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April 13, 2019 Nursing

This essay will discuss the importance of communication and of developing a therapeutic relationship with a service user on an acute ward. The names included in this essay have been changed to respect the service user’s privacy and confidentiality (Nursing and Midwifery Council, 2018).
Maria, a 64-year-old lady, was admitted to an acute psychiatric ward following a deterioration in her mental health, she a has a longstanding diagnosis of schizophrenia, but little is known about her historically, as it appears she has not been involved with mental health services for a long period of time.
Her Core assessment recognises that she has been of no fixed abode for many years, choosing to build a shelter within the grounds of the local cathedral. This has never been a problem, until recently when Maria started to gather, burn wood, and rubbish, this could have been due to the cold conditions she was having to live through. Maria was assessed under the Mental Health Act 1983 and detained on a Section 2 for assessment. The Mental Health Act 1983 states an application for admission and assessment should be made on the grounds that a person is suffering from a mental disorder of a nature or degree which warrants the detention for assessment of a limited period, and should be detained in the interest of themselves or others in regard to health and safety. Considering Maria’s diagnosis of Schizophrenia, and the risk to herself and others in setting fires in a public place, this would appear to be the only option available to those assessing Maria at the time.
According to Lewis and Buchanon schizophrenia as a disease has often been debated. It is strictly speaking a syndrome, a disorder for which there is no objective test or pathology, but is identified by a cluster of symptoms over a period of time (Lewis and Buchanan, 2015). These symptoms are characterised into positive and negative, with positive symptoms related to perception disturbance, hallucinations, delusions and thought disorders, whilst negative symptoms refer to a deficit in normal mental activity including lack of motivation, difficulty in concentrating, anhedonia (difficulty in experiencing pleasure) and alogia (having a feeling of emptiness (Norman and Ryrie, 2013 p.526).
On admission Maria could communicate, though this was stinted, with her only speaking when spoken to, and giving one-word answers. Two-way communication is of obvious importance when assessing and caring for someone; Article 8 0f the Human Rights Act 1998 states that an individual’s wishes and preferences must be considered wherever possible, for this to be achieved, effective communication is a must. Mental Health legislation provides the ability to enforce treatment and detain a person, but this should be based on a participatory approach with professionals also considering diversity, choice and acting in the best interest of the individual (Barker, 2003, p497-502), we can only learn of a person’s choices through effective communication. The communication process can easily be disrupted on an acute psychiatric ward, where a service user’s illness, ward dynamics, time restraints and noise may prevent or hinder effective communication. (Laker, et al, 2014) The NMC code of practice recognises that it is the mental health nurse’s responsibility to overcome these communication issues (Nursing and Midwifery Council, 2018).
This lack of effective communication makes assessment difficult, NICE guidelines on schizophrenia, state assessment should include a comprehensive assessment from a multi-disciplinary team. (NICE, 2014), but one could argue, more important, is the difficulty in developing and maintaining a therapeutic relationship. A therapeutic relationship is one of the mainstays of the care that we give, this theory was developed and has evolved from Peplau in the 1950s. By developing therapeutic relationships, we can work in partnership with service users, who are often experts on their own mental health, and are able to help us as professionals identify their strengths and needs, which in turn can aid recovery. In relation to Maria, we were unable to develop this relationship in the short term, leading to what could possibly have been a lack of trust, her mood appeared to deteriorate, Marias diet and fluid intake was poor and she eventually stopped getting out of bed.
It is suggested that those who have, or currently use mental health services value communication and interpersonal skills on both an individual and group basis. A research paper called Most Important Events’ and Therapeutic Factors: An Evaluation of Inpatient Groups for People with Severe and Enduring Mental Health Difficulties, identifies communication as the second most important event in group activities. Being given the opportunity to express one self, give an opinion and to be listened to and understood was of upmost importance to them. (Bledin and Lost, 2016).
Marias deteriorating mental health could have been an obstacle to developing a therapeutic relationship, Barker suggests that disturbances in thought could be a barrier (Barker, 2003. p140), though it could be argued that nurses often fail at the first phase of developing a therapeutic relationship, this stage is the orientation stage, it is at this stage we should develop trust, take time to listen, reflect on what is being said, provide structure and be consistent, though with workloads continually growing, the high turnover of patients on an acute ward, limited recourses, for example staffing, and the service user already distrusting us due to being detained under the Mental Health Act (1983) there are already real barriers to communication. (Laker, 2014)
Obstacles in communication can cause difficulties when making decisions about care. In Maria’s case, her refusal of most fluid and diet had a detrimental effect on her physical health, with a low BMI and spending time in bed causing her skin to break down. The Mental Capacity Act 2005 Code of Practice states that a duty of care is applying certain standards and skills, and that staff should act in the best interest of a person (Mental Capacity Act 2005). It may appear obvious to nursing staff that at this moment in time Marias physical health should take priority, conversely Maria is able to communicate with staff, that she does not wish to eat or drink, she achieves this with nonverbal communication. Egan’s skilled helper model (in this case the skilled helper is the registered nurse) acknowledges that effective helpers need to learn body language and how to use it effectively with clients. (Egan, 2010) One could argue that nonverbal communication is subjective, and if this is the case, Maria could be hungry because nursing staff have interpreted what is being said wrongly.
Maria’s lack of communication would not necessarily mean that she lacks capacity, as already stated, her lack of communication could just be mistrust in an individual or a service. With the Mental Capacity Act 2005 stating that a person should be presumed to have capacity and that should a person make an unwise decision, they do not necessarily lack capacity, this aides best interest and encourages service users to be able to make informed decisions. It is difficult to know if a service user’s refusal of care, for example diet and fluid is due to lack of capacity or an autonomous decision. Autonomy is based around informed consent and demonstrates the NHS values of respect and dignity, whilst also showing many of the principles of nursing values (NHS England, 2013). Informed consent requires that medical treatment only be given to somebody who has been given information that makes them aware of what may happen, and the consequences of either having or not having treatment. Though care may be provided in an emergency, or authorised by law.
Beuachamp and Childress definition of paternalism is ‘the intentional overriding of one’s personal preference or actions by another person, where the person overriding justifies the action by the goal of benefitting or avoiding harm to the person who’s will is overridden’. Despite staff working in the best interest of Maria, it could be that they were being paternalistic or manipulative. Barker argues that this is common practice, and a
service user’s refusal of food often creates conflict, requiring capacity to be assessed, and at times even subtle coercion used, though when this happens there is a potential breach of ethics as the service user’s autonomy is compromised. (Barker, 2003. p 510) It could be argued that if Maria was known to services, or the orientation phase of the therapeutic process had been achieved to a better standard staff would have a greater awareness of Maria, and an understanding of her identity and her decisions. In the case Malette v Shuman it is acknowledged that clinical information may be irrelevant if a decision is based on personal values that are unrelated to clinical context, meaning that a person’s decision may be based on other information or expertise other than clinical. (Malette v. Schulman 1990) (Welles, P 2013, p4-8).
Communication in mental health nursing is an essential component of all therapeutic interventions (Morrissey and Callaghan, 2011, p1) with Peplau arguing that effective personal skills are central to forming a therapeutic relationship with service users. The ability to form these relationships stems from effective communication and can enable better care delivery, a greater understanding of the service users’ needs, promote independence and allow nurses to work in a person-centered way, thus promoting effective care pathways and treatment plans, conversely, poor communication often leads to poor care delivery. It is also increasingly suggested, and documented with in research, that recovery rates are greatly improved by the use of effective communication. (Dougherty and Lister, 2007) The practice of involving people in their own care is not new, the NHS Plan boldly stated in 2000 that ‘Step by step over the next ten years the NHS must be redesigned to be patient centered – to offer a personalised service, by 2010 it will be commonplace’ (Department of Health 2000, p 17). This plan recognised that service users have a unique insight into their own needs and what will help them as individuals towards recovery. Arguably this plan has not come to fruition with the Kings Fund asking “Why, in 2014, despite increasingly having all the essential tools and knowledge available to empower patients to have greater control over their own health and care, have we failed to make significant progress”? It could be argued that there has been improvement, though there is still a long way to go, when we detain someone under the Mental Health Act and administer medication under restraint, are we working in their best interest and empowering them to make choices, one could argue not.
It is easy to see why communication is at the heart of care, and embedded into in to our base values, the 6 Cs of nursing. It is suggested that communication is central to recovery orientated practice, with nursing staff being encouraged by Shepherd to use ten top tips for recovery, showing the particular communication skills required of the nurse to promote this (Sainsburys Centre for Mental Health/Geoff Shepherd et al 2008). In using these communication skills, the mental health nurse is encouraged to reflect on whether they are using evidenced based practice, showing, and communicating core values and promoting wellbeing (Morrissey and Callaghan, p29). The Department of Health stated that mental health practice needs nurses who can offer more skilled and effective communication (Department of Health 2006). It could be argued that all care staff working in mental health, with service users, have good communication skills, after all the need to communicate is ongoing, though it is interesting that there is little training available to staff on how to communicate effectively. If as research suggests, communication is a fundamental component of all therapeutic interventions, it could be asked why so few mental health staff are aware of models and frameworks of communication. John Herons Six category model is suggested as a therapeutic model of communication (Heron, 2001). This model is proposed by Morrisey and Callaghan as a flexible, user friendly framework to develop a nurse’s therapeutic interventions, whilst facilitating the application of communication skills (Morrisey and Callaghan, 2011). It Chambers states that the model has been influential in helping mental health nurses to develop a frame-work for their interactions with patients. This influence is surprising considering the apparent lack of empirical evidence. It is suggested that the value of Herons model as an analytic tool investigating interpersonal relations in nursing be evaluated and investigated (Sloan and Watson, 2001).
The use of models in practice for mental health nursing is thought to be necessary, to organise and attempt to bridge the gap between theory and practice. It could be argued that there are so many theories and models that either focus on mental health or the wider context, that far from promoting organisation they may leave the professional feeling confused. Pajnkihar argues that nursing models fall short when it comes to being evidenced based, with many being archaic, though recognises that as a framework a model can be a useful tool. (Pajnkihar, 2011. P32-33). The nursing model activities of living, developed in the early 80s has often been used as a tick box exercise, though originally was developed to assess the changes in a service users life on being admitted in to hospital and being diagnosed, it now allows nurses to assess a service users societal needs, and what can be put in place to support service users on discharge. The activities of living are listed in words, including communication, eating and drinking, elimination, washing and dressing, controlling temperature, mobilisation and others. This list is possibly why the model is now often used as a tick box exercise, though if used correctly the model promotes individuality, with the service user placed at the centre of their own care by recognising individual needs. Roper et al recognises the importance of effective communication by including it as a heading in this model, and enables the professional to think about interventions that can be put in place to assist with this need.
When thinking about communication there are many models that one could choose from, but how helpful would any have been in communicating with Maria? Looking at a simple model Shanon and Weaver, it consists of a sender, a message, a channel through which the message travels, interference and a receiver (Shannon and Weaver, 1948) This model is missing a step in the communication process, feedback, without this it is impossible to know if the message has been understood. Wilbur Schramm modified this, arguing that the context of the relationship between communicator A and B, and the social environment the communication was taking place in, would have an overall effect on the outcome of the communication (William Schramm, 1954). It can again be seen why that initial conversation and other contextual factors are so important when speaking with service users.
Communication is essential for sharing knowledge, promoting safe practice and ensuring a service users’ needs are at the centre of the care we give. A service user often receives care from many different practitioners providing different aspects of care, whether this be for physical, mental health or both, effective communication ensures cooperation and coordination between those in an individual service and other care provided. Conversely, it can be argued that a lack of effective communication can cause, and be the leading cause for inadvertent harm to service users. This harm can include test duplication, delays in treatment, a deterioration in a service user’s health and an increase in preventable hospital admissions (Royal College of Physicians,2017).
Historically barriers to effective communication amongst professionals have included the way professional groups have been trained to communicate, with doctors being concise and nurses taking a more holistic approach, this has led to misinterpretation of messages being communicated, the SBAR meaning Situation, Background, Assessment, and Recommendation was developed to bridge this difference in communication methods, enabling effective communication in almost any clinical setting, though the author of this essay can see the benefits of using the SBAR it is a very succinct way to communicate and could discourage nurses from using holistic communication skills and handing over any human factors that are so important when caring for someone.
In conclusion, effective communication is necessary both on an individual basis, within clinical teams and the multi-disciplinary team and also between different service providers. Effective communication encourages and allows for good leadership, collaborative working, informed decision making and possibly, most importantly the inclusion of a service user at the centre of their own care. Effective communication is also essential in promoting safe working practices, aggression and what professionals often perceive as challenging behavior, these can stem from either a misunderstanding, or a service user being in distress, a therapeutic relationship, built with the use of effective communication with both the service user, their family and carers can help to prevent this.


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