This discussion opens with a definition of a therapeutic relationship and the key elements that impact on this. The discussion will focus on the different types of communication and explain the importance. I will also refer to the Multi Disciplinary Team (MDT) in a patient’s care and how this can strengthen the relationship. The discussion will end with reference to the Nursing and Midwifery Council (NMC) guidelines and the impact on the relationship. Self awareness will also be discussed.
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A therapeutic relationship is defined as “A partnership between clients and nurses, both working together to improve the client’s health status” (Balzer Riley, 1986). This relationship allows both the nurse and the patient to gain satisfaction, the patient feels supported and listened to and the nurse feels valued in his/her role. One of the significant points in the relationship is that if the patient feels they are being listened to by the healthcare provider they will recover at a much faster rate. The key elements are, attending, hearing, understanding and remembering. Attending is the physical part with both the nurse and the patient being present and keeping up to date with what is being said. Hearing is the part that pays the attention to the patient. Understanding, this is reassuring the patient that what they have said has been understood. This can be done by paraphrasing. Remembering can be very difficult, if the nurse has understood what the patient has said this does become easier. In order to do this the nurse needs to fully attend to the patient, listen to them and then respond to them. According to Barker (1971), the listening process consists of four different elements listed above. By actioning the concepts the nurse can start to empathise with the patient.
Empathy is an important aspect of this relationship, “Empathy is the act of communicating to our fellow human beings that we understand how they are feeling and what makes them feel that way” (Hogan, 1969) Empathy can be shown both verbally and non verbally, the verbal part is to reflect on how the patient is feeling and the reasons why and the goal should be to meet an accurate verbal reflection. The non verbal features of empathy are as much important as the verbal part; the non verbal part should show features of warmth and genuineness does the true caring for your patient come across. To do this verbal and non verbal communication must be used.
Questioning is a way of verbal communication between the nurse and the patient, “some would say that questioning is a way of helping others to think about their problems” (Alder and Rodman, 1982). There are two types of questions that may be asked to patients, open questions and closed questions, Open questions are asking for a more verbal response from the patient whereas closed questions is only encouraging the patient to give a short simple response. Along with questioning there are many other ways of verbal communication, establishing guidelines, acknowledgement, reflecting, paraphrasing, seeking clarification, summarising and planning .Clearly verbal communication is very important as are non verbal skills.
Non verbal communication has various components; some of these include Posture, gesture, eye contact, touch, facial expression, appearance, head nods, silence, proxemics and other body language.
Egan ( 1977) S.O.L.E.R framework has an important part to play in a therapeutic relationship, all of the points should make both the nurse and the patient is comfortable and in control of the situation, here is a bit of information to elaborate on the soler framework-
S – Sit squarely – this means sit face to face with the patient this does not mean the nurse has to sit directly opposite the patient, the nurse should sit upright not slouching, this will show the patient the nurse has a caring posture.
O – Open posture – this means sit with both arms and legs uncrossed, if both arms and legs are crossed it is said to show an element of defence from the nurse.
L – Lean slightly forward – although this does depend on the conversation, leaning forward without leaning away will lead the nurse into the intimate zone of the patient.
E – Eye contact – is recommended to be constant although this shouldn’t be a constant stare as this can be very uncomfortable for the patient.
R – Relax -the nurse must be relaxed in order to gain the confidence in the patient. This framework can also be used by other healthcare professionals.
Professionals other than nurses can strengthen the relationship; this can be another member of the health care team that needs to take part in the patients care. The professionals could include physicians, pharmacists, dieticians, occupational therapists these professionals are known as the MDT. A member of the MDT might need to be involved in the patient’s care, For example if the patient had concerns about their diet you could introduce the dietician to help. By introducing a member of the MDT it will strengthen the relationship with the patient. The patient however must consent to the involvement of other disciplines.
Consent within a therapeutic relationship is very important, obtaining consent is a process and not a one off event. The patient must be told in a sensitive manner and the patient must then make the decision on whether to accept or decline the proposal being offered. The NMC (2008) states that “you must respect and support people’s rights to accept or decline treatment and care” (NMC code May 2008). Usually the professional who is going to perform the procedure will gain the consent although it is possible this task could be delegated to another professional who has the capability of meeting the required standards, Consent maybe obtained in a number of different ways, Verbal consent – this is explaining everything verbally to the patient and the patient replying with a verbal answer, written consent this is normally obtained if the procedure has any risk or is lengthy and complex, the written consent is a record of what has taken place or could be of what has been offered and not taken place as the patient decline the opportunity. The NMC is the code that should be adhered to all times, some of the guidelines under the code includes Privacy, dignity and confidentiality, as part of the NMC code of conduct nurses are to work within their limitations. This is about the nurse being self aware.
“Self awareness is about recognising, accepting, challenging who we are, what we feel, and what we can and can not do” (Rungapadiachy, 1998). In a therapeutic relationship it is also important to be in control of your own self awareness, be aware of your own values and beliefs. According to Rokeach (1968),”a value is an important life goal or societal condition which is despired by a person”. Beliefs are subjective statements used by individuals to describe something they believe as being true. Values are seen as the central core that reflects on ones attitude this is also know to affect ones attitude. Fishben and Ajzen (1975) define beliefs as “statements which indicate a person’s subjective probability that an object has a particular characteristic”.
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The Johari window is a model that is used to explore and develop self awareness; this model concentrates on interpersonal skills that are applied to interaction, ” it deals with awareness in the human behaviour” (Luft 1969). There are four aspects to the Johari window, open, blind, hidden and unknown. The open part is the part that is known to self and others, the blind is the area that is unknown to self but know to others, the hidden part is the area that is known to self but unknown to others and the unknown is the area that is unknown to self and unknown to others. Through communication the open self is made more accessible. This strengthens the therapeutic relationship.
This Essay has defined what a therapeutic relationship is and the key elements that impact on this. Different types of communication have been discussed and explanation given to show their importance. The role of the MDT in a patient’s care and how this can strengthen the relationship has also been discussed. NMC guidelines have an impact on the relationship and discussed a key issue from the guidelines, with special reference to consent. This essay has also explained why self awareness is important within a therapeutic relationship
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