RN Psychotherapists Support Transition from Hospital to

Community Care
Ingrid Dresher, RN, BScN ; Mina Singh, RN; PhD Debora KirschbaumNitkin, RN, PhD
Transition from Hospital to Community Care Needs Support and Direction
Therapeutic alliance creates an intense crucible of cognitive and emotional intensity with
enough coherency to evoke stabilizing structural changes in the brain itself (Wheeler,
2014). This could be the neurochemical/epigenetic basis of long-term change, including
resilience (Siegel, 2012).
Breaking Cycle of Readmissions ACost-Effective Strategy
Most frequent (73%) reason for readmission was for difficulty coping (Bernardo &
Forchuk, 2001)
TRM (i.e.. therapeutic alliance) has proven effective in decreasing readmissions and
assisting with coping
Significant cost savings achieved through this model (Forchuk et al., 2012)
References
Bernardo, A. & Forchuk, C. (2001). Factors associated with readmission to a psychiatric facility. Psychiatric Services, 52 (8), 1100-1102
Davis, S. (2006). Community mental health in Canada. Vancouver: UBC.
Canadian Nurses Association (2005). Mental health and nursing: A summary of the issues. Retrieved from: http://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/bg6_mental_health_e.pdf
Forchuk, C., Jewell, J., Schofield, R., Sircelj, M. & Valledor, T. (1998). From hospital to community: Bridging therapeutic relationships. Journal of Psychiatric and Mental Health Nursing, 5, 197-202.
Forchuk, C., Martin, M., Jensen, E., Ouseley, S., Sealy, P., Beal, G., Reynolds, W. & Sharkey, S. (2012). Integrating the transitional relationship model into clinical practice. Archives of Psychiatric Nursing, 0(0), 1-8. DOI: 101016/j.apnu.2011.12.002
Jensen, E. (2005). Public consultation process respecting the regulation of psychotherapy and psychotherapists in Ontario: Submission
Links, P., Nisenbaum, R., Ambreen, M., Balderson, K., Bergmans, Y., Eynan, R., Harder, H. & Cutcliffe, J. (2012). Prospective study of risk factors for increased suicide ideation and behavior following recent discharge. General Hospital Psychiatry, 34, 1, 8897, DOI:
10.1016/j.genhosppsych.2011.08.016
Peplau, H. (1991). Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. New York: Springer
Prochaska, J., & Norcross, J. (2010). Systems of psychotherapy: A transtheoretical analysis (7th ed.). Belmont, CA: Brooks/Cole.
Registered Nurses Association of Ontario. (2002). Nursing best practice guideline: Establishing therapeutic relationships. Retrieved from: http://rnao.ca/bpg/guidelines/establishing-therapeutic-relationships
Siegel, D. (2012). Interpersonal neurobiology. London: Norton.
Spiers, J. & Wood, A. (2010). Building a therapeutic alliance in brief therapy: The experience of community mental health nurses. Archives of Psychiatric Nursing, 24(6), 373-386. DOI: 10.1016/j.apnu.2010.03.001
Smith, M. & Khanlou, N. (2013). An analysis of Canadian psychiatric mental health nursing through the junctures of history, gender, nursing education, and quality of work life in Ontario, Manitoba, Alberta, and Saskatchewan. ISRN Nursing, 2013, 1-13. Retrieved
from: http//dx.doi.org/10.1155/2013/184024
Delaney, K. & Handrup, C. (2011). Psychiatric mental health nursings psychotherapy role: Are we letting it slip away? Archives of Psychiatric Nursing, 25(4), 303-305. DOI: 10.1016/j.apnu.2011.04.005
Hopkins, C. & Niemiec, S. (2007). Mental health crisis at home: Service user perspectives on what helps and what hinders. Journal of Psychiatric and Mental Health Nursing, 14, 310-318.
Safran, J., Muran, J., Demaria, A., Boutwell, C., Eubanks-Carter, C. & Winston, A. (2014). Investigating the impact of alliance-focused training on interpersonal process and therapists capacity for experiential reflection. Psychotherapy Research, 1-17. DOI:
10.1080/10503307.2013.874054
Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse. New York: Springer.
RN Psychotherapy
Psychiatric nurses have long history of inclusion of psychotherapy in
their work with individuals, groups and families (Jensen, 2005)
Peplau (1991) defined the interpersonal relationship of nurse and patient
as therapeutic and the cornerstone of nursing
The term therapeutic relationship has been used by nurses to describe
the interpersonal skills that other disciplines refer to as psychotherapy
(Jensen, 2005)
As with all psychotherapy, sustained skills of nurses help patients
undergo self-examination and their anxiety about their current situation
(Peplau, 1991, p. 149)
Peplaus interpersonal paradigm has been expanded with current
interpersonal neuroscience and attachment research, validating the
scientific basis of the healing components of relationship (Wheeler, 2014)
Caring, connection, narrative and management of anxiety are
fundamental elements of psychotherapy (Wheeler, 2014), all of which are
central to psychiatric nursing practice
Background
Forchuk et al. (2012) established parameters for Transitional Relational
Model (TRM) from acute care to community integration
Continuous relationship with same nurse provides bridge to community
Provides safety net discharge to community re-integration
Replicable evidence for cost-effectiveness and decreased readmissions
Systemic resistance to implementing this method is a barrier
How can this evidence-based method become standard practice?
Problem
Gap in support for clients in transition
from acute care into community (CNA,
2005; Davis, 2006; Links et al., 2012)
Short acute care services increases need
for transitional care nurse services
Nurses role in this function is not
recognized, supported and funded
Manualized therapies setting trend
towards relationships without depth
(Delaney & Handrup, 2011)
Definition of Psychotherapy:
It is the relationship itself that provides the context of healingThe training normally
includes processes and activities aimed at self-awareness as part of a therapeutic alliance
or relationship. The psychotherapist must be able to gain the trust of the client and
establish a therapeutic contract that includes clear parameters and boundaries. Through
the use of self in relationship, the psychotherapist is able to move the client toward
growth and healing (Jensen, 2005).
High quality of therapeutic alliance has remained the consistent factor correlated with
positive outcome research across all disciplines and methodologies (Prochaska &
Norcross, 2010; Safran et al, 2014)
Therapeutic Alliance
The point at which the clients recognize that the nurse is fully attuned to being in the
moment as they connect to their own issues in a positive way. This consists of the
overlapping phases of establishing mutuality, finding the fit in reciprocal exchange,
and activating the power of the client (Spiers & Wood, 2010, p. 373).
Mental Health Crisis Intervention at Home (Hopkins & Niemiec, 2007)
Home treatment service team on call 24 hours
Clients reported accessible, available consistency by nurses delivering high quality skills of
listening, normalizing and responding with calm and helpful knowledge
Like a friend (p. 314), they helped with negotiations and making appropriate choices, and
assisting with effective communication
Reduced psychiatric admissions by 42% over six years
Community Resources Enhance Quality of Life - Through partnership nurses enable
clients to locate and connect with fulfilling support, and break cycle of isolation.
Implications
Forchuk et al.s TRM provides a researched-based cost-effective model for people
with serious mental disorders to reintegrate into their community
Nurses with sufficient psychotherapeutic skills are well positioned to provide care that
connects one nurse to person in hospital, and remains connected until person firmly
established in relationships within community care
B
A
C
K

T
O

H
O
S
P
I
T
A
L
TO COMMUNITY HELP
Is an RN psychotherapist trained in advanced skills
of therapeutic alliance best suited for role of
assisting client in hospital-to-community transition?
What change in system would be needed to put RN
psychotherapists in this role?
Empathic connection protects clients vulnerability and
enables a collaborative approach towards goal setting
Barriers
Insufficient support from governing bodies to maintain therapeutic relationship as
foundation of nursing practice
Ontario lags behind USA initiative to train nurses in basic and advanced psychotherapeutic
competencies (Wheeler, 2014)
Controversy regarding nurses right to practice psychotherapy autonomously can create
deskilling by prohibiting immediate psychotherapeutic responses to clients (i.e. requirement
for treatment orders)
Excessive workloads preclude the time required for effective interpersonal relationships to
be established (RNAO, 2002)
In Ontario there has been a consistent decrease in RNs working in psychiatric services
despite warnings from WHO that more services are required (Smith & Khanlou, 2013)