Uphold an Efficient Therapeutic Relationship With a Patient Essay

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Uphold an Efficient Therapeutic Relationship With a Patient Essay

n this assignment the author is going to explore what is a therapeutic relationship, by defining it and describing what elements and skills are necessary to uphold an efficient therapeutic relationship with a patient. The assignment shall explore how Multi disciplinary teams contribute to achieving a therapeutic relationship. It further will explore what governs a therapeutic relationship according to the code of practice set by the nursing governing body, the Nursing and Midwifery Council (NMC), putting into consideration what is expected from nurses as health professionals. Being ‘Self aware’ is a crucial attribute in order to maintain a therapeutic relationship, so the writer shall give a brief definition of what self awareness is ,and explain the significance of being self aware within a therapeutic relations and relate it to an incident that happened in practice that made them more self aware.

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The therapeutic relationship is fundamental to the care of a patient and was described in the 1950’s by famous psychotherapist Carl Rodgers .Rogers defines it as a helping relationship, ‘A relationship in which one of the participants intends that there should come about, in one or both parties, more appreciation of, more expression of, more functional use of the latent inner resources of the individual’ (Rodgers 1961). Other authors have come up with various definitions but they are all closely linked to that of Rodgers, Jane Stein-Parbury (2000) suggests it is unilateral because the nurse maintains most control and it is usually short or average duration, with the patient facing a non threatening situation. However (Stuart 2001) defined a therapeutic relationship “As a mutual learning experience and a corrective, emotional experience for the patient” (cited in Cutliffe and Mckenna 2005.P.304) Uphold an Efficient Therapeutic Relationship With a Patient Essay.


For a therapeutic relationship to work effectively, certain elements need to be upheld and followed, such as showing warmth towards your patient, being respectful by showing the patient that they are individual and a unique being. Dignity of the patient puts the patient at ease and they feel more valued and may in turn open up more to the nurse which aids their treatment. Demonstrating professionalism assures the patient that they are in capable hands and will effectively build trust about your capabilities. Carl Rodgers highlighted that the three core components of a therapeutic relationship are empathy, which is defined as: ‘ a continuing process whereby the counsellor lay aside her own way of experiencing and perceiving reality, preferring to sense and respond to the experience and perceptions of her client.’ (Mearns and Thorne, 2005, p.41) Where there is lack of empathy expression, patients may be left with a sense of isolation, which have an effect on their treatment plan. The second crucial element that was highlighted by Rodgers as being essential is having unconditional positive regard towards patients or client which is a label given to the fundamental attitude of the person-centred counsellor towards her client. The counsellor who holds this attitude provides care for the individual irrespective of what beliefs and values the individual (patient) may hold. (Mearns and Thorne,2005 p 64).

In other words unconditional positive regards is being non judgmental towards a patient regardless of what the care provider believes or values themselves. Unconditional positive regard should ideally commence on the onset the relationship between patient and nurse.Uphold an Efficient Therapeutic Relationship With a Patient Essay.  Other elements that constitute a therapeutic relationship include, maintaining confidentiality, and treating people as individuals at all time, good record keeping (NMC 2008).

For Therapeutic relationships to be successfully applied and implemented, nurses have to acquire certain skills to achieve this. To instate a strong therapeutic relationship a practitioner should consider their interpersonal communication skills with the patient. There are two forms of interpersonal communication skills, which are non-verbal and verbal communication.

Non-verbal communication skills are a very effective way to convey a message, empathy and active listening. Egan formulated a communication tool which aids to effective non-verbal communication skill, the skills are summarized by the acronym SOLER, meaning sitting squarely with an open posture, leaning forward to show your interest maintaining eye contact at all times showing that you are relaxed, not fidgeting nervously. Argyle (1994) suggested the main forms of non-verbal communication as, facial expression, gaze, body movement, gesture, partial behaviour, clothing and behaviour. (Cited by Rana, Upton, 2009, ).

Verbal skills are too, an essential part of interpersonal communication, these include techniques such as paraphrasing; this is where by a nurse rephrases what has been stated by the patient into their own words, i.e. by saying ‘in other words…. (Jane Stein -Parbury). Other methods of active listening are to parrot what the patient has said; this shows you have clearly heard what they have said. Practitioners should also be able to know when to use open and closed questions in the appropriate manner and time, for this skill can easily perceived as uncaring and unprofessional when not adopted carefully. In conclusion to what has been talked about, nurse and patient should reflect on what they said. Heron (2001) stated that a there are six tools of a client’s needs. Heron’s model has two basic categories, “authoritative” and “facilitative”. These two categories further breakdown into a total six categories to describe how people intervene when helping. Uphold an Efficient Therapeutic Relationship With a Patient Essay.

Authoritative Interventions are Prescriptive, which is giving advice, Informative where you provide information to guide the other person, Confronting- you challenge the other person’s behaviour in an unaggressive attitude. Facilitative Interventions include: Cathartic-you help the other person to express and overcome thoughts or emotions that they have not previously confronted. Catalytic- You help the other person reflect, and they become more self-directed in making decisions. Supportive- You build up the confidence of the other person by focusing on their competences, qualities and achievements.

A multi disciplinary team (MDT’s) is important in the care of a patient. A multi disciplinary team is a group of professionals from different disciplines, who have a role in contributing to an assessment of an individual’s needs. This should include two health professionals, i.e. nurse, clinician or therapist, as well as a representative from social care services, i.e. a social worker (NHS 2010). Chan (2004) argued that “the main mechanism is to ensure truly holistic care for patients and a seamless service for patients throughout their disease trajectory and across the boundaries of primary, secondary and tertiary care”. Multi disciplinary teams ensure a continuum in patients care and can be 24 hours. Different professions bring different type of care to the patient. MDT’s can however come to conflict, if they demonstrate allegiance to their profession.

Junor, Hole & Gillis (1994) states that multidisciplinary team working is known to “maximise clinical effectiveness”, Multi disciplinary teams have enabled health professionals to adopt the clinical care pathways where different teams within the organization outline anticipated care, place an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes. In a multi disciplinary team within a healthcare setting, one may expect to work with doctors, social workers, psychologists, occupational therapists, health care assistants (HCA’s) and other related professions. Uphold an Efficient Therapeutic Relationship With a Patient Essay.

A therapeutic relationship within nursing follows the code of professional code of practice which was set by Nursing and Midwifery Council [NMC], which acts as the governing body for nurses and midwives in the United Kingdom which was formed in 2002 by parliament. Its main objective is to safeguard the health and wellbeing of the public,(NMC 2008).The NMC outlines that Nurses should always uphold the patients respect at all times, it states that ‘nurses should always treat people as individuals and respect their dignity’. Nurses should respect patient confidentiality, and uphold it at all times, breach of confidentiality can lead to serious consequences for health professionals (NMC 2008) including disciplinary actions such as suspension or being struck off the NMC register. Consent is very important in patient care; it’s the opening avenue for any care that follows. NMC states the every adult must be presumed to have the mental capacity to consent or refuse treatment. Patient care is always going through different multi disciplinary teams therefore accurately record keeping is crucial, it should be factual ,not falsified, and clearly legible (NMC 2010), these are some of the factors that insure accurate information is passed on to different care givers to maximise effective care for the patient.

Nurses endure different feelings and emotions when interacting or treating patients, which calls for them to be more self aware, Duval and Wuckland defines self awareness as “a state in which one is aware of oneself as an object, much as one might be aware of a tree or another person” (cited by Rana and Upton 2009. p142).For a nurse to be self aware they need to treat each patient as individuals and present themselves appropriately. Uphold an Efficient Therapeutic Relationship With a Patient Essay. Patients have a plethora of beliefs and values, which always come into play in any given care setting. Beliefs can be associated with patient’s religion and culture, such as that of Muslims, to only eat halaal meat, a nurse has to be aware of this dietary requirement and honour it. Equally beliefs also play a vital role in the treatment of a patient, so a provision to fulfil this should be met at all time, i.e. providing a chapel in the hospital.

Values of a patient are crucial when in care. Downie, R. S. 1990 stated that values are preferences based on beliefs about objects, persons, or situations and are accompanied by feelings of approval or disapproval. Patients of a different culture will most certainly have different values based on what they were brought up on. On any given care setting, the way in which nurses present themselves to patients is of utmost importance, their body posture is a critical aid to supplement being self aware, and nurses can use SOLER (Egan 2001) to ensure they achieve this.

In practice, the author recalls an incident when a 92 year old lady was referred to their practice for assessment on every Wednesday of the week. On arrival the lady would engage in social activities with fellow patients. The staff provide the lady with a menu relevant to her culture of West Indian background, The staff fulfilled their role in being self aware on her values and diversity, During the meal, staff began to talk about a holiday abroad and how the food made their “bowel move rapidly”, and how they really found the food “disgusting”.

The lady did initially try to express her frustration of the conversations the staff were having whilst she was trying to enjoy. She eventually stopped having her meal as she found it not appetizing anymore, staff recorded that the patient had poor dietary at dinner time, and they were not self aware that they were the catalyst for the poor intake of her food. Had the staff been more self aware of their presentations, they would have considered that different cultures have different table manners.

In conclusion an effective therapeutic relationship is accomplished by good verbal and non verbal communication. Respecting individuality, beliefs, values, this promotes good recovery and openness between nurse and patient. A therapeutic relationship is not just between a patients and nurse but can, and often extends to other multi disciplinary teams. The therapeutic relationship can never be stated as fully complete, but can be made more effective, because different patients have different opinions i.e. different experiences in previous care, and different values and beliefs.

Within the context of healthcare one of the most important factors is the establishment of an effective therapeutic relationship between the nurse and

patient (Foster & Hawkins, 2005). The ways in which nursing staff and patients interact can be influential in terms of information transfer, provision

of psychological support, and may also provide some therapeutic benefits in themselves (Welch, 2005). Hence, there has been a renewed focus on the

importance of how nurses interact with patients in practice, in order to enhance patient outcomes (Nursing and Midwifery Council, 2008; Sutcliffe, 2011). Uphold an Efficient Therapeutic Relationship With a Patient Essay.

Understanding the fundamental components of this relationship and how to achieve these components in practice remains a vital aspect of nurse training and

continuing professional development (Ramjan, 2004; Perraud et al., 2006).

In accordance with the perceived importance of the therapeutic relationship, the aim of this paper is to provide an evidence-based review of how this

relationship may be used in nursing practice. This will be supplemented with a reflection on personal observations made by the author, utilising a

reflective model (Nielsen et al., 2007). The model in this case will be that devised by Gibbs (1988), which has been validated as a useful tool for

personal practice development and goal-setting in the clinical domain (Foster & Hawkins, 2005). This model emphasises a step-wise approach to

reflection, encompassing: description, feelings, evaluation, analysis, conclusion and action plan formulation (Gibbs, 1988). Therefore, this paper will

consider the therapeutic relationship from the perspective of a specified practice context experienced by the author, with a discussion of how practice can

be improved based on the best available evidence from the literature.

Reflection context

The main context of care that will be the focus of this essay is the elderly rehabilitation ward, where the author first encountered a number of issues

regarding the need for optimal relationships between practitioners and patients in practice. The goal of this ward is to assist elderly patients in

adapting to their functional capacities and lifestyle abilities, in order that they can achieve the maximum possible degree of quality of life in the

community setting following discharge (Routasalo et al., 2004). Consequently, numerous health professionals provide an input into the care pathway,

including physiotherapists, occupational therapists and physicians, in addition to nursing staff (Hershkovitz et al., 2007).

From the perspective of the author, there are several important aspects of this scenario that relate to the therapeutic relationship: the large increase in

personal responsibilities in terms of assisting patients with activities, the need to motivate and communicate effectively with patients to ensure that

they are able to remain psychologically motivated, and the need to coordinate personal clinical care activities with those of others to ensure the patient

journey is smooth (Siegert & Taylor, 2004). The remainder of this paper will consider the therapeutic relationship grounded within this practice

context, supplemented with personal experiences from this placement, in order to highlight these factors in greater detail. Uphold an Efficient Therapeutic Relationship With a Patient Essay.

Evidence-based reflection
Defining the therapeutic relationship

In order to fully appreciate the need for a therapeutic relationship it is important to define this relationship in a practice context. The term is often

used within the context of psychiatric or psychological therapy distribution in modern literature, although the aim of this paper is to consider the term

as a more general way in which nurses communicate and interact with patients to establish a clear clinical outcome (Bulmer Smith et al., 2009). McKlindon

& Barnsteiner (1999) suggest that the therapeutic relationship needs to be a two-way, reciprocal relationship at all times, involving nursing staff,

the patient and their family, where appropriate. There is a need to emphasise caring in this relationship, with positive communication and clear boundaries

of both personal and professional interactions (McCormack, 2004). Hence, the relationship between a nurse and patient should fit into the patient-centred

model of care, where patients are not only listened to within a clinical decision-making context, but are actively encouraged to participate in their own

care pathway (McCormack & McCance, 2006).

The therapeutic relationship encompasses three important domains of care: physical, psychological and emotional care (Pelzang, 2010). These elements may be

more profoundly encountered by nursing staff on hospital wards due to their prolonged exposure to specific patients and their in-depth interactions in the

patient care journey, when compared to other members of staff who may have less face-to-face time with individuals (Pelzang, 2010). Within the setting of

the elderly rehabilitation ward, many patients are transitioning from an acute or chronic care scenario to community care and require additional,

specialist assistance in doing so (McCormack, 2003). Consequently, nursing staff in this ward are exposed to patients for extended periods of time and need

to consider the holistic aspects of care in order to achieve successful rehabilitation (Cott, 2004). Therefore, the therapeutic relationship in this

context involves establishing the capabilities of the patient, working with the patient to achieve set goals, and ensuring that the psychological and

emotional aspects of chronic illness or disability can be managed effectively in the long term (McCormack & McCance, 2006). Uphold an Efficient Therapeutic Relationship With a Patient Essay.


In light of the definition of the therapeutic relationship within the context of rehabilitation, the remaining sections of this paper will evaluate the

core aspects involved in maintaining a therapeutic relationship, with this section focusing on communication between nurse and patient.

The specific clinical scenario the author has struggled with in the rehabilitation placement is when a patient has higher expectations than they should in

terms of their ability to perform tasks or live independently following discharge. Patients are obviously passionate in maintaining independence in the

majority of cases and this can cloud their judgement as to their genuine abilities and capabilities in functional tasks (Cott, 2004). While it is important

to acknowledge the feelings and ideas of a patient and act accordingly, it can be negligent of nursing duties not to act with the patient’s best

interests at heart (McCormack, 2003). Therefore, the nurse needs to maintain that their actions are guided by medical evidence and professional protocols,

as well as reflecting the need and desires of the patient (NMC, 2008).

Communication encompasses not only verbal communication with the patient, but is also reflected in body language and actions (Yoo & Chae, 2011). Having

an open body posture, including the avoidance of crossed arms, can help in establishing rapport, while maintaining eye contact and avoiding distractions

during conversations with patients can enhance the bond between nurse and patient (Brown & Bylund, 2008). Communication is also as much about relaying

information as it is about receiving information and therefore, nursing staff should be able to elicit patient concerns specifically and utilise these

appropriately without blocking these interactions with a one-sided approach to conversation (Yoo & Chae, 2011). The opposite is also true, whereby

overly expressive patients may limit the nurse-led component of the communication episode; both parties need to be good at communication for a perfect

mutual appreciation of ideas to occur (Sheldon et al., 2006).Uphold an Efficient Therapeutic Relationship With a Patient Essay.  In practice this may be difficult to achieve, but the obligations of the nurse to facilitate

this process are a core component of the therapeutic relationship.

Communicating effectively with patients in the elderly rehabilitation setting was a massive responsibility and challenge for the author, as this was their

first encounter with such patients in this setting. The expectation of knowledge in this setting was high and it could be frustrating to patients who want

answers from a junior or inexperienced practitioner (McCormack, 2003; Leach, 2005). Hence communication needed to focus on establishing information,

sharing action plans and building general rapport that would enable the development of trust and a mutually beneficial exchange of ideas (Leach, 2005). The

author found this form of communication challenging to achieve on a routine basis within the rehabilitation setting, due to the need to balance a

motivational approach with a realistic form of communication regarding expected patient capabilities and outcomes. Hence, the reflective scenario will

focus on aspects of this particular communication episode as a component of the therapeutic relationship. Uphold an Efficient Therapeutic Relationship With a Patient Essay.


Empathy is a cornerstone of effective communication with patients and is defined as the ability to share or identify with the emotional state of the

patient (Brunero et al., 2010). If done effectively an empathic response to patient concerns can yield a sense of shared understanding, reinforcing the

notion that the patient’s concerns are being listened to (Kirk, 2007). By establishing an empathic response with a patient, practitioners often

remark that they are better able to connect with the experiences of the patient, allowing them greater insight into how they can help the patient (Brunero

et al., 2010). Therefore, empathy is a core component of establishing a meaningful therapeutic relationship with patients in all settings.

The nurse can develop empathic communication skills in a number of ways, including through specific communication skills training (Webster, 2010). This

training often emphasises the role of open-ended questions and body language within the context of empathy, whereby nurses should ask patients specifically

about their emotions and feelings during a clinical interaction (Stickley & Freshwater, 2006). Often the process of asking a patient how they feel

about a particular reaction is sufficient to allow them to relax and become more comfortable conveying these thoughts and feelings. On the part of the

nurse, it is important to reflect these responses back to the patient by further exploring these issues and offering an active listening approach, rather

than redirecting the focus of the conversation back to more clinical matters (Brunero et al., 2010). Although it has been argued that empathy is an

intrinsic quality, which some people possess, the representation of empathy in communication is important in clinical care and should be delivered through

verbal, non-verbal and emotional communication skills (Welch, 2005). Uphold an Efficient Therapeutic Relationship With a Patient Essay.

In the present scenario, the author was able to empathise with patients on the rehabilitation ward to a high degree and many patients were frank and open

about their emotional needs and worries regarding the rehabilitation process. Often the patients’ worries were highly emotive and this affected the

author such that the patient was regarded as an object of sympathy or pity in some cases due to their hardships. This made the author feel uncomfortable

during patient interactions for a number of reasons: firstly, because it was an emotional situation, and secondly because the expectations of the patient

with regards to rehabilitation were higher than expected and it was often difficult to address these in a controlled manner. Hence, the reflective

experience demonstrates a number of feelings in this situation, which reflect problems with the therapeutic relationship.

Trust and respect

One of the primary outcomes of the therapeutic relationship is to establish a caring and trusting relationship between the nurse and patient (Brown et al.,

2006). Trust is a concept based on respect and openness within this relationship and this often takes time to establish, acting as an extension of the

professional respect a patient may hold for a nurse and vice versa (Miller, 2006). Within the context of elderly care rehabilitation, nurses need to  establish a strong bond of trust as patients will often have to make compromises in terms of assisted living devices and acceptance of their functionallimitations when attempting to optimise their quality of life (Schmalenberg et al., 2005). Unless they trust the healthcare professionals involved in theircare they are less likely to adhere to recommendations or to accept help, reducing the potential positive impacts of nursing interventions (McCabe, 2004).


Establishing trust within a therapeutic relationship requires time and demands that the practitioner is able to manage their communication skills

appropriately to ensure the patient feels that they are listened to and involved in their own care (Brown et al., 2006). Both the practitioner and the

patient must be receptive to the idea of trust within the relationship in order for this to be achieved, which often involves addressing barriers to trust,

including suspiciousness of the intentions of healthcare professionals, poor communication, and mutual respect on a personal level (Miller, 2006). When a

trusting relationship is achieved there is a greater chance that patients will be receptive to clinical interventions and nursing input, at least when

delivered on a personal level (Wolf & Zuzelo, 2006). Equally, nursing staff can trust that patients will make informed decisions about their care and

will follow guidance, when appropriate (Schmalenberg et al., 2005).

Within the present reflective context, the author felt as though there was a distinct lack of trust in the therapeutic relationship, primarily due to the

fact that a patient would often wish for their expectations to be met without heeding specific nursing advice on several occasions. This was likely

secondary to the fact that the author found it difficult to convey these ideas in a sensitive manner, while addressing the concerns of the patient in an

empathic way. Hence, it can be perceived that the patient and nurse did not enter a trusting relationship, as communication between the two was suboptimal

(McCabe, 2004). Uphold an Efficient Therapeutic Relationship With a Patient Essay. However, on a more positive note, the relationships formed with patient during the initial days on placement were friendly and demonstrated

a degree of mutual respect, which is an important facet of the therapeutic relationship (Stickley & Freshwater, 2006). Hence, there were positive and

negative aspects to the therapeutic relationships formed in practice during this placement, according to a reflective evaluation.

To make sense of this situation, the author analysed these positive and negative factors within this context. What was clear to the author was that the

communication skills that had been utilised so far in therapeutic relationship building relied heavily on patient factors, rather than nursing input.

Hence, there was an imbalance in the way information was presented and received within this relationship, to the detriment of the therapeutic journey. The

reasons for poor communication and trust establishment stemmed from multiple factors, including the younger age of the author compared to patients,

relative inexperience on the part of the author, and the highly charged emotional nature of interactions in this setting. Therefore, it was clear that one

of the main factors that was missing in the therapeutic relationships was the projection of a strong professional identity, which could guide the patient. Uphold an Efficient Therapeutic Relationship With a Patient Essay.

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