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An observational study of the nurse-patient relationship in an oncology setting Lotzkar, Michelle 1996

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AN OBSERVATIONAL STUDY OF THE NURSE-PATIENT RELATIONSHIP IN AN ONCOLOGY SETTING by MICHELLE LOTZKAR B.S.N. The University of B r i t i s h Columbia, 1993 A THESIS IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1996 ® Michelle Lotzkar, 1996 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Soli 00 I Depaj*ment of The University of British Columbia Vancouver, Canada Date DE-6 (2/88) A B S T R A C T The purpose of t h i s study was to describe the development of a nurse-patient r e l a t i o n s h i p (NPR) i n an oncology s e t t i n g . Although t h e o r i s t s and researchers have attempted to explain the nature of the NPR, and have recognized i t s p o t e n t i a l benefits, further exploration i s necessary to increase our understanding of the complexities inherent i n NPRs. Using q u a l i t a t i v e ethological research methods, videotaped recordings (VTRs) of the interactions between a nurse and patient on an active cancer treatment ward were used to investigate and delineate important features of nurse-patient interactions (NPIs) that r e f l e c t the development of a NPR. A sample of s i x t y videotaped NPIs that represented a l l the interactions between one patient and one nurse over a three-day period was selected for t h i s study. The data analysis of the VTRs was completed by reviewing a l l the interactions, i d e n t i f y i n g behavioral c l u s t e r s , i d e n t i f y i n g constituents of behavioral c l u s t e r s and constructing an ethogram. The findings of t h i s study were validated and extended by using a focus group meeting with c l i n i c a l nurse experts. Several behavioral c l u s t e r s were found on each day of t h i s three-day r e l a t i o n s h i p which r e f l e c t e d a dynamic and complex inter p l a y between the nurse and patient. Some patterns of i n t e r a c t i o n were observed i n a l l three days of the r e l a t i o n s h i p , while others changed as the r e l a t i o n s h i p developed. A dominant theme observed i n most of the i n t e r a c t i o n patterns was the one of humor. The findings of t h i s study suggested active p a r t i c i p a t i o n of I l l both the nurse and patient i n rel a t i o n s h i p development. The development of t h i s NPR was r e f l e c t e d i n the changes observed i n the behaviors of both the nurse and patient over the course of three days. The NPR i s complex. Awareness of nurse and patient behaviors that contribute to the development of e f f e c t i v e NPRs may challenge oncology nurses to r e f l e c t on t h e i r own pra c t i c e and to consciously incorporate behaviors that contribute to e f f e c t i v e NPRs into t h e i r patient care. j i v TABLE OF CONTENTS ABSTRACT i i TABLE OF CONTENTS i v LIST OF TABLES i x ACKNOWLEDGEMENT x CHAPTER ONE: INTRODUCTION 1 Statement of the Problem 1 The Context ; 2 Purpose and Rationale for the Study 3 The Research Question 4 CHAPTER TWO: LITERATURE REVIEW 5 The Emergence of NPRs as a Component of Nursing 6 Conceptualizations of the NPRs 8 The Therapeutic Relationship 8 Types of Relationships Based on Levels of Involvement 13 The NPR as an Interactive Process 16 The Developmental Process of the NPR 24 Factors Influencing the Development of the NPR 28 Factors Related to the Nurse 29 Factors Related to the Patient 30 Factors Related to the I n s t i t u t i o n 31 Nursing Cancer Patients 32 Gaps i n the Research on NPRs 34 Summary and Conclusion 35 CHAPTER THREE: METHODS 38 Research Design 38 Sample 42 Data C o l l e c t i o n 43 V Videotaped Data 43 Focus Group 44 Data Analysis 45 Reviewing A l l the Interactions 45 Identifying Behavioral Clusters 46 Identifying Constituents of Behavioral Clusters 46 Constructing the Ethogram 47 Rigor 47 E t h i c a l Considerations ; 48 Summary ] 48 CHAPTER 4: FINDINGS 49 Day One 51 Getting to Know the Nurse ** Getting to Know the Patient _ 53 Responding to Introductions «* Introductions 54 Assessing the Nurse as Person «* Assessing the Patient as a Patient 55 Acknowledging Leave-Taking «* Leave-Taking 57 Wooing the Nurse ** Creating a Foundation for Connecting _ 58 Accepting the Nurse «» Accepting the Patient 59 Complimenting the Nurse «» Carrying on i n a Usual Manner 60 Being Friendly «» Responding to Friendliness 61 Asking the Nurse for Help *» Responding to Requests for Help 61 Helping the Nurse *» Involving the Patient i n Care 62 Being V i g i l a n t «» Demonstrating Competence 63 Keeping a Watchful Eye on the Nurse «» Talking Through Her Actions 63 Checking the Nurse' s Actions «* Carrying out Nursing Tasks Expertly 64 vx Establishing the Nurse's Whereabouts «* T e l l i n g The Patient Her Whereabouts 65 Cautious Consideration «• Making Therapeutic Suggestions _ 66 Listening and Cautiously Responding to the Nurse's Suggestions «» Gently Guiding the Patient by Explaining Suggestions 67 J u s t i f y i n g Actions *> Gentle Confrontation 68 Day Two \ ; 69 Comfortable with Being Known by the Nurse ** Deepening Understanding of the Patient 71 Va l i d a t i n g Continuity «* Re-introduction 72 Discussing Problems «» Zeroing-in on Patient Problems 72 Sustaining Involvement with the Nurse «* Sustaining a Connection with the Patient 74 Engaging i n S o c i a l Conversation <* Engaging i n S o c i a l Conversation 74 Determining the Nurse's Whereabouts «» T e l l i n g the Patient her Whereabouts 76 Displaying Independence to the Nurse «* Encouraging Independence 77 Giving to Demonstrate Gratitude «* Giving to Demonstrate Caring 78 Cautious Responsiveness «* Making Therapeutic Suggestions 80 Listening to the Nurse's Suggestions *> Suggesting P o s s i b i l i t i e s 80 Going Along with the Nurse's Suggestions «» Gentle Confrontation 81 Communicating Physical Distress «» Being there f o r the Patient 82 Showing Distress «» Creating an Atmosphere of Calm Reassurance 83 Voicing Distress <* Demonstrating Genuine Concern, Applying Comfort Measures 84 Day Three 85 V l l Being Comfortable with the Nurse «* Being Comfortable with the Patient 87 Offering Personalized Greeting «» Offering Personalized Greeting 88 Discussing Problems ** Zeroing-in on Patient Problems Forecasting the Conclusion «* Responding to the Patient's Forecast of Conclusion Saying Good-Bye to the Nurse «* Saying Good-Bye to the Patient 88 Tempered Movement Toward Problem Resolution ** Pushing Toward Problem Resolution 9 0 Reluctant Progression ** Assertive Confrontation 91 Agreeing to Take the Nurse's Direction i n the Future «* Encouraging Continuance of Self-Care i n the Future 93 Making the Most of the Time L e f t «* Preparing f o r Concluding the Connection 94 Maintaining a P o s i t i v e Atmosphere «» Maintaining a Po s i t i v e Atmosphere 94 Determining the Nurse's Whereabouts *» T e l l i n g the Patient her Whereabouts 95 96 Working Toward Independence «» Encouraging Independence 97 Making Use of the Nurse's Service «» Providing Nursing Service 97 98 Acknowledging the Relationship «» Acknowledging the Relationship 99 Findings from the Focus Group 100 Beginning the Relationship 100 Maintaining the Relationship 103 Ending the Relationship 104 Summary 105 CHAPTER 5: DISCUSSION 106 Discussion of the Findings 108 v i i i Mutual P a r t i c i p a t i o n i n Relationship Building 108 Ways of Knowing i n Relationship Building 112 Fostering the Achievement of Therapeutic Goals 116 Humor i n Relationship Building 118 Reciprocity 121 Closure of NPRs 123 Discussion of the Research Method 126 Conclusion 129 Summary 130 REFERENCES 132 APPENDIX 1: Consent Form f o r Focus Group Participants 146 i x LIST OF TABLES Table Description Page 1 Behavioral Clusters and Their Constituents Observed on the F i r s t Day of the NPR 53 2 Behavioral Clusters and Their Constituents Observed on the Second Day of the NPR 71 3 Behavioral Clusters and Their Constituents Observed on the Third Day of the NPR 87 X ACKNOWLEDGEMENT I thank my committee members: Dr. Joan B o t t o r f f , Dr. Joy Johnson, and Roberta Hewat Ph.D. (cand.) for t h e i r expertise and di r e c t i o n i n the preparation of my the s i s . I p a r t i c u l a r l y thank Joan for being such a wonderful mentor to me and for making t h i s learning experience a very p o s i t i v e one. I thank my parents: Sarah and Arieh Engelberg who sewed the seed of knowledge i n me at a very young age and nurtured that seed throughout my l i f e . My parents have t r u l y given me the g i f t of education, one which w i l l undoubtedly serve me well. Last, but c e r t a i n l y not lea s t , I thank my loving husband, Gordon. His support and encouragement throughout my years i n uni v e r s i t y have been very necessary and much appreciated. He too knows something about the development of an e f f e c t i v e r e l a t i o n s h i p . 1 CHAPTER 1: INTRODUCTION A special kind of human caring r e l a t i o n s h i p — the nurse-patient r e l a t i o n s h i p (NPR) — has been discussed i n the nursing l i t e r a t u r e f o r the past three decades. This r e l a t i o n s h i p may seem simple, but i s actually complex. Although the r e l a t i o n s h i p cannot slow or stop a patient's pathology, i t has the po t e n t i a l to s i g n i f i c a n t l y influence health care outcomes (Elder, 1965; Watson, 1985, 1988). Statement of the Problem Theorists have attempted to explain the nature of the l i n k between the NPR and p o s i t i v e health outcomes i n t h e i r conceptualizations of the NPR (Gadow, 1985; Watson, 1985, 1988). Caring NPRs have been linked to improvements i n patient comfort (Gadow, 1985); increased patient p a r t i c i p a t i o n i n care delivery (Bishop & Scudder, 1990; Gadow, 1985; Peplau, 1952; Watson, 1985, 1988); promotion of growth and learning (Bishop & Scudder, 1990; Peplau, 1952, 1987); and, enabling and empowering patients to endure t h e i r i l l n e s s , (Bishop & Scudder, 1990). Elder (1965) reported that patients who f e l t relaxed and s a t i s f i e d i n relationships with t h e i r nurses required fewer sleeping p i l l s and analgesics, fewer post-operative catheterizations, used the c a l l l i g h t less frequently, and were more s a t i s f i e d with t h e i r care than patients who d i d not have good relationships with t h e i r nurses. Subsequent investigations of NPRs completed i n a v a r i e t y of c l i n i c a l settings lend support to these findings (Kelly & May, 1982). For example, empathic relationships have been shown to p o s i t i v e l y influence physical and emotional well-being among hospice patients (Raudonis, 1993, 1995). Furthermore, an 2 increase i n the general s a t i s f a c t i o n of both nurse and patient i n good NPRs has been predicted by nurse t h e o r i s t s (Peplau, 1952; Watson, 1988) and supported by researchers (Elder, 1965; May, 1993, 1995a). P r a c t i c i n g nurses have also recognized the pote n t i a l benefits of the NPR. Researchers report that nurses are w i l l i n g to r i s k involvement with t h e i r patients and perceive intense l e v e l s of attachment to be most b e n e f i c i a l (Artinian, 1995; Raudonis, 1993, 1995). Although t h e o r i s t s and researchers have attempted to explain the nature of the NPR, and have recognized i t s p o t e n t i a l benefits, a gap remains i n understanding t h i s dynamic dyad. Dyad, i n the present study, i s defined as two persons i n a continuing r e l a t i o n s h i p i n which they i n t e r a c t with each other (Guralnik, 1985). We s t i l l know very l i t t l e about how e f f e c t i v e NPRs are developed. Early t h e o r i s t s such as Peplau (1952) provided the f i r s t explanations of the i n t e r a c t i v e process inherent i n the NPR. She based her work on observations i n psy c h i a t r i c settings. Since t h i s time, researchers interested i n the nature of the NPR, have based t h e i r investigations on s e l f -reports of nurses or patients. As a r e s u l t , the complexity of NPRs has not been adequately captured. Nurses and patients are not always aware of t h e i r behaviors and, as a r e s u l t , important d e t a i l s are missed. Furthermore, se l f - r e p o r t s based on r e c a l l focus on perceptions of events and may not accurately r e f l e c t what a c t u a l l y occurs i n the NPR (Lowenberg, 1994). The Context The attention that the NPR has received i n the nursing l i t e r a t u r e points to i t s importance and c e n t r a l i t y i n nurses' 3 work i n a v a r i e t y of settings. Although there i s some consensus on the c h a r a c t e r i s t i c s of an e f f e c t i v e NPR, further exploration i s necessary to increase our understanding of the complexities inherent i n NPRs as they a c t u a l l y occur everyday i n c l i n i c a l settings. Lowenberg (1994) asserts that the only way to increase our understanding of the NPR i s by learning more about the actual interactions that take place between patients and nurses. E f f e c t i v e NPRs become es p e c i a l l y important i n situations where patients face l i f e - t h r e a t e n i n g i l l n e s s and endure complex tec h n i c a l treatments with t h e i r associated discomforts. In these sit u a t i o n s , NPRs provide an important human dimension to experiences characterized by discomforts such as pain or nausea and sometimes disfigurement. In cancer nursing i n p a r t i c u l a r , nurses are faced with the challenge of developing relationships with patients whose disease involves a number of unique phy s i o l o g i c a l and psychological stresses. Purpose and Rationale f o r the Study The purpose of t h i s study was to describe the development of a NPR i n an oncology se t t i n g . Using a q u a l i t a t i v e e t h o l o g i c a l research method, videotaped recordings of the interactions between a nurse and patient on an active cancer treatment ward were used to investigate and delineate important features of nurse-patient interactions r e f l e c t i n g the development of NPRs. Videotaped recordings of nurse-patient interactions make possible d e t a i l e d observations of both verbal and nonverbal behaviors, including the timing and sequencing of these behaviors as they naturally emerge i n the d a i l y a c t i v i t i e s of nurses and t h e i r patients. Such observations allowed the researcher to investigate and describe the i n t r i c a c i e s of the NPR as i t was ac t u a l l y enacted i n t h i s c l i n i c a l s e t t i n g . Lowenberg (1994) argues that examinations of videotaped recordings w i l l enhance the study of NPRs and augment our knowledge of what a c t u a l l y takes place i n concrete, everyday nurse-patient i n t e r a c t i o n s . The Research Question The main aim of t h i s study was to describe the process of developing a re l a t i o n s h i p between a nurse and a cancer patient. The research question was: What patterns of nurse-patient i n t e r a c t i o n r e f l e c t the development of an e f f e c t i v e NPR? 5 CHAPTER 2: LITERATURE REVIEW The purpose of t h i s l i t e r a t u r e review i s to present a summary of e x i s t i n g knowledge related to the NPR and to demonstrate a rationale for t h i s study. Theorists such as Peplau (1952) and Orlando (1961) were among the f i r s t to conceptualize the NPR as a part of nursing p r a c t i c e . Since t h i s time, the NPR has been incorporated into other nursing theories, described and attested to by expert nurse c l i n i c i a n s , and has been the focus of an increasing number of research endeavors. Furthermore, several authors have offered t h e i r own opinions and reviews of t h i s t o p i c , drawing on the l i t e r a t u r e from nursing as well as from the s o c i a l sciences. This l i t e r a t u r e review i s organized into several sections. A b r i e f h i s t o r i c a l overview i s presented to describe the emergence of the NPR as a key component of nursing p r a c t i c e . Following t h i s , three conceptualizations of NPRs are discussed. F i r s t , the NPR i s discussed as a dichotomy based on the degree to which the r e l a t i o n s h i p i s therapeutic (that i s , the NPR can be therapeutic or non-therapeutic, and within t h i s dichotomy c e r t a i n conditions define the r e l a t i o n s h i p as therapeutic and non-therapeutic) . Second, descriptions of the NPR as a typology of relationships based on l e v e l s of nurse-patient involvement i s presented. F i n a l l y , conceptualizations of the NPR as an i n t e r a c t i v e process are presented. The process of developing NPRs i s discussed including the factors influencing t h i s process. This i s followed by a description of the NPR i n cancer nursing. F i n a l l y , the gaps i n the l i t e r a t u r e on NPRs are discussed and a case i s s o l i d i f i e d for further i n v e s t i g a t i o n into the area of the 6 NPR. The Emergence of Nurse-Patient Relationships as a Component of Nursing The NPR has not always been recognized as an important aspect of nursing p r a c t i c e . P r i o r to the 1960's, the e f f i c i e n t performance of routine tasks such as, bed-making and medication administration was highly valued and c l i n i c a l attention was directed toward the patients' body care (May, 1993). Although early t h e o r i s t s attempted to point out problems with t h i s impersonal approach to providing care, i t was not u n t i l the 1960's that t h i s became a topic of debate among p r a c t i c i n g nurses (Altschul, 1972). In part, the debate was stimulated by c l i n i c a l observations that "good" relationships between nurses and patients contributed to recovery rates (Elder, 1965). However, the major stimulus for t h i s important development came a decade e a r l i e r with the publication of Peplau's (1952) book e n t i t l e d "Interpersonal r e l a t i o n s i n nursing: A conceptual framework of reference for psychodynamic nursing." Peplau's theory, based on her observations i n p s y c h i a t r i c nursing, focused on the interpersonal processes inherent, i n the NPR. She set the stage for moving beyond advocating the NPR as simply a more personal approach, to using the NPR as a diagnostic and therapeutic t o o l . This s h i f t gave further c r e d i b i l i t y to the NPR and prompted others to explore and describe the work of nurses that extended beyond the provision of physical care from the perspective of the patient as well as the nurse. Authors noted that a lack of involvement i n the patient's subjective experience depersonalized the patient and denied the patient of human dignity, reducing the 7 in d i v i d u a l to an object (Gadow, 1985; Peplau, 1952). Others noted that the caring and s k i l l the nurse brings to the NPR appears to i n s p i r e the patient's p o t e n t i a l for well-being. The patient i s able to p a r t i c i p a t e as an active subject i n his/her care, rather then being a mere physical object, and i s therefore able to actualize his/her inner p o t e n t i a l (Paterson & Zderad, 1976). Along with t h i s s h i f t toward viewing the patient as an active r e c i p i e n t of care, attention was also directed to the patient's subjective experience of the disease process and the care provided. The subjective experience of the patient could only be a r t i c u l a t e d through conversation. Thus, interpersonal relationships between nurses and patients became incorporated into approaches to nursing work such as the nursing process (Dingwall, Rafferty, & Webster, 1988) and caring theories (Bishop & Scudder, 1990; Gadow, 1985; Watson, 1988). Consequently, the approach of organizing nursing work around tasks was permanently eroded. Today the importance of the NPR i s unquestioned. It i s viewed as es s e n t i a l content i n nursing c u r r i c u l a and i s the focus of continuing education i n many c l i n i c a l s p e c i a l t i e s . Nurses have also begun to explore the ethics of NPRs ( C o l t r i n , 1992; Storch, 1992). C l i n i c i a n s are recognized for t h e i r a b i l i t y to develop NPRs and react to administrative changes that undermine t h e i r a b i l i t y to do t h i s . Researchers are increasingly turning t h e i r attention to understanding the dynamics involved i n NPRs and t h e i r therapeutic p o t e n t i a l . 8 Conceptualizations of Nurse-Patient Relationships The NPR has been described i n a number of ways: caring, supportive, therapeutic, humane and interpersonal, to name a few. However, there appears to be at least three major conceptualizations of NPRs: the NPR as a dichotomy — the NPR can be therapeutic or non-therapeutic; the NPR as a typology of re l a t i o n s h i p s based on l e v e l s of involvement; and, the NPR as an i n t e r a c t i v e process. Each of these conceptualizations w i l l be discussed. The Therapeutic Relationship One conceptualization of the NPR that pervades the nursing l i t e r a t u r e i s grounded i n the c h a r a c t e r i s t i c s of a therapeutic r e l a t i o n s h i p . According to t h i s conceptualization, the NPR i s not viewed as unique, but rather a r e l a t i o n s h i p that takes on the c h a r a c t e r i s t i c s of s i m i l a r helping r e l a t i o n s h i p s . The work of Carl Rogers (1961), a well known psychotherapist, i s c l e a r l y r e f l e c t e d i n the nursing l i t e r a t u r e espousing t h i s view. As a therapist, Rogers (1961) d i s l i k e d the r o l e of the detached expert who "figured out" the patient. He preferred a less formal approach to counselling that, i n his view, was more b e n e f i c i a l to the patient and more comfortable for the therapist. Rogers began using "nondirective therapy," allowing patients to decide what to t a l k about and when. Nondirective therapy, now known as client-centered or person-centered therapy, depended on the patient's own drive toward growth or s e l f - a c t u a l i z a t i o n . The foundation of Rogers' therapy was the creation of a r e l a t i o n s h i p . This therapeutic r e l a t i o n s h i p consisted of three i n t e r r e l a t e d components: unconditional p o s i t i v e regard, empathy, 9 and genuineness. The therapist uses unconditional p o s i t i v e regard to show genuine caring about and acceptance of the c l i e n t as a person and t r u s t i n the c l i e n t ' s a b i l i t y to change. I t would be non-therapeutic, according to Rogers (1961), for the therapist to give advice to the c l i e n t . He claimed that advice-giving c a r r i e s the subtle message that i n d i v i d u a l s are inadequate or incompetent, and as a r e s u l t makes them less confidant and more dependent on help. In using empathy as a therapeutic technique, an i n t e r n a l perspective i s required of the therapist i n order to appreciate how the world looks from the c l i e n t ' s point of view. Empathy i s communicated verbally with statements such as, "I understand," and nonverbally by making eye contact with the patient and by nodding i n recognition as the patient speaks. Reflection i s also a part of empathy and i s used to show the patient the therapist i s a c t i v e l y l i s t e n i n g and thus helps the patient to become aware of his/her thoughts and f e e l i n g s . According to Rogers (1961), i t i s non-therapeutic to ask disruptive questions. Questions may impede the c l i e n t ' s confidence and motivation to t r y and solve his/her own problem. F i n a l l y , the therapist i s genuine with the patient. That i s , there i s consistency between the way the therapist f e e l s and acts toward the c l i e n t . This means that the therapist's unconditional p o s i t i v e regard and empathy are r e a l , not fabricated. The foundation of Roger's therapeutic r e l a t i o n s h i p i s openness and honesty. This therapeutic r e l a t i o n s h i p has the p o t e n t i a l for p o s i t i v e patient outcomes such as increased s e l f -confidence, awareness of feelings, self-acceptance and r e l i a n c e 10 on self-evaluation rather than the judgements of others, comfort and genuineness with others, and a sense of relaxation. Nurses embraced Roger's concept of client-centered therapy and applied i t d i r e c t l y to the NPR. For example, Gunter (1962) substituted "patient" for " c l i e n t " i n Rogers' postulates to i l l u s t r a t e the a p p l i c a b i l i t y of the model to nursing. Researchers i n nursing (Kemper, 1992; Shanken & Shanken, 1976) as well as nursing authors i n the area of p s y c h i a t r i c nursing (Gelazis & Coombe-Moore, 1993; McMahon, 1992; Schwecke, 1995; Thomas, 1991; Townsend, 1993; V a r c a r o l i s , 1990) have advocated actions such as active l i s t e n i n g , helping patients to i d e n t i f y t h e i r feelings and empathy as key elements of a NPR. Many nurses have contended that only a therapeutic r e l a t i o n s h i p can provide the emotional environment i n which nurses can a s s i s t patients to achieve goals. Influenced by the work of Rogers and other psychologists (e.g., Egan, 1982), they cautioned against non-therapeutic responses such as f a i l i n g to l i s t e n , being defensive, agreeing or disagreeing and probing, and t e s t i n g or challenging. Such non-therapeutic responses prevent the patient from expressing true concerns, leaves the patient f e e l i n g that his/her privacy i s not being respected, and places the patient i n a defensive p o s i t i o n (Brammer, 1985). Although less obvious i n the writings of contemporary t h e o r i s t s , Rogers' (1961) work i s s t i l l i m p l i c i t i n many descriptions of the NPR. For example, King (1981) described the NPR as an i n t e r a c t i v e process i n which the nurse and patient mutually i d e n t i f y goals and the means to achieve them. Others nurse t h e o r i s t s have extended our understanding of 11 the therapeutic r e l a t i o n s h i p by incorporating the work of philosophers such as Buber (1958), as demonstrated i n Bishop and Scudder's (1990) notion of the "personal sense of nursing." These th e o r i s t s have used Buber's work to c l a r i f y the nature of a personal NPR and d i f f e r e n t i a t e i t from personal r e l a t i o n s h i p s with friends or lovers. Buber has described the pure personal r e l a t i o n s h i p as I-Thou and the I-It r e l a t i o n s h i p as that between a person and object. Based on the works of Buber, Bishop and Scudder conceptualized the therapeutic NPR as an " I - I t (Thou) re l a t i o n s h i p . " They argued that t h i s new conceptualization was necessary because i t was impossible to incorporate Buber's ideas about relationships to the nurse-patient dyad. The I-Thou re l a t i o n s h i p would be impractical i n nursing practice and the I-I t r e l a t i o n s h i p demeaning to the patient and u n f u l f i l l i n g to the nurse. According to Bishop and Scudder, the I-It (Thou) re l a t i o n s h i p i s one i n which the patient i s recognized as a person within the routine and demands of nurses' work when time i s often l i m i t e d . The fact that c e r t a i n procedures are impersonal i n t h e i r nature, such as taking a blood pressure reading or temperature, does not mean that the nurse should t r e a t the patient i n an impersonal fashion. Even when engaging i n seemingly routine tasks, the nurse should always be cognizant that s/he i s r e l a t i n g to a "Thou." Relating to the patient as a person rather than an object even during quick impersonal treatments i s the basis for valuing and respecting the patient. Thus, the structured, purposeful and contextual c h a r a c t e r i s t i c s of the I - I t (Thou) 12 r e l a t i o n s h i p and those of Rogers' (1961) person-centered therapeutic r e l a t i o n s h i p p a r a l l e l one another. The notion of the therapeutic NPR has received tremendous support from p s y c h i a t r i c mental health nurses. In the mental health context, the therapeutic NPR i s used as a basis for i n t e r a c t i n g e f f e c t i v e l y with patients i n order to work c o l l a b o r a t i v e l y toward the goal of meeting patient needs and f a c i l i t a t i n g growth (Gelazis & Coombe-Moore, 1993; McMahon, 1992; Schwecke, 1995; Thomas, 1991; Townsend, 1993; V a r c a r o l i s , 1990). In addition, researchers have also supported the usefulness of the therapeutic NPR i n the context of providing p s y c h i a t r i c nursing care (Heifner, 1993; Kemper, 1992; S h i l l i n g e r , 1983). The notion of the therapeutic r e l a t i o n s h i p has influenced nursing beyond ps y c h i a t r i c mental health settings. Caring has been recognized by many nursing t h e o r i s t s as the "essence of nursing" (Kelly, 1990; Leininger, 1985; Morse, Solberg, Neander, Bot t o r f f , & Johnson, 1990). The therapeutic r e l a t i o n s h i p has been described as consisting of e s s e n t i a l components such as respect, empathy, and genuineness, a l l of which are d i r e c t l y r e l a t e d to caring. Caring i s also considered to be an e s s e n t i a l element of the NPR by researchers (Kahn & Steeves, 19 88; Morse, 1991a; Trojan & Yonge, 1993). Although the therapeutic r e l a t i o n s h i p , as i t i s conceptualized i n psychology, has extensively influenced nursing and has seemed to be e f f e c t i v e i n some settings (e.g., p s y c h i a t r i c settin g s ) , i t i s d i f f i c u l t to incorporate i t i n other nursing settings. For example, i n acute care settings, patients' energies are focused on coping with impending prognoses, as well as pain or other discomforts. 13 Patients i n such situations may not be interested i n s e l f -a c t u a l i z i n g and promoting t h e i r personal growth. In addition, influences such as the workload on the unit, team nursing and the lack of privacy l i m i t the time nurses can spend with i n d i v i d u a l patients to es t a b l i s h rapport (Morse et a l . , 1992). In summary, the usefulness of the therapeutic r e l a t i o n s h i p i n many nursing settings remains i n question. Further in v e s t i g a t i o n i s necessary to increase our knowledge and understanding of the NPR and the components that make i t appropriate i n a vari e t y of nursing settings. Types of Relationships Based on Levels of Involvement The second major conceptualization of the NPR i s based on the notion of involvement as an es s e n t i a l feature of NPRs. In contrast to the previous conceptualization of the NPR which evolved p r i m a r i l y from the application of knowledge of relationships developed i n other d i s c i p l i n e s to nursing, t h i s conceptualization of the NPR has evolved primarily from inductive investigations of nurses' and patients' self-reported experiences. In sharp contrast to viewing rel a t i o n s h i p s as either therapeutic or non-therapeutic, when relationships are defined by l e v e l of involvement, a wider range of rela t i o n s h i p s has been i d e n t i f i e d . In addition, increased emphasis i s placed on the ro l e of patients i n influencing the nature of the rel a t i o n s h i p and the appropriateness of the d i f f e r e n t types of relationships i n the range of contexts i n which nurses work. Research by May (1991), Morse (1991a), Ramos (1992) and Hagerty, Lynch-Sauer, Patusky and Bouwsema (1993) t y p i f y the q u a l i t a t i v e studies that have led to the i d e n t i f i c a t i o n of the 14 d i f f e r e n t l e v e l s of involvement between nurses and patients. May and Ramos s i m i l a r l y c o l l e c t e d data through informal semi-structured tape recorded interviews with nurses (May) and c l i n i c i a n s (Ramos) i n medical-surgical settings. Morse interviewed nurses, some of whom had also been patients, from eight c l i n i c a l settings. Hagerty et a l . i d e n t i f i e d states of relatedness using data c o l l e c t e d i n a va r i e t y of ways, including case studies, interviews, and focus group meetings. The features found i n the varying l e v e l s of involvement i d e n t i f i e d i n these investigations appear to be cumulatively and q u a l i t a t i v e l y s i m i l a r . Three l e v e l s of involvement seemed to encompass the findings of the above researchers. The key features of the f i r s t type of involvement are r e c i p r o c i t y and exchange between the nurse and the patient. Both players are equally involved i n the rel a t i o n s h i p and i d e n t i f y with one another on an emotional and cognitive l e v e l . In t h i s l e v e l of involvement, the nurse i s oriented toward the patient. In addition, the nurse's personal, professional and organizational objectives are balanced. That i s , the nurse maintains a professional perspective while providing the patient with a sense of personal recognition. This f i r s t l e v e l of involvement has been c a l l e d a connected r e l a t i o n s h i p (Morse, 1991a), primary involvement (May, 1991), a re c i p r o c a l r e l a t i o n s h i p with resolved control issues (Ramos, 1992), and a state of relatedness referred to as connectedness (Hagerty et a l . , 1993). In the second type of involvement the nurse overemphasizes care for a p a r t i c u l a r patient. As a r e s u l t , the nurse loses 15 o b j e c t i v i t y and there i s r o l e stress. Although the nurse i s oriented toward the patient, her/his personal needs are given p r i o r i t y over patient needs. This l e v e l of involvement has been referred to as an overinvolved r e l a t i o n s h i p (Morse, 1991a), a demonstrative r e l a t i o n s h i p (May, 1991), a protective r e l a t i o n s h i p l e v e l with an emotional component (Ramos, 1992), and as a state of relatedness c a l l e d enmeshment (Hagerty et a l . , 1993). The t h i r d type of involvement i s characterized by an orientation to tasks. Since, organizational objectives take precedence at t h i s l e v e l , the nurse has l i m i t e d involvement with the patient. Interactions with patients are b r i e f and s u p e r f i c i a l , although not necessarily negative. This type of involvement i s appropriate with unconscious patients or when the nurse can only spend a minimal amount of time with the patient and must get the task completed. However, t h i s type of involvement i s inappropriate i f the patient i s f e e l i n g uncomfortable or anxious. Researchers have referred to t h i s type of involvement as c l i n i c a l and therapeutic (Morse, 1991a), associational (May, 1991), instrumental (Ramos, 1992), and as states of relatedness referred to as disconnectedness and p a r a l l e l i s m (Hagerty et a l . , 1993). The types of NPRs described i n the research studies discussed above demonstrate d i f f e r e n t i a t i o n s i n NPRs based pr i m a r i l y on nurses' s e l f - r e p o r t s . Morse (1991a) included the patient's perspective i n her study to a l i m i t e d extent by interviewing some nurses who had also been patients. Although i t may be argued that the perspectives of nurses and patients were captured i n t h i s study, the reports of nurses who were once 16 h o s p i t a l i z e d may have been influenced by t h e i r professional knowledge and experience i n developing NPRs. In order to t r u l y understand the essence of the NPR both players i n the dyad must be considered. The NPR as an Interactive Process The t h i r d major conceptualization of the NPR i s based on the NPR as an i n t e r a c t i v e process. When NPRs are defined as i n t e r a c t i v e processes, equal emphasis i s placed on both the nurse and the patient i n influencing the r e l a t i o n s h i p . The i n t e r a c t i v e process i s unlike the f i r s t conceptualization of NPRs where the r e l a t i o n s h i p i s viewed as either therapeutic or non-therapeutic and where the r e s p o n s i b i l t y for the r e l a t i o n s h i p centers on the nurse. The t h i r d conceptualization also d i f f e r s from the second conceptualization of NPRs, where NPRs are defined by varying l e v e l s of involvement, that for the most part are c o n t r o l l e d by the nurse. In contrast to the former conceptualizations of NPR, the t h i r d conceptualization i s based on an i n t e r a c t i o n a l process that occurs between the nurse and patient. Peplau's (1952) theory was one of the f i r s t t h e o r e t i c a l frameworks to describe nursing practice as occurring within a r e l a t i o n s h i p with patients. Drawing from interpersonal, learning and developmental theories, Peplau considered the r e l a t i o n s h i p between nurse and patient as the key to the nursing process. Peplau's theory l a r g e l y emerged from her c l i n i c a l observations i n p s y c h i a t r i c settings (Peplau, 1952, 1987, 1992). Her t h e o r e t i c a l model of nursing as an i n t e r a c t i v e process has been tremendously i n f l u e n t i a l i n nursing practice and on subsequent nursing theories (eg., Orlando, 1961). 17 Peplau (1952) described four "overlapping" and "i n t e r l o c k i n g " phases of the interpersonal process underlying the NPR: orientation, i d e n t i f i c a t i o n , e x p l o i t a t i o n and r e s o l u t i o n . This i n t e r a c t i v e process i s used to guide the patient from dependency toward interdependent i n t e r a c t i o n s . The purpose of the i n t e r a c t i o n i s to "...promote a patient's health i n the d i r e c t i o n of creative, constructive, productive, personal, and community l i v i n g " (p. 16). Peplau (1952) described i n d e t a i l the interpersonal dynamics during each of the four phases. In some instances, these descriptions have been extended by Orlando (1961). During the orientation phase, the nurse and patient get to know one another and each others' roles and expectations i n the r e l a t i o n s h i p . The nurse must be c l e a r and consistent i n order to be trustworthy i n the NPR. The nurse and patient can then begin to explore and i d e n t i f y problems to work on i n the r e l a t i o n s h i p . In t h i s phase, the patient seeks the assistance of a nurse based on " f e l t needs." Peplau (1952) maintains that t h i s i s the f i r s t step i n a dynamic learning experience i n which personal s o c i a l growth can occur. I n s u f f i c i e n t exploration of the patient's needs may delay restoration of comfort and/or could lead to exacerbation of the patient's condition. The patient experiences the concern of the nurse, feels safe, and i s therefore more l i k e l y to spontaneously discuss d i s t r e s s f u l situations with the nurse (Orlando, 1961; Peplau, 1952). Orlando (1961) notes that nurses are i n a unique po s i t i o n because they are d i r e c t l y and continually responsible to patients for at l e a s t eight hours at a time. As such, the nurse may c a p i t a l i z e on natural nursing 18 s i t u a t i o n s , such as bathing, medicating, and feeding, as opportunities for patients to express t h e i r needs and feelings (Orlando; Peplau). The second phase Peplau (1952) describes i s that of i d e n t i f i c a t i o n . In t h i s phase, the patient i d e n t i f i e s with his/her nurse and may respond to an o f f e r of assistance. The nurse and patient become cle a r about t h e i r expectations and may modify preconceptions of one another. Orlando (1961) describes t h i s process of c l a r i t y between nurse and patient as a "deliberative process." In the d e l i b e r a t i v e process, the nurse validates an a c t i v i t y required to meet the patient's needs before carrying i t out. Thus, the nurse understands the meaning of the a c t i v i t y to the patient and how i t w i l l a f f e c t the patient. Conversely, i f the nurse were to carry out an a c t i v i t y automatically, that i s , without exploring i t with the patient, the a c t i v i t y may be i n e f f e c t i v e i n helping the patient (Orlando). As a r e s u l t , both the nurse and the patient use the NPR as a vehicle f o r respecting one another as human beings, and for examining and responding to situations (Orlando; Peplau). In the t h i r d phase, exp l o i t a t i o n , the patient f u l l y uses the NPR for his/her s e l f - i n t e r e s t s and needs. By taking f u l l advantage of nursing service, the patient i s reassured that his/her i n t e r e s t s and needs w i l l continue to be met. A d d i t i o n a l l y , new goals begin to be established by the patient, such as returning to home and work l i f e . The phase of e x p l o i t a t i o n i s "an extension of the s e l f of the patient i n t o the future. It i s characterized by an intermingling of needs and a s h u t t l i n g back and f o r t h . Rapid s h i f t s i n behavior that express 19 mixed needs makes observation more complex" (Peplau, 1952, p. 38) . The f i n a l and terminal phase of the NPR i s resolution. The resolution phase i s a psychological phenomenon and a process of freeing the patient from i d e n t i f y i n g with the nurse, and strengthening the patient's a b i l i t y to stand independently (Peplau, 1952). A l l e a r l i e r phases of the NPR must be achieved for t h i s outcome to be met. I t i s through the nurse's "unconditional acceptance i n a sustaining r e l a t i o n s h i p that provides f u l l y for need-satisfaction; recognition of and responses to growth cues, however t r i v i a l . . . that i t i s possible for the patient to want to be free" (pp. 40-41). Although Peplau's (1952) t h e o r e t i c a l explanation about the process of developing NPRs has dominated discussions i n nursing and has been supported by other t h e o r i s t s (e.g., Orlando, 1961), there are some gaps worthy of mention. For example, Peplau (1952) and Orlando (1961) emphasize the importance of r e a l i z i n g patients' f e l t needs and understanding patients' subjective experiences. However, neither t h e o r i s t explains how the nurse proceeds i n order to accomplish t h i s task. Furthermore, because these t h e o r e t i c a l frameworks were developed to approach p s y c h i a t r i c nursing s i t u a t i o n s , i t may be d i f f i c u l t to apply them i n other patient populations, such as emergency-room patients. Building on t h i s early work, other nurse t h e o r i s t s have extended our understanding of the NPR as an i n t e r a c t i v e process by focusing on the s p e c i f i c structures of the nurse-patient dyad (Bishop & Scudder, 1990; Gadow, 1980, 1985; Paterson & Zderad, 1976; Watson, 1988). Each has explicated important aspects of 20 t h i s unique and dynamic dyad formed by the nurse and patient. For example, Bishop and Scudder describe how a personal approach i n nursing practice i s enhanced through an I - I t (Thou) versus an I-Thou or I-It rel a t i o n s h i p ; Paterson and Zderad have defined a central concept of humanistic nursing defined as a "responsible searching transactional r e l a t i o n s h i p whose meaningfulness demands conceptualization founded on a nurse's e x i s t e n t i a l awareness of s e l f and other" (p. 3); Watson discusses the c h a r a c t e r i s t i c s of a transpersonal caring r e l a t i o n s h i p ; and Gadow theorizes about e x i s t e n t i a l advocacy as one aspect of e f f e c t i v e NPRs. The single most compelling area of consensus among the above mentioned t h e o r i s t s and including Peplau (1952) and Orlando (1961) i s the contributions of both nurse and patient are viewed as s i g n i f i c a n t and quintessential to the NPR. Although the contribution of both parties i n the rel a t i o n s h i p i s seemingly obvious, i t i s in t e r e s t i n g to note that some t h e o r i s t s , including Orem (19 85, 1991) and Neuman (1982) focus only on the patient. Contemporary th e o r i s t s such as Watson (1988) a t t r i b u t e much importance to an understanding of the patient's experience. Watson explains that the foundation of the NPR depends upon a commitment by the nurse to maintain and enhance the patient's d i g n i t y by highly regarding the patient's own meaning of his/her condition; affirming "the subjective experience of the person (I-Thou versus I - I t ) " (p. 64); r e a l i z i n g and detecting the feelings and condition of the patient through a mutual union and by using verbal and nonverbal actions; and by using the nurse's own l i v e d experiences to c l a r i f y , understand and be sensi t i v e to the l i v e d experience of the patient. The nurse, according to Watson, has 21 an a r t i s t i c a b i l i t y which goes beyond being able to receive and experience the patient's f e e l i n g s . The nurse's art i s i n expressing the patient's experience i n such a way that the patient i n turn may be able to f u l l y express and release f e e l i n g s r e l a t e d to his/her experience or " f e l t needs." The experience of f e l t needs was discussed by Peplau (1952) and Orlando (1961) who associated these needs with increased anxiety and tension related energy. They argued that the nurse can use t h i s energy as a p o s i t i v e means for defining and understanding the i l l n e s s . Furthermore, the nurse can engage the patient as an active partner i n i d e n t i f y i n g and assessing his/her i l l n e s s . It i s only through f u l l p a r t i c i p a t i o n that the patient i s able to f u l l y integrate the i l l n e s s experience into his/her l i f e experience. In order to evaluate the v a l i d i t y of Peplau's claims and the claims of other nurse t h e o r i s t s , i t i s useful to look at research which has focused on the i n t e r a c t i o n a l processes of NPRs. Forchuk and her colleagues have reviewed and tested Peplau's theory (Forchuk, Beaton, Crawford, Ide, Voorberg, & Bethune, 1989; Forchuk & Brown, 1989; Forchuk, 1991; Forchuk, 1994; Martin, Forchuk, Santopinto, & Butcher, 1992). For example, Forchuk (1994) used a var i e t y of instruments ( i . e . , Relationship Form, Working A l l i a n c e Inventory) to examine the o r i e n t a t i o n phase i n a prospective-panel-longitudinal study of 124 nurse-patient dyads i n a ps y c h i a t r i c s e t t i n g . The findings of t h i s study demonstrated support for the importance of patients' preconceptions of the nurse and nurses' preconceptions of the patient as they re l a t e to the progression or regression of the 22 therapeutic r e l a t i o n s h i p . However, other tenets of Peplau's theory, for example, the assumption that patients' and nurses' previous interpersonal relationships a f f e c t the development of therapeutic r e l a t i o n s h i p s , were not supported i n t h i s i n v e s t i g a t i o n . Forchuk (1994) found that only patients' previous interpersonal relationships were s i g n i f i c a n t i n the progression of the nurse-patient r e l a t i o n s h i p . Researchers have also demonstrated how Peplau's theory can be incorporated into case management of long-term, predominantly schizophrenic patients (Forchuk et a l . , 1989; Forchuk & Brown, 1989; Martin et a l . , 1992). An instrument to a s s i s t i n monitoring the r e l a t i o n s h i p was developed and used by nurses to measure the phases of the NPR. The instrument consisted of a graph containing each phase of the NPR. Each phase on the graph had corresponding summary statements of each phase of the NPR. The nurses regularly used the instrument to plot where they perceived the r e l a t i o n s h i p phase to be on the graph. I t was argued that an accurate assessment of the NPR would allow the nurse to assess the phase i n which the r e l a t i o n s h i p i s i n and, thereby, a s s i s t nurses to select appropriate interventions (Forchuk & Brown, 1989). Although these studies provided an important beginning toward creating a v a l i d and r e l i a b l e instrument by which to measure the phases of the NPR, l i m i t a t i o n s are evident. For example, there were differences between raters i n scoring phases of the relationship; the small convenience sample of patients were a l l community based, decreasing the g e n e r a l i z a b i l i t y of findings; and, the studies were conducted from the nurses' perspective and, as a r e s u l t , only one of the 23 players i n the dyad was considered. Chalmers and Luker (1991) explored NPRs i n community health settings using a grounded theory method of research. Their findings supported Peplau's (1952) and Orlando's (1961) conceptions of the i n t e r a c t i o n a l process as c h a r a c t e r i s t i c of NPRs. Analysis of interviews with nurses revealed that establishing a p o s i t i v e r e l a t i o n s h i p was based on the nurse's a b i l i t y to demonstrate respect and genuine concern for patients and to be perceived by the patients as h e l p f u l . The mutual "giving" and "receiving" i n the NPR was found to r e s u l t i n achieving desired outcomes for the patient and the nurse. This study shed l i g h t on the i n t e r a c t i v e process of r e l a t i o n s h i p development, yet, again only considered the reports of nurses. As a r e s u l t , uncertainties remain as to why, for example, d i f f i c u l t i e s and changes i n the NPR a r i s e . Although these investigations provide support f o r the conceptualization of the NPR as an i n t e r a c t i v e process, the i n t e r a c t i v e process as i t a c t u a l l y occurs i n the c l i n i c a l s etting has not been explored. Furthermore, most studies were based on sel f - r e p o r t s of nurses. It i s u n l i k e l y that nurses are able to accurately r e c a l l a l l of the dynamics of t h e i r interactions with patients. Nurses may not be aware of a l l of t h e i r behaviors that influence i n t e r a c t i o n s . In addition, interactions are so complex that i t i s d i f f i c u l t to report on both one's own behavior as well as those of the patient. Detailed knowledge of nurse and patient behaviors that characterize the i n t e r a c t i v e process i n the NPR has the p o t e n t i a l to extend our understanding of NPRs. It i s i n t e r e s t i n g to note that, whereas nursing t h e o r i s t s focused 24 equally on the nurse and the patient i n t h e i r conceptualizations of the NPR as an i n t e r a c t i v e process (e.g., Peplau, 1952, 1992), most researchers only considered half of the dyad. Studies are needed to describe the contribution of both nurses and patients to the NPR. The Developmental Process of the NPR Although building NPRs i s not separate from the i n t e r a c t i o n a l process, there are some q u a l i t a t i v e researchers who have investigated the development of NPRs (Morse, 1991a; Raudonis, 1995; Thorne & Robinson, 1988; Trojan & Yonge, 1993). Morse (1991a) i s the only researcher to describe the development of NPRs as a process of negotiation. Her analysis of tape-recorded interviews with nurses revealed that negotiations between the nurse and patient may be e x p l i c i t or i m p l i c i t , and r e s u l t i n the establishment of the NPR. Often, negotiation depends on the seriousness of the patient's s i t u a t i o n . For example, i f the patient f e e l s vulnerable and dependent, s/he may assess the nurse to determine whether or not the nurse i s trustworthy and w i l l i n g to become involved i n her/his care. The nurse also assesses the patient to determine the patient's personal needs and support system, and whether or not to make an emotional investment i n the patient or simply get the work done (Morse). I f , however, the patient's needs are minor and contact with the nurse i s short, then hardly any negotiation i s necessary. Whereas other researchers have focused on the stages of r e l a t i o n s h i p development, Morse's findings reveal that a rel a t i o n s h i p only begins to develop as a r e s u l t of negotiation between nurse and patient. As such, the stages i n which 25 relationships progress are the end product of negotiation between the nurse and the patient. Other q u a l i t a t i v e researchers have i d e n t i f i e d stages or phases relationships progress through (Raudonis, 1995; Thorne & Robinson, 1988; Trojan & Yonge, 1993). Based on an analysis of in-depth interviews with c h r o n i c a l l y i l l patients using grounded theory, Thorne and Robinson (1988) described the evolution of health care relationships i n three stages: naive t r u s t , disenchantment, and guarded a l l i a n c e . The findings revealed patients entered into health care relationships with complete t r u s t that a l l of t h e i r health care problems would be answered. However, t h i s i n i t i a l t r u s t was soon l o s t when i t became cl e a r a remedy did not e x i s t . Furthermore, from the perspective of c h r o n i c a l l y i l l patients, health care professionals d i d not understand or even care about t h e i r patients' subjective experiences of chronic i l l n e s s . The r e s u l t i n g disenchantment, along with anger and loss of t r u s t was resolved as patients recognized that they were i n need of prolonged professional health care and entered the stage of "guarded a l l i a n c e . " Trust was restructured to allow for an a l l i a n c e that was guarded with a decreased adversarial nature. Patients developed knowledge and competence within the context of t h e i r i l l n e s s management and expressed an expectation from health care professionals to accept and encourage that competence (Thorne & Robinson, 1988). According to the informants i n t h i s study, t r u s t i n the health care r e l a t i o n s h i p i s the most s i g n i f i c a n t component, providing the basis for collaboration and cooperation on i l l n e s s management. Ad d i t i o n a l l y , r e c i p r o c a l t r u s t was found when 2 6 patients were trusted by t h e i r health care provider (Thorne & Robinson, 1988). Trojan and Yonge (1993) i d e n t i f i e d four phases i n the relationships between home care nurses and t h e i r e l d e r l y c l i e n t s : i n i t i a l t r u s t i n g , connecting, negotiating and helping. The i n i t i a l t r u s t i n g phase described i n t h i s study i s s i m i l a r to the "naive t r u s t i n g " described by Thorne and Robinson (1988). The el d e r l y c l i e n t s were found to exhibit a generalized t r u s t for the nurse based on evaluations of nurses' education and work experiences. Although the respondents i n Trojan and Yonge's study did not appear to go through a period of "disenchantment" and "guarded a l l i a n c e , " as described by Thorne and Robinson (1988), the phases of connecting, negotiating and helping share elements of mutual t r u s t i n g . This aspect was found to be quintessential to health care relationships (Thorne & Robinson). Raudonis (1995) explored the development of empathic NPRs between hospice patients and t h e i r nurses i n a n a t u r a l i s t i c study from the patients' perspective. Raudonis' study revealed that the development of the empathic r e l a t i o n s h i p occurred i n three sequential stages: i n i t i a t i n g , building and sustaining. The patients' needs, nurses' functions and nurses' a t t r i b u t e s were processes found to be present throughout a l l the phases of rel a t i o n s h i p development. During the i n i t i a l phase of the empathic r e l a t i o n s h i p , hospice patients revealed t h e i r needs to the nurse. The nurse, i n turn, entered the patient's home wanting to help meet the patient's needs. The nurse's caring and gentle approach were reported to influence the establishment of the empathic r e l a t i o n s h i p . The empathic r e l a t i o n s h i p i s 27 strengthened and deepened i n the building phase. In t h i s phase, there was a sense of mutual sharing, concern and commitment i n that there was r e c i p r o c i t y and t r u s t between nurse and patient. In addition, during t h i s phase the nurse demonstrates competence, consistence and a willingness to spend time with the patient. In the f i n a l phase, the sustaining phase, patients described the nurse as being available and 'going beyond the c a l l of duty.' Patients reported f e e l i n g secure and less anxious regarding p o t e n t i a l problems as t h e i r needs were being met. The sustained empathic r e l a t i o n s h i p was a way of knowing the patient and the context i n which nurses met patients' needs i n a h o l i s t i c and humanistic manner (Raudonis, 1995). In reviewing the above research studies, i t i s i n t e r e s t i n g to note the differences i n findings, p a r t i c u l a r l y i n l i g h t of the d i f f e r e n t perspectives from which the r e l a t i o n s h i p was studied. Raudonis (1995) and Thorne and Robinson (1988) investigated the r e l a t i o n s h i p from the patient's perspective, whereas Trojan and Yonge (1993) investigated the r e l a t i o n s h i p from the nurse's perspective. It i s i n t e r e s t i n g that themes such as t r u s t i n g and mutual negotiation surfaced i n a l l these studies. However, nurses i n Trojan and Yonge's study d i d not report observing periods of "disenchantment" or "guarded a l l i a n c e . " This difference i s important. It i s possible that patients do not share t h e i r disenchantment openly with t h e i r health care providers. A l t e r n a t i v e l y , i f nurses are not interested i n patients' subjective experiences then patients' r e l a t i o n s h i p s with health care providers and changes i n the r e l a t i o n s h i p may go unnoticed. S i m i l a r l y , the patients i n Raudonis's (1995) study did not report becoming "disenchanted" or having a "guarded a l l i a n c e " with t h e i r nurses. Perhaps the hospice patients did not become "disenchanted" with t h e i r nurses because t h e i r nurses emphasized a caring and gentle approach, a thorough assessment during the i n i t i a l phase and demonstrated a willingness to spend time with t h e i r patients. Furthermore, patients i n Thorne and Robinson's study entered the health care r e l a t i o n s h i p t r u s t i n g t h e i r health care problems would be answered, and when i t became cle a r that a cure did not exi s t for t h e i r chronic i l l n e s s , they became "disenchanted" with t h e i r health care providers. The also f e l t t h e i r health care providers did not care or understand them. In contrast, the hospice patients i n Raudonis's study had already accepted that a cure d i d not e x i s t for t h e i r i l l n e s s , and recognized t h e i r need for prolonged health care. The contradictory findings i n these studies suggest that further research i s necessary to investigate the NPR i n ways that include both nurses and patients. For example, i t may be possible to observe differences i n the way nurses and patients i n t e r a c t at each phase of the developmental process and how they negotiate movement to another stage. Factors Influencing the Development of NPR Factors that contribute to the development of the NPR have been discussed i n the l i t e r a t u r e by th e o r i s t s (Gadow, 1980, 1985; Peplau, 1952) and studied by researchers (Artinian, 1995; May, 1990, 1993; Morse, 1991a). The factors noted are rel a t e d to the nurse, the patient or the i n s t i t u t i o n a l context i n which nurses pr a c t i c e . 29 Factors Related to the Nurse Factors r e l a t e d to the nurse that appear to be linked to the development of help f u l NPRs have been conceptualized (Peplau, 1952) and investigated (Elder, 1965; May, 1993; Morse, 1991a). Nurse-related factors include the nurse's attitudes toward helping others; whether or not the nurse responds to the patient's expression of perceptions, thoughts and fee l i n g s ; the nurse's commitment to the patient as well as to the good of the profession and her/himself; and whether or not the kind of help a patient requires a f f e c t s the nurse's acceptance of that i n d i v i d u a l . Another factor influencing the NPR related to the nurse i s the personal/professional dichotomy. The issue of t h i s dichotomy has been raised i n r e l a t i o n to the nurse-patient r e l a t i o n s h i p by the o r i s t s (e.g., Gadow, 1980) and researchers (e.g., May, 1990, 1993). The t h e o r e t i c a l findings and research findings i n r e l a t i o n to t h i s dichotomy, however, are not i n agreement. Gadow argues that being professional does not necessarily mean the exclusion of being personal. The nurse can p a r t i c i p a t e i n the patient's experience by synthesizing the nurse's en t i r e s e l f . The e s t h e t i c , physical, and i n t e l l e c t u a l dimensions of the nurse can a l l be used as a resource i n the NPR and are conceptualized by Gadow as " e x i s t e n t i a l advocacy." Entailed i n Gadow's notion of e x i s t e n t i a l advocacy i s the experience of "fel l o w - f e e l i n g " (p. 91). In fel l o w - f e e l i n g the nurse p a r t i c i p a t e s i n the patient's i l l n e s s but i s not 'infected' by the patient's s u f f e r i n g thus becoming c l i n i c a l l y biased or emotionally depleted (Gadow). May (1990, 1993), conversely, noted that i n order for the nurse to 30 have t o t a l perspective of the patient's needs, respondents i n his study found i t necessary to disentangle or detach themselves from patients so that personal interests and ward objectives do not become confused. Another nurse-related aspect which influences NPR development i s the difference i n status between the nurse and patient. A p a r t i c i p a n t observation study conducted i n an elderly-care setting, found nurses dominated and exerted power by c o n t r o l l i n g the content of the conversation, and by persuading patients i n order to meet t h e i r own agenda (Hewison, 1995). Although t h i s s i t u a t i o n was accepted by s t a f f and patients, i t constituted a b a r r i e r to the NPR. Others have also noted that control a f f e c t s the NPR (May, 1995a; Lawrence, 1970; Trnobranski, 1994). These authors maintain there are problems inherent i n the NPR i n r e l a t i o n to the patient's autonomy and the nurse's authority. On one hand, a good NPR i s about the nurse a s s i s t i n g the patient to make choices. On the other hand, the patient i s an i n d i v i d u a l and i s an expert about her/his own needs. As a r e s u l t , i t i s d i f f i c u l t for the nurse to know how much expert knowledge would best serve the patient. Furthermore, some patients are not keen on p a r t i c i p a t i n g i n decisions about t h e i r care. In such a s i t u a t i o n i t may be d i f f i c u l t f o r the nurse to decide whether or not the patient should be encouraged to p a r t i c i p a t e i n her/his own care. Factors Related to the Patient Factors influencing the development of the NPR that are related to the patient have been noted by A r t i n i a n (1995) i n her study on r i s k i n g involvement with cancer patients. A r t i n i a n 31 found nurses s e l e c t i v e l y formed relationships with c e r t a i n patients based on the patient's age, v u l n e r a b i l i t y , t h e i r own s i m i l a r i t y to the patient, and i n i t i a t i o n of the r e l a t i o n s h i p by the patient. For example, a patient possessing c h a r a c t e r i s t i c s that reminded the nurse of a grandmother, or the patient having s i m i l a r aged children as the nurse seemed to contribute to forming " s p e c i a l " NPRs. Others have also observed that nurses f i n d i t easier to form relationships with some patients than others (Kahn & Steeves, 1988). Liki n g the patient was reported by nurses as " c l i c k i n g , " "meshing," or "enjoying" c e r t a i n patients and having t h e i r a f f e c t i o n returned. These researchers maintained that t h i s theme represents the "intrusion of the 'person' into the 'nurse'" (p. 207). Increased patient needs and whether the patient i s i n a c r i s i s s i t u a t i o n have been i d e n t i f i e d by researchers (Morse, 1991a; Ramos, 1992; Reid-Ponte, 1992) as important factors influencing the development of the NPR. However, patients have been reported to act u a l l y influence the development of NPRs by using strategies to increase and decrease t h e i r involvement (Morse, 1991a). The unwillingness of some patients to 'open up' or respond to overtures by the nurse are important factors influencing the NPR. May (1993) argues, as many other nurse authors (Bishop & Scudder, 1990; Gadow, 1980, 1985; Orlando, 1961; Peplau, 1952; Watson, 1988), that i n t e r a c t i o n a l obstacles with patients are sometimes i n e v i t a b l e . Factors Related to the I n s t i t u t i o n I n s t i t u t i o n a l factors influence the NPR primarily by regulating the length of contact between the nurse and the 32 patient. Factors such as rotating s h i f t s , the nurses' workload, sets of routines, technologies and bureaucracies on the ward make contact between the nurse and patient episodic and discontinuous. As such, nurses' and patients' e f f o r t s to b u i l d and maintain relationships are often undermined. Gadow (1985) cautions that the intense network of i n s t i t u t i o n a l factors assert an "otherness" that often does not require human involvement and therefore the human aspects of care are p o t e n t i a l l y alienated. That i s , technologies and bureaucracies can take on a l i f e of t h e i r own leaving the patient behind. Nursing Cancer Patients Cancer, as a l i f e threatening i l l n e s s , presents patients with a series of threats that vary i n i n t e n s i t y and duration. The patient must endure the stresses accompanied by the i l l n e s s and mobilize his/her coping mechanisms and support system (Mages & Mendelsohn, 1979). Creating relationships with cancer patients that w i l l be e f f e c t i v e i n a s s i s t i n g patients to endure t h e i r i l l n e s s e s presents nurses with special challenges. Issues p a r t i c u l a r to cancer such as uncertainties and fears about the present and future, d i f f i c u l t i e s with accepting a terminal prognosis and the nature of suffering experienced by cancer patients, increase patients' need f o r support and empathy and thus the need for an e f f e c t i v e NPR (May, 1995b; Raudonis, 1993). Health professionals, including nurses, have often found i t d i f f i c u l t to int e r a c t with cancer patients at a meaningful l e v e l . E f f o r t s to int e r a c t have been hampered by attitudes toward death and dying, secrecy around the diagnosis of cancer for many patients, and the need for some nurses to protect themselves from 33 patients' suffering (Artinian, 1995; Cohen & Sarter, 1992; Kahn & Steeves, 1994; Larson, 1992; Newlin & Wellisch, 1978; Pepper, 1985; Welch, 1981; Williams, 1982). In studying factors that influence how nurses communicate with cancer patients, researchers have focused primarily on the nurse (May, 1995b; Wilkinson, 1991). Recently, others have begun to draw attention to the r o l e patients play i n influencing the nature of nurse-patient interactions (Morse, 1991a; Raudonis, 1993, 1995). The importance of NPRs i n cancer nursing i s r e f l e c t e d i n a v a r i e t y of studies. In p a r t i c u l a r , the importance and complexity of the supportive r o l e of the nurse i n caring for cancer patients has been recognized (Davies & Oberle, 1990; Heslin & Bramwell, 1989). Furthermore, from the perspective of cancer patients, e f f e c t i v e communication has been viewed as the most important aspect of t h e i r treatment (Pepper, 1985; Thorne, 1988). Providing comfort to cancer patients was reported by nurses to be a p o s i t i v e and important nursing behavior (Degner, Gow, & Thompson, 1991; Fleming, Scanlon, & D'Agostino, 1987). In addition, observations of nurses and cancer patients revealed that comforting cancer patients comprised a s i g n i f i c a n t part of nurses' work (Bottorff, Gogag, & Engelberg-Lotzkar, 1995). Caring behaviors have also been i d e n t i f i e d as key elements of cancer nursing by researchers (Cohen & Sarter, 1992; Larson, 19 87) and others who have written i n the area of cancer nursing (Mayer, 1986; Pepper, 1985). These caring, supportive and comforting behaviors are based i n and evolve from e f f e c t i v e r elationships between nurses and cancer patients. Surprisingly, l i t t l e attention has been directed 34 s p e c i f i c a l l y to the nurse-patient r e l a t i o n s h i p i n oncology settings. Q u a l i t a t i v e researchers using in-depth interviews with cancer nurses (Artinian, 1995) and hospice patients (Raudonis, 1993, 1995) have begun to provide empirical support for the importance of the NPR i n oncology settings. As e f f e c t i v e NPRs are developed, patients are reported to be empowered to deal with personal issues associated with d i f f e r e n t phases of t h e i r i l l n e s s and improvements i n qu a l i t y of l i f e were experienced (Raudonis, 1995). In addition, patients reported f e e l i n g accepted and acknowledged as individ u a l s and persons of value by t h e i r nurses (Raudonis, 1993). Research also showed nurses to believe the only way to provide supportive care to cancer patients was by developing an e f f e c t i v e NPR (Artinain, 1995). Nevertheless, these studies are li m i t e d i n that researchers have focused on only one member of the dyad to explore aspects of the rel a t i o n s h i p (either the patient or the nurse), and have based t h e i r research s o l e l y on s e l f - r e p o r t . Clearly, the development of e f f e c t i v e NPRs depends on the behaviors of both nurses and patients. This development may not be adequately captured through s e l f - r e p o r t . As a r e s u l t , studying the NPR i s a challenge. Although there i s evidence that i n the context of working with cancer patients the development of NPRs i s c r i t i c a l , we s t i l l know l i t t l e about how these relationships a c t u a l l y evolve i n c l i n i c a l p r a c t i c e . Gaps i n the Research on NPRs There i s a consensus i n t h e o r e t i c a l and research l i t e r a t u r e that the NPR i s a key element of nursing prac t i c e . However, despite the int e r e s t and numerous studies on NPRs, gaps remain 35 and further research i s necessary. V a l i d a t i o n of e x i s t i n g t h e o r e t i c a l frameworks are needed as well as the examination of actual interactions that r e f l e c t the professional bonds developed by nurses i n c l i n i c a l settings. Most of the research concerning the NPR i s based on the self - r e p o r t s of nurses or patients. An assumption underlying t h i s approach i s that participants can accurately report on the dynamics underlying evolving r e l a t i o n s h i p s . Differences i n perceptions of nurses and patients regarding the structure of the rel a t i o n s h i p and strategies considered to be help f u l suggests that i n addition to personal subjective accounts, i t may be b e n e f i c i a l to conduct observational studies of naturally occurring nurse-patient interactions i n order to describe the evolution of NPRs as they occur i n r e a l - l i f e settings (Lowenberg, 1994). Given the complexity of interactions, observational studies that use videotaped data are l i k e l y to be the most useful (Lowenberg, 1994). This has been supported i n other d e t a i l e d observational studies of interactions between nurses and patients (Bottorff & Morse, 1994; Pepler, 1984; Solberg & Morse, 1991) and mothers and infants (Richards & Bernal, 1972; Scaife, 1979) Summary and Conclusion The topic of the NPR was introduced with a b r i e f account of how t h i s concept emerged as a central component of nursing theory and p r a c t i c e . This b r i e f h i s t o r i c a l account was followed by a description of three conceptualizations of the NPR: therapeutic and non-therapeutic rel a t i o n s h i p s ; types of relationships based on l e v e l s of involvement; and, the NPR as an i n t e r a c t i v e process. 36 These conceptualizations were followed by a discussion of some of the t h e o r e t i c a l positions that have shaped our understanding of the process of developing a NPR and subsequent research. While some of the theories were supported i n research studies, other t h e o r e t i c a l aspects need further exploration. Interestingly, a l l of the t h e o r i s t s whose works were reviewed here considered the perspective of the nurse and patient equally i n t h e i r descriptions of the NPR. Yet, researchers tended to investigate one perspective or the other. Most research studies were based on data that were primarily c o l l e c t e d by interviewing nurses i n a v a r i e t y of settings. Furthermore, differences were found i n studies that took into account the perspective of nurses and those that considered the perspective of patients. It appears that nurses and patients have d i f f e r e n t ideas regarding the c o n s t i t u t i o n of a h e l p f u l r e l a t i o n s h i p . In the l a t t e r half of t h i s l i t e r a t u r e review factors influencing the r e l a t i o n s h i p were described. The factors noted were related to the nurse, the patient and the i n s t i t u t i o n a l context i n which nurses prac t i c e . F i n a l l y , the nursing of cancer patients was discussed. Because cancer i s a disease that i s accompanied by s p e c i f i c mental and physical stresses, i t i s c r u c i a l f o r the oncology nurse to develop a r e l a t i o n s h i p with his/her patients that w i l l be h e l p f u l and w i l l contribute to the patient's a b i l i t y to endure t h i s i l l n e s s . Although a vast amount of research has been conducted i n r e l a t i o n to caring, comforting, and supporting cancer patients, only a few researchers focused on the NPR i n cancer nursing. The impact of the r e l a t i o n s h i p on the patient as well as the nurse has been supported by t h e o r i s t s and researchers. The dynamic progression of cancer and i t s tremendous impact on the indivi d u a l s enduring the i l l n e s s has also been i d e n t i f i e d . Further research on the r e l a t i o n s h i p between cancer nurses and t h e i r patients i s needed. Such research has the p o t e n t i a l for a s s i s t i n g the patient to endure the stresses of t h e i r i l l n e s s and the nurse to know how to proceed i n t h i s dynamic process. 38 CHAPTER 3: METHODS The main aim of t h i s study was to describe the process of developing a r e l a t i o n s h i p between a nurse and cancer patient. The research question was: What patterns of nurse-patient i n t e r a c t i o n r e f l e c t the development of an e f f e c t i v e NPR? Approaches used i n research should be selected according to the nature of the research question and what i s known about the phenomenon to be studied ( F i e l d & Morse, 1985). Quantitative research i s useful i n a s i t u a t i o n where the researcher i s seeking a r e l a t i o n s h i p or cause between known variables. However, when the researcher i s seeking new ways to "categorize, c l a s s i f y , or conceptualize situations [with the aim] to devise or invent labels that taken together w i l l u s e f u l l y characterize the important aspects of a given s i t u a t i o n " (Diers, 1979, p.100), a q u a l i t a t i v e design i s more conducive to the research. In order to investigate the developmental process of the NPR as i t occurs i n c l i n i c a l practice, a case study using a q u a l i t a t i v e e t hological approach i n an active treatment cancer unit was used. Presented i n t h i s chapter i s a description of the research design, s e t t i n g , sample selection, and e t h i c a l considerations. The process of data c o l l e c t i o n and data analysis w i l l be delineated. Research Design The nature of t h i s study lent i t s e l f to a d e s c r i p t i v e research approach. In d e s c r i p t i v e research, the investigator's aim i s to describe phenomena rather than explain them ( P o l i t & Hungler, 1991). Qualitative ethological methods were used i n t h i s study to provide an in-depth description of the development 39 of a NPR as i t occurred i n a single nurse-patient dyad. The study of NPRs to date has been dominated by the use of sel f - r e p o r t methods ( i . e . , open-ended interviews). The li m i t a t i o n s of using s e l f - r e p o r t i n describing and understanding complex interactions has been recognized (Bottorff, 1994; Morse & Bott o r f f , 1990). For example, nurses and patients are u n l i k e l y to be able to r e c a l l behaviors i n s u f f i c i e n t d e t a i l to reconstruct a l l aspects of t h e i r i n t e r a c t i o n s . Q u a l i t a t i v e ethological methods have the poten t i a l to capture complex behavior patterns through detailed observations of behaviors as they occur i n natural settings (Bottorff & Morse, 1994). Ethology involves the microanalysis of observed behaviors. It has been used to systematically observe, analyze, and describe animal and human behaviors i n natural contexts. For example, anthropologists have used ethology to study human f a c i a l expressions c r o s s - c u l t u r a l l y (Morse & Bot t o r f f , 1990). Etho l o g i c a l research c h a r a c t e r i s t i c a l l y has two phases: an inductive phase and a deductive phase. The present study w i l l involve the f i r s t inductive phase, referred to as q u a l i t a t i v e ethology. An ethogram, a de t a i l e d recording of the behavioral patterns observed, i s developed i n q u a l i t a t i v e ethology. The aim of q u a l i t a t i v e ethology i s to specify and describe patterns of behavior within the context i n which they occur (Erickson, 1992; Bottorff & Morse, 1994). By using t h i s research method, the investigator i s able to document these patterns i n greater d e t a i l and with more precision than i s possible with other descriptive approaches such as interviewing or pa r t i c i p a n t observation (Erickson, 1992). 40 Observational methods such as q u a l i t a t i v e ethology can be enhanced through the use of videotaped recordings (VTRs) of naturally occurring behavior. The use of VTRs makes i t possible to study events that may be rare or of such short duration they may be missed i n participant observations. Furthermore, precise information about verbal and nonverbal behaviors as they unfold moment-by-moment i s available for intense and repeated analysis. As such, subtle nuances which may otherwise go unnoticed can be v e r i f i e d and described. Behavior i s complex: i n any given s i t u a t i o n many complex events may happen simultaneously. As a r e s u l t , the use of participant observation i s l i m i t e d because one i s unable to capture the complexity. When situations are complex, the pa r t i c i p a n t observer tends to favor frequently occurring events, p o t e n t i a l l y overlooking other important aspects that may confirm or disconfirm a theory (Erickson, 1992). In contrast, VTRs present an unlimited opportunity to r e v i s i t events as they occurred i n r e a l time. The advantage of replaying events allows for a r i c h e r description of observations than those taken i n the f i e l d by the observer. VTRs allow the investigator time to deliberate on i n t e r p r e t a t i v e judgments so that f a u l t y inferences can be prevented (Erickson, 1992). The observer of VTRs also has the opportunity to thoroughly study rare events as well as frequent events (Erickson). The study of NPRs could be extended through a d e t a i l e d analysis of VTRs using q u a l i t a t i v e e thological methods. Researchers who have used interviews to explore NPRs have often based t h e i r descriptions of reports of only one of the players i n the i n t e r a c t i o n . As a r e s u l t , important information that may be 41 c r i t i c a l to the development of the re l a t i o n s h i p i s missed. In addition, s e l f - r e p o r t s , p a r t i c u l a r l y i n s t r e s s f u l s i t u a t i o n s , may be confounded by fatigue, pain, or shock. Even i n the best s i t u a t i o n s , i t may not be possible for the partic i p a n t s i n an in t e r a c t i o n to accurately report on a l l verbal and nonverbal behaviors that were important to the development of a re l a t i o n s h i p . In sharp contrast, the use of VTRs lends i t s e l f to equal observation of both p a r t i c i p a n t s . The use of VTRs as a method of data c o l l e c t i o n has other advantages for the study of complex i n t e r a c t i o n s . A wide range of behaviors, including subtle verbal and nonverbal nuances that may not have been obvious to parti c i p a n t s , are captured and available for de t a i l e d analysis and description. Reviewing VTRs i s possible as many times as necessary so attention can be directed to d i f f e r e n t features with each viewing. In addition, the review of VTRs at various playback speeds, i n slow motion or frame-by-frame, may disc l o s e new behavioral patterns not immediately apparent i n observations under normal speed. These features of VTRs make a thorough and complete analysis possible (Bottorff, 1994). Furthermore, VTRs provide an opportunity to study unconscious behaviors that are generally d i f f i c u l t i f not impossible to explicate or r e c a l l i n an interview (Morse & Bott o r f f , 1990). In q u a l i t a t i v e ethology, an inductive approach i s used to describe i n t e r a c t i o n s . This method, p a r t i c u l a r l y with videotaped data, o f f e r s an opportunity to gain a r i c h and complex understanding of the dynamics involved i n the development of a NPR (Bottorff & Varcoe, 1995). The present study involved a 42 secondary analysis of videotaped data c o l l e c t e d as part of a larger study to investigate nurse-patient interactions (NPIs) (Bottorff, 1992). NPIs are the processes of personal and mutual influence that unfold according to the c h a r a c t e r i s t i c s of each p a r t i c i p a n t and include the i n t e r a c t i v e processes r e l a t e d to how each i n d i v i d u a l adapts his/her verbal and nonverbal communication to one another. Other variables such as the context, the purpose of the i n t e r a c t i o n , and previous i n t e r a c t i o n history also influence the i n t e r a c t i v e process (Bottorff & Varcoe, 1995). Sample The primary source of data used i n t h i s study was taken from an e x i s t i n g data set of videotaped NPIs (Bottorff, 1992). A sample of 60 videotaped NPIs (a t o t a l of two hours, nineteen minutes and three seconds of VTRs) representing a l l the interactions between one patient and one nurse over a three day period was selected for t h i s study. Each i n t e r a c t i o n began when the nurse entered the patient's room and ended when the nurse l e f t the room. Stake (1994) maintains that i n se l e c t i n g a case f o r study, the investigator should choose a case that seems to o f f e r an opportunity to learn the most. Often t h i s means choosing a case with which the investigator can spend the most time. This p a r t i c u l a r dyad was selected because i t had the most frequent number of interactions over the longest period of time compared to a l l other nurse-patient dyads i n the data set. Cynthia (a f i c t i t i o u s name), the nurse i n the dyad, was an experienced f u l l - t i m e registered s t a f f nurse on the cancer ward. Bob (a f i c t i t i o u s name), the patient i n the dyad, was a 45 year 43 old married gentleman who had squamous c e l l carcinoma of the tongue and r i g h t sided lymphadenopathy. Nursing p r i o r i t i e s for Bob were mainly symptom control r e l a t e d to his radiotherapy treatments, including medications for nausea and vomiting and several mouth rinses ( i . e . , Tantum o r a l rinse and sodium bicarbonate). Bob also had a gastrostomy tube and experienced gas pains, nausea and hiccoughs when feeds were infused too quickly. Along with his gastrostomy tube, o r a l f l u i d s were encouraged. However, during the data c o l l e c t i o n period, he d i d not take o r a l f l u i d s because they seemed to increase his sensation of phlegm production and he was a f r a i d of swallowing. A focus group meeting with f i v e expert nurses was used to valid a t e and extend the analysis. The nurses were selected based on the following c r i t e r i a : A minimum of a baccalaureate degree i n nursing, at le a s t f i v e years of c l i n i c a l experience i n working with cancer patients, and who gave informed consent (see Appendix ! ) • Data C o l l e c t i o n Videotaped Data The data were c o l l e c t e d as part of a previous study of nurse-patient i n t e r a c t i o n by videotaping a convenience sample of eight cancer patients (three females and f i v e males) and 32 nurses that were t h e i r caregivers (Bottorff, 1992). To c o l l e c t data, two cameras were mounted on the wall of the patient's room and were remotely controlled and monitored from an adjacent area. The purpose of these strategies was to decrease interference with patient care and decrease the influence of the researcher. Furthermore, p a r t i c i p a n t r e a c t i v i t y to being videotaped was 44 reduced by i n s t a l l i n g cameras four weeks before actual data c o l l e c t i o n began. These strategies were found to minimize the problem of d i s t o r t i o n of behaviors related to the use of VTR i n t h i s c l i n i c a l s e t t i n g (Bottorff, 1992, Botto r f f , 1994). In the o r i g i n a l study, videotaping of each patient was continuous f o r 72 hours (Bottorff, 1992). Videotaping was discontinued only for b r i e f periods and at the request of the patient or s t a f f members i n order to complete private or invasive procedures. A remote co n t r o l l e d p a n - t i l t and zoom lens were used to ensure the nurse and patient were i n f u l l view as much as possible. Furthermore, a log was kept of a l l a c t i v i t i e s as well as f i e l d notes of comments and/or questions of s t a f f members and patients, and any a c t i v i t i e s out of camera range. To ensure maximum qu a l i t y of videotapes, Super VHS equipment was used for recording. The time i n hours, minutes and seconds was recorded on the VTRs for the purpose of analysis. Demographic and c l i n i c a l data were c o l l e c t e d on each patient. For the present study, a l l of the videotaped interactions of one of the nurse-patient dyads were extensively studied. Focus Group Data analysis for t h i s study was validated by using a focus group meeting with c l i n i c a l nurse experts. Krueger (1994) maintains that the purpose of a focus group i s to foster d i f f e r e n t points of view and perceptions on a defined area of i n t e r e s t without pressuring the participants to reach consensus. The researcher leading the focus group creates a nonthreatening, comfortable environment where participants can enjoy sharing t h e i r ideas. The purpose of the meeting was to discuss the 45 findings of t h i s study. The meeting entailed a b r i e f presentation of the preliminary findings. The group was then asked to discuss the findings i n r e l a t i o n to t h e i r own experience. Participants were encouraged to provide examples from t h e i r own personal experiences that may be useful i n augmenting or r e f i n i n g the findings of the study. The meeting was audiotaped for subsequent analysis (Krueger, 1994). An observer was also present to take notes during the focus group meeting. Data Analysis The focus of data analysis i n q u a l i t a t i v e ethology i s to consider whole events occurring i n the data, analyze these whole events by breaking them down into smaller c l u s t e r s , and then conclude by rebuilding the smaller c l u s t e r s into sequences or wholes. The purpose of t h i s kind of analysis i s to reconstruct highly d e t a i l e d phenomena into a narrative understanding of the events that occurred. I t i s important that t h i s understanding i s analogous to that held by the players i n the events themselves (Erickson, 1992). The data analysis of the VTRs was completed i n the following way: 1. Reviewing A l l the Interactions A l l of the videotaped interactions between Cynthia and Bob were systematically reviewed i n an unstructured fashion. As the VTRs were reviewed, the equivalent of f i e l d notes were taken that described the recorded a c t i v i t y . The notes i d e n t i f i e d approximate times of a c t i v i t y s h i f t s and verbal and nonverbal behaviors of sp e c i a l i n t e r e s t . 46 2. Identifying Behavioral Clusters The next step was to i d e n t i f y the patterns or cl u s t e r s of behaviors pertaining to the development of the NPR. Tapes were played and replayed at t h i s stage observing the nurse's and the patient's behaviors. While observing behaviors, the researcher asked questions such as, "What i s going on here?", "How does t h i s behavioral response or i n t e r a c t i o n d i f f e r from another?, "What are the c h a r a c t e r i s t i c s of t h i s type of response or interaction?" (Bottorff, 1994, p. 256). 3. Identifying Constituents of Behavioral Clusters In t h i s stage, the boundaries of each behavioral c l u s t e r was checked i n a second viewing. That i s , the beginning and ending of each c l u s t e r was c l e a r l y defined. Opening and c l o s i n g phrases i n each c l u s t e r , for example, were used to determine when each c l u s t e r s t a r t s and stops. These behavioral c l u s t e r s were then dubbed onto another tape to ease the process of analysis. Having i d e n t i f i e d the main behavioral c l u s t e r s , p a r t i c u l a r constituents of the cl u s t e r s were then studied. Each c l u s t e r was viewed and reviewed several times. Each time a d i f f e r e n t aspect of the c l u s t e r was watched, l i s t e n e d to, and recorded i n the form of f i e l d notes. For example, i n the f i r s t viewing attention was only directed to the content of verbal conversation. The second viewing was directed toward nonverbal behaviors. The t h i r d viewing payed attention to who i n i t i a t e s the conversation, and so fo r t h . Recording included how long each behavioral aspect lasted to the nearest second and included the time for quick reference. A l l relevant verbal and nonverbal behaviors were noted, such as who i n i t i a t e d a conversation, the content of the conversation, 47 how and why the conversation ended, the use of eye contact, the proximity of nurse to patient, and other verbal and nonverbal behaviors. Behavioral c l u s t e r s were compared to one another. For example, i t was noted whether the nurse used the same verbal and nonverbal techniques every time the patient was distressed. 4. Constructing the Ethoqram From the above data analyses, behavioral descriptions included an i n t e r p r e t a t i o n of the cause or functions of observed behaviors, and the consequences and conditions under which behaviors occurred (Bottorff, 1994). Data analysis of the focus group was completed i n two ways. F i r s t , notes taken by the observer of the focus group were reviewed. Second, the audiotape recorded during the focus group was reviewed several times, paying attention to emerging themes i n the discussion. The themes that emerged from the focus group were then used to r e f i n e and augment the findings of the study. Rigor Several measures were taken to ensure r i g o r i n t h i s study. A u d i t a b i l i t y was achieved by leaving a cl e a r decision t r a i l i n every stage of the study (Sandelowski, 1986). A journal was kept d e t a i l i n g and j u s t i f y i n g a l l decisions made during the processes of conducting the study. In the i n t e r e s t of n e u t r a l i t y , the journal also included r e f l e c i v e notes about what was happening i n terms of the researcher's own values and i n t e r e s t s and f o r speculation about emerging i n s i g h t s . A p p l i c a b i l i t y and c r e d i b i l i t y of the analysis was ensured by d e t a i l e d and repeated analysis of the VTRs to i d e n t i f y e s s e n t i a l c h a r a c t e r i s t i c s of the 48 developing r e l a t i o n s h i p . A focus group meeting was also held to evaluate the extent to which the findings were meaningful and applicable to the experiences of cancer nurses who have worked i n s i m i l a r settings. E t h i c a l Consideration Participants i n Bot t o r f f ' s (1992) study provided informed consent that included permission to use the data i n future research, subject to the approval of an ethics committee. The e t h i c a l review committee of the University of B r i t i s h Columbia was sought for approval of t h i s study. Each p a r t i c i p a n t of the focus group was given an explanation of the project, t o l d that t h e i r p a r t i c i p a t i o n i s voluntary, and that they could withdraw from the study, refuse to answer any questions, or leave the discussion at any time. A l l data used and c o l l e c t e d i n t h i s project was kept c o n f i d e n t i a l and anonymity of p a r t i c i p a n t s was maintained at a l l times. To provide anonymity, each pa r t i c i p a n t was assigned a study number. The names of p a r t i c i p a n t s were not revealed i n any f i n a l report. Summary Discussed i n t h i s chapter i s the research method that was used i n the present study. A description of the research design, set t i n g , sample selection, data c o l l e c t i o n and data analysis procedures, and e t h i c a l considerations was provided. 4 9 CHAPTER 4: FINDINGS In t h i s chapter, the findings of the study which r e f l e c t patterns of behavior and behavior c l u s t e r s between a nurse and a patient observed over the course of three days, are presented. Background information relevant to each day i s highlighted to provide a context for these observations. Some cl u s t e r s of behaviors were observed across a l l three days of the re l a t i o n s h i p , while others changed as the r e l a t i o n s h i p developed. Several behaviors r e f l e c t e d i n the c l u s t e r s appeared often and remained consistent through the three-day r e l a t i o n s h i p . For example, the humor and c o r d i a l i t y with which both the patient and the nurse undertook the beginning of interactions and the leave-takings were consistent. Behaviors observed to be consistent throughout the r e l a t i o n s h i p are described i n d e t a i l i n the section c a l l e d Day One and alluded to b r i e f l y i n descriptions of subsequent days. The development of the NPR i n t h i s p a r t i c u l a r nurse-patient dyad i s r e f l e c t e d i n the changes observed i n the behaviors of both the nurse and patient. This conclusion i s supported i n several ways. F i r s t , given the number and continuity of interactions over a three day period, an opportunity for the development of a NPR existed. Second, interview data with both the nurse and patient following the period of observation indicated that both independently acknowledged s i m i l a r aspects of the r e l a t i o n s h i p that evolved between them. The patient, Bob, expressed great appreciation of the nurse's, Cynthia's, e f f o r t s to decrease his discomfort. He indicated he f e l t more comfortable with her than the other nurses, who did not know him 50 as well, and praised her for "being great." Cynthia stated that they had developed a "good r e l a t i o n s h i p " and she enjoyed nursing Bob. She commented she was " r e a l l y involved" i n what was happening to him. F i n a l l y , p a r t i c u l a r observations of t h i s nurse-patient dyad also point to the development of an important r e l a t i o n s h i p . In p a r t i c u l a r , a g i f t exchange and sentiments expressed at the end of the nurse's assignment r e f l e c t the depth of the r e l a t i o n s h i p . One notable c h a r a c t e r i s t i c of t h i s set of interactions was the predominant use of humor on the part of both the nurse and the patient. Humor was noted i n the form of j o c u l a r i t y and lightheartedness as well as i n nonverbal behaviors such as hand gestures, smiles and laughter, and f a c i a l gestures l i k e eye r o l l i n g . Humor seemed to be a mutual process between the nurse and patient with the patient usually taking the i n i t i a t i v e . In t h i s r e l a t i o n s h i p , humor seemed to be a means of communication that contributed to a p o s i t i v e and relaxed atmosphere. Humor was also very much context bound. The nurse appeared to use i t appropriately; for example, humor was never used while the patient was i n acute physical d i s t r e s s . However, once the i n i t i a l d i s t r e s s subsided, a humorous gesture was made by the nurse. Furthermore, humor was never used at the expense of the patient or the nurse; that i s , i t was not used i n an attempt to embarrass or be s a r c a s t i c . The content of the humor was usually r e l a t e d to the patient, to his G-tube flushes or to making l i g h t of his reluctance to use his mouth therapies. The use of humor appeared to be an important basis for each of the behavioral c l u s t e r s i d e n t i f i e d i n t h i s study. 51 For the nurse, the use of humor was based on a conscious decision: She indicated that Bob needed some fun i n his days because he was at a stage where he was "sick of being sick" and needed a " l i f t . " Nevertheless, she was sensi t i v e i n the way she used humor. During the interview, she indicated that getting to know Bob and his moods was important i n determining when i t was appropriate to "joke around" and when i t was not. Bob's response to her humor, i n addition to his own use of humor i n t h e i r i n t e r a c t i o n s , indicated that he was comfortable with t h i s approach. The extent to which the use of humor influences the development of NPRs i s d i f f i c u l t to determine from the observation of a single dyad. However, the use of humor i n t h i s series of interactions appeared to serve an important purpose i n the development of the re l a t i o n s h i p between Bob and Cynthia. It introduced a sense of informality into t h e i r interactions that stimulated conversations about Bob's care and issues that arose throughout each day as well as diverted his attention, a l b e i t b r i e f l y , from his discomforts. Day One The f i r s t day of t h i s three-day r e l a t i o n s h i p between the nurse and the patient, consisted of a t o t a l of 22 i n t e r a c t i o n s . The 22 interactions made up a t o t a l of 53 minutes and 21 seconds that the nurse and patient spent i n each other's presence, with an average of 2 minutes and 42 seconds per i n t e r a c t i o n . Day one of t h i s r e l a t i o n s h i p was Cynthia's f i r s t day with Bob. During the previous week, she had nursed him for two nights and t h i s week she would be caring for Bob for three days—two twelve hour 5 2 s h i f t s , from seven i n the morning to seven i n the evening, and one eight hour s h i f t , from seven i n the morning to three i n the afternoon. During the day p r i o r to being nursed by Cynthia, Bob was experiencing pain related to his gastrostomy tube (G-tube). For the pain, he was given Codeine which resulted i n him becoming constipated. Furthermore, he was having large amounts of phlegm b u i l d up i n his mouth which was very sore. He found i t too p a i n f u l to clean his mouth e f f e c t i v e l y with either a toothbrush or prescribed mouthwashes. Bob's f i r s t day with Cynthia was preceded by a sleepless night. Throughout the previous night, Bob was awake at every hour. He had been given Codeine and Ativan, neither of which helped to s e t t l e him. Four c l u s t e r s of behaviors were observed to occur i n the f i r s t day of interactions, including: getting to know the nurse «* getting to know the patient; wooing the nurse *» creating a foundation for connecting; being v i g i l a n t «* demonstrating competence; and cautious consideration <» making therapeutic suggestions (see Table 1). Each behavior c l u s t e r i s described and i s followed by examples that i l l u s t r a t e the c l u s t e r . 53 Table 1 Behavioral Clusters and Their Constituents Observed on the F i r s t Day of the NPR Patient Behaviors l l l l l l Nurse Behaviors Getting the Know the Nurse e Getting to Know the Patient -Responding to o -Introductions introductions -Assessing the nurse o -Assessing the patient as a person as a patient -Acknowledging leave-taking o -Leave-taking Wooing the Nurse Creating a Foundation for Connecting -Accepting the nurse o -Accepting the patient -Complementing the nurse *> -Carrying on i n a usual -Being f r i e n d l y manner -Responding to f r i e n d l i n e s s -Asking the nurse for help -Responding to requests for -Helping the nurse help «» -Involving the patient i n care Being Vigilant e Demonstrating Competence -Keeping a watchful eye o -Talking through her on the nurse actions -Checking the o -Carrying out nursing nurse's actions tasks expertly -Establishing the - T e l l i n g the patient her nurse's whereabouts whereabouts Cautious Consideration O Making Therapeutic Suggestions -Listening and cautiously o -Gently guiding the patient responding to the nurse's by explaining suggestions suggestions - J u s t i f y i n g actions -Gentle confrontation Getting to Know the Nurse «» Getting to Know the Patient Behaviors that r e f l e c t e d the nurse and patient getting to know one another occurred throughout the f i r s t day of the rel a t i o n s h i p . Behaviors related to getting to know one another were embedded i n introductions at the beginning of the day and 54 the interactions that occured each time the nurse entered the room. These interactions focused on patient needs, s o c i a l conversation (including humor), and leave-taking. Responding to Introductions ** Introductions Introductions throughout the f i r s t day were lead by the nurse. The f i r s t introduction, i n p a r t i c u l a r , was characterized by personal references. For example, rather than st a t i n g her name and status, the nurse said to the patient "You have me today", a gesture which set a personalized tone for continuing i n t e r a c t i o n s . The nurse often smiled as she entered the room, focusing d i r e c t l y on the patient as she spoke. She acknowledged the patient verbally and nonverbally by announcing her entrances and t e l l i n g the patient what she would be doing. Furthermore, these introductions served to e s t a b l i s h the time frame the nurse would be with the patient during each i n t e r a c t i o n . In the f i r s t introduction the notion of length of stay was defined by the length of the s h i f t the nurse worked; i n subsequent in t e r a c t i o n s , i t was defined by the tasks to be completed. The introductions were often accompanied by humor and s o c i a l conversation. These behaviors are r e f l e c t e d i n the following segment that occurred i n the nurse's f i r s t encounter of the day with Bob. Interestingly, despite t h e i r l i m i t e d contact before t h i s i n t e r a c t i o n , the nurse helps the patient make a connection to t h e i r previous encounter a l b e i t i n d i r e c t l y . N: Good morning. How are you? P: A l r i g h t , I didn't hear you. How are you doing? N: You have me today. [She smiles at the patient, has d i r e c t eye contact.] P: I'm so fortunate. [He looks at the nurse, i n a joking voice.] N: [She smiles at his humorous comment.] Ohhh. 55 Subsequent behavior clu s t e r s that occurred at the beginning of interactions, were often missing t y p i c a l s o c i a l preludes; rather, they focused on introducing or preparing the patient for the task to be performed. In the following example the nurse enters the room with the blood pressure cuff and thermometer. N: ...Just gonna take your temperature and your blood pressure. [She gestures f o r the patient to take out his ear phones so she can take a tympanic temperature.] Two seconds. I n i t i a t i o n of and responding to introductions and leave-takings were an important part of acknowledging and getting to know one another. Assessing the Nurse as a Person «* Assessing the Patient as a Patient Behaviors that r e f l e c t e d getting to know the patient and getting to know the nurse were observed i n the nurse's assessment of the patient and the patient's assessment of the nurse. The nurse's ongoing assessment throughout the day consisted of a mix of questions about the patient's care and interactions that were lighthearted and humorous. The l a t t e r appeared to break up the monotony of routine questions. The nurse usually made eye contact with the patient when asking him questions and her voice would i n f l e c t toward the end of the question, i n v i t i n g more than a yes/no response from the patient. While assessing the patient's equipment such as his feeding pump or subcutaneous i n j e c t i o n s i t e the nurse would t a l k through her assessment and glance over at the patient to make eye contact, t e l l i n g the patient what she was looking at. For example, while assessing the patient's subcutaneous i n j e c t i o n s i t e on his abdomen, the nurse assessed the area with her f i n g e r t i p s . As she did t h i s , 56 she p e r i o d i c a l l y glanced at the patient, t o l d him she thought i t looked a b i t inflamed, and indicated she would keep an eye on i t throughout the day. During these interactions, the patient also assessed the nurse. In contrast to the nurse, who assessed the patient as a patient, the patient assessed the nurse as a person. Although the nurse had the opportunity to ask the patient assessment questions at any time, the patient had to be s t r a t e g i c i n f i n d i n g out information about the nurse. This patient took advantage of the time the nurse spent with him during r e l a t i v e l y lengthy routine tasks, such as, flushing his G-tube, which took about seven to ten minutes to complete. At these times, he would ask the nurse questions about her personal l i f e such as what her husband does for a l i v i n g , where she l i v e s , and whether she has a family. The nurse w i l l i n g l y answered his questions and, i n doing so, disclosed aspects of her personal l i f e . In these instances, the patient also shared some of his own personal l i f e with the nurse; for example, he t o l d her that he i s a builder. He also nodded his head while she was t a l k i n g and verbalized utterances such as "Uh, huh," "Oh, yeah," and "Really?" s i g n i f y i n g that he was l i s t e n i n g and interested. Their questions to one another at the beginning of the day were general and r e f l e c t e d the newness of t h e i r r e l a t i o n s h i p . For example, afte r the patient rinsed out his mouth i n the morning, the nurse asked him, "That f e e l better?" The patient also began by asking the nurse general questions such as, "How's things i n St. Albert today?" As the day progressed, questions became more s p e c i f i c on the 57 part of the nurse and personal on the part of the patient. The following i s an example of an in t e r a c t i o n i n mid-morning. In t h i s example, the nurse i s working with the patient's G-tube. N: Do you miss the taste of food? P: Right now? N: Yeah. P: Not r e a l l y . N: No. P: I've succumbed to um, to the fac t r i g h t now. But you see, you don't get the f u l l story. N: [She nods her head as she i s working, and glances up at him p e r i o d i c a l l y as he i s speaking.] Mmm Hmm. P: I might get out of the hos p i t a l on IV because I wouldn't be able to r e a l l y eat anything. N: Mmm Hmm. And you've got t h i s now. [She gestures to the G-tube.] P: Yeah. In a few weeks i t turned into this...Now, um, I know that nurses make some reasonable money, what does your husband do? [looking at the nurse] N: He's dead. P: Is he? N: Yeah. He used to be a... he used to run his own business. P: Yes. [The nurse continues to flu s h the patient's G-tube with a syringe.] P: So then why do you s t i l l have Mrs. i n front of your name? N: This i s my old I r i s h badge. P: Yes. N: I just didn't get 'round to changin' i t . P: Yeah, good o ld I r i s h . You're kind of p a r t i c u l a r aren't you? N: ...In the I r i s h h ospital where I was born, you know, you wouldn't be c a l l e d nurse, I'd be c a l l e d Miss or Mrs. P: Yeah, r e a l l y ? [ i n t e r a c t i o n continues] This exchange was t y p i c a l , with both the nurse and patient using d i r e c t questions to assess one another. Beyond simply obtaining desired information, the questions reveal an i n t e r e s t i n the other as well as the other's willingness to s e l f d i s c l o s e . Acknowledging Leave-Taking «* Leave-Taking Elements of getting to know one another were r e f l e c t e d i n patterns of behavior at the end of int e r a c t i o n s . The nurse ended interactions with the patient when her work was completed, when 58 she had to leave the room to get something, such as an addi t i o n a l piece of equipment required to complete a task, or when she was leaving f o r the day. The nurse never exited the room without announcing that she was leaving. Often, the nurse would t e l l the patient that he could c a l l i f he needed anything or that she would return shortly. In the following example the nurse had just f i n i s h e d working with the patient's G-tube feed. N: [She unplugs the patient from his G-tube feed.] That's i t . You're free for a l i t t l e while. P: Yeah. T i l l around ten o'clock. N: Yeah. T i l l I get back from coffee anyway I suppose. [She places the c a l l b e l l next to the patient.] N: . . . A l r i g h t . Just give a c a l l i f you want anything; there's someone around. P: I w i l l . N: A l r i g h t . P: Thanks. N: See you l a t e r , Luv. The patient often responded to the nurse *s gesture upon her leave-taking by saying "good-bye" or "thank you" or a l l u d i n g to the next time they would in t e r a c t , for example, by sta t i n g the time he would receive his next bolus or f l u s h . Wooing the Nurse «» Creating a Foundation for Connecting The nurse and the patient were observed to be engaging i n behaviors that r e f l e c t e d t h e i r i n d i v i d u a l attempts to e s t a b l i s h a r e l a t i o n s h i p . The nurse worked at creating a foundation for connecting with the patient by engaging i n such behaviors as accepting the patient, involving the patient i n his care, responding to his f r i e n d l y gestures, passively accepting h i s compliments and responding to his requests for help. At the same time the patient attempted to woo the nurse by demonstrating his acceptance of the nurse by complimenting the nurse; by being f r i e n d l y ; and, by helping the nurse and asking her f o r help. 59 Accepting the Nurse *» Accepting the Patient Attempts to achieve synchrony i n the r e l a t i o n s h i p was i m p l i c i t i n the tone of the interactions between the nurse and the patient. The nurse and the patient dialogued i n a way that represented acceptance of one another. For example, the nurse was found to repeat the patient's terminology. When he c a l l e d his mouthwash "the mixture," the nurse would subsequently r e f e r to the mouthwash by the same name. In another instance, when he asked i f he could apply Vaseline to his l i p s l i k e l i p s t i c k , the nurse responded by using h i s same terminology, "That's r i g h t j u s t l i k e l i p s t i c k . " The nurse was observed to accept the patient's concerns and discomforts and put him at ease with accepting statements. For example, when he seemed concerned about being behind on his G-tube flushes, she reassured him by saying, "We'll get there." i n another s i t u a t i o n when he was explaining to the nurse that he needed help to apply powder to his neck because he could not see where to apply i t himself, she quickly responded, "I believe you." Using the same terminology as the patient and reassuring him about his care seemed to a f f i r m the patient's worth as a person. The patient demonstrated his acceptance of the nurse i m p l i c i t l y through his p o s i t i v e tone. For example, he would smile at the nurse as she entered the room. The patient also demonstrated his acceptance of the nurse by o f f e r i n g his assistance to her, and by making appreciative comments when she completed tasks by simply thanking her or giving her a compliment. The following segments of interactions i l l u s t r a t e the nurse 60 and patient accepting one another. In the f i r s t example, the nurse enters the room afte r looking for new suction tubing. N: There's just some days when I can never f i n d anything. P: Is that right? N: Yeah. P: Is t h i s one of them? N: Huh? P: Is t h i s one of them? N: Well, I managed to f i n d i t anyway. [She proceeds to unwrap new suction equipment.] I t ' s just that sometimes i t takes longer than others. P: One thing about i t , i t brings you back to me. N: [joking] Of course. I don't know why you're complaining about your suction or your bolus taking so long, when i t r e a l l y means that I can stay here t a l k i n ' with you. P: Yeah. N: There we go. In the second example, the nurse i s checking his feeding pump. P: If you wait a few months now you know, I can b u i l d you a house. N: [laughs] Can you? P: That's my business. N: Building houses? P: Yeah. [The nurse continues to work with the feed pump as the patient suctions his mouth.] In both these examples, acceptance i s based on the p o s i t i v e tone and synchrony created by the nurse and patient. This p o s i t i v e tone i s e x p l i c i t i n t h e i r dialogue and i m p l i c i t i n the atmosphere created i n t h e i r i n t e r a c t i o n . Complimenting the Nurse «* Carrying on in a Usual Manner The patient was observed to compliment the nurse for bringing him what he needed and respecting his personal preferences using phrases such as "lovely, lovely lady," "you betcha," "A-Okay," and "Ahhh, good s t u f f . " The nurse was observed to passively accept the patient's compliments by continuing to do her work i n her usual manner. I t i s possible that the nurse's response was her way of being humble when 61 receiving a compliment. Nevertheless, she did not negate these compliments. Being Friendly «* Responding to Friendliness The patient was observed to be f r i e n d l y to the nurse by engaging i n s o c i a l conversation with the nurse and by using humor. For example, i f the patient was watching a hockey game on TV, he would ask the nurse i f she was interested i n hockey. The nurse responded to the patient i n an equally f r i e n d l y manner, engaging i n lighthearted conversation with the patient. These short pieces of s o c i a l conversation and innuendos of friendship seemed to help i n lightening the atmosphere and breaking up the routines of the day. Furthermore, f r i e n d l i n e s s , compliments, and s o c i a l conversation helped to create a foundation for the nurse and patient to connect with one another on a more personal l e v e l . Asking the Nurse for Help ** Responding to Requests for Help The nurse frequently provided openings f o r the patient to make requests or express concerns, by saying, "Is there anything else I can get for you?" or "Do you need anything?" In several instances the patient took the nurse up on her o f f e r , and asked for help. When the nurse responded to the request, he would compliment her and thank her. The patient also communicated his needs to the nurse. For example, when the patient t o l d the nurse that he had a sleepless night, the nurse responded by s i t t i n g on his bedside and asking him what happened during the night. She looked at him d i r e c t l y and would nod her head as he was speaking with her. The following i l l u s t r a t e s the patient's communication of a need as well as the nurse's response: P: It's tough to make a po s i t i v e decision a f t e r l a s t night. 62 N: Oh, what's wrong? What happened l a s t night? [She s i t s on the patient's bedside.] P: Not much sleep. N: Hmm? P: Sure didn't sleep. N: Didn't sleep? Why i s that? Your nerves? [interaction continues] Through his expression of a need, the patient created a context for the nurse to "legitimately" pay attention to him. In turn, the nurse's demonstration of concern appears to a s s i s t i n connecting with the patient. Helping the Nurse e Involving the Patient in Care The dynamic interplay between the nurse and patient as nursing care was being given and received also contributed to wooing the nurse (on the part of the patient) and creating a foundation for connecting (on the part of the nurse). As Cynthia c a r r i e d out routine tasks, she provided opportunities for Bob to pa r t i c i p a t e i n his care. In concert with t h i s , Bob a c t i v e l y "joined i n " i n what appeared to be e f f o r t s to help the nurse. For example, while the nurse was flushing his G-tube, the patient was observed to be holding the syringe for the nurse. In another i n t e r a c t i o n , the patient held one part of the suction catheter while the nurse reattached the other adjoining part to i t . She placed her hand on the patient's and they applied pressure together to get a t i g h t seal on the suction catheter. The patient also independently shut o f f his pump when his feed or fl u s h had fi n i s h e d or flushed his G-tube: P: See I got so independent yesterday, I d i d i t a l l by myself. N: Did what? P: A l l that. N: A l l your boluses? P: Yeah. N: You can do that yourself i f you wanted to. You don't 6 3 need me to do i t . In t h i s segment, through a somewhat boastful demonstration of competence, the patient appears to t r y to get the nurse onside by a s s i s t i n g her with his care routines. The nurse's response indicates her approval and serves to reinforce the connection she i s e s t a b l i s h i n g . Being V i g i l a n t <-> Demonstrating Competence A recurring behavioral c l u s t e r during the f i r s t day of t h i s r e l a t i o n s h i p was characterized by v i g i l a n c e on the part of the patient and the demonstration of competence on the part of the nurse. The patient's v i g i l a n c e was manifested i n his c l o s e l y observing the nurse as she c a r r i e d out routine tasks, i n checking the nurse's actions, and i n establishing the whereabouts of the nurse throughout the day. The nurse was observed to demonstrate her competence by t a l k i n g through her actions, by carrying out nursing tasks expertly, and by informing the patient about her whereabouts, such as when she was taking a coffee break. Keeping a Watchful Eye on the Nurse «* Talking Through her Actions Throughout t h e i r f i r s t day together, the patient continuously watched the nurse while she was working. His eyes would follow her c a r e f u l l y as she proceeded with routine tasks such as administering medications and working with his G-tube feeds and suction equipment. The patient's v i g i l a n c e was sometimes verbalized, using humor to avoid upsetting the nurse. For example, when she was l a t e i n coming to unhook his G-tube feed, he waved his f i s t at her to tease her about being l a t e . In other instances, as the patient watched every move the nurse made during procedures, he c a r r i e d on a lighthearted or humorous 6 4 conversation with her that was unrelated to her task. The nurse usually responded to the patient's watchfulness by explaining what she was going to do and by t a l k i n g through her actions. For example, i f she was looking at the feed pump she would "think out loud" about how much more f l u i d needed to be infused and how long i t would take. The nurse usually spoke i n a confident and clear voice, demonstrating her knowledge and expertise. Checking the Nurse's Actions «* Carrying out Nursing Tasks Expertly The patient also checked to see i f the nurse could be r e l i e d on. For example, he asked her i f she primed the tubing or checked to see i f she knew the time for his next bolus. In carrying out tasks, such as flushing the patient's G-tube or programming the feed pump, the nurse demonstrated her competence. Her actions were deliberate, sequenced, and coordinated. The nurse was also e f f i c i e n t i n carrying out her tasks i n that she managed to complete several tasks i n a r e l a t i v e l y short period of time. Often, the nurse would make humorous comments i n response to the patient's v i g i l a n c e . For example, when she was l a t e i n unhooking the patient's G-tube feed, she responded to the patient's f i s t gesture by saying, "A whole ten. Isn't that t e r r i b l e ? Oh dear. Tut, t u t . It r e a l l y w i l l make a big difference." Her humorous comments often put the patient at ease, and as i n t h i s instance, c l e a r l y demonstrated her confidence i n what she was doing. The following segment represents a t y p i c a l example of t h i s behavioral c l u s t e r . The nurse came i n with a bag of f l u i d and prepared to run i t into the 6 5 patient's G-tube. N: How fas t do you want t h i s to run? P: [He looks at the nurse as she i s working.] Oh whatever. Did you drain i t out to here? [checking whether she primed the tubing] N: Hmm? Oh Yeah. I drained i t already. P: Oh I see [He looks at the primed tubing]. N: In fact, I got i t a l l over my uniform there as you can see. P: Oh you did, eh, yeah. [He looks at the nurse's uniform.] [The nurse works with the pump.] P: [He watches the nurse working.] You got i t running? N: Yeah, i t i s 'cause i t ' s up to f i f t e e n hundred now. P: Yeah. [interaction continues] In t h i s example, the patient's v i g i l a n c e was demonstrated i n checking whether the nurse had primed h i s tubing. The nurse responded by demonstrating her competence i n having primed the tubing. Furthermore, she was able to laugh at her own clumsiness. Establishing the Nurse's Whereabouts ** Telling the Patient her Whereabouts Vigilance was observed i n the patient's questions to e s t a b l i s h the whereabouts of the nurse. That i s , the patient seemed to need to know where the nurse was. However, he d i d not appear comfortable i n asking the nurse d i r e c t questions regarding her whereabouts, such as the length of her s h i f t or when she i s going on a break. To get t h i s information, the patient often posed i n d i r e c t questions while the nurse completed routine tasks. The nurse usually answered the patient's questions d i r e c t l y , often giving more information than requested. Frequently, her answers were accompanied by lightheartedness and humor. In the following example the nurse prepares to run some f l u i d through the patient's G-tube. She talks about how much f l u i d i s going to run through as the patient watches her prepare the equipment, 66 u n t i l the patient changes the topic by introducing a question. P: So... you're o f f at three? N: No, I'm on ' t i l seven. P: Oh, yeah. N: Twelve hour s h i f t today and twelve hour s h i f t tommorow, and an eight hour s h i f t on Monday. P: Oh, yeah. N: Either way, you're stuck with me a l l weekend [laughs]. P: No doubt [j o k i n g l y ] . N: It could be worse I suppose [ j o k i n g l y ] . P: Yeah, probably, I don't mind. [The nurse continues to watch the pump, the patient also watches the process.] In t h i s segment, the patient demonstrated his v i g i l a n c e by attempting to determine the length of the nurse's s h i f t i n a casual and offhand manner. The nurse was sen s i t i v e to his need for information and responded to his question with a d i r e c t and informative answer as well as with lightheartedness and humor. Cautious Consideration ** Making Therapeutic Suggestions The fourth behavioral c l u s t e r observed on the f i r s t day i s characterized by off e r s of therapeutic suggestions by the nurse and a patient response of cautious consideration. The nurse made several therapeutic suggestions for improving aspects of the patient's care that were problematic. She accomplished t h i s by gently guiding the patient, explaining her suggestions to the patient, and gently confronting the patient about aspects of his care. The patient cautiously considered the nurse's suggestions. He attended to her suggestions but was reluctant to a c t u a l l y t r y them. Ad d i t i o n a l l y , the patient would j u s t i f y his actions to the nurse. 67 Listening and Cautiously Responding to the Nurse's Suggestions ** Gently Guiding the Patient by Explaining Suggestions Throughout the day, the nurse gently guided the patient by suggesting p o s s i b i l i t i e s for improving his care, making him more comfortable, and encouraging him to t r y her suggestions. The nurse usually began the process of gentle guidance by f i n d i n g out the patient's need. For example, she would assess his mouth care status or h i s a c t i v i t y l e v e l . Her questions were usually c l e a r and d i r e c t . Her voice often i n f l e c t e d toward the end of the question, i n d i c a t i n g her genuine i n t e r e s t and involvement i n the patient's care. Once the nurse i d e n t i f i e d a problem, she would respond by suggesting ways his s i t u a t i o n could be improved including a rationale for each suggestion. Using eye contact and other nonverbal behaviors ( i . e . , nodding her head), she reinforced her i n t e r e s t i n the patient and improving the problem at hand. Furthermore, the nurse did not pressure the patient to t r y her suggestions or reprimand him i f he did not t r y her suggestions. The patient was usually w i l l i n g to l i s t e n to the nurse. However, he was for the most part reluctant to t r y the nurse's suggestions, p a r t i c u l a r l y those re l a t e d to his mouth care because t h i s was a source of great pain for him. The patient never openly rejected the nurse's suggestions nor indicated that he would give her suggestions a t r y . He simply p o l i t e l y l i s t e n e d to the suggestions. In some instances, he would t e n t a t i v e l y agree to give her suggestions a t r y , although t h i s did not necessarily lead to a c t u a l l y t r y i n g her suggestions. In the following example, the nurse suggests that the patient t r y taking i c e chips 68 to keep his mouth clean. Although his response seems to indicate his willingness to t r y i c e chips, he never a c t u a l l y gives them a t r y . N: Are you eating at a l l ? P: No. N: Not even t r y i n g sips? Tried chips of ice? P: I've got so much junk coming into my mouth. N: [She nods her head.] Mmm hmm. Nothing there would help? P: No I don't think so. N: Oh. [She nods her head as i f to say she understands.] P: What w i l l i t [ice chips] help? N: Hmm? Just [to] give your mouth a clean wash rather than sipping on i t . P: Maybe. N: I ' l l get you some to t r y [voice i n f l e c t s ] . P: I can just t r y i t . In t h i s example, the nurse explained to the patient the p o t e n t i a l benefit to cleaning his mouth with ice chips, yet, she did not push or t r y to persuade the patient to take up her suggestion. The patient cautiously considered the suggestion and r e l u c t a n t l y responded to the nurse. Justifying Actions «* Gentle Confrontation The nurse also made therapeutic suggestions by gently confronting the patient about aspects of his care, such as, not using the prescribed medications for h i s mouth. Her confrontations were softened by her lightheartedness and humor. The patient responded to the nurse by j u s t i f y i n g his actions, or by 'making excuses' for why he was not using a c e r t a i n product. For example, when she confronted him about not using his mouthwash he responded by saying, "I don't use that s t u f f , i t ' s not strong enough." In the following example, the nurse uses gentle confrontation and the patient responds by j u s t i f y i n g his actions. The nurse enters the room with some mouthwash for the patient, he has not taken any of the medications f o r his mouth 69 she has brought him, and they are a l l s i t t i n g on his bedside table. She begins by teasing him about the number of medications for h i s mouth he has on h i s table. N: Bob, are these a l l going to be l i n e d up? [She smiles while looking at h i s c o l l e c t i o n of medications for his mouth.] P: Mmm. N: It might just help your mouth i f you give i t a b i t of a [ t r y ] . . . Maybe [ i t would] cle a r i t . [It] wouldn't be quite as thick, eh? P: Yeah, I just had a l i t t l e r e s t , so... This segment demonstrated the nurse gently confronting the patient about a care issue. Her teasing about the medications seemed to r e f l e c t her sympathy and compassion for the patient. The patient responded by attempting to j u s t i f y his actions to the nurse, a t y p i c a l response to the nurse's suggestions r e l a t e d to his mouth treatments at t h i s stage of t h e i r r e l a t i o n s h i p . Day Two The second day of t h i s three day r e l a t i o n s h i p consisted of 2 7 interactions between the nurse and the patient. That i s , they spent a t o t a l of 54 minutes and 10 seconds of i n t e r a c t i o n time together, averaging two minutes and 38 seconds per i n t e r a c t i o n throughout t h i s twelve hour day. Day two was Cynthia's second twelve hour day with Bob. As i n the f i r s t day, she worked from seven i n the morning u n t i l seven i n the evening. Bob's second day with Cynthia followed a reasonably good night's sleep. He was only up twice during the night to go to the bathroom and to get pain medication. His wife v i s i t e d during the mid-morning of the second day. During the second day of the r e l a t i o n s h i p , incidents occurred i n which the patient was observed to experience acute 70 physical d i s t r e s s related to his fear of swallowing anything. In addition, he complained of pain and discomfort during the previous night, which appeared to be associated with his G-tube feedings. Four behavior clu s t e r s observed during the second day of the re l a t i o n s h i p included: comfortable with being known by the nurse » deepening understanding of the patient; sustaining involvement with the nurse » sustaining a connection with the patient; cautious responsiveness «* making therapeutic suggestions; and, communicating physical d i s t r e s s « being there for the patient (see Table 2). Some behaviors r e f l e c t e d i n these c l u s t e r s such as humor, introductions throughout the day, and leave-takings were used i n the same way on t h i s day as they were on the f i r s t day. 71 Table 2 Behavioral Clusters and Their Constituents Observed on the Second Day of the NPR Patient Behaviors «* Hurse Behavior* Comfortable with Being Known by the Nurse «* Deepening Understanding of the Patient -Validating continuity -Discussing Problems <=-» -Re-introduction -Zeroing-in on patient problems Sustaining Involvement with the Nurse Sustaining a Connection with the Patient -Engaging i n s o c i a l conversation -Determining the nurse's whereabouts -Displaying independence to the nurse -Giving to demonstrate gratitude «» «» <-» -Engaging i n s o c i a l conversation - T e l l i n g the patient her whereabouts -Encouraging independence -Giving to demonstrate caring Cautious Responsiveness Making Therapeutic Suggestions -Listening to the nurse's suggestions -Going along with the nurse's suggestions o -Suggesting p o s s i b i l i t i e s -Gentle confrontation Communicating Physical Distress e Being There f o r the Patient -Showing d i s t r e s s -Voicing d i s t r e s s «-> <-> -Creating an atmosphere of calm reassurance -Demonstrating genuine concern, applying comfort measures Comfortable with Being Known by the Nurse «» Deepening Understanding of the Patient During the second day of the re l a t i o n s h i p , interactions r e f l e c t e d and evolved from the f a m i l i a r i t y established i n Day One. Once the nurse re-introduced herself to the patient, she immediately began to "zero-in" on patient problems. The 7 2 patient's behaviors validated the continuity of the r e l a t i o n s h i p and he began to discuss problems with the nurse more openly. These behaviors r e f l e c t e d his comfort with being known by the nurse. Validating Continuity «* Re-introduction The nurse's f i r s t introduction on the second day provided a connection to a problem they had discussed on the previous day ( i . e . , his problem sleeping). In t h i s very b r i e f exchange, the nurse e f f e c t i v e l y re-connects with the patient where they l e f t o f f the previous day. The re-introduction i s i l l u s t r a t e d i n the following segment: N: Oh you're awake. I didn't want to be wakin' you up. How are you? P: Fine. N: Better night l a s t night? P: [Puts his thumb up, giving the nurse the okay sign.] N: Sleeping p i l l helped? P: Yeah. Something helped, yeah. N: Good. [int e r a c t i o n continues] The nurse re-introduced a topic they had discussed during the previous day—the patient's lack of sleep. The patient's response of putting his thumb up and response to the nurse's b r i e f question about a sleeping p i l l indicated that both knew the nature of the subject discussed. As such, continuity of the r e l a t i o n s h i p was validated by the patient as well as by the nurse. Discussing Problems e Zeroing-in on Patient Problems On the second day, the nurse "zeroed-in" on problems that had not changed from the f i r s t day. Using her knowledge of the patient's issues from t h e i r f i r s t day together, the nurse's questions were s p e c i f i c and focused. Nevertheless, the manner i n 73 which she assessed the patient remained s i m i l a r to that i n the previous day. The nurse remained lighthearted and used humor i n combination with assessment questions. Her voice i n f l e c t e d at the end of her questions, and she stood i n close proximity to the patient, making eye contact while t a l k i n g with him. Interestingly, on t h i s day, the patient did not ask personal questions of the nurse as he did on the previous day. He continued to use humor and j o c u l a r i t y with the nurse and seemed very comfortable i n being informal, open, and t a l k a t i v e . I t i s possible that during the f i r s t day he learned a l l he needed to know about the nurse and, therefore, did not need to pursue further personal questions. He w i l l i n g l y responded to the nurse's assessment questions and comfortably discussed issues surrounding his care with her. In the following example, the nurse focuses her assessment on the patient's use of d i f f e r e n t mouth care products. N: Have you t r i e d swallowing anything at a l l ? P: No. N: Why? P: Heaven knows, i t just gets i n the way. [He gestures to suction tubing.] N: It does, eh? P: It's a l l broke up inside, eh? N: Does i t f e e l that way? P: Yeah. N: [The nurse nods.] So you've [inaudible]... P: It's too thick. [The medications for the mouth] just adds to s a l i v a and ah, i t ' s t e r r i b l e . T e r r i b l e . N: Have you found any of the mouthwashes help? Just t h i s sort of thing. P: This works the best I think, I don't know. [He refers to the soda bicarbonate.] N: Mmm hmm. P: My tongue i s s t i l l bad. N: Let me have a look. [The patient shows the nurse his tongue.] I t looks sore too. You just cleaning i t off? P: Oh, yeah. And the other one, the yellow s t u f f , i t burns. N: Does i t ? 74 P: Jeeze. It's not fun. N: I thought that you were complaining today because t h i s wasn't burning enough [joking tone]. P: Well unless i t burns a l i t t l e b i t , i t ' s not any good. N: How about the Mycostatin then? The yellow s t u f f ? P: I t r e a l l y burns, ohhh. N: [laughs] So i t burns too much? P: Yeah, I can almost can't stand i t . Like I gotta r i n s e my mouth r i g h t away. N: Cause i t ' s quite good. P: It i s ? Better than t h i s s t u f f ? N: Yeah... [interaction continues] In t h i s segment, the nurse was deepening her understanding of the patient i n that she zeroed-in on a s p e c i f i c problem. The patient seemed comfortable with discussing his problem i n d e t a i l with the nurse. In t h i s dialogue, the increased depth of problem solving i s demonstrated by the nurse's as well as the patient's focus on a problem. Sustaining Involvement with the Nurse «» Sustaining a Connection with the Patient On t h i s day, a second major c l u s t e r of behaviors r e f l e c t e d e f f o r t s by the nurse and patient to sustain the connection they began on the previous day. Behaviors r e f l e c t i n g sustaining involvement with one another included taking the time for s o c i a l conversation and giving one another g i f t s . In addition, the nurse encouraged the patient's independence and responded to the patient's determination of her whereabouts. The patient displayed his independence to the nurse and determined the nurse's whereabouts. Engaging in Social Conversation «* Engaging in Social Conversation S o c i a l conversation usually occurred i n the midst of completing tasks and was i n i t i a t e d by either the nurse or the patient. For example, while working with the patient's G-tube, 75 the nurse asked the patient about a hockey game he was watching on TV. Although the s o c i a l conversations were b r i e f , they seemed to break up the monotony of r e p e t i t i v e tasks. Furthermore, they seemed to d i v e r t the patient's attention away from h i s i l l n e s s to the outside world, even i f only momentarily. Because the nurse was usually engaged i n a task while engaging i n s o c i a l conversation, she would glance at the patient p e r i o d i c a l l y while speaking with him and nod her head at his answers, i n d i c a t i n g to the patient that she i s paying attention. In the following segment of i n t e r a c t i o n , the nurse enters the patient's room and checks on the feeding pump. N: ...Oh, yeah. It's a gorgeous day. P: Nice day out? N: Oh, yeah. It's suppose to get up to, I think plus eight today. P: Oh, i s that right? N: Mmm hmm. P: [He s i t s up i n bed so he can see outside.] B e a u t i f u l . N: And minus eight tonight, [interaction continues] Although the nurse engaged i n the routine task of checking the feeding pump, she managed to break the monotony of t h i s task by t a l k i n g about the weather. The patient's attention was directed away from the feeding pump i n his response to the nurse's comments about the weather, as well as by his gesture of s i t t i n g up i n bed to look outside at the gorgeous day the nurse referr e d to. Humor appeared to be a prevalent theme i n s o c i a l conversations as well as conversations about patient care. As during t h e i r f i r s t day together, both the nurse and patient appeared to contribute equally to the lighthearted nature of t h e i r i n t e r a c t i o n . This was r e f l e c t e d i n t h e i r dialogue and 76 t h e i r nonverbal behaviors ( i . e . , gestures, smiles). The patient's wife was v i s i t i n g during the second day of the NPR. The nurse incorporated the patient's wife i n the humorous moments as i l l u s t r a t e d i n the following segment. The nurse entered the room to check on the patient's feeding pump. N: Well? P: [The patient waves to the nurse as she comes in.] Well what? N: Well haven't you packed up your bolus? P: It's f i n i s h e d already. N: Hmm? P: I said i t ' s f i n i s h e d already. Quit bothering me [jo k i n g l y ] . N: Oh, I see. You're getting too independent now [in a joking v o i c e ] . When you put i t i n and out and a l l . I see, and I see you've got your neck talced as w e l l . P: Mmm hmm. N: So between you, you've solved the problem. P: Mmm hmm. N: Fine, Okay, I ' l l pretend I'm doin' my s t u f f . Wife: And then when you go for lunch he complains. You can't win. N: No you can't win. You get patients l i k e that, you know, you just stop t r y i n g . You just g r i t your teeth and say nothing. P: [smiles] Yeah, yeah, yeah. Wife: [laughs] This was a t y p i c a l example of the lightheartedness and j o c u l a r i t y i n which the nurse and patient r e g u l a r l y engaged throughout t h e i r r e l a t i o n s h i p . Through t h i s type of in t e r a c t i o n they a f f i r m that they have developed a re l a t i o n s h i p and that they remain connected. Determining the Nurse's Whereabouts «* Telling the Patient her Whereabouts As i n the f i r s t day, the patient attempted to e s t a b l i s h the nurse's whereabouts. Although, he was humorous and lighthearted about the nurse's comings and goings, he s t i l l seemed to need to know her whereabouts. So much so, that he even resorted to asking others about the nurse's whereabouts. The nurse usually 7 7 responded to the questions with humorous comments and by t e l l i n g him when she would be back as i l l u s t r a t e d i n the following segment. The nurse i s working with the patient's feeding pump when she i s c a l l e d over the intercom to help a patient i n another room. P: Why don't you go down and I ' l l watch i t ? You can do i t when you get back. N: No, when I go I ' l l be gone for half an hour or so. P: [jokingly] Half an hour? What about me? N: What about you? Do you think you're the only patient here? [laughs] I ' l l only be next door. P: Hey? N: I ' l l only [inaudible]... P: [jokingly] I'm the only one that's on TV. [int e r a c t i o n continues] In t h i s segment, the patient reveals his desire to have his care completed by t h i s p a r t i c u l a r nurse and therefore his need to know the nurse's whereabouts. In response, the nurse i n d i r e c t l y acknowledges and encourages the connection they have established, using the lighthearted and humorous s t y l e that t y p i f i e s her approach with t h i s patient. Displaying Independence to the Nurse ** Encouraging Independence During the second day, the patient displayed his a b i l i t y to complete some tasks independently, i n what appeared to be gestures to please the nurse. In response, the nurse encouraged and reinforced these e f f o r t s . The patient took pride i n 'being good' at looking a f t e r his G-tube and flushes; he seemed pleased when the nurse entered his room only to f i n d that he had already completed the tasks r e l a t e d to his G-tube. Although the nurse played an important r o l e i n hanging up the feeds, and engaged i n routine tasks such as changing his dressing and taking v i t a l signs, she was very 78 p o s i t i v e about the patient's independence and complemented him about i t . In some instances i t became a source of humor i n t h i s r e l a t i o n s h i p . The following segment demonstrates the patient's independence with h i s G-tube and the nurse's response to his independence. The nurse enters the room to check the feeding pump: N: Nearly through yet? You've had the l o t . Did you f l u s h i t ? P: Yes, m'dear. N: Oh, great. You're getting r e a l l y good at t h i s aren't ya? P: Yeah. N: [jokingly] Good. You can do i t yourself then the r e s t of the day. [interaction continues] In t h i s example, the patient displayed his independence to the nurse i n a way that r e f l e c t s his willingness to be cooperative. This behavior, along with the nurse's p o s i t i v e attitude toward the patient's independence, seemed to sustain the r e l a t i o n s h i p they established. Giving to Demonstrate Gratitude *» Giving to Demonstrate Caring Giving g i f t s to one another on t h i s day c l e a r l y r e f l e c t e d the progression of the r e l a t i o n s h i p between t h i s nurse and patient, given the personal si g n i f i c a n c e of each g i f t . The patient's g i f t to the nurse, green shamrock cookies f o r St. Patrick's Day, was personal and thoughtful. The nurse had mentioned St. Patrick's Day during t h e i r previous day together. Giving her the green cookies acknowledged her excitement about the holiday, her I r i s h heritage, and may have been an act of r e c i p r o c i t y for the care she was giving him. The nurse's g i f t to the patient was a crock of gold from a rainbow ornament o f f a cake she shared with the s t a f f she worked with. When she 79 presented the patient with t h i s g i f t , she described the d i f f e r e n t decorations on the cake. Of a l l the ornaments she could have given him, she chose one that was symbolically s i g n i f i c a n t . In a l a t e r interview, the nurse stated that she gave the patient the crock of gold for "luck," which i s s i g n i f i c a n t given her concern about his prognosis. The following i n t e r a c t i o n segments represent the giving of g i f t s . In the f i r s t segment, the patient rings for the nurse and she enters the room: P: Do you l i k e cookies? N: Yeah. P: These are yours. [He hands the nurse a tray of cookies he got for her.] N: [laughing] Oh thank you. P: Happy St. Patrick's Day. N: Is t h i s for St. Patrick's Day? Thank you very much. Thank you. They're very good. That's three symbols I have now. P: That's r i g h t . N: The earrings, the makeup, and the cookies. P: And the cookies. N: Thank you. You're very kind. Thank you. In the second example, the nurse enters the patient's room to give him a g i f t from her. P: Now what have you got? N: I brought t h i s down for you. [She holds up a l i t t l e gold object.] P: Isn't that something. N: It's a crock of gold. One of the g i r l s bought me a cake, brought me a cake i n . P: Yeah. N: It's got two l i t t l e Irishmen on i t with a big shamrock. I mean i t looks disgustin', a l l greens and yellows and a big rainbow. P: Yeah. N: And t h i s i s the crock of gold at the end. P: Quite a thing to do. Isn't that nice. N: So I brought i t back for you. P: Thank you. N: Okay, t a l k to you l a t e r . The personal nature of the g i f t s the patient and nurse gave one another demonstrated one of the ways i n which the patient 80 sustained his connection to the nurse and the nurse sustained her involvement with the patient. Cautious Responsiveness <» Making Therapeutic Suggestions As i n t h e i r f i r s t day together, the nurse continued to suggest p o s s i b i l i t i e s for improving the patient's care and r a t i o n a l i z e d these suggestions to the patient. The nurse also continued to gently confront the patient about problematic aspects of his care. On t h i s day, the patient acknowledged the nurse's therapeutic suggestions by responding to them cautiously. The patient was observed to not only l i s t e n to the nurse's ideas but to go along with some of her suggestions. Listening to the Nurse's Suggestions ** Suggesting Possibilities The nurse gently guided and confronted the patient more often than i n the f i r s t day and she was more persistent i n working with the patient on behaviors that had not changed. Her strategy i n gently guiding and confronting the patient remained lighthearted and often humorous. The patient responded to the nurse by l i s t e n i n g to her explanations and discussing them with her. Although the patient remained tentative about t r y i n g the nurse's suggestions, he r e l u c t a n t l y 'went along' with them. I t i s possible that the patient f i n a l l y decided to t r y the nurse's suggestions because of her persistence or because he r e a l i z e d that, i f he was going to improve at a l l , he might have to follow her advice. In the following segment, the nurse suggests a new mouth care product for the patient. N: Cause i t ' s [the Mycostatin] quite good. P: It is? Better than t h i s s t u f f ? N: Yeah. That's sort of a l o c a l anesthetic, whereas the, the Mycostatin i s an a n t i b a c t e r i a l as w e l l . We use i t for ulcers and things l i k e that too i n the mouth. 81 P: Mmm. That's maybe what I should be havin' instead, eh? N: Yeah, you might want to give i t a t r y [i n a u d i b l e ] . . . P: I can always, l i k e I can rinse with i t ? N: Yup, yup. You don't have to swallow i t . You can just r i n s e with i t . Just get to i t on your tongue. P: No, yeah, and then I could, then I could just rinse with water afte r i t . N: Rinse with water and s p i t i t out. Yeah, you don't have to swallow i t . P: I'm going [inaudible]... N: I know you're on i t for, for rinse and rinse and swallow something l i k e that. But, you don't have to. P: I t r i e d swallowing i t once, aahhhhh. N: Not good, eh? P: Really t e r r i b l e . N: If I get you some now w i l l you just t r y , just wash your mouth out with i t and you can s p i t i t out again? I f i n d that i t works very good and I f i n d that i t works fo r a l o t of our patients with sore mouths. P: Yeah. I want something that's going to cl e a r i t up, not j u s t , not just freeze i t . N: Yeah. Well, y o u ' l l have more chance of that with the Mycostatin than you would with the Tantum. P: Yeah. N: You know that? Okay, some Mycostatin coming up. P: You bet. Demonstrated i n t h i s segment was the nurse's strategy for suggesting p o s s i b i l i t e s to the patient. Throughout her discussion with the patient, she remained compassionate to his soar mouth and did not i n s i s t that he t r y her suggestion. The patient responded cautiously by p o l i t e l y l i s t e n i n g to the nurse's explanations and avoiding any kind of d i r e c t endorsement of the nurse's suggestion. Going Along with the Nurse's Suggestions ** Gentle Confrontation The following segment of i n t e r a c t i o n i l l u s t r a t e s the nurse gently confronting the patient about his mouth care and the patient 'going along' with the nurse's suggestion. The lighthearted tone of the i n t e r a c t i o n helps to maintain the nurse's sympathetic manner with the patient. One t y p i c a l i n t e r a c t i o n begins when the nurse enters the room to check on the 8 2 feed pump and st a r t s to t a l k with the patient about his mouth care. N: Did you t r y some i c e chips again? P: No. You took 'em away, remember? N: Yeah. But w i l l you t r y some i f I get you some more? P: Yeah [mumbles], N: Is that a no or a yes? It was a yes, wasn't i t ? P: No [joking tone]. N: It's not a yes? [joking tone] P: No [jokes]. N: [She points to the medications for his mouth and jokes.] What do you want to do with these? Gonna play dominos or make bales with them or something l i k e that? P: [smiles, nods] Well, I ' l l use them again here, maybe. N: Is there any point i n me going to get some Mycostatin? P: No. [He points to the jug of soda bicarbonate.] N: No, I didn't think so. Just that [ r e f e r r i n g to the soda bicarbonate]. Are you using these at a l l ? [gestures to the mouth swabs] P: [This] works the best [ r e f e r r i n g to the soda bicarbonate mixture]. N: Not very many by the look of i t [ r e f e r r i n g to the mouth swabs]. P: [He holds up three fingers to gesture that he had used three mouth swabs.] N: Pardon? P: [Again, he hold up three fingers.] N: Three, Okay [smiles]. P: Mmm [He sighs jokingly at her in t e r r o g a t i o n ] . N: I know where I'm not wanted. [laughs] See you l a t e r . P: Yeah. [interaction continues] In t h i s gentle confrontation, the nurse attempts to make therapeutic suggestions to the patient. Her p o s i t i v e and lighthearted tone remained prominent through the i n t e r a c t i o n and softened her confrontation. Furthermore, the nurse seemed to know when to stop confronting the patient. The patient's response demonstrates his t y p i c a l l y cautious manner i n taking up therapeutic suggestions on his terms and to a l i m i t e d extent. Communicating Physical Distress *» Being There f o r the Patient During t h e i r f i r s t day together, the patient was not observed to be i n any acute physical d i s t r e s s . However, during 83 t h e i r second day together, there were two instances when the patient experienced acute physical d i s t r e s s and communicated his di s t r e s s to the nurse. The nurse responded to the patient's d i s t r e s s by being there for him. These interactions stimulated by the patient's d i s t r e s s seemed to form important behavior clu s t e r s that r e f l e c t e d the nature of the re l a t i o n s h i p they had developed and provided the basis for continuing and deepening the r e l a t i o n s h i p . In both instances the patient appeared to f e e l comfortable enough with the nurse to openly share the magnitude of his d i s t r e s s , something he r a r e l y did with others. Each time the nurse's response e f f e c t i v e l y decreased his d i s t r e s s . Showing Distress «* Creating an Atmosphere of Calm Reassurance The f i r s t experience of dis t r e s s r e l a t e d to copious amounts of phlegm formation i n the patient's mouth and throat. He began to cough and choke on the phlegm. Using a suction i n an attempt to c l e a r the phlegm, he eventually obtained some r e l i e f . The nurse entered the room just as the patient was recovering from t h i s episode. He made no attempt to hide his d i s t r e s s from the nurse, as he held his head and t r i e d to catch his breath again. The nurse responded to the patient's d i s t r e s s by creating an atmosphere of calm reassurance. She rested her hand on his to comfort him, stayed close to the patient and asked him q u i e t l y i f he was a l r i g h t . She continued to observe the patient and i n a sof t , calm voice talked with him about c l e a r i n g his mouth. The following segment i l l u s t r a t e s t h i s i n t e r a c t i o n . N: You okay? P: [He nods his head.] Mmm. N: [She places her hand over his and looks d i r e c t l y at him, 8 4 then looks at feeding pump.] A l r i g h t . You're nearly through with t h i s , about half an hour i n f a c t . P: [The patient suctions his mouth.] Yeah. N: You having problems swallowing? P: [He shakes his head.] N: No? [ i n a u d i b l e ] — P: [He suctions his mouth.] There's so much, you know. N: Hmm? P: There so much more i n there f i r s t thing i n the morning, eh? N: Yeah. [She removes her hand from patient's hand.] [interaction continues] Interestingly, i n the context of d i s t r e s s , neither the nurse or patient resorted to the kind of humor that was so c h a r a c t e r i s t i c of most of t h e i r other i n t e r a c t i o n s . The intimacy created i n response to his d i s t r e s s generated a more serious and perhaps more honest dialogue and brought them closer together on a d i f f e r e n t l e v e l . Once the i n i t i a l d i s t r e s s subsided, however, the nurse made a humorous comment. Her humor at t h i s point seemed appropriate and may have helped to r e l i e v e the patient's anxiety. Voicing Distress «* Demonstrating Genuine Concern, Applying Comfort Measures The patient experienced d i s t r e s s a second time when he began to have cold sweats and a bloated f e e l i n g i n his stomach as a r e s u l t of his G-tube feeding. This time, he rang f o r the nurse and explained how he f e l t . The nurse demonstrated genuine concern by standing i n close proximity to the patient, observing and l i s t e n i n g c a r e f u l l y to the patient as he described how he f e l t , and by responding immediately to his. concerns. She brought him a hot pack for his abdomen and took his v i t a l signs. A l l the while she remained calm and spoke s o f t l y to the patient. Her actions were f l u i d and sequenced, projecting her confidence and s k i l l . A d d i t i o n a l l y , humor was incorporated into the s i t u a t i o n 8 5 once the patient's i n i t i a l d i s t r e s s had subsided. After the d i s t r e s s had dissipated the nurse reviewed the d i s t r e s s f u l s i t u a t i o n with the patient and, with him, t r i e d to figure out the reason for i t s occurrence. Day Three Day three was the f i n a l day of t h i s r e l a t i o n s h i p . On the t h i r d day the nurse was on duty from seven i n the morning u n t i l three i n the afternoon. In addition, there was a nursing student with the nurse. As a r e s u l t , the student nurse took over some of the routine tasks which would have otherwise been c a r r i e d out by the nurse. Some of the behaviors observed during the second day of the r e l a t i o n s h i p were also observed on the t h i r d day of the r e l a t i o n s h i p , such as, zeroing-in on patient problems and determining the nurse's whereabouts. Changes were noted i n some of the behaviors; for example, the nurse's gentle confrontations from the previous two days took a more assertive tone on the t h i r d day of the r e l a t i o n s h i p . Also, being t h e i r f i n a l day together, the nurse and patient concluded t h e i r r e l a t i o n s h i p . One behavior that was not observed during the f i n a l day of t h i s r e l a t i o n s h i p was that of the making therapeutic suggestions. During t h e i r l a s t day together the nurse did not suggest any new p o s s i b i l i t i e s for the patient to improve his care; rather, the nurse focused on r e i n f o r c i n g and encouraging the patient to act on her suggestions from the past two days. This occurred p a r t i c u l a r l y when the nurse confronted the patient about his care. The number of interactions between the nurse and the patient on the t h i r d day was smaller due to the shorter s h i f t the nurse 86 was working and the presence of the student nurse. A t o t a l of eleven interactions were observed between the nurse and the patient on t h e i r t h i r d day together, which amounted to 24 minutes and 11 seconds. Each in t e r a c t i o n averaged 2 minutes and 16 seconds i n length of time. Bob's f i n a l day with Cynthia followed a night that had several interruptions. Bob took a sleeping p i l l at bedtime as suggested by Cynthia during t h e i r f i r s t day together. Unfortunately, the alarm on his feeding pump was set o f f during the night interrupting his sleep. The clu s t e r s of behaviors observed during the f i n a l day of t h i s r e l a t i o n s h i p included: being comfortable with the nurse «» being comfortable with the patient; tempered movement toward problem resolution «» pushing toward problem resolution; making the most of the time l e f t » preparing for concluding the connection; and saying good-bye to the nurse ** saying good-bye to the patient (see Table 3). 87 Table 3 Behavioral Clusters and Their Constituents Observed on the Third Day of the NPR Patient Behaviors 8UK»« Behaviors-Being Comfortable with the Nurse Being Comfortable with the Patient -Offering personalized greeting -Discussing problems «» -Offering personalized greeting -Zeroing-in on patient problems Tempered Movement Toward Problem Resolution ** Pushing Toward Problem Resolution -Reluctant progression -Agreeing to take the nurse's d i r e c t i o n i n the future «* o -Assertive confrontation -Encouraging continuence of s e l f - c a r e i n the future Making the Most of the Time Left «• Preparing f o r Concluding the Connection -Maintaining a p o s i t i v e atmosphere -Determining the nurse's whereabouts -Forecasting the conclusion -Working toward independence -Making use of the nurse's service <-> «» «» «» o -Maintaining a p o s i t i v e atmosphere - T e l l i n g the patient her whereabouts -Responding to the patient's forecast of conclusion -Encouraging independence -Providing nursing service Saying Good-Bye to the Nurse o Saying Good-Bye to the Patient -Acknowledging the r e l a t i o n s h i p -Acknowledging the r e l a t i o n s h i p Being Comfortable with the Nurse Being Comfortable with the Patient The f i n a l day of t h i s r e l a t i o n s h i p began with a personalized greeting between the nurse and the patient. As i n the second day of t h i s NPR, the nurse continued to zero-in on patient problems and the patient continued to discuss his problems comfortably with the nurse. 88 Offering Personalized Greeting ** Offering Personalized Greeting The introduction to t h e i r t h i r d day together took the form of a personalized greeting. On t h i s day, the nurse entered the room along with the student nurse. Unlike the f i r s t introduction between the nurse and patient, t h i s introduction, had a very personal tone and was accompanied by humor and laughter. In the following segment, the nurse and student nurse have come to greet the patient for the f i r s t time i n the morning. N: Good morning. P: [The patient waves.] SN: Good morning. N: Do you know Shelley? P: Oh. SN: Oh yeah. N: Do you know me? [smiles] P: [jokingly] It's been a long time, babe. N: [laughs] Yeah, a whole, oh, must be twelve hours since I l a s t saw you. P: Yeah. [inte r a c t i o n continues] Discussing Problems ** Zeroing-in on Patient Problems Assessments on t h i s day continued to be focused on the patient's issues from the previous two days. The nurse knew s p e c i f i c d e t a i l s regarding the patient's care that she needed to assess and focused on what the patient may s t i l l need to accomplish, for example, increasing his a c t i v i t y l e v e l . The nurse maintained her lightheartedness and sense of humor when assessing the patient. The patient responded to the nurse's questions d i r e c t l y and i n an informal fashion, incorporating humor into his answers. The following example i l l u s t r a t e s an assessment on the t h i r d day of the r e l a t i o n s h i p . Throughout t h i s assessment there i s humor and gentle confrontations. The patient eventually admits that the nurse was r i g h t about the 89 effectiveness of a new mouth product he t r i e d . N: What's happenin' to this? [checking the feed pump] How come you're only at 81? P: I don't know. SN: Oh, your bottle's squashed again. Look at that. P: I t f e l l . N & SN: It f e l l ? N: Oh. Who dropped i t ? P: Some nurse. N: Some nurse [working with feed b o t t l e ] , there. P: They've been doin' that a l l night. N: Have they? That's why, cause i t f e l l . [She puts the feed bottle back up and fixe s the feed pump.] Okay, any problems? P: No. N: Any pain? P: Nope. N: When'd you l a s t get analgesic, about three wasn't i t ? P: I don't know. SN: Two, I think somebody said. P: I had something. N: [The nurse checks a paper i n her pocket.] Two, yeah. P: And what was that? N: You had your Codeine at two o'clock t h i s morning. P: Yeah. N: You need any now? P: No. When's my RT? [radiation therapy] N: Two. Okay. P: [shrugs] Yeah. N: You going to get up and walk about a b i t more today? P: What do you mean more? N: It's jus t , every time I look at you, you're i n bed. P: I was given 'er yesterday. N: Given what? P: It's a saying, you know, to give... [The patient makes a motion with his arm.] N: Oh, yeah. Okay, I don't know that expression. Must be one of those Canadian things. P: Yeah, yup. N: Okay. P: I put on a l o t t a miles yesterday. N: You walked three times around the sta t i o n f l o o r . Once, not even three times. P: At a time? N: Yeah, you did that twice. [The patient and nurse laugh.] It's a l l you know I have to go check. P: Yeah. I did i t at least four times, f i v e times. N: That might help though, to get that f e e l i n g of f u l l n e s s out of your stomach. P: Mmm, oh, yeah. [The nurse and patient continue to tal k . ] N: Did you use the Mycostatin? P: Yeah. N: And? 9 0 P: And what? N: And? P: And baking soda. N: And? P: And, and, and. N: What did you think of the r i g h t s t u f f ? P: Ah, I think i t might work a l r i g h t . N: You think so? I was r i g h t [smiles]. P: Of course you were. N: [laughs] I ' l l see you l a t e r . P: Yeah. N: Are you using these? [She hold up the mouth swabs.] P: This i s only the second morning. N: There's exactly the same number there now as there were yesterday. P: As a matter of fact I didn't have time to brush my teeth t h i s morning. N: I t ' s not only for morning, i t ' s f o r during the day as we l l . Keep your mouth as clean as you can. P: Yeah. N: Yeah. P: [joking] You better go see how your other patients are. N: [The nurse and patient laugh.] W i l l I go see how my other patients are doing and get o f f your case f o r a while? Okay, I ' l l be back. P: Take i t easy [smiles]. In t h i s segment, the comfort l e v e l between the nurse and patient i s evident i n the humorous and lighthearted manner i n which they are able to zero-in on and discuss problems together. Unlike the beginning of the re l a t i o n s h i p , where the nurse and patient were getting to know one another, the ease with which issues are discussed at t h i s point i n the re l a t i o n s h i p , i s a demonstration of the p o s i t i v e connection developed by the nurse and patient. Tempered Movement Toward Problem Resolution «» Pushing Toward Problem Resolution The nurse attempted to push toward problem resolution i n the f i n a l day of t h i s NPR by a s s e r t i v e l y confronting the patient about problems with his care that had not yet been resolved. Furthermore, the nurse encouraged the patient and attempted to provide him with d i r e c t i o n for the future. The patient responded to the nurse's push toward problem resolution i n a tempered 91 manner. Although r e l u c t a n t l y , he agreed to take the nurse's d i r e c t i o n f o r the future. I t i s unknown whether he followed through on his agreement. Reluctant Progression ** Assertive Confrontation On the f i n a l day of the r e l a t i o n s h i p , the gentle confrontation that was observed during the f i r s t two days of the r e l a t i o n s h i p became more assertive. That i s , the nurse was at times lighthearted and humorous about d i f f e r e n t care issues but was also quite stern about getting issues resolved and pushing the patient toward problem resolution. It i s possible that because t h i s was t h e i r f i n a l day together, the nurse was determined to resolve the issues. When the nurse a s s e r t i v e l y confronted the patient she raised her voice and was very blunt i n her questioning. The lighthearted or humorous tone c h a r a c t e r i s t i c of previous gentle confrontations was absent. She looked d i r e c t l y at the patient when speaking with him and would not leave a topic u n t i l she got a straightforward answer from the patient. The patient began responding to the nurse's assertive confrontation with i n d i r e c t answers and attempted to use humor, i n an e f f o r t to avoid responding to her suggestions. However, when he r e a l i z e d the nurse was getting i r r i t a t e d with him, he became more d i r e c t and honest i n his responses. The nurse's assertive confrontation with the patient did not seem to negatively impact on the r e l a t i o n s h i p . Once the confrontation ended, the nurse and patient c a r r i e d on i n t h e i r usual p o s i t i v e and lighthearted manner. The following example demonstrates the nurse a s s e r t i v e l y confronting the patient about his mouth care and about his pain. 92 Although the nurse's assertiveness i n t h i s segment may appear harsh, i t i s important to understand the context i n which t h i s i n t e r a c t i o n occurred. Over the course of t h e i r three-day r e l a t i o n s h i p , the nurse and patient had through t h e i r interactions and work together, come to know each other quite w e l l . As such, i t appeared that the nurse could confront the patient i n t h i s assertive manner, without upsetting him. Had the nurse a s s e r t i v e l y confronted the patient during the f i r s t day or even second day together, t h i s action may have eroded the development of the re l a t i o n s h i p . However, at t h i s point i n the rel a t i o n s h i p , her assertive confrontation seemed appropriate. Furthermore, i t did not appear to deteriorate the r e l a t i o n s h i p i n any way. In t h i s i n t e r a c t i o n , the nurse was s i t t i n g on the patient's bed and the patient was s i t t i n g i n an arm chair while they were t a l k i n g . N: That's okay, yeah t h i s looks, i t ' s less red now, there's more of a pink coating on i t . It's not painful? [The nurse looks at the patient's tongue.] P: Well, yeah. N: No? P: Mmm mmm. N: It i s ? Then why do you keep on saying you've no pain when I ask you? [ i r r i t a t e d tone of voice] P: It's immaterial. N: It's not immaterial. P: Mmm hmmm. N: Why? P: It's no big deal. N: Your such a strong lad, you can put up with the pain, eh? P: Yeah. N: There's no need to. P: That's for wimps [He gets up to suction his mouth.] N: Oh. It's got nothing to do with being a wimp or not being a wimp [ i r r i t a t e d tone of vo i c e ] . P: [The patient i s suctioning his mouth.] N: It's got nothing to do with being a wimp or not. P: [He puts his suction catheter down.] Umhmm. Sure i t 93 does. N: [inaudible] P: Yeah. N: You need to get a stand for that. P: It's not a severe pain. N: How bad i s i t ? P: It's not that bad. N: It's just a pain, i s i t ? P: Ah, i t ' s there, eh? N: A s t i n g or an ache or... [interaction continues] N: Are you using these? [She points to the mouth swabs.] P: No. N: I want to know. P: Yeah [patient shrugs]. N: Don't just keep on shrugging [ i r r i t a t e d tone of v o i c e ] . P: What? N: I asked you a question. P: What did you say? N: I said, are you using these toothettes? P: No. N: Why not? P: They hurt too much. N: Do they? [interaction continues] The assertive confrontation i l l u s t r a t e d i n t h i s segment demonstrated the nurse's push toward problem resolution by her absence of humor, ra i s e d voice, blunt questions and persistence with issues. Despite t h i s , the patient continues to be reluctant to take up some of the nurse's suggestions as demonstrated by his i n i t i a l i n d i r e c t answers to the nurse's questions and his attempt at using humor to circumvent the issues needing r e s o l u t i o n . Agreeing to Take the Nurse's Direction in the Future «* Encouraging Continuance of Self-Care in the Future Right up to the end of the r e l a t i o n s h i p , the nurse was pushing the patient to continue working on progressing with his mouth care. She was providing d i r e c t i o n for the future, as i f to l e t the patient know that although she would no longer be there to work with him, he could continue to work toward problem resolution independently. The patient responded by agreeing to 94 take the nurse's d i r e c t i o n . The following, i s a segment of the f i n a l i n t e r a c t i o n between the nurse and the patient. N: Sorry you didn't get swallowing better. P: Yeah. N: Keep up the Mycostatin, i t ' s r e a l l y good. P: Yeah, yeah, yeah. N: Okay? P: Yeah, w i l l do, thanks, [interaction continues] Right to t h i s f i n a l conversation, the nurse continued to encourage the patient to p e r s i s t with the mouth care regimen he started. The nurse was attuned to the patient's d i f f i c u l t y i n developing new behaviors with respect to his mouth care. As such, she encouraged the continuence of the behaviors he started toward caring for his mouth. Making the Most of the Time Left *» Preparing for Concluding the Connection In the f i n a l day of the r e l a t i o n s h i p the nurse and patient were observed to prepare for the ending of t h e i r three-day r e l a t i o n s h i p . Bob made the most of his time l e f t with Cynthia by engaging i n such behaviors as maintaining a p o s i t i v e atmosphere; determining the nurse's whereabouts; forecasting the conclusion; working toward independence; and making use of the nurse's service. Cynthia responded to Bob's behaviors by also maintaining a p o s i t i v e atmosphere; by t e l l i n g the patient her whereabouts; and by responding to his forecast of the conclusion to t h e i r r e l a t i o n s h i p . She also continued to encourage his independence and to provide him with nursing care. Maintaining a Positive Atmosphere ** Maintaining a Positive Atmosphere A p o s i t i v e atmosphere seemed to be present throughout the t h i r d day of the r e l a t i o n s h i p as i n the f i r s t two days. There 95 was always a sense of comfort and genuineness between the nurse and the patient. The p o s i t i v e atmosphere seemed to be enhanced by t h e i r s o c i a l conversations and use of humor with one another. This p o s i t i v e tone seemed to keep the nurse and patient i n high s p i r i t s through the day and helped to maintain t h e i r connection. The following segment of s o c i a l conversation i s a small part of a long t a l k the nurse and patient were having about a v a r i e t y of topics such as h i s mouth care, pain, and G-tube feeds. N: ...Aren't these lovely. P: Mmm hmm. N: Are those from the spring? P: Yeah. N: Mmm, gorgeous. At home we c a l l these pussy willows. P: Here too. N: You c a l l them pussy willows here too? P: Mmm hmm. N: Aren't they gorgeous. Oh, these are [ l i k e ] s i l k . P: Yeah. N: Wow. P: Yeah, that one i s n ' t going to waste away. N: No, I guess not. Oh, there's a l i t t l e b i r d i n there as w e l l . P: Yeah. [interaction continues] By continuing to combine lighthearted s o c i a l conversations with c l i n i c a l work, a p o s i t i v e atmoshere was maintained i n t h i s r e l a t i o n s h i p . Determining the Nurse's Whereabouts *» Telling the Patient Her Whereabouts The patient continued his e f f o r t s to e s t a b l i s h the nurse's whereabouts. As on the second day, the patient seemed to be se n s i t i v e to the nurse's comings and goings and would comment about them i n a humorous way. On t h i s day, however, the patient seemed to ask the nurse about her whereabouts more frequently than during the f i r s t two days. The nurse responded to the patient i n the manner she previously used, lightheartedly and 96 with humor. In the following segment the nurse had just come i n for the f i r s t time i n the morning to greet the patient. N: Okay, I ' l l see you i n a l i t t l e . P: Where are you going? N: I just came i n to say "good mornin'" to you. P: [jokingly] Oh, i s that what i t was? N: Yeah, that's what i t was. [int e r a c t i o n continues] I l l u s t r a t e d i n t h i s segment was the patient's continued need to determine the whereabouts of the nurse. Although the nurse used a humorous response to answer the patient's question, she provided him with the information he needed. Forecasting the Conclusion «* Responding to the Patient's Forecast of Conclusion Ending the r e l a t i o n s h i p began early on the t h i r d day of the r e l a t i o n s h i p when the nurse and patient talked about t h i s being t h e i r f i n a l day together and not seeing each other again. This i n t e r a c t i o n was important as i t may have made the closure of t h e i r r e l a t i o n s h i p easier. The following i s a segment of t h i s i n t e r a c t i o n . P: You'll soon be o f f t h i s s h i f t . N: Yeah. I'm only working u n t i l three today and then I'm o f f u n t i l the weekend. P: So I won't see you. N: Oh, that's r i g h t . You'll be gone. Are you going Wednesday? Have they been i n here to show you how to use a l l this? P: No. This afternoon or tommorow. [interaction continues] By forecasting when the r e l a t i o n s h i p w i l l end, the patient could make the most of his time l e f t with the nurse. The nurse responded to the patient's forecast by preparing him for the conclusion of the r e l a t i o n s h i p i n t e l l i n g him the length of time they have l e f t together. 97 Working Toward Independence ** Encouraging Independence During the t h i r d day of the r e l a t i o n s h i p , the patient was i becoming increasingly independent with the care of his G-tube and feeds. The nurse continued to encourage and support the patient's independence by t e l l i n g him how well he i s doing with the care of his G-tube and by encouraging him to be as independent as possible as he w i l l have to carry out h i s own care when he i s at home. The following segment i l l u s t r a t e s the patient's independence and the nurse's support for his independence. N: Have you had the water hooked up? P: Yeah. N: Doin' i t yourself? P: Yes. N: Independent Joe. P: Yeah. [The nurse and patient go on to t a l k about the medications for his mouth.] The patient made the most of his time l e f t with the nurse by continuing to demonstrate to her that he i s working toward becoming independent with the care of his G-tube. The nurse prepared to conclude her connection with the patient by continuing to check-in with the patient about the care of his G-tube and by continuing to encourage his independence. Making Use of the Nurse's Service o Providing Nursing Service Although the patient was able to carry out a large portion of his care independently, he was observed to ask the nurse to help him with some aspects of his care on the t h i r d day, such as, applying powder to his neck. It i s possible that he was aware of the l i m i t e d amount of time he has l e f t with the nurse and was not quite ready to l e t go of a l l of her help or that he was making 98 sure that the nurse would be there to help him r i g h t u n t i l the end. The nurse responded to his request for help by carrying out the task the patient asked f o r . While carrying out the task, the nurse explained to the patient how he may have c a r r i e d out the task independently. The patient responded to the nurse with a humorous comment. His humor seemed to indicate that he knew how to carry out the task on his own but s t i l l wanted the nurse to help him. P: Put a b i t of powder on me, would you? N: Sure. P: Gotta make the best use of you I can. N: [The nurse applies powder to patient's neck.] Oh, that's r i g h t [ j o k i n g l y ] . P: I t ' s been a l i t t l e dry from l a s t night. N: [She rubs powder into his neck.] Hmm, been put t i n ' t h i s on? P: It's suppose to be put on three or four times a day. N: So? Why aren't you doin' i t ? P: Well, i t ' s too hard for me to do. N: Oh [inaudible]... P: I can't see to get i t i n the r i g h t places. N: Look i n a mirror. Learn to do as much as you can f o r yourself for when you're not i n h o s p i t a l . P: When I've got a l l these b e a u t i f u l women around me? N: Oh, yes. That's your attitude i s i t ? P: Oh, no, i t i s n ' t . [ interaction continues] Although the patient was becoming increasingly independent with some aspects of his care, i t seemed that one of the ways he was making the most of h i s time l e f t with the nurse was by using her nursing service. By carrying out the patient's request the nurse demonstrated that although the conclusion to t h e i r connection i s nearing, she i s s t i l l involved i n his care and i s a v a i l a b l e to help him. Saying Good-Bye to the Nurse <» Saying Good-Bye to the Patient Their f i n a l good-bye to one another was accompanied by compliments, humor and well-wishing. Furthermore, both the 99 patient and the nurse acknowledged that something s p e c i a l had happened between them. This l a s t i n t e r a c t i o n between the nurse and patient was important i n that they sought a d e f i n i t e closure to t h e i r r e l a t i o n s h i p . The ending to t h i s r e l a t i o n s h i p was d i r e c t and obvious. Acknowledging the Relationship «* Acknowledging the Relationship In t h e i r f i n a l i n t e r a c t i o n , the patient and nurse stated that they would miss one another as they parted. A l b e i t i n d i r e c t l y , they both acknowledged that something s p e c i a l happened i n t h e i r r e l a t i o n s h i p . The following i s a segment of the f i n a l i n t e r a c t i o n between the nurse and patient. The nurse was s i t t i n g at the patient's bedside and they had become involved i n a humorous conversation that led up to t h e i r f i n a l good-bye. N: [She touches the patient's hand and holds i t . ] Okay, anyway, I'm goin' o f f . P: I'm goin' to miss you. N: Yeah, I'm going to miss you too. Anyway...[inaudible] P: Thanks very much. You, you're excellent. N: Oh, thank-you. P: I appreciate everything you've done. N: Yeah. Take care of yourself. P: W i l l do, yup. [interaction continues] N: I won't be back t i l l Friday and y o u ' l l be gone by then. P: Yeah, I ' l l be gone by Wednesday, Thursday. N: [inaudible] P: Yes, very much so. N: Yup, take care. P: I look forward to i t . N: Bye, bye. [The nurse gives patient's hand a couple of taps. ] P: Bye now. Two important things happened i n t h i s f i n a l good-bye between Cynthia and Bob. F i r s t , they i n d i v i d u a l l y acknowledged the close r e l a t i o n s h i p they developed by t e l l i n g one another they w i l l be missed. Second, they said a conclusive f a i r w e l l by wishing each other well and by b r i e f l y noting that Bob w i l l be discharged by 100 the time Cynthia w i l l return to work af t e r her days o f f . As a r e s u l t , neither would have been l e f t with ambiguous thoughts regarding whether they would see one another again. Findings from the Focus Group A ninety-minute focus group discussion was used to valid a t e and augment the findings. Five participants contributed to the focus group discussion including three nurses with extensive background i n oncology and p a l l i a t i v e care, a c l i n i c a l nurse s p e c i a l i s t i n p a l l i a t i v e care, and a nurse who had recently been an oncology patient. The focus group participants discussed the NPR as an in t e r a c t i v e process that develops over time, much l i k e that observed i n the present study. They talked about the re l a t i o n s h i p i n terms of beginning the re l a t i o n s h i p , maintaining the r e l a t i o n s h i p , and ending the r e l a t i o n s h i p . The group then discussed behaviors r e f l e c t e d i n each of the stages of t h i s i n t e r a c t i v e process. Beginning the Relationship Getting to know the patient and getting to know the nurse was agreed to be a necessary part of beginning the r e l a t i o n s h i p . Participants of the focus group added that t h i s process was accomplished through s o c i a l conversation and s e l f - d i s c l o s u r e . They also cautioned that although s e l f - d i s c l o s u r e i s a necessary part of the NPR, there i s a f i n e d i s t i n c t i o n between revealing to the patient what they want to know about the nurse and s e l f - d i s c l o s i n g too much to the patient. One part i c i p a n t , who had been a patient, talked about f e e l i n g powerless and being dependent on the nurse for c l i n i c a l 101 expertise and guidance. As such, i n order to ensure getting the care she needed, she t r i e d to be f r i e n d l y with the nurse and asked the nurse personal questions. This p a r t i c i p a n t f e l t i t was easier to connect with the nurse on a personal l e v e l rather than a professional l e v e l . Other nurses i n the group agreed that patients are dependent on the nurse and thought that patients wanted t h e i r nurses to l i k e them. Focus group participants validated that demonstrating competence i s an important part of nursing patients. The partici p a n t s who had been patients recounted that they quickly knew which nurses did and did not f e e l comfortable with t h e i r a b i l i t i e s . As patients, they were p a r t i c u l a r l y v i g i l a n t when ce r t a i n nurses worked with them. Furthermore, when a nurse that demonstrated competence worked with them, they f e l t r e l i e v e d and relaxed about t h e i r care while that nurse was on s h i f t . Other focus group members extended the notion of demonstrating competence beyond performing an action to t a l k i n g about the action. As observed i n the present study, focus group participants validated that an important behavior i n demonstrating competence i s t a l k i n g through actions. That i s , explaining to the patient what t h e i r medications are f o r or what t h e i r treatments do. Furthermore, a nurse's competence must be combined with her/his a b i l i t y to care. Participants discussed how a nurse must be competent to complete a task and must also be competent to care. Incorporating humor and s o c i a l conversation were some of the ways a personal sense can be brought into the technology of routine tasks. That i s , the nurse needs to be able to care for 1 0 2 the patient i n a humane manner, rather than focusing on the patient's machines. Humor was seen by the group as a strategy to be used with s e n s i t i v i t y . One p a r t i c i p a n t explained that d i f f e r e n t people have d i f f e r e n t senses of humor, and for humor to be used i n a r e l a t i o n s h i p , the nurse and patient should have the same ideas about what i s humorous. One p a r t i c i p a n t explained that, as a patient, she experienced both p o s i t i v e and negative a f f e c t s of humor. In some instances, she f e l t the nurse used humor to avoid connecting with her. The p a r t i c i p a n t stated that t h i s use of humor made her f e e l uncared for and increased her d i s t r e s s l e v e l . In sharp contrast, there were instances when others r e a l i z i n g that she needed a l i f t , made her laugh at herself and what was happening. In these instances, she f e l t connected with the nurse and the humor helped her relax. In discussing making therapeutic suggestions and the patient's cautious response to the suggestions, p a r t i c i p a n t s f e l t that making therapeutic suggestions i s a "dance" or a process of negotiation. Suggestions need to be "opened up", e s p e c i a l l y when the patient does not take up these suggestions. This process was seen to help uncover reasons for patient's reluctance to t r y the suggestions without being judgmental. A d d i t i o n a l l y , participants talked about dealing with t h e i r own emotions while watching a patient i n pain who had refused any analgesic. Measures such as holding a patient's hand or staying with the patient through t h e i r s u f f e r i n g were viewed as d i f f i c u l t for the nurse but e f f e c t i v e for helping a patient through a d i s t r e s s f u l period. 103 Maintaining the Relationship Drawing on past c l i n i c a l experiences, participants emphasized the importance of re-connecting with the patient at the beginning of the next s h i f t to maintain and b u i l d on the re l a t i o n s h i p already established. This was often simply done by r e f e r r i n g to something that was relevant to the patient that had occurred during the previous day. Re-connection or re-introduction with the patient was seen as very important, p a r t i c u l a r l y i f a strong connection was established during t h e i r f i r s t day together. One participant emphasized that re-connecting made her f e e l that the nurse remembered her, and she f e l t r e l i e v e d to be cared for again by that nurse. When t h i s did not happen, the development of the re l a t i o n s h i p was threatened. The participants agreed that i t was courteous and res p e c t f u l to l e t patients know how long t h e i r s h i f t s were and when they were leaving for coffee breaks. When patients f e l t safe with a p a r t i c u l a r nurse, they made an e f f o r t to f i n d out how long s/he would be working with them. The nurses' response to physical or emotional d i s t r e s s , while important i n enhancing patient comfort, was also described as a key factor i n developing the NPR. For patients, i t i s c r i t i c a l that the nurse acknowledge t h e i r d i s t r e s s without diminishing or negating i t i n any way. One pa r t i c i p a n t recounted her experience as a patient when one nurse diminished her dis t r e s s by not acknowledging a sleepless night that had l e f t her f e e l i n g distressed. The end r e s u l t , from the patient's perspective, was that the connection they had previously established was i n s t a n t l y l o s t . 104 Ending the Relationship Participants expressed that ending a r e l a t i o n s h i p s t a r t s e a r l i e r than the f i n a l contact between the nurse and patient. In practice, they often started to say good-bye at the beginning of the r e l a t i o n s h i p by l e t t i n g the patient know how many days they would be working with a patient. For patients, t h i s seemed important so that they could make the most of t h e i r time together with the nurse. Stories of f i n a l good-byes between nurses and patients included "well-wishing," encouragement, and gratitude. Gratitude was expressed by both the nurse and the patient. Patients often expressed appreciation of the nurse's good care, while nurses appreciated having learned something from the patient. The group agreed that a clear and d e f i n i t e closure to any NPR was important. Participants also validated the importance of ending interactions throughout the rel a t i o n s h i p , that i s , t e l l i n g the patient that they are going on a break, going home for the day, or even going o f f for several days. The group reported that neglecting t h i s kind of "checking-in" with the patient can be a source of uncertainty and d i s t r e s s for patients. In summary, the focus group discussion validated many of the behavior clu s t e r s i d e n t i f i e d to be important i n the development of a r e l a t i o n s h i p between Bob and Cynthia. In some instances, the possible consequences of not engaging i n these behaviors to the developing r e l a t i o n s h i p were described. On the basis of t h e i r experiences, i t appears that the development of NPRs may be hindered or undermined when nurses and patients do not engage i n these behaviors. 105 Summary In t h i s chapter, the findings of the study which r e f l e c t e d patterns of behavior and behavior c l u s t e r s between a nurse and patient over t h e i r three-day r e l a t i o n s h i p were presented. Background information relevant to each day of the r e l a t i o n s h i p was highlighted to contextualize these observations. Some of the behavior clu s t e r s were observed i n a l l three days of the re l a t i o n s h i p , while others changed as the r e l a t i o n s h i p developed. The development of t h i s NPR was r e f l e c t e d i n the changes observed i n the behaviors of both the nurse and patient over the course of three days. A d d i t i o n a l l y , findings from the focus group discussion were presented. Focus group participants discussed the NPR as an i n t e r a c t i v e process that develops over time. The NPR was discussed i n terms of beginning the re l a t i o n s h i p , maintaining the re l a t i o n s h i p , and ending the r e l a t i o n s h i p . 106 CHAPTER 5: DISCUSSION Although every nurse-patient r e l a t i o n s h i p (NPR) i s unique, a l l r e l ationships have some common features that can be observed and studied. The purpose of t h i s study was to describe the development of a NPR i n an oncology s e t t i n g . Using a q u a l i t a t i v e e t h o l o g i c a l research method, videotaped recordings (VTRs) of the interactions between a nurse and a patient on an active cancer treatment ward were used to investigate and delineate important features of nurse-patient interactions that r e f l e c t e d the development of a NPR. Although there i s some consensus on the c h a r a c t e r i s t i c s of an e f f e c t i v e NPR i n the l i t e r a t u r e , further exploration i s necessary to increase our understanding of the complexities inherent i n NPRs as they ac t u a l l y occur everyday i n c l i n i c a l settings. The findings of t h i s study revealed patterns of behavior r e f l e c t i n g the development of an e f f e c t i v e NPR. The set of NPIs used i n t h i s investigation involved approximately two hours and twenty minutes of interactions between one nurse and one patient over a three-day period. The si x t y interactions occurred during two twelve-hour s h i f t s and one eight-hour s h i f t . Despite the l i m i t e d amount of time the nurse and patient spent together over t h i s three-day period, they were able to develop an e f f e c t i v e r e l a t i o n s h i p . Analysis of t h e i r interactions revealed patterns of behavior that appeared to contribute to the development of t h i s r e l a t i o n s h i p . These patterns of behavior included both verbal and nonverbal behaviors on the part of the nurse as well as the patient. These behavior patterns were referred to as behavioral c l u s t e r s . 107 S p e c i f i c c l u s t e r s were i d e n t i f i e d on each day of t h i s three-day r e l a t i o n s h i p . Some of the behavioral c l u s t e r s and constituent behaviors were i d e n t i f i e d i n a l l three days of the rel a t i o n s h i p , while other behaviors changed as the r e l a t i o n s h i p developed. Each c l u s t e r r e f l e c t e d the dynamic inte r p l a y of patient and nurse behaviors. Behavioral cl u s t e r s on the f i s t day included: the nurse and patient getting to know one another; the patient wooing the nurse and the nurse responding by creating a foundation for connecting; the patient being v i g i l a n t of the nurse and the nurse responding by demonstrating her competence; and, the nurse making therapeutic suggestions with a patient response of cautious consideration. On the second day of t h i s NPR, behavioral c l u s t e r s were r e f l e c t i v e of the patient's comfort with being known by the nurse and the nurse deepening her understanding of the patient; the nurse and patient sustaining t h e i r involvement and connection with one another; the nurse making therapeutic suggestions to the patient and the patient cautiously responding to the suggestions; and, the patient communicating physical d i s t r e s s and a nurse response of being there for the patient. On the t h i r d and f i n a l day of t h i s three-day r e l a t i o n s h i p , the nurse and patient were observed to be comfortable with one another; the nurse was pushing toward problem resolution while the patient responded with tempered movement toward problem resolution; the patient was making the most of the time l e f t as the nurse prepared for concluding the connection; and, the patient and nurse said good-bye to one another. The development of t h i s r e l a t i o n s h i p was characterized by 108 the mutual p a r t i c i p a t i o n of both the nurse and patient i n a l l i n t e r a c t i o n s . In addition, the extensive use of humor by t h i s dyad appeared to be an important factor i n t h i s r e l a t i o n s h i p . The depth of the re l a t i o n s h i p developed between t h i s nurse and patient was r e f l e c t e d i n demonstrations of respect for the other and i n expressions of sentiment to each other. Discussion of the Findings Presented i n t h i s chapter i s a discussion of the study findings. This discussion w i l l be organized along several key findings including: mutual p a r t i c i p a t i o n i n r e l a t i o n s h i p building; ways of knowing i n a rel a t i o n s h i p ; f o s t e r i n g achievement of therapeutic goals; humor i n r e l a t i o n s h i p building; r e c i p r o c i t y ; and closure of NPRs. Questions or issues nurses need to consider i n r e l a t i o n to developing NPRs as well as research needs w i l l be incorporated into t h i s discussion. A d d i t i o n a l l y , the research method used for t h i s study w i l l be discussed and l i m i t a t i o n s of the study considered. F i n a l l y , conclusions of the study w i l l be presented. Mutual P a r t i c i p a t i o n i n Relationship Building The over-riding boundaries and agenda for encounters between nurses and patients are to some extent determined by the organizational context i n which nurse-patient dyads are located (May & Purkis, 1995). In t h i s sense, both the nurse and patient i n t h i s study began the r e l a t i o n s h i p within a set of constraints and expectations about nurse and patient r o l e s . Nevertheless, within these parameters, there appeared to be space for mutual p a r t i c i p a t i o n i n building a r e l a t i o n s h i p . This mutual p a r t i c i p a t i o n was most v i v i d l y demonstrated i n 109 the dynamic interplay between the nurse and patient, r e f l e c t e d i n behavior patterns of r e l a t i n g . For example, on t h e i r f i s t day together when the nurse made therapeutic suggestions, and the patient responded by cautiously considering her ideas. In turn, the nurse offered explanations for her suggestions i n what appeared to be an attempt to gently guide the patient to take up these suggestions. This p r e c i p i t a t e d a patient response characterized by l i s t e n i n g and cautiously responding to the suggestions. This dynamic interplay was c h a r a c t e r i s t i c of a l l interactions, c l e a r l y demonstrating that the r e l a t i o n s h i p was c o n t r o l l e d and directed by both the nurse and patient. Neither was a passive r e c i p i e n t of t h i s process. This finding i s unlike some descriptions of NPRs i n which the development of the r e l a t i o n s h i p i s based on the behaviors of the nurse. Comprehensive nursing texts, p a r t i c u l a r l y those i n the area of psychiatry and mental-health maintain that the nurse has the primary r e s p o n s i b i l i t y of focusing, d i r e c t i n g , continuing, and terminating the NPR (Brady, 1993; Gelazis & Coombe-Moore, 1993; McMahon, 1992; Schwecke, 1995; Thomas, 1991). The active p a r t i c i p a t i o n of both the nurse and patient i n r e l a t i o n s h i p building i s supported by some researchers (Morse, 1991a) as well as theorists (Peplau, 1952). For example, Morse's analysis of in-depth interviews with nurses revealed that nurses and patients negotiate r e l a t i o n s h i p s . Morse's findings are congruent with those of the present study because they point to more active and equal roles on the part of both the nurse and patient i n building r e l a t i o n s h i p s . Morse (1991a) points out that the outcome of the negotiation 110 between the nurse and patient i s d i f f e r e n t l e v e l s of involvement. Based on Morse's typology, the nurse and patient i n t h i s study seemed to negotiate a mutual r e l a t i o n s h i p referred to as a connected r e l a t i o n s h i p . In the connected r e l a t i o n s h i p , the nurse maintains a professional perspective while viewing the patient as a patient as well as a person. In turn, the patient t r u s t s , respects, and f e e l s g r a t e f u l to the nurse. In t h i s r e l a t i o n s h i p the patient believes the nurse has 'gone the extra mile.' In the connected r e l a t i o n s h i p , Morse (1991a) maintains that there i s active p a r t i c i p a t i o n on the part of the nurse and patient i n r e l a t i o n s h i p building. The findings of t h i s study suggest t h i s process of active p a r t i c i p a t i o n continues throughout the NPR, including closure. Other researchers (Roberts, Krouse, & Michaud, 1995) have found negotiation i n the NPR i s a process that encourages patient s e l f - c a r e behaviors r e s u l t i n g i n patients becoming more responsible and f e e l i n g s a t i s f i e d with treatment decisions and outcomes. However, these researchers did not describe what t h i s process of negotiation e n t a i l s , and how negotiation i s linked to building the r e l a t i o n s h i p . Researchers have described a l e v e l of involvement based on r e c i p r o c i t y and exchange between the nurse and patient to provide the patient with a sense of personal recognition (May, 1991a; Morse, 1991a; Ramos, 1992; Hagerty et a l . , 1993). These researchers described a deep involvement between the nurse and patient. However, i t was unclear what s p e c i f i c behaviors contribute to t h i s l e v e l of involvement. Although the r e l a t i o n s h i p observed i n t h i s study appeared to r e f l e c t a c e r t a i n degree of involvement between the nurse and patient, the nurse's I l l primary focus was on the patient as a patient not on the patient as a person. Behavior clu s t e r s r e f l e c t i n g her focus on the patient included: making therapeutic suggestions, deepening understanding of the patient, and being there for the patient. Two important issues must be considered i n r e l a t i o n to mutual p a r t i c i p a t i o n i n r e l a t i o n s h i p b u i l d i n g . F i r s t , i t i s evident that there i s a discrepancy between nursing texts, p a r t i c u l a r l y those i n the area of psychiatry and mental-health (Brady, 1993; Gelazis & Coombe-Moore, 1993; McMahon, 1992; Schwecke, 1995; Thomas, 1991), and research on the NPR (May, 1991; Morse, 1991a; Ramos, 1992; Hagerty et a l . , 1993). Authors of nursing texts maintain that the NPR i s primarily directed by the nurse, whereas the present study as well as other research studies on NPRs have found that building the NPR i s a mutual and r e c i p r o c a l process between the nurse and patient. Such a discrepancy could confuse nursing students and neophyte nurses. Second, the research that has been conducted on the r e c i p r o c a l nature of the NPR has been conducted mainly from the perspective of the nurse. Furthermore, s p e c i f i c behaviors contributing to the mutuality of the r e l a t i o n s h i p have not been previously described. The observational method used i n t h i s study to investigate the behaviors of both the nurse and the patient contributed to a r i c h description of these behaviors. Researchers need to give equal attention to nurses and patients to gain a deeper understanding of the development of the NPR i n the c l i n i c a l s e t t i n g . A d d i t i o n a l l y , the mutual p a r t i c i p a t i o n i n r e l a t i o n s h i p b uilding found i n t h i s investigation shed l i g h t on behaviors that 112 contribute to the development of an e f f e c t i v e NPR. Awareness of nurse and patient behaviors that contribute to the development of e f f e c t i v e NPRs may challenge oncology nurses to r e f l e c t on t h e i r own practice, and to consciously incorporate behaviors that contribute to e f f e c t i v e NPRs into t h e i r patient care. Ways of Knowing i n a Relationship Getting to know one another seemed to be an important piece i n b u i l ding a r e l a t i o n s h i p . In t h i s dyad, s o c i a l conversations, s e l f - r e v e l a t i o n s , and the use of humor contributed to getting acquainted on a personal l e v e l . Getting acquainted on a professional l e v e l was noted i n both verbal and nonverbal behaviors. For example, the nurse used assessment strategies to become f a m i l i a r with the patient's needs for nursing care. To get to know him on a personal l e v e l , she used s o c i a l conversations and lighthearted humor. In a s i m i l a r way, the patient i n t e n t l y watched the nurse, i n what appeared to be attempts to learn about and perhaps assess her professional a b i l i t i e s . The patient used d i r e c t personal questions about the nurse and humor to get to know the nurse as a person. As such, getting acquainted with one another was played out i n observations of verbal and nonverbal behaviors and incorporated the recognition of the nurse and patient beyond t h e i r roles i n the h o s p i t a l s e t t i n g . The findings of t h i s i n v e s t i g a t i o n lend support to conceptualizations of the NPR i n which the patient i s recognized as a person within the routine and demands of nurse's work (Bishop & Scudder, 1990; Watson, 1988; Gadow, 1985). The nurse i n t h i s study c l o s e l y matched the description of an expert nurse (Benner, 1984, 1985; Benner, Tanner, & Chelsa, 113 1992; Tanner, Benner, Chelsa, & Gordon, 1993). She knew the patient's patterns and responses, f o r example his mouth care routines and response to t r y i n g new mouth care products. As the nurse completed her work, she also came to know the patient as a person. She knew his occupation, i n t e r e s t i n sports, and sense of humor. She also new his moods, fears, and s t o i c behavior at times. Her practice was s k i l l f u l and she managed complex sit u a t i o n s , such as when the patient was i n physical d i s t r e s s , i n a calm and comforting manner. Add i t i o n a l l y , as the r e l a t i o n s h i p progressed, she helped the patient make some progress with his mouth care, an accomplishment other nurses did not manage to achieve. This nurse's expertise enabled her to understand the patient and to o f f e r the patient r e a l i s t i c p o s s i b i l i t i e s . Researchers have found that knowing the patient as a patient as well as knowing the patient as a person are central to s k i l l e d c l i n i c a l judgement and to patients f e e l i n g cared for and cared about (Tanner et a l . ) . Less recognition has been given to the patient's need to know the nurse on a professional as well as personal l e v e l . Some researchers, however, have i d e n t i f i e d t h i s need (Morse, 1991a; Raudonis, 1993, 1995; Thorne, 1993). Thorne describes how ch r o n i c a l l y i l l patients look for health care providers they can t r u s t and demonstrate respect f o r t h e i r expertise. This suggests that patients need to get to know t h e i r health-care providers. It i s possible that patients are not able to f e e l "safe" i n the hands of nurses u n t i l they determine that t h e i r nurse i s a competent and caring p r a c t i t i o n e r . Morse (1991a) notes that patients assess nurses on a 114 personal as well as a professional l e v e l . On a personal l e v e l patients assess nurses by asking them personal questions. Asking personal questions helps patients evaluate whether the nurse i s a 'good person,' whether the nurse i s 'nice,' and whether they can 'get along.' Patients also observe the nurse to see whether the nurse i s dependable. On a professional l e v e l , patients determine i f the nurse i s experienced, confident, and gentle. Morse's findings suggest that i f the nurse's behaviors s a t i s f y patients, then patients are w i l l i n g to t r u s t the nurse and place themselves i n the nurse's care. Morse's (1991a) findings lend support to several of the behavioral c l u s t e r s observed i n the present study. For example, the behavioral c l u s t e r of the nurse and patient getting to know one another with constituent behaviors such as the nurse assessing the patient as a patient and the patient assessing the nurse as a person was si m i l a r to Morse's fi n d i n g . S i m i l a r l y , the behavioral c l u s t e r of the patient being v i g i l a n t and the nurse demonstrating her competence, was r e f l e c t e d i n Morse's study. Raudonis (1993, 1995) investigated empathic relationships between terminally i l l patients and t h e i r nurses. These patients reported that t h e i r r e l a t i o n s h i p depended on the nurse's competent interventions and responses to t h e i r needs, sharing of the nurse's personhood and humanity, and the patient's r e c i p r o c i t y . The sharing of personhoods f a c i l i t a t e d the development of empathic r e l a t i o n s h i p s . Raudonis's studies suggest that there i s a need for personal knowing i n order for the nurse to r e l a t e to another human being. In the present study, the patient demonstrated his need to know personal 115 information about the nurse. The nurse w i l l i n g l y shared some intimate d e t a i l s of her l i f e with the patient. S e l f - d i s c l o s i n g personal information may have contributed to balancing the r e l a t i o n s h i p . Investigators and t h e o r i s t s i n nursing have pointed to the importance of the establishment of a strong personal r e l a t i o n s h i p with patients to f a c i l i t a t e c l i n i c a l decision-making and to permit the i n d i v i d u a l i z a t i o n of care (Benner & Wrubel, 1989; Carper, 1978; Jenks, 1993; Jenny & Logar, 1992; Meleis, 1991; Watson, 1988). F a i l u r e to do so can r e s u l t i n less e f f e c t i v e or inappropriate nursing care, patients' lack of t r u s t i n t h e i r nurses, and f a i l u r e to achieve desired therapeutic outcomes (Jenks, 1993; Jenny & Logar, 1992). In t h i s study, knowing the patient and knowing the nurse on both a professional and personal l e v e l appeared to serve two important purposes. F i r s t , t h e i r knowledge of one another enhanced therapeutic interventions. The nurse was able to i n d i v i d u a l i z e her approach to the patient based on her knowledge of his needs, moods, i n s e c u r i t i e s , and personal preferences. At the same time, by knowing the nurse, the patient was able to f e e l comfortable enough to discuss problems, and show as well as voice his d i s t r e s s to the nurse. Second, t h e i r knowledge of one another seemed to decrease the power d i f f e r e n t i a l between them. Porter's (1994) study of NPRs revealed that reducing the power d i f f e r e n t i a l s between nurses and patients resulted i n more relaxed and f r i e n d l y r e l a t i o n s h i p s . As a r e s u l t , patients f e l t more at ease to discuss t h e i r concerns with t h e i r nurses and f i n d out about t h e i r condition and treatments. This increased 116 communication gave patients more control over t h e i r care rather than conforming to the authority of the nurse. Furthermore, a less authoritarian environment was also a benefit to nurses, who f e l t happier with more open r e l a t i o n s h i p s . These findings may challenge nurses to r e f l e c t on t h e i r sources of knowledge i n c l i n i c a l p r a c t i c e . By becoming conscious of t h e i r own knowledge, nurses may become aware of sources of knowledge which they have not used that could contribute to t h e i r r e l a t i o n s h i p with patients. Observations from the present study pointed to the importance and c e n t r a l i t y of the patient's need to know the nurse personally as well as p r o f e s s i o n a l l y . Fostering the Achievement of Therapeutic Goals In the nursing l i t e r a t u r e , authors such as Newman (1990, 1994), Parse (1992), Watson (1988), and others have embraced the the notion of nursing as a human science. In human science, the i n d i v i d u a l i s referred to as a whole and i s thus the obvious source of knowledge of her/his l i v e d experience (Mitchell & Cody, 1992). Human science, therefore, focuses on t h i s l i v e d experience, that i s , the meaning, values and relationships within the humanly l i v e d experience. In t h i s paradigm, the human being i s referred to as a subjective whole who i s situated in-the-world, who i s i n t e n t i o n a l and f r e e - w i l l e d ( M i t c h e l l & Cody). Incorporating t h i s b e l i e f into nursing practice means that "the nurse would seek no more fundamental reference than the l i v e d experience of the person" (Mitchell & Cody, p. 57). For the nurse, the notion of human science emphasizes the importance of "being there" and suggests that the nurse should not impose her/his views on the patient. 117 Contrary to the nursing r o l e depicted i n the human science paradigm, i n the present study, the nurse was observed to be involved i n making therapeutic suggestions to the patient and pushing the patient toward problem re s o l u t i o n . Within these behavior clu s t e r s the nurse engaged i n behaviors such as gently guiding the patient by explaining suggestions, gently and as s e r t i v e l y confronting the patient about care issues, and encouraging the patient's continuance with s e l f - c a r e . The nurse was observed to engage i n these behaviors despite the patient's cautious consideration of her suggestions and reluctant progression toward problem resolution. These observation are in t e r e s t i n g because they indicate that the nurse i n t h i s study a c t i v e l y directed care and thus acted i n a manner contrary to the human science approach. It i s d i f f i c u l t to i n f e r what may have happened had the nurse acted within the human science framework. It i s possible that the patient may not have t r i e d any of the prescribed mouth treatments and his discomforts may have escalated. Although the nurse guided the patient, and suggested and explained therapeutic options to him, she never coerced the patient into t r y i n g her suggestions or reprimanded him for not taking up her ideas. As such, the nurse did maintain the patient's f r e e - w i l l to the extent that she provided him with the opportunity to choose. As a r e s u l t , the patient had knowledge of his options and was empowered to act upon that knowledge. This nurse's actions were not unlike those observed i n most c l i n i c a l settings. In nursing education programs, nurses are taught to use the nursing process i n the context of a t h e o r e t i c a l 118 framework to guide t h e i r p r a c t i c e . Using t h i s approach, nurses take an active r o l e i n planning and implementing nursing care with patients as well as enhancing patients' knowledge and s k i l l to improve s e l f - c a r e and health status. The findings of t h i s study indicated that the nurse fostered the achievement of therapeutic goals i n a manner unlike that suggested by some nursing t h e o r i s t s . The observed patient outcomes would suggest that her actions were appropriate and appreciated and demonstrated her caring and concern for the patient. As such, t h i s f i nding implies the l i v e d experience i n the c l i n i c a l s e tting c o n f l i c t s with the b e l i e f s i n t h i s t h e o r e t i c a l conceptualization. Questions a r i s e about the l i m i t s of the human science perspective i n nursing p r a c t i c e . Humor i n Relationship Building In t h i s p a r t i c u l a r nurse-patient dyad humor was a prevalent behavior i n many of the behavioral c l u s t e r s . From the s t a r t of the r e l a t i o n s h i p , both the nurse and patient incorporated humor into t h e i r conversations. At the beginning of the r e l a t i o n s h i p , humor took the form of lighthearted conversations. As the r e l a t i o n s h i p progressed, humor became more spontaneous and was directed at p a r t i c u l a r s i t u a t i o n s . Humor was used to soften discussions of unresolved issues surrounding the patient's care or was simply used to "lighten" the patient's mood or break up the monotony of routine tasks. The claim that humor can be an e s s e n t i a l aspect of the NPR i s supported i n the l i t e r a t u r e . Humor has been described to have communicative and s o c i a l functions by demonstrating kindness, a f f e c t i o n , caring, and humanity (Hulatt, 1993; Robinson, 1970, 119 1977). In addition to these communicative functions, humor and laughter have been reported to improve v e n t i l a t i o n and to increase blood oxygen as well as c i r c u l a t i o n ( C a r l i s l e , 1990). It i s also believed to have the a b i l i t y to release endorphins, a body chemical which acts as a natural anesthetic (Gruner, 1990). In r e l a t i o n to the NPR, humor i s thought to provide consolation, diversion, and reinforcement of empathic understanding (Hulatt, 1993; Simon, 1988). Researchers have found that a nurse who shows a sense of humor i s viewed as approachable to the patient. Being approachable, makes for an easy and sincere r e l a t i o n s h i p and f a c i l i t a t e s the development of dialogue between the nurse and patient (Astedt-Kurki & Liukkonen, 1994; Sumners, 1990). In the present investigation the nurse seemed to know the appropriate times to use humor. For example, humor was never used while the patient was i n apparent physical d i s t r e s s . However, once the i n i t i a l d i s t r e s s subsided the nurse used humor i n what appeared to be an attempt to decrease the patient's tension. In a study of the use of humor by ps y c h i a t r i c nurses, findings suggested that nurses i n t u i t i v e l y knew when i t was appropriate to use humor with t h e i r patients (Dunn, 1993). Elements such as knowing the patient, i n t u i t i o n , and caring helped nurses determine how, when, and where humor should be used i n the NPR (Dunn). Sumners (1990) i d e n t i f i e d that humor enhances problem solving and i s needed for creating innovative solutions. By allowing humor to enter the rel a t i o n s h i p , other perspectives and f l e x i b i l i t y of thinking may lead to creative solutions. The enhancement of problem solving with the use of humor was 120 supported i n t h i s i n v e s t i g a t i o n . The nurse made therapeutic suggestions to the patient, gently confronted the patient about his care issues and encouraged the patient's independence. The patient cautiously considered the nurse's therapeutic suggestions and displayed his independence to the nurse. It i s cle a r from the description of these behaviors that the nurse and patient did not always agree on therapeutic ideas and the patient did not e a s i l y take up the nurse's suggestions. The patient never outwardly refused to t r y the nurse's suggestions and the nurse never reprimanded or judged the patient for not agreeing with her ideas. Any tensions that may have arisen on the basis of these differences appeared to be dissolved by using humor and engaging i n s o c i a l conversations. The use of humor i n situations where the nurse and patient were not i n synchrony was also supported by Robinson (1983) who maintained that humor i s an i n d i r e c t form of communication that can be used to relay ideas or suggestions that may be otherwise unaccepted i f they were conveyed d i r e c t l y . Although humor appeared to serve t h i s r e l a t i o n s h i p p o s i t i v e l y i t i s arguable that i t was also used negatively. The nurse and patient i n t h i s study never discussed serious issues around the patient's i l l n e s s . Issues such as the patient's prognosis, and the impact of his i l l n e s s on his wife and business were never addressed. I t i s possible that the extensive use of humor prevented the nurse and patient from addressing these d i f f i c u l t issues. There was at lea s t one s i t u a t i o n where the nurse used humor to cope with her own feel i n g s and by doing so avoided a p o t e n t i a l l y d i f f i c u l t t o p i c . In an interview with the nurse, the nurse reported f e e l i n g uneasy and awkward when the 121 patient offered to build her a house. She stated being saddened by the thought that the patient would not li v e long enough to build her house. She handled her uneasiness with the topic by laughing i t off and quickly changing the subject. The findings of this study point to the importance of nurses questioning the motives behind their humor. Nurses who choose to use humor in their practice need to ask themselves whether their use of humor is to cope with d i f f i c u l t issues; whether they use humor at appropriate times; whether the patient shares in the humor; and most importantly, whether the humor diminishes the patient's worth and importance. Reciprocity Social exchange was an important aspect in this investigation. In addition to statements of gratitude, the patient gave the nurse a g i f t . In return, the nurse gave the patient a small g i f t in what appeared to be a demonstration of her caring. Furthermore, the gifts they gave one another were personal and symbolically significant. Social exchange in relationships i s a process in which we provide others with something, and expect to receive something in return (Baron & Byrne, 1987). Morse (1989, 1991b) maintains that although the nurse works for the hospital, s/he 'gives' the patient care. As a result, this situation creates an imbalance in the NPR. The act of giving a g i f t to the nurse is the patient's way to reciprocate for the nurse's care and pay a debt of gratitude to the nurse. Morse (1991b) argues that the patient may feel passive and in a dependent role unless s/he has the opportunity to reciprocate. Morse (1989) suggests that 122 hospitals with p o l i c i e s p r o h i b i t i n g g i f t - g i v i n g to nurses i n h i b i t patient recovery and place the nurse i n an awkward s i t u a t i o n . Morse (1991b) found that g i f t s presented by patients were symbolic of the NPR. The timing of giving a g i f t was considered by nurses to be most important, whereas the nature and value of g i f t s were less important. If the g i f t was given too early, i t was perceived by nurses as manipulative—as a bribe. G i f t s that were given to the i n d i v i d u a l nurse, as opposed to the unit for a l l the nurses to share, s i g n i f i e d that p a r t i c u l a r nurse's care "made a difference." Morse delineated several categories of g i f t s , for example, g i f t s to reciprocate for the care given and g i f t s intended to manipulate or to change the q u a l i t y of care, were two categories i d e n t i f i e d . Morse reported that i n general, nurses reported f e e l i n g uneasy about receiving g i f t s from patients as they were taught to not accept g i f t s . Morse's (1991b) category of g i f t giving c a l l e d , " g i f t s to reciprocate" c l o s e l y resembled the type of g i f t - g i v i n g observed i n the present study. The g i f t of green shamrock cookies was given to the nurse at the mid-point of t h i s NPR. This g i f t was s i g n i f i c a n t given the nurse was I r i s h and the cookies were presented to her on St. Patrick's day. Throughout the r e l a t i o n s h i p , the patient complemented and thanked the nurse for her care. Morse c l a s s i f i e d copious thanks as manipulative g i f t s . The patient i n the present study did not thank the nurse copiously and his verbal gratitude to the nurse seemed genuine and sincere. In t h i s study, the nurse also presented the patient with a symbolic g i f t . Perhaps t h i s g i f t was i n reciprocation for the 123 cookies the patient had given her e a r l i e r . I t i s unknown whether the nurse's g i f t to the patient l e f t the patient f e e l i n g indebted again to the nurse. Interestingly, during the f i n a l i n t e r a c t i o n between the nurse and patient, the patient i n i t i a t e d warm sentiments and compliments to the nurse. Perhaps by expressing his feelings about the nurse and saying to her that she was " r e a l l y excellent," he repaid the nurse for her e a r l i e r g i f t . Current understandings of r e c i p r o c i t y suggest that nurses should be encouraged to examine the meaning, r o l e , and function a patient's g i f t may have i n t h e i r NPR. Furthermore, the complex phenomenon of g i f t - g i v i n g should be considered by hos p i t a l s ' administrators. It has been suggested that p o l i c i e s i n h i b i t i n g g i f t - g i v i n g impede patient recovery as well as place nurses i n the awkward position of refusing the g i f t (Morse, 1989). Closure of NPRs In t h i s study, the opportunity to observe the closure of a re l a t i o n s h i p revealed some important behaviors on the part of both the nurse and patient that may be important to s a t i s f a c t o r y closures. During interactions, patient behavioral c l u s t e r s r e f l e c t e d tempered movement toward problem resolution; making the most of the time l e f t ; and, saying good-bye to the nurse. On the part of the nurse, behavior clu s t e r s pointing to the closure of the r e l a t i o n s h i p included: pushing toward problem resolution; preparing for concluding the connection; and, saying good-bye to the patient. Interestingly, some researchers who focused on describing the phases of the NPR have not discussed ending the r e l a t i o n s h i p (Raudonis, 1995; Thorne & Robinson, 1988) or discussed the ending 124 of the r e l a t i o n s h i p i n a s u p e r f i c i a l manner (Trojan & Yonge, 1993). The termination phase of the r e l a t i o n s h i p has been discussed by theorists (Peplau, 1952) and c l i n i c a l experts (Brady, 1993; Gelazis & Coombe-Moore, 1993; McMahon, 1992; Schwecke, 1995; Thomas, 1991). Peplau referred to ending the re l a t i o n s h i p as the stage of res o l u t i o n . She contended that t h i s f i n a l stage needs close attention to avoid destroying the advances made throughout the r e l a t i o n s h i p . Furthermore, focus i s on the patient's accomplishments throughout the r e l a t i o n s h i p and on s e t t i n g future goals. Comprehensive nursing texts, p a r t i c u l a r l y those with a focus i n psychiatry and mental-health have addressed ending the NPR as the phase of termination (Brady, 1993; Gelazis & Coombe-Moore, 1993; McMahon, 1992; Schwecke, 1995; Thomas, 1991). The termination phase i s described to begin during the s t a r t of the re l a t i o n s h i p and to continue throughout the NPR. The goal of terminating the re l a t i o n s h i p i s to bring a therapeutic end to the re l a t i o n s h i p . The therapeutic end i s accomplished by the nurse and patient reviewing feelings about the r e l a t i o n s h i p , evaluating the progress made toward goals, and es t a b l i s h i n g ways f o r the patient to meet future care needs. Although l e t t i n g go of close, s a t i s f y i n g , and mutually accepting relationships can be d i f f i c u l t , f a i l u r e to terminate the r e l a t i o n s h i p i s believed to v i o l a t e the boundaries of therapeutic NPRs. Experts suggest strategies nurses should use for terminating the r e l a t i o n s h i p , including exploration of feelings about termination, discussing the future, and a n t i c i p a t i n g possible situations the patient may face (Brady; Gelazis & Coombe-Moore; McMahon; Schwecke; Thomas). 125 There i s no mention i n these texts of the patient's r o l e i n the termination phase. The conclusion of the r e l a t i o n s h i p i n t h i s study contained some of the elements discussed by nursing experts. For example, the nurse and patient i n t h i s study shared t h e i r f e e l i n g s about one another and the nurse gave the patient encouragement to maintain newly established behaviors related to his mouth care. Nevertheless, i t i s i n t e r e s t i n g that some of these behaviors were i n i t i a t e d by the patient. For example, i t was the patient who was f i r s t to share his feelings for the nurse at the closure of t h e i r r e l a t i o n s h i p . It i s impossible to speculate what would have happened i f the patient would have not taken t h i s i n i t i a t i v e . This example provides additional support for the active r o l e patients are able to take i n a l l phases of the r e l a t i o n s h i p , including the termination phase. These behaviors were unlike those observed i n the beginning or middle of the r e l a t i o n s h i p providing support for defining t h i s part of the r e l a t i o n s h i p as a separate phase. Ad d i t i o n a l l y , i n preparing for concluding the connection, the nurse i n t h i s investigation did not make any new therapeutic suggestions and began encouraging continuance of s e l f - c a r e for the patient. The patient responded to the nurse by agreeing to take her d i r e c t i o n for the future and continue to work on the therapeutic suggestions she had previously made. S i m i l a r l y , authors have noted that i n the termination phase of the NPR, the nurse indeed focuses on the future and does not explore new areas with the patient (Brady, 1993; Gelazis & Coombe-Moore, 1993). Focus group participants discussed the importance of closure 126 i n a r e l a t i o n s h i p . They agreed that an ambiguous ending to the re l a t i o n s h i p can leave both the nurse and patient f e e l i n g uneasy and may contribute to patient d i s t r e s s . Closure i n t h i s nurse-patient dyad was marked with f i n a l good-byes, compliments to one another, by t e l l i n g one another that they w i l l be missed, and by wishing each other w e l l . These findings were important because ending a r e l a t i o n s h i p has not been given adequate attention i n much of the l i t e r a t u r e on the NPR or i n cancer nursing. Discussion of the Research Method The nature of t h i s study lent i t s e l f to a desc r i p t i v e research approach. Using a q u a l i t a t i v e e t h o l o g i c a l method, the complex behavior patterns of the NPR were captured through d e t a i l e d observations of behaviors as they occurred i n a natural s e t t i n g . By using t h i s research method, the investigator was able to document patterns of behavior i n greater d e t a i l and with more precision than i s possible with other approaches such as interviewing or participant observation. The use of videotaped recordings (VTRs) made i t possible to study events i n the NPR that may have been rare or of short duration. A d d i t i o n a l l y , precise information about verbal and nonverbal behaviors as they unfolded moment-by-moment was available for intense and repeated analysis. The use of VTRs presented an unlimited opportunity to r e v i s i t events as they occurred i n r e a l time, allowing for a r i c h d escription of the events. Furthermore, the use of VTRs lent i t s e l f t o equal observation of both the nurse and the patient. This study involved a secondary analysis of videotaped data 127 c o l l e c t e d as part of a larger study to investigate nurse-patient interactions (NPIs) (Bottorff, 1992). A sample of s i x t y NPIs that represented a l l the interactions between one patient and one nurse over a three day period was studied. The VTRs of t h i s r e l a t i o n s h i p were analyzed by reviewing a l l the interactions, i d e n t i f y i n g the behavioral c l u s t e r s , i d e n t i f y i n g constituents of the behavior c l u s t e r s , and constructing an ethogram. The investigator found the task of viewing VTRs arduous. In order to remain focused when viewing VTRs repeatedly, i t was important to take short breaks often. A d d i t i o n a l l y , VTRs were r e v i s i t e d on a regular basis to ensure that frequently occurring events were not favored over other aspects that may be important. To validate the findings, a focus group of f i v e expert nurses was used to valid a t e and extend the analysis. Furthermore, participants of the focus group suggested d i f f e r e n t perspectives on some of the behaviors found i n the study which prompted the investigator to recheck segments of interactions for important aspects that may have been overlooked. A l i m i t a t i o n of the focus group was that patients were not included i n the discussion. Because the findings of the study highlighted the active p a r t i c i p a t i o n of both nurses and patients i n b u i l ding r e l a t i o n s h i p s , i t would have been b e n e f i c i a l to have patients' insights about the v a l i d i t y of the study findings. Although two of the focus group parti c i p a n t s also had the experience of being patients, t h e i r nursing background did not allow them to speak exclusively from a patient's perspective. The addition of patients to the focus group discussion may have 128 revealed important patient behaviors that were overlooked i n the present study. Furthermore, these insights could have p o t e n t i a l l y extended the findings and knowledge about NPRs. One major l i m i t a t i o n of the use of VTRs i n q u a l i t a t i v e ethology i s that information i s l i m i t e d to what can be observed. Bott o r f f (1992) interviewed the nurse and patient asking each questions related to her study. The nurse and patient alluded to t h e i r r e l a t i o n s h i p i n t h e i r interviews, and provided some valuable information about t h e i r r e l a t i o n s h i p which helped to extend the findings of the present study. However, the nurse and patient did not speak about t h e i r r e l a t i o n s h i p s p e c i f i c a l l y . As a r e s u l t , i t was not possible to determine i f the understanding of the events that occurred i n the NPR i s analogous to that held by the nurse and patient. There were advantages as well as disadvantages of using a case study to learn about the development of a NPR. The rigorous exploration of a single NPR can be extremely useful i n the production of hypotheses on NPR development which can then be tested i n subsequent research. The intensive analysis that took place i n t h i s study has provided insights into previously unnoticed behaviors i n NPRs. Add i t i o n a l l y , t h i s case study captured the depth and richness of the NPR as i t occurred i n a c l i n i c a l s e t t i n g i n a way that i s not possible using larger samples. The l i m i t a t i o n of using a case study i s that one cannot make predictions or generalizations to other settings based on the findings of t h i s single case. It would be impossible to argue that the same re l a t i o n s h i p would manifest i t s e l f i n other nurse-patient dyads. 129 Several steps were taken to ensure r i g o r i n t h i s study. A cle a r decision t r a i l was l e f t at every stage of t h i s study (Sandelowski, 1986). The investigator kept a journal d e t a i l i n g and j u s t i f y i n g the decisions made during the process of t h i s study. The journal also included r e f l e c t i v e notes about the investigator's own values and interests as well as for speculation about emerging i n s i g h t s . Furthermore, d e t a i l e d and repeated analysis of the VTRs to i d e n t i f y e s s e n t i a l c h a r a c t e r i s t i c s of the developing r e l a t i o n s h i p was c a r r i e d out to ensure a p p l i c a b i l i t y and c r e d i b i l i t y of the study. A ninety minute focus group meeting was also held to evaluate the extent to which the findings were meaningful arid applicable to the experience of nurses who have worked i n s i m i l a r settings. The focus group discussion validated many of the behavior c l u s t e r s i d e n t i f i e d to be important i n the development of a NPR. In some instances, the possible consequences of not engaging i n c e r t a i n behaviors were described. Future research on the NPR i n other nursing contexts could further our understanding of relationships between patients and nurses. Furthermore, the use of additional research methods such as open-ended interviews i n combination with d e t a i l e d observation and analysis of nurse and patient behaviors as they occur i n a natural setting, would strengthen the v a l i d i t y of future research and further add to our understanding of NPRs. Conclusions Although the importance of the NPR has been recognized, l i t t l e i s known about the development of the NPR as i t unfolds i n c l i n i c a l settings. The purpose of t h i s study was to investigate 130 and delineate important features of NPIs r e f l e c t i n g the development of a NPR. On the basis of the findings of t h i s study, four main conclusions can be drawn. F i r s t , the development of the NPR i s based on a dynamic, complex interplay between the nurse and patient. Furthermore, i t i s possible to i d e n t i f y i n t e r a c t i o n patterns that contribute to the development of NPRs. Second, e f f e c t i v e relationships can develop between nurses and patients over a short period of time. Third, the use of humor and s o c i a l conversation appear to f a c i l i t a t e the development of NPRs. F i n a l l y , in-depth analysis of observational data of both nurse and patient behaviors can make an important contribution to understanding NPRs. Summary Presented i n t h i s chapter was a discussion of the study findings. The discussion focused on s ix key findings including: mutual p a r t i c i p a t i o n i n r e l a t i o n s h i p building; ways of knowing i n a r e l a t i o n s h i p ; fostering achievement of therapeutic goals; humor in r e l a t i o n s h i p building; r e c i p r o c i t y ; and, closure of NPRs. Each of these key findings was discussed i n l i g h t of e x i s t i n g l i t e r a t u r e and was followed by a discussion of implications for practice and research. F i n a l l y , a discussion of the research method as well as conclusions were presented. The NPR i s a complex r e l a t i o n s h i p . I t involves personal elements such as mutuality and caring and at the same time, the NPR i s c l i n i c a l and therapeutic. Since the NPR i s at the heart of nursing, i t i s e s s e n t i a l that we come to understand the complexities of t h i s dynamic r e l a t i o n s h i p as well as how to foster i t i n order to serve therapeutic ends. The NPR i s an 131 i n t e r a c t i v e process and as such, to understand i t and research i t both the r o l e of the patient and the nurse must be equally considered. Learning more about the actual process of interactions involved i n the development of the NPR has important implications for patient outcomes, patient s a t i s f a c t i o n with nursing care and nurses' work. This study took advantage of a unique opportunity to gain a r i c h and complex understanding of the dynamics involved i n the development of a NPR by completing a secondary analysis of VTRs of 60 consecutive interactions between one nurse and patient. 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Bottorff (xxx-xxxx) The purpose of t h i s study i s to describe the development of nurse-patient relationships as they occur i n cancer nursing. This research has involved a det a i l e d analysis of videotaped recordings of the interactions between one nurse and one patient. Important patterns of behavior have been i d e n t i f i e d from t h i s case study. It i s now important to check these findings with experienced cancer nurses. As such, you are being i n v i t e d to pa r t i c i p a t e i n a focus group meeting to hear about the preliminary findings of t h i s study and respond to them. Several things w i l l take place during the focus group meeting. You w i l l be asked to: 1) L i s t e n to the preliminary findings of the study. 2) Discuss your perceptions and thoughts about the preliminary findings. 3) Share some of your own experiences i n developing relationships with patients. 1/2 147 The e n t i r e discussion w i l l take about 90 minutes, and w i l l be audiotaped. An observer w i l l also be taking notes during the discussion. The audiotapes and notes taken during the discussion w i l l be reviewed and the information obtained w i l l be used to augment the findings of t h i s study. To maintain c o n f i d e n t i a l i t y and anonymity, audiotapes and notes taken during the focus group meeting w i l l contain no names or i d e n t i f y i n g c h a r a c t e r i s t i c s . No one w i l l have access to t h i s material except myself and three research advisors. P a r t i c i p a t i o n i n t h i s focus group meeting i s voluntary and you may choose to not p a r t i c i p a t e i f you wish. If you wish to not p a r t i c i p a t e or withdraw from the focus group, your employment w i l l not be affected. If you do agree to p a r t i c i p a t e , you may withdraw from the study, refuse to answer questions, or leave the discussion at any time. By signing t h i s consent form I indicate that I have received and read the information provided here and have a copy of t h i s consent form. I agree to p a r t i c i p a t e i n the focus group meeting. Date: Pa r t i c i p a n t : Date: Investigator: 2/2 

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