Client With a Voice - Establishing a Therapeutic Nurse-Client Relationship
Today's health care systems have called attention to the importance of therapeutic nurse-client relationship which needs to be reinstated back into the forefront of thoughts and dialogues about nursing pactice since it has been overpowered by a technology driven medical model. Kleiman (2009. p2). In clinical placement, I will meet with clients for the first time and interact with them in the weeks to follow. This is one of the most important aspect of a nursing student like me, as it will further cement my practical and theory knowledge in the real world. Establishing and maintaining a nurse-client relationship that is therapeutical is crucial in this setting. Although it has been argued that health care organizations do not appear to value or recognize the importance of nurses using a patient-centered approach when communicating with patients, (McCabe 2003; Robb, Seddon, & EPIQ, 2006) I will show that in order to provide quality and safe client care, establishing and maintaining a therapeutic nurse-client relationship is a key component in nursing.
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Therapeutic relationship refers to a professional relationship between a nurse and a patient who unites in a nursing occasion. This is carried out through communication in a manner which focuses solely on the patient (patient-centered care). An effective communication between a nurse-client is a mutual process of sending and receiving messages clearly from thoughts, feelings, actions and approaches through spoken, written and nonverbal means. Nurses must be skilled communicators as outlined by the NZNO Competency in Interpersonal relationships principles. Robb, Seddon & EPIQ (2006) mentions the NZ Ministry of Health's Improving Quality document perceive "people-centred" rather than patient-centred care, and defines this as: "the extent to which a service involves people, including consumers, their families and whanau and is accessible to their needs and values. It includes participation, appropriateness and adherence to the Code of Health and Disability Services Consumer Rights 1996 and adherence to other consumer protections such as the Health Information Privacy Code 1994.10". Kleiman (2009, p14) pointed out that through therapeutic relationships, a nurse adopts an awareness for the patient as an individual, living, feeling, and thinking human being as they interact in a shared lived experience. This shared life experience begins when the nurse and client meets, and ends when the goals of the clients are met or concluded. Common characteristics of a patient-centred care include: informing, involving and engaging patients and their families in all care processes, eliciting and respecting patient preferences, treating patients with dignity, empathy, and warmth, designing care processes to suit patient needs, ready access to health information and continuity of care. Robb and Seddon (2006). As reported by Bauman, Fardy, and Harris (2003), studies have shown that there are benefits of therapeutic relationships in terms of improved patient satisfaction, adherence to best-practice protocols, a fall in anxiety level, and progress in quality of life. Any breakdown in communication can prove disastrous for the patient.
The nurse-client relationship as identified by Dempsey, French, Hillege and Wilson (2009) consists of three phases in addition to the pre-interaction phase. These three phases are; the orientation phase, working phase and termination phase. The initial data gathering part is the pre-interaction phase where the therapeutic relationship preferably begins and the nurse gathers information about the client. Expectations and planning are undertaken about their health needs in terms of time and resources required and their desired role in decision-making. The orientation phase encompasses familiarization whereby the client and nurse gets to know one another. Here, roles and responsibilities are clarified whereby patients are informed about recommended preventive service or management options, and agreements about the relationship are reached to the extent where a trusting bond is established before the nurse embarks on data collection and judgement calls. Commonly the longest phase, the working phase as its name implies, is involved with the nurse-client working together to meet the client's physical and psychosocial needs as well as in achieving their goals and objectives. This can be accomplished through assistance, education, and motivation through persuasion and encouragement. Once goals and initial agreements are identified or met, the terminating phase occurs. In this last phase, the goals (whether met or not) are evaluated with the patient. The relationship is clearly ended and responsibility is handed over by organizing follow up and continuity of care or relinquished. At all times, the nurse ensures that this relationship is professional, respectable and culturally sensitive.
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Johansson, Oleni, and Fridlund (2002) assert that patient satisfaction has become a recognized evaluator of the effect of quality and the effectiveness of the health care systems. According to Merkouris, Ifantopoulos, Lanara, and Lemonidou, (1999), measurement of patient satisfaction can also be perceived as a therapeutic involvement, an important criterion for making and evaluating organizational and administrative decisions, a tool for patient-client marketing or as an ethical obligation which has the potential to humanize care by bringing forth patients' views.
Agreement on a common definition for patient satisfaction is still ongoing (Williams, Coyle, and Healy (1998) due to its complexity and individualized concept which presents vague limitations and variables (Walsh and Walsh, 1999). As suggested by Oberst (1984), although the concepts of patient satisfaction and the patients' perceptions of quality are often interchanged, the two concepts are rather separate. Patient satisfaction with nursing care as described by Risser (1975) is the extent of combination between patient expectations of ideal care and perception of the care actually received. The framework of expectations as mentioned by Oberst (1984), states that patients enter the health care system with a range of characteristics, attitudes and past experiences which, together with the knowledge and information they receive, enable them to define the situation and their needs. Thus, care expectations are formed and it provides a personal standard against which the quality of care received is measured up. Merkouris, Papathanassoglou, & Lemonidou (2004). Marram, Flynn, Abaravich, and Carey (1976) defined patient satisfaction as patients' satisfaction with their nursing care and the degree to which they believed it was individualized and personalized. Additionally, Petersen (1988) provided a more general definition and explained patient satisfaction as "patients' perceptions of how their care was provided, excluding the outcome of their health status or the appropriateness of their therapy" (p 26).
Numerous studies have been carried out to get patients' view on quality care and some examples are shown. Zwier (2008) reports on a NZ nationwide survey employed by the District Health Boards which identified quality service from the patient's perspective as: dignity, respect, listening, providing information, better service, and cultural sensitivity. In another study, using a sample of 199 hospitalized adult patients in South Central United States, Larrabee, and Bolden (2001) claims qualitative good nursing care as; providing for needs, being nice and caring, competent and prompt care. A UK study conducted by Attree (2001) found that the kind of care provided as well as interpersonal care aspects were the main quality issues for patients. "Good" quality care was characterized as being personalized, patient-centered, need-related, humanistic, caring, involving, dedication, and concern based. 'Not so Good' quality care was routine, unrelated to need, impersonal, distant, and lacking involvement. In Sweden on the other hand as pointed out by Jangland, Gunningberg, & Carlsson (2009), patients' and relatives' criticism in regards to their disappointment with the aspects of communication and encounters of health care identified information, respect and empathy as lacking.
These findings support the need for interpersonal proficiency and quality in nursing practice from the patient's perspective. It stresses the need to involve patients in the shared experience and communicate effectively with them. Patient satisfaction with nursing services gains even more importance, since owing to the nature of nursing, patients may judge the overall quality of hospital services on the basis of their perceptions of the nursing care received (Yellen et al., 2002).
Doing this essay has further deepened my understanding on the aspects and importance of therapeutic relationships. It has also given me insights into how and what to do in preparing myself for establishing and maintaining a therapeutic relationship during clinical placement. In saying this, I am looking forward to experiencing therapeutic relationship first hand with clients and reflecting at the end of each day on what I have practiced and those which require improvement.
In conclusion, the patient driven and patient centered nature of nursing practice highlights the importance of therapeutic relationships through effective communication and teamwork for the delivery of high quality, safe, accessible, effective, and efficient patient care. Enabling therapeutic relationships with clients through communication is one way that nurses demonstrate expected public standards of professional competency and conduct. Professional relationships have boundaries that are essential to recognize. Last, but not the least, to improve the quality of nursing care, evaluation is especially crucial because it supports the basis of the usefulness and effectiveness of nursing practice.
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