Table 5.1 Responses to the caring role (adapted from Twigg and Atkin: 1994) Response to the caring role Features of response
Engulfment mode Cannot articulate needs as a carer No other occupation
Generally female spouse
Total sense of responsibility and duty
Balancing/boundary setting mode Have a clear picture of themselves as carers (e.g. how they save nation money) Generally male
Often adopt language of an occupation – treat role as a job May emotionally detach themselves from recipient
Symbiotic mode Positive gain by caring
Does not want role taken away
Discussion point
How do you define friendships? What are the potential dangers in becoming friends with people and families that you are caring for in the community? What dangers exist in discussing personal issues and treating as your friend someone who is receiving care from your community nursing service? In keeping secrets with the person? In believing you are the only member of staff that can provide the correct level of care for that person? In meeting outside the work environ- ment as friends? In speaking in a derogatory way regarding other members of staff or the work setting? In showing favouritism? What can you do if someone that you are providing care for wants to develop a friendship with you? Discuss your ideas with a professional colleague. (Questions are adapted from NCSBN, 2014.) ACTIVITY 5.5
In reality it is hard to learn about boundaries unless one is involved in setting them, and extending beyond the therapeutic boundary may only be apparent once it has been breached. It may be that it is in the interests of an individual and his or her carer to encourage the professional to develop a relationship of friendship since this has the potential to ‘normalise’ the situation, as it is ‘normal’ to have friends who visit. This is perhaps more likely to occur if nurses do not wear uniforms. Fam- ilies may be keen that friendships do develop since a friend is likely to respond to requests for help, perhaps more swiftly than a detached professional. Therefore, nurses must consider their actions carefully in case actions are misinterpreted, as perhaps was the case when Ann attended John’s party.
Example 5.7
Consider the case of Ann, who is John’s community children’s nurse. Ann has cared for John, aged 5, for the last 2 years and supported Gill, his single mother, through some difficult times while John has received treatment for acute lymphoblastic leu- kaemia. During Ann’s recent visit to the home, Gill and John invite her to John’s sixth birthday party the following weekend. Ann considers this briefly and agrees to come. At the end of the party, Gill asks Ann if she would be willing to babysit for John, as ‘she’s the only person she feels she can trust to care for John’. What should Ann do now? It would appear the edges of the professional boundary have become significantly blurred such that Gill feels it is appropriate to ask Ann to babysit.
Hylton Rushton et al. (1996) describe over-involvement as a lack of separation between the nurse’s own feelings and those of the person receiving care. Typically the nurse may spend off-duty time with the client, appear territorial over the care or treat certain clients with favouritism (Parkes and Jukes, 2008). The consequences for the person may result in an over-dependence on that particular nurse and a lack of support in reaching therapeutic goals (Moyle, 2003). For the community nurse, the implications can involve significant stress, eventual compassion fatigue and burnout especially where clients are experiencing trauma, pain and suffering (Gandi et al., 2011). The NMC (2015) directs nurses to stay objective and have clear professional boundaries always with people (including those cared for in the past), their families and carers. Of course, the balance in the therapeutic relationship may be tipped the other way. The detached, cold nurse who seems indifferent to a person’s emotional needs may be familiar to the reader. The results of under-involvement are a lack of understanding by the nurse of the person’s perspective, conflict and standardised rather than contextually dependent care (Milton, 2008). The overwhelming feelings that a nurse may have for a person’s situation can lead to dissociation by the nurse within the therapeutic relationship (Crowe, 2000). The consequence of under- involvement is that the nurse can have a lack of insight into the other person’s per- spective and be unable to facilitate a person in meeting therapeutic goals.
Mackintosh (2006) suggests that it is the inter-personal aspects of the caring rela- tionship that nurses value most highly. Ensuring therapeutic relationships is viewed as having an important place (Brunero et al., 2009). To establish the goal empathy
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When the Balance Is Not Maintained: Failures in Therapeutic Relationships is often regarded as one of the most desirable qualities for a nurse. It is described as the process of understanding a person ‘as if’ you were that person (Drydon and Mytton, 1999). Definitions also stress empathy as the ability to perceive the mean- ing and feelings of another and to communicate those feelings to the other person (La Monica, 1981; Wiseman, 1996: Stein-Parbury, 2005). It is often viewed as having two parts; cognitive and affective (Verducci, 2000; Hojat et al., 2002). The cognitive domain involves understanding of the other’s inner experience and feelings with an ability to view the world from the other’s perspective. The affective domain involves entering or joining in the emotional experience of the other. It may be difficult for nurses acting in the affective domain as they are at risk of losing objectivity and becoming overwhelmed by the emotions of others (Brunero et al., 2009).
Empathy is also seen as a crucial part of emotional intelligence and highlights the importance of having emotionally skilled community nurses. Gandi et al. (2011) argues that nurses’ empathy for and connection with people demonstrate core pro- fessional values which are often seen as essential but as a consequence attract cer- tain factors capable of inducing stress. It is suggested that when caring for those experiencing trauma, pain and suffering, nurses can be affected resulting in com- passion fatigue. Therefore, behaviour can reveal a central theme of the ‘negative effects’ of overly identifying with those receiving care, and as mentioned, this can result in unintentional vicarious experience of the other person’s pain and anxiety (Abendroth and Flannery, 2006). Community nurses need to strive towards being skilled and competent nurses who are also emotionally skilled, able to understand the benefits and dangers of empathy and also able to recognise indifference among others within teams. Empathy and empathic listening skills have the potential to enable community nurses to deliver dignified and compassionate care while build- ing therapeutic relationships. However, knowledge and understanding regarding the benefits of cognitive empathy and empathic concern, and an appreciation of the danger of excessive affective empathy and emotional contagion are required.
Viktor Frankl, post holocaust, powerfully describes the choice that humans have in taking time to respond and choose an attitude in a particular set of circum- stances (Frankl, 2006). It is important for community nurses to take time. Taking time during the therapeutic relationship can be facilitated with clinical supervision as part of continuing professional development. Clinical supervision can offer a valuable opportunity to explore self and promote emotional skill and empathy in community nursing practice in order to enhance the therapeutic relationship.
Reflection point
Think of a likeable person with whose care you have recently been involved.
Reflect on the following: What were the characteristics of the individual and their care that made it a positive experience for you? If other colleagues were involved, do you think they felt the same way? Was the care you gave the person affected by these feelings? Are there any consequences for yourself, the person and other people on your caseload?
ACTIVITY 5.6
Maintaining a therapeutic relationship is particularly challenging within the com- munity because of the commonly intense nature of care, duration of contact and the non-clinical environment. Reflection with colleagues and clinical supervision become invaluable tools to facilitate the nurse in developing appropriate relationships with people.