The recognition 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 patient, and she asserts this is the way in which all nursing care is delivered. The importance of this relationship has continued to be widely acknowledged and indeed McMahon and Pearson (1998) suggest that it is central to patient health, well-being and recovery. Since a therapeutic relationship is so important, it is essential to consider what features characterise such a relationship. In reviewing various definitions it becomes apparent that the important factors are:
- appropriate boundaries are maintained
- meets the needs of the patient
- promotes patient autonomy
- positive experience for the patient
Appropriate boundaries are maintained
A boundary, as defined in the dictionary (Chamber, 1993) is: ‘a limit, a border, termination or final limit’. Within the therapeutic relationship, boundaries define how far the nurse is willing to go to meet the needs of the patient and his family.
Therefore it is important that the nurse, patient and family are clear regarding their relationship and what is reasonably expected of each party. This will protect all those involved in the relationship. A publication from the UK Central Council (1999: p.5) on this subject states that: ‘boundaries define the limits of behaviour which allow a client and practitioner to engage safely in a therapeutic, caring relationship’. The practitioner has the responsibility to maintain appropriate professional boundaries at all times (UKCC 1999). However, the process of finding the boundaries of care is far from automatic (Totka 1996), as will be discussed later in this chapter.
Meets the needs of the patient
The purpose of the relationship between the nurse and patient is to meet the nursing needs of that patient. It is therefore important that the nursing needs of the patient are discussed at the outset of the relationship in order that mutually identified goals can be set and each person within the relationship can be clear as to their role in the achievement of those goals. This might include the nurse, patient, family members, other professionals and carers. This will require expert communication skills on the part of the nurse in order that a relationship of trust can develop. Whilst the relationship exists to meet the needs of the patient it is likely that the nurse will experience satisfaction in helping the patient to meet those needs. This is entirely appropriate. However, it is important that nurses do not allow their personal needs for positive self-esteem, control and belonging to undermine the professional relationship (Jerome and Ferraro- McDuffie 1992). This requires the nurse to be self- aware and open to seeking support from others when the need arises.
Promotes patient autonomy
Autonomy is the right to self-determination. Self- determination can be defined as an ability to understand one’s own situation, to make plans and choices and to pursue personal goals (McParland et al. 2000). This further supports the need for excellent communication skills on the part of the nurse in order to assist the patient to understand their own situation. Within a relationship that promotes patient autonomy the patient will contribute to the achievement of personal goals and will move towards independence.
Positive experience for the patient
The experience of participating in a therapeutic relationship will be positive for the patient as nursing needs will be met, in a way that is most appropriate to the patient and their family. Truly therapeutic relationships can empower the patient, the family and the nurse.
These features are embodied in the Code of Professional Conduct, which states:
You must at all times, maintain appropriate professional boundaries in the relationships you have with patients and clients. You must ensure that all aspects of the relationship focus exclusively upon the needs of the patient or client. (NMC 2002: Clause 2.3)
CHALLENGES OF DEVELOPING THERAPEUTIC RELATIONSHIPS IN COMMUNITY SETTINGS
Having considered the features of a professional relationship, some of the challenges of achieving such a relationship in the community setting will be discussed. Professional relationships with the patient are influenced by a number of factors.
The delivery of care within the home can provide a feeling of security for the patient and his carer/s as they are on familiar territory. This can make it easier to develop a good relationship, such that they are able to share their concerns and worries. It is also probable that patients and carers will be able to learn new skills more readily as they are likely to feel more relaxed within their ‘normal’ environment.
In this example the benefits of home visiting are apparent. These opportunities could be lost if health visitors change their mode of practice to give more care in clinic settings, as has been reported by Normandale (2001). However, caring in the home environment can leave the nurse feeling vulnerable. A nurse who has recently left a hospital-based job to work in the community can feel very isolated. 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 the confidence of patients.
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 herself, particularly if the situation has developed over time. The support and guidance of colleagues is essential, as is the willingness of the nurse to be open to that support. Totka (1996) notes that peers often recognise unhealthy situations before the nurse involved, but find it difficult to discuss the situation with their colleague.
Care given by the nurse within the workplace will also be different from the more traditional hospital setting. The occupational health nurse works within a three-way relationship between the employer, employee and the nurse (Atwell 1996).
Developing therapeutic relationships may also be affected by a clinic or surgery setting, where the patient 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 a participatory relationship between professional and patient, and although the nurse is likely to be as busy, if not more so, when undertaking home visits the interaction may be less distracted than in a busy clinic.
In other cases the relative anonymity the surgery or clinic provides may be of benefit in facilitating the development of a therapeutic relationship. Initial assessments are often the first point of contact between community nurse and patient and the nurse must develop skills to enable a conducive environment in order to establish the start of a therapeutic relationship (Bryans and McIntosh 1996).
Working in the community, many nurses find that not wearing a uniform removes an unnecessary barrier, which 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 patient’s home, gain the patient’s trust and explain her nursing role, since a symbol, which for many carries some degree of status, has been lost.
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 present 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 consider the appropriateness of the clothing that is worn. Entering a home inappropriately 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 entry into some homes. In order to meet the needs of individual families the nurse must enquire as to family preferences and be willing to adapt behaviours to respect values different from her own, in order to facilitate good 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 wellbeing of patients.
Nature of care
A key element in the nature of the therapeutic relationship with all patient groups is the duration of the relationship. Morse (1991) describes three appropriate relationships. Firstly, she describes the one-off clinical encounter that, for example, a practice nurse may have with a patient 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–patient relationship there should be a different focus, with the development of what Morse terms as a connected relationship. Morse suggests that the key characteristic of a connected relationship is that the nurse views the patient as a person first rather than a patient.
Whilst 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 explored later in the chapter.
In the home environment the patient and his carer could be perceived to have greater control within the relationship. Should the patient decide not to concur with recommended treatment, this may not be immediately evident as the nurse is
spending only a short period of time within the home environment. Parkin (2001) notes that professionals are unable to control the home environment. If, unbeknown to the nurse, the patient has not adhered to the recommended treatment, the therapeutic relationship is threatened, since a relationship based on trust no longer exists. Within a therapeutic relationship the patient should be able to tell the nurse of his intentions. This might allow treatment to be modified such that the patient feels able to follow the regimen, but even if this is not the case at least the nurse is aware of the true situation and can modify her nursing care accordingly.
Expectations of the nurse and of the community nursing service may also impact on the relationship between the nurse and adult patient. Over the past 25 years there has been a rapid rise in consumerism (May and Purkis 1997), with a corresponding rise in expectations of the Health Service. In community nursing this can be seen by the use of time bands in allocating home visits and the proliferation of charters and mission statements displayed on clinic and surgery walls.
Many patients have clear ideas on the service they expect from community nurses with a consequential detrimental effect on the therapeutic relationship when these expectations are either not met or are unrealistic.
However, despite trends in healthy ageing and participation in health care (Lorig et al. 1996), many older adults were bought 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 (Dukes Hess 1996). There is some evidence that not all adult patients wish to be an active partner in the therapeutic relationship (Waterworth and Luker 1990) and there may be a significant number of patients who feel more comfortable with the paternalistic model of care (Roberts 2001). The nurse ‘doing for’ the patient rather than enabling them to self-care contradicts the current trend towards empowerment (Copperman and Morrison 1995), which is a central theme in the National Service Framework for Older People (DOH 2001a). The community nurse may find a challenge in helping some patients in developing the confidence and ability to self care, and again the therapeutic relationship will be focused on trust and the facilitation of realistic independence.
The main purpose of the nursing or health visiting intervention may also have a significant impact on the therapeutic relationship. The patient within the relationship may have significant physical and emotional needs, such as happens in palliative care. The relationship in such cases may be based on intensive input by the nurse (Goodman et al.1998). In contrast, the practice nurse or occupational health nurse may see a person 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 mental health needs (Brooker and Repper 1998) has resulted in a rapidly developing role for community nurses in supporting this group. With approximately one in six people at any one time suffering from mental illness in the United Kingdom (DOH 1999a) the role is constantly evolving. The National Service Framework for Mental Health (DOH 1999a) is firmly underpinned by a patient focus. However, empowering patients with mental health needs is often challenging, not least because of concerns from society and professionals as to whether some patients have the capability of making decisions over their care and treatment (Feenan 1997).
Table 5.1 Responses to caring role:
Response to 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
- The 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
The therapeutic relationship with this group is essential in empowering patients to actively participate in decisions about their care. Peplau’s (1952) developmental model is often used as the framework for developing a therapeutic relationship (Collister 1986) with the assessment (or orientation) phase focusing on the development of mutual trust and regard between nurse and patient, as well as data gathering. Addressing anxiety is the overarching aim of the therapeutic relationship (Aggleton and Chalmers 2000), and the community nurse may take on a number of roles to facilitate this including that of counsellor, resource, teacher, leader or surrogate. All nurses working in the community develop knowledge of local resources and other agencies and facilitating the patient to access these may be the key component within this relationship.
It should also be acknowledged that the therapeutic relationship in the community setting is not only formed between nurse and patient, but will often encompass an informal carer. In the United Kingdom there are approximately 6 million informal carers who are the primary carers for a range of patients ranging from young people with learning disabilities, to the frail elderly (Bond et al. 1999). The Carers Recognition and Services Act (DOH 1995) and the Carers and Disabled Childrens Act (DOH 2000) enshrined the principle that carers should be assessed and acknowledged as an individual rather than simply an adjunct to the patient. For the community nurse this reinforces that an individual therapeutic relationship must also be developed with the informal carer, but this poses a number of challenges.
First, a significant number of informal carers are unknown to the community nurse, with Henwood (1998) estimating that only half of all carers receive any support from community nurses. Second, the more an informal carer does for the patient, the less intervention there will be from the community nurse (Pickard et al. 2000). Consequently, the informal carers most likely to benefit from a therapeutic relationship are less likely to be visited by the community nurse. Third, there are often misguided assumptions by many professionals that informal carers should undertake the caring role and that the role is taken on very willingly (Procter et al. 2001).
Finally, studies have shown that many informal carers have significant health needs of their own which often are unrecognised (Henwood 1998) and undertake very complex and technical tasks (Pickard et al. 2000). All too frequently community nurses first meet an informal carer when there is a crisis and the nursing input is a short-term measure to help the patient and carer over this period. However, the therapeutic relationship with informal carers should ideally be long-term, with the nurse aiming to provide information 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, given in Table 5.1. It is important for the community nurse to recognise the informal carer’s response to their situation.
Another frequently met scenario is that of the husband caring for his wife. He has every detail organised and is business-like in his approach to the community nurse. Again, this may hide a number of physical and emotional needs, and the community nurse must develop a therapeutic relationship in order to enable him to express these. The needs of informal carers are only now being recognised and the community nurse must develop a relationship and provide intervention appropriate to both the patient and informal carer as individuals.
WHEN THE BALANCE IS NOT MAINTAINED: FAILURES IN THERAPEUTIC RELATIONSHIPS
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 the patient and his carer to encourage the professional to develop a relationship of friendship since this has the potential to ‘normalise’ the patient, as it is ‘normal’ to have friends who visit. This is perhaps more likely to occur if nurses do not wear uniforms. Families 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.
Hylton Rushton et al. (1996) describes over- involvement as a lack of separation between the nurse’s own feelings and that of the patient. Typically the nurse may spend off-duty time with the patient (Barnsteiner and Gillis-Donovan 1990), appear territorial over the care (Morse 1991), or treat certain patients with favouritism (Wilson 2001a). Consequences for the patient are an over- dependence on that particular nurse and a lack of support in reaching therapeutic goals. For the community nurse the implications are often significant stress and deterioration in job satisfaction (Hylton Rushton et al. 1996) and an inevitable detrimental effect on team working.
Of course, the balance in the therapeutic relationship may be tipped the other way. The detached, cold nurse who seems indifferent to her patient’s emotional needs may be familiar to the reader. The results of under-involvement are a lack of understanding by the nurse of the patient’s perspective, conflict, and standardised rather than contextually dependant care (Hylton Rushton et al. 1996). It has been suggested that the overwhelming feelings that a nurse may have for a patient’s situation can lead to dissociation by the nurse within the therapeutic relationship (Crowe 2000). Within the community setting the feelings of being the last resort in care has also been linked to under- involvement within the therapeutic relationship (Wilson 2001a). The consequences of under- involvement for the patient is that the nurse has a lack of insight into the patient’s perspective and is unable to facilitate the patient in meeting therapeutic goals.
Maintaining a therapeutic relationship is particularly challenging in the community nursing context 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 the appropriate relationship with patients.
THE INFLUENCE OF THE CURRENT AND FUTURE CONTEXT ON THERAPEUTIC RELATIONSHIPS
Long-term interventions within the community setting will continue to increase with an ageing population and rise in chronic illness (Kalache 1996; Wellard 1998; DOH 1999b), and this chapter has already explored the impact of duration of care on the therapeutic relationship. One response by policy makers to the rise in long- term conditions is the facilitation of individuals to self-manage their own conditions. The expert patient programme (DOH 2001b) recognises that individuals often have significant expertise about their chronic illness which has developed over years through experience and the aim of the programme is to further develop this expertise in order to promote symptom control, quality of life and effective use of health resources (Wilson 2001b). Within all spheres of community nursing, nurses are now dealing with far more knowledgeable patients not least because of the readily available access to information via the Internet (Timmons 2001). Therapeutic relationships in the current climate must be based on an acknowledgement that the patient may have considerable expertise in their own condition, exceeding that of the nurse. There has been some debate as to how comfortable community nurses are with this (Wilson 2002), but there can be little doubt that a therapeutic relationship that fails to take into account the knowledge that both nurse and patient bring will fail.
The expert patient programme is one example of a policy that is based on partnership and responsibility (Wilson 2001b). Another example is the move towards concordance (Royal Pharmaceutical Society of Great Britain 1997), where the patient’s views are considered of equal importance in treatment plans.
Community nurses are required to demonstrate evidence-based practice (Woodward 2001) and the challenge of today’s therapeutic relationship is to balance this with informed choice by the patient (Wilson 2002). There is a balance to be maintained between the rights of the child (dependant on their age and understanding) and rights of the parents in decision-making, against the risks of significant harm that might result from the treatment. The parents in the above scenario should be advised to ensure the advice regarding the complementary treatment comes from a registered practitioner. Community nurses need to assess their own knowledge base regarding complementary therapy and seek specialist advice if necessary. Within a therapeutic relationship the nurse will be aiming to facilitate an atmosphere where the parents feel able to be honest about the treatments the child is currently receiving, and should be able to direct patients and their families to sources of appropriate information.
A final feature of the current context of care that may have an effect on the therapeutic relationship is the fragmentation of care. In particular the division of health and social care (DOH 1990) means that patients within the community often have to deal with a vast array of professionals, which can inhibit the development of a therapeutic relationship (Hyde and Cotter 2001).
In this chapter features of a therapeutic relationship have been identified, leading to an exploration of some of the challenges community nurses face in establishing therapeutic relationships. In future community health care provision, challenges will be shaped by an increasingly multi-cultural, ageing and informed population. The growing provision of health care in the community only serves to reinforce the need to establish appropriate relationships with patients, their families and other carers. Current government policy emphasises partnership in care at all levels; the challenge for the community nurse is to develop this opportunity in everyday working practice.