Common ground

Edinburgh University senior lecturer in clinical communication Sarah Collins says recognising the unique role of the nurse among clinicians, and the opportunities that this can bring, is a simple first step.

Patients encounter nurses in a different way to other healthcare professionals, explains Dr Collins, who began her own career as a nurse. Unlike other clinical staff, nurses have an almost constant presence on a ward, and this availability can be an asset to the start of a therapeutic relationship.

While a doctor often enters into a clinical space that they do not necessarily have a home in, the nurse and the patient are in the same territory with each other, explains Dr Collins.

‘All conversations that nurses have will usually begin with a note of informality because of that sense of being on the same ground,’ she says.

‘You have fewer barriers than other healthcare professionals and that’s such an asset, for you as a nurse and for your patients.’

Dr Collins says that a nurse has more opportunities to build trust with a patient than does a doctor caring for the same person.

‘Spending your time caring allows lots of opportunities for trust-building,’ she says. ‘It’s in a lot of the tasks or care activities, such as bed baths or helping someone shave.’

Therapeutic care team volunteers might help with a patient’s personal care, or just spend time chatting

Picture credit: iStock

ATTACH: how to develop a therapeutic relationship

Authentic – be authentic with service users

Trustworthy – be a reliable and well-informed professional so service users trust you, your judgement and your practice

Time-maker – make time to be with service users, which makes them feel cared for and listened to and enables professionals to discuss the time frame of care, including the ending of the therapeutic relationship

Approachable – be approachable and visible, a good listener and provide empathic responses

Consistent – provide a consistent message, work as part of a team within recognised models of practice and within the requirements of the Nursing and Midwifery Council

Honest – have open and realistic conversations with service users

Source: Wright KM (2021) Exploring the therapeutic relationship in nursing theory and practice. Mental Health Practice. 24, 5, 34-41.

The value of small gestures

Knowing the value of these small exchanges and encounters is essential, she says. Even when you are under pressure, there are ways to let your patient know they matter.

Whether it is a smile to someone in distress or letting a patient know you have seen their need and will be back in a moment, small gestures can make all the difference to maintaining an effective rapport with a patient.

Touch is also a vital part of the relationship and, even if it may not always be possible in our post-pandemic world, Dr Collins suggests the gesture of touch is still a good option.

‘The extension of an arm as though you were going to touch can be just as effective,’ she says. ‘It is a caring gesture that takes no time and can be done at the same time as listening to the doctor, handover or whatever.’

Putting patients in control

Patients Association trustee Julie Thallon says that patients overwhelmingly want to be heard and be part of the decision-making relating to their care.

‘What patients tell us is that they want to be involved,’ she says. ‘They want someone to take the time to plan with them. They want people to understand that they’ve got a voice and that their view is important.’

NHS England has made a commitment to become better at involving patients (and their carers) in their care to develop patient-centric models of healthcare and better therapeutic relationships.

This is something patients raise often, Ms Thallon says. ‘They say “I want someone to actually treat me as an equal”, as opposed to someone who’s just having something done to them,’ she says.

Ms Thallon spent many years working as a district nurse and her experience taught her the value of developing a relationship with patients.

‘Nurses have a role to play in maintaining an individual’s independence, seeing people as who they are and treating them as a person. They are better at that than any other clinical group,’ she says.

‘That’s where the nurse relationship becomes important; having the time to have those conversations and explore them.’

Shared decision-making

Greater patient advocacy helps develop the therapeutic relationship across all specialties, but is nowhere more essential than in mental health nursing.

Bringing a therapeutic dog onto the ward can help boost patient mood

Picture credit: iStock

Bradford District Care NHS Foundation Trust senior clinical psychologist Samantha Hartley says: ‘Unlike medication, you can’t give therapy to someone. It just doesn’t work like that – it’s a mutual endeavour.

‘That’s the difference, that the patient will be actively involved in that process – they have to be. There has to be room for that collaboration and that shared decision-making.’

In mental healthcare, therapeutic relationships are the strongest predictor of good treatment outcomes, no matter what intervention or treatment approach is used. Dr Hartley describes the therapeutic relationship in mental healthcare as ‘the treatment itself’.

Her research involves looking at interventions that aid the development of effective therapeutic relationships in mental health. The findings are being used in the development of a new NHS e-learning package for healthcare assistants in England.

Creating a sense of community and family

South Tees Hospital NHS Foundation Trust interim nursing, midwifery and allied health professional (AHP) workforce lead Debi McKeown (pictured) set up the organisation’s Therapeutic Care Team with eight volunteers in 2013.

Today, the team works across all trust sites, with 35 full-time staff and 209 volunteers.

‘The main aim of the team is to support our existing workforce and provide a therapeutic interaction with patients. The therapeutic team actually get to do all of the things that we would love to do all of the time,’ she says.

‘As nurses, we want to be able to provide for every kind of need our patients have, but with the climate that we’re in now, it’s a challenging and demanding role.

‘The volunteer is someone the patient can develop a relationship with who isn’t purely focused on their medical condition.’

The most critical thing the therapeutic care team gives to their patients is time, she says.

The volunteers may be doing anything from taking someone for some fresh air or doing their hair to playing board games or bringing the therapeutic dog around the ward.

‘They look after our patients like we would want someone to look after our mam or dad,’ Ms McKeown says. ‘It’s about creating that sense of community and family.

‘One of the biggest things that families talk about is that they felt reassured when leaving a loved one at the hospital, that someone was with them.

‘Every day, we see things that are unexpected and things that give you that nice glow, and you think that’s been a job well done.’

However, Dr Hartley says that developing a successful therapeutic relationship is not just about training. Developing a nurse-patient relationship is like learning how to dance with someone, she says.

‘It’s a live, dynamic thing that’s going to have ruptures along the way,’ she says. ‘It’s going to need to flex. In a therapeutic relationship, you have to respond to the other person’s movements.’

Nurses must be able to respond in a therapeutic way to events and changes that occur, she adds, and maintaining a good nurse-patient relationship is not always easy. Patients who are unwilling or unable to interact with nurses can bring added challenges.

She suggests that nurses need support to develop and maintain therapeutic relationships with patients and, where challenges arise, interventions such as clinical supervision or reflective practice to help.

‘Often we don’t give enough time or resources to support that relationship to be effective,’ she says.

‘We see it is so core to what we do, and yet we don’t support people to develop and maintain it in an effective way.’

Rising pressures

At a time when the NHS is under intense stress, investment in the development of therapeutic relationships is essential. The Patients Association warned in a recent report that shared decision-making between clinician and patient, essential to an effective therapeutic relationship, is slipping down the NHS agenda, due to the disruption caused by the COVID-19 pandemic and strain on NHS services.

Simple gestures such as a comforting touch can help to strengthen the relationship

Picture credit: iStock

But for Ms Thallon, the importance of the therapeutic relationship only increases in this climate.

With patients waiting longer for care and treatment, the relationship between them and clinicians is becoming more important.

‘They need to get into a shared decision around what they’ve got, what’s happening and what they can expect,’ she says.

‘Patients still see nurses as the ones that they can turn to, the ones that they can rely on. They expect nurses to do the nurturing and caring that they don’t necessarily expect from other clinical staff.’

A good relationship between nurse and patient can improve outcomes

Picture credit: iStock

She adds: ‘We can be as technical as we like, we can have as many skills as we like, but if we lose that relationship with the patient, none of that’s important anymore.’

Compassion in nursing: how to develop and maintain your skills and communicate it to patients rcni.com/communicating-compassion

Further information

Flückiger C, Del Re AC, Wlodasch D et al (2020) Assessing the alliance–outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons. Journal of Counseling Psychology. 67, 6, 706–711.

Molina-Mula J and Gallo-Estrada J (2020) Impact of nurse-patient relationship on quality of care and patient autonomy in decision-making. International Journal of Environmental Research and Public Health. 17, 3, 835.

NMC (2018) Standards for competence for registered nurses tinyurl.com/NMC-code

The Patients Association (2021) Making shared decision-making everyday practice tinyurl.com/TPA-shared-decision-making

Wright KM (2021) Exploring the therapeutic relationship in nursing theory and practice. Mental Health Practice. 24, 5, 34-41.