Nurses’ Experience of Maintaining Their Therapeutic Relationship With Outpatients With Bipolar Disorder and Their Caregivers During Different Stages of a Manic Episode: A Qualitative Study

This study explores nurses' experiences of maintaining their therapeutic relationship with outpatients with bipolar disorder and their caregivers during different stages of a manic episode. The findings suggest that nurses experience dual loyalty when facing conflicting interests and strive to stay connected to patients and caregivers with an open and nonjudgmental attitude. Early involvement of caregivers in the treatment is recommended.

Nurses’ Experience of Maintaining Their Therapeutic
Relationship With Outpatients With Bipolar Disorder and
Their Caregivers During Different Stages of a Manic Episode:
A Qualitative Study
Titus A.A. Beentjes, MSc, MANP, RN, Peter J.J. Goossens, PhD, MANP, RN, FEANS, and
Irene P. Jongerden, PhD, RN
Titus A.A. Beentjes, MSc, MANP, RN, is PhD Student, Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare,
Nijmegen, Lecturer, Saxion University of Applied Science, Faculty of Health, Deventer, Nurse Practitioner, Dimence Group Mental Health Care
Bipolar Specialists Center, Deventer, and Student, Nursing Science Program, Clinical Health Sciences, University Medical Center Utrecht, Utrec
Netherlands; Peter J.J. Goossens, PhD, MANP, RN, FEANS, is Nurse Practitioner, Dimence Mental Health Care Centre, Bipolar Specialists Center
Deventer, the Netherlands, Lecturer, Ghent University, Department of Nursing Sciences, Ghent, Belgium, Senior Researcher, Radboud Univers
Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands, and Senior Lecturer, GGZ-VS, Institute for E
of Clinical Nurse Specialist in Mental Health, Utrecht, the Netherlands; Irene P. Jongerden, PhD, RN, is Nurse Researcher, Department of Intens
Care Medicine, University Medical Center Utrecht, and Lecturer, Clinical Health Sciences Program, University Medical Center Utrecht, Utrecht,
the Netherlands.
Search terms:
Bipolar disorder, caregiver burden, dual loyalty,
manic episode
Author contact:
[e-mail], with a copy to the
Editor: [e-mail]
Conflict of Interest Statement
The authors declared no conflicts of interest
with respect to the study, authorship, and/or
publication of this article. The authors received
no financial support for the study, authorship,
and/or publication of this article.
Author contributions
Study design: Beentjes. Data collection:
Beentjes. Study supervision: Goossens,
Jongerden. Writing of the article: Beentjes.
Critical review of the article: Goossens,
Jongerden.
First Received October 12, 2014; Final Revision
received January 19, 2015; Accepted for
publication February 11, 2015.
doi: 10.1111/ppc.12109
PURPOSE:Caregiversoften consultcommunity mentalhealth (CMH) nurses
when they recognize prodromes of mania in the outpatient. The purpose of this
study was to determine nurses’experiences of their therapeutic relationship and
nursing interventions to outpatients and caregivers during different stages of m
DESIGN AND METHODS:A qualitative study was conducted. Nine nurses were
interviewed.
FINDINGS:CMH nurses experienced dual loyalty when facing conflicting inter-
ests. They strived to stay connected to patients and caregivers with an open an
nonjudgmentalattitude.In euthymic episodes,nurses anticipated by developing
good relationships with both and by making relapse prevention plan.
PRACTICE IMPLICATIONS:Early involvement of caregivers in the treatment is
recommended.
Background
Bipolar disorder is a major mentalillness with a lifetime
prevalence of 1.3% in the Netherlands (De Graaf, ten Have,
van Gool, & van Dorsselaer, 2012) which follows a pattern of
recurrent manic, hypomanic, depressed, or mixed episodes
(Kupka & Regeer,2007).In outpatient clinics,community
mental health (CMH) nurses focus their treatment
on preventingrelapses(Goossens,Beentjes,de Leeuw,
Knoppert-van derKlein, & van Achterberg,2008).In
euthymic and depressive episodes, patients with bipolar dis-
order are generally aware of the disease. The first most recog
nized manic prodromes reported by the patients, currently in
euthymia, are increased energy and social functioning, and
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decreased need for sleep (Goossens, Kupka, Beentjes, & van
Achterberg,2010).However,during the developmentof
manic episodes, patients often deny having bipolar disorder
and subsequently may not acknowledge the manic symptoms
(Goossenset al.,2010;Mantere,Suominen,Valtonen,
Arvilommi,& Isometsa,2008). When experiencing mania,
patients might not recognize the high potentialfor painful
consequences like overspending, aggressiveness, losing sense
of reality,adultery,suspiciousness,and psychosis,nor the
heavy burden mania imposes on their (informal) caregivers.
These manic behaviors induce discomfort in other people,
rendering it impossible for caregivers to remain unaffected.
In spite of the burden, caregivers contribute a great deal to
overallillness management (Dore & Romans,2001).They
develop a keen awareness to monitor changes in the patients’
mood state to bolster their effort in preventing damaging
consequencesof mania (Tranvåg & Kristoffersen,2008).
Caregivers often experience a lack ofprofessionalsupport
during the treatment process. The caregivers’ search for pro-
fessional support has been characterized as a new source of
stress which increases the levelof experienced burden for
them (Van der Voort, Goossens, & van der Bijl, 2009).
In quantitativestudies,caregiverburden ispositively
related to depressive episodes (Ostacher et al., 2008; Perlick
et al., 1999). However, little is known about a possible relation
between caregiver burden and manic episodes. One possible
explanation is that caregiver burden scales do not attend to
the cyclic nature ofbipolar disorders (Martire et al.,2009;
Ogilvie, Morant, & Goodwin, 2005). Another explanation is
that adequate recruitment of caregivers of patients in manic
state is complex partly because ofthe little time spentin
mania (Calabrese,Hirschfeld,Frye,& Reed,2004;Coryell
et al., 1993; Kupka & Regeer, 2007).
Nonetheless,it remains unclear how nurses can support
caregivers in different stages ofa manic episode (Beentjes,
Goossens,& Poslawsky,2012).The momentcaregivers
consult CMH nurses about observed manic prodromes in the
outpatient’s condition might be an opportunity for nurses to
support the caregiver effectively. In this case, however, CMH
nurses are confronted with caregivers and outpatients who
hold conflicting opinions about the manic prodromes and
possible consequences. The caregiver’s wishes to prevent the
damaging consequences of mania may conflict with the out-
patient’s desire to continue their involvement in pleasurable
activities. This situation may subsequently lead to a role con-
flict for the CMH nurse who must cope with this complexity,
in order to sustain a therapeutic relationship with the outpa-
tient, or support the caregiver, or focus on both.
The Dutch treatment guidelines do not provide informa-
tion on how CMH nurses should actin these situations
(Nolen et al., 2008). CMH nursing care focuses on informing
and educating the outpatient, supporting and counseling the
outpatient, nurse accessibility, developing relapse prevention
plans,and monitoring medication use(Goossenset al.,
2008). To contribute to the body of knowledge on caregiver
burden during stages ofa manic episode,we conducted a
study focusing on the CMH nurses’ experiences and interve
tions in situations ofconflicting interests ofpatients and
caregivers.
Method
Study Design
We performed a qualitative study with open interviews focu
ing on the CMH nurses’experiences when nursing outpa-
tientswith bipolardisorderand theircaregiversduring
different stages of a manic episode.
Population and Setting
The sampling method in this study was purposive. Partici-
pantswere recruited from CMH nurseswho attended a
master class organized by the Dutch Foundation for Bipolar
Disorders entitled “Nursing Care for Patients with Bipolar
Disorder.” To reduce the risk of repeated data, one nurse pe
outpatient clinic was approached. The study was explained
the nurses, full anonymity was guaranteed, and a statemen
indicating willingness to participate was requested.
CMH nurses eligible for inclusion were registered nurses
working for more than 2 years in an outpatient clinic treatin
patients with bipolar disorder on a daily basis. These nurses
have long-term therapeutic relations with patients and their
caregiver during all stages of bipolar disorder, and were the
fore considered eligible to enclose the necessary informatio
CMH nurses who worked with this patient group for less tha
2 yearswere regarded ashaving too little experience in
nursing outpatients during the severe stages ofmanic epi-
sodes, since the mean time patients spend in severe stages
mania is only 1% (Kupka et al., 2007).
When a CMH nurse could not participate because of holi-
days,illness,or non-eligibility,a colleague from the same
mental health institute was contacted. None of the contacte
nurses refused to be interviewed. Initially, interviews with fi
participantswere planned.Additionalinterviewswere
arranged until data saturation was achieved. All participants
signed informed consent forms.
Data Collection
In August and September 2012,nine open interviews were
held at the respective offices of the participants. The interv
began with the introduction of a vignette to get context spe
cific information instead of abstract information (Richman &
Mercer, 2002). To enable an open-ended question, we aske
participants to respond to the vignette: “A caregiver is callin
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you and tells you that the patient is manic. The caregiver tells
you he is argumentative and irritable, is spending money, and
should be hospitalized immediately.” The opening question
was:“Have you experienced situationslike this?” When
answered positively, the subsequent request was: “Please tell
me more about this experience.” A topic list was used to help
the interviewer focus on the specific situation and explore
experiences in depth. The topic list was based on a literature
review of caregiver burden (Beentjes et al., 2012), the descrip-
tion of interviewers’ own experiences, and discussions with
the second author.The interviews were tape-recorded and
transcribed verbatim.Interviewswere coded to facilitate
anonymous analysis.
Data Analysis
A practical approach to the process of interviewing and ana-
lyzing wasguided by the modified Stevick-Colaizzi-Keen
method (Creswell, 2007). This method consists of six steps:
(a) describing experiences of researchers with the phenom-
enon under study, (b) developing a list of significant state-
mentsfrom the textsof the verbatim transcriptsof the
interviews, (c) grouping statements with comparable content
into larger “meaning” units, (d) describing what the nurses
experience, (e) describing setting and context of the nurses’
experience,and (f) writing a composite description ofthe
essence of the experience (Creswell, 2007).
As part of bracketing, the interviewer (TB) began with a
full description ofhis own experiences,prior knowledge,
assumptions, values, and interests to draw awareness to his
presuppositionsregardingthe topic (Silverman,2013;
Tufford & Newman, 2010).Discussionsenabledthe
researcher to detach himself from his presuppositions and set
them aside, to direct his focus on the experience of the partici-
pants. Throughout the research process, the first author kept a
logbook to record all thoughts, ideas, and interpretations. To
enhance the reliability of the study, the content of the logbook
was discussed,which led to modifications in the topic list.
Two authors (TB, PG) coded the first two interviews indepen-
dently and the codes were discussed untilconsensus was
reached.The first author coded the subsequent interviews
and completed the analysis. After the seventh interview, data
saturation was reached since no new codes emerged from the
data (Silverman, 2013). To confirm data saturation, two more
interviews were held in which we did not find new informa-
tion that added understanding. Further sampling was consid-
ered unnecessary.During the third step,the researchers
consistently paid attention that the meaning units could be
traced back to the original data. To increase the validity, the
participants were invited to contribute to a member check,
meaning that they were asked whether the interpretations
represented their perspective. Seven of nine nurses responded
and validated the findings.
Findings
Nine participants were interviewed and the interviews lasted
between 45 and 75 min. All participants agreed to participate;
one CMH nurse did not fulfill the inclusion criteria and was
replaced by a colleague. The number of years that the partici-
pants had worked with outpatients with a bipolar disorder
varied from 3 to 19.The caseload consisted of40–100%
patientswith bipolar disorder.In the findings,the word
patient stands for outpatients.
All participants experienced consultation with caregivers
worried abouta manic recurrence in the patient.Three
themes emerged from the data. The first theme,“dual loyalty,
characterized the way participants experienced the develop-
ment of conflicting interests between patients and caregivers
during different stages of a manic episode. The second theme
“staying connected,” referred to the participants’different
interventions in these stages.The CMH nurses’effort was
aimed at staying in contact with the patient as well as the care
giver. The last theme, “anticipating,” described the interven-
tions in euthymic episodes when anticipating the difficulties
described in the first two themes.
Dual Loyalty
Participants experienced dual loyalty when confronted with
conflicting interests between the patient and the caregiver. On
the one hand, participants could imagine that caregivers con-
sulted with them because they recognized prodromes and
worried about a manic recurrence. On the other hand, par-
ticipants felt that the patient’s privacy and autonomy were
violated. Blindly trusting the caregiver could affect their con-
fidentialrelationship with thepatient.When consulted,
nurses stated that a caregiver placed them under a lot of pres
sure, for example, when urging that the patient should be hos
pitalized. This interfered with the participants’ emphasis on
the patients’ self-management of their life and disease. As a
nurse stated:
I don’t like partners talking about the patient. I think
everyone should be able to direct his own life as much as
possible, even when hypomanic. For me, that’s number
one. The patient is always responsible for himself. That
has to do with my own values. In relationships you are
equals. (Participant 6)
According to the participants, some caregivers proclaimed
too easily that the patient was manic, that is, when a patient
laughed aloud or was angry. This evoked feelings of discom-
fort in participants,especially when the patient’s behavior
seemed to be misinterpreted and unjustly labeled as manic
prodromes. In such cases, participants wanted to protect the
patientagainstthe caregiver’soverconcerned orcritical
attitude.
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I understood clearly that there was a quarrel going on. The
woman was angry because her husband did not support
her. In reaction, she teased and provoked him. Her
husband said: “She’s becoming manic again, say goodbye
to the holiday.” But she was still sleeping well, and that is
her very first sign of a relapse. (Participant 1)
The participants’ loyalty tended to shift when the patients’
manic symptoms increased. They knew that caregivers suf-
fered enormously from mania.Participants stated that the
caregivers were very important to the patients, but also for
themselves. When mania was developing, participants needed
the caregiver’s information since patients often denied the
symptoms. Participants mentioned that they remained loyal
with respect to the discussions with the patients during the
euthymic episode when a relapse prevention plan for mania
was drawn up as an aid to protect them from the damaging
consequences of mania.
When he (the patient) is picking quarrels all day long, you
certainly see relatives suffer. At that moment, it might be
the patient’s own interest. But when he was in a euthymic
mood state he came to me and asked me something else
and that was: “When I am not well, I want you to act
firmly.” (Participant 3)
When patients’manic behavior became dangerous,the
participants’ loyalty clearly shifted in favor of the caregivers.
Participants stated that mania could never be in the interest of
the patient. In this stage, participants fully agreed with care-
givers in asserting that the consequences of mania should be
prevented. When compulsory actions were necessary, the par-
ticipants no longer worried about their confidentiality with
the patient. Participants sympathized with caregivers since it
often took a long time before the patient’s behavior was dan-
gerous enough to justify a compulsory admission.
At that moment, confidentiality in your relationship with
the patient is of secondary interest. You want to get the
crisis under control as soon as possible. (Participant 8)
Staying Connected
When the caregiver consulted with a participant, the partici-
pants’first question waswhether the caregiver informed
the patient. Participants favored open communication with
the patient in order to prevent evoking suspiciousness in the
patient. Not being open carried the risk that patients could
lose their confidence in the nurses and the treatment. In addi-
tion, the caregiver’s openness with the patients provided par-
ticipants with a reason to contact the patient.
To a caregiver: “When you ask me not to say that you
called me, where do I stand? Should I call the patient out
of the blue saying: Well hello, this is (name of the
participant), how are you today? That’s a silly opening,
don’t you think.” (Participant 2)
When it appeared that problems were the result of an ove
concerned attitude on the part of the caregiver, participants
tried to stay connected with both the patient and the care-
giver.Participants needed them both in order to provide
support in resolving their quarrels. Participants recognized
their mutual distress and discussed this with both patient an
caregiver to resolve the quarrel and create understanding f
each other’s position and interest.
Well what can I say to make it clear that I am present for
both parties? I mostly try to consider both sides. I ask the
caregiver what they need, and the patient what they can
to lessen their partner’s worries. (Participant 3)
I will always look for recognition of both of them, for they
both suffer in these episodes. (Participant 5)
When patients were hypomanic,the participants inter-
vened in the same way, taking both sides seriously. Howeve
the urge to stay in contactwith the patientwas stronger.
Because of their irritability, patients were easily offended an
could discontinue contact. Participants wanted to prevent th
patient from feeling like a wall had been constructed agains
them.When patients were tending toward denial,patients
could feel this way when participants relied more on the car
givers’ opinion. The nonjudgmental attitude of participants
was meant to prevent patients from losing contact. Partici-
pantssaid they intended to betransparentabouttheir
thoughts and their intervention strategies.They simplified
their feedback to the patient to aid in comprehension. Partic
pants sought to achieve a patient’s willingness to admit tha
he or she is in a manic mood state.
I’m alert; otherwise you’re in a boxing match. In the wors
case, people step out of contact. I notice I choose my
words more carefully. (Participant 9)
I am becoming diplomatic, so to speak. I will ask the
patient to explain exactly what they mean. I tell them ver
specifically what I see and also say that I see that their
partner is suffering too. (Participant 8)
When the patientwasno longerresponsive orwhen
contact with the patient was lost, the participants remained
contact with the caregiver. Through the caregivers, the par-
ticipants could monitor the patient’s condition. Sometimes
this contactwasbehind thepatient’sback withoutthe
patient’s consent, and thus participants were ignoring priva
regulations. At the same time, participants took time to liste
to the caregivers and estimated the extent of the caregiver
burden.
In some cases I did not ask permission for contacting the
caregiver because I expected that the patient would not
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allow it. Sometimes you fiddle with privacy regulations. I
think reducing the risks and danger is of greater
importance to the interest of the patient. (Participant 7)
Participants stated that their connection with the patient
waseasily restored when mania wasin remission.Often
patients were relieved that the mania had stopped because
they felt ashamed for their manic behavior. Looking back, it
was very rare that patients disapproved of the participants’
interventions performed without their consent in the manic
mood state.
Well yes, she was very angry because of the admission. I
will see her next week. I will explain the condition she was
in and the reason why we intervened compulsorily. I am
not afraid that she will remain angry. I have never
experienced that. (Participant 6)
Participants felt that going through a tough episode bol-
stered their relationship with the patient and the caregiver.
During the interview, a number of participants realized that
inadvertently, contact with the caregiver easily diluted after
the episode.They considered inviting caregivers more fre-
quently to stay connected.
When she recovered, my contact with her son stopped. I
should have contacted the patient’s children earlier and
more frequently; not only when it was going wrong.
(Participant 5)
Anticipating
During the euthymic episodes, participants anticipated the
aforementioned difficultiesin handling dualloyalty and
staying connected. Having contact with the patient and the
caregiver, and being acquainted with both, made it easier to
handle these difficulties in different stages of a manic episode.
Hypomanic behavior ofthe patient and an overconcerned
attitude of the caregiver were easier to recognize, and patients
and caregivers were more compliant with the participant’s
interventions during the different stages of mania.
A daughter of a patient called and I acted immediately,
because I know that within a few days it can escalate into a
very bad psychotic condition, including all the
consequences. (Participants 1)
For this reason, five of the participants stated they always
invited the caregiver early on in the treatment process. The
other participants reported that the patient or caregiver initi-
ated the first contact. All participants made agreements with
patients and caregivers that both could contact the partici-
pants when they observed early signs of mania. However, par-
ticipants required thatthe caregivers inform the patients
before actually contacting the nurse. Some participants stated
that it is important to be absolutely clear about this message
of openness from the very start oftheir relationship with
both. Other participants were less strict.
To a patient’s mother: When you recognize symptoms,
don’t hesitate to call me. Only then can I take action. And
your daughter is always welcome to make an appointment
with me in advance. (Participant 4)
Right from the start I am clear about the rule of open
communication in case of being called by the caregiver.
(Participant 2)
Most participantsmade relapse prevention planswith
patients and caregivers. This plan described specific behavior
of the patient during stages ofdifferent episodes and pre-
scribed what to do in order to stay in control. The agreement
to make contact in the event of early signs was written down
in the relapse prevention plans.Feedback on the patient’s
behavior during different episodes was related to the relapse
prevention plan. Therefore, the feedback was more objective.
Furthermore, participants were motivated and justified the
necessary compulsory actionsbecause they were written
down and the patient had agreed to them.
When mania was in remission, participants evaluated the
manic episode with the patient. They explained their inter-
ventions and the compulsory actions. The participants’ trust-
worthiness with patients was easily restored and became even
more intense. Evaluations of the episode led to more insight
into what triggered the episode and how to handle it effec-
tively in the future.The relapse prevention plan was then
revised according to this new insight. When the contact with
caregivers dropped off after the episode, they were not privy
to the evaluation.
(During mania) What can we do? A relapse prevention
plan is helpful. We have written it out in a euthymic mood
state. It describes what can occur and what to do. So we go
through the plan and look for what we agreed on. . . . After
the episode we discuss what went well and what went
wrong. What should we do differently next time? We
revise the relapse prevention plan. (Participant 2)
Discussion
This study examined the experiences of nurses working with
outpatients with bipolar disorder,with particular focus on
being confronted with outpatients and caregivers during dif-
ferent stages of a manic episode. We identified three themes:
dual loyalty,stayingconnected,and anticipation.The
reported experiences matched the definition of the phenom-
enon of dual loyalty: a clinical role conflict between profes-
sional duties to a patient and obligations to the interests of a
third party (InternationalDual-Loyalty Working Group,
2008). On the one hand, participants felt a duty to preserve
the outpatient’s autonomy and privacy in order to maintain
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their trustworthiness and sustain the therapeutic relationship
with the outpatient. On the other hand, participants recog-
nized the interest ofcaregivers in preventing the observed
manic prodromes from developing into full-blown mania
along with all its damaging consequences.
In this study, CMH nurses’ interventions were focused on
staying in contact with the patient. The used interventions,
like being open, transparent,non-judging,present,
empathic,and, if necessary,decisiveand settingclear
boundaries, relate to the constructs of a high-quality thera-
peutic relationship (Dziopa & Ahern,2009).The moral
background of the participants’ experiences could be related
to the four fundamentalbiomedicalethicalprinciples:
respectfor autonomy,beneficence,non-maleficence,and
justice (Gillon,1994).The patient’sautonomy and these
rights are described in the Dutch MedicalTreatmentAct
(WGBO,2006) and were respected by the participants as
long as possible. The participants had to ignore it when out-
patients’actions and decisions became potentially danger-
ous.The participantsconsidered that,during mania,the
outpatient’s rightto self-determination violated the prin-
ciplesof beneficence and non-maleficence.These ethical
considerationsmatched similarcompulsory situationsin
mental health (Leung, 2002). Participants took a risk when
discussing manicsymptomswith the caregiverwithout
informing the patient,thereby violating the law.No CMH
nurse in the Netherlands has yet been prosecuted for ignor-
ing privacy regulations in these described situations. As far
as the participants were concerned, doing nothing was not
an option because of the havoc mania can create. Tolerating
manic behavior would cause a heavy burden for the caregiv-
ers and evoke feelings of embarrassment in the patient after
the episode.
The participants justified their choices by referring to the
relapse prevention plan. They stated that patients evaluated
the compulsory interventionspositively afterthe manic
episode. The participants acted as though the relapse preven-
tion plan was a Ulysses arrangement.In mentalhealth,a
Ulysses arrangement would entaila client’s deliberate and
freely given consent that, in case of a future crisis situation,
involuntary commitment or treatment may be an option on a
lessstrictbasisthan currentlaw allowsfor (Gremmen,
Beekman,Sevenhuijsen,Widdershoven,& Zuijderhoudt,
2002). Using a relapse prevention plan to justify admission,
however,is nota legalized procedure.A legalized Ulysses
arrangement procedure has been operational in the Nether-
lands since January 2008. An evaluation of this arrangement
revealed that the instrument led to more autonomy for the
patient; however, the instrument is scarcely used because of
the very complex and time wasting proceduresinvolved
(Klink, 2009).
The agreementsbetween participantsand patientsin
euthymic episodes corresponded with the patients’ need for
“timelyindication of early warningsigns”(Goossens,
Knoppert-van der Klein,Kroon,& van Achterberg,2007).
Caregivers might have the same needs, and participants m
agreements with caregivers regarding timely consultation a
documented in relapse prevention plans.These plans are
common in the Netherlands (Goossens et al., 2008) and can
reduce the number of manic episodes (Perry, Tarrier, Morris
McCarthy,& Limb,1999). Crisis plans may be an effective
intervention forreducingcourt-orderedadmissionsin
patients with bipolar disorder (Ruchlewska et al., 2014).
Involving the caregiver, preferably, from the very first sta
of the treatment provides a number of possibilities to antici
pate the difficulties during the manic episodes. It also gives
opportunities to supportpatients and caregivers in every
stage of the bipolar disorder. However, the described inter-
ventions might not resolve the experienced lack of profes-
sionalsupport,as reported by Van der Voort et al.(2009).
Involving caregivers from the start of the treatment is not y
common practice, and nurses might not be able to resolve a
problems in manic episodes. For instance, it may take some
time before the patient’s behavior is dangerous and compu
sory admission is justified (BOPZ, 1993).
Strength and Limitations
The strength of this study is the exploration of nurses’ expe
ences during this specific illness episode.Most studies on
bipolar disorder focus on patients or caregivers (Beentjes
et al.,2012).In addition,the results ofthe currentstudy
reflected the pattern and linear direction of the CMH nursin
interventions to both outpatients and caregivers during dif-
ferent stages of a manic episode. However, the study is lim
for its concentration on what nurses do instead of how the
nurses intervened in relation to literature about acute ment
health nursing (Bowers, Brennan, Winship, & Theodoridou,
2009; Cleary & Edwards, 1999; Cleary, Edwards, & Meehan,
1999; Deacon & Cleary, 2013).
Another limitation of this study is the possibility that the
interviewer was biased by his own presuppositions because
his personal experiences with this patient group. To increas
the reliability of the study, experienced nurses were recruit
and the interviewer’spresuppositionsand interpretations
during the analytic process were thoroughly discussed.A
member check was performed to increase the validity of the
data. Two thirds of the participants acknowledged and vali-
dated the findings.
Implications for Practice and Further Research
The themes “anticipation” and “staying connected” with ou
patientsand caregiverscomprisean open,transparent,
nonjudgmental attitude. Both correspond with the attribute
of a high-quality therapeutic relationship:being present,
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empathic, decisive, and setting clear boundaries (Dziopa &
Ahern, 2009). Being present and paying attention to the care-
giver’s burden during times of mania could be of even greater
importance when outpatients stop contacting professionals.
When professionals stick to their privacy regulations,the
caregivers are also cut off from professional support and are
left to deal with the inevitable burden on their own.
Continuity ofprofessionalrelationships is necessary to
execute the themes “staying connected” and “anticipation.”
Bipolar disorder is characterized by its chronic course (Kupka
& Regeer,2007) and outpatients therefore need long-term
professional relationships. This study illustrates that caregiv-
ers should share in the benefits of a long-term relationship
with the nurse as well. From the very beginning of treatment,
CMH nurses should offer easy access for the outpatient and
the caregiver.During euthymic states,CMH nurses should
teach outpatients and their caregivers personalized strategies
to manage the manic symptoms and write these into relapse
prevention plans.
Afterthe episode,relapse prevention plansshould be
evaluated with outpatients and caregivers to enable them to
learn from the experiences as well. Learning from experience
is probably the best way to acquire skills for managing manic
prodromes (Goossens et al., 2010). During manic episodes,
CMH nurses are in an excellent position to support the care-
giver in managing their burden even when outpatients,in
their manic mood state,disagree on contactbetween the
CMH nurse and the caregiver. The participants in the current
study experienced outpatients approving their relatives being
supported afterward.
In the scientific literature, little information is provided on
caregivers’ perspectives and specific needs for support during
a manic episode. This gap in scientific knowledge should be
studied in order to empower CMH nurses to support caregiv-
ers effectively and enhance their willingness to continue their
contribution to the overall disease management.
Conclusion
CMH nurses experienced dual loyalty when the outpatient’s
interests conflicted with the interests ofthe caregiver who
observed prodromes of mania in the outpatient. CMH nurses
responded to outpatients and caregivers by staying connected
with them.Interventionsin differentstagesof a manic
episode were easier when anticipated by maintaining solid
relations with both outpatients and caregivers and by making
relapse prevention plans. The results of this study led to the
following recommendations:
• Early involvement of caregivers in the treatment and during
euthymia coupled with making a relapse prevention plan
facilitates coping with manic prodromes and mania when it
occurs.
• Evaluation of relapse prevention plans with the outpatients
and caregivers after each episode could enable learning from
experiences.
• Do not hesitate to contact the caregiver when an outpatient
in mania is dropping out of contact. Patients do not contest
this afterwards.
• Further research on caregivers’supportneeds during a
manic episode is necessary.
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