The ward worked on is an Acute Assessment Ward. It is a short stay ward in which patients are assessed and then stabilised before being transferred to the relevant ward or being sent home. During my placement, I endeavoured to form therapeutic relationships with each patient individually. I did this by engaging patients in conversation, being empathetic, listening and maintaining a non-judgemental attitude, skills that Boyd (2008) found to be important when studying to be a mental health Nurse. Patient A was a female with a diagnosis of Paranoid Schizophrenia and Borderline Personality Disorder. I found it very difficult to build any form of relationship with Patient A as she often stayed in her room, and when she did leave her room she would sit in the lounge huddled in a ball with her knees up to her chest. She would not engage in conversation and did not make any eye contact with anyone else. Every time I encountered Patient A, I greeted her with a smile or try to engage her in some form of conversation but it was to no avail. I often spent my time with her in the lounge, maintaining an open posture but remaining silent. I took this approach because I felt it was a route into communication by appearing approachable and friendly and also that by continually trying to engage her in conversation may be more of a hindrance than a benefit.
At one point during a shift Patient A came up to me with a paper cup full of blood and asked me to put it in the bin as she had self-harmed. I asked Staff Nurse D for some guidance and was directed to the correct place to dispose of the cup of blood, which I did with the support of a Staff Nurse D, we then both offered Patient A support to dress her wound as stated in her care plan but she declined and said she would do this herself. After she had dressed her wound she went back to the lounge and huddled up into a ball again. I approached her to ask her if she was OK and she did not make any eye contact or respond to the question.
The purpose of returning to this particular incident is that it was a situation I had never encountered before and I wanted to reflect on my behaviour and how I had managed to form a therapeutic relationship with a patient with no verbal interaction.
I found it frustrating that I was unable to form a relationship with Patient A and especially that I felt she wouldn’t communicate verbally with me. I respected her refusal to communicate but still felt disheartened each time I tried to communicate and she did not engage. When Patient A then approached me with the cup of blood I felt apprehensive of the situation that could occur but also felt happy at the fact she felt she could approach me for support. I felt more reassured about dealing with the situation by asking Staff Nurse D for support but in turn it left me feeling more confused when Patient A resumed her previous behaviour of non-engagement.
On reflection I have realised that not all patients may feel comfortable communicating with new people and that it takes time to build a relationship where a patient feels they can trust you. Also it highlighted the fact that some patients’ mental health condition may impair their ability to communicate (Durham and Molle, 2003). Mitchell and Cormack (1999) state that ‘Patients themselves value therapeutic relationships which offer respect, trust and care’ and I feel I took the right approach to building a trustworthy, respectful relationship with Patient A by ensuring that I always greeted her and had an open posture whenever I was sitting with her. Peplau (1952) found that without a Nurse-Patient relationship effective nursing is not possible and I believe that even though there was no verbal interaction, I built the basis of a therapeutic relationship by using the tool of non-verbal communication.
The NMC (2008) states that ‘You must work cooperatively within teams and respect the skills, expertise and contributions of your colleagues’ and I am pleased I asked Staff Nurse D for guidance and support as not only was it utilising her knowledge and skills base, it showed effective teamwork and communication (Belbin, 1996). Sharif and Masoumi (1988) found that student nurses felt more anxious surrounding new situations due to the fear of appearing incompetent. At first I felt apprehensive when Patient A approached me with the cup of blood, but then felt more assured as we engaged further.
After further investigation, Nairne (2008) stated that ‘People with schizophrenia may also refuse to engage in the most basic and important everyday tasks. They may refuse to speak or interact socially.’ I found that this was the case with patient A and although at first I found this difficult to deal with it, it was beneficial that I had researched further into the condition and gained a wider understanding of it. I believe that this would be really useful in my future practice; this highlights the importance of continuous professional development throughout my nursing career.
Using Driscolls Model of Reflection (2006) has enabled me to consider all the different foundations that make up the basis of therapeutic relationship. It has highlighted the importance of non-verbal communication as it can convey up to 93% of a messages meaning (Mehrabian, 1981) and how it can be effective if there is a barrier to verbal communication. It has also emphasized how being empathetic is central to Mental Health Nursing and how it leads to feelings of acceptance and being understood (Boyd, 2008).
Reflecting on this experience has highlighted the fact that one of my Learning Objectives will be to further my knowledge of therapeutic relationships and ensure I have an in-depth knowledge surrounding such a vital part of nursing. Another action will be to find out more information surrounding the different types of communication and the effects each one can have on building effective relationships as well as conditions that have effects on communication. The use of my PDP has vastly improved my ability to reflect on what I have learnt and achieved but also allows me to focus on areas of weakness. I feel this experience has been integral to my continual development as a nurse as it has helped me to gain confidence in my performance and professionalism in what I perceived to be a challenging situation.
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