Therapeutic Relationships Essay
This essay will explore the use of the Gibbs reflective cycle upon the development of therapeutic relationships within health and social care contexts. The Gibbs reflective cycle will be described and applied as a tool to an experience with a patient within health and social care. The Gibbs reflective cycle will then be evaluated for its efficacy and placed in context with the importance of reflective practice within health and social care.
The development of therapeutic relationships in health and social care are important in order to create and maintain a successful, professional relationship between staff and service user. This helps to promote congruence between intervention planning and treatment, increasing the likelihood of success when implementing a treatment or care plan. The Gibbs cycle (Gibbs, 1988) is a tool with which health and social care professionals and employees apply to enable reflective practice within their workplaces. Reflective practice is particularly important in health and social care contexts due to the high frequency and sensitive level of interactions between staff, patients and third parties. Reflective practice is an integral part of health and social care, particularly within nursing care (Bulman and Schutz, 2008).
The Gibbs cycle is frequently used within the National Health Service (NHS) and is utilised as a part of employee supervision to enable the individual to successfully reflect on their experiences. The outcome of these reflections can then be applied to their future practice. Reflection also contributed to continuing professional development (CPD), an integral part of the employee supervision process in the NHS and other health and social care employers. The Gibbs cycle is a particularly effective reflection tool due to its applied analysis of specific experiences, rather than arbitrarily discussing particular skills or strengths. For example, a worked Gibbs cycle example would identify specific sections of a specific scenario that may be improved upon in the future, such as ‘have more patience with an individual with a hearing impairment’. This is easier for the individual to apply rather than a general statement such as ‘have more confidence’.
The Gibbs cycle has six stages which are worked through systematically. The stages combine to form a cycle, indicating the continuous process of evidence-based learning and personal development. In breaking an experience into stages, the Gibbs cycle enables the individual to distinguish the different aspects of a process that led to a particular outcome in a particular context. For example, if an individual identifies that they felt nervous before the experience they then may be able to identify whether this had an impact upon their subsequent behaviour. Creating links between feelings, thoughts and outcomes is a fundamental purpose of the Gibbs cycle.
The first stage of the Gibbs cycle is DESCRIPTION- what happened. This is followed by identifying FEELINGS, what the person was thinking or feeling at the time of the event. Thoughts and feeling can be positive, negative or neutral. EVALUATION follows, identifying positive and negative aspects of the experience. This stage helps the individual to focus upon positives instead of just the negatives which can help to promote self-esteem, demonstrating the positive value of the person’s contribution to the situation.
A second stage of DESCRIPTION follows to establish what sense the individual can make of the experience. A CONCLUSION identifies if there was anything further the individual could do if the situation were to arise again. The individual then creates an ACTION PLAN to put these points into practise for the next time the situation happens. These points can also be transferable to other contexts and scenarios, for example, ‘ensuring read patients’ medical notes are read before meeting with them’.
The six stages of the Gibbs cycle will be applied to a real life example from practice within health and social care. Shirley is an 83 year old woman whom lives independently with her partner in her own home, receiving care twice a day from external agencies. Shirley has experienced several strokes and has hearing loss due to meningitis as a child. She has motor weaknesses in her arms and legs, associated problems with co-ordination and cognitive difficulties due to the strokes. Shirley is resistant to engaging with services and is keen to retain as much independence for as long as possible. Shirley is also a bariatric patient which increases the level of support she requires when carrying out activities of daily living and increasing her dependence on others, partly due to the unsuitability of her current living environment.
I will apply the Gibbs cycle to my first interactions with Shirley to evaluate the role of reflective practice in developing a therapeutic relationship with a service user. The first step of the cycle is description: I met with Shirley at her own home with my mentor, whom had previously met with Shirley several times. The second stage is to describe my thoughts and feelings. Before I met with Shirley I felt slightly apprehensive and thought I may be out of my depth working with a service user with such complex needs. I was also worried that I would find it difficult to understand her speech and communicate with her effectively. I had previous experience of working with service users who have a hearing impairment, but not with service users who have speech production difficulties. When I first met with Shirley I felt nervous and panicked at first when it was difficult to understand what she was saying due to her facial muscle weakness.
This also made me rather self conscious. As time passed and I acclimatised to her speech I relaxed, increasing in confidence when communicating with her and applying my active listening skills. Each time I have met with Shirley since then has helped to further develop my abilities to communicate effectively with her as an individual. I also knew it was important to be aware of the Mental Capacity Act- assuming full capacity unless proven otherwise (Mental Capacity Act, 2005). I knew that Shirley had difficulties with motor co-ordination and ensured that I was sensitive of this and did not rush her in any way. I was aware that Shirley was a bariatric patient before I met her and was unsure if she may be embarrassed of this, so I ensured not to refer to this unless it was entirely relevant. I was also aware that she has been resistant to health and social care services in the past and wondered if she may present with challenging behaviour towards myself or my mentor.
When reflecting on the development of a therapeutic relationship with Shirley it is important to identify positive and negative aspects in accordance with the third stage of the Gibbs cycle to develop reflective practice. Positive aspects included using my previous experiences with other service users to help think on my feet as I continued to communicate with Shirley, noticing particular sounds that had significant meaning to her and remembering these for future reference. Other positive aspects included observing my mentor in how she communicated effectively with the service user and mirroring these techniques myself. My mentor also discussed used open-ended questions to discuss particular topics with Shirley that she clearly enjoyed and witnessing these conversations provided me with ideas for what to talk about in the future. Negative aspects of the experience included being unable to understand Shirley at first due to her difficulties with speech production and also feeling self-conscious when I was unsure of what to say to her.
Completing the previous stages of reflection also helped me to make sense of the situation, the fourth stage of the Gibbs cycle. In highlighting the positives and negatives it is clear that my preconceptions may have compounded my nerves and uneasiness when presented with a situation that I was unfamiliar with. However, by following my mentor’s example and modelling her behaviour, my confidence increased and my proficiency with it. Future exposure to situations like this will help to develop my active listening skills further.
There are other things I could have done to improve both my and Shirley’s experience. I could have been more assertive and confident on our first meeting, which may have helped to ease my nerves and would have helped her also feel more at ease. This would have helped develop our therapeutic relationship, confirming her faith in me as a healthcare professional and providing her with the confidence that I was fully capable of confidently carrying out my assigned duties. I could have been more honest with Shirley and asked her politely to repeat herself if I did not understand. I believe that if I hadn’t anticipated difficulties in understanding Shirley before I had even met her than I may have felt more at ease when first communicating with her. Whilst I knew Shirley was resistant to engaging with services, this shouldn’t have led to my prejudgment that she may be difficult to talk to or communicate effectively with.
The final part of the Gibbs cycle is to create an action plan to identify what could be done if the situation were to arise again. When developing a therapeutic relationship with Shirley, I feel in the future it would be beneficial to address my concerns in further depth with my mentor prior to meeting a service user. This would enable me to obtain advice that I could then implement to improve my ability in developing therapeutic relationships. For example, Shirley has associated language comprehension difficulties. If I had discussed her case further in depth with my mentor, this would have enabled me to gain strategies on how to best overcome this, such as repeating information or using different language styles. I could also improve my knowledge as to the difficulties the service user may experience.
For example, whilst I was aware that Shirley experienced ‘cognitive difficulties’ prior to meeting her, I was unsure as to the specifics of this and the true impact that these may have upon her ability to live independently within the community. Identifying the different aspects of cognition such as word production and comprehension, memory and processing skills would have helped me to understand fully the difficulties she may have experienced, particularly when communicating with others. Researching relevant topics would also help me to identify a possible relationship between Shirley’s cognitive difficulties and her subsequent disengagement with services.
Completing the Gibbs cycle with a patient example from my experiences of working in health and social care highlights the necessity and importance of reflective practice. Reflecting on an experience in a structured way enables the individual to become self critical, increasing self awareness of thoughts, feelings, behaviours and actions for future practice (Ghaye, 2011). Reflective practice increases staff competency and can be completed alone or within a structured supervision session.
However, the accurate recording of reflective practice can be limited despite its great value to service improvement (Norrie et al, 2012). It also opens channels to create peer discussion on how best to improve the service and experience for service users. Receiving an external opinion by discussing completed self-reflective tasks with others can be beneficial by gaining insight and experience from an alternative source. Due to the personal nature of reflective practice it can be difficult to be self-critical and objectively identify areas of improvement.
In many health and social care professions reflection is a required process that must be continually carried out throughout employment as a registered professional, including social workers, adult, learning disability and mental health nurses and occupational therapists. This can also be a requirement of the associated professional bodies as reflection is considered to demonstrate the individual’s ability to continually improve their ongoing professional development as an employee. Reflection encourages professionals to develop appropriate therapeutic relationships with their service users. The continuation of evidence-based practice is vital to the consistent improvement of health and social care services and helps each practitioner to continue their personal and professional development in a person-centred way.
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Gibbs, G. (1988). Learning by Doing: _A guide to teaching and learning methods_. Further Education Unit. Oxford Polytechnic: Oxford.
Mental Capacity Act 2005. C.9. London: HMSO
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