I NTERPERSONAL SKILLS IN RELATION TO PATIENTS AND THEIR RELATIVES

This area deals with different aspects that have an impact on the relationship between the student and the patient with their relatives. This is an area that has been highly emphasized by all the different respondent groups. Two subcategories stood out when dealing with this subject: the encounter between the students and patients/relatives, and the qualities in the students themselves in regards to their own values and attitudes. Subcategories were consequently defined as:

• Encounters with patients and their relatives – communication and interaction

• Personal qualities and experiences

The two subcategories will be presented separately.

4.2.1 Encounters with patients and their relatives – communication and interaction

The respondents frequently mentioned how to communicate and interact with the patients and their relatives as an issue. Different aspects of this encounter were discussed. Some would say only ”communication” or ”interaction” as an area, but others elaborated on what communication and interaction actually dealt with.

”How to communicate with the patient who is dying and the relatives. It’s difficult to know what to say and do in that situation.”

Some of the respondents stated that communication skills were important both in relationship with the patient and their relatives, others said only patients, others again said only relatives. I will use the term ”patient/relatives” when discussing the issue, since communication was the main theme were respondents saw the patient and the relative as a unit.

The main emphasis of communication was the general skill of talking to the patient/relatives. Mostly on how to talk about death and dying but also how to talk about hope, feelings, the patients disease and how to organize their last time in life.

Not just difficult subjects were mentioned when it comes to how to talk to the patient/relatives. How to talk about everyday life were also emphasized. How to make sure that conversations not only were concerning difficult issues and tragedy, but also on positive things in life - how to make small talk and light conversation with dying patients and their relatives. As a summary, I would say that the respondents stated that both ”the ordinary conversation” and the ”extraordinary conversation”

were of great importance. In the encounter with the patient, the awareness that both verbal and non-verbal communication were equally important was underlined as an issue.

In terms of interaction, the importance of listening to the patient/relatives and open up to questions they may have were made a point out of.

” Purposeful communication and active listening. Open up to questions”.

The students need to respect the patients right to self-determination and cooperate with the patient to make sure self-determination is implemented in the palliative care process. How to carry out palliative care on the patients term are essential, and the students need to find out what issues are important to the patient and how to meet their wishes for how the situation should be organized. The respondents argue that in many cases, little things mean a lot; this is referred to as ”significant trifles”. The students also have to see the overall picture of the situation the patient is in, and not just the disease or what goes on in the patients’ room.

Some of the answers dealt only with the relatives as a specific group as opposed to the patient. The emphasis in these answers was mainly on two different themes:

• How to be supportive towards the relatives in a difficult situation and

acknowledgement of the fact that the relatives could be a vital collaborator for the student when dealing with the patient.

”Communicating with the relatives when they are tired and in grief”.

In other words, how the student can be a resource for the relative, and how the relative can be a resource for the patient.

• How to include the relatives as a part of the patient in his/her situation were also stressed as a main point. The student need knowledge on the possibilities for organizing the situation in a way that gives the relatives the opportunity to be a part of the patients life the last time. The relatives should be informed about progress and practicalities, and to some extent be included in the decision making about the patient.

How to relate to children as relatives were mentioned as a particular subject the students need awareness on.

4.2.2 Personal qualities and experiences

This subcategory deals with the qualities within the students in regards to values, attitudes and their own experiences and how this impact on the relationship with the patients and their relatives.

”To have empathy without being overwhelmed by sympathy”.

Different aspects were listed, both on how the students need to take care of themselves and their own reactions, and also how they should take care of the patient/relatives and their reactions. It was argued that the students’ previous

experience with death and dying in their own life had an impact on how the were able to relate to the issue now. The importance of preparing the students for the fact that palliative care can be very difficult and demanding on them and lead to strong reactions on their part was stressed by quite a few of the respondents.

”How to feel secure with oneself when daring to be exposed to a difficult situation, and be a support for both the patient and the relatives.”

The respondents expressed that there are challenges in two directions. The students meet dying patients and relatives, whom they might grow a relationship with, and the students might experience emotional distress when they have to watch the patients die. The students also have to face their own mortality in a way they might be unprepared for, and the students will often experience a high level of death anxiety.

In some situations they might meet patients in a somewhat similar stage of life as themselves, who are dying.

”Prepare the students to meeting their own mortality. Meet people in similar life situations as their own, who are dying.”

This is a particular difficult situation to encounter, and the students will be confronted with their own death in a way that might be unfamiliar to them. Death should be a natural subject to talk about, and regarded as a part of life.

”The students relationship to their own death.”

The students that are unfamiliar with dealing with death can have strong emotional reactions to the situation they find themselves in. These reactions or feelings need to be normalized, as a part of the challenge of being a nurse, and the ability to cope with these feelings are essential for a nursing student. All together, the respondents

frequently mention the issue of taking care of oneself when dealing with patients facing death.

The respondents use several differing terms to describe the different qualities that are essential for the students to have in order to carry out palliative care. Most commonly is the term ”empathetic” used for what qualities are the most important when

encountering patients and their relatives. Among other terms that are mentioned to describe the palliative care nurse is comforting, caring, listening, thoughtful, friendly, loving, respectful, understanding and humble. These are all descriptions of attitudes towards the patient and relatives and in what manner the students should act.

Another major theme within this subcategory is ethics. The students need to know the ethical guidelines in palliative care, and how to reflect on ethical problems and

dilemmas.

”Ethical questions revolving around how to behave when relating to dying patients and their relatives.”

Some of the respondents claimed that it’s not always only one solution that is right, and the optimal solution for the patient might be impossible to carry out due to practicalities. Examples of ethical dilemma noted by the respondents, is when there are disagreements between what the relatives and the medical personnel believes is the best care for the patient, mostly on whether or not to prolong treatment. The debate of euthanasia is also mentioned as an area of reflection. In relation to ethics, taking care of the patients’ dignity was regarded as important.