The nursing profession takes place with different individuals and it is vital for the nurses accept each one and be truly present as they improve their quality of life (Parse, 1998). Nurses have the key, if used correctly, to connect, interact and relate to other individuals and building therapeutic relationships. Looking deeper than the surface and critically thinking are skills that acknowledge therapeutic client centered care [CCC]. According to Registered Nursing Association of Ontario [RNAO] (2006), CCC is defined as an “Approach to care delivery where clients are considered the brokers of care, and receive what they ask for.” (p. 14). CCC is a theme nurses are encouraged to follow that will improve and guide them with their performance of competent care. Therapeutic professional relationships are the way to the clients and by effective communication thus relationships could be formed.
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Throughout student’s experiences they are challenged with several types of obstacles that teach and increase their knowledge and critical thinking skills. During my clinical journey, I was determined to dialogue with different clients and have a grounded base on initiating dialogues and then allowing the patient to lead the conversation. The different dialogues I partook in improved by either less use of communication blocks, seeking more depth and clarity, or being able to listen effectively. This paper will outline a brief explanation on my key learning from my experience and literature related to CCC. In addition, the importance of the incorporation of the core processes of CCC and the importance of the different communication skills that include listening, asking open ended questions to seek more depth, and overcoming the use of communication blocks will be presented. Also, new patterns and trends will be highlighted that could be used to further develop my skills. Overall, this paper will provide a synthesis of my reflection of the dialogues.
In the past years of experience in becoming a nurse, I had the basic knowledge of communication techniques. I was provided several opportunities were options for building therapeutic relations were possible. Fear of articulating in a manner where potential incorrect information may be presented was the main reason for lack of communication with clients. Research has shown that one of the main reasons for nurses to enquire about communication techniques or use other tools and methods that can reduce the uncertainty (Doane & Varcoe, 2005). In relation, it always has been a concern to be in a situation where I would not know what to say and how to respond. The dialogues I participated in opened my eyes to view the importance of being in relation with the clients. Listening and honouring the clients requires one to move beyond one’s own fear and angst to focus on the clients experiences by being in relation with them (Doane & Varcoe, 2005). Prior to having the dialogues the fear of uncertainty was greatly present but as relationships with my clients were started to develop, the fear started to diminish. This shows that by being in relation with the clients and following their lead would reduce ones fear and build therapeutic relationships.
Along with being in relation to the clients, it is also important to understand the nursing processes that include the four elements: assessment, planning, implementing, and evaluating. The nursing process is the outcome from the four CCC core processes. The core process include identifying needs or concerns, caring and services, evaluating outcomes and finally making decisions (RNAO, 2002). All these four core process work together focusing on ways to enhance the client’s quality of life. The core process assisted me with the structure of my dialogues. The main core processes that were applied to my dialogues where identifying the clients concerns and caring and services.
When each dialogue was initiated and the clients were able to relate to me, the immediately expressed their concerns. Some questions that were asked to recognize their trepidation were “How has that affected you?” (Appendix A), “What do you see yourself doing?” (Appendix B), also “Tell me more about that.” (Appendix C).Once needs and concerns were recognized, then caring and services component was applied. Caring and services refers to building therapeutic relationships by involving the client and allowing them to lead remembering to be non-judgmental by respecting and listening openly (RNAO, 2002). As each client uncovered information on their private lives, there were relationships formed and they all had different perspectives that were respected equally. Listening was the most important factor that unfolded the client’s deeper thoughts and feelings.
In order for one to accomplish all the steps of the core processes, it is vital to further one’s listening skill. Sharing one’s private and personal world with another is recognized as an act of courage and therefore the listener is perceived as an honoured person who can promote healing (Stickley & Freshwater, 2006). Nurses are granted the honour when they apply their listening skills even for several minutes. Giving clients the undivided attention is acknowledged to be the best approach to assess the client’s needs (Messner, 1993). Therefore throughout the dialogue I focused on listening to clients and assess them thoroughly. Although listening is the key to thorough assessment, it also demonstrates to the clients that they are being taken seriously (Nichols, 1995). With each dialogue, I was able to listen and connect deeply with their inner self. Listening is not just paying attention to the words but being truly present. As Parse (1998) explained true presence is a free flowing devotion that does not occur from one attempting to be there for the other, since “trying to” is a distraction that requires attention away from the other. In relation to Parse, it was essential to listen to the clients and connect with them to a different level where they were able to trust and share their inner experiences.
Furthermore effective listening has an impact on modern nursing skills and nurses ought to detect cues for therapeutic enquiry (Stickley & Freshwater, 2006). Once the cues have been detected, it is essential for the nurses to ask questions to profoundly understand the client`s concerns or worries. The questions asked can be in many different forms but open ended questions are preferred to seek more depth and clarity. There were several closed ended questions in my dialogues such as “You must be used to healthcare providers?” (Appendix A), “Did you know you were on the news yesterday?” (Appendix B), “That must have been scary?” (Appendix B). These questions lead to simple yes or no answers limiting my access to the client’s deeper thoughts and concerns. Participating in different dialogues facilitated in forming more accurate question structures. I limited the use of closed ended questions and more questions that guided the dialogues to more deep understanding of the client.
In all my dialogues I was able to ask open ended question to see the clear picture and attempt to relate to their feelings. Most of the open ended questions consisted of “How has that affected you?” (Appendix A), “Well how did you feel?” (Appendix B), “How does this affect your life?” (Appendix B), “Has anything changed that could affect your health?” (Appendix C). These questions led the client to disclose their personal information and elaborate. The client’s explanations directed my critical thinking skills to their concerns and how the client and I would work together to reach the outcomes they chose to achieve. All of three clients faced no challenges with sharing their concerns and it was helpful to seek clarity about the client’s perspectives.
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On the other hand, there are factors that affect the flow of conversation. Conversation blocks were present during my dialogue experience. It was difficult to refrain from comments that are identified as communication blocks but as I was able to practice with different situations, I began to recognize and improve my skills. My first dialogue had the most blocks for example “I understand….you will not have to worry about that here.” (Appendix A). These statements were validating statements by showing empathy and reassurance. Empathy is the main cause for health care providers to refocus their attention on themselves away from the patient (Bietel, 1998). By reassuring the client I prevented the client from expanding on his thoughts and feelings.
In addition, another issue that was illustrated was the change of direction away from the client’s topic. On the second dialogue, the client’s main concern was his pain and required pain medication but by directing the topic towards the clients cause for hospitalization. This affected the dialogue and I was unable to allow the client lead but yet follow. Also, there were several blocks on the third dialogue that limited a thorough assessment of the client. The blocks were all from my comments and questions such as “I understand that it can be nerve wrecking… anyone would be nervous” (Appendix C).I also validated the client’s emotions and experience along with reassuring him. Similar to the second dialogue, there was also change in direction away from the client’s topic. The client stated he was frustrated and instead I directed the topic towards changes in his life.
Although the communication blocks were evident, there is room for improvement and success with having dialogues with clients. Changing the direction of the topic was evident and although I attempted to allow the clients to lead, I unintentionally interrupted the free flowing dialogue. Listening to the clients and seeking more information on their topic instead of directing the flow is an area that could be improved. Also, there has been tremendous improvement with the limited use of communication block. One can attempt to put their shoes in the shoes of the person going through the experience but can never experience the same meaning (Bietel, 1998). Refraining from such validating communication blocks and continuing to be non-judgemental are also areas that require continuous improvement.
In conclusion, analysing the dialogues has demonstrated the significance of the skill of questioning to look beyond the surface. The clients are the best source of knowledge because they are the ones who lived the experience (Doane & Varcoe, 2005). Therefore by listening to them would open several doors to trusting and respecting relationships. Listening is more than understanding what is said but also requires opening up to hear what is expressed (Doane & Varcoe, 2005). Using the core processes guided the dialogues that encourage the use of various communication skills. Seeking depth and clarity of the dialogues and limiting communication blocks affects the dialogues. There is room for improvement and by partaking in many dialogues will benefit my skills. According to Doane & Varcoe (2005), “Inner movement occurs when life can be received as it is without asking it to be something else” (p.201). Therefore, along with all the different actions that can be taken to build relationships, accepting the unique individuals as they are is the start to CCC.
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