I will be using a reflective model which explores the processes involved in developing and maintaining such relationships bearing in mind theoretical knowledge and how it applies to this clinical experience. Jasper (2003) describes reflective practice as one of the ways that professionals learn from experience in order to understand and develop their practice. As a trainee health care professional, I have learnt the importance of reflection in practice as a platform for judging one’s progress, strengths and weaknesses and also as a tool for appraising what went well during an intervention and what needs to be improved upon. Reflective practice is an important factor for nurses when building a therapeutic relationship with clients.

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Though this is essential in all nursing practices, it cannot be over emphasised in Mental Health nursing as this is based on quite a lot of understanding and trust between nurses and client. It is also now a respected and required learning and assessment method in many nursing programmes worldwide. The Nursing and Midwifery Council (NMC, 2008) requires nurses to keep knowledge and skills up to date throughout their working life. Considering the importance of clinical competence in the nursing profession, then it will suffice to say that reflection is an important tool in the nurse’s range of skills which aids the achievement and maintenance of clinical competence and performance (Mattews, 2004). I have chosen to use the Gibb’s, (1988) reflective cycle as a model of reflection to help me systematically analyse the experience better for the purpose of this essay and for future practice.

This model is made up of six stages depicted as a cycle which supports the notion that learning is a continuous process as through reflection; we are able to continuously learn from our experiences and thereby improve our nursing practice in future. This cycle is made up of description of the event, the feelings that was experienced, an evaluation of that event, an analysis to make sense of the experience, a conclusion drawn about the experience and finally an action plan put in place in preparation ofa future reoccurrence.

Page 2 Therapeutis relationship Essay

Siviter, (2004) sees reflection as a way of gaining self confidence, identifying when to improve, the ability to learn from own mistakes and behaviour, looking at issues from the perspective of others and becoming self aware to improve the future by learning from the past. My clientwhose relationship I will be discussing is a seventy-two year old lady with a diagnosis of Dementia called Trisha. This is a pseudonym to protect her identity as necessitated by the code of conducts of the Nursing and Midwifery Council (NMC, 2004a). The clinical setting was a specialist care unit for older adults with Dementia, the incident involved issues around compliance with prescribed medication and the dilemma that ensued over what was an appropriate course of action to take as well as the effect it had on my relationship with Trisha.

The therapeutic relationship that exists between a nurse and their client is built on a series of interactions which is developed over a period of time. Although not all interactions develop into a relationship they may still be therapeutic. This relationship is usually for the benefit of the client only and differs from social relationships as the Nursing and Midwifery Council (2004b) expects that at all times nursing staff must maintain appropriate professional boundaries in the relationships they have with patients and clients. It is time limited, goal oriented and in phases (Arnold & Boggs, 2003).

Peplau (1952) describes the nurse – client relationship as the foundation of nursing practice, shifting the focus from what nurses do `to clients’ to what nurses do `with clients’. She identified six professional roles the nurse assumes in this relationship. They are the stranger, the resource, the teaching, the counselling, the surrogate and active leadership roles. This view is also supported by Chambers (1998) who sees Interpersonal and therapeutic relationships as the centre of nursing work. This relationship often acts as the source of strength and motivation to continue treatment and sometimes the ability to persevere when faced with life threatening situations.

DESCRIPTION

At this stage, I will start by describing the event as it occurred at a specialist care unit for older adults with Dementia whilst on a four weeks clinical placement at the unit. Gibb’s reflective cycle is appropriate for accounts such as mine as it encourages description of events especially as this event is simple and easy to convey. It was my second week, so I had already gone past my ‘stranger’s role (Peplau) and become acquainted with most of the residents by then. During the shift whilst on a drug round with my mentor, I was told to administer Trisha’s medication under supervision. This was just after the evening meal, with a few other residents still in the lounge at the time. Although my mentor was not right by my side, she was only a few metres away. Once I had gained her consent to administer the medicines, Trisha took all of her medication as prompted but for one (her calcium tablet) which she sneaked back into her empty pot of yogurt and gave it to me to throw away.

I was quite taken aback by what I had witnessed but I was at a dilemma as to whether I should let her know I was aware of what has just transpired, thereby possibly embarrassing her or inform my mentor as I didn’t know the implication of the medication she had omitted. On a second thought I decided to tell my mentor what had happened. McCabe, (2004) has demonstrated the value of patient-centred communication in facilitating a positive nurse-patient relationship towards the delivery of quality nursing care so in that light my mentor suggested we meet with Trisha in private and discuss the incident.

She admitted that she has never liked the size of the tablet and we offered to ask the doctor to prescribe her a dispersible alternative to which she readily agreed. I am pleased to now see her take her medication without anymore dislike for it because of its size. This means she no longer misses out on a vital part of her prescription. After the incident, my nurse- patient relationship with Trisha suffered as she struggled to trust me again.

FEELINGS

With respect to my feelings, for the first few minutes after the incident, I struggled over the decision to inform my mentor about what I had witnessed or otherwise. I found it particularly challenging because as a first year student on my very first clinical placement, I had little or no clinical experience yet. I can relate this feeling to Carper’s (1978) fundamental pattern of knowing in nursing in which “during the personal way of knowing, the practitioner responds to situations in terms of their own mental models, vision, attitudes, feelings, concerns and ignorance. This way of knowing is necessary to understand and acknowledge the humanness of another and is critical to the success of the nurse-client relationship.

Personal knowing occurs when the nurse is able to intuitively understand and treat each individual client or patient as a unique human being”. I also struggled with the ethical way of knowing which encompasses knowledge of what is right and wrong, attention to standards and codes in making moral choices, and taking responsibility for one’s actions as well as professional values in providing healthcare (Johns, 1995) as I found it difficult to respond to the situation in terms of what was the best or right action to take or as the case may be, non action to take. I was trying to justify my actions and still be able to uphold the professional conduct expected of me in practice as stipulated by the Nursing and Midwifery Council.

To me, disclosing what I had witnessed felt like I was questioning Trisha’s integrity as well as breaching confidentiality by mentioning it to someone else who in this case was my mentor (NMC 2002). To re-iterate, reflection is often triggered by negative or unpleasant feelings (Boyd & Fales, 1983). Often people (practitioners) generally reflect on what has not gone down well or not according to plan and seek ways of undoing it so to say in future, they hardly worry about what has already been accomplished with the desired outcome as they wonder what there is to reflect upon on something that has gone really well. However, reflecting on positive experiences is good for practice and learning as it allows for maintenance and replication of such experience. It also serves as a morale booster.

EVALUATION

In my evaluation, looking back now I know I made the right decision by informing my mentor about the incident as it gave us the opportunity to address the issue and proffer a solution. Although this left a strained relationship between me and Trisha as she felt betrayed. She couldn’t bring herself to trust me anymore. McHugh S (2000) acknowledges that communication plays a vital role in the development and maintenance of a therapeutic relationship and suggests that the nurse is a central figure in patient care and therefore best placed to provide much of these psychological cares.

This demands good interpersonal skills to form the relationship with patients and to communicate more effectively with relatives and other health care professionals. The NMC (2004c) also states that nurses must recognize and respect the role of the patient or client as partners in their own care and the contribution they can make to it. National Institute for Health and Clinical Excellence, (2009) guidelines suggests that treatment and care should take into account patients’ needs and preferences and patients should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. Good communication between healthcare professionals and patients is therefore essential. So by speaking to Trisha in private, we respected her dignity and her right to privacy.

Through effective and patient centered communication, we found out what her reservations were concerning her calcium tablets which in this case was just the size and we were able to offer a much preferred alternative to her with the help of the Doctor. On the other hand, I felt if I had more empirical knowledge about medications at the time I might have made less fuss about it, but then it meant that the issue would have remained unsolved and perhaps she would have continued to throw away her calcium tablets even though she could have it prescribed in soluble form thereby missing out on the positive effects it has on her aging body. The incident initially destroyed the trust and relationship I had built with Trisha before the event because she felt betrayed by the fact that I had to report what went on to my mentor. So I had to try to build the trust she previously had in me back within the limited time that I had left at the unit. This meant I had to go through (Peplau’s) developmental phases of the nurse – client relationship again.

ANALYSIS

Gibbs at the analysis stage of the cycle encourages the reflector to analyse the experience by trying to make sense of the situation. I will do this by referring to the NMC code of conduct which states that as a nurse or student nurse, we must respect the patients right to confidentiality, treat them as individuals and respect their dignity (NMC 2008). In this case, Trisha has the right to decline her medication and her decision could have been upheld but she did otherwise probably due to her condition and mental capacity in view of her diagnosis. With the Mental Capacity Act (2005) in mind it became necessary for me to determine the severity of her non adherence with regards to her best interest as I owe her a duty of care.

However, I was ill-equipped for this task as I had little experience just yet; hence maintaining confidentiality became less realistic as I needed superior advice. Gould & Mitty (2010) discusses the difference between medication compliance and adherence. Compliance is associated with the medical model of health care, where the clinician dictates the medical regimen which the patient is expected to comply. This puts nurses at odds with patients.

However, promoting good health outcomes for older adults is not about the clinician. It is about the older adult. It is about being patient-centred and non- judgmental. This is why moving beyond the concept of compliance to that of adherence is recommended as this puts us in partnership with them. Non-adherence to medication could be intentional or otherwise and in the case of Trisha, it was unintentional so by listening to her concerns, we were able to encourage a patient-centred, non-judgemental and collaborative adherence.

CONCLUSION

Looking back at the incident, my conclusion is that on one hand I took the best decision to disclose the incident to my mentor as it meant we were able to address the reason behind Jenny’s behaviour and encourage adherence. Even though the decision was likely to have caused her some embarrassment, putting her well being above my doubts boosted my confidence and I felt I had acted right. However, I could have acted in a more professional and empathic way by informing Trisha of my intentions of reporting the incident in her interest. That way she would not have been caught by surprise and she would have felt much more involved in her own care.

It is recommended that patients as much as possible should be involved in their care plan and periodic medication assessments among other things as this would be beneficial and enable staff become aware of any changes in patients’ preferences. Nevertheless, I was able to salvage the relationship between Trisha and I as I put to good use all the theoretical teachings I have had. I began to communicate better with her, imagine things from her own perspective and involved her in most decision making regarding her care as far as her capabilities would allow. Although I was time constrained, I made good progress in that regard. ACTION PLAN

On reflection, I would be prepared to take the same steps as I have done with this experience but will definitely tell the patient of my intension to inform my mentor next time, so they don’t feel marginalised. A systematic review of randomised control trials by Joosten et al (2008) shows that there are positive effects of shared decision-making (SDM) on patient satisfaction, treatment adherence and health status in long term decision making especially in the context of a chronic illness. However, the limitation is sample size and evidence for the effectiveness of SDM in the context of other types of decisions, or in general, is still inconclusive.

Future studies of SDM should probably focus on long-term decisions. I will definitely speak out when faced with this kind of situation or any for that matter in future where I need clarification. I would also seek to practice patient centred care where I will involve them as much as practically possible in their own care. I would seek improve on my interpersonal skills so as to communicate better with clients and foster appropriate nurse-client relationship, so that I can develop and maintain an excellent therapeutic relationship.

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