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Communication Essay Draft When looking at the role of communication in nursing practice, it is necessary to demonstrate an understanding of self-awareness, and prior experiences in a way that also shows independent research and theoretical understanding. Due to the vulnerability of the service user’s position, the professional boundaries that are often implemented in the workplace can be almost impossible to maintain. When the aim of nursing is indeed to build a nurturing, trust-based relationship that allows for honest and open discussion regarding personal situations and often uncomfortable details, it can be more beneficial for the working nurse to utilise skills in communication, even though that often requires more personal introspection and openness to genuine conversation.

According to Carl Rodgers ‘Humanistic’ model of communication, the end goal of most interactions should be ‘self-actualisation’ which can be described as a state of being where one’s idealised self, is congruent with one’s behaviours. This is conducive to creating a positive therapeutic relationship because it creates a balance between high self-awareness and high self-esteem in the participants, however, Rodgers’ neglects to mention the importance of implementing and respecting limitations in order to preserve the integrity of the relationship. These boundaries are something that can be arguably just as important to communication as self-actualisation because, without the ability to protect one's self, people can become vulnerable to abusive power exchanges (both deliberate, and not). The issue of implementing proper boundaries becomes even more prevalent when discussing a Nurse/Patient relationship because there is already a power imbalance in the relationship- The nurse is a professional with some level of perceived authority, whereas the patient is in a vulnerable position, and is somewhat dependant on the interaction going well. The ideal therapeutic relationship would encompass trust and a genuine human connection which would allow for an open, and non-judgemental exchange of information whilst maintaining some level of distance to allow the patient to protect their self-image. To achieve the above, the nurse must assume the most responsibility, as they are the ones who need to humanise themselves to re-distribute the uneven levels of power. A number of both verbal, and visual communication techniques can be utilised to aid in this endeavour, as stated in Empathy in Nursing Practice ( Wiliams & Stickley 2010) the key concepts a nurse must consider are: 1.The provisions of support and comfort 2.Promoting feelings of validation in the patient 3.Unconditional positive regard 4.Impartial understanding The combination of the above can often be simplified and referred to as ‘Empathy’ which despite being an innate human response, caused by mirror neurones that form in the brain during infancy, is something that can be honed with practice and proper socialisation. In conflict with both Rodger’s theorem and Williams & Stickley’s writings, there exists an ‘Inter-personal theory’ which suggests that at the heart of every interaction is the aim of avoiding anxiety, and increasing individual self-esteem, the three main strands of this idea are: 1.Interpersonal-Complementary (Being complementary to one's self is integral to the maintenance of good self-esteem) 2.Interpersonal-Rigidity (Those with Rigid personality types struggle more, as they 4 Page 1 of

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may miss the ability to adapt) 3.Interpersonal-Circumplex (This refers to a model of conceptualising and assessing interpersonal behaviours) Although every existing model of communication is reductionist, I find the interpersonal theory to be the most simplistic in its view of human behaviour, due to its assumption that self-preservation is at the route of peoples actions. The idea of neglecting an individuals selflessness is dangerous not just because it does not allow for un-motivated good intentions, but also because this cynicism can put those genuinely with a lack of self-regard in danger because it overlooks the possibility of someone being naive.

The NMC standards discuss communication on many occasions, and it’s often cited as one of the core skills required in nursing, and although warnings are in place regarding the management of in-practice communication, the basic human skill remains integral when interacting with both peers and service users. There are many situations in which a person may find it challenging to adapt to the requirements of either the subject of communication or to the needs of the individual, in these cases it is important to know where to find resources and support are available. Some of the most delicate topics, such as self-harm, palliative care, and all forms of abuse, both confirmed and suspected can be found in a health-care setting, and although nurses are trained in how to handle such subjects, they can still take an emotional toll, especially when the aim is to open oneself to understanding. Due to this, most employers support their staff by offering free, and anonymous counselling services. Utilising this ensures that professionals can maintain their mental health, and therefore implement better techniques when assisting with the needs of their patients. During my placement in intensive care, I was able to be a part of several discussions centred around the transition from curative interventions, to palliative care measures. Due to the acuteness of the environment, these were often difficult conversations to be involved in, as the situations leading families to this endpoint were often, completely unpredictable. Nursing patients who had suffered from a traumatic event, that resulted in them being in a persistent vegetative state was different from other forms of nursing I’ve experienced because the patient’s themselves required no emotional support, or verbal reassurance, which meant that the therapeutic relationship we usually seek to cultivate came into effect with their relatives and loved ones, instead. Using the Discroll Model of reflection, I will be attempting to analyse one of these conversations to gain further insight into the positive and perhaps, negative aspects of the interaction. The specific ward I was on, along with the names of all those involved have been changed per the NMCs guidance on confidentiality, however, the details of the event will be as accurate as possible; Our patient was Carl, a 51-year-old man who had suffered from a suspected out of hospital cardiac arrest with a downtime of around 35 minutes. Family dynamics are always complex, so we read his file before visiting time. Once we were fully up to date with the previous interactions staff had had with Carl’s family it became obvious that the main people involved would be his mother in law ( Carol), his wife (Susan), and his two sisters, (Lucy and Sarah). The conversation began by everyone going around the room and introducing 4 Page 2 of

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themselves, and stating their role, or relationship to the Carl. The doctor then proceeded to explain the reason behind this meeting and asked Carl’s next of kin (Susan) to explain what she understood to be the current situation. Susan explained that she knew that Carl had had a ‘heart attack’ and fallen over, hitting his head- She told us that she understood the plan had been to take him off his sedation and wait to see what he was going to be like when he woke up. The doctor then asked if she was aware of the scans which Carl had undergone. She said she had been told about them the day he was admitted, and again when they had been repeated, and said that the ‘chest one’ was ‘clear’ and the ‘head one’ had shown ‘brain damage’ which they wouldn’t be able to tell the severity off until he ‘came round’. He agreed with the assessment, making sure to validate her understanding, before reiterating to everyone that although there had been nothing obvious on the chest scan, they couldn’t rule out some kind of cardiac issue being the initial cause of the event, he then went on to explain that Carl had now had two separate brain scans, with sufficient time free from sedation, and due to the images they had compiled, he felt confident in saying that any kind of significant recovery was unlikely. He explained, using clear, clinical terms that Carl’s brain was so severely damaged, over such an expansive area that he was currently unable to breathe on his own, and, it was no longer a matter of ‘waiting to see what would happen’ as the result was already largely apparent. Susan then spoke, she told everyone that although they hadn’t discussed it at length, she knew that Carl wouldn’t want to ‘linger like this’, he would want ‘go with dignity’. Susan agreed with the doctor’s suggestion that after the lunchtime ‘quiet period’ on the ward, we would look at moving Carl into a side room, and removing his ventilation. He assured them that they would be allowed to stay by his side without concern for the usual restrictions of visiting hours and bed space constraints. He then asked if they had any questions, and when they didn’t. He left, instructing them to take as much time as required to digest what had been discussed, and making it clear that he would be available to answer any further questions they may have at a later date. My mentor and I stayed behind to allow the family to say or ask anything they might not have felt comfortable asking the doctor. This is a technique that is widely practised by nurses, especially those used to working in an environment where consultants often take the role of explaining ‘diagnosis's’ to patients or their families; This is to try and relieve the burden placed on those who need to be thorough and clinical in their communication to make the reality of the situation clear even though the unpleasantness of it can lead to denial in those affected. Nurses tend to take on a more ‘human’ position in these discussions and often find themselves translating medical jargon into something more relatable. Although they should be careful not to give conflicting advice or information, they can often provide comfort in the wake of often destructive news. Overall, I was pleased with the way the conversation had gone, although it had taken some time for the sad reality of the situation to sink in for his family, the doctor had done a very good job at explaining things in a kind, but clear way without offering any false hope or unrealistic expectations, and my mentor and I were able to bridge the gap, addressing their lingering concern and offering a compassionate shoulder for them to vent to about the unfairness of the situation. Throughout this conversation, I was able to see many of the previously discussed techniques in practice, and although certain aspects of this, such as empathy, patience and being an undogmatic audience came without any prior planning, some others, such as making sure to ask the relatives to convey what they understood to be the situation, and allowing them time to absorb what had been told to them, were more deliberate.

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Going forward, I feel as though the only thing I would have added into this scenario would have been to extend the offer of counselling services to the family. Although this was discussed after Carl’s passing, this experience gave me a different perspective, and I found myself wondering if it wouldn’t have been more beneficial to offer these services sooner, to allow the relatives time to consider the choice without feeling pressured by the time constraints of the ward. Upon mentioning this to my mentor, she agreed with the idea in principle but suggested that this might only contribute to the amount of importation given to them at once, raising the risk of confusion. I agreed with this possibility, and together we concluded that things like this should be considered on a one to one basis, since each family, and in turn, conversation, is different, and it will be down to personal judgement in regards to deciding how much might be ‘too much’ for people to take in. When considering my current role as a student nurse I found that because as I was even further removed from those in a position of power (in this context, the qualified professionals) I was even more able to form a humanistic connection with the families in my care. This enabled them to come to me, both with my mentor present and without and initiate conversations that they may have struggled to have with other members of the team. I believe this was due to both my lack of perceived authority and due to my availability, having time to create a rapport is, unfortunately, something that other members of the team often lacked. The breaking down of barriers is what’s integral to beneficial communication, as this is what leads to an honest exchange of dialogue, and this is what leads to the formation of a therapeutic relationship. Even though the barriers we are discussing are not always deliberate, they are damaging none the less, and they usually stem from a perceived hierarchy of power. This hierarchical dissection is prevalent throughout society, and all though it is in no way specific to a hospital setting, it’s very easily witnessed there. When looking specifically at nursing, which is historically seen first and foremost as a ‘caring’ profession, communication is one of the most valuable tools we have when treating our patients.

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