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The following essay aims to discuss and explore the impact of diversity between nurse and patient within the confines of the therapeutic relationship; this will be achieved through reflecting upon an interaction which occurred between a patient and myself during clinical placement. Stuart and Sundeen (1995, p.992) describe the ‘therapeutic nurse-patient relationship’ as:
“A mutual learning experience and a corrective emotional experience for the patient, in which the nurse uses self and specified clinical techniques in working with the patient to bring about behavioural change.”
This definition is implicit of the need for purpose and direction within such a relationship, and is also suggestive that an effective therapeutic relationship is advantageous to both nurse and patient. Wilson and Kneisl (1996, p.G-15) refer to a ‘therapeutic alliance’, defining it as:
“A conscious relationship between a facilitative person and a client in which each implicitly agrees to work together to help the client address personal problems and concerns.”
The need for the therapeutic relationship to be goal-orientated is reiterated here; however, it is interesting to note that this second definition fails to recognise or acknowledge any potential benefits for the nurse, and appears to regard the patient as the focus of the therapeutic relationship. Akerjordet and Severinsson (2004) support this view, reporting that the delivery of holistic care to a high standard necessitates a patient-centred therapeutic relationship.
Peplau (1952) considers the therapeutic relationship to be the central focus of all nursing practice; the relationship between nurse and patient provides the “backbone upon which all other care is delivered” (Forchuk, 2002). Furthermore, Graham (2001), Lauder et al (2002) and Hewitt and Coffey (2005) all describe the therapeutic relationship as forming the “cornerstone” of modern nursing practice.
Egan (1994) illustrates the ‘skilled helper model’ of counseling, which is reported by Sloan (1999) to promote warmth and genuineness during interactions with patients; this model focuses on the patient (Egan, 1994), and can be described as a “humanistic” approach to helping (Jones, 1998). It is for these reasons that I have elected to apply the use of this model to the interactions, which occurred between the patient and myself.
The model as outlined by Egan (1994, p.22) details three stages to the helping process, which “overlap and interact with one another”; the first stage aims to help the patient “identify, explore, and clarify their problem situations”. Jones (1998) states that this initial stage promotes and facilitates the “exploration and identification” of problems which are faced by the patient. Egan (1994, p.23) reports that the second stage intends to help the patient highlight “goals and objectives”, and recognise different options and choices available in overcoming their problems. The third stage of the model is involved in “identifying strategies for movement from the present to the preferred scenario” (Jones, 1998); Egan (1994, p.24) states that the purpose of this stage is to help the patient determine “ways of achieving results”. Cutcliffe (1997) suggests that this model empowers the patients, by requiring them to actively participate, which helps them to “gain a critical understanding of their problems” and also offers responsibility. Such empowerment can help the patient to feel more in control (Gibson, 1991), perpetuate feelings of hope (Miller, 1989) and improve the patient experience (Downie et al, 1990).
Explicit consent was obtained from the patient in question for the material which was obtained during these interactions to be used within this assignment; and in order to conform to the code of conduct detailed by the Nursing and Midwifery Council (2004), and to maintain the confidentiality of the patient, throughout this essay they will be referred to as Howard.
Howard is a 38-year-old man, who had been unemployed and living in ‘bed and breakfast’ accommodation for the six months preceding his admission to hospital, following the breakdown of his marriage. It appeared that the stress, which culminated with the separation from his wife and their pending divorce, had led to a progressive deterioration in his mental state and mood, which had made it difficult for him to work (Eysenck and Flanagan, 2001). Gross (2001) supports this notion, suggesting that the stress experienced by Howard is not only likely to increase his susceptibility to mental illness, but is also likely to be a contributory factor to his altered mental state and low mood. He began drinking alcohol heavily during this period, and was eventually admitted to hospital after being picked up by the police under Section 136 of the Mental Health Act (1983) following an incident involving criminal damage and irrational behaviour. However, in the three weeks since admission his mental state and mood had appeared to improve with the use of medication and the benefits of a therapeutic environment.
The goal of my interaction with Howard was to generate discussion and provoke interest in possible employment and accommodation options available for Howard, as these presented issues which he repeatedly raised concerns about during his time in hospital; subjectively, he appeared to partially attribute his recent deterioration in mental state to these issues.
I attempted to use open questions as often as possible during the interaction. Tschudin (1995) reports that the use of open questions allows the patient to guide or steer the conversation, enabling them to discuss their true feelings and concerns, and also allows them to respond with fluidity; adding that this may have also illustrated to Howard that I was both listening and attending. Furthermore, I made a conscious effort during the interaction to paraphrase information with Howard; Bush (2001) suggests that this may help to reduce the occurrence of misunderstanding and miscommunication between nurse and patient, enabling the progress of comprehensive communication between Howard and myself. This may have also satisfied Howard that I understood his point of view (Sloan, 1999), and is beneficial to the development of the therapeutic relationship.
Hertzberg (1990) and Ramjan (2004) both highlight that difficulties can be encountered when attempting to establish therapeutic relationships with patients; Hewitt and Coffey (2005) reinforce this view, stating that the development of a therapeutic relationship can be a problematic and time-consuming process. Therefore, it may be beneficial to consider issues of diversity between Howard and myself, and discuss the impact of these differences on our therapeutic relationship. Miller (2002) highlights a number of factors of diversity, which may impact upon the development of a therapeutic relationship including culture, age, gender, ethnicity and education background.
Nurses must be cautious that the development of a therapeutic relationship between themselves and their patients is not hindered or obstructed by negative stereotyping (Mandy et al, 2004). Dexter and Wash (1991) state that it is imperative for nurses to be non-judgemental and accepting of their patients; furthermore, Miller (2002) adds that stereotyping can cause nurses to become dismissive of the individual needs of their patients. Therefore, one may assume that if nurses are to deliver safe, holistic and patient-centred care, the use of stereotypes must be avoided. Forchuk (2002) and Ramjan (2004) both emphasise the relevance of this specifically in the context of mental health nursing, stressing the need to steer away from negative stereotypes, stating that it is not uncommon for people suffering with mental illness to encounter social stigma and social exclusion which is associated with their illness; adding that an understanding and empathic approach is more likely to be valued. Existing feelings of negative self-belief and low self-worth may be reinforced, if nurses express negative emotion, whilst responding to the needs of their patients (Rayner et al, 2005). In addition to this, Shafer (1997), Graham (2001), Hewitt and Coffey (2005) and Langley and Klopper (2005) all report that patients suffering with mental health problems can experience difficulty in forming and sustaining relationships, as a result of their illness. This has clear implications for all nurses, and demands sensitivity and consideration.
The challenges, which are presented to the therapeutic relationship by significant differences in age between nurse and patient are noted by Deering and Cody (2002) with reference to young children, and conversely by Miller (2002) with reference to older people. Nurses require effective communication skills, and must consciously utilise these skills in order to communicate in an age-appropriate manner (Deering and Cody, 2002); furthermore Miller (2002) reiterates the need to “demonstrate sensitivity” when interacting with patients of an older age, adding that “barriers” can develop within the therapeutic relationship resulting from a lack of sensitivity to the ages of our patients. I feel that this is especially relevant to my therapeutic relationship with Howard, as I am eighteen years younger than him. I became aware of this issue of diversity upon meeting Howard shortly after his admission, and this is important as Spence (2001) reports that it is essential for nurses to recognise issues of diversity, if they are to be successful in the provision of sensitive care. However, at times during our interaction Howard disclosed that he saw no value in discussing his personal issues with a nurse of a younger age than himself, explaining that he felt I was lacking in life experience, and could therefore do little to help him; I feel that this caused Howard to be dismissive of my input at times.
Antai-Otong (1999b) highlights that our “cultural background” can be an issue of diversity, which can impact upon the development of therapeutic relationships. Pearce (2003) reinforces this view, arguing that there is a need for 'transcultural nursing’, in order for the barriers posed by issues of cultural diversity to be crossed; therefore one can assume that in order for nurses to develop an effective therapeutic relationship with their patients, it is important for them to be mindful of cultural issues (Burnard, 2003). Despite this, I do not feel that there were any obvious issues of cultural diversity between Howard and myself, which threatened or hindered the development of our therapeutic relationship; we are both of British and Caucasian ethnicity, from working-middle class social backgrounds, educated, residing in the same region, and both Christians. The factors noted here appeared to provide material, which facilitated “phatic” conversation between Howard and myself (Burnard, 2003); this allowed us to relate to one another, and is useful as it helps to establish, maintain and enhance relationships. I feel that this is also true of the therapeutic relationship I had developed with Howard, as we had previously discovered a number of shared interests, which I feel provided me with many options for initiating an interaction, and allowed me to develop a rapport with Howard. Nevertheless, Vandekieft (2001) reiterates that it is imperative for nurses to be sensitive to the personal and cultural differences between themselves and their patients.
Shafer (1997) notes that gender issues may also perpetuate difficulties within the therapeutic relationship. Simpson and Fothergill (2004) support this notion, highlighting that when working with patients who have been the victims of sexual abuse, there can be complex implications pertaining to gender; adding that there is a “potential for sexual exploitation” within the therapeutic relationship that demands consideration. Furthermore, historically, the nursing profession has possessed a “sexually provocative stereotype”, which can also present dangers (Campbell-Heiber and Hart, 1993). Shafer (1997) adds that sexual attraction between nurse and patient “violates the boundaries” of the therapeutic relationship; Dexter and Wash (1991, p.12) stress the need for nurses to avoid such relationships with their patients, reiterating the need to work collaboratively with patients, “without emotional entanglement”, if they are to be successful in helping their patients objectively. There were no obvious issues pertaining to gender which were likely to challenge the therapeutic relationship between Howard and myself.