Module Title:

Self Awareness and Relating to Others

Module Code:

NH1060

Module Leader:

Rob Preece

Cohort:

111

Student Name:

Jennifer Noble

Student Number:

1009928

Named Marker:

Rita Bayley

Word Count Declaration: 2185

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In this essay the author will provide a sound definition of a therapeutic relationship and accurately identify its elements. The author will go on to discuss the essential skills required to develop and maintain a therapeutic relationship including professional standards and guidelines. The author will demonstrate insight into the contribution of others in maintaining a therapeutic relationship within the practice setting and will then go on to discuss issues relating to a therapeutic relationship held within the code of professional conduct and, drawing from personal experience, discuss the impact of self-awareness in the therapeutic relationship. The author will then critically assess this process and offer suggestions of change in their own approach in future settings.

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Nurses provide an invaluable link between patients, their families and the multidisciplinary team and in order for them to do so, this requires the successful development of a therapeutic relationship. Egan, (2002) defines the therapeutic relationship as a partnership between a patient and a nurse, both working together to improve the state of the patients health. Russell, (2002) broke a therapeutic relationship down into a three step process identified as, establishment, development and termination. Simple as these steps may appear they will incorporate a number of essential skills required of a good nurse. In the establishment stage the nurse and patient will go through an initial introduction and data collection process, where the purpose for the relationship is set out, the goals to be achieved and the timescale it will be expected to follow. In order to develop and maintain trust these things must be agreed by both nurse and patient. The development stage is where nurse and patient will begin to form a mutual trust and respect, which is ongoing throughout the relationship. At the point of termination the nurse and patient will agree that the goals have been achieved and there will be a sense of satisfaction between them. In order for the earlier three step process to be successful within the therapeutic relationship Rogers,(1957) established three core qualities which a nurse needs to demonstrate; empathic understanding, genuineness and unconditional acceptance. Empathic understanding is about being sensitive to the feelings of another person at that time without assuming to know how they feel, to help make a patient feel they are understood.

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Russell (2002) observed that lack of honesty with patients can cause them to refrain from communicating and push away all attempts of interaction, therefore genuineness is about being open and honest and having the ability to show yourself without putting on a faade. Egan (1975) discussed guidelines to help the nurse show genuineness through behaviours which include being non patronising, non defensive, open and spontaneous. Not being afraid to use your own life reflection and emotions will help encourage the patient to open up during conversation. Unconditional acceptance is not about pretending to like everyone you have contact with, a nurse has to be able to show acceptance of everyone as an individual and know that all patients are entitled to care and respect. The nurse must not judge a patient based on their own beliefs and values. Having the skills to demonstrate these core qualities and following the defined process enables health care providers to give an element of control back to the patient, enabling a more efficient and effective delivery of treatment through the successful establishment of a therapeutic relationship.

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There are a number of essential skills which are integral to developing therapeutic relationships with patients. Communication can be defined as the reciprocal process in which messages are sent and received between two or more people (Balzer Riley, P40,2004) Essential for all aspects of daily living, as identified by Roper, Logan and Tierney (1980) communication is an integral assessment tool in the nursing process. In 2010, guidance from The Department of Health identified communication as one of the most basic goals for nursing staff, combining verbal and non verbal for effective patient care. Verbal communication incorporates many aspects; appropriate tone of voice for the patient, and the nurse must refrain from being patronising. The skills of language and interpretation need to be combined as the nurse will very often be required to interpret information given by the doctor and present it in language that the patient is familiar with. Questioning and understanding skills are essential within verbal communication as open questioning is used within the assessment process to determine the issues that the patient may have. Argyle (1994) talks of non verbal communication being given special attention as it can convey very powerful messages and it combines skills pertaining to body language, eye contact, facial expression and gestures. It is communicating without the use of spoken language. This is the first thing nurses use and will be a patients first impression. Six emotional states can be identified through facial expression alone and Nurses must develop a sense of how they portray themselves to a patient so as to be non discriminatory and non judgemental NMC, (2008). Eyes can tell a lot about a person, likes and dislikes reaction to stresses, emotional states; even a gaze can convey direction of attention
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or lack of interest. Part of a nurses role is to develop the skills to interpret the different stories being told by the eyes, for example a smiling patient with sad eyes may be hiding something important to establishing their needs. Gestures are used by everyone in everyday circumstances and their interpretation is a key skill for nurses to have. As Argyle (1994) highlights, hand, body and head movements along with speech can create a complete communication package. Egan, (2002) talks about effective listening being a key skill and introduced a concept covered by the acronym SOLER. This gives guidance on how to be an effective listener; by sitting squarely to the patient, maintaining an open posture, leaning towards the patient if appropriate, maintaining appropriate eye contact and being relaxed (Egan,2002) Egan,(2002) supports that this encourages openness and honesty from the patient as they are more likely to be comfortable conversing with a nurse who is actively listening and openly interested. This will also form the basis of trust between the patient and nurse, a critical element for a successful therapeutic relationship. Patients may distrust a nurse or doctor who cannot maintain eye contact as they believe them to be telling untruths or being deceptive. Actively listening to the patient when developing caring communication skills is referred to by Myerscough and Ford (1996). They discuss comfort, acceptance, responsiveness and empathy which without actively listening to the patient cannot be achieved. Professionalism and maintaining clear professional boundaries is a key issue within maintaining a therapeutic relationship as addressed within the NMC Code of

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Conduct, (2008). It is the responsibility of the nurse to establish these professional boundaries at the very start of the relationship, skills involved in professionalism include, maintaining dignity for the patient and confidentially over the information held on them. This can further establish trust between nurse and patient.

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A Nurse is not alone in the role of patient care, they form one element of a multidisciplinary team, which can be defined as, A group of individuals with different training backgrounds who share common objectives and make a different but complementary contribution to the care of a patient. (Marshall et al, 1979) All members of a multi-disciplinary team are responsible for contributing and maintaining the therapeutic relationship. Members of the multi-disciplinary team can include, Doctors, Nurses, Pharmacists, Physiotherapists, Dieticians, family members and the patient. McCray,(2002) talks about every member having their own individual set of skills to bring to the team, and that there is a need for collaboration between team members to meet the needs of the patient and collaborating together within a multi-disciplinary team will form an integral part of everyday practice. Loxley,(1997) talks about mutual respect and support for other team members skills and opinions. Some members of the team would be focused on the diagnosis whilst others would be focused on the patient holistically. Hudson (1999) discussed that each member of the team must establish professional boundaries so as to ensure they understand their own professional role and where that responsibility ends, ensuring this helps to maintain the therapeutic relationship as the patients continuity of care is not affected by different professional roles. As discussed previously by the author, one skill involved in the development of a therapeutic relationship is communication, both verbal and non verbal. The Department of Health,(2010) discuss that to ensure the continuity, safety and quality of health care given to patients the staff should communicate effectively with each other. The more effective the teamwork, the better the patient care (Niven,2006).
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The people within your care must be able to trust you with their health and wellbeing (NMC,2008) This statement is at the forefront of The Code, Standards of Conduct, Performance and Ethics for Nurses and Midwives (2008) and is the backbone to a successful therapeutic relationship. The Nursing and Midwifery Council (NMC) was established to safeguard the health and well-being of the public and nurses within the profession. Nurses establish therapeutic relationships with patients and uphold this code every day and almost every point within the code can directly relate back to the development of a therapeutic relationship. The code outlines guidance for gaining trust, consent, maintaining dignity, being non-discriminatory and non judgemental. The code states, you must listen to the people in your care and respond to their concerns and preferences (NMC, 2008). In 2010 the NMC introduced a document called Guidance for the care of older people which outlines skills in dealing specifically with the older generation, discussing communication skills required but also outlining that these should be applicable for patients of all ages. Listening to patients and taking into account their individual concerns whilst supporting them with a goal to maintain their health and well-being is at the forefront of the nursing profession. Being an advocate for the patient within the the Code of Professional Conduct NMC, (2008)is an integral part of a therapeutic relationship. To fully be able to stand up for what your patient wants through their own choices and judgements you must have formed some kind of trust, whilst being non-judgemental of a patients decisions. The Royal College of Nursing in collaboration with the DH, NMC, Registered Nurses and

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healthcare professionals, have developed nine principles of nursing practice. Number five being effective communication Nurses and nursing staff are at the heart of the communication process they assess, record, and report on treatment and care, handle information sensitively and confidentially, deal with complaints effectively, and are conscientious in reporting the things they are concerned about. (Casey,A & Wallis,A, p35,2011)

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Rawlinson, (p177,1990) defines self-awareness as narrowing the gap between the individuals own perception of self and that perceived by others. Burnard,(1992) introduces the concept that in order to understand the significance of self-awareness within a therapeutic relationship you must be able to understand the way you see yourself, the way you see others and the way others see you. Understanding yourself, your skills and your own limitations affects your ability to help and care for others. Being self-aware can help skill development within the nurses role, using Gibbs (1988) model of reflection, the author was able to identify an area she was uncomfortable with. The author was already aware of issues relating to death and dying, but was unaware of how she would react until faced with a situation on her first placement. The result, a struggle to deal with her own emotions and appropriately control her verbal and non verbal communications, the authors own feelings about death and dying influencing her interaction with a

patient. The author would avoid the patients room and failed to be an effective listener when her patient had feelings of depression they wanted to discuss. The author found herself taking these feelings and emotions away from the hospital, which began to affect her personal relationships. Using Gibbs, (1988) model of reflection, which focuses on the feelings of the person involved, the author was able to identify the feelings that were causing her emotional problems with this particular patient. In combination with the Johari window, Luft, (1969) and a trusted colleague the author was able to gain insight about the way she was handling the situation. The author had to reveal a portion of her hidden self, effectively removing her faade, in order to develop her open self enough to deal with the emotions. The author has gained valuable insight into her own feelings about death and dying and is now self aware enough to realise that she does have limitations within this area.
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The author recognised that she has extensive interpersonal skills and is aware that she would have issues with this area in the future but is now able to prepare herself by drawing on her own life reflections and emotions and better use her active listening skills to understand the emotions of the patient. This will help to form more beneficial therapeutic relationships with her patients throughout her nursing practices. The author is developing skills to maintain the correct balance between work and home by compartmentalising her personal feelings and memories and trying not to relate them to her patients situation. In this particular situation the authors beliefs and values did impact on the therapeutic relationship, but using personal development and reflection the author was able to recognise and respond to this appropriately. Had the author no sense of self awareness then this would have been an ongoing issue for her and she would have found it harder to develop coping mechanisms.

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In conclusion the author has provided a sound definition of a therapeutic relationship and correctly identified its elements. The author went on to discuss the skills involved in maintaining a therapeutic relationship and included professional standards and guidelines. The author defined a multi-disciplinary team and was able to demonstrate insight into the contribution of others in maintaining the therapeutic relationship. The author then discussed issues relating to the therapeutic relationship within the professional code of conduct and drawing on personal experience discussed the impact of self-awareness in the therapeutic relationship, offering suggestions of change in her own approach in future settings.

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References
Balzer-Riley.J (2004). Communication in Nursing, 5th Edition. St Louis: Mosby. Burnard,P.(1992) Know Yourself! Self Awareness Activities for Nurses. London: Scutari Casey,A. & Wallis,A. (2011).Effective communication :Principle of Nursing Practice E. Nursing Standard,25(32),pp.35-37. Department of Health (2010) Essence of Care 2010: Benchmarks for communication. http://bit.ly/hloYIx(Last accessed :March 22) Egan, G. (1994). The Skilled Helper, A Model for Systematic Helping and Interpersonal Relating Fifth, Edition. California: Brooks Cole. Egan, G. (2002). The Skilled Helper, A Problem-Management and Opportunity Development Approach To Helping, 7th edition. California: Brooks Cole. Gibbs,G (1988) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Oxford Brookes University. Hogston,R & Simpson,P.M (ed)(2004). Foundation of Nursing Practice, Making the Difference 2nd Edition. Basingstoke: Palgrave MacMillan. Hudson,B. (1999) Primary health care and social care: working across professional boundaries Managing Community Care, 7 (1),pp15-22 Jack,K. & Smith,A. (2007) Promoting self-awareness in nurses to improve nursing practice. Nursing Standard,21 (32), pp.47-52 Jootun,D & McGhee, G (2011). Effective communication with people who have dementia. Nursing Standard, 25(25) ,pp. 40-46. Loxley,A. (1997) Collaboration in Health and Welfare. London: Jessica Kingsley Myerscough,P.R & Ford,M (1996). Talking with Patients, Keys to goog communication, 3rd edition. Oxford: Oxford University Press. Niven,N. & Robinson,J. (2006) The Psychology of Nursing Care, 2 Macmillan.
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Edition, Basingstoke: Palgrave

Nursing and Midwifery Council (NMC). (2008). The Code, Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: Nursing and Midwifery Council. NMC. (2008). Guidance for the care of older people. London: Nursing and Midwifery Council Roper,N. Logan,W. Tierney,A. (2001) The Roper-Logan-Tierney Model of Nursing: based on activities of living. Edinburgh: Churchill Livingstone

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