SRC 90th Anniversary

The Whirring Machine: Untangling the knots of therapeutic relationships

An exploration of the deep and fast paced connections that flow between student nurse and patient.

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I’ve mastered the speed walk. In fact blisters are developing on the soles of my feet from the spring in my step. My head is whirring; trying to decide what task to do first feels overly complex. It’s been a busy shift; I’ve lifted, I’ve ran, I’ve asked a series of overly personal but necessary questions, I’ve been screamed at and my pants are only just drying of suspicious looking fluid. On my hurried way to the storeroom I hear “Nurse! Nurse!” Screeching to a halt I realise that the person calling is not my patient. I don’t have time for this but it feels inhumane to walk away.

She’s a tiny old woman all alone. She’s trembling in a hospital bed that looks like its swallowing her minuscule frame.

The words are childlike but totally justified, “I’m scared”.

My indignation that she breached usual protocol, that she yelled instead of pressing her button, quickly fades. Though we’ve never met she grasps hold of my hand with unexpected trust. She needs someone to listen. As I let her speak her eyes go hazy and gradually her breathing slows as she drifts to sleep. I feel content.

Nurses are the clinicians that spend the most time with a patient. We have the opportunity to form connections with people that help them through the most difficult of times. Caring for people through their worst life experiences isn’t easy but it feels like a privilege, particularly when you get beneath the surface.Trust and human connection blossom and suddenly working in a place that most people avoid is worth it.

Nursing students are valued for their ability to fill the care gaps missing from a registered nurse’s time. As junior practitioners, we are task limited and energy fuelled, meaning we have the opportunity to share conversations with patients that a registered nurse would have to cut short. These therapeutic relationships are key because they promote trust and consent, in accordance with the need to care  for people in very direct and interpersonal ways.  Connecting with a nurse helps improve people’s perception of their condition or illness experience.

Due to the fast paced and task heavy nature of the hospital environment, senior nurses are often less than pleased when junior nurses “take too long”  caring for “emotional” patients.

This could be for several reasons. Though it is recognised that nurses have the responsibility to provide holistic care, the current hospital system is unable to uphold properly invested patient relationships. Therapeutic relationships depend on time and energy which nurses do not have. Australian health facilities are systematically overloaded with patients. Care is rushed and there is little time to form connections beyond the absolute minimum. In addition, with the lack of mandated nurse patient ratios and the recent increase in nurses’ responsibilities the job can rapidly become overwhelming. Levels of burnout are high, meaning that care becomes depersonalised and cynical, leading to poorer patient outcomes. Nurses who have been in the job for a longer period simply do not have the energy to provide such care and can’t understand why others would want to.

Being a patient is hard enough as it is without the feeling of burden that being treated like a problem brings. Substandard nursing care puts the pressure on patients to advocate for their own illness experience as they feel misinterpreted and undervalued. This is exhausting, particularly when afflicted by poor health. For student nurses, observing such care can change the way we think about nursing. We witness first hand the effect nursing interventions have on patients.

Student nurse Emily recounts how the behaviour of some  nurses towards their patients have made her “uncomfortable” while also “shaping the kind of nurse she wants to be”.

The biomedical health model, which underpins the Australian healthcare system is partially responsible for this country’s depersonalised nursing care. The model’s goals; diagnosis and cure, make it a cost and time effective intervention. However when applied to a system with a high patient flow, the model promotes treatment which is focussed on body parts, resulting in a mind body dichotomy for patients. This is particularly apparent when facilities are under resourced and health workers are burnt out. To free space for the next case, patients are reduced to their problem parts and identified only by their bed number. Their harrowing illness experience tends to remain unaddressed as the hospital machine keeps whirring.

Therapeutic relationships themselves are not without their challenges. Conversation doesn’t always flow in the busy hospital environment, particularly for junior contingents like student nurses.

Hospitals cluster a variety of extreme states of emotion. This is confronting for those who lack experience. A patient may experience feelings of guilt for being a burden on their family or biographical disruption if their illness was an unexpected twist in their personal life plan. Coming to terms with such a situation brings about intense emotions which nurses are at the forefront of.

Communication escalates quickly, particularly if not properly handled. Due to the level of trust patients  place in nurses, queries are almost always of a sensitive nature; “ Am I going to die?” is frequently asked. These statements shock the conscience into fight or flight mode and cannot effectively be answered by the verbal fall back response of student nurses: “I’ll ask my nurse”. You quickly learn to appreciate living a healthy life.

Physical violence against nurses is not uncommon and affects student nurses drive; not only to make a difference in their patients lives but to even enter the nursing field.

I remember the first time I was hit by a patient, as we rolled him over he struck out at my stomach. It was a quick moment as other nurses restrained him but I went home that night feeling drained, dreading work the next day.

Mimi*, an enrolled nurse, suggests that unfortunately aggression is a common part of the job due to the ward environment or the patient’s diagnosis. She claims that one of the hardest things for a student nurse to do is to develop a thicker skin when faced with such behaviour. A tough attitude is commonly enforced as a prerequisite for nursing perhaps because of the limited infrastructure against this violence.

Student nurses initially believe our role in therapeutic relationships is solving all patient problems, but quickly grapple with the fallibilities and limitations of this.

When faced with people experiencing the worst life has to offer we wish our super hero status incorporated the use of some magic wand capable of fixing everything.

Though it is important to make a difference if possible, sometimes just being there is enough. Mimi found that one of the greatest skills she picked up as a student nurse was the use and control of silence, a common tool for the junior or student nurse.

Though difficult to accomplish in a busy ward environment, it allows  the patient to know that someone is there for them, whether they are going through something too difficult to verbalise or need someone to vent to. Mimi remembers one special moment when she held a patient’s hand as she died. Though not saying anything, it, “gave the woman peace of mind as it let her know someone was there to help her let go”. Providing this support made her realise that “no one should die alone.”

Time is a necessary ingredient for therapeutic relationships and holistic care. Yet when nurses are forced to balance an incredibly intense workload, their ability to do to look after all of their patient needs is limited. For now, student nurses are often relied on to fill holes in care relationships.

Still “new” and filled with drive and passion, we enjoy the opportunity to connect with each element of the health care world. This energy surely cannot remain for the rest of our nursing careers. Perhaps soon, hospitals will ensure patients and nurses alike are given the attention they deserve. For now, I can only hope.