CHAPTER 2

RELATED LITERATURES

Conceptual Literatures

Nurse-client relationship:

A therapeutic relationship between a nurse and a client built on a series of interactions

and developing over time. All interactions do not develop into relationships but may

nonetheless be therapeutic. The relationship differs from a social relationship in that it is

designed to meet the needs only of the client. Its structure varies with the context, the client's

needs, and the goals of the nurse and the client. Its nature varies with the context, including

the setting, the kind of nursing, and the needs of the client. The relationship is dynamic and

uses cognitive and affective levels of interaction. It is time-limited and goal-oriented and has

three phases. During the first phase, the phase of establishment, the nurse establishes the

structure, purpose, timing, and context of the relationship and expresses an interest in

discussing this initial structure with the client. Data collection for the nursing care plan

continues, and basic goals for the relationship are stated. During the middle, developmental,

phase of the relationship, the nurse and the client get to know each other better and test the

structure of the relationship to be able to trust one another. The nurse is careful to assess

correctly the degree of dependency that is necessary for the particular client. Plans may be

devised for improved ways of coping with problems and achieving goals. The nurse is alert

to the danger of losing objectivity during this phase. The last phase, termination, ideally

occurs when the goals of the relationship have been accomplished, when both the client and

the nurse feel a sense of resolution and satisfaction (medical-dictionary, 2009).

Related Studies

Effectiveness of Nurse-Client Relationship

A study conducted to examine the concept of partnership. Findings revealed that the

nurse–client relationship as partnership evolved from a growth in democratic thinking and

progress in clarifying how to honor basic human rights in health care relationships. The

attributes of partnership include structural and process. The structure of partnership includes

the phases of the relationship, focus and aims of each phase, and roles and responsibilities of

the partners. The process of partnership embodies power sharing and negotiation. The main

consequence of partnership is client empowerment, which is understood to be the improved

ability of the client to act on his/her own behalf (Gallant, Beaulieu & Carnevale, 2002).

Another study conducted to identify factors influencing movement of nurse-patient

dyads from Peplau’s orientation phase to working phase in tertiary psychiatric setting. The

following factors were identified. Factors causing the relationship to progress, from the

clients' perspective, were the perceived attitude of the nurse, the nature of the planned

therapeutic sessions, and what happened between therapeutic sessions. Factors hindering the

development of the relationship included a nurses or client's unavailability, a sense of

distance/inequity, differences in realities/values, and mutual withdrawal. The relationship

was perceived as supportive and “powerful” when it progressed to the working phase, but as

very negative and like “limbo” if instead it moved to a phase of mutual withdrawal. The

conclusions made that nurses can help clients move from the orientation phase to the working

phase by remaining available, consistent, and acting in a way that promotes trust. When the

relationship does not progress to the working phase within 6 months, a therapeutic transfer

should be considered (Forchuk et al., 1998).

Self-awareness and monitoring, debriefing, and availing oneself of supervision and education

are important tools in creating and maintaining boundaries, nurses must acquire a

professional training to have the ability to make decisions about boundaries based on the best

interests of the clients in their care(Taylor & Yonge, 2008).

Forchuk (2009) studied the length of the orientation phase with clients with chronic

mental illness. Findings suggested that the orientation phase was related to the number and

length of hospitalizations, while demographic variables such as psychiatric diagnosis were

unrelated to the length of the orientation phase. A return to the orientation phase can be

triggered by a change of staff, even for brief periods, or internal factors within the client,

such as worsening of paranoia or depression.

Findings obtained that humor helped the client to cope with difficult situations by

offering a moment of rest and a new perspective on an altered life situation. Humor also

helped clients to show their emotions and to preserve their dignity. In the nurse–client

relationship, humor enabled the client to communicate criticism or to express themselves.

Nurses can alleviate clients' anxieties through humor, and humor can help nurses to cope

(Kurki, Isola, Tammentie & Kervinen, 2001). Facilitative affiliation is a new concept

developed to capture the essence of effective nurse-client inter-actions, regardless of the

client population or the practice setting. This concept has been synthesized within the

theoretical framework of Modeling and Role-Modeling. Defining attributes have been

identified as (a) presence, (b) assessment of needs based on the client's self-care knowledge

and perceived resources, (c) creative individualized interventions, (d) selective normative

disregard, (e) mutual trust, v) nurturance, and (g) advocacy. Facilitative affiliation is defined

as any nurse-client interaction in which the nurse assesses the client's needs based on that
individual's self-care knowledge and perceived resources and creates individualized

interventions based on those identified needs. The relationship is then characterized by

availability, nurturance, and advocacy on the part of the nurse and a sense of mutual trust

between the client and the nurse. Several client outcomes have been posited including that of

enhanced healing (Rogers, 1996).

Research study conducted to examine a written nurse-client encounter.

Qualitative analysis of the merged data yielded five common themes and descriptive

patterns: common elements in the encounter, descriptors portraying the encounter,

meanings conveyed by the illness, spiritual needs uncovered, and a framework to

apply to practice. Caregivers must be able to see illness as a meaning-intensive

experience to be able to help clients understand their own spirituality. The

reciprocity of the spiritual connection in health care encounters is proposed as a

significant factor in renewal, satisfaction, and healing outcomes for both nurse and

client (Sherwood, 2000).

Reynolds and Scott (2001) stated that empathy is crucial to all forms of helping

relationships. While most studies cited are more than a decade old, the relationship between

empathy and helping remains unchallenged in the 1990s. Additionally, while there is

confusion about whether empathy is a personality dimension, an experienced emotion, or an

observable skill, it is shown that empathy involves an ability to communicate an

understanding of a client’s world. Finally, a definition of empathy considered to be relevant

to clinical nursing is introduced, which includes the need to understand clients’ distress, and

to provide supportive interpersonal communication. It is argued that there is a need to revisit

the role of empathy in the context of current health care delivery.

 Another conducted study aimed to describe what clients using health care services

and nurses themselves expect of nursing, the role of patient, and also how these expectations

are met. The study is based on qualitative research where both clients and nurses have been

interviewed and their own perspectives have been revealed. Expectations expressed by both

nurses and clients differ from each other. The clients described a good interactive

relationship in a much more diverse and many-sided manner than nurses. Interactive

situations seem to be taken for granted by nurses. The results show the starting points of

good nursing care and the need to continue nursing development in the client-centered

direction (Laitila & Kurki, 2004).

McNaughton (2005) performed a case study with 5 nurse-client groups to determine

if Hildegard Peplau’s theory of the nurse-client relationship was correct. Audio recordings

and the Relationship Form, which rates the interaction during each phase of the nurse-client

relationship on a scale of 1(beginning of orientation phase) to 7(end of resolution phase),

examined the phases the relationship went through. During the orientation phase, the nurse

assessed the client, identified problems, and discussed plans for the visit. In the working

phase, the client identified their problems, asked questions, and recognized the nurse was

beneficial. In the resolution phase, problems were solved, the client became independent and

established goals, and the relationship ended. The findings of the study of the author is

supporting to the theory of Peplau, for the development of the nurse-client relationship

because as the relationship progressed through the phases the interaction increased.

Building trust is beneficial to how the relationship progresses. Wiesman used

interviews with 15 participants who spent at least three days in intensive care to investigate

the factors that helped develop trust in the nurse-client relationship. The findings of this
study show how trust is beneficial to a lasting relationship based on the client’s comments.

Patients said nurses promoted trust through attentiveness, competence, comfort measures,

personality traits, and provision of information. Every participant stated the attentiveness of

the nurse was important to develop trust. Competence was seen by seven participants as

being important in the development of trust. The relief of pain was seen by five participants

as promoting trust. A good personality was stated by five participants as also important.

Receiving adequate information was vital to four participants. One participant stated that

explained things in a step-by-step manner by a nurse lead to development of trust (Wiesman,

2010).

Nurses’ Personal Quality

The study describes the practices of community child health nurses in engaging the

parent and developing a complementary and therapeutic relationship that enables the nurse to

promote the health of the child and family. There is recognition in the literature of the

importance of the personal qualities which the nurse brings to the relationship with the client.

Value is placed on an empathetic and caring health professional, able to understand and

appreciate the client (usually the mother's) point of view. Davies (1988) notes that the British

health visitor was very early described as the 'mother's friend'.

The skills and qualities of the community child health nurse are crucial in

determining the degree of acceptability of the service to the client (Normandale 2001). Jack

et al. (2005) record that reliability, genuineness, warmth and ability to be caring and

empathetic was cited by participants in their study as being of paramount importance. These

mothers preferred a professional behavior which was not overly bureaucratic, and which

respected the mother's confidentiality. The mothers in a study by Fagerskiol et al. (2003)
wanted the nurse to be sensitive to their emotional needs, to take their voiced concerns

seriously and to see things from their perspective. They valued nurses in whose knowledge

and nursing experience they could feel secure.

Flexibility, or moving with the client, is seen as a positive attribute of the nurse.

Being flexible enables the nurse to shift the focus when a more important or immediate

problem arose unexpectedly (Cowley 1995a). The nature of the practice is such that the nurse

has to be prepared to attend to whatever is identified by the client as important, rather than

rigidly stick to a pre-set agenda. According to Cowley's (1995a) study, this was so

commonplace in health visiting practice that they were not necessarily consciously aware that

they were shifting focus, rather it was explained in terms of remaining responsive to client

needs.

Being prepared to seize the moment was another example of flexibility. In her study

de la Cuesta (1994b) identified health visitors' willingness to shift their agendas in response

to a perceived need. The nurses' ability to step out of the structured schedule or the formal

policy agenda to consider other issues allows them to address issues or matters that may have

more relevance to the family than the formal agenda set by the health authority.

Whilst these attributes may be seen as relevant to all nursing roles, they have particular

relevance in community health nursing. In this type of nursing work, conducted in the largely

informal setting of a community clinic or the client's home, the literature suggests that

personal qualities that engender a strong nurse client relationship and the ability to respond to

rapidly shifting demands are most suitable to the community nursing role.

Where the first encounter is likely to occur in a community clinic, the community child

health nurse must set up conditions that attract the client to the clinic. If the health service in
which the nurse is located is well known and accepted in the community this is noted as a

pivotal means of gaining access to clients. The interpersonal aspects of the engagement

process have an enormous impact on the outcome of the first meeting between the child

health nurse and the client.

Orientation Phase

De la Cuesta (1994a) explored the tactics used by health visitors to gain entry to the

family, and characterized this as a marketing exercise. Health visitors use a combination of

commercial techniques to make their services accessible, acceptable and relevant to their

clients, such as promoting the service to the prospective client, adjusting the delivery of the

service to suit the client and tailoring the 'product' of health promotion to the client's needs.

Chalmers (1992) suggests that the entry work continues through the presentation of Offers' of

assistance to the client. In this manner the nurse has an opportunity to present the service and

her health promotion 'product'. In home visiting the community child health nurses may

contact the client even before a request to visit is made, in a tactic that sales personnel

describe as 'cold calling'. Therefore they must in the first instance convince the client of the

legitimacy of the contact and get them to agree to continue with the contact. For example,

one of the tactics used by health visitors to gain access to families with new babies was to

present the service as a routine or expected requirement (Chalmers 1992).

Luker and Chalmers (1990) identified women as the 'gatekeepers' to the family for

health visiting services. They identified factors that either facilitated or blocked entry to the

client and thereby the nurse's work. Entry was facilitated when the health visitor had met the

mother ante-natally, there was an identified need or problem needing to be addressed and the

client's previous experience with health visitors had been positive. Entry was more difficult if
the clients did not value the health visiting service or perceived they did not need such a

service. The health visitors were aware their behavior had an effect in determining their entry

to the house, so they consciously presented in a non authoritarian manner respectful of the

client's needs and their position as a guest in the client's home. The nurses also consciously

modified their speech and behavior to suit the situation in an attempt to make themselves

more acceptable to the client.

Working Phase

Cowley (1991) uses symbolic interactionism to explain the process of 'getting to

know' each other that opens the interaction between the client and the health visitors in her

study. The client is not passive in the interaction and will establish his or her own grounds for

the interaction so the nurse must identify the position and basic beliefs of the client. By doing

so the nurse may avoid dissonance and make suggestions or negotiate situations in a way that

is compatible with the perceptions and values of the client. A second and parallel process of

'getting known' occurs, in which the nurse explains her role, assuming that to do so would

encourage clients to accept the service. Cowley postulates that if clients could predict a

helpful response from the health visitor they might 'open out and express needs, especially

about sensitive or private concerns' (1991: 653). A high value was placed on respecting the

rights, needs and explicit wishes of the client expressed as 'not imposing' (1991: 654).

Cowley concludes that the health visitors' tolerance of diversity in their clients, acceptance of

individual client values and receptiveness to a broad range of perceived needs were important

in establishing the relationship.

Settling in the relationship; once access has been established, and the two participants

have gone some way to establishing the ground rules of the interaction, then the next phase
of settling in the relationship begins. Cowley (1991) identified three conditions; legitimacy

(convincing the client that the continuing contact is warranted), normalcy (agreement on

basic concepts and values) and activity (agreement on how the actions will proceed) as

central to the process of setting up the relationship. That is, unless these conditions are met,

the relationship is unlikely to grow. The nurse and client get to know each other so that

sufficient common ground is established to enable the building of trust. Trust is seen as

central to the relationship before the client would be able to open up and express their needs.

This was particularly important if the topics were sensitive or deeply personal.

For a mutually respectful relationship to grow and develop the nurse must

demonstrate to the parent her trustworthiness. Jack et al. (2005: 190) found that for the

mothers, the most important outcome of the interaction with the nurse 'was the development

of a connected relationship' with the home visiting nurse built on a foundation of trust. The

mothers 'tested' the nurse to see if they were trustworthy. The mother's decision to trust the

nurse and the extent of the trust was influenced by the personal characteristics of both the

mother and the nurse. Mothers judged the nurse's trustworthiness according to whether they

perceived the nurse as reliable, maintained confidentiality and was accepting. How rapidly it

was established differed with whether the mother was willing to discuss more personal and

sensitive issues. If they did not trust the nurse then the mothers limited the nurses work by

keeping the relationship at a superficial level, 'playing along with the nurse' (2005: 187), not

openly sharing.

Nurses who were perceived as being disconnected were those who 'mechanically

collected family assessment data' (Jack 2005: 188) or behaved in a bureaucratic or

paternalistic manner, lecturing the mothers. Jack concludes that the creation of a connected
mother-client relationship was most likely when the nurse treated the mother first as a

person, and only secondly as a client. This included the nurse entering into a mutual

exchange of information with the mother, which allows the mother to see them as an

individual person. Jack (2005) notes that mothers felt more connected when they perceived

the nurse as having had similar personal experiences. The development of a rapport with the

mother allows the formation of a more egalitarian relationship that Jack characterizes as

mutuality.

The purpose of the relationship building is to enable the community child health

nurse to carry out health promotion activities with the family. However, health promotion is

not a value free activity. Seedhouse (1997) argues that persuasion and coercion are intrinsic

to health promotion practice, although frequently unacknowledged. The community child

health nurse may not be consciously exerting power over the client but none the less it is

present in the nurse-client relationship.

Persuasion may be used to induce clients to change lifestyle or simple health habits,

to accept a referral to another health service or to take up preventive health actions such as

immunization. For example, the health visitors in de la Cuesta's (1994a) study persuaded

clients to take up immunizations by commenting in positive terms about the benefits of the

immunization and the professional expertise of the immunizers. Similar tactics were used to

persuade clients to join a group (1994a).

Synthesis:

The literatures from different authors discussed thoroughly about the nature of nurse-

client relationship. Different attributes presented which directly involves on the nurse

characters which considers very important on the process of building relationship with the
clients. Other authors discussed about the policy and convincing power of the nurses. Some

literatures explain well about the preconceptions of the participants during the orientation

phase for it affects on the thorough process on the following phase during the process. There

are some literatures focusing on the spiritual aspect which is a vital involvement on the

relationship process; one authors also commented about the inclusion of humor in the

relationship process.

All of these literatures conveyed many different opinions about the nurse-client

relationship; wherein it can supported well of the findings obtained in this study.