Nurse-client relationship

The nurse–client relationship in Hildegard E. Peplau's Interpersonal Relations Model theory is essential to nursing practice. It is the nurse–client interaction that is toward enhancing the client's well-being, and the client may be an individual, a family, a group or a community. Peplau thought the basic element of the relationship is what goes on between the nurse and patient (Interpersonal Theory 5). The relationship depends on the interaction of thoughts, feelings, and actions of each person (5). The patient will experience better health when all their needs are fully considered in the relationship (Peplau, Interpersonal Relations 9).

Elements

1. Contract: the time, place and purpose of meetings as well as conditions for termination are established between the nurse and client
2. Boundaries: roles of participants are clearly defined, the nurse is defined as a professional helper, the client's needs and problems are the focus of the interaction
3. Confidentiality: the nurse should share information only with professional staff who need to know. The nurse should obtain client's written permission to share information with others outside the treatment team
4. Therapeutic nurse behaviors: a.) self-awareness; b.) genuine, warm and respectful; c.) empathy; d.) cultural sensitivity; e.) collaborative goal setting; f.) responsible, ethical practice

Peplau's theory

In 2005, McNaughton performed a case study with five 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. Table 1 shows the amount of interaction and progression of the relationship in each phase for each group during the visits (433). For example, group G had 64.4% interaction in the orientation phase during the first visit. By the fourth visit the relationship had progressed to the working phase with 53.7% interaction and was rated a 3.

Table 1

Dyad	HV 1	HV 2	HV 3	HV 4	HV 5	HV 6	HV 7	HV 8	HV 9	HV 10
G
Orientation	64.4%	45.4%	30.8%	47.3%
Working	35.6%	54.6%	69.3%	53.7%
Resolution	0	0	0	0
Relationship	1	2.8	3	3
D
Orientation	71.5%	52.2%	39.4%	47.3%
Working	28.5%	47.8%	60.6%	49.7%
Resolution	0	0	0	3%
Relationship	2	2.8	3	4
H
Orientation	66.4%	61.8%	47.8%	-c	29.2%	59.7%
Working	33.6%	38.2%	52.2%	-c	70.8%	40.3%
Resolution	0	0	0	0	0	0
Relationship	3	3	2	1.5	5	5
F
Orientation	52.7%	44.5%	32.2%	31.9%	32.4%	12.0%
Working	47.3%	55.5%	67.8%	68.1%	67.6%	88.0%
Resolution	0	0	0	0	0	0
Relationship	1.6	4	4	5	5	6
E
Orientation	69.8%	40.2%	45.1%	23.5%	68.8%	26.2%	36.0%	28.0%	27.3%	38.0%
Working	30.2%	59.8%	54.9%	76.5%	31.2%	73.8%	64.0%	72.0%	72.7%	62.0%
Resolution	0	0	0	0	0	0	0	0	0	0
Relationship	1.8	2	4	4.5	5	5	5.6	5.4	5	5

Note. HV = home visit.
a. Orientation, working, and resolution based on percentage of interaction coded in each phase from transcripts.
b. Refers to rating of relationship on a scale of 1–7 using the Relationship Form. 1–2.9 = orientation, 3–4.9 = working/identification, 5–6.9 = working/exploitation, and 7 = resolution.
c. HV was not audio-recorded because the client asked the nurse to leave and reschedule the home visit before the tape was turned on.

The table shows all relationships began in the orientation phase. Then the groups entered the working phase on or after the second visit; showing multiple visits were needed for clients to develop trust and discuss problems. For example, group E entered the working phase on visit 2 with 59.8% interaction compared to 30.2% interaction in the working phase on the first visit. These findings support Peplau's theory for the development of the nurse–client relationship because as the relationship progressed through the phases the interaction increased.

Clients' perspectives

Coatsworth-Puspoky, Forchuk, and Ward-Griffin conducted a study on clients' perspectives in the nurse–client relationship. Interviews were done with participants from Southern Ontario, ten had been hospitalized for a psychiatric illness and four had experiences with nurses from community-based organizations, but were never hospitalized. The participants were asked about experiences at different stages of the relationship. The research described two relationships that formed the "bright side" and the "dark side". The "bright" relationship involved nurses who validated clients and their feelings. For example, one client tested his trust of the nurse by becoming angry with her and revealing his negative thoughts related to the hospitalization. The client stated, "she's trying to be quite nice to me ... if she's able to tolerate this occasional venomous attack, which she has done quite well right up to now, it will probably be a very beneficial relationship" (350). The "dark" side of the relationship resulted in the nurse and client moving away from each other. For example, one client stated, "the nurses' general feeling was when someone asks for help, they're being manipulative and attention seeking" (351). The nurse didn't recognize the client who has an illness with needs therefore; the clients avoided the nurse and perceived the nurse as avoiding them. One patient reported, "the nurses all stayed in their central station. They didn't mix with the patients ... The only interaction you have with them is medication time" (351). Neither trust nor caring was exchanged so perceptions of mutual avoiding and ignoring resulted. One participant stated, "no one cares. It doesn't matter. It's just, they don't want to hear it. They don't want to know it; they don't want to listen" (352). The relationship that developed depended on the nurse's personality and attitude. These findings bring awareness about the importance of the nurse–client relationship.

Building trust

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. 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. One said the nurses "are with you all the time. Whenever anything comes up, they're in there caring for you" (57). Competence was seen by seven participants as being important in the development of trust. "I trusted the nurses because I could see them doing their job. They took time to do little things and made sure they were done right and proper," stated one participant (59). The relief of pain was seen by five participants as promoting trust. One client stated, "they were there for the smallest need. I remember one time where they repositioned me maybe five or six times in a matter of an hour" (60). A good personality was stated by five participants as important. One said, "they were all friendly, and they make you feel like they've known you for a long time" (61). Receiving adequate information was important to four participants. One participant said, "they explained things. They followed it through, step by step" (63). The findings of this study show how trust is beneficial to a lasting relationship.

Emotional support

Yamashita, Forchuk, and Mound conducted a study to examine the process of nurse case management involving clients with mental illness. Nurses in inpatient, transitional, and community settings in four cities in Ontario were interviewed. The interviews show the importance of providing emotional support to the patients. One nurse stated that if the client knows "somebody really cares enough to see how they are doing once a week ... by going shopping with them or to a doctor's appointment. To them it means the world" (66). The interviews showed it was crucial to include the family as therapeutic allies. A nurse stated that "we're with the families. We can be with them as oppositional and overly involved and somewhere else in between, and we're in contact with them as much as they want" (66). With frequent contact the nurse was able to discuss possibilities with the family. The study reaffirmed the importance of emotional support in the relationship.

Humour

Humour is important in developing a lasting relationship. Astedt-Kurki, Isola, Tammentie, and Kervinen asked readers to write about experiences with humour while in the hospital through a patient organization newsletter. Letters were chosen from 13 chronically ill clients from Finland. The clients were also interviewed in addition to their letters. The interviews reported that humour played an important role in health. A paralyzed woman said, "well you have to have a sense of humour if you want to live and survive. You have to keep it up no matter how much it hurts" (121). Humour helped clients accept what happened by finding a positive outlook. One participant stated, “... when you're sick as you can be and do nothing but lie down and another person does everything in her power to help, humour really makes you feel good" (121). Humour also serves as a defense mechanism, especially in men. A participant said, "for male patients humour is also a way of concealing their feelings. It's extremely hard for them to admit they're afraid" (123). The patient finds it easier to discuss difficult matters when a nurse has a sense of humour. "A nurse who has a sense of humour, ... that's the sort of nurse you can talk to, that's the sort of nurse you can turn to and ask for help ..." reported a participant (123). This study lends support that if humour is generally important to people, then in times of change it will remain important.

Practice of the nurse–client relationship

The theory of the nurse–client relationship is important to the outcome of the patient. However, little to no evidence exists to support when and where this theory is practiced. Also, little to no evidence exists to support exactly who uses this theory. More research needs to be done to provide evidence to support this theory.

References

Nursing portal

• Päivi Astedt-Kurki, Arja Isola, Tarja Tammentie, and Ulla Kervinen. "Importance of humour to client–nurse relationships and clients' well being." International Journal of Nursing Practice 7 (2001): 119–125. EBSCOHost. McIntyre Lib., UW-Eau Claire. 14 November 2006.
• Coatsworth-Puspoky, R., C. Forchuk, and C. Ward-Griffin. "Nurse–client processes in mental health: recipient's perspectives." Journal of Psychiatric and Mental Health Nursing 13 (2006): 347–355. EBSCOHost. McIntyre Lib., UW-Eau Claire. 12 November 2006.
• McNaughton, Diane B. "A Naturalistic Test of Peplau's Theory in Home Visiting." Public Health Nursing 22 (2005): 429–438. EBSCOHost. McIntyre Lib., UW-Eau Claire. 14 November 2006.
• Peplau, Hildegard E. Interpersonal Relations in Nursing. New York: G.P. Putnam's Sons, 1952. Interpersonal Theory in Nursing Practice: Selected Works of Hildegard E. Peplau. New York: Springer Publishing Company, 1989.
• Wiesman, Shirley A. "A Development of Trust in the Nurse–Client Relationship." Diss. UW-Eau Claire, 1992.
• Yamashita, Mineko, Cheryl Forchuk, and Bronwyn Mound. "Nurse Case Management: Negotiating Care Together Within a Developing Relationship." Perspectives in Psychiatric Care 41.2 (2005): 62–70. EBSCOHost. McIntyre Lib., UW- Eau Claire. 14 November 2006.