The health professional–patient relationship

Everyone has had the experience of feeling helped by someone else. It hasn’t simply been that someone has done something to us or for us but the way we felt the helper, whether professional or not, had given something of her or himself in the interaction. The philosopher Heidegger (1927) has written about the experience of realising what it is to be human and existing, or being. But, he adds, we are also in this world with others and can, at times, sense an experience of our lives being shared with others, or a being withness. Through the helping relationship, the practitioner and patient may share this sense of two individuals working together (Stein-Parbury 2005). There are important and useful skills that can aid in effective health professional–patient communication but there is a danger of focusing on the skills, or how to, of communication and leaving out why one is communicating. Experiences with patients and colleagues have the potential to have some meaning; a sense of a shared humanity. It is important to bear this in mind when reflecting on the rest of this chapter.

The humanity of health professionals

Stein-Parbury (2005) has pointed out that health professionals don’t ‘leave themselves behind’ (p 50) when working with patients. We are human beings with our own unique personality and style of relating. But, on the other hand, the interactions between people in a healthcare setting have a purpose: the primary focus is the patient; that is, what are this person’s needs at this time? This might not just be the immediately apparent problem. For example, a person may require an exercise program but be worried about how they will cope with it. It might be necessary to explore his/her fears. It is possible, especially when carrying out patient care for the first few times, to become preoccupied with the tasks one is ‘doing’ to the patient, rather than being aware of the individual’s needs: psychological and spiritual as well as physical. This can also be a problem when an activity may become so much a routine that one doesn’t give much conscious thought to what they are doing.

Social interactions and helping relationships

Another issue that arises in the clinical setting is the possibility of confusing social interactions with helping relationships. There is a different quality to interactions in a clinical setting to those with friends. With friends it is possible to often share very personal aspects of one’s life: enjoyment as well as suffering or disagreement. In an ongoing friendship or relationship each has, over time, got to know the other and appreciate their interests and wants; one knows what things can be discussed, what are the other’s weaknesses and strengths. In short, there is a level of trust in each other that only a long-term relationship can achieve, with a freedom to talk about anything and share little things, such as a particular sense of humour. Sometimes one may help the other or be a good listener when their friend needs someone to talk to. The roles are not fixed.

Health professionals don’t reveal their personal lives to patients, nor are they usually in the role of being helped by patients; the focus is on the patient. There are invisible boundaries that all individuals erect around themselves, depending on the situation. It is not usually considered appropriate to talk to a stranger about all of the personal details of one’s life. But that boundary is not usually so strong when with family or friends whom one trusts. With experience, the developing young person learns where and with whom to share their thoughts and feelings. Thus health professionals direct their attention to the patient’s needs, not to one’s own, and to gathering all the objective and subjective data necessary for a successful outcome to the clinical intervention.

Patients are not friends

Beginning professionals may sometimes not realise that patients are not friends and that there are different ‘rules’ in communicating with them. It may be possible to initially be informal and engage in social chit-chat with some patients but it is important to first be sensitive to the individual one is caring for and be prepared to work at establishing a helping relationship. For example, it might be more appropriate to address someone by their title and surname until it is established that the person is comfortable to be called by their first name. It takes a long time to establish the relationship style one has with friends and there isn’t usually that amount of time available in working with patients. That doesn’t mean one either treats patients as friends or, at the other extreme, with no concern for their feelings. Although clinical skills and knowledge are very important in being a safe and competent health professional, it must never be forgotten that the tasks and procedures are being done to real people with real feelings of pain, fear or any others of a wide range of emotions and sensations. To be able to enter into their experiences is not simply a right for practitioners but a privilege that patients have given through their consent and trust.

Interpersonal communication

It is part of being human to socialise with others. Communication has always been an important aspect of creating the basis of civilisation as it is today. Through communication, we can share our experiences and knowledge, teach each other skills and help each other. In 1960 David Berlo described his SMCR communication model. This involves a source (encoder), message, channel and receiver (decoder). He emphasised a two-way, simultaneous process involving two people in a dynamic relationship. The success of the encounter depends on the encoding and decoding skills of both, that is, the meanings each person gives to each aspect of communication. This can be an issue in healthcare as the professional may not always possess good communication skills and the patient, for a variety of reasons including their health status or not having a shared culture or language, may not either.

As well, the meanings for each will be different. What a professional regards as routine may be novel and possibly frightening to a patient. A health professional may do the same thing day in, day out but not everyone will get as much practice at being a patient. Simply having to be a patient may be challenging for many people. Admission to a health service may be elective or planned, or it may be due to an emergency. Either way patients are usually only in that role for a brief time and may not usually have the opportunity to develop a sense of familiarity in the role. Usually it is also not a situation most of us would choose to be in. However, health professionals, after some time in their position, have acquired a skills and knowledge base within which they practise, perhaps without giving much thought to their everyday activities. After some years of education and training in their chosen discipline it has become part of their lives. It can become easy to forget these differences in roles between professionals and patients.

CRITICAL THINKING

Consider how you like to be addressed by a stranger. Try to ask people you know from different age groups what their preferences are and compare. For example, what are the differences between talking to a teenager and someone who is 65 years of age? Consider the SMCR model and organise these differences under each heading. This is an important issue to think about, in that the majority of individuals in hospital are now aged over 60 (AIHW 2007).

Being professional: distance and intimacy – focus on the patient

In today’s healthcare, roles are much less differentiated than in previous years and health workers might now be more open and reveal more of their own personalities than before (Nelson & Gordon 2006). For example, in many public hospitals many doctors do not wear white coats; health professionals might wear more casual-looking clothes rather than formal white or green uniforms so that a patient might be confused about which role the person assisting them has. This may cause concern to some patients.

At a time when roles are more blurred and many express the need to be treated as equals, what is the best way to relate to patients? How do they want health professionals to relate to them? One should be sensitive to how a patient behaves in interactions and modify responses in line with this. Sitting in different health professionals’ waiting rooms one may observe the approaches of various receptionists to patients. Some vary their style depending on the patient. They may addresss them using their first name or title; they know their patients and how to communicate with them. Others don’t vary in their approach, always using the first name or a term such as ‘darl’ and it is interesting to see how some patients are quite relaxed about this, while others visibly bristle.

Being an effective communicator means trying to ‘read’ patients and how they respond to what one says and does. Of course, the task will often dictate the interaction; one might be assessing the individual’s health status, taking a blood specimen or consulting them about their dietary needs, while at the same time engage in a conversation about the weather or their interests outside the healthcare situation. Conversation may act as a means of lessening the patient’s (as well as sometimes one’s own) anxiety or generally defusing the tension of a situation. Again, the focus should always be on the patient and what their needs are.

Being aware of one’s own effect on others

Sometimes health professionals can behave in ways that might aim more at easing their own difficulties in dealing with people. It is important to be aware of one’s own emotional reactions when with patients and consider possible ways to adapt alternative styles of relating to patients. It is useful to reflect on one’s usual response to others before actually being with patients. Harms (2007) describes an incident where a student social worker screamed when seeing a patient’s injuries. This was the first time she had confronted such a situation. This was not helpful to the patient, although for her it was what she might have normally done. Responding to patients requires us to be aware of our own feelings and reactions in different situations. Seeing a sick or injured person for the first time might be stressful or anxiety provoking. But if one has spent some time considering the range of individuals likely to be encountered in healthcare beforehand, the shock may not be so dramatic. It is common practice in many disciplines or healthcare agencies to have preceptors, mentors or clinical supervisors. The aim is to provide support and teaching to novice health professionals from a more experienced professional. If such an individual is not available in one’s workplace, it is important to try to seek out someone who can be trusted to provide the opportunity to debrief or ventilate one’s feelings and consider new ways of managing new or stressful clinical experiences. Not only does it provide an opportunity to share the experience and reactions with another, it also gives the chance to gain insight into how one copes with different situations.