While there is a lack of clear consensus regarding definition, Pullen and Mathias (2010) describe a therapeutic relationship as one that offers support based on mutual trust, respect, sensitivity to self and others, while nurturing faith and hope and
CHAPTER
5
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Identify the features and potential benefits of a therapeutic relationship.•
Discuss some of the challenges for community nurses in establishing a therapeutic relationship.•
Critically examine the challenges involved and potential consequences of failing to establish or maintain a therapeutic relationship.•
Analyse the impact of changes in policy on the development of therapeutic relationships.LEARNING OUTCOMES
embracing the physical, emotional and spiritual needs of the person. The recogni- tion of the importance of the therapeutic relationship is not a new phenomenon.
Peplau’s (1952) theory of nursing is based upon the importance of the relationship between the nurse and the individual. She asserts this is pivotal to the way in which all nursing care is delivered. The importance of this relationship has continued to be widely acknowledged. It is recognised as central to advancing the best interest and outcomes for the person and the families (Porr et al., 2012; Canning et al., 2007).
However, discussions regarding the quality of relationships inevitably introduce a degree of subjectivity. Furthermore, the inter-subjective qualities involved in thera- peutic relationships such as empathy, respect, trust, positive regard, support, com- munications skills, person- and family-centred care, acceptance, empowerment and so on are not easily measureable (Greenhalgh and Heath, 2010). It is suggested, however, that positive therapeutic relationships can improve communication (Porr et al., 2015; Pinto et al., 2012; Edwards et al., 2006), achieve concordance (Martin et al., 2005), service user satisfaction (NCSBN, 2014), help in professional fulfill- ment, save time, empower and also reduce risk of litigation (Stewart, 2005). Since a therapeutic relationship is so important, it is essential to consider which key fea- tures characterise the relationship. In reviewing various definitions it becomes apparent that important factors include
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Maintaining appropriate boundaries•
Meeting the needs of the person•
Promoting autonomy•
Providing a positive experience for the person and/or family receiving careMaintaining appropriate boundaries
The Nursing and Midwifery Council (NMC) (2015) highlights the need for clear professional boundaries with people receiving care, including family and carers.
This is important whether care is being received at the present time or received in the past, in order to ensure the promotion of professionalism and trust. Boundaries are generally mutually understood and often unspoken physical and emotional lim- its of a relationship (Farber et al., 1997). However, it is important that the nurse, individual and family are clear regarding their relationship and what is reasonably expected of each party. This will protect all those involved in the relationship.
There is a delicate balance between caring for people and families and becoming over-involved. The process of finding a positive boundary of care, especially nursing in the community, can be challenging to discern as is discussed later in this chapter.
Meeting the needs of the person
The purpose of the relationship between the community nurse and person is to meet the needs of that person. Policy and guidelines support person- and family-centred care (DH, 2015a; Healthcare Improvement Scotland, 2014; NICE, 2012; Davies and Wackerberg, 2012; DHSSPS NI, 2011a). Person- and family-centred healthcare strives to empower individuals and families by providing information and education
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The Features of a Therapeutic Relationship regarding the person’s health condition and encouraging active participation in the decision-making process (Foot et al., 2014). It is therefore important that the needs of the person are discussed at the outset of the relationship in order that mutually identified goals can be set and everyone within the relationship can be clear about their role in achieving these goals. This might include the nurse, the person receiv- ing care, carers, family members or friends, other health and social care profession- als or relevant agencies. Discussion will require expert communication skills on the part of the nurse in order that a relationship of trust can develop. Although the relationship exists to meet the needs of the person, it is likely that the nurse will experience satisfaction in helping to ensure the needs are met. This is entirely appro- priate. However, it is important that nurses do not allow their personal needs for positive self-esteem, control and belonging to undermine the professional relation- ship (Milton, 2008). This requires enhanced self-awareness, engagement in reflective inquiry and critical-thinking skills (Waugh et al., 2014). It may also require a will- ingness to seek support from others (Foster and Hawkins, 2005).
Promoting autonomy
Autonomy is derived from the Greek autos-nomos meaning self-determination or self-rule. While the original meaning of autonomy relates to ‘self-rule’, it can also refer to liberty of thought, freedom of choice, freedom of action, self-determination and freedom from coercion (Dworkin, 1988). Therefore, it is about self-governance, the ability to make choices and decisions about things that will affect oneself (Ellis, 2015). This further supports the need for excellent communication skills on the part of the nurse in order to assist the person and to understand the person’s perspective and situation. There is general acknowledgement regarding the therapeutic value of empathically understanding the person (Clarke, 2010). Empathic understanding is deemed to facilitate autonomy and so empathy is explored later in this chapter.
Within a relationship that promotes autonomy the person receiving care can con- tribute to the achievement of personal goals and move towards independence.
Providing a positive experience for the person
The experience of participating in a therapeutic relationship will be positive for all, given needs will be met in a way that is most appropriate for the person and their family. Truly therapeutic relationships can be remembered and valued for a long time. They empower the person, the family and the nurse, they facilitate trust, respect, autonomy, and encourage self-awareness for the nurse and person alike. A positive experience for the person is supported by the National Institute for Health and Care Excellence (NICE, 2011) in the publication of ‘The quality standard for the service user experience in adult mental health services’ and NICE (2012) in ‘The quality standard for the patient experience in adult NHS services’. Person-centred care is supported by organisations like the Picker Institute (www.pickereurope.org);
it monitors patients’ experience of care and highlights deficiencies. Community nurses providing care need to be mindful with regard to the key determinants of a
good experience and be proactive in seeking and acting on individual feedback (Spencer and Puntoni, 2015).
These features are evident in guidance provided by the NMC (2015) which high- lights the importance of relationships prioritising people and promoting profes- sionalism and trust.