Rachel Fisk looks at the concept of nursing presence and how students can use it to enhance nursing actions and improve care.
- Nurses provide an important link between patients, their families, and the Multidisciplinary team.
- Strong therapeutic relationships are key to effective health promotion.
- Mentors should encourage student nurses to spend time building relationships with patients and their families, rather than focussing primarily on signing off skills.
- The integration of therapy programmes into nursing care is vital to providing good quality, holistic care.
In a climate in which the quality of care provided by the NHS is under close scrutiny following Lord Darzi’s Next Stage Review, understanding what constitutes high quality care is more important than ever.
Fundamentally the literature has, for many years, shown that the key to high quality care is a multi-disciplinary team (MDT) that works well together, with a key role being played by nursing staff.
It has been suggested that good quality nursing practice involves a balance of knowledge, presence and caring. In particular, nursing presence demonstrates sensitivity, empathy and connection; qualities that allow a trusting therapeutic relationship to be built between nurse and patient. Considering the nature of family centred care in paediatric nursing, I found that relationships of this kind often developed between nurse and family in addition to the nurse-patient relationship. Personally I greatly valued these professional relationships and recognised the contrast of this with the day to day nursing actions that may all to easily become the primary focus of student nurses, particularly when a fundamental goal of practice is to achieve competencies and collect signatures. Although some argue that nursing presence and nursing actions cannot exist without one another, the difficulty comes in quantifying the innate qualities of a positive nursing presence and consequently there is no official guidance on this.
Since qualifying, I have been able to reflect on my own nursing actions and nursing presence as a student nurse, exploring how this impacted on the multidisciplinary team. Examples from practice have been used whilst maintaining confidentiality as per the NMC code of professional conduct. The focus will be taken from two of the outcomes of Every Child Matters: “Being Healthy” and “Staying safe”.
As a pre-registration nursing student, I was able to meet health needs on a daily basis. Christopher* was admitted to the ward from clinic with newly diagnosed Cystic Fibrosis (CF) requiring IV antibiotics. Chronic illness of young children often causes a great deal of distress to the family. This was indeed the case for Christopher’s parents, Mel* and Carl*, who were in a fragile state when I was asked to admit Christopher.
In undertaking this role, I became the first point of contact in an environment which would become familiar to them and a MDT that would become like an extended family whilst they underwent the stressful journey that is raising a child with a chronic health problem. This gave me the opportunity to form the basis of a beneficial therapeutic relationship with Christopher and his family as I was able to spend a significant amount of time with them, listening to their concerns, answering questions and reassuring them. Being a student I was able to spend extensive time with the family during their stay as I did not have the responsibility of a large case load. This enabled me to bond with Mel in particular, as we were the same age.
As a result of this, I was able to interact with Mel on a level and empathise with her situation as I was at a similar stage in my life and thus although I was unable to understand what Mel was going through, I could at least attempt to live her experience with her. These actions contributed to standard 2 of the NSF: Supporting Parenting.
In addition, literature has shown that simply being with the patient and their family, in addition to empathising and living their experiences with them are key factors in establishing a therapeutic relationship of trust which benefits the mental health and well being of the nurse, the patient and their family.
The care of Christopher was managed by the consultant paediatrician, with input from CF nurse specialists, ward staff and physiotherapists. One of the key issues arising was the fact that both Christopher’s parents smoked. As would be expected, it was one of the main priorities of the MDT to promote health by helping Mel and Carl to quit smoking in order to improve Christopher’s long term health prospects. Policy highlights health promotion as a particularly important aspect of healthcare, with the NSF addressing this in standard 1 and Every Child Matters highlighting health promotion as a vital part of the “Being Healthy” Outcome.
However, Mel felt that the MDT was judging her for her lifestyle, particularly as the family lived in a council flat and survived just above the poverty line. This already put Christopher at risk of poorer health than a child with a similar diagnosis living in better conditions and thus the MDT wanted to do everything in their power to make his health outcomes as good as possible. As a result of this feeling of judgement, Mel was reluctant to take instruction from much of the MDT, especially the more senior health care professionals with whom she had little contact previously. I therefore made use of the relationship I had built up with Mel in order to help overcome this issue. Because I had spent a large amount of time with the family, and as such a sense of trust had developed, Mel and Carl did not feel that I judged them in the same way as they perceived other members of the MDT did. This meant I was able to give health promotion advice and contacts for stop smoking services which was taken readily by Christopher’s parents as they wanted to do the best for their son’s health. This demonstrates how nursing presence is necessary in conjunction with nursing actions in order to empower individuals to do the right thing without feeling like they are being judged.
The safety of children is consistently highlighted as a key priority in healthcare. Due to the nature of the twenty-four hour care given by nurses, situations may occur when the safety of a child whilst in their home environment becomes a primary concern. I experienced a situation like this when I met Toby*.
Toby was admitted to the ward following an incident in which his mother had jumped down a flight of stairs whilst holding him as a result of mental illness. Subsequently, Toby’s mother was admitted to a secure mental health unit. This meant that Toby was alone on the ward, an unfamiliar environment with nobody he knew around him. I was allocated to care for Toby on the day shift. Although Toby required minimal physical care, from a psychological and social perspective, Toby was a patient requiring possibly some of the most intensive care I provided during my training. From my initial assessment of his condition, it was clear to me that Toby was very withdrawn from those around him and scared of his new environment.
To this end, he was reluctant to talk to me or visit the playroom. Instead of pushing Toby into socialising, I spent a lot of time just being around him, watching TV, and sitting with him whilst he ate his breakfast. Gradually, as Toby became more familiar with me, he would answer questions when asked and engage with me during play activities. I felt this was a real achievement and my investment of time was hugely beneficial as it allowed me to build a trusting relationship with Toby in a short time. This was valuable to the rest of the MDT, as prior to discharge the doctors were required to carry out a full skeletal survey of Toby for the social services report. As with other unfamiliar people, Toby was reluctant to allow the Doctors to do this, and refused to answer any questions. However, I was asked to be present during the survey and by sitting with Toby and engaging him in conversation, provided a source of security and confidence. This further demonstrates the value of nursing presence in conjunction with nursing actions.
Working on a children’s ward, it is important to be aware of the process of child development so any abnormalities or delay can be picked up and acted upon promptly. However, many children with health problems will have a different rate of development due to their condition. For example, children with Down’s syndrome have a low muscle tone and, as such, physical development may be delayed (Glasper and Richardson, 2006). Ben* was an eight month old baby I cared for on the general medical ward as he had a long term oxygen requirement after suffering from bronchiolitis. He also had Down’s Syndrome and consequently had a developmental delay. During his admission, the MDT worked with Ben on his development in addition to offering the medical treatment he needed. This was primarily the role of the physiotherapists and the play specialists.
After an initial assessment, it was determined that he was not meeting a number of developmental milestones including supported sitting and head control that should be achieved by his age (NHS, 2004). Therefore an exercise plan was put in place to help Ben develop further. Similarly, the play specialists designed a play programme to improve his motor skills, integrating this with colour, sound and movement stimulation for his cognitive development. Although the physiotherapists and play specialists put together the plans designed to improve Ben’s development, these professionals were not always on the ward i.e. at weekends. This meant that the nurse caring for Ben was required to maintain the continuity of the development programmes in their absence in order to provide the best quality holistic care possible.
As I cared for Ben a number of times during his stay, I became familiar with his development plan and thus was able to provide holistic continuity of care. This nursing action of spending time with Ben working on his play programme meant that I became familiar to him and he associated me with enjoyable activities rather than just unpleasant nursing intervention, thus building a relationship of trust. Being well known and trusted by Ben was beneficial at times when he was unsettled and his parents were not present, as the caring relationship I had developed with him meant that I was able to provide comfort as necessary. This integration of therapy into nursing care and therapeutic relationships is a skill I have carried with me into my current area of practice.
Throughout my training, I have come to understand the fundamental role that nurses play within the MDT, both pre and post registration. This is because, for the most part, nursing actions and nursing presence integrate to provide services beneficial to children and young people in a way that other health professionals may not. Family support is also indicated. Government and local policies are available to standardise the quality of care given in terms of physical actions, but are unable to govern the persona and emotional aspects required by nurses whilst caring for their patients. In some respects it is this sense of a caring presence that is most appreciated and needed, enabling patients and families to feel secure and important whilst in an unfamiliar environment.
Most importantly, it is the relationship built between nurses, patients and their families which facilitates the high standards of care that have come to be expected. It is vital that nursing students are aware of this whilst in practice, and that they reflect on how their nursing presence benefits patients and their families and how they can develop this within themselves to improve the care they provide. This is even more necessary when it is considered that nursing presence is a somewhat innate quality that cannot be taught.
*Names have been changed to maintain anonymity.
Rachel Fisk is a staff nurse and The Children’s Trust, Tadworth.