Issue 1.
When the nurse first approached the patient during the orientation phase, she did not identify herself, establish her qualifications or role in the patient’s treatment, and in particularly, she did not greet the patient by her preferred name. This was seen when she walked into the room and unprofessionally addressed the patient by; “Mandy”. To this, the patient uncomfortably proceeded to correct her name to be “Sandra” and yet even after this correction, the nurse chose to call her “Sandy” instead, which violated the patient’s right to choose her preferred name. It is essential that this first level of information is correctly gathered and implemented as it is one of the key steps in building rapport and trust if one wants to form a strong foundation of a therapeutic relationship (Sheldon 2014). It is a step that forms a professional bond, and without it, the nurse immediately becomes under involved with the patient and essential information may not be interchanged within the relationship (Sheldon 2014).
To improve this situation, the nurse should have walked into the room with professionality, ready to address the patient using a title such as ‘ms’ or mrs’, in conjunction with the patient’s surname listed on the chart (Tsernov 2017). This information should have been gained during the pre-interaction phase where the nurse was expected to learn basic information about the patient (Renjulal 2017). After this, the nurse could have then proceeded to ask if the patient had a preferred name that she would rather be addressed as. This would ensure the patient felt respected and could see the nurse as involved and considerate of her identity. In a recent survey, it was also found that 80% of patients wished to shake hands upon meeting someone as it was seen as a more traditional, respectful and familiar way of greeting someone (Tsernov 2017). By improving her non-verbal cues of communication, such as improving her body language (ie open body language), shaking the patient’s hand, maintaining her personal appearance before, during and after associating with the patient, as well as respecting the patient’s space and territoriality (Tsernov 2017), the meaning and sincerity behind her verbal cues would have been accentuated and the therapeutic relationship improved.
Issue 2.
During the working phase, the student nurse severely undermined the patient’s feelings and did not possess adequate information as to suggest to the patient herself that her diagnosis was not important. Regardless, a patient’s feelings should be valued and in person-centred care, the patient should be treated as an expert on their own health (Sepucha, Uzogarra & O’Conner 2016). This was not evident and you could visibly see that the patient was suffering discomfort but didn’t disclose the information in fear that it would be brushed off once again by the nurse. It is essential that all patient information be gained and recorded because if a complication was to arise, the incorrect treatment could be given based on this unreliable information (Goulden, 2013).
During the pre-interaction phase, the therapeutic relationship should have already begun, meaning the nurse should have already looked over Sandra’s charts and become familiar with who she was, past-history and reasons for her treatment (Kelley, Docherty, Brandon 2014). Unlikely to be her primary caregiver due to being a student nurse; information should have also been retrieved from the care team or person (ie her collegues) primarily responsible for Sandra’s care. These external sources provide valuable information which can aid in knowing the patient beyond their clinical diagnosis (Kelley et al. 2014) and in Sandra’s case, asking external sources would have been the best option due to her ample breathlessness and lethargy, which would mean reliable and accurate information would have been difficult to obtain. Furthermore, the student nurse’s inefficient therapeutic communication techniques should have been observed and intervened by the supervising nurse prior to being left unattended in the first place as this would’ve ensured that they knew that the practice nurse was incapable of treating the patient alone. Further actions should have then been taken to ensure that the practice nurse be entirely removed from the hospital setting due to her negligent and inappropriate therapeutic behaviour.
Issue 3.
Talking about the nurse’s weekend in a clinical setting also severely violated her boundaries by over disclosing her personal information instead of solely treating the patient (Levett-Jones 2018). Even though sharing person information can be effective in showing empathy and realness to the patient to decrease their anxiety (Simon 2017), in this case, the information which was shared did not aid in the patient’s wellbeing or clinical treatment.
Instead, the nurse should have been aware of her boundaries and kept within them to maintain professionality, respect and trust. By only addressing relevant information key to Sandra’s treatment, she would have avoided this boundary crossing which would have thus prevented the patient-nurse relationship from being affected. Once affected, the relationship between them may have also been irreversibly damaged (Simon 2017). Furthermore, the nurse should have been consistently psychologically self-aware (ie empathetic) of how any events occurring outside the healthcare setting could have affected her wellbeing (Cooklin, Lucas, Strazdins, Westrupp, Giallo, Canterford & Nicholson 2013). For instance, the patient could have been experiencing maternal separation anxiety which could have heightened her feelings of anxiety by being separated from her two children (Cooklin et al. 2013), and instead of the nurse focussing on these underlying issues, she chose to reverse the patient-nurse role and focus on herself.
Issue 4.
During the pre-interaction or introductory phase, the nurse should have made herself aware of her patient’s holistic health status and known that she had a partner and kids at home. Regardless, the nurse bluntly bringing up a past relationship of the patient in this clinical setting directly breached her professionalism and majorly disregarded the patient’s dignity towards her family. It subjected the patient to an awkward situation and in respect to the ‘Nursing Professional Standards of Practice and Behaviour for Nurses and Midwives’, the nurse thus failed to promote necessary professionalism and trust which is a key theme to this practice (NMBA 2018). More specifically, the nurse failed to comply to Standard 2 of purposely engaging in a therapeutic and professional relationship (NMBA 2018).
In nursing, boundaries can be easily crossed and even violated if one is not careful in distinguishing the line between a therapeutic and personal relationship with the patient (NMBA 2018). In this case, the student nurse violated the boundary by talking about irrelevant information which did not help build nor have any significance to their therapeutic relationship. Even though she believed to know Sandra, she should have remained professional in treating the patient and/or told her supervisor about her history with the patient and how it would affect their professional therapeutic relationship (Montenegro 2013). This is important as a nurse should not treat someone they have a personal connection to for various reasons. For instance, the patient may not only feel uncomfortable disclosing certain information that may be essential in the establishment of a diagnosis (Kling 2015) but the nurse themselves may also feel uncomfortable with ascertaining this sensitive information or conducting an exploiting or sensitive procedure (Kling 2015).