Nurse Education Today 35 (2015) e1–e5
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Review
Nursing therapeutics: Teaching student nurses care, compassion and empathy☆ Cliff Richardson ⁎, Marcus Percy, Jane Hughes University of Manchester, School of Nursing Midwifery and Social Work, Jean McFarlane Building, Ox ford Road, Manchester, M13 9PL, United Kingdom
a r t i c l e
i n f o
Article history: Accepted 19 January 2015 Keywords: Caring Compassion Empathy Therapeutic relationship Nursing therapeutics
s u m m a r y Background: Debate continues regarding whether humanitarian values such as care and compassion can be taught or are innate in individuals who wish to become nurses. Objectives: To undertake a discursive review of the literature on caring, compassion and empathy. To understand the teaching and learning issues associated with these concepts. To design and implement an Undergraduate Unit of study which addresses the development of caring, compassion and empathy in student nurses. Methods/data sources: MEDLINE, CINAHL, and a wide range of literature including books and governmental reports were used for a discursive narrative review. Results: Caring, compassion and empathy are ill-defined; however healthcare users are clear that they know when nurses use skills and attitudes associated with these concepts. Evidence is available to show that caring, compassion and empathy can be taught and there are tools available to measure them in neophytes through their training. Central to the androgogical embedding of these concepts into nursing curricula is the development of therapeutic relationships. Conclusions: It is possible to develop materials to enable student nurses to learn how to care using compassion and empathy. Nursing therapeutics is a term devised to describe how student nurses can exploit the therapeutic potential of any patient contact especially when related to specific and routine nursing interventions. Muetzel's model for understanding therapeutic relationships is one framework that can be adopted to help student nurses to appreciate how to build patient relationships and encourage them to move towards therapeutic advantage using care, compassion and empathy. © 2015 Elsevier Ltd. All rights reserved.
Background
Method
There is much debate about humanitarian values such as caring, compassion and empathy in nursing. In particular there are questions about whether these values are innate or if they can be taught. Additionally there is interest and discussion amongst nurse educators about how to develop students to function therapeutically. This paper will describe how one UK University is addressing this topical issue with nursing students by asking them to explore the therapeutic potential underpinning nursing interventions. Objectives: To undertake a discursive narrative review of the literature on caring, compassion and empathy. To understand the teaching and learning issues associated with these concepts. To design and implement an undergraduate unit of study which addresses the development of caring, compassion and empathy in student nurses.
Data sources: MEDLINE, CINAHL, and a wide range of literature including books and governmental reports were used for this discursive review. Individual and combined searches were undertaken using car*, compassion, empathy, therapeutic relationship, learn* and androgogy. The resulting literature were read and topics themed to ensure that all areas could be linked together into a coherent collective that enabled sufficient rigour to construct an undergraduate module of study based on the subject matter. The following review incorporates literature from Australia, Canada, Cyprus, Finland, Greece, New Zealand, Norway, Republic of Ireland, Spain, Turkey, USA and all four countries of the UK.
☆ No funding was used for this paper. ⁎ Corresponding author. Tel.: +44 161 3067639; fax: +44 1613067077. E-mail address: [email protected] (C. Richardson).
http://dx.doi.org/10.1016/j.nedt.2015.01.016 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
Care, Compassion and Empathy Kindness, concern, sensitivity, caring, compassion and empathy are known to be the most valued activities of nurses (Attree, 2001). A recent UK focus group study of 52 health service users overwhelmingly found that the top requirement for nurses was a caring and professional attitude (Griffiths et al., 2012). Although these health service users wanted the nurse to be skilled technically, they valued non-judgemental and patient-centred care more highly. Arguably, caring is the core business
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of nursing (Shields, 2013) but despite patients respecting nurses for their caring nature, academically it has been difficult to produce a definition that everyone will sign up to, potentially because it is hard to measure scientifically (McCrae, 2012). Additionally the inter-relatedness and nebulous nature of concepts such as caring, compassion and empathy make it difficult to be sure that everyone is talking about the same thing. In the international literature, caring is often described in terms of, or associated with, aspects of the nurse patient/client interactions, such as having a sympathetic presence and person-centeredness (McCance et al., 2009). It is seen as intrinsic to the core of nursing, shaping the nurse's therapeutic drive and is activated when patient-centred care is delivered by developing a therapeutic relationship (Welch, 2005, Granados Gamez, 2009, Canning et al., 2007, Dewar and Mackay, 2010). As an illustration the most commonly utilised tool for measuring caring, the Caring Behaviours Inventory (CBI), captures four elements; assurance of human presence, knowledge and skill, respectful deference to others and positive connectedness (Wolf, 1986, Wu et al., 2006). These four essentials for caring are clearly related to the features identified by health service users, but it is unclear whether they are the same, as a pan-European study of patients (n = 1659) and nurses (n = 1195) from 34 different hospitals identified many similarities in the descriptors used for caring across the countries but also found some differences too (Papastavrou et al., 2012). Despite being utilised frequently by a wide variety of contemporary professional and political stakeholders, compassion is also defined vaguely and often in terms of the human reaction to suffering (Straughair, 2012). Compassion has been associated with the advancement of nursing education in the 20th century and with the moral virtues of the technically competent nurse (Bradshaw, 2011). Expressions such as dignity, kindness and humanity are used to describe compassionate care (DH, 2010b, DH, 2010a, RCN, 2010) and recent international discussions suggest that, as part of ‘fundamental practice’ and ‘everyday nursing care’, compassion underpins professional nursing (Straughair, 2012). One example where compassion influences care is pain management where it is known that patients can often report high satisfaction despite high levels of pain. If compassion is at the centre of the nurses pain management care this may be able to explain this dichotomy (Quinlan-Cowell, 2014, Slatyer et al., 2014). As part of his ‘Core Conditions’ known as empathy, congruence and unconditional positive regard, Carl Rogers defined empathy as: ‘the capability to sense the client's private world as if it were your own’ (Rogers, 1957) p99. Notwithstanding the simplicity of this definition, and the elegance of the principle, in the context of talking therapies and the humanistic approach, it is clear that during his lifetime Rogers felt the need to return to his definition and to refine its qualities. In terms of contemporary nursing practice whether empathy is a skill that can be taught and tapped into or an innate quality that is then fostered and inserted into everyday professional behaviours continues to attract debate (Brunero et al., 2010). Unlike caring and compassion, empathy is mostly designated as a cognitive or emotional concept and is less likely to be described in terms of behaviours; however user groups associate empathy with kindness and warmth and have clearly stated that they recognise when it is not present (Griffiths et al., 2012, Williams and Stickley, 2010). Despite the complications arising from the vagueness of the definitions of caring, compassion and empathy, it is clear that health service users can detect these and other related qualities in nurses' behaviours and attitudes. This evidence was used for the development of a unit of study intended to help student nurses learn about and explore the nature of care, compassion and empathy in nursing. The following sections describe how an international evidence-based approach was utilised to identify frameworks to confirm the educational validity of helping the students to learn about these essential nursing concepts. The unit of study was entitled ‘Nursing Therapeutics’.
Nursing Therapeutics The remit of the Nursing Therapeutics Unit Team was to apply the principles of the therapeutic relationship to nursing interventions. In order to do this the team had to: • ensure that the therapeutic relationship is appropriate to nursing • identify an evidence-based model for therapeutic relationship building • make clear links between the internationally derived concepts of therapeutic relationship, care, compassion and empathy • understand whether (and how) caring, compassion and empathy can be taught • identify an androgogical strategy for implementation to second year student nurses.
Each of these was considered at length and a précis of the processes involved in meeting these 5 criteria is given below. Therapeutic Relationships A full appreciation of the complexities of the therapeutic relationship remains elusive however nurses continue to publish on the individual elements, the complexities and benefits of developing such relationships. In order to teach the development of therapeutic relationships we required a simple but effective model. One such model was proposed by Muetzel and incorporates three components; partnership, intimacy and reciprocity which coalesce to create a therapeutic relationship (Muetzel, 1988). Muetzel illustrated the model by representing the three concepts as overlapping circles (Fig. 1) and suggested that the middle section where the circles signifying partnership, intimacy and reciprocity overlap is the point at which a therapeutic relationship occurs. An imbalance in any one would disrupt the potential for the therapeutic relationship to influence the care delivered (McMahon, 1998). Recent empirical research confirms that Muetzel's model continues to resonate with the therapeutic relationship. Partnership is universally found to be important and is associated with other concepts such as collaboration, trust, mutuality, respect, understanding, shared decisionmaking and empowerment. In one mixed methods study, using focus groups of nurses (n = 13) and service users (n = 13) followed by a survey constructed from the focus group discussions, shared participation and partnership was clearly articulated as being important by both
Fig. 1. Muetzel's model of therapeutic relationships.
C. Richardson et al. / Nurse Education Today 35 (2015) e1–e5
groups (McCloughen et al., 2011). Another study interviewed mental health nurses to find out their impressions of what makes a therapeutic relationship (Welch, 2005). Partnership development was inherent in the identification of the need for trust, congruence and mutuality which is confirmed by other studies (Canning et al., 2007, Scanlon, 2006). Indeed these key active ingredients are also noted in studies where the nurse is working with vulnerable or stigmatised clients such as criminals, single mothers or people with eating disorders where connections between nurse and client may be a greater challenge (Snell et al., 2010, Porr et al., 2012, Rose et al., 2011, Ramjan, 2004). The need for intimacy was identified by (Maslow, 1970) in the context of love and belonging. Stickley and Freshwater offer that Rogers' idea of unconditional positive regard is equivalent to altruistic love which they propose is fostered in an alliance with the client that is therapeutic (Stickley and Freshwater, 2002). Therefore in the context of the therapeutic relationship, recognising the other person creates a bond of professional intimacy. Recent evidence captures intimacy within concepts such as nurse presence, providing comfort, empathy, befriending, care and compassion. Shattell et al (2007) interviewed 20 health care users asking them for their experiences of the therapeutic relationship. Intimacy was reflected within two of the three overarching themes identified from those interviews. Theme 1 was called ‘Relate to me’ and included elements such as self-disclosure, openness, genuineness which made them feel special whilst theme 2 ‘Know me as a person’ included genuine concern, sincerity and understanding (Shattell et al., 2007). In a larger grounded theory interview study (n = 145) of daycase patients 4 core categories of the therapeutic relationship were identified (Mottram, 2009). These were: nurse presence; being made to feel extra special; befriending; and comfort-giving. All four categories have intimacy as a fundamental element. The interesting aspect of Mottram's study was that the nurse was able to introduce the essential components of the therapeutic relationship with fleeting contact time, and once introduced the patients considered that their effect persisted even when the nurse wasn't present in person. Therefore, at the therapeutic encounter, the nurse recognises an interconnection and is able to look beyond the mundane and superficiality to the person and their humanity. Muetzel's third contributor to the therapeutic relationship, reciprocity, is a little harder to find within the recent literature. The principle that relationships are two-way and that the nurses should recognise that they receive benefit from the nurse/patient relationship is arguably found within concepts such as collaboration, mutuality, congruence, reciprocal exchange and the sharing of values and beliefs. Shattell and colleagues' third theme ‘get to the solution’ included the need for practitioners to work together to achieve agreed goals. The service users identified that the agreement within these goals is suggestive that the nurse/practitioner has as much investment in the achievement as the service user (Shattell et al., 2007). Complementary to those results a care home constructivist case study which included observation, focus groups and interviews found that reciprocal exchange and shared values were important to create a therapeutic relationship (Brown Wilson, 2009). In addition joint experiential learning was identified as one constituent of therapeutic relationships by a grounded theory study which interviewed mental health nurses (Scanlon, 2006). Overall therefore, Muetzel's model is verified by recent research findings and could be utilised as an androgogical framework for understanding and developing therapeutic relationships. Further support of the utility of developing therapeutic relationships arises from findings that patient outcomes are improved when a therapeutic relationship has been developed. Unravelling the therapeutic relationship from the health treatment or therapy is often challenging, with many studies appearing to rely upon narrative or description to convey the improvement. There is an urgent need for more research in this area. Mixed methods to triangulate and specifically identify the therapist effect
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rather than deliberately controlling it out, as undertaken by randomised controlled trials, would be an appropriate strategy. Even so there is some evidence to suggest that outcomes are improved by developing the therapeutic relationship. A literature review evaluating the benefit of using the therapeutic relationship with people with enduring mental health problems concluded that when the practitioner/client relationship becomes therapeutic, outcomes are improved (Hewitt and Coffey, 2005). Further evidence of the effect of therapeutic relationships arises from a two-part survey and interview study of specialist palliative care nurses (n = 74) which identified the development of the therapeutic relationship as the most important aspect of practice (Canning et al., 2007). The specialist nurses identified all of the key elements of Muetzel's model and were clear that outcomes were improved when the therapeutic relationship was established. Pain studies have shown that nurses endorse more potential therapies than any other professional group (Brown and Richardson, 2006) and a more recent study suggests that they may use nonpharmacological methods of pain relief as a way to develop therapeutic relationships (Svendsen and Bjørk, 2014). Building such relationships improved pain, mood and relationship satisfaction in a randomised study of couples (n = 47) where one of the pair was experiencing chronic pain (Miller et al., 2013). Although more studies to confirm improved outcomes are needed, these examples in addition to the tacit nursing agreement that therapeutic relationships are a positive thing suggested that they should be encouraged in nursing students. Before embedding this into the curriculum the Nursing Therapeutics team required links between the therapeutic relationship, caring, compassion and empathy and contextual markers that could be used to create learning resources targeted towards the development of caring, compassionate and empathetic nurses through therapeutic relationships.
Caring, Compassion, Empathy and Therapeutic Relationships Following another critical health care inquiry and report in the UK there has been a search to establish what needs to change to produce a culture of care and compassion. The Francis report (2013) identified areas where care delivery had been poor (Francis, 2013) and in response, the Chief Nursing Officer of England championed the 6C's initiative (Care, Compassion, Communication, Competence, Courage and Commitment). Although not explicitly mentioned in the consultation document it is heavily implied that incorporating the 6C's into nursing care will make a difference to the nurse/patient/ client relationship (DH, 2012). So alongside Rogers' core conditions the 6C's could be utilised as a compass point for the core values of nurses and provide a useful landmark from which to orientate the therapeutic relationship. Several authors make the link between care, compassion and empathy and the therapeutic relationship. In an observational study of nurses working in three emergency departments in Australia, compassionate caring was found to be central to experienced nurses' everyday practice (Fry et al., 2013). Technical nursing functions were found to be no barrier to caring, indeed Fry and colleagues suggest that compassionate caring itself is a highly skilled and technical undertaking which allows a nurse to make a difference. Another study using focus-groups of experienced paediatric nurses (n = 14) found that non-pharmacological approaches to pain management were utilised at least in part to enable the nurse to build a therapeutic relationship (Svendsen and Bjørk, 2014). Additionally motivational therapeutic assessment of couples (n = 47) in which one spouse had chronic pain showed that spousal empathy increased in those randomised to the therapeutic arm of the study (Miller et al., 2013). Care, compassion and empathy can therefore be said to be linked to therapeutic relationships (Granados Gamez, 2009).
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C. Richardson et al. / Nurse Education Today 35 (2015) e1–e5
Links Between Care, Compassion, Empathy, Therapeutic Relationships and Education In the UK the requirement for all nurses to be trained to degree level has only recently been adopted. This however has sparked a debate about whether the move towards degree trained nurses has been partly responsible for the ‘crisis’ in care identified by the Francis Report (Darbyshire and McKenna, 2013). Whilst this debate has been popularised by a number of key stakeholders, in essence the argument revolves around the potential that as nurses become more highly educated, and take on ever more complex technological duties, they increasingly delegate and move away from the patient and care delivery. At the same time there is an increasing body of literature exploring how to teach care, compassion and empathy. Using transformational learning one study of 108 nursing units eloquently describes how caring can be taught and how such a training programme can affect change in attitude and care (Herbst et al., 2010). Another study used Action Research to identify practical processes and issues which enable nurses to deliver compassionate care (Dewar and Mackay, 2010). This four phase project used observation, interviews and discussion groups with nurses, patients and family members to identify action plans which aimed to assist with enhancing the compassionate approaches within an elderly care unit. From the results it is clear that being supportive, valuing relationships and reflection are pivotal to conveying compassion, all of which could be taught and embedded into nursing registration programmes. A review of the effectiveness of empathy education in nursing found 17 studies (Brunero et al., 2010). The majority (n = 11) found that empathy scores were statistically higher following education. Another paper, published after Brunero and colleagues' review, utilised two different empathy tools on pre-registration nurses in Turkey and found a statistical improvement in empathy communication skills (p b 0.05) at the end of the programme (Ozcan et al., 2010). Overall the majority of evidence suggests that empathy can be taught; however the best education method and empathy assessment tool have yet to be elucidated (Larocco, 2010). Nevertheless, the likely content of any course will need to focus on a number of areas including the process of nurse socialisation (Mackintosh, 2006) any dissonance between professional idealism and practice realism (Curtis et al., 2012), the relief of loneliness, providing comfort and meeting the need to be understood (Williams and Stickley, 2010). Introducing Nursing Therapeutics Into the Curriculum Having clearly established that care, compassion empathy and the therapeutic relationship are fundamental to nursing and that these concepts can be taught we then turned to how they would be delivered to undergraduate nurses. The Nursing Therapeutics Unit of study was designed to allow second year student nurses to explore caring, compassion and empathy whilst undertaking common nursing interventions such as bed-bathing or catheter insertion. Within small group seminars Muetzel's model is used as a prism through which the students explore Field specific (Adult, Child and Mental Health) content using case scenarios and vignettes. The facilitator for the sessions encourages students to consider the scenarios and interventions from alternative perspectives rather than pure delivery of the intervention. For instance the students are asked to consider questions such as ‘How do you make a difference?’ ‘What must it feel like?’ ‘What would you do or think?’ and ‘How would you like to be treated if you had this intervention undertaken on you?’ The term nursing therapeutics was coined to establish the connection between a nurse's actions and patient outcome. For the assessment each student produces a poster incorporating 4 sections. Section 1 identifies a nursing intervention and requires the student to state clearly why the intervention is important to nursing.
It explores the assessment element underpinning the need for the intervention and then feeds into section 2 which requires the student to appraise the evidence supporting the intervention and asks then to identify any competing interventions. For example if the intervention is mouth care the appraisal should include comparisons between agents used to clean the mouth. Section 3 reviews the literature on therapeutic relationships and section 4 links the therapeutic relationship with the intervention chosen. The student is asked to show how the principles of relationship building can be incorporated into the delivery of their chosen intervention. An example would be to explore partnership, intimacy and reciprocity (Muetzel, 1988) whilst helping a patient to reposition. The poster enables students to identify the ‘science’ and ‘art’ of nursing and envisions them to create potential therapeutic advantage in all nurse/patient/client interaction.
Conclusions Caring, compassion, empathy and the therapeutic relationship can all be taught. We have chosen to use Muetzel's model as a framework to allow students to consider how they would exhibit caring, compassion and empathy whilst undertaking common nursing interventions and to use these traits to develop a therapeutic relationship. Our intention is to utilise the strong nursing posters to publish papers, with the students, showing how to become ‘therapeutic’ whilst delivering ‘basic’ or fundamental nursing care. This will enable the student to develop skills of academic writing and dissemination, whilst also building the nursing therapeutics curriculum for future student cohorts. Further evaluations are ongoing and we hope to use these to publish further in this area.
References Attree, M., 2001. Patients' and relatives' experiences and perspectives of ‘Good’ and ‘Not so Good’ quality care. J. Adv. Nurs. 33, 456–466. Bradshaw, A., 2011. Compassion: what history teaches us. Nurs. Times 107, 12–14. Brown, C.A., Richardson, C., 2006. Nurses' in the multi-professional pain team: a study of attitudes, beliefs and treatment endorsements. Eur. J. Pain 10, 13–22. Brown Wilson, C., 2009. Developing community in care homes through a relationshipcentred approach. Health Soc. Care Community 17, 177–186. Brunero, S., Lamont, S., Coates, M., 2010. A review of empathy education in nursing. Nurs. Inq. 17, 65–74. Canning, D., Rosenberg, J.P., Yates, P., 2007. Therapeutic relationships in specialist palliative care nursing practice. Int. J. Palliat. Nurs. 13, 222–229. Curtis, K., Horton, K., Smith, P., 2012. Student nurse socialisation in compassionate practice: a grounded theory study. Nurse Educ. Today 32, 790–795. Darbyshire, P., Mckenna, L., 2013. Nursing's crisis of care: what part does education own? Nurse Educ. Today 33, 305–307. Dewar, B., Mackay, R., 2010. Appreciating and developing compassionate care in an acute hospital setting caring for older people. Int. J. Older People Nursing 5, 299–308. DH, 2010a. Front Line Care: Report by the Prime Ministers Commission on the Future of Nursing and Midwifery in England. In: UK, D.O.H. (Ed.), The Stationary Office, London. DH, 2010b. The NHS Constitution. In: UK, D.O.H. (Ed.), The Stationary Office, London. DH, 2012. Compassion in practice: Nursing, Midwifery and care staff, our vision and strategy [Online]. Available:. http://www.england.nhs.uk/wp-content/uploads/2012/12/ compassion-in-practice.pdf. Francis, R., 2013. The Mid Staffordshire NHS Foundation Trust Public Inquiry. In: UK, D.O.H. (Ed.), HM Stationery Office, London, UK. Fry, M., Macgregor, C., Ruperto, K., Jarrett, K., Wheeler, J., Fong, J., Fetchet, W., 2013. Nursing praxis, compassionate caring and interpersonal relations: an observational study. Australas. Emerg. Nurs. J. 16, 37–44. Granados Gamez, G., 2009. The nurse–patient relationship as a caring relationship. Nurs. Sci. Q. 22, 126–127. Griffiths, J., Speed, S., Horne, M., Keeley, P., 2012. ‘A caring professional attitude’: what service users and carers seek in graduate nurses and the challenge for educators. Nurse Educ. Today 32, 121–127. Herbst, A.M., Swengros, D.I., Kinney, G., 2010. How to teach human caring: nurse educator role in transformational learning for a large healthcare system. J. Nurses Staff Dev. 26, E6–E11. Hewitt, J., Coffey, M., 2005. Therapeutic working relationships with people with schizophrenia: literature review. J. Adv. Nurs. 52, 561–570. Larocco, S.A., 2010. Assisting nursing students to develop empathy using a writing assignment. Nurse Educ. 35, 10–11. Mackintosh, C., 2006. Caring: the socialisation of pre-registration student nurses: a longitudinal qualitative descriptive study. Int. J. Nurs. Stud. 43, 953–962. Maslow, A., 1970. Motivation and Personality. Harper and Row, New York.
C. Richardson et al. / Nurse Education Today 35 (2015) e1–e5 Mccance, T., Slater, P., Mccormack, B., 2009. Using the caring dimensions inventory as an indicator of person-centred nursing. J. Clin. Nurs. 18, 409–417. Mccloughen, A., Gillies, D., O'brien, L., 2011. Collaboration between mental health consumers and nurses: shared understandings, dissimilar experiences. Int. J. Ment. Health Nurs. 20, 47–55. McCrae, N., 2012. Whither nursing models? The value of nursing theory in the context of evidence-based practice and multidisciplinary health care. J. Adv. Nurs. 68, 222–229. McMahon, R., 1998. Therapeutic Nursing — Theory, Issues and Practice. In: PEARSON, A. (Ed.), MCMAHON, R. Nursing as Therapy. Cheltenham, Stanley Thornes. Miller, L.R., Cano, A., Wurm, L.H., 2013. A motivational therapeutic assessment improves pain, mood, and relationship satisfaction in couples with chronic pain. J. Pain 14, 525–537. Mottram, A., 2009. Therapeutic relationships in day surgery: a grounded theory study. J. Clin. Nurs. 18, 2830–2837. Muetzel, P.-A., 1988. Therapeutic nursing. In: Pearson, A. (Ed.), Primary Nursing: Nursing in the Burford and Oxford Nursing Development Units. Croom Helm, Beckenham. Ozcan, C.T., Oflaz, F., Sutcu Cicek, H., 2010. Empathy: the effects of undergraduate nursing education in Turkey. Int. Nurs. Rev. 57, 493–499. Papastavrou, E., Efstathiou, G., Tsangari, H., Suhonen, R., Leino-Kilpi, H., Patiraki, E., Karlou, C., Balogh, Z., Palese, A., Tomietto, M., Jarosova, D., Merkouris, A., 2012. A crosscultural study of the concept of caring through behaviours: patients' and nurses' perspectives in six different EU countries. J. Adv. Nurs. 68, 1026–1037. Porr, C., Drummond, J., Olson, K., 2012. Establishing therapeutic relationships with vulnerable and potentially stigmatized clients. Qual. Health Res. 22, 384–396. Quinlan-Cowell, A., 2014. Understanding the paradox of patient pain and patient satisfaction. J. Holist. Nurs. 27, 177–182. Ramjan, L.M., 2004. Nurses and the ‘therapeutic relationship’: caring for adolescents with anorexia nervosa. J. Adv. Nurs. 45, 495–503. RCN, 2010. Principles of Nursing Practice: Principles and Measures Consultation Summary Report for Nurse Leaders. Royal College of Nursing, London.
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Rogers, C., 1957. The necessary and sufficient conditions of therapeutic personality change. J. Couns. Psychol. 21, 95–103. Rose, D.N., Peter, E., Gallop, R., Angus, J.E., Liaschenko, J., 2011. Respect in forensic psychiatric nurse–patient relationships: a practical compromise. J. Forensic Nurs. 7, 3–16. Scanlon, A., 2006. Psychiatric nurses' perceptions of the constituents of the therapeutic relationship: a grounded theory study. J. Psychiatr. Ment. Health Nurs. 13, 319–329. Shattell, M.M., Starr, S.S., Thomas, S.P., 2007. ‘Take my hand, help me out’: mental health service recipients' experience of the therapeutic relationship. Int. J. Ment. Health Nurs. 16, 274–284. Shields, L., 2013. The core business of caring: a nursing oxymoron? Collegian. J. Royal Coll. Nursing Aust. http://dx.doi.org/10.1016/j.colegn.2013.03.001. Slatyer, S., Williams, A.M., Michael, R., 2014. Seeking empowerment to comfort patients in severe pain: a grounded theory study of the nurse's perspective. Int. J. Nurs. Stud. 52, 229–239. Snell, L., Crowe, M., Jordan, J., 2010. Maintaining a therapeutic connection: nursing in an inpatient eating disorder unit. J. Clin. Nurs. 19, 351–358. Stickley, T., Freshwater, D., 2002. The art of loving and the therapeutic relationship. Nurs. Inq. 9, 250–256. Straughair, C., 2012. Exploring compassion: implications for contemporary nursing. Part 2. Br. J. Nurs. 21, 239–240. Svendsen, E.J., Bjørk, I.T., 2014. Experienced nurses' use of non-pharmacological approaches comprise more than relief from pain. J. Pediatr. Nurs. 29, e19–e28. Welch, M., 2005. Pivotal moments in the therapeutic relationship. Int. J. Ment. Health Nurs. 14, 161–165. Williams, J., Stickley, T., 2010. Empathy and nurse education. Nurse Educ. Today 30, 752–755. Wolf, Z., 1986. The caring concept and nurse identified caring behaviours. Top. Clin. Nurs. 8, 84–93. WU, Y., Larrabee, J., Putman, H., 2006. Nurs. Res. 55, 18–25.
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Review
Nursing therapeutics: Teaching student nurses care, compassion and empathy☆ Cliff Richardson ⁎, Marcus Percy, Jane Hughes University of Manchester, School of Nursing Midwifery and Social Work, Jean McFarlane Building, Ox ford Road, Manchester, M13 9PL, United Kingdom
a r t i c l e
i n f o
Article history: Accepted 19 January 2015 Keywords: Caring Compassion Empathy Therapeutic relationship Nursing therapeutics
s u m m a r y Background: Debate continues regarding whether humanitarian values such as care and compassion can be taught or are innate in individuals who wish to become nurses. Objectives: To undertake a discursive review of the literature on caring, compassion and empathy. To understand the teaching and learning issues associated with these concepts. To design and implement an Undergraduate Unit of study which addresses the development of caring, compassion and empathy in student nurses. Methods/data sources: MEDLINE, CINAHL, and a wide range of literature including books and governmental reports were used for a discursive narrative review. Results: Caring, compassion and empathy are ill-defined; however healthcare users are clear that they know when nurses use skills and attitudes associated with these concepts. Evidence is available to show that caring, compassion and empathy can be taught and there are tools available to measure them in neophytes through their training. Central to the androgogical embedding of these concepts into nursing curricula is the development of therapeutic relationships. Conclusions: It is possible to develop materials to enable student nurses to learn how to care using compassion and empathy. Nursing therapeutics is a term devised to describe how student nurses can exploit the therapeutic potential of any patient contact especially when related to specific and routine nursing interventions. Muetzel's model for understanding therapeutic relationships is one framework that can be adopted to help student nurses to appreciate how to build patient relationships and encourage them to move towards therapeutic advantage using care, compassion and empathy. © 2015 Elsevier Ltd. All rights reserved.
Background
Method
There is much debate about humanitarian values such as caring, compassion and empathy in nursing. In particular there are questions about whether these values are innate or if they can be taught. Additionally there is interest and discussion amongst nurse educators about how to develop students to function therapeutically. This paper will describe how one UK University is addressing this topical issue with nursing students by asking them to explore the therapeutic potential underpinning nursing interventions. Objectives: To undertake a discursive narrative review of the literature on caring, compassion and empathy. To understand the teaching and learning issues associated with these concepts. To design and implement an undergraduate unit of study which addresses the development of caring, compassion and empathy in student nurses.
Data sources: MEDLINE, CINAHL, and a wide range of literature including books and governmental reports were used for this discursive review. Individual and combined searches were undertaken using car*, compassion, empathy, therapeutic relationship, learn* and androgogy. The resulting literature were read and topics themed to ensure that all areas could be linked together into a coherent collective that enabled sufficient rigour to construct an undergraduate module of study based on the subject matter. The following review incorporates literature from Australia, Canada, Cyprus, Finland, Greece, New Zealand, Norway, Republic of Ireland, Spain, Turkey, USA and all four countries of the UK.
☆ No funding was used for this paper. ⁎ Corresponding author. Tel.: +44 161 3067639; fax: +44 1613067077. E-mail address: [email protected] (C. Richardson).
http://dx.doi.org/10.1016/j.nedt.2015.01.016 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
Care, Compassion and Empathy Kindness, concern, sensitivity, caring, compassion and empathy are known to be the most valued activities of nurses (Attree, 2001). A recent UK focus group study of 52 health service users overwhelmingly found that the top requirement for nurses was a caring and professional attitude (Griffiths et al., 2012). Although these health service users wanted the nurse to be skilled technically, they valued non-judgemental and patient-centred care more highly. Arguably, caring is the core business
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of nursing (Shields, 2013) but despite patients respecting nurses for their caring nature, academically it has been difficult to produce a definition that everyone will sign up to, potentially because it is hard to measure scientifically (McCrae, 2012). Additionally the inter-relatedness and nebulous nature of concepts such as caring, compassion and empathy make it difficult to be sure that everyone is talking about the same thing. In the international literature, caring is often described in terms of, or associated with, aspects of the nurse patient/client interactions, such as having a sympathetic presence and person-centeredness (McCance et al., 2009). It is seen as intrinsic to the core of nursing, shaping the nurse's therapeutic drive and is activated when patient-centred care is delivered by developing a therapeutic relationship (Welch, 2005, Granados Gamez, 2009, Canning et al., 2007, Dewar and Mackay, 2010). As an illustration the most commonly utilised tool for measuring caring, the Caring Behaviours Inventory (CBI), captures four elements; assurance of human presence, knowledge and skill, respectful deference to others and positive connectedness (Wolf, 1986, Wu et al., 2006). These four essentials for caring are clearly related to the features identified by health service users, but it is unclear whether they are the same, as a pan-European study of patients (n = 1659) and nurses (n = 1195) from 34 different hospitals identified many similarities in the descriptors used for caring across the countries but also found some differences too (Papastavrou et al., 2012). Despite being utilised frequently by a wide variety of contemporary professional and political stakeholders, compassion is also defined vaguely and often in terms of the human reaction to suffering (Straughair, 2012). Compassion has been associated with the advancement of nursing education in the 20th century and with the moral virtues of the technically competent nurse (Bradshaw, 2011). Expressions such as dignity, kindness and humanity are used to describe compassionate care (DH, 2010b, DH, 2010a, RCN, 2010) and recent international discussions suggest that, as part of ‘fundamental practice’ and ‘everyday nursing care’, compassion underpins professional nursing (Straughair, 2012). One example where compassion influences care is pain management where it is known that patients can often report high satisfaction despite high levels of pain. If compassion is at the centre of the nurses pain management care this may be able to explain this dichotomy (Quinlan-Cowell, 2014, Slatyer et al., 2014). As part of his ‘Core Conditions’ known as empathy, congruence and unconditional positive regard, Carl Rogers defined empathy as: ‘the capability to sense the client's private world as if it were your own’ (Rogers, 1957) p99. Notwithstanding the simplicity of this definition, and the elegance of the principle, in the context of talking therapies and the humanistic approach, it is clear that during his lifetime Rogers felt the need to return to his definition and to refine its qualities. In terms of contemporary nursing practice whether empathy is a skill that can be taught and tapped into or an innate quality that is then fostered and inserted into everyday professional behaviours continues to attract debate (Brunero et al., 2010). Unlike caring and compassion, empathy is mostly designated as a cognitive or emotional concept and is less likely to be described in terms of behaviours; however user groups associate empathy with kindness and warmth and have clearly stated that they recognise when it is not present (Griffiths et al., 2012, Williams and Stickley, 2010). Despite the complications arising from the vagueness of the definitions of caring, compassion and empathy, it is clear that health service users can detect these and other related qualities in nurses' behaviours and attitudes. This evidence was used for the development of a unit of study intended to help student nurses learn about and explore the nature of care, compassion and empathy in nursing. The following sections describe how an international evidence-based approach was utilised to identify frameworks to confirm the educational validity of helping the students to learn about these essential nursing concepts. The unit of study was entitled ‘Nursing Therapeutics’.
Nursing Therapeutics The remit of the Nursing Therapeutics Unit Team was to apply the principles of the therapeutic relationship to nursing interventions. In order to do this the team had to: • ensure that the therapeutic relationship is appropriate to nursing • identify an evidence-based model for therapeutic relationship building • make clear links between the internationally derived concepts of therapeutic relationship, care, compassion and empathy • understand whether (and how) caring, compassion and empathy can be taught • identify an androgogical strategy for implementation to second year student nurses.
Each of these was considered at length and a précis of the processes involved in meeting these 5 criteria is given below. Therapeutic Relationships A full appreciation of the complexities of the therapeutic relationship remains elusive however nurses continue to publish on the individual elements, the complexities and benefits of developing such relationships. In order to teach the development of therapeutic relationships we required a simple but effective model. One such model was proposed by Muetzel and incorporates three components; partnership, intimacy and reciprocity which coalesce to create a therapeutic relationship (Muetzel, 1988). Muetzel illustrated the model by representing the three concepts as overlapping circles (Fig. 1) and suggested that the middle section where the circles signifying partnership, intimacy and reciprocity overlap is the point at which a therapeutic relationship occurs. An imbalance in any one would disrupt the potential for the therapeutic relationship to influence the care delivered (McMahon, 1998). Recent empirical research confirms that Muetzel's model continues to resonate with the therapeutic relationship. Partnership is universally found to be important and is associated with other concepts such as collaboration, trust, mutuality, respect, understanding, shared decisionmaking and empowerment. In one mixed methods study, using focus groups of nurses (n = 13) and service users (n = 13) followed by a survey constructed from the focus group discussions, shared participation and partnership was clearly articulated as being important by both
Fig. 1. Muetzel's model of therapeutic relationships.
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groups (McCloughen et al., 2011). Another study interviewed mental health nurses to find out their impressions of what makes a therapeutic relationship (Welch, 2005). Partnership development was inherent in the identification of the need for trust, congruence and mutuality which is confirmed by other studies (Canning et al., 2007, Scanlon, 2006). Indeed these key active ingredients are also noted in studies where the nurse is working with vulnerable or stigmatised clients such as criminals, single mothers or people with eating disorders where connections between nurse and client may be a greater challenge (Snell et al., 2010, Porr et al., 2012, Rose et al., 2011, Ramjan, 2004). The need for intimacy was identified by (Maslow, 1970) in the context of love and belonging. Stickley and Freshwater offer that Rogers' idea of unconditional positive regard is equivalent to altruistic love which they propose is fostered in an alliance with the client that is therapeutic (Stickley and Freshwater, 2002). Therefore in the context of the therapeutic relationship, recognising the other person creates a bond of professional intimacy. Recent evidence captures intimacy within concepts such as nurse presence, providing comfort, empathy, befriending, care and compassion. Shattell et al (2007) interviewed 20 health care users asking them for their experiences of the therapeutic relationship. Intimacy was reflected within two of the three overarching themes identified from those interviews. Theme 1 was called ‘Relate to me’ and included elements such as self-disclosure, openness, genuineness which made them feel special whilst theme 2 ‘Know me as a person’ included genuine concern, sincerity and understanding (Shattell et al., 2007). In a larger grounded theory interview study (n = 145) of daycase patients 4 core categories of the therapeutic relationship were identified (Mottram, 2009). These were: nurse presence; being made to feel extra special; befriending; and comfort-giving. All four categories have intimacy as a fundamental element. The interesting aspect of Mottram's study was that the nurse was able to introduce the essential components of the therapeutic relationship with fleeting contact time, and once introduced the patients considered that their effect persisted even when the nurse wasn't present in person. Therefore, at the therapeutic encounter, the nurse recognises an interconnection and is able to look beyond the mundane and superficiality to the person and their humanity. Muetzel's third contributor to the therapeutic relationship, reciprocity, is a little harder to find within the recent literature. The principle that relationships are two-way and that the nurses should recognise that they receive benefit from the nurse/patient relationship is arguably found within concepts such as collaboration, mutuality, congruence, reciprocal exchange and the sharing of values and beliefs. Shattell and colleagues' third theme ‘get to the solution’ included the need for practitioners to work together to achieve agreed goals. The service users identified that the agreement within these goals is suggestive that the nurse/practitioner has as much investment in the achievement as the service user (Shattell et al., 2007). Complementary to those results a care home constructivist case study which included observation, focus groups and interviews found that reciprocal exchange and shared values were important to create a therapeutic relationship (Brown Wilson, 2009). In addition joint experiential learning was identified as one constituent of therapeutic relationships by a grounded theory study which interviewed mental health nurses (Scanlon, 2006). Overall therefore, Muetzel's model is verified by recent research findings and could be utilised as an androgogical framework for understanding and developing therapeutic relationships. Further support of the utility of developing therapeutic relationships arises from findings that patient outcomes are improved when a therapeutic relationship has been developed. Unravelling the therapeutic relationship from the health treatment or therapy is often challenging, with many studies appearing to rely upon narrative or description to convey the improvement. There is an urgent need for more research in this area. Mixed methods to triangulate and specifically identify the therapist effect
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rather than deliberately controlling it out, as undertaken by randomised controlled trials, would be an appropriate strategy. Even so there is some evidence to suggest that outcomes are improved by developing the therapeutic relationship. A literature review evaluating the benefit of using the therapeutic relationship with people with enduring mental health problems concluded that when the practitioner/client relationship becomes therapeutic, outcomes are improved (Hewitt and Coffey, 2005). Further evidence of the effect of therapeutic relationships arises from a two-part survey and interview study of specialist palliative care nurses (n = 74) which identified the development of the therapeutic relationship as the most important aspect of practice (Canning et al., 2007). The specialist nurses identified all of the key elements of Muetzel's model and were clear that outcomes were improved when the therapeutic relationship was established. Pain studies have shown that nurses endorse more potential therapies than any other professional group (Brown and Richardson, 2006) and a more recent study suggests that they may use nonpharmacological methods of pain relief as a way to develop therapeutic relationships (Svendsen and Bjørk, 2014). Building such relationships improved pain, mood and relationship satisfaction in a randomised study of couples (n = 47) where one of the pair was experiencing chronic pain (Miller et al., 2013). Although more studies to confirm improved outcomes are needed, these examples in addition to the tacit nursing agreement that therapeutic relationships are a positive thing suggested that they should be encouraged in nursing students. Before embedding this into the curriculum the Nursing Therapeutics team required links between the therapeutic relationship, caring, compassion and empathy and contextual markers that could be used to create learning resources targeted towards the development of caring, compassionate and empathetic nurses through therapeutic relationships.
Caring, Compassion, Empathy and Therapeutic Relationships Following another critical health care inquiry and report in the UK there has been a search to establish what needs to change to produce a culture of care and compassion. The Francis report (2013) identified areas where care delivery had been poor (Francis, 2013) and in response, the Chief Nursing Officer of England championed the 6C's initiative (Care, Compassion, Communication, Competence, Courage and Commitment). Although not explicitly mentioned in the consultation document it is heavily implied that incorporating the 6C's into nursing care will make a difference to the nurse/patient/ client relationship (DH, 2012). So alongside Rogers' core conditions the 6C's could be utilised as a compass point for the core values of nurses and provide a useful landmark from which to orientate the therapeutic relationship. Several authors make the link between care, compassion and empathy and the therapeutic relationship. In an observational study of nurses working in three emergency departments in Australia, compassionate caring was found to be central to experienced nurses' everyday practice (Fry et al., 2013). Technical nursing functions were found to be no barrier to caring, indeed Fry and colleagues suggest that compassionate caring itself is a highly skilled and technical undertaking which allows a nurse to make a difference. Another study using focus-groups of experienced paediatric nurses (n = 14) found that non-pharmacological approaches to pain management were utilised at least in part to enable the nurse to build a therapeutic relationship (Svendsen and Bjørk, 2014). Additionally motivational therapeutic assessment of couples (n = 47) in which one spouse had chronic pain showed that spousal empathy increased in those randomised to the therapeutic arm of the study (Miller et al., 2013). Care, compassion and empathy can therefore be said to be linked to therapeutic relationships (Granados Gamez, 2009).
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Links Between Care, Compassion, Empathy, Therapeutic Relationships and Education In the UK the requirement for all nurses to be trained to degree level has only recently been adopted. This however has sparked a debate about whether the move towards degree trained nurses has been partly responsible for the ‘crisis’ in care identified by the Francis Report (Darbyshire and McKenna, 2013). Whilst this debate has been popularised by a number of key stakeholders, in essence the argument revolves around the potential that as nurses become more highly educated, and take on ever more complex technological duties, they increasingly delegate and move away from the patient and care delivery. At the same time there is an increasing body of literature exploring how to teach care, compassion and empathy. Using transformational learning one study of 108 nursing units eloquently describes how caring can be taught and how such a training programme can affect change in attitude and care (Herbst et al., 2010). Another study used Action Research to identify practical processes and issues which enable nurses to deliver compassionate care (Dewar and Mackay, 2010). This four phase project used observation, interviews and discussion groups with nurses, patients and family members to identify action plans which aimed to assist with enhancing the compassionate approaches within an elderly care unit. From the results it is clear that being supportive, valuing relationships and reflection are pivotal to conveying compassion, all of which could be taught and embedded into nursing registration programmes. A review of the effectiveness of empathy education in nursing found 17 studies (Brunero et al., 2010). The majority (n = 11) found that empathy scores were statistically higher following education. Another paper, published after Brunero and colleagues' review, utilised two different empathy tools on pre-registration nurses in Turkey and found a statistical improvement in empathy communication skills (p b 0.05) at the end of the programme (Ozcan et al., 2010). Overall the majority of evidence suggests that empathy can be taught; however the best education method and empathy assessment tool have yet to be elucidated (Larocco, 2010). Nevertheless, the likely content of any course will need to focus on a number of areas including the process of nurse socialisation (Mackintosh, 2006) any dissonance between professional idealism and practice realism (Curtis et al., 2012), the relief of loneliness, providing comfort and meeting the need to be understood (Williams and Stickley, 2010). Introducing Nursing Therapeutics Into the Curriculum Having clearly established that care, compassion empathy and the therapeutic relationship are fundamental to nursing and that these concepts can be taught we then turned to how they would be delivered to undergraduate nurses. The Nursing Therapeutics Unit of study was designed to allow second year student nurses to explore caring, compassion and empathy whilst undertaking common nursing interventions such as bed-bathing or catheter insertion. Within small group seminars Muetzel's model is used as a prism through which the students explore Field specific (Adult, Child and Mental Health) content using case scenarios and vignettes. The facilitator for the sessions encourages students to consider the scenarios and interventions from alternative perspectives rather than pure delivery of the intervention. For instance the students are asked to consider questions such as ‘How do you make a difference?’ ‘What must it feel like?’ ‘What would you do or think?’ and ‘How would you like to be treated if you had this intervention undertaken on you?’ The term nursing therapeutics was coined to establish the connection between a nurse's actions and patient outcome. For the assessment each student produces a poster incorporating 4 sections. Section 1 identifies a nursing intervention and requires the student to state clearly why the intervention is important to nursing.
It explores the assessment element underpinning the need for the intervention and then feeds into section 2 which requires the student to appraise the evidence supporting the intervention and asks then to identify any competing interventions. For example if the intervention is mouth care the appraisal should include comparisons between agents used to clean the mouth. Section 3 reviews the literature on therapeutic relationships and section 4 links the therapeutic relationship with the intervention chosen. The student is asked to show how the principles of relationship building can be incorporated into the delivery of their chosen intervention. An example would be to explore partnership, intimacy and reciprocity (Muetzel, 1988) whilst helping a patient to reposition. The poster enables students to identify the ‘science’ and ‘art’ of nursing and envisions them to create potential therapeutic advantage in all nurse/patient/client interaction.
Conclusions Caring, compassion, empathy and the therapeutic relationship can all be taught. We have chosen to use Muetzel's model as a framework to allow students to consider how they would exhibit caring, compassion and empathy whilst undertaking common nursing interventions and to use these traits to develop a therapeutic relationship. Our intention is to utilise the strong nursing posters to publish papers, with the students, showing how to become ‘therapeutic’ whilst delivering ‘basic’ or fundamental nursing care. This will enable the student to develop skills of academic writing and dissemination, whilst also building the nursing therapeutics curriculum for future student cohorts. Further evaluations are ongoing and we hope to use these to publish further in this area.
References Attree, M., 2001. Patients' and relatives' experiences and perspectives of ‘Good’ and ‘Not so Good’ quality care. J. Adv. Nurs. 33, 456–466. Bradshaw, A., 2011. Compassion: what history teaches us. Nurs. Times 107, 12–14. Brown, C.A., Richardson, C., 2006. Nurses' in the multi-professional pain team: a study of attitudes, beliefs and treatment endorsements. Eur. J. Pain 10, 13–22. Brown Wilson, C., 2009. Developing community in care homes through a relationshipcentred approach. Health Soc. Care Community 17, 177–186. Brunero, S., Lamont, S., Coates, M., 2010. A review of empathy education in nursing. Nurs. Inq. 17, 65–74. Canning, D., Rosenberg, J.P., Yates, P., 2007. Therapeutic relationships in specialist palliative care nursing practice. Int. J. Palliat. Nurs. 13, 222–229. Curtis, K., Horton, K., Smith, P., 2012. Student nurse socialisation in compassionate practice: a grounded theory study. Nurse Educ. Today 32, 790–795. Darbyshire, P., Mckenna, L., 2013. Nursing's crisis of care: what part does education own? Nurse Educ. Today 33, 305–307. Dewar, B., Mackay, R., 2010. Appreciating and developing compassionate care in an acute hospital setting caring for older people. Int. J. Older People Nursing 5, 299–308. DH, 2010a. Front Line Care: Report by the Prime Ministers Commission on the Future of Nursing and Midwifery in England. In: UK, D.O.H. (Ed.), The Stationary Office, London. DH, 2010b. The NHS Constitution. In: UK, D.O.H. (Ed.), The Stationary Office, London. DH, 2012. Compassion in practice: Nursing, Midwifery and care staff, our vision and strategy [Online]. Available:. http://www.england.nhs.uk/wp-content/uploads/2012/12/ compassion-in-practice.pdf. Francis, R., 2013. The Mid Staffordshire NHS Foundation Trust Public Inquiry. In: UK, D.O.H. (Ed.), HM Stationery Office, London, UK. Fry, M., Macgregor, C., Ruperto, K., Jarrett, K., Wheeler, J., Fong, J., Fetchet, W., 2013. Nursing praxis, compassionate caring and interpersonal relations: an observational study. Australas. Emerg. Nurs. J. 16, 37–44. Granados Gamez, G., 2009. The nurse–patient relationship as a caring relationship. Nurs. Sci. Q. 22, 126–127. Griffiths, J., Speed, S., Horne, M., Keeley, P., 2012. ‘A caring professional attitude’: what service users and carers seek in graduate nurses and the challenge for educators. Nurse Educ. Today 32, 121–127. Herbst, A.M., Swengros, D.I., Kinney, G., 2010. How to teach human caring: nurse educator role in transformational learning for a large healthcare system. J. Nurses Staff Dev. 26, E6–E11. Hewitt, J., Coffey, M., 2005. Therapeutic working relationships with people with schizophrenia: literature review. J. Adv. Nurs. 52, 561–570. Larocco, S.A., 2010. Assisting nursing students to develop empathy using a writing assignment. Nurse Educ. 35, 10–11. Mackintosh, C., 2006. Caring: the socialisation of pre-registration student nurses: a longitudinal qualitative descriptive study. Int. J. Nurs. Stud. 43, 953–962. Maslow, A., 1970. Motivation and Personality. Harper and Row, New York.
C. Richardson et al. / Nurse Education Today 35 (2015) e1–e5 Mccance, T., Slater, P., Mccormack, B., 2009. Using the caring dimensions inventory as an indicator of person-centred nursing. J. Clin. Nurs. 18, 409–417. Mccloughen, A., Gillies, D., O'brien, L., 2011. Collaboration between mental health consumers and nurses: shared understandings, dissimilar experiences. Int. J. Ment. Health Nurs. 20, 47–55. McCrae, N., 2012. Whither nursing models? The value of nursing theory in the context of evidence-based practice and multidisciplinary health care. J. Adv. Nurs. 68, 222–229. McMahon, R., 1998. Therapeutic Nursing — Theory, Issues and Practice. In: PEARSON, A. (Ed.), MCMAHON, R. Nursing as Therapy. Cheltenham, Stanley Thornes. Miller, L.R., Cano, A., Wurm, L.H., 2013. A motivational therapeutic assessment improves pain, mood, and relationship satisfaction in couples with chronic pain. J. Pain 14, 525–537. Mottram, A., 2009. Therapeutic relationships in day surgery: a grounded theory study. J. Clin. Nurs. 18, 2830–2837. Muetzel, P.-A., 1988. Therapeutic nursing. In: Pearson, A. (Ed.), Primary Nursing: Nursing in the Burford and Oxford Nursing Development Units. Croom Helm, Beckenham. Ozcan, C.T., Oflaz, F., Sutcu Cicek, H., 2010. Empathy: the effects of undergraduate nursing education in Turkey. Int. Nurs. Rev. 57, 493–499. Papastavrou, E., Efstathiou, G., Tsangari, H., Suhonen, R., Leino-Kilpi, H., Patiraki, E., Karlou, C., Balogh, Z., Palese, A., Tomietto, M., Jarosova, D., Merkouris, A., 2012. A crosscultural study of the concept of caring through behaviours: patients' and nurses' perspectives in six different EU countries. J. Adv. Nurs. 68, 1026–1037. Porr, C., Drummond, J., Olson, K., 2012. Establishing therapeutic relationships with vulnerable and potentially stigmatized clients. Qual. Health Res. 22, 384–396. Quinlan-Cowell, A., 2014. Understanding the paradox of patient pain and patient satisfaction. J. Holist. Nurs. 27, 177–182. Ramjan, L.M., 2004. Nurses and the ‘therapeutic relationship’: caring for adolescents with anorexia nervosa. J. Adv. Nurs. 45, 495–503. RCN, 2010. Principles of Nursing Practice: Principles and Measures Consultation Summary Report for Nurse Leaders. Royal College of Nursing, London.
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Rogers, C., 1957. The necessary and sufficient conditions of therapeutic personality change. J. Couns. Psychol. 21, 95–103. Rose, D.N., Peter, E., Gallop, R., Angus, J.E., Liaschenko, J., 2011. Respect in forensic psychiatric nurse–patient relationships: a practical compromise. J. Forensic Nurs. 7, 3–16. Scanlon, A., 2006. Psychiatric nurses' perceptions of the constituents of the therapeutic relationship: a grounded theory study. J. Psychiatr. Ment. Health Nurs. 13, 319–329. Shattell, M.M., Starr, S.S., Thomas, S.P., 2007. ‘Take my hand, help me out’: mental health service recipients' experience of the therapeutic relationship. Int. J. Ment. Health Nurs. 16, 274–284. Shields, L., 2013. The core business of caring: a nursing oxymoron? Collegian. J. Royal Coll. Nursing Aust. http://dx.doi.org/10.1016/j.colegn.2013.03.001. Slatyer, S., Williams, A.M., Michael, R., 2014. Seeking empowerment to comfort patients in severe pain: a grounded theory study of the nurse's perspective. Int. J. Nurs. Stud. 52, 229–239. Snell, L., Crowe, M., Jordan, J., 2010. Maintaining a therapeutic connection: nursing in an inpatient eating disorder unit. J. Clin. Nurs. 19, 351–358. Stickley, T., Freshwater, D., 2002. The art of loving and the therapeutic relationship. Nurs. Inq. 9, 250–256. Straughair, C., 2012. Exploring compassion: implications for contemporary nursing. Part 2. Br. J. Nurs. 21, 239–240. Svendsen, E.J., Bjørk, I.T., 2014. Experienced nurses' use of non-pharmacological approaches comprise more than relief from pain. J. Pediatr. Nurs. 29, e19–e28. Welch, M., 2005. Pivotal moments in the therapeutic relationship. Int. J. Ment. Health Nurs. 14, 161–165. Williams, J., Stickley, T., 2010. Empathy and nurse education. Nurse Educ. Today 30, 752–755. Wolf, Z., 1986. The caring concept and nurse identified caring behaviours. Top. Clin. Nurs. 8, 84–93. WU, Y., Larrabee, J., Putman, H., 2006. Nurs. Res. 55, 18–25.
