Nurseables: Nurse Snow and her Seven Patients: Thoughts on Therapeutic Communication

Once upon a time, on a hospital floor far, far away, there worked a young nurse named Snow. Now Snow was just like any other nurse, working hard to provide the best care she could for the patients in her charge, but she had a little problem… no matter what she did, one of the clients in her care just wouldn’t smile. In fact, if anything, he was just being down-right grumpy! After catching up with all her work and checking to make sure her patients had all they needed, Snow did something that rarely happens outside of storybook land… she sat down. But when she sat, she let out a long, frustrated sigh and plopped her head down into her hands.

Just as she did, the charge nurse came up beside her and decided it would be prudent to see what could be done to cheer the novice nursling. “Oh Snow, whatever is the matter? You’re always so happy to be working on the floor, whistling while you work and seeming to dance along. It’s just so strange to see you so down, what happened?” she inquired.

“Oh I can’t complain Mother Goose, all of my patients have been just wonderful to me… for the most part that is,” Snow replied as she let out another long sigh.

“Well, how about you give me a little report about them then.”

“Ok, let’s see, there’s Mr. Achoo in room 3 that came in just sneezing and sneezing away, but now that I’ve got him set up with some allergy medication and a big box of tissues, he’s doing as well as his raw nose will let him. Then, there’s my funny little gentleman in room 6 that acts a little dopey, but he’s really been the sweetest patient that I’ve had the pleasure to work with. Oh, and there’s room 4 who’s a bit modest and room 2 who’s always looking up more information about his condition, but once I assured them that I’ll protect their privacy and answer their medical questions as best as I can, they both opened right up. And there’s room 1 who’s always sleeping and room 5 who’s just pure smiles and laughter! Who could ask for better patients?”

“But…”

“But… even though all my other patients have been such a joy to care for, I just can’t seem to accept the fact that room 7 doesn’t like me.”

“What makes you say that Snow.”

“Well, no matter what I do, he just sits in his room being cantankerous and sullen. It’s like he just wants me to give him his medications and leave him alone, but I can’t do that. I want to help!”

“Oh Snow, you should know by now that you can’t please everyone!”

“Yes, I know that, but it was the way he got that way that bothers me. When I first went into his room, I introduced myself and started my normal assessment process. As I went along, I asked him a few questions about his life, hoping to put him at ease and to develop a good working relationship with him. Well… he answered a few of them, but then he turned the tables on me and started asking about whether I was married and how many kids I have! Not that I have anything to hide, but I always learned in nursing school that it’s important to keep boundaries in the nurse-patient relationship, so I turned the conversation right back around to him without really answering his questions.”

“Ah, so then he shut down on you?”

“Yes, that’s about the time he started getting really cross with me. Unfortunately, I didn’t have any more time to sit there and try to mend the drawbridges that I’d somehow burned. So, I finished up my work and rushed off to take care of my six other patients in the castle ward. Oh Mother Goose, what should I have done differently?”

“You ask that age old question Snow, how do you set up professional, yet caring, boundaries in a therapeutic nurse-patient relationship? That’s a topic that’s filled multiple books and been the focus of many a study. I’ll give you a few of those resources so that you can learn from people far wiser than I about preparing for your future interactions, but here’s a little tip I’ve learned. Don’t be afraid to share a little bit about yourself as long as you’re being safe and not giving out personal information like where you live and such. Part of your job is to establish trust with your patients and that’s hard to do when you’re avoiding their questions. Just make sure to examine your motives behind what you share. Are you sharing to fulfill your own need to be understood, or are you sharing to put your patient at ease and to communicate effectively?”

“So, it’s ok to share as long as I use that to put them more at ease? Then they’ll be more interested in sharing with me in the future when I redirect to help them?”

“Yes, it’s ok. Just remember when you start down that path that boundaries are important for a reason. If you get too close or share too much, it could be detrimental to both you and your patient. There’s a fine balance that takes a lot of practice, but with time you should be able to get the hang of it.”

“Oh thank you so much for your advice Mother Goose! I’m so excited that there’s hope and I don’t have to be so distant from my patients in order to take good care of them! High ho, high ho, it’s off to work I go…” and off she went to try her hand once again at therapeutically communicating with Mr. Grumpy in room 7, but this time with a little more understanding and preparation.

-----------------------------------------------------------------

As nurses, we ask our patients all sorts of personal questions not only to develop a professional relationship with them, but also because it’s an important aspect of coordinating their care. Not only that, but we hold their physical well-being in our hands and demonstrate that as we assess them and provide them with their prescribed treatment. So, it’s only natural that our patients try to learn a little more about the people who are providing such important care, not only to relieve some of the discomfort, but also to feel reassured that their provider is human and cares. However, while trying to maintain professional boundaries in the nurse-patient relationship, it seems like some nurses err on the side of remaining very distant from their patients rather than developing a strong relationship with them. While we want to provide patient-centered care, it can sometimes be very difficult to create that therapeutic nurse-patient relationship.

Now, there are very good reasons for establishing strong boundaries and enforcing them. I’m not advocating that we should throw those out the window, I’m just saying that in the nurse’s effort to find the right balance, many patients have had a hard time connecting with and trusting their healthcare providers. I love the description of a therapeutic relationship that Nursing Made Incredibly Easy gives and it’s worth quoting: “A therapeutic nurse-patient relationship is defined as a helping relationship that's based on mutual trust and respect, the nurturing of faith and hope, being sensitive to self and others, and assisting with the gratification of your patient's physical, emotional, and spiritual needs through your knowledge and skill.” How can you develop mutual trust and respect or be sensitive to your patients if you don’t connect with them?

Image via National Council of State Boards of Nursing

So nurses, don’t be afraid to share some information about yourself in order to foster that therapeutic relationship. Of course, when you do, be safe with what you share and remember to keep in mind that the motive behind doing so is for the patient’s good, not to fulfill your own personal needs. Just remember, your patients want to trust that you’re looking out for their best interest. Distance yourself too much and they might feel that you’re not trustworthy or that you don’t really care about them. Show them that you’re not just interested in checking off a box on your to do list, and you might just be surprised by the healthy impact that you can have on their lives.

P.S. To all the patients and families that have touched our hearts out there, thank you for giving us the honor of taking care of you in your most vulnerable times.

What do you think? Do you agree that you have to share a little bit of yourself to develop trust with people? Have you ever had a hard time communicating therapeutically with your patients?

Medical Morales to Remember:

According to Nursing Made Incredibly Easy, “A therapeutic nurse-patient relationship is defined as a helping relationship that's based on mutual trust and respect, the nurturing of faith and hope, being sensitive to self and others, and assisting with the gratification of your patient's physical, emotional, and spiritual needs through your knowledge and skill.”
Don’t be afraid to share some details about your own life to put your patient and their family at ease, but use it as a way to develop a therapeutic relationship and conversation for your patients.
Make sure that the “nurse-client relationship and nursing strategies are developed for the purpose of promoting the health and well-being of the client and not to meet the needs of the nurse” - College of Nurses of Ontario