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.
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Challenges of Developing Therapeutic Relationships in Community Settings
Example 5.1
Consider Mrs Patel whose 2-year-old son has recently been in hospital as a result of an asthma attack. Mrs Patel speaks some English but found the experience of her son being in hospital very stressful. When the health visitor made a visit to the home Mrs Patel was unsure how to use the prescribed medication, particularly the spacer device to administer the inhalers. Teaching within Mrs Patel’s home is likely to be more successful as she will be more relaxed and it will be possible for the health visitor to reinforce any aspects of the care at a later date if this is necessary.
However, caring in the home environment can leave the nurse feeling vulnerable.
The Queen’s Nursing Institute (QNI, 2015) highlights some of the challenges facing community nurses, in particular if they first move from hospital-based jobs to work in the community. Despite the use of mobile phones and pagers it is more difficult to seek the advice of a colleague, and help may not be instantly at hand. A nurse who feels vulnerable and isolated will find it more difficult to inspire confidence.
Working in the relative isolation of the home can provide challenges to nurses in maintaining standards of care. If the relationship is not ‘therapeutic’ it can be difficult for the nurse to identify this himself or herself, particularly if the situation has devel- oped over time. The support and guidance of colleagues is essential, as is the willing- ness of the nurse to be open to that support. It is important that peers recognise unhealthy situations that colleagues are involved in (Halter et al., 2007). However, it can be difficult to express concerns with colleagues and so a shared culture of open discussion where the person is the priority as directed by Francis (2013) is essential.
Furthermore, the QNI provides a useful online resource, ‘Transition to Commu- nity Nursing Practice’, which offers practical support and guidance for community nurses to address personal challenges and identify sources of support which can reduce feeling of isolation. The resource can be found at www.qni.org.
Care given by the nurse within the person’s workplace will also be different from the more traditional hospital setting. The occupational health nurse addresses the health and well-being of the working population in their place of work (Thornbury, 2013). They are often the first point of contact for individuals with health-related problems. Moreover, the occupational health nurse holds a unique public health role towards the improvement of health, social well-being and towards improving the quality of working lives in the workplace (RCN, 2015a).
Example 5.2
Although work-related mental ill health is being increasingly recognised as a legiti- mate occupational health issue (TUC, 2015) many employees will still consider it detrimental for their career prospects to report mental health needs to their occupational health nurse. The challenge for the nurse within this context is to promote trust with the employees in order to facilitate a therapeutic relationship.
Developing therapeutic relationships can also be affected by a clinic or surgery setting, where the person may gain the impression of busy workloads inhibiting the time they spend with the nurse. Paterson (2001) identified lack of time as a major
inhibitor in developing participatory relationships. More recently Ball et al. (2013), in a survey of district and community nurses identified 13% of respondents cited
‘lack of patient contact time’ as a significant frustration affecting quality of care.
Similarly, the King’s Fund (2016) highlights research indicating activity amongst district nurses has increased significantly both in terms of people seen and complex- ity of care provided. While the community nurse is likely to be as busy if not more so, when undertaking home visits, there may be fewer distractions than in a busy clinic. However, it can be argued that even the briefest episode of caregiving presents the community nurse with an opportunity to capitalise on time (Chan et al., 2013) and with purposeful focused communication enhance the therapeutic relationship.
Example 5.3
Consider the scenario of the new mother trying to explain her depression to the health visitor and how much harder this might be in a busy baby clinic rather than in the privacy of her own home. In other cases the relative anonymity that the surgery or clinic provides may be of benefit in facilitating the development of a therapeutic relationship. Clearly, as a community nurse it is important to recognise the impact that the working environment has upon relationships with people, carers, family and colleagues. It is a key element of care influencing communication together with the quality and safety of healthcare provided (Godsell et al., 2013). Initial assessments are often the first point of contact between community nurse and the person receiving care; the nurse must develop skills to enable a conducive environment, in order to establish the start of a therapeutic relationship (Hagerty and Patusky, 2003).
Working in the community many nurses find not wearing a uniform removes an unnecessary barrier and makes the development of a therapeutic relationship an easier task. It does however require skills on the part of the nurse to gain access to the a person’s home, gain the trust and explain the nursing role since a symbol, which for many carries some degree of status, has been lost (Shaw and Timmons, 2010).
For those community nurses who do wear a uniform other challenges arise.
Wearing of a uniform can enable almost instant entry to some homes, but may pres- ent a barrier to acceptance by some people. This may be especially apparent with children who have perhaps learnt to associate uniforms with pain and discomfort.
In these situations it will take time to address prior conceptions before a therapeutic relationship can be established.
If nurses do not wear a recognised uniform it is particularly important to con- sider the appropriateness of the clothing that is worn. Entering a home inappropri- ately dressed may cause offence and prevent establishment of a relationship. Perhaps this might require the nurse to cover her arms and legs if visiting Asian families, or maybe to remove shoes prior to entering some homes. In order to meet the needs of
Reflection point
Do you wear a uniform when working in the community? What are the advantages and disadvantages of wearing a uniform? If you had a choice, would you wear a uniform?
ACTIVITY 5.2
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Challenges of Developing Therapeutic Relationships in Community Settings individual families the nurse must enquire about family preferences and be willing to adapt behaviours to respect values different from her own in order to facilitate positive relationships.
A final point about dress code: whether wearing uniform or not it is essential to carry identification at all times in order to protect the well-being of people living in the community.
A key element in the nature of the therapeutic relationship is the duration of the relationship. Morse (1991) describes three appropriate relationships. First, she describes the one-off clinical encounter that, for example, a practice nurse may have with a per- son seeking healthcare in a travel clinic. There are also encounters that last longer but focus on a specific need, such as maintenance of hormone replacement therapy. Both of these relationships are mutual and appropriate to certain situations, but Morse argues that within a much longer-term nurse-person relationship, there should be a different focus, with the development of what she terms a connected relationship.
Morse suggests that the key characteristic of a connected relationship is that the nurse views a person as a person first rather than a patient, client or service user, and so on.
Example 5.4
A district nurse has been visiting an elderly lady for several years. The visits now may often include a chat over a cup of tea about how the grandchildren are progressing or other issues in the person’s life that the nurse has developed a wealth of knowl- edge on over the years. Although it may be a venous ulcer that initiated the referral to the district nurse, the connected relationship that has developed with time allows the nurse to deal with other issues that may be far more important to the person, such as feelings of loneliness. During the chat, a skilled nurse will be able to assess for signs of depression or other psychosocial needs that are common for people expe- riencing long-term conditions. Although for many families and professionals this can only be positive, there is a potential to step over the professional boundary and it is essential to maintain the appropriate balance within the therapeutic relationship. The consequences of not maintaining the balance will be returned to later in the chapter.
In the home environment individuals and carers could be perceived to have greater control within the relationship. Should a person decide not to concur with
Nature of care Discussion point
Have you cared for someone over a long period of time? How did your relation- ship with that person develop? Did you find yourself becoming ‘closer’ to the individual? How did this make you feel? Discuss this with your mentor/preceptor.
ACTIVITY 5.3
Reflection point
Have you ever cared for someone who did not follow the recommended treatment programme? Why do you think that they did not adhere to the treatment regimen? How did it make you feel?
ACTIVITY 5.4
recommended treatment, this may not be immediately evident as the nurse is generally spending only a short period of time within the home environment. If unbe- known to the nurse, lack of adherence to treatments takes place, the therapeutic rela- tionship may be threatened. However, the focus for the community nurse needs to be towards concordance and facilitation of person/family centred care. At times challeng- ing, this is about ensuring a partnership approach with people and families. This approach can facilitate decisions that reflect the person’s needs and preferences and ensure individuals have the education and support required to make such decisions and participate in their care (IOM, 2001). It is less about fitting people into predeter- mined services and more about empowering people to work towards outcomes that matter to themselves (King’s Fund, 2015a; Healthcare Improvement Scotland, 2014;
WG, 2014; The Health Foundation, 2014; DHSSPS NI, 2010). Therefore, within a thera- peutic relationship a person receiving care is comfortable enough to tell the nurse of his or her intentions. This might allow treatment to be modified to the extent that the person feels able to follow the regimen, but even if this is not the case at least the com- munity nurse is aware of the true situation and can modify the nursing care accordingly.
Example 5.5
Consider the following scenario and your responses.
Rosie is 14 years old and has been diagnosed as having type 1 diabetes for 6 months. She has been asked to record her blood glucose levels once daily, varying the time of day she takes the readings, but she finds this requirement tiresome and does not do it. Prior to the community children’s nurse’s visit she wonders what to do – should she make up some values to keep the nurse happy or should she tell the truth? Hopefully if Rosie and the community nurse have a good relationship Rosie can be truthful and they can work together on what can reasonably be expected. A study by Schaeuble et al. (2010) found teenagers felt it took time to develop trust in healthcare providers, with respect from the provider being a para- mount issue. Some of the adolescents in the study stated that they withheld information out of fear of a provider’s reactions; however, they still wanted to know the consequences of refusing or delaying treatment. Concordance describes a part- nership approach to treatments and care; it recognises the importance of individuals being able to make their own decisions about lifestyle and whether or not to adhere to advice from health professionals (DH, 2015b). Therefore, concordance returns us to the theme of person-centred care and decision making. The subject is visited again in the next and last sections of this chapter.
Expectations
Expectations of the nurse and community nursing service may also impact on the therapeutic relationship. Over the past 25 years, there has been a rapid rise in consum- erism resulting in the NHS becoming more business-like with a rise in expectation and subject to similar consumer drivers identified in other parts of society (Sturgeon, 2014). Recent health policy emphasises person-centred choice and involvement in care (Foot et al., 2014). Many people have clear ideas on the service they expect from
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community nurses, with a consequential detrimental effect on the therapeutic relationship when these expectations either are not met or are unrealistic. However, despite trends in healthy ageing and participation in healthcare (Healthcare Com- mission, 2006), many older adults were brought up in a society where medicine was seen to have all the answers and the public was expected to be the passive recipient of care (Coulter, 1999). There is some evidence that some people do not wish to be an active partner in the therapeutic relationship (Davis et al., 2007), and some may prefer a more paternalistic model of care (Roberts, 2001).
The community nurse may find a challenge in helping some people to develop the confidence and ability to self-care, and so the therapeutic relationship will be focused on trust and the facilitation of realistic independence. Self-care is key policy strategy for the NHS across all countries in the United Kingdom (Drakeford, 2013; DHSSPS NI, 2012; DH, 2009; Scottish Government, 2008). Skills for Health (2015) set out some key principles to support self-care; it involves creating environments in which people who need care and support are perceived as active and equal partners, rather than passive recipients. It includes self-management, which means people drawing on their strengths and abilities to manage or minimise limitations imposed by a condition, as well as what they can do to feel happy and fulfilled (Skills for Health, 2015). Furthermore, it is suggested by Drakeford (2013) that self-care links closely to person-centred care, person experience, co-production and improving quality.
Therefore, the nurse ‘doing for’ the individual rather than enabling them to self-care contradicts current perspectives on best practice (Wilson et al., 2007).
Needs
The main purpose of the nursing or health-visiting intervention may also have a significant impact on the therapeutic relationship. The patient within the relation- ship may have significant physical and emotional needs such as in palliative care.
The relationship developed within these cases may be based on intensive input by the nurse (Dunne et al., 2005). In contrast, the practice nurse or occupational health nurse may see a patient for health screening with less obvious health needs as the focus of the intervention.
The substantial shift of care from hospitals to the community for those with men- tal health needs (Malone et al., 2007) has resulted in a rapidly developing role for community nurses in supporting this patient group. With approximately one in six people at any one time experiencing mental illness in the United Kingdom and one in four of people experiencing problems some time in their life (DH, 2011) the role for community nurses supporting people living in the community is constantly evolving. Recent mental health frameworks and guidance (DH, 2012; Scottish Gov- ernment, 2012; DHSSPH NI, 2011b; WG, 2010) are firmly underpinned with focus on the patient. However, empowering people with mental health needs and imple- menting empowerment initiatives is often challenging. The World Health Organi- zation (WHO, 2010) suggests it requires the person, service and societal levels to be aligned for this to happen and for stigma, discrimination and marginalisation to be prevented. Therefore, the therapeutic relationship with this group is essential in
empowering people to actively participate in decisions about their care. Peplau’s (1952) developmental model is often used as the framework for developing a thera- peutic relationship (Merritt and Procter, 2010), with the assessment (or orientation) phase focusing on the development of mutual trust and regard, as well as data gath- ering. Developing a therapeutic interpersonal relationship is the foundation stone of quality nursing care (McKenna and Cutcliffe, 2008), and the community nurse may take on a number of roles to facilitate this, including that of counsellor, resource, teacher, coach, leader or surrogate. All nurses working in the community develop knowledge of local resources and other agencies and facilitating individu- als and families to access these may be the key component within this relationship.
It should also be acknowledged that the therapeutic relationship in the commu- nity setting is not only formed between nurse and the person, but will often encom- pass a family carer. Carers UK (2014) suggest that there are 1.4 million people providing care round the clock in the United Kingdom and approximately six and half million people providing some level of care supporting friends and family with various conditions and disabilities. The law relating to carers differs across the four countries of the United Kingdom. The Care Act (2014) in England, the Social Ser- vices and Well-being (Wales) Act 2014, Carers (Scotland) Bill (2014) and Carers and Direct Payments Act (Northern Ireland) 2002 have provided carers the legal right to needs assessment and support. The law across the United Kingdom requires local authorities assess carers’ need for support wherever they appear to have such needs.
For the community nurse this reinforces that an individual therapeutic relationship must also be developed with the family carer, but this poses a number of challenges.
Caring is associated with increased risk of mental health problems (Stansfield, 2014).
It is important for community nurses to recognise the potential need for interventions and be familiar with local services available to reduce the stress of caring. Unfortu- nately some family carers will be unknown to the community nurse (Simon and Ken- drick, 2001). The more a family carer does for a person, the less intervention there will be from the community nurse (Gerrish, 2008). Consequently, the family carers most likely to benefit from a therapeutic relationship are less likely to be visited by the com- munity nurse. This highlights the need for the community nurse to identify carers and liaise with other health professionals, social services and other agencies accordingly.
Furthermore, there are often misguided assumptions by many professionals that fam- ily carers should undertake the caring role and that the role is taken on very willingly (Procter et al., 2001). All too frequently, community nurses first meet a family carer when there is a crisis and the physical input and support are limited to when the crisis is over or the person has been admitted to hospital. The therapeutic relationship with family carers should ideally be long term, with the nurse aiming to provide informa- tion and acting as a resource (Seddon and Robinson, 2001) and responding to the role the carer is happy to undertake. Twigg and Atkin (1994) describe three different responses by individuals to the informal caring role (Table 5.1).
It is important for the community nurse to recognise the carer’s response to their situation and not take the carer for granted as a readily available resource (Man- thorpe et al., 2003).