics of the sample

A questionnaire was developed by the researchers and consists of 25 statements that assessed the implementation of the therapeutic relationship phases by nurses, in addition to the barriers for providing the phases according to the nurses. The four point's Likert scale questionnaire was reviewed by an expert panel consisting of nurse educator, nurse administrator and senior nurse colleague to establish its content validity. The stability reliability was checked by administering the questionnaire to a group of 40 registered nurses selected conveniently from both genders with different experiences. Then after 3 weeks, the same instrument was administered to the same group. The correlation coefficients were calculated, and it was equal to (+0.83).

The data collection was carried out on 21 st of July 2013. The response rate was 85% (n=170).

Results
The therapeutic relationship in our study was divided into four sequential phases: preinteraction phase, introduction phase, working phase, and termination phase. The preinteraction phase involves preparation for the first encounter with the client, which includes obtaining available information about the client from the available sources; like their file, family, and other health team members(2+4+5). The preinteraction phase also includes examining the client's feeling, fears, and anxieties before the interaction with the client(10). In our study, the majority of the nurses either always (46%) or usually (40.1%) practice the preinteraction phase during their encounter with their clients, while (10.3%) rarely do it, and (3.6%) not at all. (Table 2)


Table 2: The results of preinteraction phase

The second phase of the therapeutic relationship is the introduction phase. During this phase, the nurse and client become acquainted (2). This phase includes creating an environment for establishment of trust and rapport, identifying the client's strength and limitations, and exploring feelings of both client and nurse (2+4+5). The introduction phase also includes formulating nursing diagnosis, setting mutually agreeable goals, in addition to developing a realistic plan of action to meet the established goals (4+5+9). In our study, almost three quarters of the nurses stated that they were either always (32.4%) or usually (38.5%) practicing the introduction phase of the therapeutic relationship, while (20.1%) rarely did it, and (9% ) not at all. (Table 3)


Table 3: The results of introduction phase

The third phase of the therapeutic relationship is the working phase, in which the therapeutic work of the relationship is accomplished (4+7+9). This phase includes problem solving and overcoming client's resistance, in addition to maintaining the trust and rapport that was established during the introduction phase (2+5). The working phase also includes continuously evaluating progress toward goal attainment by using direct and purposeful questions during the interaction with the client, while keeping eye contact with them (4). In our study, the majority of the sample either always (32.8%) or usually (41.8%) practice the working phase of therapeutic relationship, while (19.7%) of the nurses stated that they did it rarely and (5.6%) not practicing it at all. (Table 4).


Table 4: The results of working phase

The fourth and last stage is the termination phase, in which therapeutic conclusions were brought to the communication and relationship with the client (2+4). This phase includes attaining of mutually agreed-on goals and setting a plan for continuing care, in addition to providing health education according to the client's needs(5). In our study, just one third of the nurses were either always (13.8%) or usually (21.2%) practicing the termination phase, while (35.8%) rarely did and (29.2%) were not practicing the termination phase at all. (Table 5).


Table 5: The results of termination phase

On the other hand, in response to a question about the biggest perceived barrier to practicing therapeutic relationship phases with their clients; 40% of the nurses think that the most common barrier is gender differences, while 35.4% of the nurses think that the nursing shortage and educational background differences are considered as barriers for the practicing of the therapeutic relationship phases.

Discussion
Although each phase of the therapeutic relationship is presented as specific and distinct from each other, there may be some overlapping of tasks, particularly when the interaction is limited (4). Even then, there are major tasks and goals during each phase and the client-nurse relationship must progress through these phases in succession. So, nurses must identify and practice these phases to build a healthy therapeutic relationship with their clients.

In our study, the preinteraction phase, introduction phase, and working phase were practiced always and usually by the majority (more than 65%) of the participants, while, the termination phase was practiced always and usually by just about one third (35%) of the participants. The small percentage of practicing the termination phase by the participants in comparison with the other phases reflects the high need to train nurses about how to practice the phases of therapeutic relationship, because the therapeutic relationship must progress through the phases in succession to build a healthy relationship with the clients. The termination phase is often expected to be difficult and filled with ambivalence (2+4), which could be caused by the feeling of sadness and loss that may be experienced by both the nurse and the client. However, if the previous phases have evolved effectively, the client generally has a positive outlook and feels able to handle problems independently (5).

The results of our study also show that both male and female participants practice the first three phases of therapeutic relationship in almost the same percentage, but on the other hand, the male participants practice the termination phase more than female participants. This could be caused by the nature of warm emotions that females have more than males.

In related to years of experience, the results show that the less experienced nurses (1-10 years) practice the first three phases of therapeutic communication more than the highly experienced nurses (11-20 years), which may be because the less experienced nurses are more restricted by the rules of the hospital, and their knowledge is fresher than the highly experienced nurses. In contrast, the results show that termination phases are practiced by highly experienced nurses more than the less experienced nurses, because the termination phase is more difficult to practice than the other phases and needs more experience in dealing with and building relationships with clients.

In addition, the results show that the phases of therapeutic relationship are more practiced in the general floors/wards than the critical units, which may be caused mostly by the fact that the consciousness and orientation status of clients in the critical units are lower than in general floors/wards. Indeed, consciousness and orientation status of the clients is considered as an integral element of nurse-client interactions to build the therapeutic relationship (3).
Furthermore, the barriers of practicing the therapeutic relationship by nurses in our study were mainly the gender differences between the nurse and the client, then by the huge workload that is caused by nursing shortage. In the previous studies, the barriers were mainly the nursing shortage (4+6+7).

Conclusion and Recommendations
The therapeutic relationship is the foundation on which nursing care is delivered. So, nurses who practice therapeutic relationships effectively are better able to initiate change that promote the health, establish trust relationship with the patient, and prevent legal problems associated with the nursing practice. Healthcare institutions must provide effective training to enhance the therapeutic relationship. Indeed, we hope that the hospitals will heed the call to improve discretion for the patients who entrust us with their care.

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