Empathy in Therapeutic Relationship: Analytical Essay

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Introduction

Therapeutic relationship is the primary component of interactions that allow nurses to apply their professional skills, knowledge, experiences and abilities towards meeting the needs of the patients and their families (McCormack & McCance, 2017). The therapeutic nurse-patient relationship is defined by Nursing and Midwifery Council (NMC, 2015) that it protects the patient’s dignity, privacy and autonomy which helps for the development of respect and trust. Professional values are guiding beliefs and principles of person-centred nursing that demonstrate through all the nurses’ relationships and practices such as effective communication (Baillie & Black, 2015). The Domain 1: Professional Values (NMC, 2015) articulates that all nurses need to understand of each patient as an individual human being by responding their concerns and preferences considerately. This type of therapeutic relationship between nurses and patients, associate with improvements in quality of life, adherence to treatment, patient satisfaction and the decrease of health care cost which promote the quality of nursing care (Kornhaber et al., 2016). Furthermore, the patients’ experience provides different feedback in the course of receiving care or treatment which a positive care experience, indicates the patient feeling valued (Farrelly, 2014). Consequently, with an increasing to focus on person-centred care, it is necessary for nurses to engage with patient therapeutically to promote health related outcomes (Price, 2017).The purpose of this assignment, is to discuss about the factors that influence the maintenance and development of a therapeutic relationship in nursing practice, facilitators such as effective communication, compassion care and barriers as power imbalance and advocacy in the context of palliative and end-of-life care.

The therapeutic relationship is an important key element in palliative and end-of-life care that relate to the person- centred nursing framework (World Health Organization (WHO), 2018). McCormack and McCance (2017) state that person-centred care requires all nurses to recognise individual’s differences, needs and values, respect their dignity and privacy and involve them in all decisions regarding to their needs and care. Banks and Gallagher (2009) explained that the central to the person-centred nursing framework is about knowing self and by extension knowing the values and beliefs of others which become more achievable through the patient’s perspectives and narratives. This is more highlighted by Negri and Recagno (2014) that narratives is an valuable tool to guide nurses how to direct the diversity of clinical practice and to assist personalized care with compassion and empathy in all care setting. It can be then argued that narratives not only connects to history, literature and sociology (Joyce, 2015), but also connects to practice and by extension to person-centred care (Baillie & Black, 2015). Patient’s narrative allows nurses to find concrete applications of ethical principles such as patient’s values, beliefs and preferences that relevant to nurses’ daily experiences which as a consequence promote their caring relationships and decision making (Negri & Recagno, 2014).

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Nurses would allow patients to achieve harmony and healing in body, mind and spirit by engaging in a therapeutic relationship based on effective communication which is central to the provision of compassionate and high quality of nursing care (Bramhall, 2014). The NHS 6C’s defines that communication is one of the six fundamental values of nursing that is the most important key principle to build and maintenance of a successful therapeutic relationship (Department of Health, 2012).

Furthermore, the “Standard of Competence for Registered Nurses” (NMC, 2015) stats that all nurses must use effective communication strategies and negotiation techniques in order to build a therapeutic relationship in palliative and end-of-life care to achieve the best person-centred outcomes.

Communication has been described by Doherty and Thompson (2014) as a mutual connection between two or more people in which messages are received and sent. McCormack and McCance (2017) argued that an effective communication requires the combination use of verbal and non-verbal techniques. Bramhall (2014) suggests that verbal communication deals with the act of listening and speech either spoken or signed whilst non-verbal communication is concerned with body language, facial expression, posture, eye contact, touch, gesture and movements. Both verbal and non-verbal communication skills are equally important, for example the volume and tone of a voice may indicate a pleasure or dismay as can a body movement and touch, emphasis Price (2017). the National Institute of Health and Clinical Excellence ( NICE, 2015) suggests that touch can heighten communication and bring great comfort and trust between nurses and dying patient, particularly in difficult circumstances such as patient’s speech or cognitive status deterioration. The value of personal touch may indicates as friendliness and kindness (Bauckham, 2016) which can also be used to support understanding, empathy and compassion (Doherty & Thompson, 2014). However, Mari Curie (2019) suggests that nurses have to respect patient’s personal space and try to gain concept before touching them as it may not be culturally appropriate or they may not prefer to be touched. According to the “Liverpool Care Pathway” New Guidelines on the end-of-life care published by NICE (NHS, 2015) that recommend nurses to apply a sensitive communication with patients who are in the last days of life, share decisions respectfully and prioritise their care to ensure their needs and wishes being met. This is similarly reinforced by Department of Health (2014) that good communication skills are necessary at palliative care to develop a relationship and establish rapport with patients and their families to respond and elicit their preferences and concerns. Moreover, Doherty and Thompson (2014) have no doubt that high quality care for patients and their families is dependent on expert communication skills which for this reason McCormack and McCance (2017) argued that providing palliative and end-of-life care requires continuous development of interpersonal skills as well as self-awareness to be able to respond in different circumstances that living with or dying from long-term illness may rise for patients. For example this may include being able to attend to the patient’s meaning of dying and death which would associated with fears, concerns and losses (Brownie et al, 2016). The evidence above supports that training in communication skills should be mandatory for all nurses particularly who are involve in palliative and end-of-life care to reinforced and advance their abilities, knowledge and professionalism, highlighted Bramhall (2014).

Compassion is one another important element in nursing practice that was built on the values of the 6Cs (Compassion in Practice NHS, 2016). According to the Department of Health (2012) compassion is described as “intelligent kindness” and care giving through relationships which dependent on respect, dignity and empathy. Furthermore, “Basis of the Essential Skills Cluster: Care, Compassion and Communication” (NMC, 2010) states that the concept of compassionate care are the elements of effective communication skills, respect, dignity, trust and co-operation with patients and their families which are required for the provision of high quality care. It was also added that for building an effective therapeutic relationship, all nurses are expected to provide compassionate patient care in across all healthcare setting (NMC, 2010). Compassion is in direct connection with empathy which is the ability to understand of other person’s situation and feeling (Bramhall, 2014). Nyatanga (2013) believes that compassion and empathy, both essential aspects of end-of-life care which can contribute to show feeling towards patients who are in tight situation and aims to help them adjust to current circumstances. Ernst et al (2013) argued that if empathy is displayed, neural changes appear within the brain effectively, however, it has been showed in some people there is not the biological capacity existing for being empathetic.

According to Brooker and Waugh (2013) to enhance the quality of therapeutic relationship in planning palliative and end-of-life care, requires an open and honest communication such as listening. Furthermore, Doherty and Thomson (2014) state that to provide a compassionate empathetic palliative care requires listening actively to the patients, to what they are saying and understanding its meaning. Similarly, Ordille (2016) highlighted that listening is a vital component on non-verbal therapeutic skills which requires nurses to focus with complete concentration on patient needs, concerns and preferences. Bloomfield and Pegram (2015) pointed up that being an active listener, may encourage patients to speak up about their current physical, psychological and emotional level which is a great opportunity for nurses to elicit key concerns and develop trust and rapport quickly with patients. Patients in end-of-life might prefer to talk about their concerns, fears, wishes, anger, guilt and regret where the nurses must allow them to express themselves (Power, 2016). Lewis and Kitchen (2010) argued that not only listening to patients can seriously affect the therapeutic relationship, as well as “Hearing the patient’s underlying feelings”. All these evidence focused attention that active hearing allows nurses to pick up cues given by patient to identify their main concerns and palliative needs where not only prevent of missing any advance care planning but it can also develop an effective therapeutic relationship between them (Power, 2016).

One of the professional boundaries is about the gap between patient’s vulnerability and nurse’s power. The national Council of State Boarders of Nursing (NCSBN, 2018) states that healthcare professionals have power driving from their expertise and special knowledge, therefore, it is important to be aware of the people’s vulnerability who are seek to use their services. Power is defined by Buka (2014) that having an influence over someone by taking control to achieve an intended effect where as Bauckham (2016) described power as “bi-directional” which something can be used positively (through legitimate and empowerment leadership or authority) or used negatively (such as coercion, force and threat). Smith & Granger (2016) agreed that engaging positively with patients and involving them in health and care decision requires nurses to establish rapport with them through communicating and exchanging information effectively and developing a therapeutic relationship.

For instance, patient is vulnerable with long term condition in palliative and end-of-life care who often is in unfamiliar situation, away from their own secure environment, and isolated from family and friend, may desperately has to discuss about her/his personal issues or uncomfortable sensitive procedures, revealed Stephenson (2014). In contrast, Granger (2013) highlighted that nurses are in familiar working environment where in a position of authority with having enough patient’s personal information, which as a result this creates a very one sided power imbalance in nurse-patient relationship, mentioned Smith & Granger (2016). Joseph-Williams et al. (2014) suggest, the important way to begin to redress of this power imbalance is that nurses to introduce themselves to patients which is the first step of providing truly compassionate, patient-centre care and building a therapeutic relationship. Granger (2013) argued that although nurses wear name badge to identify themselves on the care floor, their aim must be to strengthen a verbal introduction rather than to replace it. Furthermore, the writing on most NHS identify badges are often so small and unreadable for the terminally ill patients who are on hospital bed (Granger, 2013). As a result, the #hellomyis Twitter Campaign was lunched with the aims of reinforcing the valuable nature of introduction and encouraging healthcare professionals to pledge their commitment to routinely introduce themselves to patients, indicated Guest (2016). The above information can prove that the introduction may allow therapeutic relationship to be formed between healthcare professionals and patient which is the first step for providing a patient-centred compassionate care and preventing of any power imbalance experiences, highlighted Granger (2013).

According to Buka (2014), establishing a therapeutic relationship between healthcare professionals and patients also requires to involve analysing the ethical aspects of care which can be related to patient’s advocacy and autonomy. Advocacy is defined by Choi (2015) as “encompassing paternalistic” concepts that may protect patients from harm. Baillie and Black (2015) believe that advocacy is one of the important ethical concepts that may rely on nurse’s decision making. Similarly, Gallagher et al. (2012) mentioned that advocacy can empower patients who are terminally ill and unable to assert their needs for a variety of reasons.

There are many important barriers and arguments for advocacy, as some commenters believe that nurses must act as the patient’s advocate for the many roles they have to fulfil, mentioned Ellis (2017). However, some others emphasise that if nurses demonstrate advocacy, as a result patients would not be able to represent themselves and instead of empowering them, patients would appear “infantilised” by acting in a manner which can regard as “parentalistic” (Ellis, 2017). Similarly, Choi (2015) mentioned that patients may assume that they have been neglected and the decisions relating to their illnesses are “overruled” by nurse’s advocacy who are forced to finish their jobs and make decisions as soon as possible to decrease the service demands. Moreover, Holt and Convey (2012) indicate that nurses who defend and advocate patients may labelled as “whistle-blowers” or “troublemakers” by their colleagues and peers which may cause a negative emotion responds to nurses such as damaged relationship or loose of jobs. Furthermore, Buka (2014) pointed out that for being a patient’s advocate and autonomy as an ethical guideline, sometimes becomes more challenging in terms of the acts for the patient’s best interest and wishes. Buka (2014) suggested that the ethics of care or principles-based approach can be also identified as competing moral framework; where a nurse found an unconscious terminally ill patient in palliative care, having taken an overdose of medication, wishing to be allowed to die. However, Banks and Gallagher (2009) emphasised that the value of involvement with patients in terms of promoting a harmonious relationship, healthcare professionals require to prevent patients harming themselves, although it is morally justified as disobeying patient’s interest and wishes. As a result, according to The Code: Professional Standards of Practice and Behaviour for Nurses and Midwifes (NMC, 2015) states that all nurses must be able to advocate for patients, challenge discriminatory attitudes and poor practice and involve them fully in decision making related to their care. All nurses must respect individual’s rights and choices, recognised ethical challenges and help them to find acceptable solutions (NMC, 2015).

Conclusion

In conclusion of this assignment, it is important to bring to the attention that improving communication skills are fundamental for all healthcare professionals to develop a therapeutic relationship and deliver a high quality palliative and end-of-life care to patients and their families (Brooker & Waugh, 2013). Effective communication is a core skill for all healthcare professionals in particulary nurses who spend more time with patients and their families by aiming to promote both physical and psychological wellbeing whatever the patient’s illnesses and stages (Doherty & Thompson, 2014).

All the information above, can prove that for being as an adult student nurse it is vital, first of all, to comply to all aspects of professional nursing values which is requiring to treat individuals kindly, respect and maintain their dignity, respond to their preferences and concerns, gain consent and engage them in decisions related to their care (NMC, 2015). Secondly, provide a sensitive communication skills in palliative and end-of-life care which gives patients and nurses the opportunity to clarify common care goals by undertaking holistic assessment and providing emotional engagement with compassion and empathy as part of person-centred processes (NHS, 2015). Finally, an adult nurse can play an important role to recognise ethical challenges relating to individual’s decision making and choices such as power imbalance and advocacy, surrounding the end-of-life care preferences (Joseph-Williams et al, 2014). Supporting a therapeutic relationship with patients grow from effective communication with interest, listen to them actively, learn from their narratives, demonstrate empathy and compassion and involve in their advocacy which all may improve by increasing knowledge base of communication skills and following the guidelines that may help nurses to manage in difficult circumstances.

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