Nature of the therapeutic relationship

Question 1

What is relational work

Answer 1

• Relational work involves nurses therapeutically relating to their patients in ways that:
• facilitate the patient’s or family members’ ability to cope with their circumstances
• to understand the meaning of this episode of illness or injury in their lives
• to take ownership for their own healing and recovery.
• RW is developing deep human connections with others, moral acts
• Emotionally, physically, socially, psychologically

Question 2

The therapeutic relationship

Answer 2

• A relationship where focus is on ministering to the needs of the person receiving care
• The needs of the caregiver are met outside of the therapeutic relationship
• Characterized by principles of empathy, compassion, and caring
• Relationship is characterized by administering to the needs of someone without expecting anything in return
• You meet your own needs outside of that therapeutic relationship

Question 3

Empathy

Answer 3

• The experience of understanding another person’s condition from their perspective
• Empathy vs. sympathy
• Empathy is about seeing the experience of someone else and seeing it from their perspective
• How are they healing and how they are experiencing something
• Sympathy is feeling sorry for someone; wrong because can amplify someone’s experience of suffering, stuck in own understanding of what’s going on, want to move beyond that (doesn’t matter how I’d respond to that)
• Starts with curiosity and asking those kinds of questions
• Empathy might manifest by being cognizant of what experiences might be for that individual; what that person needs to do to get through that moment

Question 4

Compassion

Answer 4

• A deep awareness of the suffering of another, coupled with the wish to relieve it
• Involves an interaction of somatic, affective, cognitive, attentional and embodied processes
• Recognition of suffering, empathetic engagement with suffering, actions in attempt to relieve suffering
• Broad literature of compassion is around recognizing suffering (looking for it), empathetic engagement with that suffering (trying to understand the nature of that suffering), taking actions to relieve the person’s suffering

Question 5

Caring

Answer 5

• Genuine kindness and an authentic concern for others, evidenced by qualities of gentleness, warmth, affection and concern
• What does that look like? It looks different for every person. How do I enact those things in day-to-day life for myself?
• It’s thinking about how we’re engaging with people with those kinds of values in mind
• Caring is distinct from nice; it is not surface. Kindness is something deeper, it is actually looking and seeing the person
• Kindness and caring is work; nice is east and where people want to stay
• When you crack yourself open to the full human experience you see the full beauty of life

Question 6

Are empathy, compassion and care all intrinsic attributes of people who want to be nurses?

Answer 6

• They are learned enacted skills that you develop and practice
  • There is value and skill that goes into relational work; all things you can learn and do. Doesn’t not have to be innate

Question 7

The purpose of the therapeutic relationship

Answer 7

• “The purpose of the therapeutic relationship is to promote, guide, and support the healing of another person through knowledgeable and authentic connection.”
• It takes that therapeutic relationship to do all of the other skills of nurses
• It makes the inhumane humane; it makes people think things are being done with them instead of to them

Question 8

What does it mean to heal?

Answer 8

• The experience of a patient being healed is related but distinct from the experience of being cured.
• Cure is contingent on many factors and may or may not be possible
• Healing is always possible
• Cured is to be physiologically or mentally disease free
• Healing is about learning how to cope, how to become a new person, how to transcend one’s suffering
• Healing is about becoming whole
• Emotional, psychological, spiritual terms
• There is always some possibility of transcending of suffering
• Hope in innately woven into this concept of healing
• Healing and curing work in tandem of one another
• Caring is essential to relational work

Question 9

Theories of healing through caring: Sidney Journard

Answer 9

• A person can attain health only insofar as the person is able to be themselves
• Rote care and inauthentic, prescriptive interactions are about ‘controlling’ the patient and obscuring their personhood
• Bedside manner is used as a shield to protect HCPs from patients’ suffering
• Processes of objectification in health care
• To achieve health, you need to be as close at to your authentic self as possible
• They more we cancel from people, the more likely we are to get sick
• They way we organize care works to promote the concealment of people’s identities which leads to the objectification of individuals
• We have a cloak we put on for bedside manner (our armour) which shield us from the patients suffering; control of the patient
• We don’t know what people need of we don’t talk to them about their experience
• It circles back to this notion of curing and healing
• If we’re just interested in the notion of curing, we’re only caring about the person’s body
• If we want to heal as well, we need to know about the person as a whole

Question 10

Theories of healing through caring: Martin Buber & C. Terry Warner

Answer 10

• Continue with the theme of objectification within interpersonal relationships
• ‘I-It’ (resistant) relationships vs. ‘I-Thou” (responsive) relationships
• Desire and curiosity to truly understand and be responsive to the other
• Their needs, values, experiences
• I-It is that we are detached, not interested, seeing the person as a patient
• The I-Thou is about shard humanity, authentic connection
• We can easily see how processes of objectification occur in our health care system (we strip people of their personal identifiers — just one of the many ways that we start to erode the people of themselves)
• Small details that get overlooked (i.e. brushing teeth before/after breakfast). Small micro-objectification
• When you start to add them all up that how people get objectified
• It takes active resistance to work against that
• You need to be curious about the person, ask questions, get to know them
• Small things covey care about the person

Question 11

Theories of healing through caring: Kristen Swanson

Answer 11

• Five caring processes to inform therapeutic practice:
• Maintaining belief
• Knowing
• Being with
• Doing for
• Enabling/Informing
• Middle-range theory to capture and make visible relational work
• Maintaining belief: about hope and finding it when they can’t
• Knowing: how this event is effective this person
• Being with: emotional present with them, you lean into it and hold space for it when others would turn away
• Doing for: what we do for them what they can’t do for themselves. Doing do in a way that someones dignity in intact
• Enabling/informing: different transitions, navigating the system itself, spending time with patient and families, wondering with people when there are no answers
• These are all intentional practices nurses enact; it’s the work

Question 12

Theories of healing through caring: Rachel Naomi Remen

Answer 12

• Importance of the illness narrative
• Loving connection in care
• The illness narrative: Arthur Klienman
• People’s story about illness and impairment beings the whole narrative
• You can’t begin caring until you know their perspective
• Mobilizing a real genuine care about what happed to the person, what they’re going through

Question 13

The impact of objectification

Answer 13

• Objectification makes you feel lonely and misunderstood, unworthy, depressed, neglected, irritated, isolated
• Often it causes stress; biochemical cascades take off
• Can impede both the physical and the emotional/spiritual recovery process

Question 14

Why would nurses participate in the objectification of their patients?

Answer 14

• It’s complicated!!!
• Our healthcare system is organized in a way that tends to objectify people
• Nurses fell pulled in many different directions; becomes a commodity instead of a series of moral acts

Question 15

The current climate of healthcare

Answer 15

• Neo-liberalism reflected in health care policies and practices
• Rhetoric of efficiency, ‘cost-cutting’
• Census/bed pressures
• Increased patient acuity
• Higher nurse-patient ratios
• Shorter admission times
• Something’s got to give, doesn’t it?…

Question 16

Fear

Answer 16

• Emotional difficulty bearing witness to patients’ suffering
• Not knowing what to say
• Saying the ‘wrong’ thing
• Feelings of helplessness
• Relational work takes courage and bravery; you see suffering and you lean in
• Take a deep breath and face that fear
• You can try things again when you’re having bad conversations; you care enough to come back and revisit it

Question 17

Misperception abut what constitutes relational work

Answer 17

• Time consuming

* Overlook the caring aspects of relational work

Question 18

What is relational work?

Answer 18

• Relational work involves nurses therapeutically relating to their patients in ways that:
• facilitate the patient’s or family members’ ability to cope with their circumstances
• to understand the meaning of this episode of illness or injury in their lives
• to take ownership for their own healing and recovery.
• When we give people the emotional and psychological space to do this they become more active in their care
• Way we enter a room
• Way we introduce ourselves
• Language we use
• Way we touch and minister to people’s bodies
• Attention to patients’ particular preferences
• Ways we prepare patients for procedures
• Ways in which we convey information when the patient’s condition is changing
• Ways in which we integrate patients’ priorities into care planning
• The energy we bring to the room
• We tend to think about the illness narrative when it comes to RW: but there are all kinds of RW that take seconds which active fight and ease the micro-objectifications that patients face
• Simple things but makes a huge difference
• Asking people what pronouns they use, what names they use, gentleness, warning someone of what you’re going to do before
• Truth telling in what is happening, especially when it comes to pain (don’t lie)
• Asking what the person wants to accomplish for the day
• When you’re in the room, you have nowhere else you need to be (even though you do) (it’s a skill that we learn through RW)
• Sitting down when a patient is talking to you
• All of these things strengthen our therapeutic relationship and help people feel cared about and heard

Question 19

Presence through attunement

Answer 19

• “To be present means to be consciously attuned to the person before you… it happens when you see the other, listen to and hear the other, and for the moment, give your undivided attention to the one or ones in your care.”
• This happens when we take a genuine interest in the people in front of us while tuning out all the outside distractions

Question 20

What does being present through attunement allow us to do within the context of a therapeutic relationship?

Answer 20

• Causes us to notice things
• Makes us curious about people
• Draws us into rhythmic interactions
• Allows to see the impact that our own presence in the room has on our patients
• Helps us align ourselves with others
• Allows us to see a person as a person
• Compels us to claim a stake in the welfare of the person we’re caring for

Question 21

How do you start practicing presence through attunement?

Answer 21

• It takes a sense of who you are, what your values are, assumptions you make about people and the world, how it affects your interactions with others
• Sense of ourselves before we get a sense of other people
• We don’t see things as they are, we see them as we are; there is no objective reality it is all subjective
• Need to understand that other’s experiences are and can be completely different from our own
• The more we reflect about ourselves the more curious we become about others

Question 22

Becoming present through attunement: Beginning with ourselves

Answer 22

• Reflect on different aspects of your identity and how these shape your perspectives/values/beliefs as a nursing student.
• Think explicitly about assumptions that you have about particular people, ‘choices’, ‘lifestyles,’ and/or different health conditions.
• How do these assumptions affect the language you use; the kinds of things you notice; the ways you interact with different people; the ways you respond to particular circumstances?

Question 23

Becoming present through attunemnet: Practicing mindfulness

Answer 23

• “Mindfulness is simply a way of learning to live more fully in the present. It is the practice of becoming more aware and engaged in every moment of our lives by brining our attention, with curiosity and acceptance, to bear on our present-moment experience. With mindfulness practice we learn to release our worries about the future, release our regrets about the past and focus with a sense of calm acceptance on the present moment.
• Informal practice of mindfulness
• A way to bring moment-to-moment awareness to anything you do during the day
• Beginning mindful attention to the breath
• Mindful walking
• Mindful hand washing
• Undivided attention, have to cut out all other distractions
• Mindfulness can be done doing anything
• Hand sanitizer as a mindfulness moment, focus on sensation and prepare to go into room and leave everything else behind

Question 24

What the therapeutic relationship is about

Answer 24

• Letting patients know that they are seen as unique persons
• Giving patients the opportunity to be partners in their care
• Ministering to people’s bodies with kindness, dignity and care
• Recognizing and respecting the magnitude of the patient’s illness or injury
• Cultivating a sense of hope
• Conveying information that is timely, truthful, and accessible
- If this is the way you approach RW, people will find it easier to cope; they’ll feel seen, safe and it will make all of the other work easier