Ttherapeutic_Relationships_in_Nursing

Therapeutic relationships in nursing In this reflective assignment I will provide information to establish how I have used and improved my interpersonal skills with patients and the staff I worked with. I will also show how I established a therapeutic relationship with a selected patient from my second placement. I will provide a brief description of my chosen patient and the importance of gaining informed consent and patient confidentiality will be discussed. I will utilise Roper, Logan and Tierney’s (2003, p.81) Model of Nursing, which places importance on the 12 activities of living (ALs) and focused on the most appropriate of the 12 activities. Gibbs’s reflective cycle was chosen to reflect upon each step of the therapeutic model in Jasper (2003, p.77). To define therapeutic communication it involves using of carefully chosen ways of communication to help the patient and their family to overcome stress and the inevitable situation the patient finds him- or herself in, McHugh Schuster (2000, p. 7). Stein-Parbury (2005, p.4, part 1) describes a therapeutic relationship as ‘listening without judging and responding with understanding help to create a relationship based on acceptance and respect. In effective Nurse- patient interactions there is an orientation on the part of the nurse to be of benefit to the patient and more importantly the patient feels assisted in some way by the interaction.’ Patient A is a 65 year old lady who lives on her own somewhere in the north east. She has been suffering from chronic obstructive pulmonary disease (COPD) for the past five years. She was a heavy smoker until approximately 3 years ago, but managed to stop smoking with some help. Up until 6 months ago she coped well with her illness and managed to control her symptoms. Unfortunately, her health started to deteriorate over the last 6 months and she was admitted to the ward I worked in, on my second placement, after a severe attack of breathlessness. A neighbour and good friend of patient A had accompanied her to hospital. I introduced myself to patient A and her friend. Once I had identified myself to the patient, I enquired with the patient whether she would allow me to use her information in my assignment and my decision making tool. I gained informed consent from patient A to carry out the assignment (Appendix. 1), which my tutor witnessed me obtain. My tutor then asked me if I would feel happy to admit patient A and take care of her for the rest of my shift. I was happy to do so. I explained to patient A that she could refuse, if she so wished, but she was happy to go ahead. According to the Nursing and Midwifery Council (2005) students of nursing and midwifery ‘must respect the wishes of patients and clients at all times. They have a right to refuse to allow you, as a student, to participate in caring for them and you should make this clear to them when they are first given information about the care they will receive from you. Patients also have the right to ask students to leave when asked to do so, because patients rights must be respected at all times and put above personal knowledge acquisition.’ I explained to patient A, that she had the right to withdraw her consent at any stage in the process and that any information she gives me would be treated as confidential and that her name would be changed to provide anonymity. The Department of Health’s Data Protection Act (1998) gives an individual the right to stop any processing of personal data with regards to themselves. The NMC guide for students (2005) states that ‘any information provided by a patient must be treated as confidential and only used for the purpose for which it was originally given. If students wish to include details of patients in their written work they must do it in such a way in which the person participating cannot be identified from their work.’ Griffith and Tengnah (2008, p.81-82) write that ‘consent is a continues process and may be withdrawn at any time. Nurses must accept that if a patient changes their mind and refuses continue their treatment it must cease or trespass to the person occurs.’ I have chosen the Roper et al ( 2003,p.81-82) Model of Nursing, to write this reflection, which includes 12 activities of living (ALs) these are ; Maintaining a safe environment, breathing, communicating, mobilizing, eating and drinking, eliminating, personal cleansing and dressing, maintaining body temperature, working and playing, expressing sexuality, sleeping and dying. ‘The concept of each activity does not stand alone; it interacts with the other components of the model, and it is the interaction that results in individuality’. According to Walsh (1998, p.1) ‘Nursing models were first to emerge in the United States and became more prominent in Britain in the 1980s. To define models of nursing you have to see them as simplified ways of representing reality and therefore facilitate understanding.’ I will use Gibb’s reflective cycle as my guide through this assignment which consists of six stages these are; Stage1: Description of the event. Stage2: Feelings, Stage3: Evaluation, Stage4: Analysis, Stage5: Conclusion and Stage 6: Action Plan. Jasper (2003, p.78 ) writes that ‘Gibb’s reflective cycle has achieved the status of a seminal theory in reflective practice and most reflections written in the past 15 years that did look upon Gibb’s cycle as a reference to reflective writing’. Reid (1993, p.306) in Bulman et al (2008, p.3) informs that ‘Reflection is a process of reviewing an experience of practice in order to describe, analyse, evaluate and so inform learning about practice.’ The first stage of Roper et al (2003, p.81) is maintaining a safe environment. Spouse et al (2008, p.408-409) see the promotion of a safe environment as one of a nurses many functions. No actions must be taken to endanger the safety and wellbeing of the patient and any unsafe practice or environmental danger must be reported. When I first started patient A’s admission I made sure she was comfortable in her bed and had her call button ready by her side and explained how to use it ,so I would not forget it later. I also had closed the curtains around her bed space to provide her with some privacy. I then sat by patient A’s bedside and asked her if it was okay for her neighbour to be present, who then sat on the opposite side of the bed as to not crowd the patient too much. This made patient A feel at ease from the start. My mentor made sure I felt confident to go through the admission process, which I did, as I had already completed some admissions on previous occasions. The NMC Code of Conduct (2008) specifies that ‘the person delegating a task must make sure that anyone that is delegated to must be capable of carrying out the instructions given and works to the standards required. You must also make sure that students or anyone you are responsible for are suitably supervised and supported.’ I introduced and identified myself again as a student nurse and asked the patient how she would prefer to be addressed. She was happy to be called by her Christian name. I smiled at her and said what a lovely name she had. According to McHugh Schuster (2000, p.7-8) ‘from the moment you and a patient meet, a reaction occurs as you interact and attempt to establish mutual goals, objectives, and a plan of action to solve health-related problems. The nurse has preconceived goals and objectives which she needs to achieve in order to obtain maximum health benefits for the patient. The patient herself has a set of goals and objectives which she thinks she has to achieve for maximum health benefit. These objectives on both the nurses and the patient’s side may not match at the time of the first meeting but mutual goals and objectives must be formed in order to establish a therapeutic relationship between the patient and the nurse.’ Batehup and Wilson-Barnett (1988, p. vii) state that ‘planned nursing care begins with an assessment. A thorough assessment provides data to enable the nurse to identify the problem areas.’ I felt much more confident in my second placement than I did in my first. My knowledge base has widened over the course of my last placement and I felt able to talk to my patient in a much more comfortable and assured manner, which in return made my patient feel more at ease. The second and third stage is breathing and maintaining body temperature. When I first met patient A, I noticed that she was very short of breath and her chest was rising and falling rapidly. I checked her blood pressure, pulse, respirations, and her oxygen saturation level and took her temperature, which was raised. My Mentor then put her on oxygen and I gave the patient some Paracetamol to reduce her temperature, both of which had been prescribed by the doctor. He explained to me that the patient cannot stay on a high amount of oxygen for long and that it would have to be reduced gradually to prevent carbon dioxide from accumulating in the patients lungs. Marieb (2006) in the Royal Marsden (2008, p952) informs that ‘when the level of carbon dioxide rises, the pH level of the CSF drops which in turn causes excitation of the central chemo receptors, and hyperventilation occurs.’ Parker (2007, p.142) states that COPD is usually made up of chronic bronchitis and emphysema together which cause progressive damage to the tissues in the lungs with increasing shortness of breath. Normal oxygen flow in and out of the lungs is restricted .This would in actual fact make breathing more difficult for the patient. I helped patient A to sit up, as this would help with her breathing and made sure she kept her oxygen mask on throughout the admission. My mentor then came with a Nebuliser which we gave to patient A to inhale the vapours. I felt relieved, as I could see that she was struggling for breath and I was reluctant to ask her too many questions. Patient A did improve a little after that and I felt I could continue with my admission. Peplau (1973, p.18) points out that ‘a nurse must take into consideration the current anxiety level of the patient. If this anxiety increases the nurse would have to use shorter and more concrete sentences in order to be understood.’ I feel that now that I have seen how ill patients with COPD can become very quickly and what treatment they need, I can emphasise with the patients need to make the admission as short as is possible, without missing vital points. According to Sundeen et al (1994, p.173) ‘the ability of the helping person to empathise with the client gives depth and meaning to the relationship.’ Kalish (1973, p.1548) states ‘empathy is the ability to enter into the life of another person, to accurately perceive his current feelings and their meaning.’ During my first placement there was no opportunity to form true therapeutic relationships with the patients because patients had an approximately 6 – 8 hour stay in which time the patient was admitted, went to theatre and then recovered within 2 hours of leaving theatre. Most of the time I only saw patients for a short period of time and did not get to speak to the patients that much because of the patients recovering from the anaesthetic. In my second placement I interacted with patients much more, spending most of the day caring for them. This made it easier to chat to the patients and form a therapeutic relationship with them. The next stage of Roper et al (2003, p. 81) model is communicating. Williams (2008, p.41) writes that ‘nurses may fear not knowing what to say or to say the wrong thing, this is normal in an uncomfortable and unfamiliar situation. Such worries arise when the nurse focuses on herself rather than the client. Once the nurse starts to concentrate on the patient’s experience this fear lessens. Everything we do or say conveys a message and the nurse must master these skills in order to establish a therapeutic relationship.’ As I proceeded to ask patient A about her personal details it emerged that she had been a widow for 12 years and that her husband had died of a heart attack. She also told me that she has a son who lives abroad and only visited every couple of years. At this stage she did not go into further detail and I finish my admission without further delay and thanked patient A for her patience with me. As it was the finish of my shift and I felt tired, I was relieved to go home. On my way home I considered what had past between patient A and myself and felt that I could have been more thoughtful when she told me about her husband and son. I resolved to ask my mentor if I could care for her the following day and that I would make time to listen to her more closely. The next stages are eliminating, eating and drinking, personal cleansing and dressing, mobilising and expressing sexuality. The next day I started my shift in the morning, I asked my mentor if I could look after patient A’s needs for the morning and he agreed. I went to her room and entered with a bright ‘good morning’ to everyone in the room. I again told her my name and asked how she had been the previous night. She told me that after initially feeling quite unwell, she now felt a little better. She had started treatment with antibiotics as it was discovered that she had a chest infection. I asked the patient if she needed any help with her personal hygiene and she asked if she could just have a wash at her bedside, because she did not feel up to going to the bath room. I offered to bring her all the required utensils and asked if she would like the commode by her bed as she finds walking exhausted her too much and brought on a cough. The patient was grateful that I was so thoughtful and had offered a way of relieving herself without having to ask. I promptly went and got everything need. I helped her to get out of bed and then left Patient A to use the commode in peace, gave her the call bell and drew the curtains around her bed for privacy. According to Pellatt (2007, p.351) ‘elimination of urine and faeces is a vital function and people are usually independent from early childhood. It is a private function but if a person becomes physically or mentally unwell he or she may need some assistance.’ After the patient had used the commode I removed it promptly and offered to help her get a wash. Nightingale (1859, p.53) wrote ‘the amount of relief and comfort experienced by sick after the skin has been carefully washed and dried, is one of the commonest observations made at the sick bed.’ The patient asked if I would wash her back for her and while we went through the procedure of cleansing we chatted away. She told me about her live with her husband before he passed away and how much she missed him as they had been together since they were at school. Then 8 years ago her son had moved abroad with his family and that this had left a huge gap in her life. Patient A told me about her grand children and how she wished that she had the money to go and visit them every so often. I felt a connection between us because I myself understood how it feels to be separated from your loved ones for a long time, as I am German and don’t see my family very often. As I had listened more carefully to the patient I could reply in an effective way by disclosing some of my own experiences of separation and loneliness. Rungapadiachy (2001, p.214) states that ‘Listening can be defined as the art of capturing the true essence of the sender’s message.’ I then helped my patient to get dressed and offered to help her comb her hair. The patient was grateful that I had remembered that her appearance was still important to her. I made her comfortable in her bed and then patient A had her breakfast. According to Spouse et al (2008, p.239) ‘A nursing student should inform herself of the patients beliefs and preferences. This should be used as a guide as, to many people eating in the correct way is important.’ Throughout caring for the patients needs I wore personal protective clothing as necessary to protect myself as well as the patient and to prevent the spread of infection I frequently washed my hands. Throughout the rest of the morning I attended to other patients as well as patient A. I stayed now and again for a friendly word and I could see that the patient really appreciated the fact that I took an active interest in her. I also included the other patients in the room in our conversation and got the patients talking amongst themselves, in effect helping patients to communicate together. In my first placement my communication skills were at a lower level and I felt anxious to talk to and interact with the patients. I have learned patients in their ill state are vulnerable and may lack the confidence to communicate with others. It is therefore important for the nurse to help and establish a basis on which communications and trust can be build. I understand that to truly help a nurse to achieve successful therapeutic relationships between her and the patients she has to build her knowledge base of professional issues and communication techniques. She has to be empathetic, reliable, listen, and use her body language and observation skills effectively. In depth reading, experience and observing my mentor will help me to achieve this goal. Overall, my I have enjoyed both my placements. I enjoyed looking after patient A and all the other patients in this past year. Gibb’s reflective cycle and Roper et al have helped me in writing this reflection. My mentor was instrumental in helping me to achieve my set goals. I have learned about illnesses such as COPD and how to look after patients with the disease. To analyse your own thoughts and actions helps a nurse to achieve a better understanding of how to change her own practice for the benefit of the patients she cares for on a daily basis. It provides the background to a successful relationship build on mutual understanding, trust, respect and the knowledge that everything that the patient divulges to the nurse is kept confidential. The nurse has the professional duty to keep her knowledge up to date and to treat the patient according to the best evidence available to her. The patient has the right to refuse treatment if he/she wishes to do so. I have resolved to strive to achieve a better understanding of therapeutic relationships by studying hard and observing my mentor in my next placement. I hope to achieve the required standard to make a good nurse and team member. References Batehup,L. and Wilson-Barnett, J.(1988) Planning Patient Care. London: Macmillan Education Ltd. Collis Pellatt, G. (2007) Clinical skills: bowel elimination and management of complications. British Journal of Nursing, Vol. 16, Iss. 6, pp 351 – 355 at:http://www.internurse.com/cgi-bin/go.pl/library/article.cgi'uid=23008;article=BJN_16_6_351_355 [10.08.2009]. Department of Health (1998) The Data Protection Act. London: HISMO, Department of Health. Griffith, R. and Tengnah, C (2008) Law and professional issues in nursing. Learning Matters Ltd: Exeter. Jasper, M. (2003) Beginning Reflective Practice. Cheltenham: Nelson Thornes Ltd. Kalisch, B. (1973) What is Empathy. Am J Nurs 73:1548 cited in: Sundeen, S. J., Stuart, G. W., Rankin, E. A. D., Cohen, S. A.( 1994) Nurse- Client Interaction. Implementing the Nursing Process. Fifth edition. St. Louis: Mosby- Year Book, Inc. Marieb, E. N. (2006) Human Anatomy and Physiology and Brief atlas of the Human Body, 7th edn.Benjamin Cummings, New York. In Doherty, L. and Lister, S. (2008) The Royal Marsden Hospital Manual of Clinical Nursing Procedures Student Edition. Seventh Edition. Chichester: John Wiley & Sons Ltd. McHugh Schuster, P. (2000) Communication. The key to the Therapeutic Relationship. Philadelphia: F. A. Davies Company. Nightingale,F. (1859) Notes of Nursing. London: Gerald Duckworth& Company Limited. Nursing and Midwifery Council (NMC) (2005) An NMC guide for students of nursing and midwifery. London: NMC. Nursing and Midwifery Council (NMC) (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. London: NMC. Parker, S. (2007) The Human Body Book. London: Dorling Kindersley Ltd. Peplau, H. E. (1973) Interpersonal Nursing Theory. London: Sage Publications. Ltd. Reid, B. (1993) ‘But we‘re doing it already!’ Exploring a response to the concept of reflective practice in order to improve its facilitation. Nurse Education Today, 13, 305-309. In Bulman, C. And Schutz, S. (2008) Reflective Practice in Nursing. Fourth edition. Chichester : John Wiley and Son Ltd. Roper, N., Logan, W., Tierney, A. J. (2003) The Roper, Logan, Tierney Model of Nursing. Philadelphia: Churchill Livingstone. Rungapadiachy, M. D. (2001) Interpersonal Communication and Psychology for Health and Social Care Professionals, Theory and Practice. Oxford: Butterworth- Heinemann. Spouse, J., Cook, M. and Cox, C. (2008) Common Foundation Studies in Nursing. Fourth edition. Philadelphia: Churchill Livingstone. Stein-Parbury, J. (2005) Patient and person Interpersonal Skills in Nursing. Third edition. Marrickville: Churchill Livingstone. Walsh, M. (1998) Models and Critical Pathways in Clinical Nursing. Conceptual Frameworks for Care Planning. Second edition. London: Balliere Tindall. Williams, C. L. (2008) Therapeutic Interaction in Nursing. Second edition. London: Jones and Bartlett Publishers International.