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A retrospective evaluation of the nurse's role in unplanned counselling interaction using Egan’s Model. Reflective practice has become a keystone of modern nursing practice. Nurses are expected to deliver holistic care and perform varied roles within their practice and are often viewed as “experts”. However, within the therapeutic relationship it must be acknowledged that the patient is the expert when it comes to their own needs. They must retain control over their situation at all times and we as nurses are there solely facilitate their journey. Nurses are privileged to intimate details about those they care for and the utmost respect must be shown. This can be demonstrated by using varied verbal and non verbal communication within a safe, private environment. Nurses subconsciously use non verbal communication to assess patient needs on a daily basis, whether physical or psychosocial. Analysis of this interaction and surrounding literature has identified several themes. Positives identified from this interaction include the finding that limited self disclosure can be an effective tool in developing rapport and demonstration of the core conditions. Also, the concept of “just being there” and allowing the patient to tell their story are highly valued roles that we cannot underestimate within our patients’ journey’s. These steps alongside personality, probative questioning and the use of leverage are vital tools we must employ to facilitate the best possible outcome. Barriers that emerged were the time constraints placed upon the delivery of nursing care and the subconscious power struggle between nurses and patients. This may manifest as the “sick role” and the stigma surrounding illness. These must not be underestimated as both have direct inferences on the outcome for all parties involved. However, the most devastating finding from this interaction lies in the use of the professional role to hide behind and
reluctance by “professionals “to admit that they do not have all the answers. This also lends support to the development of clinical nurse specialist roles within multidisciplinary team. The following reflects upon an interaction between a student nurse and patient who was faced with a life altering, potentially life threatening diagnosis namely breast cancer. Samples from the dialogue have been included solely to lend support my assertions. Pseudonyms have been used to protect the privacy of those involved.
As nurses we are often in contact with patients during traumatic and devastating incidents relating to their health (Gilbert and Leahy 2007). Therefore we must be able to demonstrate a counselling role in order to help patients and their families cope with their diagnosis (Ying Chen and Hui Chen 2011). Van Vliet et al (2011) reinforce these requirements as they state that healthcare professionals have a duty to assist their patients to develop new perspectives related to their diagnosis. Egan (1998) model and The Person Centred Approach (Rogers 1976) was utilised in this interaction and will be referred to in this text. Egan (1998) provides a model which may be useful to nurses who engage in the counselling process and it can be used to identify which stage of the counselling process the patient is at. However in order to gauge which stage the client is at we must first engage into a counselling relationship. The Person Centred Approach (Rogers 1976) outlines that the counsellor must demonstrate the necessary core conditions for the relationship to develop. These conditions are congruence, unconditional positive regard and empathy. When a patient presents in an incongruent state the counsellor promotes the actualising tendency by demonstrating these conditions (Sanders et al 2009). The actualising tendency exists within us all and it is driven by the need to grow, develop and realise our actual potential. This insinuates that the patient knows best what the problem is and is best placed to solve these problems (Joseph 2003). The counsellor is there to facilitate the patients journey through t he crisis in order to restore a state of congruency (Stang and Mittlemark 2010). Upon reflection on practice I was reminded of a counselling interaction that took place while on placement in a Day Services Unit. My duties on the day ward were the immediate post operative care of my allocated patients and their preparation for discharge. After lunch I returned to the ward and given a very brief handover by the staff nurse in charge. In fact details were limited to their patient names and procedures. Mrs Doherty was one of these
patients and I was informed that she had undergone a breast lump biopsy. A pseudonym has been used in order to maintain confidentiality in accordance with An Bord Altranais (2000a, 2000b) policies. I had been allocated several patients and my first steps involved introducing myself while at same time attempting to make a provisional assessment of their most urgent needs. I find that something as simple as introducing yourself can have a huge impact on the rapport you build up with patients (Banning 2007). Mrs Doherty was resting on a recliner with the curtains drawn around her. She appeared very pale and her non verbal communication suggested to me that she was in some form of distress. Of course the medical model within me popped up with multiple possible causes for her pallor and the first question I asked was “are you feeling okay? Are you in pain? She responded with “um, well, I am but, don’t worry about it, your far too busy!” I responded to this statement by telling her that I am never too busy and that our sole purpose is to be there for our patients. Manning-Walsh (2005) argues that nurses should provide an environment where the patient can have the space and privacy to facilitate communication and or silence in order to demonstrate “being there” In order to provide her with as much privacy as possible I ensured the curtains were fully drawn(Bitsuka et al 2010). By treating patients with respect and confidentiality the nurse it can demonstrate unconditional positive regard (Whitaker 2010).To facilitate communication I pulled a chair over beside her in order to make eye contact and to be physically close to her as proximity is vital to effective communication(Edwards 1998). In order to identify what was causing her distress I attempted to engage Mrs Doherty in a probative conversation. This allowed Mrs Doherty to maintain control of the conversation. The conversation was initiated by asking her to explore what exactly had happened up until today. She informed me that she had already been diagnosed with breast cancer and was due
to have major surgery the following week. The cancer had been detected in her right breast only but she had attended on this occasion for a biopsy of her left breast. She then proceeded to tell me the story of how she had found a lump and went for investigations. Between finding this lump and receiving her diagnosis she had very little time to process what was going on as it had all happened within the space of two weeks. Boehme and Dickson (2006) have identified this lack of time to deal with their diagnosis contributed greatly to their psychological distress. At various times/ stages within the conversation I would nod or use other gestures to let her know that I was listening to her. When opportunities’ presented I would paraphrase the information she had given me and reflected back to her to confirm my own understanding. At several stages Mrs Doherty said to me that she felt that she was wasting my time and that she was just being silly. I tried my best to empathise with her and asked her why she thought she was being silly? I must admit I did say to her that “this is what student nurses are here for”. Tighe et al (2011) further reinforces the value of just being there and allowing these women time to tell their story as a major factor of supportive care. I believe that this was the right thing to this was my own unique attempt to demonstrate authentic concern while using the professional role to hide behind. Christiansen (2009) lends supports this approach stating that nursing students must be able to be spontaneous and adaptive as they use their own personality to tailor interactions to demonstrate genuineness in a congruent fashion. By retrospectively looking at this interaction I am now able to identify that this was the leverage that I needed in order to allow this lady to accept that I was genuinely able to be there with her. The conversation was then directed towards Mrs Doherty’s daughter. “My daughters a student nurse, she’s up in Galway, 3rd year” was her immediate response. My prompt had allowed her to raise other issues and let her know that I was listening to her. The change in her body language was immediate. Her posture relaxed, she initiated eye contact
and the tone of her voice became lighter, more conversational. We proceeded to make small talk and I got the impression that she and her daughter were very close. My interpretation of their relationship was based on the verbal and non verbal communication she utilised when talking about her daughter. This form of assessment is used each and every time a nurse carries out an assessment, especially when trying to determine the patients state of mind (Matsumoto et al 2010). I then asked her “how does your daughter feel about your diagnosis? “ She doesn’t know, I can’t tell her, I wouldn’t burden her with it; she’s got far too much to contend with! Her tone sharpened, the pace became brusque and her body language became defensive. She demonstrated this by pulling the bed linen up around her as a form of a barrier. The behaviour that Mrs Doherty demonstrated has been described by Kissane et al (2004) as predictable. Breast cancer patients often withdraw in order to protect their family and use this behaviour as a coping mechanism. By challenging her I attempted to make her take a more realistic view on her predicament. She then attempted to turn the conversation to me. Kübler Ross (2005) and Bowlby (1953) both indicate that anger is often directed at healthcare professionals as a part of the grieving process so her responses were not entirely unexpected. “How would you cope if it was your mother? I left it a few seconds before I responded, she was making direct eye contact and I could see that her eyes were starting to well up. I leaned forward and put my had on top of hers which was clenched in a fist, a visible sign of anxiety (O Farrell 1999). I stated that I had no idea what I would do but that I was sure my nursing background would be a huge help in helping me to deal with it. This response confirmed the bond between Mrs Doherty and I while acknowledging the bond between Mrs Doherty and her daughter.
This was likely an attempt by her for me, the nurse, and the “expert” to provide the solution to her problem (Sellman 2007; Eriksson and Nilsson 2008). This is a major pitfall that nurses could easily fall into. The patient must always remain as the focus of the conversation and they alone can find the solution to their problem (Joseph 2003). CRNBC (2006) support the use of self disclosure when appropriate .Self disclosure must be constantly monitored as the nurse could easily make the conversation about themselves. This behaviour may be an attempt by the clients to protect themselves from issues that they don’t want to deal with (O Farrell 1999). It would also constitute as an abuse of power by the nurse as it removes all personal responsibility from the patient (Frieberg and Hansson-Scherman 2005; An Bord Altranais 2000a; An Bord Altranais 2000b). I sensed that it was the prospect of telling her daughter that was likely to be causing Mrs Doherty’s present distress. Sadler-Gerhardt (2010) indicates that this is likely an attempt to protect her daughter. I asked her why she felt that she could not tell her daughter. “She’s so far away; it’s not something you could tell her over the phone”. She then elaborated that she was coming home at the weekend and that she didn’t know what she was going to break the news to her. It could be implied that this lady was also grieving for the loss of contact with her daughter and not just distressed about her diagnosis (Arditti and Few 2008). However I’m sad to say that this possibility was not explored due to time restraints. Boehmke and Dickerson (2006) and Ambler et al (1999) have identified that the nurse is best placed to recognise the need for multidisciplinary referrals within the therapeutic relationship. I felt I was not competent to fully assist this lady appropriately so I suggested that I invite the breast care specialist nurse(CNS) down to have a talk with her. I assured her that the CNS would be able to help her to identify a way she could disclose her diagnosis to her daughter (Brennan et al 2011).The literature indicates that nurses are often reluctant to admit that they do not have the answers as this admission may be construed as vulnerability. They
may also feel that their role as the expert is undermined. Such an approach is not conducive to a therapeutic relationship as the most skilled helper will not hide behind a professional role (O Farrell 1999; Cutliffe and Mc Kenna 2005). Rogers (1976) would view this as incongruence on behalf of the nurse which is incompatible with authenticity and the necessary core conditions. Egan’s (1998) Model has been applied to this scenario and this has enabled the identification of the stages that Mrs Doherty progressed through. Stage 1A involved allowing her to tell her story and allowed me to identify whether or not this lady felt that she was in control of the situation. By analysing the language she used and interpreting what was unsaid through listening, reflection, paraphrasing and encouragement we were able to explore her perception of the situation. Although there were multiple issues causing Mrs Doherty distress, she accepted ownership of them and prioritised the need to tell her daughter that she had cancer. This was only achieved after challenging statements that she made which allowed her to address her “blind spots” (Egan 1998). The next stage, 1B involved my facilitating Mrs Doherty to take on a different perspective of the situation. Mrs Doherty perceived that her daughter would not be able to manage the added stress that her diagnosis would bring her. This perception was based on the assumption that her daughter was struggling with the stresses of student life such as course work or exams. By asking probative questions I was able to identify that these assumptions were unfounded. Mrs Doherty identified that her daughter was happy and coping well with her course. Therefore she had the solution to her own question the whole time (Joseph 2003). It was suggested to Mrs Doherty that her daughter was perhaps best placed to assist her as a safe secure relationship existed as ascertained though conversation (Bowlby 1953). It was also suggested that her daughter may be able to help Mrs Doherty to comprehend her diagnosis
and treatment due to her nurse training. This was achieved by demonstrating respect, genuineness and congruence. Stage 1C involved setting achievable goals. Mrs Doherty ultimately agreed to talk to her daughter when she was home at the weekend. In order to reach these goals it was decided that the Breast CNS was best placed to help Mrs Doherty disclose her diagnosis to her daughter and a meeting time was arranged. This was achieved by demonstrating empathy and the use of limited but judicious self disclosure on my behalf. I believe that being honest plays a huge part in demonstrating congruency, unconditional positive regard, and empathy. This opinion concurs with that of Langtry et al (2009) who identify honesty as an important factor in developing a therapeutic relationship. They further recognise “not knowing what to say” as a major problem. This is often related to a fear of causing further distress. Another contributing factor may be found in Goffman (1959) who describes a process of dramaturgical awareness. Nurses are constantly struggling to maintain a balance between what they want and what they need. You may want to help your client to accept their diagnosis but you may need to look after the other six patients! Persoon and Frieberg (2009) indicate that during a health conversation it is important for both parties to be able to ask questions and obtain honest answers which allow a relationship based on equality and trust to develop. Although some people may not recognise that each interaction is a learning experience for both parties on a conscious and unconscious level. I assumed that I knew how to listen but having taken the time to reflect back on this interaction I can now identify a different type of listening. This involves listening for what is not being said and being comfortable with silence (Johnstone and Smith 2005). At the end of my placement I received feedback from my preceptor and she highlighted to me that I sometimes fail to pick up on body language cues from patients. She indicated that I seem to
need to talk all the time and she suggested to me that this is a method that student nurses often fall back on when faced with uncomfortable discussions. I now have a better understanding of her views and realise it comes down to a lack of self awareness on my behalf. She also highlighted that I was very patient and highly approachable which were two highly valued qualities within the therapeutic relationship. Working through the theory and reviewing the literature has allowed me to make the link between theory and practice. In the beginning of this course I honestly didn’t believe that reflection on practice was beneficial but I was wrong. I now believe that self awareness and critical thinking are the keystones to being a successful nurse who can excel in whichever field they practice. The link between critical thinking and self awareness must also be acknowledged as one cannot exist without the other (Cottrell 2005). Rogers (1976) person centred care approach while undoubtedly useful in some situations it is not a case of one size fits all as it often fails to recognise the impact that culture, society and stigma have on an individual. Goffman (1963) indicates that stigmatised individuals work in order to pass unnoticed in society and his view was further explored by Sontag (1979) whose work was related to the breast cancer journey. Breast cancer has been identified as an illness with huge stigma attached and this illness exists within a society dedicated to assigning blame and secrecy (Kaiser 2008). The person centred approach also fails to acknowledge the “sick role” as identified by Parsons (1951) which expects patients to conform to certain roles and expectations. It also negates the abuse of power demonstrated by nurses as identified by Hewison (1994). Whether or not nurses make a conscious decision to use their power to coerce patients, it forms a huge barrier to the demonstration of the core conditions. Conformity is a huge barrier to positive interpersonal communication as everyone wants to feel accepted by their peers. In the context of my own personal practice, as a student, one
feels pressurised to always be busy, or at least look that way (Levett-Jones and Lathlean 2009). There is still a mentality within healthcare that it is inappropriate to sit down and have a chat with your patients, that it is much more important and meaningful to be doing something to a patient! (Davey et al 2005). I believe that getting to know your patients and letting them get to know you is the foundation of nursing practice. Balzer Riley (2008) supports this assertion surely as they indicate that nurses are involved in incredibly intimate aspects of these people’s life which requires access to sensitive personal information. The information will only be divulged within a confidential trusting relationship (An Bord Altranais 2000a). While I recognise that nursing is a professional role I do believe the move away from a more curative approach formed the greatest barrier to treating patients in an individualised, holistic, and ethical manner. In practice there are multiple barriers to the facilitation of good communication between nurses, their patients and with other members of the multidisciplinary team. These include personal, interpersonal and environmental factors (Bach and Grant 2011). The image of the busy nurse forms a huge barrier to communication, as does false pity or reassurance. This is providing false information which is wrong on a legal, ethical and moral basis. In a vast majority of the literature reviewed the biggest barrier encountered was lack of time (Eriksson and Nilsson 2008). This often results in poor continuity of care (Lafferty et al 2011). Personal experience has informed my opinion upon care delivery locally. Even though the Health Service Executive (2011) state that care delivery is patient driven this is not always true of practice. Nicholson et al (2002) identify that the hospital environment is often uncontrolled and as such is not conducive to communication in many scenario. Hargie and Dickson (2004) have led me to understand that nurses need to think about their assumptions. With the ever changing nature of culture and society it has never been more
important for nurses to provide individualised tailored care while taking into considerations their patients role in society (McCann et al 2010) as the individuals experience of illness is hugely influenced by the social context in which they live in (Kaiser 2008). Nishizawa et al (2006) have identified that student nurses often act in a way which promotes acceptance by their peers and patients. It is described as a performance of an accepted role. Surely this clearly demonstrates a huge barrier to congruency if as a student we are forced to put on an act in order to be accepted. Roger’s (1976) theory sets an unachievable goal as we all have unique and personal interpretations of our journey through life. By becoming aware of these preconditions; we can strive towards unconditional positive regard. Alas, this can never be perfected as we are constantly learning and adapting so perfection can never be achieved (O Farrell 1999).
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