Комуникация и терапевтична връзка с пациента
Комуникацията и терапевтичната връзка с пациента са в основата на предоставянето на добра и позитивна грижа. Тази теория се застъпва още в ранното обучение на кадри в западна Европа и би било положителна промяна в България, за което обаче е необходимо допълнително обучение на медицинският персонал.
COMMUNICATION AND THERAPEUTIC RELATIONSHIP
Anelia Rumenova Chevrakova-Mihaylova
Patient care is highly dependent on the establishment of a therapeutic relationship between the nurse and the patient (Fleischer et al. 2009). Professional nurses have to development the therapeutic relationship in their daily practice (Arnold and Boggs 2015). By definition, a therapeutic relationship is a helping relationship between a patient and a nurse and is based on respect, being sensitive to self and others, nurturing of hope and faith, providing physical, spiritual and emotional needs of the patient through skill and knowledge (Peplau 1997; Pullen & Mathias 2010). Building therapeutic relationship is critical to nursing practice and such relationships are enhanced by effective communication (Fleischer et al. 2009; McEwen and Wills 2007). Nursing practice is guided by nursing theories that were developed by nursing theorists. For this paper, I will use the nursing theory by Hildegard Peplau on interpersonal communication to describe my experience as a nurse in a community hospital attending to a patient called Joan. In accordance with The Nursing and Midwifery Council (2015) Code of Conduct, nurses must respect people’s right to confidentiality. Therefore, for the purpose of this essay the patient discussed is not with real name, and any personal or identifiable information has also been altered so as to protect their privacy and dignity which are also enshrined in the Nursing and Midwifery Council (2015) Code of Conduct.
A brief to Joan’s case
Joan was admitted to the hospital for rehabilitation after a fall. An hour later she started vomiting and had loose stool. Initially, barrier nursing was provided to the patient and was kept isolated in a side room. Observing her there made me feel sympathetic as I thought of the frustrations arising from one being kept alone and socializing being limited. The patient was on warfarin, and high INR was discovered at 22.44. The patient was also bleeding from the nose and she was send back to hospital. After the patient had been stabilized, she came back to continue with her rehabilitation. Later on a morning, the patient experienced difficulties and was unable to wake up and after examination by the round ward doctor, she was suspected of having a stroke. It was recommended that she went back to the hospital where the results confirmed that she had a stroke. A week later, Joan was back in the facility to continue with rehabilitation, but it was evident that she suffered from anxiety and that she had lost her confidence. Since the first day I met Joan, she was perceived and viewed as a difficult patient due to her sarcastic nature as well as her unwillingness to cooperate in her rehabilitation. However, such comments were surprising to me because I never had any experience of problems while communicating with her and involving her in the care plan. Joan is still in the hospital, and I have developed a very good patient-nurse relationship with her, and this has helped me in care delivery and ensuring that the rehabilitation goes well.
Hildegard Peplau theory of interpersonal relations
Hildegard Peplau (1909-1999) was an American nursing theorist who came up with the middle range theory called interpersonal relations in 1952 (Nursing-theory.org 2016; Alligood and Marriner-Tomey 2010). Since then, this theory has been adopted by other theorists and found major application in nursing practice as the emphasis on evidence-based practice increases. This theory explains the purpose of nursing which is to help others to identify their difficulties. As such, nurses ought to apply human relations principles in the problems that may arise in their experience (Alligood and Marriner-Tomey 2010; McKenna and Slevin 2007). Peplau saw nursing as therapeutic in that by itself; it is a healing art where a sick individual is helped (Fawcett and Desanto-Madeya 2013; Forchuk and Boyd 2008). It is also an interpersonal process as it involves the interaction between two or more people who have a common goal (Peplau 1997; Wachtel 2011). As such, the attainment of a goal is achieved through a series of steps that follow a series of a pattern. In the process, the nurse, as well as the patient, becomes mature and knowledgeable as they work together through the process (McEwen and Wills 2007). Through this theory, Peplau explains the phases of the interpersonal process as well as the roles in a nursing situation.
Before I describe my experience with Joan as well as the role of establishing a therapeutic relationship with her, I will first define some key terms that are relevant to this theory. A person is defined as a developing organism striving to reduce the anxiety and tension caused by needs (Nursing-theory.org 2016). As such, the client is someone presenting with a felt need. Health is defined as “a word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living” (Nursing-theory.org 2016). The environment is defined as an existing force outside the person regarding culture. Finally, according to Nursing-theory.org (2016), Peplau saw nursing as a “significant, therapeutic, interpersonal process” and defined it as a human relationship existing between the person who is sick or seeking health services and an educated nurse to recognize as well as respond to the client’s needs for help.
Phases of interpersonal relationship
It is necessary that I say that this was my first placement in the community hospital that specializes in rehabilitation as well as the end of life care. Having said that, I will describe my relationship with Joan based on the Hildegard Peplau model of communication and interpersonal relations which have four phases; orientation; identification; exploitation and; resolution(Arnold and Boggs 2015) . In each phase, I will describe the effective development of a therapeutic relationship enhanced by effective communication.
The nurse directs the orientation phase and this phase starts when the nurse meets the client as a stranger and involves engaging the patient in treatment, providing them with relevant information and explanations as well as answering questions (Alligood and Marriner-Tomey 2010; Forchuk 2009). My initial contact with Joan was when she came to the rehabilitation facility for the first time. We both were strangers. According to Peplau, a nurse should act like a stranger in that he or she should receive a client in a similar way as when they meet a stranger in other situations in life and provide him or her an accepting climate that can build trust (Nursing-theory.org 2016; Forchuk 2009; McKenna and Slevin 2007).
Upon meeting Joan, I greeted her and welcomed her to the facility and assured her that she was going to receive the best care. My goal at that particular moment was to establish a relationship based on trust with the client. Since it is believed that a compassionate verbal, as well as nonverbal communication coupled with a respectful approach and a non-judgmental behavior, is significant in the role of a nurse as a stranger, I was keen to ensure that I did the same to Joan. Successfully, I was able to form a foundation for building a therapeutic relationship with her, and this also provided the basis for me to assume the other roles of a nurse as per Peplau as described in sections below. As this initial phase concerns about defining the problem as well as deciding on the service needed for the problem, I decided to talk to Joan about her condition.
Peplau came up with other nurse roles except being a stranger during this phase. As indicated earlier, the nurse serves a teaching role where the obligation is to impart knowledge regarding the patient needs. According to Courey et al. (2008), as a teacher, the nurse provides “provides specific factual health information in response to a client’s questions and interprets the clinical plan of care”. This has to be done in a sensitive manner and requires critical thinking skills so that one can process the client’s questions and offer them therapeutic responses. Engaging her provided her with a chance to ask questions. These questions were not only about her condition but revolved around many aspects of her life and what was likely to happen to her. She willingly spoke of her worries about death, her preconceptions as well as her expectations. Providing the client with means to attain knowledge as a way of improving health is seen as a primary duty of the nurse teacher role. To help Joan, I used both formal and informal strategies. When I found that she was eager to learn more about her condition, I gave her some leaflets about stroke and rehabilitation. While it was not easy to interact with her in the days at the beginning of her program, I realized that she felt free to talk to me more.
The other important role is the leader role. This role involves helping the client to have maximum responsibility so that treatment goals can be met in a way that is satisfactory to the patient and the nurse (Courey et al. 2008). Assuming this role I sought Joan’s collaboration so that we could meet the desired outcome. I made it clear that she would play a critical role if she committed to the care plan and made it her responsibility to follow the rehabilitation care plan. I guided her on what to do, offered support and direction as a way of promoting her participation in maintaining her health. She was very committed, and such responsibility was going to have an impact on her health.
The counselor role helps the patient understand and integrate what their current life circumstances mean and provide them with guidance as well as encouragement to make appropriate changes (Courey et al. 2008). Assuming this role, I asked Joan how she felt about what she was going through and give me her feeling on her current situation. Recognizing discussing such an issue would make her anxious, I first ensured that I created the right environment conducive for her to freely and safely express her concerns. I managed this in a private room where I sat on her bed and leaned towards her. I used my therapeutic communication techniques such as therapeutic silence and listening skill guide her and support her in the process of discovering herself. I was keen to maintain professional boundaries as well as self-awareness. Although I was compassionate and emotional, I did not let that distract my aim of letting her become self-aware regarding her condition.
The surrogate role helps the nurse to clarify the domains of dependence, independence, and interdependence and helps the nurse to act as an advocate on behalf of the patient (Courey et al. 2008). During the interactions, the client may unconsciously transfer emotions of behaviors connected to a significant other such as a parent, friend, sibling, et cetera to the nurse. The nurse accordingly addresses such a reaction. I helped Joan realize that although I was her advocate, she had to recognize the difference and similarities between myself and her significant others.
The other important role is the technical expert role where the nurse demonstrates their technical skills in performing nursing care (Courey et al. 2008). This role is considered as a primary helping role in the establishment of a nurse-patient relationship. Such skills were evident in my physical assessments of the patient as well as interventions and the use of necessary equipment, for instance, the intravenous pumps, ventilators and blood pressure cuffs. While some of the said roles were important in the orientation phase, it is important to note that I continued with some of the roles into the other phases.
The orientation phase is influenced by various factors that are nurse-related and patient-related, and this eventually influences the development of the nurse-patient relationship (Alligood and Marriner-Tomey 2010). On the nurse side, the nurse’s values, culture, beliefs, past experiences, preconceived ideas as well as expectations have a significant role (Fawcett and Desanto-Madeya 2013). As a student nurse, I am trained to be culturally competent and appreciate the culture and beliefs of the patients even if they differ to mine. Fortunately, my patient and I shared similar culture and beliefs and therefore that could only enhance our understanding of each other. On values, my personal values as a nurse are to provide holistic care to all patients following professional guidelines as well as ensuring that I achieve the desired outcome of improving the quality of life of my patients. For Joan, I was committed to applying similar values with resilience.
On patient’s side, possible factors included personal values, beliefs, culture race, expectations and past experiences (McEwen and Wills 2007; Wayne 2014). As I mentioned earlier, my patient did not have different beliefs. However, I noticed that she was low, and self-esteem and her confidence had been greatly reduced. Despite that, she was always sarcastic. Her worst fear was that she expected to die because she had previously heard that people who suffer from stroke eventually do die and never live long. As a professional, I talked her out of that mentality of my relationship with her grew positively. In general, the orientation phase was enhanced by the fact that we understood each other well. She felt free to ask or talk about anything. Her cooperation was critical to the establishment of a successful nurse-patient relationship.
During this phase, a decision on what is appropriate to assist the patient is made (Wayne 2014). Also, the patients increasingly get a feeling of belonging as well as the capability of dealing with their problem. This consequently reduces hopelessness and helplessness (Peplau 1997). For Joan, we agreed on a rehabilitation care plan, and she was very open to it. Though she recognized her condition, she felt that she could recover. As such, she embraced the help offered, and her attitude changed. She seemed more positive and hopeful with always a smile on her face.
During this phase, the client recognizes and makes full use of the services as well as professional assistance given to her. The patient increasingly feels like an important part of the assisting environment. For Joan, we developed a care plan which we wanted to use to rehabilitate her. It was evident during this phase that Joan was high with confidence. She made several minor requests and used attention-getting techniques when she needed assistance. I had developed an effective therapeutic relationship with her such that I understood her.
During this stage, it is important to employ effective communication and principles of interview techniques to successfully explore, understand and accordingly deal with the underlying problem adequately (Wayne 2014). It was important that I effectively communicated to her to get information on how she felt. Active listening and maintaining eye contact was important at this stage as described by Pullen and Mathias (2010). Therapeutic communication in the form of therapeutic touch where I would give her a gentle touch and then ask a therapeutic open ended or closed questions helped me follow her progress. Using general leads, I was able to make her talk of how she felt and importantly using therapeutic silence gave her a chance to express herself while I interpreted her message. My role here was to aid Joan to exploit all possible avenues of help given to her and make sure she made progress as she was towards the final step in her road to recovery.
The resolution phase
The final stage is the resolution phase where the patient gives up dependent behavior (Wayne 2014). In this essay, I will not discuss this phase because Joan is still at the hospital receiving care. Over the period I have been attending to her, I have developed a therapeutic relationship that helps me deal with her even when she seems angry and frustrated. As such, as per Peplau, I am not allowed to take Joan’s behavior or mine literally rather I should see it as meaningful and see it as my responsibility to interpret such behavior. Such is important when a patient feels that there exist discrepancies between what the nurse says and what they do (D'Antonio et al. 2014). Being aware of that not only helped me understand her needs better but it also helped me not to take her frustrations as if she no longer needed my help. In my opinion, I feel that failure to understand Joan’s anger and frustration were the main reasons why others saw her as difficult and uncooperative.
While attending to Joan, I recognized the importance of being an effective communicator. The establishment and building of a therapeutic relationship with a patient are highly dependent on communication (McEwen and Wills 2007). She was difficult, but I was determined to change her attitude. Since communication may be verbal and nonverbal, I had to be very keen to ensure that whenever she made any body language, I would understand what she wanted. As a patient suffering from stroke, she did not talk much, but I always recognized the facial impressions she made at times to convey her message. Such was important because Kirkevold (2010) indicated that the nurse’s role in the treatment of a stroke patient is very important in ensuring that the care plan is effective. One of the most evident non-verbal cues was anxiety. Peplau’s model of communication was specifically tailored to ensure that nurses address anxiety issues in the patient. To Joan, much of the anxiety was stemming from the fear she was not going to recover. However, recognizing this, I was able to transform such anxiety into positive energies that lead to positive attitude and an increased level of confidence in the care plan.
While I feel that I effectively was able to establish a therapeutic relationship with Joan following the Peplau’s model of communication and interpersonal skills, I feel that there is more that I need to improve. It is never easy to deal with a difficult client. As such, it requires high levels of professionalism and commitment to nursing practice. My values as a nurse to provide holistic care to my patient have always played a significant role in ensuring that I attend to my patients in the best way possible, and that was key in providing care to Joan. While this is my first placement, I feel that it is a great leaning opportunity, and my experience with Joan helped me recognize and appreciate the role played by effective communication and therapeutic relationship in care delivery. Professionally I am equipped with communication skills important in nursing such as active listening and using non-verbal cues such as leaning forward, eye contact, et cetera as described by Sully and Dallas (Sully and Dallas 2006). I felt that I would not have been able to attend to Joan if I was not an effective communicator. In general, it is my belief that with continued adherence to the care plan, it is possible to continue the quality of life of Joan, and hopefully, she will recover from her stroke.
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Това е моя разработка на теориите и моделите на комуникация, приложими в медицинска среда.