There are many different aspects to being a ‘good nurse’, but there are six core principles of nursing which have emerged through progression of the nursing profession, (DoH 2012). The core principles were brought in as a result of issues raised within the National Health Service (NHS) and have been identified as caring and compassion; dignity; communication; professionalism; emotional intelligence and the nurse-patient relationship. The three principles I have chosen to analyse are communication, dignity and nurse-patient relationship because it is my belief that when a nurse lacks awareness of these, they will also lack the ability to be a successful nurse. From my own research and experience, these three principles are the ones I noticed the most, particularly when considering the experience I will be talking about in my reflective section. Although these principles are essential for being a ‘good nurse’, ensuring that you promote the health and wellbeing of patients, and providing support sufficient to encourage independence are also vital in caring for patients.
Communication, according to Oxford Dictionary, is the disclosing and exchanging of information by verbal communication, non-verbal communication or using some other medium. However, when looking at what communication means within the nursing profession, it is much more complex in order to meet the needs of patients and their families. Patient experience can be strongly affected by the way in which nurses and care staff communicate with them. Communication, as described by Benbow and Jordan (2013), is a two-way process of reaching mutual understanding, in which participants not only exchange information, but also create and share meaning. As nurses, we need to constantly send messages to our patients, their families and our colleagues. We can do this by the way we present ourselves (Burnard and Gill, 2008). There are many different ways in which we can communicate with other individuals; verbal and non-verbal are the most commonly known ones, however, there are other types such as written, (kinesics), and (tactile).
Kinesic communication refers to the ways in which body movements or gestures are used as a non-verbal way of communicating, whereas tactile communication is communicating by the sense of touch. All nurses need to be able to promote good communication in order to improve patient experience; for good communication to take place, nursing professionals need to have certain skills, such as: interpersonal skills, a good understanding of both verbal and non-verbal communication, an awareness of any barriers to communication and have good and effective listening skills. Not only will these communication skills help the communication cycle to take place much quicker and easier than without them, but it also helps the nurse or caring professionals to form a ‘relationship’ with the patient. This nurse-patient relationship will then provide a strong basis for the communication to take place throughout the patients care process.
Allender and Spradley (2005) suggested there are three particular types of interpersonal skills which build on sending and receiving skills: respect; rapport and trust. Respect is a way of the nurse showing genuine interest in their patient, both in the patient themselves and in anything they may say or do. This can be done in many ways, including showing concern for the patient or being patient with them. Rapport is about creating this ‘relationship’ with the patient to enable communication to occur more easily. Trust is about putting your faith in someone else. It is widely acknowledged that ‘Trust can be seen in terms of openness, sincerity, love and patience…It is important to ‘be there’ for the person being cared for’ (Hayes and Llewellyn, 2008).
Dignity is the state of mind of feeling that you are being respected. Dignity is defined by a person depending on what their own beliefs and values are. A belief is an individual’s opinion, based on their personal knowledge or thoughts on a particular aspect of something. Value is what the individual feels is important to them. Both beliefs and values are established from an individual’s personal experiences and culture, throughout their lifetime. ‘Dignity is concerned with how people feel, think and behave in relation to the worth or value of themselves and others. To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals’, (Royal College of Nursing (RCN), 2008).As you can see from the RCN’s interpretation of what dignity is, it is based entirely on how an individual thinks because of the worth and value of themselves, and other individuals. Defining dignity is difficult as individuals have varied views and meanings of what it is, which is why it is important for health care professionals to respect individual’s dignity and let them participate in decisions regarding their care.
Patient experience is important to individuals, not only as it can affect how they feel but may also have an effect on their recovery. By allowing patients to retain some element of control, their confidence and self-esteem will be enhanced and they may gain more faith and trust in the health system and the professionals involved in their treatment and care. It is extremely difficult to maintain a patient’s modesty when they are being forced to share their personal space with other individuals. It is critical; therefore, to provide patients with all the privacy they need throughout their care to help maintain their dignity. When individuals come into a care setting, often unexpectedly, their dignity also becomes threatened due to their own independence and routines being disrupted. Maintaining dignity is not only meaningful in the first stages of caring for an individual, but essential throughout a patient’s care; by giving the element of control, it will help promote patient independence. Promoting dignity can be achieved more easily if the patient and nurse establish a good working nurse-patient relationship, further enhanced by treating each individual equally, regardless of protected characteristics, (e.g. age, culture, race, religion, etc.), to ensure everyone is given the same level of care and importance.
Zion (2011) said that consistency within the unit, by the way the care staff approached patients right through to the way they communicated amongst colleagues, gave him what he needed to go back into society and get back hold of his dignity. Zion’s perception supports the idea that nurses and care staff have a significant role in patient’s experiences. Although it’s his personal opinion, he is speaking as the patient and talking about of an experience which has directly affected him. He clearly states that due to the staff consistency and communication, they gave him back his dignity that he perhaps lost on arrival to the hospital. He tells us about how he was restrained onto a bed whilst being taken from the emergency room to the unit, after suffering from mental illnesses, including Post Traumatic Stress Disorder (PTSD). This directly links dignity to the patient experience, and reinforces how crucial it is that professionals respect the dignity of patients.
Kachelski (1961) describes how the relationship between a nurse and their patient is a ‘bond’ between the two people, where they both bring something to the relationship as they both need something from it. Kachelski (1961) also quoted ‘Patients do not choose the nurse-patient relationship. They enter into it because of an accident, a heart attack, childbirth, the necessity of losing a part of their body, or because living has become too frightening or too overwhelming’. I think this quote really shows what the nurse-patient relationship is, and it identifies one of the key issues, it is not a chosen relationship. Patients often do not come into care settings voluntarily, it is often a cause of something they cannot prevent or take care of by themselves, so they seek care professionals. This is why the nurse-patient relationship is so important; it is the nurse’s responsibility to try and reassure patients and ensure all their needs are met so they feel as comfortable as possible; promoting a positive patient experience.
‘The therapeutic alliance between nurse and client is defined as a helping relationship based on mutual trust and respect’, quoted by Ross and Clarke (2013). Hagerty and Patusky (2003) stated that the foundation of nursing care is the nurse-patient relationship, and that it is a process which develops over time. This is an important element of the nurse-patient relationship because the relationship between the nurse and patient has a significant role in how positive a patients’ experience has been. However, if the individual is only in the care of the nurse a short period of time, they may not be able to build on this bond, making it more uncomfortable on the patient, which then has an indicative effect on how patients perceive what their experience has been like. As this relationship is built widely on trust and respect, if the nurse and patient only with each other briefly, it becomes hard for the patient to put their trust into the nursing staff, meaning it is also difficult to learn to have respect for each other.
As previously mentioned, patients often don’t foresee that they will be entering the caring environment, and will generally feel very vulnerable, for the same reasons as cited in the dignity section. The majority of individuals have their own unique routine, their own beliefs and values and are most certainly independent, so by arriving into a care setting, they will be stripped of these qualities and often feel unsettled by these changes. The nurse can reassure their patient and by building up trust, the patient can be more honest with them about details which may improve their rate of recovery, whilst also making their patient experience at the care setting feel more satisfying for their needs. A crucial point about the nurse-patient relationship is that it is about more than the physical and medical care an individual may need, it’s about building the trust, rapport and respect which becomes so vital for communication to occur.
Building trust between a patient and their nurse can help them both to be more open with each other, leading to a more honest approach of care. Without this relationship, patients may become vulnerable and find their experience much more uncomfortable. Another essential thing to remember is patients do not judge a nurse on how many years’ experience they may have, or how many qualifications, but they judge them for the individual who they see in front of them providing their care.
Communication- non-verbal communication:
Communication is the key to making sure patients’ experiences in a care setting are positive and as comfortable as possible. Although there are different ways to communicate with people, I am going to focus on non-verbal within this section as it contributes to 55% of communication, (spoken words contribute 7%, and tone of voice contributes 38%, (Mehrabian, 2007)). As mentioned earlier in the essay, rapport, respect and trust are three key components to non-verbal communication. If a nurse has effective skills on which the patient can build this rapport, respect and trust, then it becomes much easier for the patients care to take place as both the nurse and patient learn to feel comfortable around each other, therefore they can have a much more honest approach into the care of the patient. If a patient doesn’t feel like these three components have been achieved, they may become defensive and may feel ‘unwanted, developing a ‘closed posture’ because they do not wish to communicate. The acronym ‘SOLER’ is a good way for nurses to remember the key aspects of non-verbal communication.
Egan, (1998), produced the acronym ‘SOLER’ to represent effective non-verbal communication in an easy-to-remember way. SOLER stand for Squarely facing the patient (being in a full, frontal position directly facing the patient); keep an Open posture (not having arms folded or legs crossed as this can suggest a ‘closed’ posture and patients can often feel like a burden so don’t want to ‘trouble’ the nurse); Lean towards the patient ; Eye contact – maintain this appropriately and finally (keeping eye contact with the patient whilst communication, however, making sure you don’t stare at them or make them feel uncomfortable); Relax, be as relaxed as you can with the patient (keep a relaxed posture, talk calmly and be comfortable around them). By following this strategy when using non-verbal communication, it is allows the communication process to be more pleasant and familiar for both the patient and nurse, not only promoting communication effectively but ensuring the patient has a more positive patient experience.
An alternative model is the model of communication, made up of four key components. Firstly there is the sender; who sends the message through a channel, which then presents itself to the receiver. Once the receiver has read the message the process of feedback then begins back to the original sender. The sender is the ‘initiator’ of communication, this could either be one individual or many which start a communication process. The message can then be sent either verbally or non-verbally to represent the ideas of the sender/s. The channel is how the message gets conveyed to the receiver, for example, written, tactile, verbal, non-verbal, etc., so can be used for most types of communication. The receiver is then the individual or individuals who have to interpret the message.
However, since individual differences occur between patients, including protected characteristics, people need to ensure that when they are using non-verbal communication they do so in an appropriate manner as to not cause offence to anyone, (for example, if you are treating a patient who has been the victim of domestic violence, abuse or a sexual attack), using bodily contact could be inappropriate and come across as highly insensitive to the individual in question). Despite there being the process of communication and ‘SOLER’ to help effective communication take place, there are barriers to non-verbal communication which make it increasingly difficult to complete the cycle. Barriers to effective communication, (Benbow and Jordan, 2013 p23), can include non-verbal (body language); linguistic (talking too slow or quick, language differences, technical jargon etc.); cultural (different values, social norms and rules, etc); social (background and education); personal (sensory deficits, poor cognitive skills, etc).
To overcome barriers to communication, there are several elements which should be considered. Selecting the best location to provide an environment to encourage effective communication to take place, (making sure you are somewhere that all individuals are comfortable in and it isn’t too noisy); ensuring that the best channel of communication is used so that both the sender and receiver can interpret the message clearly (switching between verbal and non-verbal can be useful to give individuals time to reflect on the communication which has just taken place); be culturally and socially aware of who you are communicating with (different words may have other meaning in other cultures and may have a different view on ‘social norms’ when communicating); ensure communication is always clear and accurate (do not speak too quiet or too fast, and make sure you say only what you need to so you don’t overwhelm individuals), and finally use repetition to ensure receivers understand the message being sent, (Benbow and Jordan, 2013).
Department of Health (2012) stated that we should care for patients how we would like to be cared for, by listening to what they want. Listening is one of the key components of effective communication. ‘Listening involves more than simply hearing what is being said’, (Docherty and McCallum, 2009). By hearing more than what is being said, you are looking out for cues by the patients, including things such as body language, hesitations, lack of eye contact, etc. Docherty and McCallum, (2009) also suggested we can give reassurance along with support through means of communication, when unexpected plans arise at ideal opportunities. A good factor in promoting listening and communication is ‘patient-centred care’.
Nurses can achieve this by empowering their patients and making them feel they are the only important thing at that time and they are the only person needing care at that point in time. Sometimes nurses can focus too much on their verbal communication and making sure they are constantly talking to their patient that they forget about non-verbal communication. Body language, such as eye contact and posture can be just as important to the patient as you physically talking to them. ‘Empathising with a patient, a carer, etc., can only enhance the ability to communicate effectively’, (Benbow and Jordan, 2013).
To be a successful nurse, it is essential that I am able to effectively reflect on my experiences, allowing me to become more confident and develop my professionalism. Reflective practice takes into account practice as the holistic matter that cannot be rationalised all the time, (Howatson-Jones, 2011). I chose to enter adult nursing as I believe it is a career in which you never fully finish your training, therefore, making it challenging and demanding, yet rewarding. From an early age I have used my own experiences to move forwards. My course has helped me gain confidence and acquire skills enabling me to reflect effectively, taking as much as possible from my experiences, whether positive or negative. Alongside my experience, I will reflect on how communication affected my experience of the event. With this in mind, I have chosen a personal event which I found extremely difficult to cope with at the time, yet can reflect on positively.
As with my reflective journal, I have used Gibbs Reflective Cycle (1988) (Howatson-Jones, 2011), as it has specific stages in which I can work through in order to process my experience properly, whilst learning as much as I can from it, and setting myself goals for the future. These goals should be in the form of SMART goals, (MacLeod, 2012), Specific, Measurable, Achievable, Relevant and Time bound. Stage one of Gibbs Cycle is the Focus- description of the issue. I was fourteen years old at the time, and although my great-grandmother had previously suffered several minor strokes since the death of my great-grandfather, this time it was different. We’d had a call early evening to say she had been taken to hospital, and just after midnight, we received a further call suggesting we make our way to the hospital. On arrival at the hospital, we weren’t really sure what to expect and stood outside the room, I wasn’t sure what to think.
All we knew was that my great-grandmother had suffered a major stroke. After glancing around the room, my eyes were drawn to the frail woman who laid motionless in the bed, with only an oxygen mask attached to her. She looked so peaceful; I remember thinking, just like she was sleeping. When a nurse entered, I recall the look on her face as she observed who was present; we all knew it wasn’t good news. She tried to stay strong, holding back the tears as she had previously looked after my great-grandmother; I knew they had built a strong bond in their time together. She seemed to share our pain, and right then all I wanted to do was go and show my support for her, despite it being us who needed it more. By the nurse communicating she had previously known my great-grandmother, it brought a warm sense of relief to us all; it wasn’t a stranger treating her, but someone she already knew. The nurse always maintained my great-grandmothers dignity throughout by ensuring she looked presentable and continuing to communicate with my great-grandmother about what was happening.
The nurse explained that due to the severity of the stroke, my great-grandmother would not recover, however, her body had not fully shut down. It was an unusual experience, watching her body still moving calmly up and down, knowing the end was near yet reassuring to see she was in no pain, with nurses making sure she was completely comfortable. We got the fright of our lives when my great-grandmother jolted up, sick appeared in the oxygen mask and a horrible, eerily choking sound came from her lifeless body. The nurses politely asked us to leave the room whilst they composed her. Upon returning, my great-grandmother had a new mask on, and had been cleaned up and laid back down, just as peacefully as when we had first arrived. The nurse respectfully explained to us that what we had witnessed was my great-grandmothers body by trying to cough to remove something in her throat. This links to the importance of communication.
The nurses had a previously developed rapport with my great-grandmother, whether she could respond or not and communicated with both us and my great-grandmother at all times. Although she couldn’t respond, they maintained her dignity at all times and still told her what they would be doing and why. We valued this as my great-grandmother was a very proud woman, so retaining her modesty was essential. Thanks to the magnificent nurses we had the pleasure of meeting; she received the best care I have ever witnessed. The family remained with her that night, emotions whirring round the room, the atmosphere constantly changing. We moved from sobbing our hearts out, to sitting in silence, and then singing all her favourite songs and laughing about the memories she would leave with us. The following morning we said our goodbyes and at exactly 11.09pm that evening, we received the call we had been waiting for, my great-grandmother had given up her fight, she was now in peace and with my great-grandfather.
Throughout the whole experience, one thing which got me through was the amazing communication skills from the nurses involved in the care of my great-grandmother. They always ensured the family knew what the latest update in my great-grandmothers health was, and knew what the next step would be. They communicated with us effectively, showing good non-verbal skills in the first few hours, probably finding this easier than communicating to us verbally. Stage two in Gibbs Reflective Cycle is about feelings produced. At first it was shock, everything seemed surreal. Initially sitting at her bedside, no one knew what to say. We were just numb at first. I remember feeling happy as I recalled the things she would want us to remember. We sang to her, smiling and laughing about our best memories with her until sadness crept back in. We tried staying positive, but guilt crept back upon us. Nothing can ever explain the mix of emotion I felt that weekend. Sadness like I never knew existed, happiness for which I felt guilty about anger at how selfish I thought she was being giving up on us all and heartbreak when finally she couldn’t fight anymore.
Everything seemed like a nightmare, and the lack of sleep made it hard to tell what was real and what wasn’t. One minute it seemed so certain, and the grief for the family member we had lost overwhelmed us, changing to utter hysteria and me not being able to control myself. The nurses were fantastic support for my family, communicating with us that what we were feeling was ‘normal’ in this situation, and also provided us with effective ways in which to channel our emotions. My initial evaluation (third stage) of what had happened was that although an extremely traumatic and unsettling, it was a peaceful way my great-grandmother finally went. She was comfortable and pain-free due to the empathetic nurses taking care of her. They could not have communicated any better with us; they kept information to a minimum yet ensured we knew everything we needed to. They kept us up to date with what was going to happen and made sure the family was comfortable at all times. Analysing the situation (fourth stage), I used this moment to learn to celebrate my great-grandmothers life, rather than grieve for it.
My great-grandmother was always a smiley, happy woman, she would have hated it if we sat there crying all day long. We made sure we had an appropriate mourning process for her, mixed with crying and laughter but focused on celebrating her life. The nurses assured us that it was just as important to celebrate her life, as it was to mourn the fact she was no longer with us. The fifth stage is the Conclusion and what else could I have done? Because of what had happened and how it had affected my great-grandmother, I could not wish for anything to have gone differently, other than wishing she was still here with us today. Looking back, I, nor anyone else, could do anything else for my great-grandmother. We all ensured she remained comfortable and pain free at all times, like she was sleeping.
It was at this stage that we all realised just how much the nurse’s communication had really effected our experience. Although it was still an awful experience, it was made much easier because of the nurses principles and communication skills, and it wasn’t just their communication skills with us, but those with my great-grandmother, despite the fact she could not communicate back. The final stage of Gibb’s Cycle is the Action. Due to the nature of my experience, I hope to never have to be in that situation again. However, if I was, I would like to offer more support to the nurses treating my great-grandmother. Although she was just doing her job, that nurse went beyond her duties as a nurse and became more like a friend of the family.
Throughout this essay, I have achieved a great knowledge and understanding of the six core principles of nursing. I was required to use literature to help me develop my understanding of the principles and in doing so I now know more about what is required of me as a student nurse. I am more aware of what I need to do to ensure I always meet patients’ needs, and ensure they have the most positive patient experience as possible. In order for me to do this I will strive to communicate effectively and in the appropriate manner; always respect patients’ dignity; always provide care and compassion in everything I do; I am able to create a nurse-patient relationship built upon trust, respect and rapport; I will show professionalism in all aspects of my nursing career and be aware of my emotional intelligence and learn to control my emotions appropriately.