In this assignment the author is going to explore what is a therapeutic relationship, by defining it and describing what elements and skills are necessary to uphold an efficient therapeutic relationship with a patient. The assignment shall explore how Multi disciplinary teams contribute to achieving a therapeutic relationship. It further will explore what governs a therapeutic relationship according to the code of practice set by the nursing governing body, the Nursing and Midwifery Council (NMC), putting into consideration what is expected from nurses as health professionals. Being ‘Self aware’ is a crucial attribute in order to maintain a therapeutic relationship, so the writer shall give a brief definition of what self awareness is ,and explain the significance of being self aware within a therapeutic relations and relate it to an incident that happened in practice that made them more self aware.
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The therapeutic relationship is fundamental to the care of a patient and was described in the 1950’s by famous psychotherapist Carl Rodgers .Rogers defines it as a helping relationship, ‘A relationship in which one of the participants intends that there should come about, in one or both parties, more appreciation of, more expression of, more functional use of the latent inner resources of the individual’ (Rodgers 1961). Other authors have come up with various definitions but they are all closely linked to that of Rodgers, Jane Stein-Parbury (2000) suggests it is unilateral because the nurse maintains most control and it is usually short or average duration, with the patient facing a non threatening situation. However (Stuart 2001) defined a therapeutic relationship “As a mutual learning experience and a corrective, emotional experience for the patient” (cited in Cutliffe and Mckenna 2005.P.304)
For a therapeutic relationship to work effectively, certain elements need to be upheld and followed, such as showing warmth towards your patient, being respectful by showing the patient that they are individual and a unique being. Dignity of the patient puts the patient at ease and they feel more valued and may in turn open up more to the nurse which aids their treatment. Demonstrating professionalism assures the patient that they are in capable hands and will effectively build trust about your capabilities. Carl Rodgers highlighted that the three core components of a therapeutic relationship are empathy, which is defined as: ‘ a continuing process whereby the counsellor lay aside her own way of experiencing and perceiving reality, preferring to sense and respond to the experience and perceptions of her client.’ (Mearns and Thorne, 2005, p.41) Where there is lack of empathy expression, patients may be left with a sense of isolation, which have an effect on their treatment plan. The second crucial element that was highlighted by Rodgers as being essential is having unconditional positive regard towards patients or client which is a label given to the fundamental attitude of the person-centred counsellor towards her client. The counsellor who holds this attitude provides care for the individual irrespective of what beliefs and values the individual (patient) may hold. (Mearns and Thorne,2005 p 64).
In other words unconditional positive regards is being non judgmental towards a patient regardless of what the care provider believes or values themselves. Unconditional positive regard should ideally commence on the onset the relationship between patient and nurse. Other elements that constitute a therapeutic relationship include, maintaining confidentiality, and treating people as individuals at all time, good record keeping (NMC 2008).
For Therapeutic relationships to be successfully applied and implemented, nurses have to acquire certain skills to achieve this. To instate a strong therapeutic relationship a practitioner should consider their interpersonal communication skills with the patient. There are two forms of interpersonal communication skills, which are non-verbal and verbal communication.
Non-verbal communication skills are a very effective way to convey a message, empathy and active listening. Egan formulated a communication tool which aids to effective non-verbal communication skill, the skills are summarized by the acronym SOLER, meaning sitting squarely with an open posture, leaning forward to show your interest maintaining eye contact at all times showing that you are relaxed, not fidgeting nervously. Argyle (1994) suggested the main forms of non-verbal communication as, facial expression, gaze, body movement, gesture, partial behaviour, clothing and behaviour. (Cited by Rana, Upton, 2009, ).
Verbal skills are too, an essential part of interpersonal communication, these include techniques such as paraphrasing; this is where by a nurse rephrases what has been stated by the patient into their own words, i.e. by saying ‘in other words…. (Jane Stein -Parbury). Other methods of active listening are to parrot what the patient has said; this shows you have clearly heard what they have said. Practitioners should also be able to know when to use open and closed questions in the appropriate manner and time, for this skill can easily perceived as uncaring and unprofessional when not adopted carefully. In conclusion to what has been talked about, nurse and patient should reflect on what they said. Heron (2001) stated that a there are six tools of a client’s needs. Heron’s model has two basic categories, “authoritative” and “facilitative”. These two categories further breakdown into a total six categories to describe how people intervene when helping.
Authoritative Interventions are Prescriptive, which is giving advice, Informative where you provide information to guide the other person, Confronting- you challenge the other person’s behaviour in an unaggressive attitude. Facilitative Interventions include: Cathartic-you help the other person to express and overcome thoughts or emotions that they have not previously confronted. Catalytic- You help the other person reflect, and they become more self-directed in making decisions. Supportive- You build up the confidence of the other person by focusing on their competences, qualities and achievements.
A multi disciplinary team (MDT’s) is important in the care of a patient. A multi disciplinary team is a group of professionals from different disciplines, who have a role in contributing to an assessment of an individual’s needs. This should include two health professionals, i.e. nurse, clinician or therapist, as well as a representative from social care services, i.e. a social worker (NHS 2010). Chan (2004) argued that “the main mechanism is to ensure truly holistic care for patients and a seamless service for patients throughout their disease trajectory and across the boundaries of primary, secondary and tertiary care”. Multi disciplinary teams ensure a continuum in patients care and can be 24 hours. Different professions bring different type of care to the patient. MDT’s can however come to conflict, if they demonstrate allegiance to their profession.
Junor, Hole & Gillis (1994) states that multidisciplinary team working is known to “maximise clinical effectiveness”, Multi disciplinary teams have enabled health professionals to adopt the clinical care pathways where different teams within the organization outline anticipated care, place an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes. In a multi disciplinary team within a healthcare setting, one may expect to work with doctors, social workers, psychologists, occupational therapists, health care assistants (HCA’s) and other related professions.
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A therapeutic relationship within nursing follows the code of professional code of practice which was set by Nursing and Midwifery Council [NMC], which acts as the governing body for nurses and midwives in the United Kingdom which was formed in 2002 by parliament. Its main objective is to safeguard the health and wellbeing of the public,(NMC 2008).The NMC outlines that Nurses should always uphold the patients respect at all times, it states that ‘nurses should always treat people as individuals and respect their dignity’. Nurses should respect patient confidentiality, and uphold it at all times, breach of confidentiality can lead to serious consequences for health professionals (NMC 2008) including disciplinary actions such as suspension or being struck off the NMC register. Consent is very important in patient care; it’s the opening avenue for any care that follows. NMC states the every adult must be presumed to have the mental capacity to consent or refuse treatment. Patient care is always going through different multi disciplinary teams therefore accurately record keeping is crucial, it should be factual ,not falsified, and clearly legible (NMC 2010), these are some of the factors that insure accurate information is passed on to different care givers to maximise effective care for the patient.
Nurses endure different feelings and emotions when interacting or treating patients, which calls for them to be more self aware, Duval and Wuckland defines self awareness as “a state in which one is aware of oneself as an object, much as one might be aware of a tree or another person” (cited by Rana and Upton 2009. p142).For a nurse to be self aware they need to treat each patient as individuals and present themselves appropriately. Patients have a plethora of beliefs and values, which always come into play in any given care setting. Beliefs can be associated with patient’s religion and culture, such as that of Muslims, to only eat halaal meat, a nurse has to be aware of this dietary requirement and honour it. Equally beliefs also play a vital role in the treatment of a patient, so a provision to fulfil this should be met at all time, i.e. providing a chapel in the hospital.
Values of a patient are crucial when in care. Downie, R. S. 1990 stated that values are preferences based on beliefs about objects, persons, or situations and are accompanied by feelings of approval or disapproval. Patients of a different culture will most certainly have different values based on what they were brought up on. On any given care setting, the way in which nurses present themselves to patients is of utmost importance, their body posture is a critical aid to supplement being self aware, and nurses can use SOLER (Egan 2001) to ensure they achieve this.
In practice, the author recalls an incident when a 92 year old lady was referred to their practice for assessment on every Wednesday of the week. On arrival the lady would engage in social activities with fellow patients. The staff provide the lady with a menu relevant to her culture of West Indian background, The staff fulfilled their role in being self aware on her values and diversity, During the meal, staff began to talk about a holiday abroad and how the food made their “bowel move rapidly”, and how they really found the food “disgusting”.
The lady did initially try to express her frustration of the conversations the staff were having whilst she was trying to enjoy. She eventually stopped having her meal as she found it not appetizing anymore, staff recorded that the patient had poor dietary at dinner time, and they were not self aware that they were the catalyst for the poor intake of her food. Had the staff been more self aware of their presentations, they would have considered that different cultures have different table manners.
In conclusion an effective therapeutic relationship is accomplished by good verbal and non verbal communication. Respecting individuality, beliefs, values, this promotes good recovery and openness between nurse and patient. A therapeutic relationship is not just between a patients and nurse but can, and often extends to other multi disciplinary teams. The therapeutic relationship can never be stated as fully complete, but can be made more effective, because different patients have different opinions i.e. different experiences in previous care, and different values and beliefs.
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