Communication is a vital part of the nurses role. Theorists such as Peplau (1952), Rogers (1970) and King (1971) all emphasise therapeutic communication as a primary part of nursing and a major focus of nursing practice. Long (1992) further suggests that communication contains many components including presence, listening, perception, caring, disclosure, acceptance, empathy, authenticity and respect. Stuart and Sundeen (1991, p.127) warn that while communication can facilitate the development of a therapeutic relationship it can also create barriers between clients and colleagues.
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Within Healthcare, communication may be described as a transitional process that is dynamic and constantly changing (Hargie, Saunders and Dickenson, 1994, p.329). It primarily involves communication between the nurse and the patient. If the interaction is to be meaningful, information should be exchanged; this involves the nurse adopting a planned, holistic approach which eventually forms the basis of a therapeutic relationship.
Fielding and Llewelyn (1987) contend that poor communication is the primary cause of complaints by patients. This is supported by Young (1995) who reports that one third of complaints to the Health Service Commissioner were related to communication with nursing staff. Studies by Boore (1979) and Devine and Cook (1983) demonstrate that good communication actually assisted the rate of patient recovery thus reducing hospital admission times. This suggests that good communication skills are cost effective.
In this assignment, I have reflected on situations that have taken place during my clinical work experience. These situations have helped to develop and utilise my interpersonal skills, helping to maintain therapeutic relationships with patients. In this instance, I have used Gibbs’ (1988) reflective cycle as the framework for my reflection.
Gibbs’ (1988) reflective cycle consists of six stages in nursing practice and learning from the experiences.
Description of the situation that arose.
Conclusion of what else would I could have done.
Action plan is there so I can prepare if the situation rises again.
Analysis of the feeling
Evaluation of the experience
Analysis to make sense of the experience
My Reflective Cycle
Baird and Winter (2005) illustrate the importance of reflective practice. They state that reflecting will help to generate knowledge and professional practice, increase one’s ability to adapt to new situations, develop self esteem and greater job satisfaction. However, Siviter (2004) explains that reflection is about gaining self confidence, identifying ways to improve, learning from one’s own mistakes and behaviour, looking at other people’s perspectives, being self aware and making future improvements by learning from the past. I have come to realise that it is important for me to improve and build therapeutic relationships with my patients by helping to establish a rapport through trust and mutual understanding, creating the special link between patient and nurse as described by Harkreader and Hogan (2004). Peplau (1952), cited in Harkreader and Hogan (2004), notes that good contact in therapeutic relationships builds trust as well as raising the patient’s self esteem, often leading to the patient’s personal growth. Ruesh (1961), cited in Arnold and Boggs (2007), states that the purpose of therapeutic communication is to improve the patient’s ability to function. Therefore, in order to establish a therapeutic nurse/patient interaction, a nurse must possess certain qualities e.g. caring, sincerity, empathy and trustworthiness (Kathol, 2003) (P.33). These qualities can be expressed by promoting effective communication and relationships by the implementation of interpersonal skills. Johnson (2008) defines interpersonal skills as the ability to communicate effectively. Chitty and Black (2007, p 218) mention that communication is the exchange of information, thoughts and ideas via simultaneous verbal and non verbal communication. They explain that while verbal communication relies on the spoken word, non-verbal communication is just as important, consisting of gestures, postures, facial expressions, plus the tone and level of volume of one’s voice. Thus, my reflection in this assignment is based on the development of therapeutic relationships between the nurse and patient using interpersonal skills.
My reflection is about a particular patient, to whom, in order to maintain patient information confidentiality (NMC, 2004), I will refer to as Mr R. It concerns an event which took place when I was working on a surgical ward. Whilst there were male and female wards, female and male surgical patients were encouraged mingle. On this particular day, I noticed that one of the male patients was sitting alone on his bed. This was Mr R., a 64 year old gentleman who had been diagnosed with inoperable cancer of the pancreas, with a life expectancy of 18-24 months. He was unable to control his pain, and whilst some relief could be provided by chemotherapy, Mr R. had a good understanding of his condition and knew that there was no cure available. He was unable to walk by himself and always needed assistance even to stand up or sit down. Because of his mobility problems I offered to get him his cup of tea and I then sat with him as he was lonely.
I would now like to discuss the feelings and thoughts I experienced at the time. Before I gave Mr R. his cup of tea, I approached him in a friendly manner and introduced myself; I tried to establish a good rapport with him because I wanted him to feel comfortable with me even though I was not a family member or relative. When I first asked Mr R. if I could get him a cup of tea, he looked at me and replied “I have asked the girl for a cup of tea, I don’t know where she is.” I answered “Well, I will see where she is and if I can’t find her, I will gladly get one for you Mr R”. In doing this, I demonstrated emphatic listening. According to Wold (2004, p 13), emphatic listening is about the willingness to understand the other person, not just judging by appearance. Then I touched MrR.’s shoulders, kept talking and raised my tone a little because I was unsure of his reaction. At the same time, I used body language to communicate the action of drinking. I paused and repeated my actions, but this time I used some simple words which I though Mr R. would understand. Mr R. looked at me and nodded his head. As I was giving him his cup of tea, I maintained eye contact as I didn’t want him to feel shy or embarrassed.
Fortunately, using body language helped me to communicate with this gentleman. At the time I was worried that he would be unable to understand me since English is not my first language but I was able to communicate effectively with him by verbal and non-verbal means, using appropriate gestures and facial expressions. Body language and facial expressions are referred to as a non-verbal communication (Funnell et al. 2005 p.443). I kept thinking that I needed to improve my English in order for him to better understand and interpret my actions. I thought of the language barrier that could break verbal communication. Castledine (2002, p.923) mentions that the language barrier arises when individuals come from different social backgrounds or use slang or colloquial phrases in conversation. Luckily, when dealing with Mr R. the particular gestures and facial expressions I used helped him to understand that I was offering him assistance. The eye contact I maintained helped show my willingness to help him; it gave him reassurance and encouraged him to place his confidence in me. This is supported by Caris-Verhallen et al (1999) who mention that direct eye contact expresses a sense of interest in the other person and provides another form of communication. In my dealings with Mr R., I tried to communicate in the best and appropriate way possible in order to make him feel comfortable; as a result he placed his trust in me and was more co-operative.
Evaluation
In evaluating my actions, I feel that I behaved correctly since my actions gave Mr R. both the assistance he needed and provided him with some company. I was able to successfully develop the nurse-patient relationship. Although McCabe (2004, p-44) would describe this as task centred communication – one of the key components missing in communication by nurses – I feel that the situation involved both good patient and task centred communication. I feel that I treated Mr R. with empathy because he was unable to perform certain tasks himself due to his mobility problems and was now refusing chemotherapy. It was my duty to make sure he was comfortable and felt supported and reassured. My involvement in the nurse-patient relationship was not restricted to task centred communication but included a patient centred approach using basic techniques to provide warmth and empathy toward the patient.
I found that I was able to improve my non-verbal communication skills in my dealings with Mr R. When he first mentioned having chemotherapy, he volunteered very little information, thus demonstrating the role of non-verbal communication. Caris-Verhallen et al (1999, p.809) state that the role of non-verbal communication becomes important when communicating with elderly people with incurable cancer (Hollman et al 2005, p.31)
There are a number of effective ways to maximise communication with people, for example, by trying to gain the person’s attention before speaking – this makes one more visible and helps to prevent the person from feeling intimidated or under any kind of pressure; the use of sensitive touch can also make them feel more comfortable. I feel that the interaction with Mr R. had been beneficial to me in that it helped me to learn how to adapt my communication skills both verbally and non-verbally. I used body language to its full effect since the language barrier made verbal communication with Mr.R. difficult. I used simple sentences that Mr R. could easily understand in order to encourage his participation. Wold (2004, p.76) mention that gestures are a specific type of non-verbal communication intended to express ideas; they are useful for people who have limited verbal communication skills.
I also used facial expressions to help encourage him to have chemotherapy treatment which might not cure his problem but would give him some relief and make him feel healthier. Facial expressions are the most expressive means of non-verbal communication but are also limited to certain cultural and age barriers (Wold 2004 p.76). My facial expressions were intended to encourage Mr R. to reconsider his decision with regard to chemotherapy treatment. Whilst I could not go into all the details about his treatment, I was able to advise him to complete his treatment in order to alleviate his symptoms.
Analysis
In order to analyse the situation, I aim to evaluate the important communication skills that enabled me to provide the best level of nursing care for Mr R. My dealings with Mr R. involved interpersonal communication i.e. communication between two people (Funnell et al 2005, p-438).I realised that non-verbal communication did help me considerably in providing Mr R. with appropriate nursing care even though he could only understand a few of the words I was speaking. I did notice that one of the problems that occurred with this style of communication was the language barrier but despite this I continued by using appropriate communication techniques to aid the conversation. Although it was quite difficult at first, the use of non verbal communication skills helped encourage him to speak and also allowed him to understand me.
The situation showed me that Mr R. was able to respond when I asked him the question without me having to wait for an answer he was unable to give. Funnell et al (2005, p 438) point out that communication occurs when a person responds to the message received and assigns a meaning to it. Mr R. had indicated his agreement by nodding his head. Delaune and Ladner (2002, P-191) explain that this channel is one of the key components of communication techniques and processes, being used as a medium to send out messages. In addition Mr R. also gave me feedback by showing that he was able to understand the messages being conveyed by my body language, facial expression and eye contact. The channels of communication I used can therefore be classed as both visual and auditory. Delaune and Ladner (2002 p.191) state that feedback occurs when the sender receives information after the receiver reacts to the message, however Chitty and Black (2007, p.218) define feedback as a response to a message. In this particular situation, I was the sender who conveyed the message to Mr R. and Mr R. was the receiver who agreed to talk about his chemotherapy treatment and allowed me to assist. Consequently I feel that my dealings with Mr R. involved the 5 key components of communication outlined by Delaune and Ladner (2002, p.191) i.e. senders, message, channel, receiver and feedback.
Reflecting on this event allowed me to explore how communication skills play a key role in the nurse and patient relationship in the delivery of patient-focussed care. Whilst I was trying to assist Mr R. when he was attempting to walk, I realised that he needed time to adapt to the changes in his activities of daily living. I was also considering ways of successful and effective communication to ensure a good nursing outcome. I concluded that it was vital to establish a rapport with Mr R. to encourage him to participate in the exchange both verbally and non-verbally. This might then give him the confidence to communicate effectively with the other staff nurses; this might later prevent him from being neglected due to his age or his inability to understand the information given to him about his treatment and the benefits of that treatment.
I have set out an action plan of clinical practice for future reference. If there were patients who needed help with feeding or with other procedures, I would ensure that I was well prepared to deal patients who weren’t able to communicate properly. This is because, as a nurse, it is my role to ensure that patients are provided with the best possible care. To achieve this, I need to be able to communicate effectively with patients in different situations and with patients who have differing needs. I need to communicate effectively as it is important to know what patients need most during there stay on the ward under my supervision. Whilst I have a lot of experience in this field of practice, communication remains a fundamental part of the nursing process which needs to be developed in nurse-patient relationships. Wood (2006, p.13) states that communication is the key to unlock the foundation of relationships. Good communication is essential if one is to get to know a patient’s individual health status (Walsh, 2005, p.30). Active learning can also help to identify the existence of barriers to communication when interacting with patients. Active learning means listening without making judgements; I always try to listen to patients’ opinions or complaints since this gives me the opportunity to see the patients’ perspective (Arnold, 2007, p.201). On the other hand, it is crucial to avoid the barriers that occur in communication with the patients and be able to detect language barriers. This can be done by questioning patients about their health and by asking them if they need help in their daily activities. I set about overcoming such barriers by asking open-ended questions and interrupting when necessary to seek additional facts (Funnell et al, 2005, p.453).
Walsh (2005, p.31) also points out that stereotyping and making assumptions about patients, by making judgements on first impressions and a lack of awareness of communication skills are the main barriers to good communication. I must not judge patients by making assumptions on my first impression but should go out of my way to make the patient feel valued as an individual. I should respect each patient’s fundamental values, beliefs, culture, and individual means of communication (Heath, 300, p.27). I should be able to know how to establish a rapport with each patient. Cellini (1998, p.49) suggests a number of ways in which this can be achieved, including making oneself visible to the patient, anticipating patients’ needs, being reliable, listening effectively; all these factors will give me guidelines to improve my communication skills. Another important factor to include in my action plan is the need to take into account any disabilities patients may have such as poor hearing, visual impairment or mental disability. This could help give the patient some control and allow them to make the best use of body language.
Once I know that a patient has some form of disability, I will be able to prepare a course of action in advance, deciding on the most appropriate and effective means of communication. Heath (2000, p.28) mentions that communicating with patients who have an impairment requires a particular and certain type of skill and consideration. Nazarko (2004, p.9) suggests that one should not repeat oneself if the patient is unable to understand but rather try to rephrase what one is saying in terms they can understand e.g. try speaking a little more slowly when communicating with disabled people or the hard of hearing. Hearing problems are the most common disability amongst adults due to the ageing process (Schofield. 2002, p.21).
In summary, my action plan will show how to establish a good rapport with the patient, by recognising what affects the patients’ ability to communicate well and how to avoid barriers to effective communication in the future.
Conclusion
In conclusion, I have outlined the reasons behind my choosing Gibbs’ (1988) reflective cycle as the framework of my reflection and have discussed the importance of reflection in nursing practice. I feel I have discussed each stage of the cycle, outlining my ability to develop therapeutic relationship by using interpersonal skills in my dealings with one particular patient. I feel that most parts of the reflective cycle (Gibbs 1988) can be applied to the situation on which I have reflected. Without the model of structured reflection I do not feel I would have had the confidence to consider the situation in any depth (Graham cited in Johns 1997 a, p.91-92) and I fear reflection would have been remained at a descriptive level. I have been able to apply the situation to theory; as Boud Keogh & Walker (1985, p.19) explain that reflection in the context of learning is a generic term for those intellectual and effective activities whereby individuals engage to explore their experiences in order to lead to a better understanding and appreciation. Boyd & Fales (1983, p.100) agree with this and state that reflective learning is the process of internally examining and exploring an issue of concern, trigged by an experience that creates and clarifies meaning in terms of self and which results in a changed conceptual perspective. However, I personally believe that the reflective process is merely based on each individual’s own personality and beliefs as well as their attitude and approach to the life.
Appendix
Mr R., a 64 year old gentleman, was an inpatient on a surgical ward. Earlier that day his consultant had directly informed him that he had inoperable cancer of the pancreas with a life expectancy of 18-24 months. Some relief might be offered by chemotherapy, but there was no cure. Mr R. was understandably shocked, but had suspected the diagnosis. At that time he remained in the care of the specialist nurse. Later in the day, as I was passing through the ward, I notice Mr. R. alone on his bed.
Prescriptive
A prescriptive intervention seeks to direct the behaviour of the client, usually behaviour that is outside the client-practitioner relationship. My first intervention was to open the conversation and demonstrate warmth. I provided information myself and gave Mr R. the choice of staying on his own or engaging with me. By shaking Mr R.’s hands I was attempting to provide reassurance and support as well as communicating warmth in order to reduce his anxiety and promote an effective nurse-patient relationship.
Practitioner: Hello Mr. R, I am one of the nurses here this morning with Dr. M. Is there anything I can get you or would you rather be on your own? (Shook hands).
Mr. R: NO, I remember you from this morning, come and sit down. I’ve asked the girl for a cup of tea, I don’t know where she’s got to.
Practitioner: Well give me a minute and I’ll bring you one in. Do you take sugar?
Mr. R: I suppose I shouldn’t, then why worry. Two please.
Practitioner: (Returning with a cup of tea) Here we are, don’t blame me if it’s horrible, I got it from the trolley. (I smiled at Mr.R. and tried to establish eye contact, then sat down in the chair next to him).
Mr. R: Thanks, that’s just what I need.
2. Informative
An informative intervention seeks to impart knowledge, information and meaning to the patient. My intention was to reinforce the nurse-patient relationship by smiling and attempting to establish eye contact as well as using facial expressions to put the patient at ease and establish a good rapport. By making Mr. R a cup of tea it created a pleasant response in a time of crisis.
Practitioner: Jane (specialist nurse) was here this morning, what did you think about what she had to say?
Mr. R: Oh yes she was very nice, mind you I’m an old hand at this, I looked after my wife when she had cancer.
Mr. R: She was riddled with cancer, but we kept her at home and looked after her. She could make a cracking cup of tea (Mr.R. smiles)
Practitioner: (smiles and nods) When did she pass away?
3. Confronting
A confronting intervention seeks to raise the client’s consciousness about limiting behaviour or attitudes of which they are relatively unaware. By meeting the patients’ needs at that time I felt the urge to continue to show a display of warmth and develop the relationship further.
Mr. R: It will be two years next month that she died.
Practitioner: You must miss her.
Mr. R: There’s not a day goes by that I don’t talk to her. Goodness knows what she would make of all this, it’s brought it all back.
4. Cathartic
A cathartic intervention seeks to enable the client to discharge/react to a painful emotion – primarily grief, fear and/or anger. Mr. R spoke emotively and angrily by using such words as ‘riddled’ and ‘cancer’. He spoke loudly and angrily with congruent non-verbal cues.
Practitioner: Has what you’ve been discussing with Jane reminded you of your wife’s death?
Mr. R: Yes, (patient covers his face with his hands).
Practitioner: What is it about what you’ve heard that is worrying you, do you think you can tell me?
5. Catalytic
A catalytic intervention seeks to elicit self-discovery, self direct living, learning and problem solving in the client. Mr. R had a broad scope in which to discuss any concerns he may have had, but his response only concerned his wife, not him as his wife was the one who suffered from cancer.
Mr. R: (Pause)………..I’m an old hand at this and I don’t want any of that chemo.
Practitioner: What is it about the chemotherapy you don’t like?
Mr. R: My wife had it and we went through hell.
Practitioner: You went through hell
Mr. R: The doctors made her have the chemo and she still died in agony.
6. Supportive
A supportive intervention seeks to affirm worth and value of the client’s person, qualities, attitudes and actions. It is done to encourage the client to say more and to explore the issue further. Support is provided by non-verbal means like giving warmth, supportive posture and maintaining eye contact. I wanted to convince Mr. R that I was interested in what he had to say and help him believe that he was worth listening to – that his opinions really mattered.
Practitioner: Do you think the same thing will happen to you?
Mr. R: Yes, that’s the one thing I’m worried about.
Practitioner:.em, if I’m honest with you chemotherapy treatment is not a subject I know a lot about. (Pause), would you like to see the specialist nurse again? She can go over things with you and explain your options.
Mr. R Well if she doesn’t mind, I’m just not sure the chemo will be worth it.
Learning outcomes
From this experience, I have learned the importance of:-
Practice in accordance with the NMC (2004) code of professional conduct, performance, when caring for adult patients including confidentially, informed consent, accountability, patient advocacy and a safe environment.
Demonstrating fair and anti-discriminatory behaviour, acknowledging differences in the beliefs, spiritual and cultural practices of individuals.
Understanding the rationale for undertaking and documenting, a comprehensive, systematic and accurate nursing assessment of physical, psychological, social and spiritual needs.
Interpreting assessment data to prioritise interventions in evidence based plan of care.
Discussing factors that will influence the effective working relationships between health and social care teams.
Demonstrating the ability to critically reflect upon practice.
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