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RELATED LITERATURES
Conceptual Literatures
Nurse-client relationship:
and developing over time. All interactions do not develop into relationships but may
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
A study conducted to examine the concept of partnership. Findings revealed that the
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
ability of the client to act on his/her own behalf (Gallant, Beaulieu & Carnevale, 2002).
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
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
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
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
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,
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
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
client population or the practice setting. This concept has been synthesized within the
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
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
Qualitative analysis of the merged data yielded five common themes and descriptive
significant factor in renewal, satisfaction, and healing outcomes for both nurse and
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
to clinical nursing is introduced, which includes the need to understand clients’ distress, and
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
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
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.
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
2010).
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
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
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
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
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
Working Phase
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
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
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
health nurse may not be consciously exerting power over the client but none the less it is
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
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.