Nursing Management

Title

A reflective essay on the knowledge and skills in relation to your role in maintaining effective interpersonal relationships within the context of an episode of patient care

Introduction

Nursing is as much about building relationships with people as it is possessing medical/clinical skills. It takes place in the presence of others and, according to Peplau (Peplau, 1952) can “be viewed as essentially an interpersonal process”, and is inextricably linked to interactions with environments and people with one being just as important as the other and both being inseparable. This means that, although the aim of this work is to identify the skills and knowledge used within a specific example of an interpersonal relationship, it would be amiss if the environmental factors were eliminated in their entirety.

The nurse’s ability to relate to others is a very important aspect of interpersonal communication. This includes the nurse’s ability to “take initiative in establishing and maintaining communication, and to respond appropriately to the other person” (Potter & Perry, 2001). Using an example of patient care drawn from my own experiences within a busy inner city Accident and Emergency (A&E) department, interpersonal skills that were essential to communication within the episode of care will be identified and critically analysed for success or failure, environmental factors considered, and conclusions drawn with recommendations highlighted for future improvement.

The episode of care for which the interpersonal relationship is to be analysed looks at a 67 year old man who has come to the A&E department in an Ambulance. He was reporting symptoms of central chest pain, difficulty in breathing, an elevated temperature and a non-productive cough (A more complete transcript of the patients clinical details can be found in Appendix 1). The patient’s identity and the location of the hospital he was treated in have been withheld to uphold legal and professional confidentiality requirements (Nursing and Midwifery Council (NMC), 2002), instead the patients name has been replaced by the pseudonym of Mr Jones.

The rationale in choosing this particular episode of care involving Mr Jones is that it raises issues about developing a relationship within a very limited timeframe between the giver of nursing career and the receiver of nursing care.

Defining the Interpersonal Relationship

A logical first step would be to define the term “interpersonal relationship” (IR) so as to provide a framework to explore later in this work. However, doing so at this stage proves a little problematic because any encompassing definition of an IR offered now would be subject to a high degree of criticism. I believe that an IR is a product of an Interpersonal Interaction (II), or maybe more than one II and individual factors (See Figure 1 for a formulaic representation of the IR. See Appendix 2 for an exploration of the Individual Factors). This is cumulative over time with a relationship not being instant and in a state of flux, changing between each II. This means that the term relationship as posed in the provided title is, perhaps, not entirely accurate so it might be more suitable to talk in terms of the II, with the IR being reserved for terming the cumulative effect from multiple II events.

*Figure 1 not currently available 0n-line*

The Interpersonal Interaction

It is tempting to say that the II started the moment Mr Jones entered the department however this would be incorrect. While the specific skills and knowledge I would use would only have an impact from the moment I met Mr Jones the interaction has its foundations elsewhere, some of which date back many years. For example, Mr Jones had not been an in-patient in a hospital since his birth, and his only real contact with the health profession had been through his General Practitioner (GP) whom had been looking after him for the past 20 years. As such his experience within a health care setting was quite limited. This may or may not have negative connotations in that it means Mr Jones was likely not to have had any ‘bad’ previous experience within hospitals, however it is a common saying that people ‘fear the unknown’ so it is very possible that some of the anxiety that he was displaying came not from his medical symptoms, but from the fact that he had been rushed into hospital in an ambulance. The paramedic crew, being his first point of contact, would have a massive role to play in the beginning of the II as anything they told him or did for/to him could have attributed to any increase or decrease in anxiety levels before I even knew he was on his way into the department.

Due to the nature of medical emergencies, it might often be the case that life saving treatment takes priority during the interaction and to some extent this can be noticed within this II. Medically speaking, it was more preferable to ensure Mr Jones was in a physically stable condition (i.e. not having an active Myocardial Infarction as his symptoms might suggest) and as such I was more preoccupied with connecting him to monitoring equipment, initiating oxygen therapy and obtaining a 12 lead Electrocardiogram.

However, even during this ‘preoccupied’ time, II skills and knowledge were being exercised with the emphasis being initially placed upon Interpersonal Communication. According to Potter and Perry (Potter & Perry, 2001), interpersonal communication is a “one to one interaction between the nurse and another person. It is the level most frequently used in nursing situations and lies at the heart of nursing practice. It takes place within a social context and includes all the symbols and cues used to give and receive meaning”. Breaking down interpersonal communication as described here leaves us with two core aspects, verbal and non-verbal (or body language) communication.

Verbal communication uses spoken words, a form of code, to convey specific meaning. It was appropriate with Mr Jones to use verbal communication as a first line of contact between us because it allowed me to seek consent for initiating medical interventions and establish a medical history, both of which would influence emergency treatment, the differential diagnosis and subsequent treatment. According to literature about communication (Potter & Perry, 2001; Gumperz, 1968; Kenworthy et al, 2002) verbal communication includes aspects of vocabulary, denotive and connotative meaning, pacing, intonation, clarity and brevity, and timing and relevance. There are obvious advantages to the use of verbal communication in that it can provide a highly descriptive and easy to understand message within a short period of time and is a form of communication that more than one person can partake in, also known as small group communication (Potter & Perry, 2001), perfectly demonstrated by me asking him where his chest pain was, how long it had been there, and whether it was radiating anywhere as the other members of the team could hear all of my questions plus his answers.

It is important to remember that communication may be unsuccessful if those involved in the communication cannot translate each other’s words and phrases. Health care jargon and technical language often exclude patients (Gumperz, 1968) from meaningful communication, as such any verbal interaction I had with Mr Jones had to be tailored to his level of understanding. Having never met him before, I had no idea what his level of understanding would be therefore it seemed logical to make my language as simple as possible to aid his understanding. There is evidence that verbal communication in stressful situations may not often be taken in until it has been repeated several times, or until the stress has been dealt with (Ong L, De Haed J, Hoos A & Lammed F, 1995) which theoretically reinforces the notion of using accessible language to improve understanding.

There was a different barrier to our communication. Due to his difficulty in breathing, he was wearing an oxygen mask and these can be restrictive to communication as they provide a physical impediment to speaking. Therefore careful listening to any answers to questions we asked or any comments he made was essential. If, at any point it was difficult for me to understand him, simply moving the mask slightly for a moment removed this barrier.

For a long time researchers and theorists focused on verbal communication, and in doing so neglected non-verbal communication (Larsen & Smith, 1981). However in recent years it has been realised that patients are very sensitive to and observant of non-verbal communication. Friedman (Friedman, 1979) explains that; “Illness usually involves emotions such as fear, anxiety, and emotional uncertainty. As a consequence, patients will look for subtle cues to find out what they ought to be feeling and/or thinking”. Non-verbal communication includes aspects like touch, proxemics, posture, kinesics, facial expressions, gaze and appearance, all of which we normally refer to as ‘body language’. Reinforcing Friedman’s work, Kenworthy, Snowley and Gilling (Kenworthy, Snowley & Gilling, 2002) said, “Non-verbal communication has a regulatory effect on the control and flow of information giving clues as to information uptake, understanding and emotions…” Within the confines of this II, my body language was most helpful in trying to give Mr Jones assurance that I was confident in my own skills and that his situation did not alarm me. The subsequently hoped for effect is that he might be less anxious if I am not anxious myself.
However, Potter and Perry (Potter & Perry, 2001) also caution, “Since meaning resides in persons, and not in words, messages received may be different from messages intended.” Therefore a degree of self-awareness is a vital aspect in communication and one reason why communication may be ineffective is a lack of awareness of aspects of ‘us’ that significantly affect our interactions with others. Facets of us, which are beyond our consciousness, are also beyond our control (Kenworthy et al, 2002). My attitudes, beliefs, values, feelings and behaviours can all have an impact on communication and although I may not be able to change them, it is only reasonable that I put them aside when they conflict with the interests of my patients.

A well-documented barrier to communication is the change of dependence status. According to Roper, Logan and Tierney (Roper, Logan & Tierney, 2001), the loss of independence can have a negative effect on mood and outlook, often raising issues of uncertainty and mortality all resulting in stress. It cannot be denied that Mr Jones had a sudden and drastic change in his dependence status, relying on myself and the other members of the team to meet his every need. As such his stress was well founded and understandable. But was it possible to deal with it? Identifying stress in the healthy adult can be fairly straightforward, however, in the un-well adult internal and external signs of stress can be masked by medical symptoms. Some of the classic signs of stress include increased perspiration, skin flushes, an elevated heart rate and increased rate and depth respirations all linked to the ‘Fight or flight’ response that has evolved in humans. In Mr Jones’ case, he had altered heart rate, temperature and respirations due to an underlying pneumonia infection and pain, meaning identifying stress would be complicated, but this did not mean he was stress free!

Dealing with stress in this instance was difficult. Normally I would seek to take the patient somewhere quiet that they and I could talk about what was making them anxious and explore possible ways to counter any problems. In this situation, that was impossible. Two doctors, two nurses and myself surrounded him so privacy was out of the question, and it was still unknown at that point if his chest pain was related to a possible MI so taking him somewhere quiet where he could gather his thoughts was also out of the question as he needed constant cardiac monitoring. This really only leaves verbal and non-verbal communication as an agent to counter his stress.

Environmental factors were not really within my control and prove difficult to work around. Firstly, Mr Jones was in a strange and disorientating environment (Roper, Logan and Tierney 2001), surrounded by strange people doing strange things and where strange equipment made strange noises and, by necessity, had to have many of his clothes removed. Countering all of these factors while making sure he was medically stable is a complex task, but with only a little thought, each factor can be reduced or eliminated from the environment. I took the role of communicator in Mr Jones’ case, as he was to be my patient during his stay within the resuscitation area of A&E. I introduced myself, providing my first name and telling him I was to be his nurse all while I connected the monitoring equipment. I then told him who else was helping me to look after him and their positions (i.e. Rebecca and Sarah are two more nurses who are helping me and your doctors are Chris and Ben). Not to introduce the other members of the team and myself could, according to Potter & Perry (Potter & Perry, 2001) have created uncertainty and convey an impersonal lack of commitment or caring. Whenever possible, eye contact was maintained with Mr Jones to enforce my recognition that he was a person and not simply a disease.

As mentioned earlier, due to medical necessity many of the factors of his dependence status had been compromised, but the maintenance of his dignity could be, in part, preserved, an aspect reinforced by the NMC (NMC, 2003). There are ways to ensure that his dignity is maintained as during the removal of his shirt a hospital gown was draped over him to cover him up.

Pain relief, positioning and oxygen therapy helped to alleviate many of his symptoms and it was noticeable that his anxiety decreased as well. As the II progressed I attempted to keep up a commentary about what we were doing, keeping explanations to their most simple levels to ensure a greater chance of understanding with phrases like “we need to get a picture of what is going on Mr Jones, so I’m going to take a small sample of blood from the cannulae that was placed in your arm by the paramedics. Don’t worry, it won’t hurt”.

As more medical details were revealed by diagnostic tests, ruling out an MI and indicating a severe community acquired pneumonia infection, as such I was able to put his mind at rest over the central chest pain not being a heart attack. He was in a medically stable state so there was less urgency and subsequently more time for me to talk to him and perform a proper assessment of his communication skills and understanding. It was during this time that a deeper relationship could be worked upon. More time meant I was able to sit and talk to him in greater depth, establish his (and his wife’s) level of understanding and explain in more detail what we had done for him so far and what the next step in his treatment was likely to be. At this point complimenting him on seeking help and on his performance so far provided positive feedback (Balzer-Riley J 1996). By doing so I was working towards establishing a good foundation for further communication not with myself, but the nurses on the ward he was going to be admitted to in much the say way the paramedics did before Mr Jones arrived in the A&E department.

Conclusion

I agree with Kenworthy et al (Kenworthy et al, 2002) that a patient is a person who happens to be ill, and that “the therapeutic interaction a combination of key communication skills and a human, personal relationship… the quality of which significantly affects any treatment or caring interventions”. These behavioural and relational aspects of communication enable a therapeutic relationship to be established, as I believe it was between Mr Jones and myself. A professional relationship was created through my application of knowledge, understanding of human behaviour and communication and a commitment to ethical behaviour (Potter & Perry, 2001). Having a philosophy based on caring and respect for others, I believe, helped me to be a better nurse I established an II and more effectively steered it towards building a prosperous IR with Mr Jones.
Looking back at the II, it has become apparent that evaluation of communication can be a useful tool. It has given a boost to my confidence by identifying areas of competence and good practice in relation to interpersonal skills and I find that, even though I was satisfied with my behaviour around Mr Jones at the time I was looking after him, that satisfaction has been reinforced during this re-examination of the events.

Bibliography and References
Adams J, Schmidt T, Sanders A, Larkin GL & Knopp R (1998) Professionalism in emergency medicine Academic Journal of Emergency Medicine. 5(12):1193-9. Society for Academic Emergency Medicine; Ethics Committee. Department of emergency medicine, Brigham and Women's Hospital Boston.

Balzer-Riley J (1996) Communications in Nursing [3rd edition]. Mosby. St Louis

Barkausas V (1998). Health and Physical Assessment. 2nd edition. Mosby, St. Louis

Byrne M & Curtis R (2000) Designing health communication: Testing the explanations for the impact of communication medium on effectiveness. British Journal of Health Psychology 5(2): 189-199

Ellis R, Gates R & Kenworthy N(1995) Interpersonal Communication in Nursing. Churchill Livingstone. Edinburgh.

Kenworthy N, Snowley G & Gilling C (2002) Common Foundation Studies in Nursing [3rd edition] Churchill Livingstone. London

Ley P (1982). Satisfaction, compliance and communication. British Journal of Clinical Psychology. 21(4): 241-54.

Nursing and Midwifery Council (NMC), 2002 Professional Code of Conduct. NMC. London

Ong L, De Haed J, Hoos A, Lammed F (1995) Doctor-patient communication: a review of the literature. Social Science and Medicine www.sciencedirect.com [Accessed on 18/03/2004]

Paavilainen E, Astedt-Kurki P (1997) The client-nurse relationship as experienced by public health nurses; toward better collaboration. Public Health Nurse 14(3): 137

Peplau H (1952) Interpersonal Relations in Nursing. GP Putnam’s Sons. New York

Potter P & Perry A (2001)Fundamentals of Nursing [5th edition] Mosby. United States

Roper, Logan and Tierney (2001) The Elements of Nursing; A model for nursing based on a model for living. Churchill Livingstone. London

Society for Academic Emergency Medicine (1996) Taskforce on physician-patient communication. Physician-patient communication in the emergency department. Academic Journal of Emergency Medicine. 3:1146-1153.

Williams J (1991) Meaningful dialogue. Nursing Times 87(4) 52-53

Wood J (1999) Interpersonal Communication [2nd edition] Wadsworth. Cincinnati.

Appendix 1 – Patient details transcript

Episode details

67-year-old male accompanied by his wife, ‘blue-lighted’ into A&E by Ambulance at 22:10 on a Friday. Taken to Resuscitation room.

Reported Central chest pain for 4 hours
Shortness of Breath for unknown time
Non-productive cough for 2 weeks
Says he “feels too hot”

On examination

+Airway
Clear and adequately maintained.

+Breathing
Respirations rapid at 25 per minute. Slightly
shallow.
Chest rise and fall even on both sides
Lung sounds Left Crackles at base of lung
Right Crackles at base of lung
Communication Able to finish sentences
Coherent

+Circulation
Pulse Tachycardic at 109 beats per minute.
Strong and regular
Blood Pressure 152 / 92
ECG presents as normal - no ischaemic changes
Sp02 92% on Room air, rising to 99% on 60% 02
No evidence of peripheral or central cyanosis
Temperature 37.7oc (tympanic)
Appears sweaty and flushed.

+Neurological
Glasgow Coma Scale 15/15
Conscious and orientated to time and place
Disposition Appears anxious and stressed.
Pain Reported in central chest area with no
radiation to extremities. Increases in
severity on inspiration and partially
relieved on positioning (sitting upright)

+Allergies
Penicillin (Patient unsure of type of reaction)

+Abdominal exam revealed slightly distended bladder.

+Past Medical History
No recent surgery
No known chronic medical conditions

No asthma, non-Smoker for 15 years, no chest trauma, no Malaria risk, no T.B. and no cystic, fibrotic, bullous or emphysematous lung disorders

No recent G.P visits or inpatient admissions.

Recently returned from trip to French Alps

No current medications

+Social History Accompanied by his wife.
Lives in a terraced house
Retired train driver

+Investigations ordered

Chest X-Ray
Arterial Blood Gas
Full Blood count
Urea and Electrolytes
Glucose
Blood cultures
Sputum sample for MCS (not sent due to no sample obtained)

+Diagnosis was of “Community acquired Pneumonia”

+Treatment provided

Pain relief 2.5mg IV Morphine initially for Chest pain

40% O2 on Venturi mask provided to aid S.O.B.

Paracetomol for temperature

Salbutamol nebulisers

IV Cefuroxime and Oral Clarithromycin

Referred to Medical Specialist Registrar and admission to medical ward

Appendix 2

Factors influencing the individual within an interpersonal relationship

Diagrammatic adaptation of text by Roper, Logan and Tierney (2001) The Elements of Nursing; A model for nursing based on a model for living. Churchill Livingstone. London (Chapter 5 - Factors influencing the Activates of Living of communication)

*Not currently available on-line*