Relational Ethics and Nurses-Client Relationship in Nursing Practice: Literature Review

Core Elements of Relational Ethics

Engagement is about human to human connection. It is situated in the commitment between individuals. Ethical professional practice requires understanding the other’s situation, perspective, and vulnerability [15, 16, 17, 18]. An opening question when nurses and family members form a relationship is “How do we engage with each other?” [12]. Looking at a person as a whole, appropriate vulnerability, conversation, and time management are Copyright© Upasen R.

Embodiment, in relational ethics, refers to the role emotion play in our ethical decisions and actions. Relationships require both objective and subjective knowledge. That means that relationships cannot occur without embodiment. Our body is the means by which we experience the world [22]. It is impossible to separate our mind from our body [23]. Embodied knowledge focuses on healing the division between body and mind, self and others, and objective and subjective. Within relationships, we will find a relational space between body and mind, objective and subjective, and self and others are found. The relational space in a relationship needs attention to inter subjectivity where body and mind cannot be separated [12]. In nursing practice, nurses will provide holistic care for the patients, including for patients’ bodies, minds, and spiritual dimensions as well as their environments. Interdependent environment, the practice of relational ethics requires recognizing that we exist in an interdependent environment. The environment is defined as the circumstances, objects, or conditions by which one is surrounded. Health professionals need to attend to the environments of individuals, including the health care system, society at large, and local communities. Ethical practice cannot occur without personal, social, or political elements. Supportive environments not only help people who are vulnerable to cope better, but also increase their ability to related to other people [11]. This type of environment requires giving freedom and choice for making decisions, inclusive of individual and social choice. The context of care should be always considered in clinical practice [12]. For example, in providing care for terminal ill patients, there are many factors that influence or are significant to health care providers’ caring, such as families, relationshipswith physicians, and restrictions of the unit or organization. The health care providers should attend particularly to the environment where there may be high incidents of adverse outcomes (Leung & Esplen, 2008) [21].

Nurse-Client Relationship: A Powerful Tool in Psychiatric Nursing

The nurse-client relationship is a key element in the nursing process [2]. It is an important way in which nurses are able to assess accurately client’s needs, diagnose clients, help clients establish outcomes, plan and implement interventions, and evaluate the effectiveness of nursing process [4]. In psychiatric nursing, practitioners often interact with people who are experiencing mental health problems or disorders and are in need of mental health services. It is a challenge for nurses and requires them to have the skills, knowledge, and perception to think carefully about what will be the best for and most helpful to clients [24, 25]. At various points during their relationship with a client, a psychiatric nurse’s role may encompass being an educator, advocate, counselor, teacher, or socializing agent [8, 26, 27, 28]. Moreover, the nurses use themselves as a tool to create a therapeutic relationship with clients to help them to grow, change, and heal [29]. Peplau (1991) [8] suggests that nurses must have self-understanding to promote a client’s growth and to avoid limiting a client’s choices. Wright (1994) [30] explains further that nurses are expected to use their own feeling responses in a professional way, in order to better understanding of client’s emotion and needs, which lead to providing appropriate and therapeutic care. This “therapeutic use of self” is a core skill of psychiatric and mental health nursing practice [31]. In addition, the interpersonal dimension of the nurse-client relationship can be the vehicle for implementing the nursing process. Peplau (1991) [8] shows this well in her work on the nurse-client relationship, Interpersonal relations in Nursing: A conceptual frame of reference for psychodynamic nursing. Her theory guides nurse practitioners in deepening their understanding of interpersonal relations in nursing situations. Similarly, King’s (1990) [5, 32] nursing theory in which the nurse-client relationship is perceived as a learning experience where two people interact to face health problems, share, discover ways to support the situation, and resolve the problems, further enriches the role of interpersonal relations in nursing practice. Several studies have explored the effectiveness of the nurse-client relationship [29, 30, 31, 32, 33]. This includes a study in forensic psychiatric nursing, a setting in which trust between client and nurse is made more complex by security demands [16], that indicated nurses recognized the nurse-patient relationship as a powerful tool. These researchers found, as well, that oral communication was significantly more powerful than written communication with patients [33]. In another study, Eby & Brown (2005)[28] found that nurses learn from this process how to engage with clients and how to provide appropriate nursing interventions. Some studies focus on the process of developing interpersonal relationships in psychiatric nursing [34, 35]. For instance, Hanson & Taylor (2000) [34] used a model of the mental health nurse-client relationship based on Martin Buber’s concepts of the I-Thou (Being-with) and I- It (Doing-with) relationship. They found that the model is very useful for community mental health nurses in Copyright© Upasen R.

helping persons with mental illness in the community. The framing of the relationship in Buber’s model fosters the sharing of client experiences with nurses which in turn allows nurses to help clients to cope better and to live more effectively in the world.

The Nurse-Client Relationship and Relational Ethics

Nurse-client relationship is a therapeutic relationship that encompasses the tool of therapeutic use of self. It is goal- directed. That means that the nurse and client decide together what the goal of the relationship will be. The objectives of the relationship are focused on learning, growth promotion, and problem solving. Essentially, it is an effort to promote change in some aspect of the client’s life. The nurse and client determine together how much time they are able to spend. Nurses need to provide information based on facts and without bias and personal opinion Moreover, it is the client’s feelings and opinions that are significant and, thus, the nurse must work to foster an atmosphere of mutual respect and mutual understanding to facilitate the client’s comfort in sharing [26, 27, 36]. This atmosphere that evolves through the therapeutic relationship can be understood as a space, a relational space where the ethics of the relationship is shaped [10]. In addition, their findings indicate that some parts of the interaction between health care providers and clients/families reflect an element of relational ethics, that of mutual respect. Mutual respect occurs when people connect meaningfully with others. It includes self-respect and respect for others and from others. With mutual respect, power is understood as predominately “power- with”, not “power-over” [12]. One such study was McCann’s and Baker’s (2001) [35] research into mutual relating, a model of interpersonal relationships (between nurses and family members) in the community context. They found that many strategies are related to mutual relating, including attempting to understand, being friendly, turning in, revealing oneself, being there for clients, and maintaining confidentiality. They also found that mutual relating is built within a relationship of trust and mutual respect. This research suggests that mutual respect, a core element of relational ethics, is essential to therapeutic relationships. Other studies reveal the presence of several core elements of a relational ethics, including mutual respect, engagement, and attention to the environment (or context) in the nurse-client relationship. These elements offer a basis for considering ethical practice. Nurses may use these elements to inform their care, including how to respond in crisis situations [15]. Austin and colleagues (2009) [37] conducted a participatory action research study to examine the relationships between families of residents of traditional continuing care facilities and the health care team. In one of the findings, the researchers found that mutual respect was shaped through the interaction between health care team and families of the residents. The mutual respect was evidenced in the knowing one another’s names and the acknowledging of the need to understand another’s perspectives. The researchers also explicitly noted that mutual respect is a basis element of ethical relationships. In addition, genuine engagement and the interdependence of family and health care team were key to enable the residents to gain or maintain quality of life. The findings indicate further that relational ethics is important to therapeutic interpersonal relationships. Marcellus (2005) [38] found that four themes of relational ethics appeared within the relationship between public health nurses and families: mutual respect, engaged interaction, embodiment, and creating environment. These four themes appeared to evoke a sense of trust in the relationship. Considering explicitly the ethical foundations of therapeutic relationships may guide public health nurses in their work with families. Another study by Gladstone and Wexler (2000) [39, 40] found that a collaborative relationship between staff and family members can have ethical dimensions: open communication, attentive behavior, and display empathy towards each other. Families’ work with staff is interdependent, they share responsibilities, and they share decision making. The communication between staff and family members is characterized by two-way communication. This finding indicates that staff and family members were mutually respectful and tried to engage each other’s concerns by sharing their own perspectives.

Relational Ethics: A Powerful Guide to Ethical Nursing Practice

Relational ethics is a powerful guide to ethical and effective nursing practice. Studies have used relational ethics as a framework to explore human experiences and to understand clinical phenomena [11, 15, 20, 37, 38, 39, 40, 41, 42]. Relational ethics help nurses recognize the value of opening dialogue, considering a diversity of perspectives, and understanding the need for attention to environments in order to provide therapeutic care [13, 15]. In a study conducted by Galvin (2010) [42], critical care nurses were found to place clients at the center of critical care. The critical care nurses provided critical care with a balance of hand, head, and heart.

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“Hand” is defined as technical skills of nurses. “Head” is defined as protocols and evidences that were employed by nurses. “Heart” is defined as ethical and human dimensions that are acknowledged by nurses. Galvin (2010) [42] also suggests that nurses’ specialized knowledge, expertise care, and the capacity of caring through openheartedness and embodied relational understanding can guide the critical care nursing to be completed and meet optimal nursing outcomes. Moreover, the relational ethics can be a concrete ethical model for health professional to response the different ethical issues in health care practice and research [43, 44]. In another study in the mental health field by Austin, Bergum&Nuttgens (2004) [20], “Addressing oppression in psychiatric care: a relational ethics perspective,” it was suggested that, in providing care for patients with mental illness,practitioners focused on using protocols and procedural guidelines. Such protocols and procedures were too often insufficient in addressing systemic problems in psychiatric practice. Relational ethics was offered as a better way to address the issue of oppression in psychiatric care and to practice effectively and ethically in caring for persons made vulnerable by mental health problems and disorders. In general fields, there are studies that reported that relational ethics is a new way to help health professionals resolve health problems of clients. Evans, Bergum, Bamforth and MacPhail (2004) [10] examined relational ethics and genetic counseling. The goal of their study was to explore the realities of genetic counseling in order to identify effective ways to counsel clients, as well as to consider how relational ethics might enhance counseling effectiveness [45, 46, 47, 48]. The researchers found the three aspects of relational ethics –engagement, dialogue, and presence – that can improve quality care and the outcome of genetic counseling. For instance, many of the participants perceived value in the friendliness of counselors; dialogue was seen as a connection between clients and counselors; and “presence” helped clients to connect with and share their experiences with someone. In a study conducted by Sellevold, Egede-Nissen, Jakobsen & Sorlie (2013) [41], researchers explored healthcare providers’ experience with quality care and described the healthcare providers’ experience with ethical challenges. Relational ethics was also used as the framework for the study. The researchers found three themes; healthcare providers experienced quality care when they emphasize the patient’sresponse by accepting the patients as an individual and sentient awareness;

when they understand the patient’s expression, in particular emotion and bodily expression; and reciprocity in expression is based on the patient’s bodily responseand recognition by the patient. These findings reflect the importance of using relational ethics as a framework in providing quality care for the patients. The literature shows that relational ethics is a new way to conceive of ethical practice. It can be a basic concept for health practitioners and help them to consider how to act ethically in complex and critical care situations. Psychiatric nurses and others can use relational ethics to guide the development of their relationships with persons with health problems and their families. The authors believe that if psychiatric nurses or general nurses emphasize relational ethics through the interpersonal relationship processes, patients and their families will be effectively supported when dealing with serious health problems.