Nurse Patient Relationship Essay Conclusion
The nurse–client relationship is an interaction aimed to enhance the well-being of a "client," which may be an individual, a family, a group, or a community. Peplau's theory is of high relevance to the nurse-client relationship, with one of its major aspects being that both the nurse and the client become more knowledgeable and mature over the course of their relationship. Peplau believed that the relationship depended on the interaction of the thoughts, feelings, and actions of each person and that the patient will experience better health when all their specific needs are fully considered in the relationship. The nurse-patient relationship enables nurses to spend more time, to connect, to interact with their patients as well as to understand their patient’s needs. It assists nurses to establish a unique perspective regarding the meaning of the patient’s illness, beliefs, and preferences of patients/families. Thus, the patients/families feel that they are being cared for and they feel more motivated to open up to the nurses as well as working together to achieve better outcomes/satisfaction.
The nurse-client relationship is composed of several elements.
Main article: Professional boundaries
Boundaries are an integral part of the nurse-client relationship. They represent invisible structures imposed by legal, ethical, and professional standards of nursing that respect the rights of nurses and clients. These boundaries ensure that the focus of the relationship remains on the client’s needs, not only by word but also by law. The College of Nurses of Ontario (CNO) Standards identifies that it is the nurse’s responsibility to establish the boundaries and limits of the relationship between the nurse and client. The boundaries have a specific purpose and health goal, and the relationship terminates when identified goal is met.
Any action or behaviour in a nurse-client relationship that personally benefits the nurse at the expense of the client is a boundary violation. Some examples of boundary violations are engaging in a romantic or sexual relationship with a current client, extensive non-beneficial disclosure to the client and receiving a gift of money from the client. Abuse and neglect are extreme examples. They involve the betrayal of respect and trust within the relationship. This includes withholding communication from a client because it is considered to be an example of neglect.
It is the nurse’s job to be aware of signs that professional boundaries may be crossed or have been crossed. Warning signs of boundary crossing that may lead to boundary violations include frequently thinking of a client in a personal way, keeping secrets with a specific client, favouring one client’s care at the expense of another’s and telling a client personal things about yourself in order to make an impression. Anything that could comprise the client’s well-being if the relationship with a registered nurse is continued or discontinued can be considered a warning sign. Boundary violations are never acceptable and it is the nurse’s job to handle any situation with any regards to it professionally and therapeutically regardless of who initiated it.
This makes the relationship safe and establishes trust. The patient should feel comfortable disclosing personal information and asking questions. The nurse is to share information only with professional staff that needs to know and obtain the client's written permission to share information with others outside the treatment team.
Therapeutic nurse behaviours
Nurses are expected to always act in the best interests of the patient to maintain a relationship that is strictly with all intent to only benefit the client. The nurse must ensure that their client’s needs are met while being professional. Extensive research and clinical observation has shown that the body, mind and emotions are in unity. Therefore, in order to help another person, one must consider all these aspects; this means not neglecting the person and strictly just treating the illness. Caring for patients is beyond the treatment of disease and disability.
The necessary knowledge aspects that are needed to maintain a therapeutic nurse-client relationship are: background knowledge, knowledge of interpersonal and development theory, knowledge of diversity influences and determinants, knowledge of person, knowledge of health/illness, knowledge of the broad influences on health care and health care policy, and knowledge of systems.
Background knowledge is the nurse’s education, and her life experience. Knowledge of interpersonal and development theory is the knowledge of theories of the sense of self and self influence on others. The specific theories are: The Interpersonal Theory, Object relation theory, Developmental theory, and Gender/developmental theory. Knowledge of person explains that nurses must take the time to understand the client, and their world; what is meaningful to them, and their history. Knowledge of Health and Illness is the knowledge that the nurse must attain about their client’s health issue. Knowledge of the broad influences on health care and health care policy explains that nurses need to be aware of the influences of the client’s care; social/political forces, expectations of health-care system, and changes in accessibility, and resources. Knowledge of Systems explains that the nurse needs to know about the health-care system so they can help their clients access services. Effective communication in nursing entails being empathic, non-judgmental, understanding, approachable, sympathetic, caring, and having safe and ethical qualities. The first statement of the CNO Standard is Therapeutic Communication, which explains that a nurse should apply communication and interpersonal skills to create, maintain, and terminate a nurse-client relationship.
All of the aspects to a therapeutic relationship are interrelated. You cannot efficiently use one aspect without the other; they are all connected and work together to create a successful relationship. Nurses assist clients to achieve their health related goals including improving their relationship with others. "The help that nurses offer to their clients is much more than technical expertise. The relationship between nurse and client is a powerful healing force by itself.
Main article: Self-awareness
Self-awareness is an internal evaluation of one self and of one’s reactions to emotionally charged situations, people and places. It offers an opportunity to recognize how our attitudes, perceptions, past and present experiences, and relationships frame or distort interactions with others. An example of self-awareness would be acknowledging that showing anger is not a sign of weakness, because there were emotions outside of your control. Self-awareness allows you to fully engage with a client and presence; being with the client in the moment, allows the nurse to know when to provide help and when to stand back. Until individuals can fully understand themselves they cannot understand others. Nurses need self-awareness in this relationship to be able to relate to the patient’s experiences to develop empathy. </Self awareness may be the nurses's most important facet of their professional practice
Genuine, warm and respectful
Highly skilled, experienced nurses must possessed certain attributes or skills to successfully establish a nurse client relationship. Attributes such as being genuine, warm and respectful are a few to mention. An aspect of respect is respecting an individual’s culture and ensuring open-mindedness is being incorporated all throughout the relationship up until the termination phase. The nurse works to empower the client along with their family to get more engaged in learning about their health and ways in which it can be improved. It is highly beneficial for the client to incorporate their family, as they may be the most effective support system. Revealing your whole self and being genuine with clients will accomplish the desired nurse client relationship.
Behaving therapeutically may require remaining silent at times to display acceptance, incorporating open ended questions to allow the client control of the conversation and encouragement to continue. In addition, the nurse may also reduce distance to demonstrate their desire in being involved, restating and reflecting to validate the nurse’s interpretation of the client’s message, directing the conversation towards important topics by focusing in on them. Nurses also seek clarification to demonstrate the desire to understand, summarizing to help aid the client in separating the relevant information from the irrelevant ones. Nurses must make their client feel confident that they will be treated courteously and that their nurses show genuine interest in them.
The strong connections between clients and nurses are made by presence, touch and listening. Furthermore, being polite and punctual displays respect for the client in addition to remembering to be patient, understanding, also to praise and encourage the client for their attempts to take better care of their health. A primary factor in establishing a nurse client relationship is the non-verbal message or behaviours you send out unconsciously, resulting in a negative perception and may distort your attempts in effectively assisting the client to achieve optimal health. One of the non-verbal factors is listening. Listening behaviours are identified as S.O.L.E.R; S-sit squarely in relation to client, O-maintain an open position and do not cross arms or legs, L-lean slightly towards the client, E-maintain reasonable and comfortable eye contact, R-relax. These behaviours are effective for communication skills, and are useful for thinking about how to listen to another person.
Main article: Empathy
Having the ability to enter the perceptual world of the other person and understanding how they experience the situation is empathy. This is an important therapeutic nurse behaviour essential to convey support, understanding and share experiences. A client to a nurse in a general sense is seeking help. Patients are expecting a nurse who will show interest, sympathy, and an understanding of their difficulties. When receiving care patients tend to be looking for more than the treatment of their disease or disability, they want to receive psychological consideration. This happens through good communication, communication with clients is the foundation of care.
During hard times, clients are looking for a therapeutic relationship that will make their treatment as less challenging as possible. Many patients are aware that a solution to their problems may not be available but expect to have support through them and that this is what defines a positive or negative experience. Empathy is used as a tool to enhance the communication between the nurse and client. Past experiences can help the clinician can better understand issues in order to provide better intervention and treatment.
Healthcare is a multicultural environment and nurses have to expect that they will care for patients from many different culture and ethical backgrounds. Cultural backgrounds effect people’s perceptions of life and health. The goal of the nurse is to develop a body of knowledge that allows them to provide cultural specific care. This begins with an open mind and accepting attitude.
Cultural competence is a viewpoint that increases respect and awareness for patients from cultures different from the nurse's own. Cultural sensitivity is putting aside our own perspective to understand another person’s perceptive. Caring and culture are described as being intricately linked. This is believed because there can be no cure without caring and caring involves knowing the different values and behaviours of a person’s culture. It is important to assess language needs and request for a translation service if needed and provide written material in the patient’s language. As well as, trying to mimic the patient’s style of communication (e.g. little direct eye contact, slow, quiet).
A major obstacle to cultural sensitivity and good communication is ethnocentrism, which is the belief that ones ethical group is superior to another; this causes prejudice and stops a nurse for fully understanding the patient. Another obstacle is stereotyping, a patient’s background is often multifaceted encompassing many ethic and cultural traditions. In order to individualize communication and provide culturally sensitive care it is important to understand the complexity of social, ethnic, cultural and economic. This involves overcoming certain attitudes and offering consistent, non-judgemental care to all patients. Accepting the person for who they are regardless of diverse backgrounds and circumstances or differences in morals or beliefs. By exhibiting these attributes trust can grow between patient and nurse. Nurses need to know the outcome of social, cultural, and racial differences, and how they can affect the therapeutic relationship. Nurses need to acknowledge the impact of culture in order to practice health in a way that respects a person’s beliefs and values.
Collaborative goal setting
A therapeutic nurse-client relationship is established for the benefit of the client. It includes nurses working with the client to create goals directed at improving their health status. Goals are centered on the client’s values, beliefs and needs. A partnership is formed between nurse and client. The nurse empowers patient and families to get involved in their health. This relationship has three phases, a beginning (first time contact/introduction), a middle (develop a relationship to deliver care) and an end (the patient is no longer dependant on the nurse). To make this process successful the nurse must value, respect and listen to clients as individuals. Focus should be on the feelings, priorities, challenges, and ideas of the patient, with progressive aim of enhancing optimum physical, spiritual, and mental health.
Responsible, ethical practice
This is a communication-based relationship, therefore, a responsibility to interact, educate, and share information genuinely is placed upon the nurse. The fourth statement of the CNO Standard is, Protecting Clients from Abuse. It is stated that it is the nurse’s job to report abuse of their client to ensure that their client is safe from harm. Nurses must intervene and report any abusive situations observed that might be seen as violent, threatening, or intended to inflict harm. Nurses must also report any health care provider’s behaviors or remarks towards clients that are perceived as romantic, or sexually abusive.
Coatsworth-Puspoky, Forchuk, and Ward-Griffin conducted a study on clients' perspectives in the nurse–client relationship. Interviews were done with participants from Southern Ontario, ten had been hospitalized for a psychiatric illness and four had experiences with nurses from community-based organizations, but were never hospitalized. The participants were asked about experiences at different stages of the relationship. The research described two relationships that formed the "bright side" and the "dark side".
The "bright" relationship involved nurses who validated clients and their feelings. For example, one client tested his trust of the nurse by becoming angry with her and revealing his negative thoughts related to the hospitalization. The client stated, "she's trying to be quite nice to me ... if she's able to tolerate this occasional venomous attack, which she has done quite well right up to now, it will probably be a very beneficial relationship".
The "dark" side of the relationship resulted in the nurse and client moving away from each other. For example, one client stated, "The nurses' general feeling was when someone asks for help, they're being manipulative and attention seeking". The nurse didn't recognize the client who has an illness with needs therefore; the clients avoided the nurse and perceived the nurse as avoiding them. One patient reported, "the nurses all stayed in their central station. They didn't mix with the patients ... The only interaction you have with them is medication time". Neither trust nor caring was exchanged so perceptions of mutual avoiding and ignoring resulted. One participant stated, "no one cares. It doesn't matter. It's just, they don't want to hear it. They don't want to know it; they don't want to listen". The relationship that developed depended on the nurse's personality and attitude. These findings bring awareness about the importance of the nurse–client relationship.
Building trust is beneficial to how the relationship progresses. Wiesman used interviews with 15 participants who spent at least three days in intensive care to investigate the factors that helped develop trust in the nurse–client relationship. Patients said nurses promoted trust through attentiveness, competence, comfort measures, personality traits, and provision of information. Every participant stated the attentiveness of the nurse was important to develop trust. One said the nurses "are with you all the time. Whenever anything comes up, they're in there caring for you". Competence was seen by seven participants as being important in the development of trust. "I trusted the nurses because I could see them doing their job. They took time to do little things and made sure they were done right and proper," stated one participant. The relief of pain was seen by five participants as promoting trust.
One client stated, "they were there for the smallest need. I remember one time where they repositioned me maybe five or six times in a matter of an hour". A good personality was stated by five participants as important. One said, "they were all friendly, and they make you feel like they've known you for a long time" (61). Receiving adequate information was important to four participants. One participant said, "they explained things. They followed it through, step by step". The findings of this study show how trust is beneficial to a lasting relationship.
Emotional Support is giving and receiving reassurance and encouragement done through understanding. Yamashita, Forchuk, and Mound conducted a study to examine the process of nurse case management involving clients with mental illness. Nurses in inpatient, transitional, and community settings in four cities in Ontario Canada were interviewed. The interviews show the importance of providing emotional support to the patients. One nurse stated that if the client knows "Somebody really cares enough to see how they are doing once a week ... by going shopping with them or to a doctor's appointment. To them it means the world".
The interviews showed it was crucial to include the family as therapeutic allies. A nurse stated that "We're with the families. We can be with them as oppositional and overly involved and somewhere else in between, and we're in contact with them as much as they want". With frequent contact the nurse was able to discuss possibilities with the family. The study reaffirmed the importance of emotional support in the relationship.
Humour is important in developing a lasting relationship. Astedt-Kurki, Isola, Tammentie, and Kervinen asked readers to write about experiences with humour while in the hospital through a patient organization newsletter. Letters were chosen from 13 chronically ill clients from Finland. The clients were also interviewed in addition to their letters. The interviews reported that humour played an important role in health. A paralyzed woman said, "Well you have to have a sense of humour if you want to live and survive. You have to keep it up no matter how much it hurts".
Humour helped clients accept what happened by finding a positive outlook. One participant stated, "... when you're sick as you can be and do nothing but lie down and another person does everything in her power to help, humour really makes you feel good". Humour also serves as a defence mechanism, especially in men. A participant said, "For male patients humour is also a way of concealing their feelings. It's extremely hard for them to admit they're afraid". The patient finds it easier to discuss difficult matters when a nurse has a sense of humour. "A nurse who has a sense of humour, ... that's the sort of nurse you can talk to, that's the sort of nurse you can turn to and ask for help ..." reported a participant. This study lends support that if humour is generally important to people, then in times of change it will remain important.
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Communication is one of the essential factors to maintain a good quality of life because it allows humans to interact and provide comfort. In hospitals, the importance of communication becomes even more evident. Therapeutic nurse-patient communication helps nurses to build positive relationships with patients by showing warmth, respect, and empathy. In order to accomplish the effective communication and empower the patient, a nurse needs to identify and be aware of the patient’s physical, psychological, or social barriers. Communication skills may be useful to overcome the barriers that inhibit nurses from building healthy patient-nurse relationship.
Keywords: Therapeutic communication, nurse-patient relationship
Overview of issue:
Communication is one of the essential factors to maintain a good quality of life because it allows humans to interact and to provide comfort. Communication includes verbal and nonverbal. During verbal communication, there are many factors that affect the choice of words. For example, age, race, socioeconomic status, education background, gender, place, and situation are the factors. Nonverbal communication includes body language, facial expressions, and active listening. The ability to classify information in ways that can be understood by self and others would be severely impaired if spoken languages were not used (Arnold&Boggs, 1999). In hospitals, the importance of communication becomes even more evident. Not only a lot of information is given and understood by communicating, but also a patient’s needs and feelings are mostly learned through communication. Therefore, therapeutic communication is as important as knowledge, evidence based practice, and so on. But, often significance of therapeutic communication is forgotten. So, the importance of effective communication should be thoroughly discussed and learned.
Importance in professional practice:
Therapeutic nurse-patient communication helps nurses to build positive relationships with patients by showing warmth, respect, and empathy. It also increases confidence of the nurse by enabling nurses to ask for support, open up for feedbacks, and overcome anxiety. Therefore allows nurses to provide the best possible care for patients. Effective nurse-healthcare provider communications assure optimal patient-centered care (Ashurst & Taylor, 2010).
Application to a patient scenario:
BD, 85 years old male, was admitted from a nursing home with complaint of short of breath and a change in mental status. When I assessed BD, his mental status was stabilized. However, he was very demanding and wanted to get things done in his own way. BD’s nurse and LNA seemed very agitated with him and did not want to communicate with him unless it was necessary. It was a good time for me to learn how to deal with a difficult nurse-patient relationship. However, I believe that even if a patient may be difficult to have pleasant interactions with, a nurse should never abandon or avoid communicating with the patient.
BC, 72 years old diabetic female, was admitted with CHF. She was a very pleasant lady, and I assumed she would not have any frustration or depression with her health and life. However, while I was talking to her, she said “I don’t want to bug anyone, and I just want to die soon.” I was very surprised, and at first I did not know what to say to her. But then I asked her what made her to think that she would be “bugging” anyone and why would she want to die soon. She told her frustration of limited mobility and not being able to do activities she enjoys. I told her she will get better and held her hand. However, I did not know if saying ‘you will get better’ would be a false hope and not an appropriate therapeutic communication.
ND was admitted due to CHF and headache. When I assessed her, I heard crackles on her base of lungs and her pain was 6 out of 10. I notified her nurse to give the prn pain medication, but she was too busy to give the medication. My patient hesitated with asking for the pain medication again because she felt it would be too demanding. The nurse seemed distracted with other issues and was very stressed out, so she failed to meet my patient’s needs. She finally did ask for the medication, but the nurse came back about 30 minutes later. I wish I could have spoken up for my patient, but because I am a nursing student, it was hard for me to step up and talk to the nurse. There are many barriers that distract nurses from providing better care for patients. In this situation, stress and overload of work made the nurse draw attention away from my patient. In addition, I believe if a nurse properly communicated with other healthcare providers and patients, positive outcomes, such as faster patient’s optimal physical and psychological health/wellness achievement, would more likely to be produced.
II. Discussion/analysis of findings from your reading of the literature
According to Weaver (2010), in order to accomplish the effective communication and empower the patient, a nurse needs to identify and be aware of the patient’s physical, psychological, or social barriers. Within patients, physical barriers may include sensory impairment and environment issues. Psychological barriers could include personality or disability. Social barriers include cultural values, religious beliefs, socio-economic status, and so on. While nonverbal communication is almost similar among any country, verbal communication depends on cultural tradition, religious values, geographic location, and so on. Nurses may have conflicting values, commitments, and lack of value that would affect communication, therefore leading to a failure of accomplishing patient-nurse relationship (Arnold &Boggs, 1999).
Furthermore, nurses who participated in Sheldon, Barrett, and Ellington’s (2006) research reported the difficulties in communicating specific diagnoses and clinical situations, patient and family emotions, nurses’ emotions, triangle of nurse-physician-patient communication, and nurse coping behaviors with difficult communication. They felt they were not educated enough to communicate with patients in difficult situations. Therefore, education to improve communication skill is needed.
Improving Communication Skills
Communication skills may be useful to overcome the barriers that inhibit nurses from building healthy patient-nurse relationship. The research done by Duxbury and Whittington (2005) found that while nurses thought the environmental condition and the patient’s mental illness precipitated the patient’s aggression, the patient perceived the environmental condition and poor communication as the aggression precursor. According to Robinson and Watters (2010), communication skills can be attained and improved through practice. Effective therapeutic communication skills gather or transmit information successfully and promote healing and recovery of the patient. Active listening is required since hearing without actually listening may cause a problem (Jasmine, 2009). Listening allows nurses to gain essential information, to understand patients, and to provide better care. Egan (1990) suggested the proper body position that would help a person to effectively engage in conversation: sit squarely in relation to the client, lean slightly towards the patient, maintain open position, make reasonable eye contact, and relax.
In addition, communication should be taken in place with minimal distraction. For example, drawing curtains and moving a patient to a private counseling room would provide less distraction. However, changing to a quiet room may be difficult in real clinical setting due to lack of room availability or a patient’s immobility. (Jasmine, 2009) Furthermore, patients may need some encouragement and trust needs to be established to communicate their feelings and concerns to the nurse. Encouragement can be done through using touch, humor, and tears.
Among various communication skills, exploring is another essential skill, and “it largely involves the use of effective questioning techniques to probe deeper into the issues concerning a patient” (Jasmine, 2009). For the better therapeutic communication, open-ended questions can be used to assist the patient to discuss and clarify what he or she is thinking, concerning, and feeling. Then, paraphrasing conversations helps nurses to repeat and reinterpret what has been said during communication (Jones, 2009).
The communicator needs to be assertive and responsive. In order to be assertive, one needs to have competent knowledge, confidence, and “ability to start, continue, and stop conversations” (Schuster, 2000). Brunero and Lamont’s research showed that the e-learning package reduced stress and increased knowledge, skill, and confidence of nurses in managing the difficult nurse-patient relationship (2010). The e-learning package used scenario based learning method. According to the authors, it is not only cost-effective, but also easily accessible. Moreover, a nurse educator, clinical nurse specialist, and registered nurses contributed in expanding and developing the scenario to maximize its purpose. Improvement of difficult Patient Stress Scale (DPSS) total, confidence, skill, and knowledge were statistically significant. According to the authors, the e-learning package should be implemented and developed more since it had positive outcome, which delivers better care to patients and reduces stress. The scenario and problem based e-learning package could improve communication skills and difficult nurse-patient relationship because the nurse has more knowledge, skill, and confidence. As a result, patients may receive optimal care from the nurse.
III. Summary, Conclusion and next steps based on the literature.
There are many barriers that disrupt therapeutic communication. Based on my findings, I need to carefully assess at my patient’s culture, religion, education background, socio-economic status, and so on before I see my patient. Comprehensive assessment will help me to find out what my patient’s needs are. Moreover, I would be able to resolve barriers and to respect my patient’s beliefs. Furthermore, I am going to carefully observe my patient’s nonverbal cues, such as facial expression, voice tone, body language, and so on to make sure if he or she has any distress or issue. Also, when my patient wants to discuss his or her concern, or if I notice something different with my patient, I will stop what I am doing, sit down, listen, and solve the problem with the patient. Then, I will continuously evaluate the progress until the goal is achieved.
IV. Epilogue/reflection/learning/so what
I believe communication could represent the aesthetic part of nursing. How I artistically present myself and communicate with my patient could influence healing processes. Based on the literatures I reviewed, I learned to practice and focus on communicating with patients and building therapeutic relationship with my patient. Since communication assures healthy nurse-patient relationship and promotes healing process, I will focus on the whole person rather than disease or tasks.
I learned to use appropriate therapeutic communication techniques according to the situation. For example, making observation, asking opened question, offering self, encouraging, accepting, using silence, focusing, exploring, and so on can be used when my patient is having a difficult time or when I need to get to know about my patient. In addition, I should never reject, tell patient what to do without discussion, ask too many questions, make stereotyped or unrelated comments, or interrupt my patient while communicating.
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Duxbury, J., & Whittington, R. (2005). Causes and management of patient aggression and violence: staff and patient perspectives. Journal of Advanced Nursing, 50(5), 469-478. Retrieved from EBSCOhost.
Egan G. (1990). The Skilled Helper: A systematic approach to effective helping. Brookes/Cole, California
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Robinson, K., & Watters, S. (2010). Bridging the communication gap through implementation of a patient navigator program. Pennsylvania Nurse, 65(2), 19-21. Retrieved from EBSCOhost.
Schuster, P. (2000). Communication: The Key to the Therapeutic Relationship. Philadelphi,PA: F.A. Davis
Sheldon, L., Barrett, R., & Ellington, L. (2006). Difficult communication in nursing. Journal of Nursing Scholarship, 38(2), 141-147. Retrieved from EBSCOhost.
Weaver, D. (2010). Communication and language needs. Nursing & Residential Care, 12(2), 60-63. Retrieved from EBSCOhost.