Importance of the Nurse Patient relationship in delivering care

The nurse-patient relationship is essential to the delivery of care. By use of verbal and non-verbal communication skills, nurses can offer the three core conditions of all therapeutic relationships to patients, empathy, genuineness and unconditional positive regard. It is the intention of this essay to discuss in depth the nature of one of the core conditions associated with effective helping skills. In relation to communication and an effective nurse-patient relationship the application of the core condition will also be examined

The first core condition that is associated with effective helping skills is empathy. This is the beginnings of a helping relationship, the ability to enter into and understand the world of the other person and being able to communicate this understanding to them (Egan 2002). The second core condition is genuineness which Rogers (1994) defined as a personal quality or relationship characterised by open and honest communication where professionals do not hide behind their role. Unconditional positive regard often described as acceptance is the third core condition and this involves taking a non-judgemental attitude towards the client accepting and respecting them for who and what they are (Freshwater 2010). According to Rogers (2003) the core conditions are the necessary and sufficient tools needed to achieve a positive outcome in therapy. The core condition that has been chosen to be discussed in this essay and is associated with effective helping skills is unconditional positive regard. Unconditional positive regard is a very difficult skill to learn but also a very important one as nurses’ and patients’ beliefs and values may conflict altogether. It is important to note that no single core condition stands in isolation from the others and that the three conditions are automatically brought into the natural communication style (Wickman and Campbell 2003).

Unconditional positive regard is often defined as acceptance. According to Rogers (2003) it is when one person is completely accepting towards another person. This is not just a show of acceptance but it is an attitude that is then demonstrated through behaviour. The patient should be able to feel as if they can freely express their emotions without fear of being rejected by the nurse. Hough (2007), says the patients need to feel valued unconditionally even when what they bring to the nurse may not be positive — in fact it may be frightening or upsetting. This may be particularly true of patients who have been abused who may feel embarrassed and ashamed and could also be anxious as to what the nurse will think of them. The nurse must therefore own the necessary skills to put aside any personal prejudices and provide a safe and accepting environment for the patient. Hough (2007) is careful to point out that whilst this does not necessarily mean that the nurse must like or approve of everything the patients says or does, it is important for the nurse to be able to separate their own views from that of the patient. Hough (2007) suggests that the whole philosophy behind unconditional positive regard is to allow the patient to feel accepted, therefore the patient is more likely to accept themselves and be confident in their own abilities. Unconditional positive regard is the necessary and sufficient condition to allow the patient to change in a constructive manner (Wilkins and Bozarth 2001).

There are a number of key components that put together unconditional positive regard, and according to Aengel (2010), these include respect, nurturing and caring for the other person, and being compassionate and understanding to a person’s personal struggle with issues and problems. Unconditional positive regard might be difficult because of the manner or style of the matter or something about the patient might conflict with our own personal values. Nurses must put aside any pre-judgements and opinions, accept the patient at face-value and to try to treat the issue that they are currently presented with. Nurses cannot let any judgements affect the relationship with the patient because it might affect the care and treatment they receive. The counsellor’s guide (2009) emphasises that unconditional positive regard as being one of the most difficult counselling skills to learn because people are very skilled at being able to accept people for who they are, without considering whether they really are who they claim to be. This prevents them from allowing stereotypes and personal opinions affect their judgements. As for unconditional positive regard it may be possible that the nurse may come to like or even love the patient with whom they may at first have not felt much connection (Tschudin 1995). According to The Nursing and Midwifery Council (2008) Code of Conduct nurses are required to treat people as individuals and respect their dignity. They should not discriminate in any way, recognise diversity and respect and value beliefs of others. Thus part of valuing the other person is to accept them for who they are. Carl Rogers (1994) called acceptance unconditional positive regard. It implies that there should be respect for the other person irrespective of what he or she may do or has done.

Acceptance of another person involves an non-judgemental attitude as Ruddick (2010) suggests, as this creates a safe environment in which the patient can explore their most sensitive thoughts and feelings. The nurse must recognise that being non-judgemental is not always possible and if the nurse lays judgement on the patient then they will compromise their relationship with them and because they feel judged then they may become defensive rather than opening up and exploring their issues (Geldard and Geldard 2003). Geldard and Geldard (2003) also suggest that the opposite of being accepting is to be critical. Being critical of someone will make them become fixed in their thinking and their behaviours and they will generally resist changing. When they are accepted they feel good about themselves and they can get in touch with their personality and positive parts and learn to move forward. Collins (2009) argues that judgemental attitudes can stand in the way of getting to know your patient and that labels attached to individuals such as ‘demented’ can act as a language barrier. Effective nursing requires us to be assertive, responsible and to help our patients achieve the best possible health status (Balzer Riley 2008). Effective communication is more than delivering high quality patient-centred care. It also allows patients to feel involved in their care, which can make a significant difference to their outlook on their treatment (Collins 2009).

The personal qualities of a nurse should include compassion, respect and a non-judgemental approach, according to The Royal College of Nursing (2003). The nurse must provide holistic care for patients and the goal is to listen to the whole person and provide them with empathetic understanding. Another key point is that the nurse must be non judgemental no matter what the patient’s circumstances are and be keen to develop a therapeutic relationship as they learn to accept people for who they are as each of us have had different experiences throughout life and these experiences make us who we are. Wilkins (2010) is keen to point out that there is not much difference between the nurse’s attempt to communicate unconditional positive regard and empathic understanding and the patient’s awareness of them. What the nurse communicates is not always understood and perhaps with respect to simplifying the understanding of unconditional positive regard, it may be necessary to have patience, consistency and genuineness of acceptance (Wilkins 2010). According to Dunne (2005) it is important that nurses develop their communication skills so that they can become more skilled in their interpersonal contact with their patients.

The beginning of any nurse-patient relationship are needs which should be based on some fundamental aspects. Rogers(2003) described these as the core conditions, because the aforementioned argued that for a positive outcome to the therapeutic nurse-patient relationship, the nurse must display these core conditions. The nurse-patient relationship does not exist without the core conditions or at least it will not have a positive outcome. It is important to build up a good working relationship with any patient – trust, respect and good communication skills are all essential but the counselling relationship has to go that bit further because it tends to deal with deeper issues (The Counsellor’s Guide 2009).

Nurses work with a diverse variety of people from a wide range of social circumstances, with difference beliefs and values around health. This could be related to sexual health, alcohol consumption, smoking and so on. Freshwater (2010) suggests that many patients continue with their dangerous health behaviours despite having information about the adverse and potentially damaging aspects of their actions. This makes it difficult for the nurse to engage in any health promotion activities whilst continuing to value and respect the patient and in fact it may be that the patients’ and nurses’ beliefs may cause conflict on the whole (Freshwater 2010). The nurse-patient relationship is a professionally close and private one and in order for it to be effective it needs to reflect trust, caring, hope and autonomy (Brooker and Nicol 2003). By demonstrating this core condition of unconditional positive regard the nurse is offering support to others. Brooker and Nicol (2003) suggest that active listening skills are essential in any therapeutic relationship and the nurse needs to explore how they can use communication skills; verbal and non-verbal to develop the relationship. The nurse-patient relationship is a series of interactions between the nurse and the patient in which the nurse assists the patient to reach a positive communicative change. The skills of active listening, open questioning and reflection promote better communication and the evidence suggests the need for nurses and other health professionals to develop their communication skills so that they can simplify the process of communication with the patient (Dunne 2005).

It is in the therapeutic relationship that true person-centred care is the product of genuine engagement with the patient whose fears are being uncovered according to Ruddick (2010) A therapeutic relationship cannot be maintained with the expression of unconditional positive regard and before the patient can understand themselves they must be able to accept themselves (Dexter and Wash 2001). The core condition of unconditional positive regard is a very difficult skill to learn and probably one of the hardest things a nurse has been asked to do. According to Dexter and Wash (2001) the nurse is asked to accept an individual without any kind of judgement and without criticism. The nurse is not only being asked to accept the patient but respect them too even though the nurse may not know what the patient’s previous behaviour has been. To be an effective counsellor, the nurse is asked to dissolve their own values, beliefs, prejudices and stereotypes and must try to understand the patient’s values, beliefs, prejudices and stereotypes even though they are totally opposed to their own (Dexter and Wash 2001).

In conclusion, this essay has briefly discussed all three of the core conditions, which are, empathy, genuineness and unconditional positive regard. It has explained the rationale for choosing unconditional positive regard to discuss in this essay. Unconditional positive regard is often defined as acceptance and this is often demonstrated through behaviour. The key point that has been examined in this essay is that of how the nurse must put aside their own feelings and views and accept the patient for who and what they are. The essay has included how the core condition is used in relation to communication and an effective nurse-patient relationship. Another key point is that active listening skills are essential in any therapeutic relationship and the essay has explored how the nurse can use different communication skills to help to develop the relationship with the patient. Finally, the essay has discussed how unconditional positive regard is a very difficult skill to learn. It is probably one of the hardest conditions associated with effective helping skills because the beliefs and values of the nurse and patient may conflict together.

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