Communication is perhaps the most important contributing factor in a successful therapeutic relationship; humans are social beings and spend a large part of each day communicating with each other. What exactly do we mean by communication? Schroeder (1999) suggests communication is any form of message, which has been sent, received and understood. Communication is much more than just the spoken word, it involves body language, facial expression, eye contact and hand movement, good communication is about listening to patients and understanding their fears and expectations. Nichols (1993) advocates effective communication as a “Positive contribution to an individual’s recovery by acting as a buffer against fear and confusion”. Garnham (2001) indicates the need to be aware of barriers to effective communication including making assumptions, and being aware of the environment. Both verbal and non-verbal communication are equally important, the tone and volume of our voice for example can indicate our pleasure or dismay, as can our body movements and touch. Our patient is the central focus whatever the situation, procedure or activity and we communicate from the first moment our patient enters the ward. Our biological body structure can be a barrier to good communication but often problems can be overcome, for example using a hearing aid to correct a hearing impairment. It is possible to communicate even when speech is difficult. Burton (1998) suggests that generally we use one of the three main models of communication, the Linear, Exchange or Contextualised model.
Whilst reflecting on my placement experiences I realised I had used the Linear model to communicate with a patient who had suffered a stroke, resulting in very limited speech, I felt guilty because I could not understand her. I began to dread answering her buzzer calls. How I would feel if the situation was reversed? Very frustrated with the words in my head not able to make myself understood. Instead of panicking I took time to really listen to the sounds she made, repeated what I thought she had said. If I was wrong she would use her good hand to demonstrate. By nodding and shaking her head eventually we would understand each other, I learned a great deal about good effective communication from her. Next time I am faced with a similar situation I will remember communication is more than just the spoken word.
Not all patients are agreeable and likeable and some may be particularly surly or ungrateful. It can be very difficult to work with such people, but as professionals we need to remember equality of care vital to our Code of Conduct as professionals NMC (2002), and also to the therapeutic relationship. It is easy to develop a relationship when faced with a likeable, co-operative person. What happens when we are faced with a difficult and un-cooperative patient, how can our therapeutic relationship develop, what strategies can we adopt to help it? Cava (1996) suggests a difficult person is one whose behaviour causes problems for you, or others. When coping with a difficult patient it is the behaviour we need to deal with. Behaviour revolves around communication; it is not about liking or disliking a patient but identifying behaviour and dealing with it. Communication is a two-way procedure, if we react negatively to difficult behaviour we are entering a vicious circle. As part of our therapeutic relationship we need to identify difficult behaviour and respond positively, actively developing our therapeutic relationship. Fein et al (1995) in his view of therapeutic communication suggests a communication model based on “rules” which may be used as a starting point for developing good communication. These encompass the virtues of respect, negotiation, honesty and individuality, all vital to a successful therapeutic relationship.
On my first placement ward one of the male patients was particularly disagreeable and hostile. He would complain constantly and frequently said “The nurses in this place are useless”. He made such a comment one day when I had just finished the patient drinks; I decided to ask him why he thought we were useless. He liked really hot weak tea, as he was in the end bed he was the last to be served and by then the tea was cool and strong. Perhaps normally this would have been a minor irritation for him, as a part of the therapeutic relationship with our patients we need to be aware of the little things which are all important. I always tried to make sure he had hot fresh tea, whilst it may not have totally changed his views, some of his hostility diminished and I did at least get a smile from him. On reflection I shall try to remember that tasks such as handing out food and drinks are important, to always ask how a patient likes their drink. When assisting with feeding make sure the patient is comfortable, the food is not too hot, ask which part of the meal they would like to eat, and not rush the process. Taking time, making the patient feel cared for, forms an important part of the relationship.
Nightingale (1859) believed the environment and its’ effects to be central to a patient’s recovery. Her model of nursing suggests “By improving the environment we aid the recovery”. The environment is central to comfort, is the patient comfortable in bed or when sitting in a chair? Do pillows need adjusting? Is the ventilation and lighting adequate? Two important elements of comfort are hygiene and sanitary requirements. We should encourage independence by patients looking after their own hygiene whenever possible, but when we carry out hygiene for them there are many things we should consider. We should ensure privacy, dignity, safety and self-esteem are always maintained, when we have finished leave the patient comfortable with all essential items, buzzer, spectacles, tissues etc. within easy reach. One of my first tasks on placement was to assist with a bed bath, I was horrified when the carer removed the nightdress and top sheet, leaving the elderly patient naked, cold and feeling vulnerable. We should place ourselves in a reverse situation and treat our patients with the respect and dignity we would expect. The same principles apply when dealing with sanitary requirements, from a patient perspective the most private bodily functions are being discussed and attended to by others, causing embarrassment and loss of dignity. A sensitive carer gives reassurance, is careful with body language, ensures the privacy, comfort and safety of the patient at all times. She makes sure the brakes are on when using the commode, the bed is properly screened, tissue and buzzer are within easy reach, and most importantly the patient is not left on the commode or bedpan longer than is necessary
Within a therapeutic relationship we need to be self-aware and also reflective practitioners. Being self-aware means not forcing yourself or your values onto others, we need to be conscious of our own character including our beliefs, strengths and limitations. Bulman et al (2000) instills the thought that to be self-aware is to know yourself, and this is the foundation upon which reflective practice is built. When reflecting we look back at ourselves in a certain situation and think how the situation has affected us, and how we may have affected the situation. Reflection forces us to attend to our feelings and attitudes, it helps us to analyse how we feel and in doing so hopefully learn from the situation and react differently next time we are faced with a similar situation. Keogh et al (1985) epitomizes reflection in terms of “Making use of positive feelings, and dealing with negative ones”.
The NMC (2002) states as part of its Code of Conduct “Act to identify and minimize risk to patients and clients”. There are many aspects to safety and maintaining a safe environment, (Roper 2000) illustrates the theory that our bodies naturally have their own safety and defence mechanisms, tears to protect our eyes, and skeletal structure for protection of vital organs for example, injury, disease or infection can reduce our natural defences. Maintaining a safe environment is not only about taking care of the physical and visual elements of safety, but also ensuring our natural defences are safeguarded and given the appropriate care when necessary. By doing so we show patients we care about them, they are important to us. A safe environment gives patients comfort and confidence; basic comfort is the main priority for patients upon entering hospital. Total comfort cannot be achieved without first ensuring safety, safety in hospital has many facets. The initial assessment is a vital part of developing the relationship and ensuring patient safety, it will ensure that comfort and hygiene needs are met, dietary requirements are adequate and assistance provided where necessary. Sanitary needs are documented, the first foundations for the therapeutic relationship have begun, daily interaction and further monitoring all build the therapeutic relationship. The nurse in her daily routine is paramount in ensuring safety, many daily tasks such as risk assessments, temperature and BP checks, pre theatre checks are all part of keeping our patients safe. The wearing of wristbands for identification, placing of wet floor signs as a warning or cot sides as a preventative measure, by ensuring a patient takes his drugs when they are distributed, or assisting with a walk to the bathroom, all are important safety measures. Bond (1986) employs the view that when in hospital patients are outsiders, everything is unfamiliar the system, building, language and daily routine. All of these factors can make patients feel vulnerable, for many people hospital is a place of fear associated with trauma, pain and dying. In making our patients feel safe we are addressing these fears and so developing the therapeutic relationship.
When on placement one of the things I noticed was how many elderly patients had a fear of falling, when assisting with mobility quite often “Please don’t let me fall” would be the starting point. As I began to feel more confident I would explain what I wanted them to do in order to help me maintain their safety, I learned to do this from the ward physiotherapist when assisting her, and observed her giving instructions bit by bit to build confidence. When considering safety we need to be acutely aware of our own limitations and knowledge and always work within them at all times.
In developing our therapeutic relationship we are assuring our patients we are doing our very best to care for them. In order to do this we need to look constantly at new research and changing methods. Evidence based care is a change in procedure, a new procedure based on evidence produced with statistics to prove it is safer or better way of working. McKenna (1999) promotes the view that it should be the accepted practice that health care in today’s society will automatically be based on best practice. However there are sometimes barriers to evidence based care, and not all of these can be removed by determination alone. When I was in placement I refused to “drag” a patient who needed to be moved, brushing aside the reasoning that the patient was only slight and would be easy for two of us to lift, insisting instead that we use a slide sheet. Research and evidence have shown that by using moving and handling techniques we protect not only ourselves from injury but also our patients. I felt it better to be unpopular for a short period of time than knowingly compromise safety. Our patients have a right to safety whilst in our care.
Everyone has rights, we may have different needs, but we all have the same rights. Ethics in nursing helps us to adhere to the principles when promoting rights and equality. Nursing ethics is about what nurses do in practice, how our actions are good or bad, right or wrong in their consequences. We work by the Code of Conduct and in our daily interactions with our patients we are promoting this Code, doing good not harm, being honest, listening, maintaining confidentiality and human rights. It is whilst we are doing all this our therapeutic relationship is developing, the complex parts fitting together, growing and strengthening the relationship. A simple example of upholding patient rights is the practice of asking before writing a patients name on the bedside board. Do we sometimes fail to promote rights and equality? Stockwell (1972) suggests that by labeling and stereotyping certain patients it can affect the care they receive. As the study is quite old it is possible to think that this could not happen in today’s modern care settings. I witnessed such an incident recently whilst on placement. A female cancer patient, HIV positive, was frequently distressed because of the amount of pain she was suffering. When you went to her room she would take your hand for comfort. When one particular auxiliary nurse took food or drinks to her she would literally “drop the food and run” when I asked her why she did this her answer “Because she touches me”. I saw this as discriminatory and contravening patient equality. We need to always be aware of our own views and prejudices and never inflict them on others, especially people in our care.
We work as part of a multi-disciplinary team and it is important for us to have knowledge and an understanding of the role each member plays, together with each other’s strengths and weaknesses. Good team working requires effective communication and cooperation, the whole team working together to achieve a common goal. Kenworthy (2002) advocates the need to understand how the team is made up remembering that each patient will have his own team. I was fortunate whilst on placement to attend a team meeting in preparation for a patient discharge. I had not appreciated the number of people who would be involved, social workers, physiotherapists, occupational therapists, district nurse, family members, I found it to be an interesting and valuable learning experience. I also witnessed professional argument within the multi-disciplinary team. A patient was medically fit for discharge, but the nursing team argued that socially intervening factors rendered her home environment as not considered safe for her biological well-being. Other members disagreed and felt that social factors were outside of nursing control. If we are truly giving holistic care then all factors need to be considered, and I felt the nursing staff were correct in their objection.
A therapeutic relationship develops as we care for our patient; we assess, evaluate and implement our care plan. We give thought to the patient as an individual, with rights and needs. We find the best method of communication and we aim for holistic care to treat the whole person. Caring is a team effort, about doing the very best for a person in your care, it is the therapeutic relationship which is at the heart of this care. Within this care safety is vital, safety is about thinking, anticipating and taking preventative measures, critical thinking is essential for safe practice. Critical thinking and evidence based care are essential elements of a therapeutic relationship. In adopting these we can assess, plan and implement the best course of action so that the most effective care can be given, holistic care. This is fundamentally at the heart of the therapeutic relationship and why it is so important in the delivery of care.
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Bond, D., Keogh, R., and Walker, D., (1985) Reflection : Turning Experience into Learning, London, Kogan Page.
Bond, M., (1986) Stress and Self Awareness : A Guide for Nurses, London, Heinemann.
Buckle, J., (1993) When is Holism not Complementary? British Journal of Nursing, Vol.2, No.15, pp744-745.
Bulman, C., and Burns, S., (2000) Reflective Practice in Nursing, Oxford, Blackwell Science.
Burton, M., and Watson, M., (1998) Counselling People with Cancer, Chichester, John Wiley.
Cava, R., (1996) Dealing with Difficult People, London, Piatkus Publishers.
Cavanaugh, C., Montgomery, J., Morrison, F.E., Schroeder, R.E. and West, M.P., (1999) Improving Communication among Health Professionals through Health Education : A Pilot Study, Journal of Health Administration Education, Vol. 17, No. 3, pp175-198.
Cutcliffe, J., and McKenna, P., (1999) Evidence Based Practice : Demolishing some Myths, Nursing Standard, Vol. 14, No. 16, pp39-42.
Fein, E., and Schneider, S., (1995) The Rules, London, Harper Collins.
Garnham, P., (2001) Understanding and Dealing with Anger Aggression and Violence, Nursing Standard, Vol. 16, No. 6, pp 37-42, 44-45.
Gilling, C., Kenworthy, N., and Snowley, G., (2000) Common Foundation Studies in Nursing, 3rd edition, Edinburgh, Churchill Livingstone.
Hobbs, (1994) cited in Royal College of Nursing Clinical Effectiveness Initiative – A Strategic Framework, London, Royal College of Nursing.
Logan, W., Roper, N., and Tierney, A.J., (2000) The Roper Logan Tierney Model of Nursing, 5th edition, London, Churchill Livingstone.
Nicholls, K., (1993) Psychological Care in Physical Illness, 2nd Edition, London, Chapman Hall.
Nightingale, F., (1859) Notes on Nursing : what it is and what it is not. Cited in Peet, R. van der, (1995) The Nightingale Model of Nursing, Edinburgh, Campion Press.
Nursing & Midwifery Council, (2002) Code of Conduct, London, NMC.
Pearson, A., and Vaughan, B., (1994) Nursing Models for Practice, Oxford Butterworth-Heinemann.
Stockwell, F., (1972) The Unpopular Patient, London, Royal College of Nursing.
