Paplau's interpersonal theory and how it relates to my nursing practice in the emergency department of a rural hospital

This assignment will address reflection on self awareness and skills in the counselling role, I will look at the ethical aspects of private and confidential information that a client shares with the counsellor.   The importance of self understanding and reflection, in the role of counselling and how it aids the counsellor as well as the client. I will discuss Paplau’s interpersonal theory and how it relates to my nursing practice in the emergency department of a rural hospital, how culture impacts on communication using my experiences with the local Indigenous culture and how I will continue to develop counselling skills in the future using skills gained from this course. In the geographical location I live in and consequently my workplace there is a large indigenous population.  I am from an Anglo Australian back ground, and have had to learn some of the local culture in order to practice culturally safe nursing and communicate effectively.

Firstly counselling can be defined as a process in which the counsellor helps the client understand the causes of problems and helps them develop a process of learning to make good life decisions (Counselling Services, 2006).   It is usually a theory-based process that helps clients resolve everyday life issues and concerns, each process is tailored to meet the client’s needs and help enable the client to be more self aware to understand why and make positive changes (Ivey, Ivey & Zalaquett, 2010).  Counsellors are good listeners, they are neutral and non-judgemental, and they are there to help their clients explore alternatives in order to make positives changes rather than giving out advice (Counselling Services, 2006).

Each counsellor must follow a code of ethics and code of practice.  In Australia the Australian Counselling Association (ACA) has a code of conduct which includes a code of ethics and code of practice, this code also covers the counselling environment, including physical and emotional factors (section 2.7) (www.aca.com.au).  See appendix one.  Ethical practice codes are in every major helping profession worldwide and could be summed up as “Keep the best interest of your clients in mind; do no harm to your clients; treat them responsibly with full awareness of the social context of helping” (Ivey, Ivey & Zalaquett, 2010, p35).  It is suggested that the counsellor and client discuss and set up a contract, at the beginning of the relationship, the counsellor should discuss elements of the counselling sessions, the goals, risks and benefits with the client,  a written contract can then be initiated including  confidentiality surrounding the discussions between the counsellor and client (Ivey et al, 2010; www.aca.com.au).  Section 2.4.3 Contracting with clients, of the ASA code of conduct (appendix one, p10), talks about counsellors contracting with their clients and the counsellors responsibilities.  All of this is important in protecting the client and ensuring a safe environment for them, as well as allowing them some autonomy.  Clients entering a helping relationship with a counsellor or other helping professional such as a nurse are usually in a vulnerable state, it is the counsellors ethical duty to protect their client from harm, this would include informed consent, in terms of written consent such as a contract where the counsellor outlines their role and discusses what the client wants from counselling, what their goals might be and any procedures, benefits and risks counselling may cause (Ivey et al, 2010).  Setting boundaries with the client is also important and would include defining the professional relationship at the beginning and not taking advantage of a client who is in a valuable state by entering into other relationships such as sexual or financial (www.aca.com.au).

The ACA code of conduct states under section 1. Code of ethics, p3

“Ensure client understanding of the purpose process and boundaries of the counselling relationship, offer a promise of confidentiality and explain limits of duty of care, for the purpose of advocacy receive written permission from the client before divulging any information or contacting other patients”

The ACA code of conduct also discusses confidentiality regarding information received during verbal discussions with clients and their written records see section 2.3 confidentiality, which ensures client safety and privacy as well as offering client autonomy, any breech in confidentiality will likely decrease any benefits of the counselling experience for the client (www.aca.com.au).  See also section 2.3.4 exceptional circumstances. Exceptional circumstances are those in which the counsellor believes that serious harm may occur to the client or others (for example - suicidal ideation or planning physical violence towards others), even then, where possible the counsellor should endeavour to discuss changes to the confidentiality agreement – or contract with the client (www.aca.com.au).  See also Section 2.3.5 management and confidentiality.  (www.aca.com.au).  Other principles counsellors as well as anyone in the medical profession such as nurses should follow include 1) Do no harm – to the client physically, emotionally or mentally; 2) beneficence – where the counsellor acts to promote well being; 3)non-maleficence – where the counsellor is committed to avoiding harming the client; 4) Justice – the fair and impartial treatment of the client and the provision of services (The ethical framework for good practice in counselling and psychotherapy within the NHS, 2004).  As nurses we are also bound by the Australian Nursing Midwifery Council Code of Conduct and Code of Ethics, The Code of Conduct states “Nurses treat personal information obtained in a professional capacity as private and confidential” (www.anmc.com.au).  Nursing in an emergency department is no exception.  According to the code of ethics, we – as nurses are required to value confidential and private information as well as our role in providing health counselling and education to broader community (code of ethics,2010, www.anmc.com.au).  

As a nurse working in the emergency department and having studied nursing theory recently as part of my masters degree at the University of Queensland I can relate to Hildegard Paplau’s  – Theory of interpersonal relations, which was developed for psychiatric nursing but can and has been applied to many other areas (Tomey & Alligood, 2006; Pearson & Vaughan 1986). The interpersonal approach is different to other counselling and psychotherapy theories as it emphasises the growth of both the counsellor or health professional and the client (NUR 5520 Introduction to counselling, study book, 2010).  The purpose of this theory is to facilitate the development of problem solving skills within the context of the interpersonal relationship between the nurse and the client using education and therapeutic interrelations (Pearson et al, 1986). Stress cannot be avoided however, “nurses can help patients to use stress situations as learning experiences through which they can acquire new patterns of behaviour and thus change” (Pearson et al, 1986 p143). This interpersonal approach works well in the emergency department as client counselling enables the client to develop realistic expectations and to have the knowledge available to prepare them for future events such as managing at home after a stroke or fractured limb (Paaviliainen, Salmimen-Tuomaala, Kurikka and Paussu, 2009).  Paplau’s interpersonal theory has four stages of overlapping nurse-client relationship, firstly orientation, where a client seeks out professional help and the nurse helps the client identify and understand the problem and establish what help is needed (Comley, 1994). Secondly identification where a nurse helps the client explore and express their feelings during the illness allowing the client to re evaluate and strengthen positive forces in their personality (Comley, 1994).  Thirdly exploration where the client uses the interpersonal relationship with the nurse to develop and work towards new goals, the client gradually becomes independent from the nurse (Comley, 1994). Fourthly and lastly the resolution phase where old goals are disregarded and forgotten and new goals are adopted (Comley, 1994).  In Paplau’s interpersonal theory the function of the nurse –client relationship is to promote growth and development of both parties (Tomey & Alligood, 2006; Pearson & Vaughan 1986).  A patient presenting to the emergency department with a fractured leg, once the pain is under control and the leg is immobilised in plaster will be thinking or worrying about how they are going to get their children ready for school, or negotiate a flight of stairs. The nurse can counsel the client; draw out their fears and concerns and offer information and education.  This occurs on a regular basis with many clients and illnesses while talking with the client about their illness or injury I as the nurse often also learn and grow professionally as I expand my medical knowledge, gain an understanding of the recourses available in terms of allied health team members and continue to develop my counselling skills, as I counsel more clients.

Reflection can be defined as the consideration of personal actions with the ability to review those actions and analyse the situation and evaluate the events, it is the basis for insight learning and self discovery (Martin, 2003).  Self-reflection, the practice of inspecting and evaluating one’s own thoughts, feelings and behaviour, and insight, the ability to understand one’s own thoughts, feelings and behaviour are important to learning. “Self awareness is the broad concept of the knowledge of one’s self” (Ivey, Ivey & Zalaquett, 2010, p6).  Self understanding is the ability to understand one’s own actions (Martin, 2003).

Reflection can occur in different ways with different purposes.  Reflection in action occurs while the individual is participating, they watch, review and adjust to their surroundings, reflection on action occurs afterwards, where the individual recalls the event and reviews what happened and why and gains new insights and is able to make adjustments in the future if necessary (Lian, 2001).  “Reflection identifies one’s professional capabilities, increases knowledge of self and improves understanding and management of patients. Conducting reflective practice is conducive to professional development and growth.”(Lian, 2001, p217).  Reflection should be used as a learning tool and teaching tool for professional growth as well as improving professional standing, reflection can help with self understanding by allowing the professional to develop new insight (Lian, 2001). It’s by participating in reflection that professionals can learn their limitations as well as their capabilities, this will help the counsellor interact with their clients and allow the counsellor to refer the client if they are no longer able to help the client (Lian, 2001) Self evaluation and self understanding promotes professional growth.  Reflection was introduced to me when I first started nursing it is often used in the emergency department as a debriefing tool after major trauma, by talking about the incident and reviewing our actions we can come to terms with the outcome – Reflection allows us to have insight into our actions, review the event and see if anything could have been done differently, it helps us come to terms with our actions particularly if there is an undesirable outcome such as death.  By reflecting on the events we often see our limitations or inexperience in a particular area, this allows us to seek further education or request in-services on particular procedures such as arterial line monitoring, by doing this reflection has served to increase professional growth.

Culture impacts on communication, people of different cultures can often have to deal with communication barriers.  Culture can include religion, class, ethnic background, gender and lifestyle (Reid & Trompf, 1991).  People with differing cultural backgrounds will have different communication patterns (Reid & Trompf, 1991).   This assignment will show some of these difficulties between Anglo Australian and indigenous peoples.  There are several barriers to cross communication including stereotyping, as counsellors and nurses we have to be aware of our beliefs about groups or individuals, perceptions and attitudes by reflecting and having a good self understanding we can know our limitations and barriers for example if as an atheist you can’t relate to someone with strict christen views then counselling will be limited and it might be wise to refer the client (Ivey et al, 2010; Kelsey, 2010).

When communicating with indigenous persons it is important to remember men’s and women’s business are separate and discrete issues where disclosure is set by strict social rules and breeches are punished (Reid and Trompf, 1998). Health professionals should be mindful of this when treating members of the opposite sex. Most indigenous groups have complex avoidance relationships, including not using the name of a deceased person (Reid and Trompf, 1998).  Transfer or evacuation to hospital can mean a person is away from their family group, this can be extremely distressing (Reid and Trompf, 1998).  Indigenous people don’t generally like to tell their name immediately which in Anglo Australian culture is a normal way of meeting or introducing people (Reid and Trompf, 1998).  In indigenous culture, social relationships always take priority overriding medical appointments and even the illness itself (Reid and Trompf, 1998). indigenous people don’t make eye contact, and generally feel more comfortable sitting side by side rather than face to face, they have no obligation to answer a question, and like to take time to think about a question before answering, meaning there could be long pauses in the conversation, indigenous people prefer one question at a time and find it difficult when peppered with multiple questions regarding their health, they often use hand signals as a way of answering (Reid and Trompf, 1998).  Indigenous groups have their own culturally determined and socially structured health care systems and in some cases have little faith in the Anglo Australian health care system (Reid & Trompf, 1991).   In indigenous health, bush medicines and traditional healers (medicine man or witch doctor) play important roles in health care (Reid and Trompf, 1998).  This is very different to my culture; I would generally make eye contact, introduce myself, and answer questions promptly, rapidly and with much information.  It can be difficult to keep in mind the cultural differences and practice culturally safe nursing; it is easy to revert to my natural communication style.  With this in mind I am learning through this course to develop good communication skills as previously mentioned.  Self reflection and listening are important communication tools (Ivey, etal, 2010; Kelsey, 2010). 

I work in a relatively small but busy emergency department, since starting this course I have noticed that I am listening more closely to what client’s are saying.  I am watching for cues such as body language that may suggest distress or anger, a person may cross their arms and turn away when a subject comes up they don’t want to discuss, facial expressions such as a frown or pursed lips may indicated worry. Non verbal communication is an important tool for a counsellor as discussed throughout Ivey et al, 2010.  It is also important to remember different cultures have different communication styles which can hinder communication, if a client feels unsafe they will not take in the information they are given nor will they return to the emergency department in the future (Reid & Trompf, 1991).  If in doubt ask a college who may have more experience with that culture or seek out interpreting services. When Clients arrive at the emergency department they are usually acutely ill or injured giving rise to feelings of fear and helplessness adding to their stress and causing unpredictable responses such as anger and lashing out either verbally or physically (Paaviliainen et al, 2009).  Nurses working in the emergency department need to be able to provide effective counselling it should “ foster optimal coping and independent living ability of patients so as to help them identify their own resources and strengths and see new possibilities in their life situation marked by acute illness” (Paaviliainen et al, 2009, p18).  talking to clients, and listening to what they are saying, either verbally or non-verbally, practicing paraphrasing their comments as discussed in Ivey et al, 2010, as well as using open ended questions to draw the client out has been particularly helpful in determining what the client understands of the illness and medical treatment required. I have discovered since starting this course and by using these skills I am becoming better at communicating with my patients.  Ongoing development of these skills would allow me to continue to grow professionally and provide more effective aid to my clients.  In order to do this – practice is the key I need to keep referring back to Ivey et al, 2010, attending in-services around counselling and communication, discussing these skills with colleges.  Practice with colleges the role of a counsellor. Use counselling contracts with colleges and clients and counselling sessions to continue to develop my listening and observation skills in both verbal and non-verbal communication.

In conclusion counselling is a skill that requires practice, it requires good listening and communication skills, and it is a valuable tool in the emergency department which can help the nurse provide effective nursing care.  Counselling people with different cultural backgrounds requires the counsellor to have good communication, reflection skills and a self understanding.  This course has given me a good knowledge and skill base from which I can develop further in the future.