Chapter 3 1. Define mutuality in nurse–client relationships 2. Discuss the use of face work and politeness theory in approaching clients 3. Discuss mutual problem solving to involve the client in the implementation of the nursing process 4. Complete exercises to practice a mutual problem-solving approach to the nursing process 5. Examine the steps in making contracts with clients 6. Participate in exercises to build skills in solving problems with clients We must not talk to them, or at them, but with them. Florence Nightingale [on partnership with clients] (Atwell, 2010) Mutuality, a concept grounded in research, is an essential element in building relationships with the client, although it is not always easy to achieve (Berg, 2005; Chalmers, 2005; Geanellos, 2005; Jack, 2005; Porr, 2005; Zoffmann, 2005). Mutuality is characterized by empathy, collaboration, equality, and interdependency (Jeon, 2004). Mutuality is “the experience of real or symbolic commonalities of visions, goals, sentiments, or characteristics, including shared acceptance of difference that validates the person’s world-view” (Hagerty et al, 1993, p. 294). Responsive relationships between the nurse and client are based on respect, trust, and mutuality that reflect both personal moral knowledge and ethical nursing knowledge (Tarlier, 2004). Mutuality is a sharing of collective knowledge (McCance et al, 2008). An ongoing sharing of knowledge between healthcare professionals and shared decision making help ensure patient satisfaction (Cerda et al, 2010). The outcome of the client–nurse interaction depends on the nurse’s ability to engage the client in decision making and share the control and power in the relationship (Roberts et al, 1995; Spiers, 1998). Nurses build their communication skills by study and practice of techniques, trial and error, observation of role models, experience, and achievement of comfort with the use of their own intuition. Face work and politeness theory point to the need to consider the client’s and nurse’s “sense of self-esteem, autonomy, and solidarity in conversation” (Spiers, 1998). We speak of “saving face” or helping the other “save face” and mean the preservation of dignity so that each party continues to be willing to invest in the interaction without experiencing any threat. Consider a patient stepping up on the scale to be weighed. Clients want to preserve or manage their image of self or “face.” How the nurse handles this situation can influence the client’s willingness to problem solve if the weight is “face threatening,” that is, not what the person wanted or expected (Pillet-Shore, 2006). If the client is discouraged, the nurse might offer, “We all have things to work on. If your weight is not what you desire just now, we can work together to meet your goals.” In the complex process of problem solving with the client to promote health, many factors can present barriers, including perceptions and negotiations about the rules, norms, expectations, and boundaries that can distort both information and interpersonal intent (Cauce and Srebnik, 1990). Nurses must “negotiate a mutually acceptable and satisfying level of distance or intimacy, self-disclosure, privacy, and information exchange with a context of power differences, a need for help, and a right to act” (Spiers, 1998). Each party wants to maintain a sense of personal competency and control. Attacks on these or on the person’s poise or sense of belonging or being liked are called face threats. Consider the actions of the nurse in assessment: questioning about the client’s behavior, a physical assessment, and assessment of and intervention in spiritual needs. These actions are invasive. Polite behavior, which is more than just our notion of the conduct traditionally required by mothers and is a part of the consideration of face theory, refers to ways in which nurses ease the interaction to help decrease fear, embarrassment, and anger. Polite behaviors lessen the threat of the intimate nature of nursing interventions. Nurses may gently and indirectly encourage the client’s participation in problem solving, whereas a direct order in such a situation would be considered impolite and inappropriate. When discussing a potentially embarrassing situation such as safe sex, the nurse is careful about the language used and asks questions gently to help the client save face. Because of the complicated balance between considerations of face work and politeness and the necessity for client involvement, further research is required to identify methods to supplement successful intuitive strategies, which are difficult to teach. Nurses understand the importance of tact in engaging the client’s participation. Nursing research validates the concept that treating the client as a unique individual and actively engaging the client in problem solving are associated with increased client satisfaction, an important quality indicator (Roberts et al, 1995). In Chapter 1 we identified a five-step model of the nursing process, the problem-solving process: A mutual problem-solving process in nursing looks like this (Iyer et al, 1995): A Setting priorities for resolution of identified problems with the client B Determining expected and desired outcomes of nursing actions in collaboration with the client C Writing nursing interventions to achieve these outcomes in collaboration with the client A Implementing nursing actions with assistance from the client B Encouraging client participation in carrying out nursing actions to achieve the outcomes C Continuing to collect data about the client’s condition and interaction with the environment Validation invites the collaboration that is essential for successful client change. The trust developed from working together is likely to increase the accuracy and validity of the database and thus enrich the foundation for the rest of the nursing process. The trust growing out of mutuality provides the clients with an anchor, giving them the support they need to risk changing health behaviors. Collaboration ensures the benefits of two heads working on a health problem; this is essential because nursing cannot exist in a vacuum. We cannot strive for excellence without including the full participation of our clients. Nurse researchers report that “recognition of the client as a unique person and encouragement of active client participation in the nursing encounter are highly associated with client satisfaction, one important indicator of quality care” (Roberts et al, 1995). “Nursing interactions characterized as task oriented and that disregard the client as an equal participant have been related to acts of resistance” by clients (Hallberg et al, 1995). The client contracts for services with a qualified healthcare provider. This relationship is a negotiated partnership in which the client implicitly agrees to comply with the plan they generate together. The proliferation of advanced nurse practitioners in response to the demands for cost-effective care in a managed care environment demonstrates such a partnership from a holistic perspective. Advanced nurse practitioners identify collaboration with clients and other healthcare professionals as part of their nursing philosophy (Grando, 1998). C. Everett Koop, former U.S. surgeon general, emphasized that clear communication between clients and physicians could prevent serious medical problems. He reported results from a Louis Harris poll indicating that of 1000 clients questioned, 25% admitted a hesitancy to talk with their physicians because the physician seemed rushed or distracted or because the client was embarrassed (Koop, 1998). Nurses can build working relationships among nurses, clients, and physicians by assisting with collaborative communication. Not all healthcare customers think of themselves as active, responsible partners in their care. Some do what healthcare professionals tell them, living out the definition of the label “patient.” The passive nature of this role creates an imbalance between the power of the nurse and that of the client. The passivity of this stance creates an inequitable relationship between nurses and others. As nurses, we can help reverse this apathy and listlessness by encouraging our clients to be partners in their own healthcare (Cooper and Powell, 1998). This means appreciating the worth of our clients and calling on their strengths. We can transform our nursing care into a mutual problem-solving process when we invite, even request, the full participation of our partners, the clients. The standards set forth in Standards of Clinical Nursing Practice by the American Nurses Association (2004)—quality of care, diagnosis, outcome identification, planning, implementation, and evaluation—provide support for a mutual problem-solving approach with clients. The following statements are taken from two of the standards of nursing practice.
Solving problems together
Mutuality in nurse–client relationships
Face work and politeness theory
Defining the difference between problem solving and mutual problem solving in nursing
Problem solving: the nursing process
The mutual problem-solving process in nursing
Validation
Solving problems together
Moments of Connection . . .
