The nurse-patient relationship: theme and variations

Does Connectedness Matter? The Association Between Mutuality and Job Satisfaction Among Home Health Aides Caring for Adults With Heart Failure

Home health aides (HHAs) provide care to many adults with heart failure (HF) in the home. As the demand for HHAs increases, there is a need to promote HHAs' job satisfaction and retention. In this cross-sectional community-partnered study, we examined whether mutuality (e.g., quality of the HHA-patient relationship), is associated with job satisfaction among HHAs caring for adults with HF. Mutuality was assessed with the Mutuality Scale, which measures overall mutuality and its four domains (reciprocity, love and affection, shared pleasurable activities, and shared values). Our final sample of 200 HHAs was primarily female. The mean overall mutuality score was 2.92 out of 4 (SD 0.79). In our final model, overall mutuality and each of the four domains were associated with increased job satisfaction; however, only the shared pleasurable activities domain was significant (aPR: 1.15 [1.03-1.32]). Overall, mutuality may play a role in promoting job satisfaction among HHAs.

The influence of engaging authentically on nurse-patient relationships: A scoping review

The current international healthcare focus on ensuring the perspectives and needs of individual persons, families or communities are met has led to the core tenet of person-centred care for all. The nurse-patient relationship is central to the provision of care, and enhancing this relationship to ensure trust and respect supports optimal care outcomes for those accessing healthcare services. Engaging authentically is one of the recognised key approaches in person-centred practice, and this scoping review of the literature aims to gain an understanding of the role this process plays in developing effective relationships between nurses and the people they care for. A systematic search of databases and grey literature was undertaken, and twenty-one research papers met the inclusion criteria. A thematic analysis revealed four themes: 'getting to know the patient as a person', 'the complexity of relationship building-it takes time', 'the nurse: characteristics and behaviours that support the nurse-patient relationship' and 'the patient voice'. Nurses and patients both benefit from effective relationships, feeling valued and experiencing greater satisfaction with care. Key elements of engaging authentically were revealed as a nurse-patient relational process through this literature review; however, further research is needed to gain a greater understanding of this concept.

Impact of Nurse-Patient Relationship on Quality of Care and Patient Autonomy in Decision-Making

BACKGROUND

The patient is observed to acquire a passive role and the nurse an expert role with a maternalistic attitude. This relationship among others determines the capacity for autonomy in the decision making of patients.

OBJECTIVES

The aim of this study is to analyse the nurse-patient relationship and explore their implications for clinical practice, the impact on quality of care, and the decision-making capacity of patients.

DESIGN

A phenomenological qualitative study was conducted.

SETTINGS AND PARTICIPANTS

Thirteen in-depth interviews with nurses and 61,484 nursing records from internal medicine and specialties departments in a general hospital from 2015-2016.

METHODS

A discourse analysis and triangulation for these sources were conducted.

RESULTS

The category elaborated from nursing records was defined according to the following codes: Good Patient, Bad patient, and Social Problem. Analysis of the interviews resulted in a category defined as Patient as a passive object.

DISCUSSION

A good nurse-patient relationship reduces the days of hospital stay and improves the quality and satisfaction of both. However, in contrast, the good relationship is conditioned by the patient's submissive role.

CONCLUSION

An equal distribution of power allows decisions about health and disease processes to be acquired by patients, autonomously, with the advice of professionals. The nurse-patient relationship should not pursue the change in values and customs of the patient, but position the professional as a witness of the experience of the health and illness process in the patient and family.

Family Caregivers’ Perspectives on Hospice Nursing Care

In hospice nursing, dying persons and their families are the unit of care and the focus of nursing interventions which are provided within the context of interdisciplinary care. The key component of hospice nursing is the interaction between the nurse, the terminally ill person, and the family. This naturalistic study was designed to describe the family caregiver's relationships between the hospice patient, the nurse, and themselves. The intent was to determine if family caregivers would develop empathic relationships with the hospice nurses. Nine bereaved family caregivers participated in the study. All were bereaved at least six months prior to being interviewed. The major finding of the study was that family caregivers perceived the hospice nurses as part of the family. The hospice nurses were characterized as respectful, kind, caring, clinical experts whose presence and interventions helped meet the needs of the family experiencing death.

Clinical Wisdom Among Proficient Nurses

This article examines clinical wisdom, which has emerged from a broader study about nurse managers' influence on proficient registered nurse turnover and retention. The purpose of the study was to increase understanding of proficient nurses' experience and clinical practice by giving voice to the nurses themselves, and to look for differences in their practice. This was a qualitative study based on semistructured interviews followed by analysis founded on Gadamerian hermeneutics. The article describes how proficient nurses experience their practice. Proficient practice constitutes clinical wisdom based on responsibility, thinking and ethical discernment, and a drive for action. The study showed that poor working conditions cause proficient nurses to regress to non-proficient performance. Further studies are recommended to allow deeper searching into the area of working conditions and their relationship to lack of nurse proficiency.

Development and Psychometric Testing of the Humanistic Nurse-Patient Scale

Quality of life and well-being of older patients in chronic care facilities is often determined by their relationships with nurses. The authors developed and tested a scale to assess patients' views of what matters most when relating to nurses. Based on the humanistic nursing theory by Paterson and Zderad (1988), 69 items were created and tested with a sample of 40 patients, resulting in refinement of a scale with 24 items. This scale was factor analysed on responses from 249 patients residing in five facilities in Ontario, Canada. The Humanistic Relationship Importance Scale demonstrated strong internal consistency, stability, and reliability with a five-factor solution (α = .87). Construct validity was supported through factual identification. This scale is a valid measure of patients' perspectives of a nurse-patient relationship in chronic care and can be used to measure health professionals' relationships with their older patients and evaluate interventions to enhance relational care.

The Care Relationship Required by Seniors in Nursing Homes: A Qualitative Meta-study

Objetivo: describir que tipo de cuidados y de interacción humana demandan de sus enfermeras las personas mayores que viven en un hogar para ancianos, a partir de la síntesis y el reanálisis de los datos proporcionados por una serie de estudios primarios que han abordado la experiencia de vivir en un hogar para ancianos. Antecedentes: los estudios de tipo cualitativo que han tratado el tema de las experiencias vitales en un hogar para ancianos se han centrado en aspectos como la vida diaria, la calidad de vida, las experiencias de sufrimiento, los cuidados recibidos, la proximidad de la muerte y las relaciones personales. Materiales y métodos: metaestudio cualitativo de tipo análisis de metadatos. Las bases de datos empleadas han sido: ISI Web of Knowledge, CINAHL, EMBASE, LILACS y CUIDEN PLUS. Se han seleccionado 29 estudios. Resultados: las categorías centrales emergentes de los datos han sido: las cualidades personales demandadas al personal cuidador, las intervenciones cuidadoras, la relación personal con los cuidadores y la influencia de la relación persona mayor-cuidador en otros aspectos. Conclusión: con este trabajo hemos pretendido sintetizar las evidencias proporcionadas por una serie de investigaciones primarias tratando de proporcionar un nivel de conocimientos mayor sobre las necesidades de atención de las personas residentes en un hogar para ancianos, siempre a partir de los testimonios, las experiencias y las vivencias de los protagonistas.

Articulating the role of relationships in access to home care nursing at the end of life

In this article, we draw on data collected from two samples of home care nurses to examine how relationships between nurses and family caregivers intersected with access to palliative home care nursing services. Participants referred to relationships as important for their practical benefits and for access to care: good relationships enhanced the nurse's ability to assess clients and families and fostered the family's trust in the nurse's care. Although emphasizing the need to build and maintain relationships (often requiring time), participants simultaneously referred to beliefs about the need to control the personal emotions invoked in relationships so as to ensure appropriate access for clients and families. Future research should further explore how the organizational and resource context, and the culture of palliative care, shape nurses' beliefs about relationships in their practice, the nature and types of relationships that can develop, and both client and family caregivers' access to care.

Commendations, conversations, and life-changing realizations: teaching and practicing family nursing

This article embeds a piece of reflective writing and analysis from an undergraduate nursing student about the integration of course content to practice in the nursing of families. Surrounding the reflection of the student, the course professor discusses the content, intent, history, and delivery of the family nursing course and examines how the theory taught is necessarily mirrored in the way it is taught and the ways that students are invited into experiencing and "practicing" the skills, philosophies, theories, and beliefs of nursing families well.

A dimensional analysis of patient-centered care

BACKGROUND

Patient-centered care (PCC) is a poorly conceptualized phenomenon and can indicate anything from soothing room design, emotional support of patients, customization of meals, to support of patient decision making. This inconsistency across the clinical and research literature makes the application of PCC difficult.

OBJECTIVES

The objective of this study was to identify dimensions of PCC as found in the literature.

METHODS

A dimensional analysis of PCC was conducted from 69 clinical and research articles published from 2000 to 2006. Coding of the literature for the perspective, context, conditions, process, and consequences of PCC was completed. These codes were used to determine literature selected for inclusion, organize article content, and frame the delineation of PCC.

RESULTS

Alleviating vulnerabilities, consisting of both compromised physiological states and threats to individual identity, was constant throughout the literature. Therapeutic engagement was the process sustaining the patient during an illness episode that necessitated service use and involved allocating time, carrying out information practices, knowing the patient, and developing a relationship. This process occurs during nurse-patient interaction, sustained during successive interactions, and reinforced by the information practices of a particular setting.

DISCUSSION

The interaction between nurse and patient is central to the effective study and application of PCC. Appropriate use of PCC can improve study outcomes and measurements by clarifying the variables involved, and PCC holds great promise to frame patient outcome and satisfaction research by analyzing how and with what effect nurses alleviate patient vulnerability. Moreover, consideration of information practices as a critical supporting structure of nurse-patient interaction can be explored.

Client-nurse relationships in home-based palliative care: a critical analysis of power relations

AIM

To elicit an in-depth understanding of the sources of power and how power is exercised within client-nurse relationships in home-based palliative care.

BACKGROUND

As in all social relations, power is present within client-nurse relationships. Although much research has focused on interpersonal relationships in nursing, the concept of power within the client-nurse relationship in palliative care settings has not been extensively investigated.

METHODS

Applying a critical lens, secondary qualitative data analysis was conducted. Seventeen nurse and 16 client transcripts from a primary study were selected for secondary data analysis. These 33 transcripts afforded theme saturation, which allowed for both commonalities and differences to be identified. Data analysis involved analytic coding.

RESULTS

Study findings help make explicit the underlying power present in the context of home-based palliative care and how this power is used and potentially abused. In analysing the sources and exercise of power, the linkage between macro and micro levels of power is made explicit, as nurses functioned within a hierarchy of power. The findings suggest that educational/occupational status continues to be a source of power for nurses within the relationship. However, nurses also experience powerlessness within the home care context. For clients, being able to control one's own life is a source of power, but this power is over-shadowed by the powerlessness experienced in relationships with nurses. The exercise of power by clients and nurses creates experiences of both liberation and domination.

CONCLUSIONS

Nurses who are willing to reflect on and change those disempowering aspects of the client-nurse relationship, including a harmful hierarchy, will ultimately be successful in the health promotion of clients in home-based palliative care. Additionally, it should be recognized that nurses work within a specific health system context and, therefore, their practice is influenced by policies and funding models implemented at various levels of the health care system.

RELEVANCE TO CLINICAL PRACTICE

The insights gained through this investigation may assist nurses and other health professionals in reflecting on and improving practices and policies within home-based palliative care and within home care in general.

Nurses' experiences of caring for families with relatives in intensive care units

AIM

This paper reports an exploratory study of nurses' experiences of caring for families who have relatives in adult intensive care units.

BACKGROUND

The admission of a critically ill patient into adult intensive care is universally accepted as a crisis for both patients and their families. Family members of critically ill people may experience emotional turmoil and therefore have many needs throughout the course of the relative's illness. It has been identified that nurses are best placed to meet families' needs. Whilst there is a substantial evidence base associated with family needs, little is known about nurses' experiences of caring for these families.

METHOD

Interviews, informed by Heideggerian philosophy, were conducted with a purposive sample of 12 Registered Nurses working in an adult intensive care unit. Interview transcripts were analysed using Colaizzi's framework. The data were collected in Autumn 2005.

FINDINGS

Participants' experiences were categorized into the following themes: defining the nurse's role, role expectations and role conflict. Participants reported lack of confidence, doubts about their professional competence and conflicts between their professional and personal self. These experiences were linked to participants' expectations and self-imposed standards.

CONCLUSION

Registered Nurses caring for families who have relatives in adult intensive care units face a fundamental conflict both between role expectations and patient care and between professional ideals and being a human. This not only highlights a disparity between nurses everyday family care practice and the underpinning theories but also may contribute to occupational stress.

Being a real nurse – Concepts of caring and culture in the clinical areas

In this paper we discuss the issues of caring and culture in practice settings and how they affect student nurses in their endeavours to learn how to be a 'real nurse'. Drawing upon differing conceptions of 'caring' we discuss the notion as a pivotal factor in becoming a nurse. We examine the degree to which boundaries are changing, not least those in which students seem currently to define the bedrock of physical and emotional care as belonging to health care support workers whom they will merely supervise. Complicating this picture are developments in medical and nursing boundaries which may, or may not help to 'professionalise' nursing. We conclude by arguing that complex cultural norms and the negotiated order of health care need to be properly recognised by curriculum developers if, within contemporary higher education nurses are to be fit for purpose and practice.

Culturally diverse patient--nurse interactions on acute care wards

The nurse-patient interaction is central to providing nursing care. This qualitative study explores nurses' and culturally diverse patients' experiences within nurse-patient relationships in acute care wards. Eight nurses and their respective patients volunteered to join the study and were interviewed. The three themes identified in relationships between nurses and culturally diverse patients were shared tension, perceived difference and held awareness. It is concluded from the study that relationships between nurses and culturally diverse patients in acute care wards during short episodes of hospitalization are not easy for nurses and need to receive deeper consideration as to how they can be developed more effectively. It is recommended that educational support be provided to develop more effective interactions between nurses and patients with research being carried out to investigate factors that can strengthen culturally diverse patient-nurse interactions in acute care settings.

Reconceptualizing the nurse's role in the newborn period as an "attacher"

In the first few days and weeks after a child's birth, attachment is a major task for the mother and her newborn. Success in this long-term psychological process is associated with positive life-long outcomes for both the parenting mother and her child. This article proposes a relational approach to newborn nursing grounded in the principles of attachment theory. Understanding this "attacher" approach can benefit nurses by bringing a gratifying depth to their practice and can benefit families by helping mothers and newborns address the most compelling task before them.

Analysis of nurse conversation: methodology of the process recording

Analysis of nurse conversation: methodology of the process recording The study explored elements of effective nurse-client interaction between a nurse and a nursing home resident on the third day of the client's recovery from surgery. The interaction was recorded from memory in the form of a process recording then divided into unique conversation segments. Two nurses independently used seven typologies to classify segments of the conversation. Cohen's coefficient kappa for inter-rater reliability of the classifications was 0.98. Findings from the study revealed that two-thirds of the nurse's conversation was effective and consistent with the orientation phase of the nurse-client relationship. The nurse communicated her role through the provision of leadership, resources and help, and technical expertise. Her approaches were rather evenly divided between making requests, giving information, and affirming the client's experience. One-third of the conversation was oriented toward assessment and diagnosis, one half toward treatment of the client's experiences, and the rest toward planning and evaluation. Themes identified in the client's conversation included issues of dependency, disorientation to time, unresolved grief, separation anxiety, and the client's need for validation. These findings are valuable for illuminating the contribution that nurse conversation makes to evidence-based clinical practices. They also have implications for further refinements in the use of the process record and multiple coding schemes for the study of the nurse-client relationship.

Perceptions on individualized approaches to mental health care

Ways of working on acute psychiatric units have come under intense scrutiny in order for service users to receive modern care and treatment. This has led to various ways not only to improve the therapeutic milieu on psychiatric wards, but also to develop standardized approaches to care. This paper reports on a study on the development of a care pathway for people diagnosed with schizophrenia, with the aim of standardizing the care process. Action research was used to develop the care pathway and views were collected, and observations made from a range of mental health professionals. Not all respondents were in agreement with a care pathway and this led to clinicians defending the individualized nature of psychiatric care. Implementation of a care pathway may help not only to rekindle the therapeutic purpose of psychiatric care, but also to build in the individualized approach to carrying out hospital care. Limitations of the study have also been briefly reported.

Nurse-patient relationships in palliative care

AIM

The aim of this paper is to report a study exploring aspects of nurse-patient relationships in the context of palliative care.

BACKGROUND

Although there are numerous studies addressing nurse-patient relationships, little research has focused on these in the context of palliative are. Furthermore, no previous study has examined the relationship in the Chinese context.

METHODS

Qualitative data were collected from 10 hospice nurses and 10 terminally ill patients by means of open ended unstructured interviews. Respondents were asked to reflect on practices and incidents that would allow an understanding of the meaning of nurse-patient relationships in palliative care.

RESULTS

Four major categories emerged from the perspectives of patients and nurses: (1) forming a relationship of trust; (2) being part of the family; (3) refilling with fuel along the journey of living and dying; and (4) enriched experiences. Responses revealed that a relationship of trust is formed, and that nurses are not only regarded as health professionals, but also become part of the family or a good friend. Nurses who develop trusting relationships demonstrate a holistic approach to caring, show their understanding of patients' suffering, are aware of their unvoiced needs, provide comfort without actually being asked, and are reliable, proficient, competent and dedicated in their care.

CONCLUSION

Trust, the achievement of the goals of patients and nurses, caring and reciprocity are important elements of nurse-patient relationships in palliative care. Such relationships not only improve patients' physical and emotional state, but also facilitate their adjustment to their illness, ease pain and can ultimately lead to a good death experience. It is nurses' personal qualities and skills, which are embedded in these relationships, that constitute excellence in nursing care. Nurses also derive satisfaction and are enriched through the relationships.

Understanding patients' lived experiences: the interrelationship of rhetoric and hermeneutics

Understanding each patient's situation or lived experience evolves from a nurse's sincere communication with the patient. Through rhetoric, the nurse's use of competent language and expressions is more likely to engage the patient in a dialogical discussion that brings forth an open, honest display of feelings and emotions. Through hermeneutics, the nurse gains an accurate understanding and interpretation of a patient's beliefs, values, and situations that supports explanations of meaning. Thus, with rhetoric being the words or expressions that give rise to hermeneutics or the interpretation, the blending of the two creates a rhetorical-hermeneutical relationship that provides accurate understanding of a patient's true lived experience. Consequently, knowing the patient depends upon the nurse's rhetorical competence and accurate assessment of each patient's authentic self. Nurses should seek to interpret and understand the lived experiences of patients in order to limit or prevent misunderstandings and inaccuracies in communication. The truth that emerges from the expressed rhetorical-hermeneutical interrelationship will enhance nurses' sensitivity to patient matters, produce relationship outcomes that emerge from a consistent and effectively applied set of interpersonal principles, and more importantly, successfully influence nurses' lives and those of their patients with meaning that ultimately improves the human condition. Thus, nurses' communication and perceptive understanding of each patient's world or lived experience becomes an integral and necessary component to effectively carrying out the practice role of caregiving.

Family-centered care: do we practice what we preach?

OBJECTIVE

To determine nurses' perceptions and practices of identified elements of family-centered care.

DESIGN

Descriptive.

SETTING

Neonatal intensive care unit (NICU), pediatrics, and pediatric intensive care unit (PICU) in an acute care hospital.

PARTICIPANTS

Sixty-two licensed nurses, 37 working in the NICU and 25 working in pediatrics or the PICU.

MAIN OUTCOME MEASURES

Scores for the Necessary and Current scales of the Family-Centered Care Questionnaire.

RESULTS

Scores representing current nursing practice of family-centered care were significantly lower than those representing its necessity (p = .000). Nurses with 10 years or fewer of neonatal or pediatric experience scored significantly higher on both the total Necessary Scale (p = .02) and total Current Scale (p = .017) than did those with 11 years or more. Nurses who work in the NICU scored significantly lower on the total Necessary Scale (p = .013) than did nurses who work in pediatrics or PICU.

CONCLUSIONS

Although nurses agree the identified elements of family-centered care are necessary, they do not consistently apply those elements in their everyday practice. Years of experience and clinical work setting influenced both perceptions and practices of family-centered care.

Emotional intelligence in nursing work

BACKGROUND

Emotional labour has been widely accepted in the literature as part of nursing work, however the contribution of emotional intelligence in the nursing context requires further study.

AIM

This paper aims to present an analysis of the literature on emotional intelligence and emotional labour, and consider the value of emotional intelligence to nursing.

METHOD

A literature search was undertaken using the CINAHL and MEDLINE databases. Search terms used were 'emotions', 'intelligence', 'emotions and intelligence' and 'emotional labour'. A hand-search of relevant journals and significant references added to the data.

RESULTS

Emotional intelligence plays an important part in forming successful human relationships. Emotional labour is important in establishing therapeutic nurse-patient relationships but carries the risk of 'burnout' if prolonged or intense. To prevent this, nurses need to adopt strategies to protect their health. The potential value of emotional intelligence in this emotional work is an issue that still needs to be explored.

CONCLUSIONS

Analysis of the literature suggests that the modern demands of nursing draw on the skills of emotional intelligence to meet the needs of direct patient care and co-operative negotiations with the multidisciplinary team. The significance of this needs to be recognized in nurse education. The link between emotional intelligence and emotional labour is a fruitful area for further research. The potential benefits of gaining a better understanding of how these concepts interact is largely conjecture until we have more evidence. The prospect that there may be advantages to both nurses and patients is a motivating factor for future researchers.

Nurses and the 'therapeutic relationship': Caring for adolescents with anorexia nervosa

BACKGROUND

Research studies suggest that hospital programmes for young people diagnosed with anorexia nervosa have high readmission rates and limited effectiveness. Nurses caring for these adolescents face a particular set of problems in seeking to establish therapeutic relationships.

AIM

This paper reports a study with the original aim of providing rich data on the development of therapeutic relationships between adolescents diagnosed with anorexia and paediatric nurses. However, it was discovered that paediatric nurses were struggling to develop therapeutic alliances with these adolescents. The study was then modified to explore the difficulties and obstacles hindering the formation of therapeutic relationships in this context.

METHOD

The study used naturalistic inquiry. The 10 participants were Registered Nurses from the acute wards of an Australian children's hospital with at least 2 years' experience of caring for adolescents with anorexia nervosa. The data were collected using semi-structured interviews that were recorded on audiotape and then thematically analysed both manually and with the aid of the NUD*IST computer package.

FINDINGS

Participants described how they struggled to develop therapeutic relationships in this clinical environment. Three themes emerged: (1) 'Struggling for understanding' explores the difficulties nurses experienced in coming to terms with the complexities of a diagnosis of anorexia nervosa and its recovery processes. (2) 'Struggling for control' examines the power struggle between nurses and patients and the mutual distrust that often developed between them as a consequence of this struggle. (3) 'Struggling to develop therapeutic relationships' describes the difficulties some nurses had in establishing therapeutic alliances with these adolescents.

CONCLUSION

Recommendations are made for improving the nursing component of hospital treatment programmes for adolescents with anorexia nervosa in the direction of more genuinely therapeutic relationships.

Living theory: enhancing the psychological support of patients

This article explores how nurses, involved in a research project incorporating teaching psychological theories and counselling skills to enhance the psychological support of patients with wounds, had, one year on, changed their professional practice. This inquiry was framed by living theory, a concept previously only used in education, which is based on the integration of known knowledge, newly taught knowledge and increased self-awareness. The major principle of living theory is that one's values are questioned, modified, clarified and sometimes changed completely in striving to improve one's professional practice. This research showed nurses creating their own living theories, aspiring to really care for the whole person by developing strong, meaningful relationships with patients. The steps that participants took from first using the enhanced way of working with patients with wounds, to using it to support all patients psychologically, are demonstrated.

The nurse-client relationship in a stress management clinic

The methodological perspective of symbolic interactionism and interpretive research emphasizes the complexity and importance of the nurse-client relationship. In a nurse-managed stress management clinic, 18 clients were interviewed at various points during their treatment trajectory, along with 6 clinicians. Clients and providers were emphatic about the importance of a broad, holistic perspective. Spiritual aspects were discussed, but not prominently. Status differential was minimized; however, this did not make participants define the relationship as less professional. The importance of trust was a key element in the nurse-client relationship.

Meaning of dependency on care as narrated by nurses

This article is part of an ongoing study aimed at illuminating the meaning of dependency on care. The aim of this particular study is to illuminate the meaning of the phenomenon 'dependency on care' as narrated by nurses. Interviews with 20 nurses were conducted, tape-recorded and transcribed verbatim. A phenomenological-hermeneutic approach was used to interpret the data. The meaning of dependency on care is revealed as laborious for both patients and nurses. The nurses' text discloses that for patients, dependency on care is a miserable loss of self-determination and self-worth. Nurses appear to be moved by dependents' difficult life and want to do whatever they can for the dependent. Dependency on care is a burdensome responsibility for nurses. For nurses dependency on care is revealed as evoking feelings of guilt and insufficiency and of being constantly concerned and worried. It is to struggle to be patient and understanding, having the arduous task of putting oneself into the dependent patients' shoes in order to cope with the demanding task of balancing between helping and not helping too much. The interpretation discloses, however, that nurses distinguish between easy and trying dependency on care. The understanding indicates that when they meet 'good' patients, nurses reappraise the situation, transform it into something new and meaningful, that is dependency on care is disclosed as 'easy to take'. When coming across'difficult' patients dependency on care is disclosed as trying. It seems that within the unique nurse-patient relationship patients may participate in such a way as to facilitate or inhibit nurses in finding meaning in the immediate caregiving situation. Nurses' evaluations of what constitutes a 'good' or a 'difficult' patient, respectively, seem to play an important role in distinguishing between dependency on care that is easy and that which is trying. The result is viewed through an existential paradigm and there is also reflection about what nurses perceive as valuable qualities in patients which might influence the quality of care.

Exploring the therapeutic potential of friendliness and friendship in nurse-client relationships

Friendliness and friendship, within the nurse-client relationship, are explored. Friendliness is superficial and includes nurses' smiling, joking, a warm tone of voice and interest in clients, while friendship is a deeper more affective involvement between client and nurse. The therapeutic outcomes of friendliness and friendship are significant. When nurses are friendly, client feelings of disease, strangeness and alienation are replaced by feelings of comfort, belonging and involvement. Friendship between nurse and client has similar outcomes but is a deeper experience that is simultaneously rewarding and sustaining for both. The therapeutic potential of friendliness and friendship suggests: (1) focused research would assist nursings' understanding of these concepts, and (2) determine their implications to nurse education and practice.

The personal and professional impact of undertaking an educational module on human caring

AIM OF THE STUDY

To evaluate the personal and professional impact of undertaking a 15-week degree level module on nursing as human caring.

BACKGROUND

Little is known about how to teach and enhance caring practices. An innovative module was implemented on a 4-year, postregistration nursing degree course in Wales to develop students' capacity to be caring practitioners. An understanding of its impact was sought to facilitate better future preparation of students.

RESEARCH METHODS

A full cohort of 25 part-time students, divided into four groups, participated in audio-taped focus groups before and after undertaking the module.

FINDINGS

From a personal perspective, the students experienced increased spiritual awareness characterized by: (1) enhanced connecting relationships with self and others, (2) finding purpose and meaning in life, and (3) clarification of values. Professionally, the module resulted in: (1) an increased knowledge and understanding of caring theory and related concepts, (2) a more holistic approach to care, and (3) enhanced caring practice.

CONCLUSIONS

Education may enhance students' capacity to be caring practitioners. Spirituality, in particular, was illuminated for the students as an important means of developing both themselves and their caring practices. They experienced transformative learning, and the focus groups, employed as the research method, served as a useful vehicle in this process. Reflective groups will be used as a teaching method on future modules.

Holistic symptom management: modelling the interaction phase

AIM

This article details an interaction model that links the way a nurse participates in a client's effort to describe the symptom experience and the eventual symptom management outcome.

RATIONALE

Symptoms represent more than clues to an underlying disease process. Within a nursing perspective, managing symptoms requires an understanding of the person's experience and the meaning associated with each symptom. All nurses engage in symptom work with clients, but the extent of their accountability varies within their scope of practice. In the United States of America (USA) model of advanced practice nursing, the scope expands to include all aspects of symptom management such as eliciting an accurate understanding, using a symptom cluster to determine underlying causes, and involving the client in management decisions. A holistic nursing approach to symptom management is particularly well suited to the increasing numbers of people with chronic illness.

METHOD

The discussion herein details the interaction phase of the evolving model of Negotiated Symptom Management in chronic illness. Analysis of the participants, process, and context governing this encounter reveal the complexities of the interaction.

FINDINGS

It is argued that variables within the interaction have the potential to compromise desired nurse and client outcomes. Although symptom acknowledgement and relief is a primary goal, the emphasis for the nurse clinician remains on the person, not the symptom. Effective symptom management is dependent on hearing and attending to the lifeworld of the client.

CONCLUSION

Attending to key areas of influence in the interaction process facilitates the achievement of desired outcomes in symptom management--accurate diagnosis, symptom relief, and agreement on a course of action. The dominance of chronic illness in health care, and the centrality of the symptom experience underscores the value of sensitizing nurses to these issues.

Negotiating trust: a grounded theory study of interpersonal relationships between persons living with HIV/AIDS and their primary health care providers

This grounded theory study is an exploration of long-term interpersonal relationships between patients and their primary health care providers, including physicians and nurse practitioners, in an urban outpatient HIV/AIDS clinic. Many providers believe that the positive interpersonal relationship enhances the health care experience for the patient, but there is a scarcity of research in this area. Persons who are patients were interviewed (N = 14) to look at these relationships from their points of view and develop theory to guide clinicians in forming such relationships. Theoretical sampling was used to find patients in this clinic population involved in long-term relationships with their providers. Open-ended interviews were conducted. These data were coded using the grounded theory method of constant comparative analysis. A basic process of negotiating trust was identified. Trust in these relationships is a state that is dynamic, volatile, and constantly renegotiated during the trajectory of the relationship through time. The trusting relationship is personally supportive for patients and may be a factor in the satisfaction found among health care providers in this clinical field despite the nature of this epidemic.

A literature review on the concept of intimacy in nursing

AIM

This paper explores the concept of intimacy in nursing.

RATIONALE

Intimacy is an increasingly important concept in nursing and feature of the nurse-patient relationship, which is perceived to be intrinsic to the proposed therapeutic potential of nursing. The introduction to the paper highlights the theoretical enthusiasm and endorsement of intimacy, the apparent lack of conceptual clarity from a nursing perspective and little published research investigating intimacy in practice.

METHOD

Literature is reviewed from nursing and a variety of health-related disciplines.

FINDINGS

The paper traces the historical background of the nurse-patient relationship and intimacy and highlights the change in value from detachment and distancing to intimacy, commitment and involvement. The nature of intimacy is examined and a concept analysis based on literature from psychology and psychiatric medicine is critically analysed. Intimacy is suggested to have psychological, emotional and physical aspects, which are explored. An ethnographic research study on intimacy in nursing is reviewed, which also recognizes physical and emotional dimensions of the concept and the importance of sufficient resources to allow the close relationships advocated. Attention is drawn to the constraints on intimacy imposed by the current market-led health service. Literature and research on the implications and consequences of intimacy for the nurse are discussed. These report practical difficulties of maintaining close relationships with individual patients and the potential for over-involvement and emotional labour.

CONCLUSION

The paper concludes with the increasing importance attached to intimacy in nursing and its complex, ill-defined nature. This serves to highlight the importance of research aimed at exploring and clarifying intimacy and further illustrating the therapeutic potential of nursing.

The required role of the psychiatric-mental health nurse in primary health-care: an augmented Delphi study

An augmented Delphi study was employed to elicit the perceptions of CPNs, GPs, social workers, managers of psychiatric nursing services and health service purchasers in England, on the role required of a psychiatric (mental health) nurse in primary health care. In the final stage of the study, users of mental health service were enlisted in a verification study of the emergent findings. A broad consensus emerged that a gap existed in mental health services in primary care. This was perceived as placing a large burden on GPs, which might be reduced by the appropriate development of community psychiatric-mental health nursing. The study suggested the possibilities for development of a 'mental health nurse consultant' role, which might augment the current CPN role, within which the nurse might offer not only direct patient care, but also support to members of the primary care team.

Nurses' experiences working with families in an NICU during implementation of family-focused developmental care

PURPOSE

To explore and describe nurses' experiences while working with parents and infants receiving family-focused developmental care (FFDC), to gain insight into the process of changing from a traditional model of care to FFDC.

DESIGN

The qualitative design was based on Spradley's method.

SAMPLE

Data were collected by interviewing ten nurses who worked in an NICU during a pilot study of FFDC. Transcripts were analyzed using Spradley's domain analysis.

FINDINGS

Four themes describe aspects of the transition from traditional care to FFDC: (1) negative experiences of FFDC, (2) transitions central to partnering with parents, (3) positive experiences of parental participation, and (4) organizational transitions necessary for the move to a family-centered model of care.

CONCLUSION

Learning to share responsibility with families will require change in the NICU culture as well as in nurses' role identity.

What do people need psychiatric and mental health nurses for?

The study reported here aimed to describe, by consulting with psychiatric practitioners of different disciplines, what people in contact with mental health services need nurses for, in terms of core nursing activity. Yet, recent trends have also been towards consumer-led definitions of good practice. The views of service and ex-service users can contribute much to an exploration of the role of psychiatric and mental health nurses and these perspectives were incorporated into the study. Given the lack of existing theory, a qualitative, grounded theory methodology was selected. In order to generate data rich enough for the analysis, focus groups of psychiatric nurses, social workers, service users, psychiatrists, carers and professions allied to medicine were sampled (13 groups, n=92) on the basis of the themes emerging from the data. Using critical incident technique (Flanagan 1954), the groups were invited to give examples of effective and ineffective nursing interventions, in relation to specific patient needs. The taped material was transcribed and analysed with the help of a computer package (QSR NUD.IST). This led to the selection of a core category, 'knowing you, knowing me', which described service users' and professionals' expectations that nurses are best placed to second guess the needs of patients and present themselves accordingly. Thus, nurses were expected, moment by moment, to know whether to be the patient's friend, a friendly professional, or take a more distant professional stance. The continuum entails different levels of knowledge and power, different language forms and different approaches to structuring time. Nurses themselves are most likely to prefer a position of friendly professional, from which they can move to a more intimate or distant role. Further study is needed to explore how nurses predict patients' expectations of them using a symbolic interactionist framework.

Factors influencing nurse-patient interaction in the acute psychiatric setting: an exploratory investigation

Nurse-patient interaction in acute psychiatric in-patient facilities has been the subject of much discussion in the literature and remains a contentious issue. How and why nurses interact with patients in the acute care setting requires definition within the current dynamic environment of mental health service provision. Factors which impact on the manner in which nurses care for patients also require investigation. This article presents the findings of a collaborative research study that investigates factors that influence nurse-patient interaction in the acute psychiatric setting. Ten nurses on the study ward were given opportunity, through semi-structured interviews, to outline and describe the factors perceived to influence nurse-patient interaction. Factors identified as influencing interaction included the ward environment, something always comes up, nurses' attributes, patient factors, instrumental support and focus of nursing. Issues which emerged from the study provide managers and clinical nurses with an opportunity for generating new possibilities for nurse-patient interaction. However, these issues must be addressed in a sensitive way that takes into account the complex and dynamic nature of acute care settings.

The need for psychiatric nursing: towards a multidimensional theory of caring

Contemporary developments in health care have encouraged a review of the professional status of psychiatric nursing. Although research has documented psychiatric nursing activity, little study has been made of the 'need' for psychiatric nursing within a multidisciplinary service. Employing adapted grounded theory methodology, substantive theory was developed concerning the expressed need for psychiatric nursing, by patients, their carers and mental health professionals. The study was based on six sites from England, Eire and Northern Ireland. The study found some consensus across both recipients and providers of mental health care, that the essential feature of nursing (the core category) involved a complex of relationships: 'knowing you, knowing me'. Within that complex, nurses either elected, or were required, to move--or 'toggle'--between three discrete domains of relating: the Ordinary Me (OM); the Pseudo-ordinary or Engineered Me (POEM); and the Professional Me (PM). Four internal dimensions involving the nurses' depth of knowing, power, use of time and use of translation distinguished these domains. The emergent theory extends current awareness of the importance of interpersonal relations in nursing. To what extent current health care policy, which emphasizes the promotion of alternative roles for nurses, will challenge this essential focus remains unclear.

Identifying outstanding clinical nurses: the 'star' shines in oncology

There are some oncology nurses who are special. They are 'good' nurses but they are more, somehow they 'shine'. They are 'stars'. Many nurses will identify the same nurse as a 'star' but what makes a nurse a 'star'? Twelve semistructured interviews were conducted in which oncology nurses were asked to describe an oncology nurse who stood out in terms of clinical practice. The 'star' nurse was easily and readily recalled and described by participants. Analysis revealed 21 grouped themes relating to the 'star' nurse. Each theme was allocated to one of four headings: 'Nurses' ways of Being; Doing; Knowing; and Giving and Receiving' (Stiles, 1990). The 'star' nurse is professional, committed and caring; delivers excellent nursing care both basic and technical; is knowledgeable; has advanced communication skills, and establishes strong relationships with clients and peers. From this, it is clear that caring and psycho-social aspects of care are only part of the make up of the 'star' nurse, and that the complexity of the 'star' nurse has not been highlighted in the literature.

Psychosocial care in oncology nursing: a study of social knowledge

A combination of focus group and individual interviews aimed to examine psychosocial aspects of nursing within a social context and social knowledge held by two teams of ward-based oncology nurses. Five core categories of knowledge emerged: knowledge of how to care, knowledge of the patient, knowledge of the ward, knowledge of nurses coping, and knowledge of involvement. Involvement or emotional closeness was seen as a necessary, inevitable and potentially stressful feature of psychosocial care. The authors conclude that interpersonal and professional aspects of nursing must be balanced in order to provide effective psychosocial care.

Parallel process in clinical supervision: enhancing learning and providing support

The introduction of clinical supervision in nursing is gaining momentum and is proposed as having numerous benefits for nurses, organizations, and ultimately patient care. The necessity for such supervision has arisen partly from a fundamental shift in the nature and definition of nursing work. The emphasis on individualized, holistic care has led to a change in role from one characterized by professional distance to one in which interpersonal involvement is seen as central. Such a shift, though seen as positive, may lead to increased vulnerability as nurses negotiate the blurred boundaries between the personal and the professional in their relationships with patients. Such boundary negotiation is a legitimate focus for learning and support in clinical supervision. However, as with many aspects of nursing, the subtle processes involved in relationship development are often hidden from consciousness, thus missing potential learning opportunities. One way that such hidden aspects of practice may be explored in clinical supervision is through attendance to the way that such processes are parallelled in the supervisory relationship. Drawing on theory and practice from the fields of counselling and mental health nursing, this paper explores the nature of 'parallelling' in clinical supervision. The implications for clinical supervision in nursing more generally are examined in relation to enhancing learning and providing support for supervisees and supervisors.

Developing reciprocal trust in the caregiving relationship

A summer camp for ventilator-dependent children provided a natural laboratory in which to explore the development of a caregiver-child relationship. The campers' routine treatments were "downplayed" to create a more "normal" camp experience while ensuring that the children had a safe environment and maintained a stable medical condition. Campers who normally had consistent home caregivers were observed as they were cared for by new caregivers. Using grounded theory methods, a model describing four types of relationships--tentative, familiar, mutually protective, and connected--was developed. Strategies used by caregiver-camper dyads to sustain a relationship or to progress to a more intense relationship were identified. Developing reciprocal trust was the basic social process that enabled the caregiver and child to reach the goal of becoming connected. Previous camp experience and caregiver contact had an impact on the initial degree of trust between camper and caregiver, and subsequently, it influenced the development of the relationship. This study provides important information about the role of trust in establishing effective caregiving relationships.

Negotiating realistic and mutually sustaining nurse-patient relationships in palliative care

This paper uses a literature review to question the proposition that nurses will be permitted to care for the psychosocial and spiritual needs of patients in the manner that is frequently presented as the nurses role. Second, it will explore qualities in nurse-patient relationships that can be not only helpful to those who are cared for but also can be a mode of sustenance to the nurse. Issues explored are the social construction of the nurse-patient relationship, reality checking, balancing emotional and cognitive functions in nursing, focus of nursing commitment, power issues, reciprocity and boundaries. Palliative care nursing will be referred to in relation to these themes as it is an area of nursing which highlights the increasing focus on psychosocial care. For this reason questions of what is realistic and sustainable for the nurse are of prime importance.