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

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.

Mental health crisis at home: service user perspectives on what helps and what hinders

This paper presents data which emerged during the process of a participatory research study to identify the perspectives of previous users of a home treatment service. Feedback was sought in order to establish the criteria for the development of a service evaluation questionnaire. Seven themes emerged from the data which were then used as a framework for the evaluation questionnaire. These themes have also been used within this paper to present what our participants told us was important to them when they received a service at home at a time of mental health crisis. Although what is described here is the experience of one group of service users in the North of England, we hope that the views of these participants will create a resonance with providers of other home treatment services and expand the knowledge about which aspects of care at home during mental health crisis are viewed as helpful and those aspects which are not.

About the Culture of In-Home Nursing

As nurses assume a multitude of roles in health care, public and professional perspectives of nursing vary and, consequently, both clients and providers, including nurses themselves, do not fully appreciate the nature of in-home nursing. In this study ethnographic methods were used to capture participants' perspectives of the actions, practices, values, and beliefs that collectively comprise the culture of nursing in the context of home nursing services in rural Australia. Findings reveal how nurses' and clients' experiences of in-home nursing differ from the textbook picture, and how interactions between nurses' practice approaches and care recipients' enactment of the client role create a cultural context affecting clients' health and well-being. Given similar findings in other countries, the insights gained merit consideration by all professionals concerned about refining home care service approaches in keeping with currently espoused valuing of client-centered, empowering care partnerships.

The Tidal Model as experienced by patients and nurses in a regional forensic unit

The Tidal Model has been implemented in Rangipapa, a regional secure mental health forensic unit in New Zealand. A phenomenological study was undertaken to obtain reflective description of the nursing care experience from the perspective's of four Registered Nurses and four Special Patients. Five major themes were identified that appeared to capture the experiences of the participants. The themes show changes to the unit's unique culture and values following implementation of the model. These changes engendered a sense of hope, where nurses felt they were making a difference and patients were able to communicate in their own words their feelings of hope and optimism. Levelling was experienced as an effect emerging from individual and group processes whereby a shift in power enhanced a sense of self and connectedness in their relationships. These interpersonal transactions were noted by the special patients as being positive for their recovery. This enabled effective nurse-patient collaboration expressed simply as working together. The participants reported a feeling of humanity, so that there was a human face to a potentially objectifying forensic setting. Implications arising from this study are that the use of the model enables a synergistic interpersonal process wherein nurses are professionally satisfied and patients are validated in their experience supporting their recovery.

Undermining self-efficacy: the consequence of nurse unfriendliness on client wellbeing

Although unfriendly nurse behaviours are noted in research findings, no study names these behaviours as such, nor investigates the impact of nurse unfriendliness on clients. Because the present findings reveal the phenomenon of nurse unfriendliness, they allow both the phenomenon and its consequences to be understood. These findings were developed through secondary data analysis of a text where participants discussed their encounters, during hospitalisation/s in 2002-2003, with friendly and unfriendly nurses. Findings reveal nurse unfriendliness is characterised by frostiness, officiousness and apathy. It results in thoughtless and inept nursing and in a hostile environment where clients feel unsafe, unwelcome and unaided. Unfriendly nurses create barriers--they are disrespectful, cheerless, unresponsive and domineering so clients feel belittled, disheartened, unprotected and distressed. When clients are placed in this position, their self-efficacy is undermined. By revealing the consequences of nurse unfriendliness on client wellbeing, findings from this study advance nursing knowledge.