Nurses have many different kinds of relationships with patients and families, ranging from the very superficial to the intensely personal. Interactive communication is central to all of these relationships. One way of distinguishing between them is in terms of the level of interactive involvement (Graber & Mitcham 2004). Quality and quantity are relevant, along with the willingness to reveal something of oneself on the part of both nurse and patient. Stein-Parbury (2005) calls these characteristics mutuality and reciprocity.

One way of distinguishing between levels of complexity in interactive involvement is to look at how the nurse interprets a person’s ability and willingness to participate in interaction and how that interpretation guides the nurse’s approach. Look at the following examples.

The nurse approaches a recently admitted young child with a smile and a friendly greeting. She recognises that friendly gestures are especially important when working with young children (Berk 2006). Unlike older children and adults who have some expectation of a health professional’s goodwill, youngsters who are out of their own environment tend to treat strange adults with suspicion or even fear unless a deliberate attempt is made to dispel negative responses. Although superficial and involving only limited interaction, the nurse’s intention in this instance is just to reassure the child that the nurse’s care will be given with goodwill and kindly attention.

In the second example, imagine you are the nurse interacting with a family about their young child’s chronic asthma. You know that the family has managed the asthma for some time, but that there was a recent acute episode. The mother asks a number of questions about the child’s asthma and care for the child. On this basis, you identify a ‘clinical relationship’ (Stein-Parbury 2005) as appropriate to the situation. The major focus of the communication between you and the mother is on clinical information. You explain procedures, answer questions and assess the mother’s understanding about the care of her child. Your intentions are to involve the child and parent in care, keep them informed about medical priorities and decisions, alert them to the reasons for treatment and prepare them to continue care outside the clinical environment.

Therapeutic relationships are often marked by more intense involvement and interaction between patient, family and nurse. They are distinguished by a focus on the feelings as well as the facts affecting the person of concern. Many authors have referred to this as a ‘helping’ relationship so as to distinguish it from psychotherapy (e.g. Brammer & MacDonald 2003, Ivey & Ivey 2003). Its goals are to enable the person to take appropriate action on their own behalf, enable problem solving and strengthen their resources and those of their family. Therapeutic relationships are appropriate in situations in which people are especially vulnerable to feelings of helplessness or are overwhelmed by circumstance (Stein-Parbury 2005). Examples of such situations are acute health episodes, both physical and mental, diagnoses of life-changing or life-threatening conditions, death of a family member and relationship crises.

In a therapeutic relationship, the nurse deliberately uses their personality, knowledge and skills to establish and maintain communication with patients and families. This deliberate use of skills and personal characteristics by the nurse to further communication is referred to as ‘use of self’ and was given particular attention by nursing theorists such as Peplau and Travelbee (McEwan & Wills 2002).

The importance of the use of self in therapeutic communication is sometimes overlooked in the current emphasis on biomedical science and economic rationalism (Jackson & Borbasi 2000). Indeed, one Australian study (Gardner et al. 2001) showed that both patients and nurses shared the perception that nurses’ technological skills were the most important aspect of nursing care. Yet it is clear that, in all areas of nursing, nurse–patient and nurse–family relationships are central to meeting the needs of the whole person. It is an area of professional practice that can contribute substantially to nurses’ personal satisfaction with nursing. It warrants attention as an important area of practice development throughout a nurse’s career.

The health and wellbeing of the family unit and the ability of family members to communicate with one another and with the larger community are central to the health of the child or young person and, indeed, to all family members and to broader society (Australian Institute of Health and Welfare 2005). Family functioning can be understood as a system with component parts that are separate but interdependent. That system is capable of growth and development, and is able to achieve more as a unit than could its individual members (DeFrain 1999). (See Ch 1 for further discussion of family.) A nurse’s understanding of the composition and functioning of a child’s or young person’s family allows the nurse to help family members mobilise resources and identify strengths. Every family is unique in the strength of its bonds and its boundaries, and these are formed in complex interactions of cultural and individual dynamics (Smith 2002).

One factor that families share, whatever their shape or size, is that the illness or injury of one member is a major stress if not a crisis for the entire family. This is particularly true when a child or young person is involved. Sometimes, families expand their boundaries in times of crisis. Family members who are not usually highly involved come to offer help, which at times is strengthening, but, in some situations, may contribute inadvertently to the family’s stress level. Information about how a family is experiencing their present circumstances, who is involved and what level of support is being offered is important to nurses for developing helpful relationships with family members.

The purposes for establishing and maintaining therapeutic relationships with families parallel those of working in this way with individuals. By helping families identify both the facts and feelings of their situation, nurses help them grow and develop. A nurse’s communicative approach can enable a family to make decisions and take positive action towards better physical and mental health for their members.

Both parents and infants are vulnerable during this period. A nurse’s communication with the child is related to meeting basic needs and expressing warmth and security. Consistency is important. A nurse has an opportunity during this period of forging an alliance with parents in giving the best possible care to the child. If the infant is ill or has a disability, it is important that parents be helped to express and explore their emotion and reactions, and search for ways to actively support their child that are appropriate to the situation. Because of their feelings of vulnerability, parents can feel challenged by carers who seem to be replacing them in a parental role (Shephard 2001). A therapeutic relationship between nurse and parents aimed at reassurance and partnership with the nurse will reduce anxiety and enable parents to develop skills and take an active role in care. See Chapter 7 for further discussion of early parenting and parenting support.

Piaget identifies these early years as a ‘sensorimotor’ period in which the young child learns through the senses. Toddlers learn about their world by physically exploring it, tasting it and listening to it. Language development is extremely rapid (Berk 2006). Erikson called this a period in which autonomy versus shame can be resolved. Children who are allowed to explore and satisfy their curiosity develop a growing sense of self-control and autonomy. Those who are unable to do this because of parental controls, environment or physical disability can become uncertain and fearful (McDevitt & Ormrod 2002).

Around the age of 2 years, the child develops ‘object permanence’—that is, where the child develops the ability to understand that just because a person or object is out of sight does not automatically mean that it has ceased to exist. Prior to the development of this concept, the departure of a parent leads to feelings of abandonment. Thus nurse–child communication is focused on reassurance (Bastable 2006). Children of this age are easily distracted and can replace fearfulness with interest in a new toy or activity.

Movement is a major form of communication for toddlers. The actions of enthusiasm and acceptance are easy to interpret, but other kinds of non-verbal communication are not always so. For example, a young child in pain may lie very still rather than cry. This behaviour can be open to misinterpretation by an adult who may believe the child is comfortable.

While language development is very rapid in these years, children understand a great deal more than they can express. Simple explanations and repetition are valuable communication tools. Some parents find that teaching their child sign language for important concepts like ‘more’ and ‘I love you’ significantly increases the child’s interaction with others.

Piaget called the preschool years ‘pre-operational’ and Erikson identified the psychosocial task as being ‘initiative versus guilt’. If children have accomplished previous psychosocial tasks positively, they will have developed a sense of purpose and be able to independently plan and undertake activities. If they are prevented from developing initiative, they will experience a sense of guilt about expressing their needs and desires (McDevitt & Ormrod 2002).

By the time children have reached the preschool years, their fine muscle control allows them to do many tasks of daily living, although they still require adult supervision. Their world expands beyond the immediate family and they learn through play.

Communicating with preschool children still requires simple, very concrete language, but they are better able to remember and categorise speech-based information (Berk 2006). They can be quite concerned about being ill or injured, so adults need to use positive rather than threatening terms to describe events. For example, ‘cut’ and ‘dressing’ might be frightening or confusing, while ‘fixing’ or ‘bandaids’ are known ideas and more easily accepted (Bastable 2006). Communication with parents can focus on the child’s positively developing skills and strengths. Child safety and communicable diseases are often topics of concern. Play groups allow parents to give each other support during these years.

These years are ones of phenomenal growth and development in many areas. Piaget described them as a period of ‘concrete operations’, meaning that logical thinking develops and the child can understand cause and effect. In the psychosocial realm, children are stimulated to become industrious and creative. Their vocabulary increases to 40,000 words, with reading supporting their verbal development (Berk 2006).

It is during the school years that many lifelong attitudes and values are shaped. For example, eating habits are formed and attitudes towards task accomplishment practised (Bastable 2006). A child who is not taught to use sunscreen and wear a hat outdoors may never value the health benefits of doing so. School-age children with chronic illnesses can be active in their own care because they understand the cause and effect related to taking medications or doing care activities like using inhalers. They can be included in patient teaching very effectively, as long as concrete methods are used such as pictures and demonstrations (Berk 2006). Parents can be helped to work with their child to understand an illness or injury and encourage the child to actively participate in care. Overprotection or condescending attitudes by adults can lead to feelings of inferiority and insecurity in the child.