THERAPEUTIC NURSING

Therapeutic nursing has been defined as ‘that practice where the nurse has made a positive difference to a patient or client’s health state, and where he or she is aware of how and why this positive health difference has occurred’ (Powell, 1991). Four main areas (Table 1.2) in which nursing can be seen to be therapeutic have been highlighted by MacMahon and Pearson (1991).

Rheumatoid arthritis is an incurable condition but the goal of well-being remains realistic. Supportive nursing has a role to play as the aim of many of the interventions (both medical and nursing) is to limit the potential for further deformity and disability. One example is disease-modifying drug therapy such as methotrexate or gold injections. However, to adopt an exclusively supportive approach would be detrimental to the patient, as it does not allow the patient to participate in the control of their management. Control is retained by the nurse, stifling any attempt by the patient to take an active part in their care.

Some nurses do not wish to develop a therapeutic relationship with patients (Salvage, 1990) and others do not value working with patients whose conditions are not amenable to cure (Nolan and Nolan, 1995).

In order to improve the patient’s well-being the nurse must play the roles of:

educator

guide

motivator

supporter.

The satisfaction obtained when the patient and the nurse grow together, will help to remove some of the negative perceptions that nurses sometimes acquire when caring for patients with long-term needs.

THE NURSE/PATIENT RELATIONSHIP

Salvage (1990) has questioned whether patients desire a close relationship if their immediate concern is relief from pain and discomfort. This may be relevant to patients experiencing acute illness, but in chronic conditions it takes time and close cooperation to cope with pain that cannot be alleviated. This is where individual patient assessment is so important. It should be remembered that some patients may not perceive benefits from developing a relationship, and so long as the patient is aware of how to renew or establish contact should a problem occur, this view must be respected.

PATIENT PERCEPTIONS

Some patients with rheumatoid arthritis have a negative concept of the future that persists even after their condition is in remission (Hewlett, 1994). The nurse should identify and address any problems perceived by the patient in the initial assessment. If the patient is convinced that the future means a wheelchair existence, it is not helpful to be told that only 5% of people with rheumatoid arthritis require a wheelchair. Patients require acknowledgement of their problems and explanations provided within their own context (Donovan and Blake, 2000).

The concept of shared care, where the patients take responsibility for their condition with support and guidance of a named nurse, offers the best way forward. Patients who believe they can influence their condition will report fewer physical problems and enhanced well-being (Newman, 1993).

Adopting a holistic humanistic approach to care requires a change from the supportive role of doing for the patient, to a therapeutic approach, which necessitates enabling the patient to feel in control (Chapter 5). For instance, if the patient’s main problem is that of pain, the nurse can have a therapeutic input by establishing in conjunction with the patient, the pattern, type and severity of the discomfort, whether or not it is related to activity, and the apprehensions and anxieties associated with it. This is a two way process, first achieving clarification of the problems from the patient’s perspective and then working in partnership to minimize the stressor. By the use of empathy, respect and trust nurses enable patients to believe in their decisions.

It is also essential to encourage those who have value in the patient’s life to participate in care management. For example, rest is an important part of the treatment for a patient with a systemic condition such as rheumatoid arthritis in which both physical and emotional fatigue can occur. If the family is unaware of this, pressure may be placed on the patient to abandon resting. This can be avoided if the family learns the role of rest in the management of the condition. If there is an absence of shared understanding within the family, the patient may try to disguise their limitations resulting in increased symptoms and a reduced quality of life.

BARRIERS TO THERAPEUTIC PRACTICE

THE VIEW OF NURSING

Some nursing activities, such as assisting a patient to bathe, are often considered to be basic or menial where in fact they are essential to a patient’s wellbeing. Technical skills are associated with greater status and are therefore deemed to be more important than basic care skills. Therapeutic nursing will include technical skills, but at its core is the realization of the value of expressive skills (Wright, 1991) which include the ability to:

be with the patient

provide comfort

provide education

provide the emotional element of care.

Within the framework of therapeutic practice, no act of care having relevance to the patient can be described as menial. Indeed high technology skills without the addition of high touch skills have little meaning for the patient concerned (Wright, 1991). The importance of these expressive skills must be emphasized and should therefore be taught at both basic and post basic level. A nurse engaged in therapeutic practice will relate to the patient as an individual, adopting a combination of skills that are perceived to be beneficial and to solve the patient’s problems. Nursing should not be embarrassed by this caring element, but should strongly endorse it as the component, which the patient directly relates to the success of their nursing care (Smith, 1992). The challenge to nurses is to combine both technical and comprehensive skills into a healing whole, which serves the patient (Wright, 1991).

EMOTIONAL INVOLVEMENT

It has been suggested that nurses do not want to develop the relationship required to nurse patients with a chronic, or indeed an acute, illness. A study of communication between nurses and patients on a surgical ward found that nurses in close relationships concentrated on medical treatment rather than emotional need (Macleod Clarke, 1983). To some nurses, working with patients who have ongoing needs offers little job satisfaction because they are unable to sustain a sense of therapeutic optimism (Evers, 1991; Reed and Bond, 1991; Reed and Watson, 1994). It is possible that rather than working in partnership with the patient to establish shared objectives, nurses set themselves unrealistic care objectives from their own frame of reference. Establishing and being committed to a relationship is demanding as it is necessary to give of one’s self to develop the trust needed for partnerships to grow. To encourage this depth of involvement or emotional labor (Smith, 1992), a nurse needs to work within a supportive framework with an assigned supervisor to assist with personal and professional development. Wright (1986) has stated that all nurses need the opportunity to:

share feelings

express views

raise questions relating to practice in a structured fashion.

WORK ENVIRONMENT

The culture in which nurses work does not encourage them to spend time talking to patients, but time is essential if a relationship is to develop. There is still emphasis on achieving tasks rather than engaging in therapeutic interventions, and emphasis on a growth of support workers at the expense of qualified nurses. If these trends continue, it is questionable whether it will remain possible for a relationship to develop on anything but a superficial level.

In some hospitals, the outpatient department may be the only environment where the patient with a chronic disease is cared for, and so all newly diagnosed patients should be referred to a rheumatology nurse to begin the process of therapeutic care. A realistic personal profile of care should be established which could be used by other key workers, such as the physiotherapist or practice nurse, so maintaining the continuity of care between the secondary and primary health care sections. Care profiling and planning needs to be dynamic, otherwise it will raise expectations and then cause dissatisfaction if identified needs are not met.

Therapeutic nursing requires a nonhierarchical method of care delivery that enables nurses to be involved in the decision-making process and places them in a position where they can develop a partnership with the patient. The philosophy of the work environment is of vital importance because if the nursing team is not committed to developing a relationship, a relationship will not occur. The belief that therapeutic practice is of mutual benefit will only become reality if it is actively fostered and reinforced by the organization that delivers care. A routinised and ritualistic approach will not serve the needs of the patients.


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