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This
assignment will discuss the relevance of therapeutic communication and its
importance in contemporary nursing practice within a healthcare setting. Key
issues such as active listening, unconditional positive regard and open-ended
questions will be addressed, specifically in relation as to how they aid the
therapeutic relationship between nurse and patient. In addition, this
assignment aims to explore the diverse nature of patient care and identify the
necessary adjustments and amendments required for different client groups. The
Nursing and Midwifery Council (NMC, 2015) Code of Conduct will also be
discussed regarding the influences it has upon therapeutic communication. This
will be followed by a brief summary of the contribution and relevance that
therapeutic communication has upon professional nursing practice.

Therapeutic
communication can be defined as the use of verbal and non-verbal cues
such as eye contact, open ended questions, positive statements affective touch,
acknowledging, clarifying and reflecting in order to foster a positive
relationship between nurse and patient (Berman and Snyder, 2012). Rather than
being concerned with curing disease, therapeutic communication requires nurses
to be accomplished communicators with an ability to demonstrate empathy and genuine
regard for patients which allows them to feel relaxed and assured (McCabe et
al, 2006). Dart (2011) suggested that a patient’s ability to be open and honest
with a nurse is key to therapeutic relationship. Therefore, therapeutic
communication skills are fundamental to contemporary nursing practice as the
development of a productive nurse-patient relationship helps generate positive
patient outcomes (Canning et al, 2007).

 A key component of therapeutic communication is active
listening. Mineyama et al (2007) defines active listening as a process of
listening and responding to an individual in such a manner that their mutual
understanding is improved. It is through actively listening and remaining quiet
through periods of silence with patients that they have the opportunity to
reflect upon their thoughts and emotions (Regnard and Kindlen, 2012). This in
turn allows for a better standard of care as patients feel their needs are
being catered for and their situation is empathised with.
Active listening requires the employment of skills such as: maintaining
appropriate eye contact and posture, paying close attention to the person
speaking, nodding in agreement, asking clarifying questions, an ability to
paraphrase another person and reserving judgement (Bambacas and Patrickson,
2008).
When used in the appropriate setting, the use of active listening in the
therapeutic relationship facilitates an alliance between nurse and patient
whereby the patient feels at ease and able to communicate freely regarding
their care (Bright et al, 2015).
This is also the case when a patient’s behaviour is challenging, and their
views are being expressed via anger. It is then vital that nurses remain an
active listener as this can facilitate the discovery of patient’s anxieties (Foster
and Hawkins, 2008).
It is widely acknowledged that one of the main barriers in therapeutic
communication is when staff shortages have resulted in a failure by nurses to
listen to their patients (Pelzang, 2010). If patient-centred care is to be
obtained, nurses must ensure they are committed to providing the highest
standard of care as this in turn promotes trust and a cohesive relationship
between nurse and patient (Pullman et al, 2013).

 In addition to active listening, unconditional
positive regard also plays an instrumental role within therapeutic
communication. Rogers (2004) defined unconditional positive regard as when one
person has complete acceptance for another despite their behaviour or conduct. This
idea is reinforced by Freshwater (2010) who states that nurses must offer an
indiscriminate approach towards patients whereby they feel respected and valued
for who and what they are. If this is to occur Hough (2007) states that nurses
must disregard any prejudices they may hold if a genuine rapport is to be
obtained between themselves and their patients. This in turn enables patients
to relinquish many of the anxieties they experience when discussing their
health issues and treatment options as a positive, non-judgemental atmosphere
has been established whereby they feel they can speak openly and honestly without
the fear of embarrassment and rejection.
However, Hough (2007) does not suggest that nurses are without prejudice or
approve of patient’s actions and choice of words but rather reinforces the
importance of their ability to separate their own views from that of their
patients if positive outcomes are to be achieved. Therefore, as Rogers (2004)
stated, unconditional positive regard must be demonstrated through learned
behaviour for it to be an effective aid in the nurse-patient relationship. This
is reiterated by Balzar-Riley (2008) who states that in the therapeutic
relationship it is vital for a nurse to appear genuine, they must respect what
a patient has said and adjust their behaviour according to the specific patient’s
individual needs.
However, this isn’t the only factor necessary got the demonstration of genuine
positive regard. A study conducted by (Stajduhar et al, 2010) shows that
patients are most concerned with the quality of care afforded to them rather
than the amount of time a nurse spends with them. This in turn highlights the
importance of a nurse drawing on her empathetic skills to maintain a rapport
with their patients (Norfolk et al, 2007).

 Open ended questions are another vital aspect of
therapeutic communication. These types of questions such as “how are you
feeling today?” elicits a response that requires a degree of thinking from the
patient and offers up more descriptive answers than a simple “yes” or “no”.
According to Neukurg (2012) these types of questions encourage patient
expression and strengthens trust in the nurse-patient relationship as it
conveys the nurse’s attentiveness and regard for the patient. Lewis
and Kitchen, (2010) reiterated this idea and emphasised that the use of open
ended questions allow patients to unreservedly discuss their care and
encourages the sharing of information.
This in turn allows for a better standard of care as nurses can direct
conversations via the use of open-ended questions to ascertain information
regarding the patient’s health and well-being (Silverman et al, 2013).  As information is being candidly shared this
enables the quicker diagnosis of conditions and allows healthcare providers to
quickly facilitate treating the health issues.
Although open ended questions are instrumental within therapeutic
communication, the intermittent use of closed questions also play a vital role in
aiding the rapport between nurse and patient (Roberts, 2013). This is due to
the nurse being able to easily clarify patients understanding and offers them
the ability to focus on particular areas of their health and treatment. Therefore,
whilst open ended questions allow for a larger degree of patient expression, closed
questions enable the conversation to become more specific and clarify key issues.
Hence, both are important and vital practices within contemporary nursing.

Variations
to the skill of therapeutic communication may be required to cater for a
diverse range of patients. It is essential for nurses to familiarise themselves
with patients, so that patient-centred care can be obtained based on the
patient’s individual needs (Harding et al., 2015). This could include ensuring
nurses are aware of patients cultural and ethnic diversities, language
barriers, specialised needs and preferences as this will affect the way care is
delivered to them (Purtilo et al., 2007). For example, a nurse must assess
whether a patient with limited comprehension of the English language is fully
aware of all options available to them in the implementation of their care (Stapleton
et al., 2003). If not, it can be argued that the patient’s autonomy has not
been respected and any examinations taken place may be deemed a physical
assault (Beauchamp et al., 2001).

As
the patient and nursing workforce become ever more culturally diverse so does
the potential for miscommunication, arising from language and cultural
differences. This in turn can seriously impact the patient’s health outcomes
and overall safety when in a health care setting (Hamilton et al, 2010). This
is particularly evident within Black, Asian and minority ethnic (BAME) patients
whereby a high degree of linguistic competence is required by nurses to ensure that
a patients physical, mental and cultural needs are met.
A study conducted by Bolstad et al (2010) observed that many nurses were perceived
as distant, cold and apathetic by patients due to a lack of touch or not
engaging in conversation with patients whilst providing care. This highlights
the need for nurses to have a complex understanding of their patients diverse
and varying needs by ensuring the therapeutic relationship is sustained via
displaying genuine empathy and regard and developing a positive rapport with
each patient. This is reinforced by Holmes et al (2011) who states that nurses
need to learn to communicate and relate in ways that are appropriate to the
cultural environment they are in. This is particularly relevant in terms of
comprehending doctor’s instructions, undertaking patient assessments and when
providing education to patients about their condition. This ability for nurses
to provide effective communication is pertinent to safe and competent patient
care (Xu et al, 2010).
However, this is a pertinent challenge within contemporary nursing practice as it
requires nurses to have a broad knowledge of what is culturally acceptable for different
client groups. For example, small gestures such as a touch may be acceptable when
offering support to one particular service user and not to another.

Gerrish
(2011) states that it is this lack of knowledge and effective communication that
coincides with a lack of understanding of a patient’s individual health needs
and preferences. A major concern can then be identified that patient care
becomes routine and based on stereotypical assumptions rather than the
autonomous approach required for safe practice. As there is little research
into the approach health professionals take when working with different
cultures and how this effects their practice, a framework of intercultural
communication that can be applied to contemporary nursing practice needs to be implemented
to support nurses in their work with patients whose cultural background differs
from their own (Grant and Luxford, 2011) Therefore, appropriate provisions and
nursing interventions should be put in place to enhance communication and
deliver positive health outcomes and improve patient satisfaction Friese and Ailey (2015).

In
relation to The Code (NMC, 2015) there are several aspects that are pertinent
to the skill of therapeutic communication.  
Section 20.2 of The Code (NMC, 2015) states that nurses should
conduct themselves with honesty and integrity consistently ensuring that they
treat people fairly, without discrimination, bullying or harassment.
 According to Van
den Heever et al., (2015) nurses must display a non-judgemental positive regard
for patients if they want to maintain the therapeutic relationship. Honesty is
paramount to the genuine regard for patients and their experiences. This can be
conveyed through the simplest of gestures such as a nurse displaying mc, warmth
compassion in regard to a patient’s health and wellbeing (Mercieca et al., 2014).

In addition to Van de Heever (2015) findings, Forrest (2012) states that trust must be a reciprocal
action between nurse and patients if a positive therapeutic dialogue between
the two individuals is to occur. Forrest (2012) determined that nurses find
providing support to patients particularly challenging when the patients
attitude towards them is unpredictable. Thus, it is argued that the key to
developing trust between the nurse and patient in the therapeutic relationship
is a clear and consistent ability for them to convey information free from
barriers. This ensures that the highest standard of patient-centred care can be
maintained.

Section 2.1 of The Code
(NMC, 2015) which emphasises the importance of working in partnership with
patients in order to provide quality care effectively. 
Preheim, Armstrong, & Barton (2009) state that to maintain the therapeutic
relationship between nurse and service-user, respect and compassion should be
demonstrated when listening to the service-user. This enables the development
of trust via a rapport between nurse and service-user which is vital to the
continuance of a therapeutic communication between the two.
Furthermore, Segaric and Hall, (2015) states that the therapeutic relationship
between nurse and patient is an ongoing process whereby both nurse and patient
undergo a process of developing engagement. It is the maintenance of this
engagement that transforms care from a standard and generic package to a
succession of revaluated and reviewed interventions, needs and mutually agreed
care arrangements.

In
conclusion, the evidence presented would suggest that therapeutic communication
is a vital skill for nurses to adopt and implement into their daily
interactions with patients. This is due to patient’s experience being greatly
enhanced by the various verbal and non-verbal techniques demonstrated by nurses
such as active listening, unconditional positive regard and open-ended
questions and via their adoption of a biopsychosocial approach towards caring
for patients whereby their sole focus is not just physical wellbeing but also a
patients mental and spiritual wellbeing (McCabe et al., 2007). The diversified
nature of patients and the care that they receive underpins contemporary
nursing. Therefore, the way a nurse interacts with a patient must demonstrate
an empathetic, person-centred approach to meet this varying demand and requires
nurses to excel in the skill of therapeutic communication. The Code (NMC, 2015)
not only reinforces these skills but ensures that nurses adopt and adhere to
the professional standards and behaviours expected of them so that patients can
receive the best possible care.