RESEARCH ARTICLES
Interpersonal relationship as a form of nursing care in family health strategies
Sueli de Carvalho VilelaI; Ana Maria Pimenta CarvalhoII; Luiz Jorge PedrãoIII
IRegistered Nurse. PhD in Sciences from the Graduate Program in Psychiatric Nursing of the Ribeirão Preto College of Nursing. University of São Paulo. Associate Professor of the School of Nursing. Federal University of Alfenas. Alfenas, Minas Gerais, Brazil. E-mail: suelicvilela@gmail.com
IIPsychologist. Associate Professor of the Department of Psychiatric Nursing and Human Sciences of the Ribeirão Preto College of Nursing. University of São Paulo. Ribeirão Preto, São Paulo, Brazil. E-mail: anacar@eerp.usp.br
IIIRegistered Nurse. Professor of the Department of Psychiatric Nursing and Human Sciences of the Ribeirão Preto College of Nursing. University of São Paulo. Ribeirão Preto, São Paulo, Brazil. E-mail: lujope@eerp.usp.br.
ABSTRACT: Qualitative research was conducted on an interview basis with 11 nurses working in family health strategies of a medium-sized municipality in Minas Gerais, Brazil, in 2011. The study aimed at bringing person-centered approach (PCA) concepts closer to nursing care. Semi-structured interviews were used for data collection and analysis procedures were guided by Bardin’s principles. Results showed that all nurses consider interpersonal relations to be essential, insofar as it allows for connecting concepts of PCA to nursing care as to congruence, positive regard, empathy, person- center approach, therapeutic encounter, and actualizing tendency. However, challenges to be overcome are still identified, such as the lack of knowledge about the therapeutic process in interpersonal relations as a form of nursing care.
Keywords: Nursing; interpersonal relations; mental health; primary health care.
INTRODUCTION
Interpersonal relationships have a significant place in the psychosocial processes and are concerned with the way people establish relationships with one other1. All interpersonal relationships share certain properties that form their structure and affective qualities; when these relationships are situated in a professional context they acquire specific implications and characteristics, for therapeutic purposes, called a therapeutic relationship or helping relationship2,3. Some theories of an existential and humanistic nature justify nursing as being an authoritative profession in interpersonal relationships. Through this relationship, the nurse can help a person, the family and the community3-5, as well as emphasize the person instead of the disease. The person as the center refers to perceiving the clients considering their ability for self-actualization and the conditions in which they experience events, making change and development possible6.
Recently, in some countries, models have emerged in which care is centered on the person, in his/her existential singularity, valorizing autonomy and authentic conscience, with the interpersonal relationships between the nurse-client as the focus in the comprehension of the meanings of human experience7-12. As an emerging model, the theoretical matrices are being constructed, explored and are providing positive results for both the client and the professional in various specialities7-14. In Brazil, there is still no evidence of the adoption of these models in nursing, however, positive results in the use of therapeutic interpersonal relationships have been found15,16. Private medical-care and public health models predominate in the country, the practices of which are instrumentalized in the biological and hygienist concepts of the health-disease process. However, they do not address the totality of the health situation or of the subject, which determines an urgency to discuss and identify alternative models that can complement them, both at the scientific level and the practical level17, which can valorize the potential of the person and the redemption of the citizenship18.
Person-centered care requires that nurses create an enabling environment, being empathic, congruent and accepting the others as they presents themselves, transforming any interaction or interpersonal relationship into a quality encounter. Based on this, the use of the person-centered approach (PCA) was chosen as the theoretical and philosophical framework of this study. Thus, the aim was to approximate the concepts of the person-centered approach (PCA) with nursing care.
THEORETICAL FRAMEWORK
Scholars of the PCA2,6,19 comprehend man as an organism worthy of trust, which in itself brings an underlying flow of movement for positive constructive achievements, i.e., the actualizing tendency. For a person to develop their full potential, from the more simple to the most complex, it is necessary to facilitate a climate, which is processed through the facilitating attitudes20,21.
In the PCA, as in most humanistic-existential nursing theories, there are facilitating attitudes: empathy, unconditional positive regard, and congruence6,19,20-22. The empathic attitude refers to the ability to accurately perceive the internal frame of reference of another person as if one were the other person, without ever losing the as if condition. Unconditional positive regard refers to appreciating people as they are, and is expressed free from judgments and evaluations. Congruence is the equalization between what is being experienced at the gut level, in the consciousness, and what is being expressed by the subject6,19-21.
Both in the PCA and in the concept of nurses, the therapeutic relationship has the following characteristics: it is a multifaceted and unique relationship, which prevents the existence of a protocol on how to start and maintain a helping relationship, it should be appropriate to the person, the situation and the current moment; it implies a process of personal growth, in which both the client and the nurse have a unique learning experience; it structures itself and evolves according to a determined process through the phases or stages of evolution; it differs from other types of relationship; it requires specific knowledge, skills, and competences related to the different issues such as beliefs, managing difficult situations, relational skills, decision-making, and the ability to recognize the most effective ways to support each situation3,4,6,20,21.
METHODOLOGY
This was a descriptive-exploratory study with a qualitative approach. The subjects were 11 family health strategy (FHS) nurses of a medium-sized municipality of Minas Gerais, and the study was carried out in 2011. The inclusion criteria for the FHS sites were be owned and managed by the Municipal Health Secretariat. All the nurses of these FHS sites were invited to participate in the study and, with their acceptance, signed the Terms of Free Prior Informed Consent.
Semi-structured interviews were used for the data collection, consisting of the following guiding question: How do you understand the interpersonal relationship as a base for the nursing practices in healthcare services? The interviews were conducted in the normal work settings of the subjects, considering conditions related to their privacy. Proximity was established between the researchers and nurses, causing an empathic climate in which the aim was to develop and express a comprehensive view regarding the statements, allowing greater openness. The interviews were digitally recorded, transcribed verbatim, and analyzed according to the theoretical framework of content analysis23.
The content analysis phases included: pre-analysis; exploration of the material; and treatment of the results23. The inferences and interpretations made allowed the manifest content to be revealed. It should be noted that the guiding question underwent prior testing with three non-participating FHS nurses, which also served as training for the researchers. In this test, no difficulties were detected, and therefore, without modifications being made to the original procedure, the subjects included in the study were interviewed.
The project was approved by the Research Ethics Committee of the Federal University of Alfenas under protocol No. 103/2010. To maintain confidentiality and anonymity, the names of the subjects were coded with letters and numbers (E1, E2...), and the other names that appear in the discourses are fictícios24.
RESULTS AND DISCUSSION
The subjects consisted of nurses, 25-52 years of age, mostly married, with children, and of the Catholic religion. The majority of them had completed more than one lato sensu post-graduation course, predominantly in Family Health Strategy. None had completed a strito sensu post-graduation course or any course focused on mental health and psychiatry. The length of time working in the current unit varied between one and 12 years; three of the subjects had experience working with people with mental disorders in psychiatric hospitals; and the others had no experience in this area.
None of them had participated in training or preparation regarding interpersonal relationships, nor did they known about the PCA.
This work is part of a project dealing with the development of a script for observing the interpersonal relationship between nurse and cliente25, which included the permanence of the researcher in the health units. Thus, the inferences presented involved, in addition to the analysis of the manifest content, an awareness of the context of the experience, which helped in the approaches to the topic of interpersonal relationships in the conjuncture of nurses of the family health strategy and the theoretical framework of the PCA. The contents originating from the interview were analyzed, with two categories emerging. The first refers to the interpersonal relationship and the approaches with the PCA, organized into four subcategories; the second refers to the challenges in the exercise of interpersonal relationship with mental disorder patients in the FHS.
The interpersonal relationship and its proximity with the PCA
In nursing, interpersonal relationships are discussed in the field of the nurse-client relationship and in the management and coordination context.
With regard to the interpersonal relationship in the context of the client, this stand out as a form of relational care, complementary to the practices and technical procedures, as it seeks to comprehend the other in his/her complexity, being aware of the meanings and feelings of the person in the context of the social, psychological and cultural life, whether related to the health-disease process or not13. Thus, it expands the scope of care, comprehending the involvement, intersubjectivity and the singularities of each subject26.
Regarding the concept of the helping relationship and the therapeutic relationship, as a process or continuous encounters27, this was not referenced to by the nurses, perhaps due to it being more involved in the care of nurses working in mental health and psychiatry. Therefore, the discussions that will be presented involve the interpersonal interaction or relationship as a encounter that happens during the consultations or nursing procedure, although this separation was also not evidenced by the discourses, but rather by the observation of the researchers. That there is a continuum of encounters between nurses and the population enrolled in the FHS cannot be ruled out, however, not in the sense of the psychotherapeutic process.
Inferences about congruence, acceptance and empathy in the interpersonal relationship for nursing
The nurses were unanimous in considering the interpersonal relationship to be of fundamental importance in the nursing practice, which coincides with some studies1,4,22,27that highlight the therapeutic process in nursing. In the case of the PCA, in the statement highlighted, the concepts of congruence and acceptance were inferred.
The interpersonal relationship is very important, it is essential. I think that we have to be true in the first place because it is this that will allow you to reach another person. The basic is you yourself, it is that you accept others without judgment, without prejudice. (E6)
The principle of congruence or authenticity, used in the sense of a unified and integrated person, is a type of experience of consciousness, in which the person needs consistency between the conscious self and the existential or phenomenal field, adequately covering the experience, the awareness and the communication21. Therefore, nurses should be aware of any attitude or feeling that they are experiencing in order to become consistent, true, and unified25. The result of this attitude is to facilitate the growth of the cliente23 and to facilitate nurses to behave consistently, enabling them to expresses themselves without ambiguity27.
Acceptance6 emerges in the tones of unconditional positive regard, appreciation and esteem. Regarding unconditionality, this means that the therapist accepts the clients as they are, as they present or express themselves, without determining conditions, behaviors or feelings. It is a combination of attitudes of tolerance, respect and empathic comprehension that merge in an attitude of acceptance2,21. If we can accept each other unconditionally, we can tolerate deviations of behavior and encourage positive attitudes20,21. However, this does not mean approving or agreeing with the feelings, behaviors and ideas of the client, because approval is a form of judgment, trial or evaluation that is established from a personal point of view. This leads to the third concept, the empathic attitude, which means comprehending the other as he/she appears, as if one were this other6,20-22,27. In the PCA, these attitudes promote a facilitating environment for personal growth, going beyond the boundaries of mere adjustment to objective situations.
Listening in the therapeutic encounter
As a tool of interpersonal relationships, the nurses were also unanimous in referring to listening.
[...] If she has any problem, is anxious, depressed. [...] A simple act of listening already helps. To accept this person, in what she needs to talk about.[...].(E5)
Listening in nursing has paramount value because, through it the information is received and the care provided. When mentioned, as a tool of the interpersonal relationship in the context of the PCA, listening involves internal availability, effort and energy on behalf of the professional, because reflective listening involves apprehending the full meaning of the experience of the other aimed at empathic comprehension, making the encounter genuine and the dialogue authentic and productive6,21. Therefore, to hear is to be in a relationship and, therefore, to become presente19. It is also to hear both the words and the thoughts, the tone of the feelings, the personal meaning, and that which underlies the conscious intentions of the interlocutor28.
Listening, when active, can even be reflected in the interpersonal responses of the professional, as in the following statement.
[...] when we get involved, when we sit and talk [...] We start evaluating [comprehending] what that person was, depending on the course of the situations, we even change our behavior of how to care. (E3) [emphasis of the author]
Thus, listening brings positive consequences for the professionals and for the interlocutors. For the professionals, it makes them actually present in the relationship, which facilitates an empathic attitude, positive consideration, and congruence. For the interlocutors, being heard means that someone gives them importance, they are grateful, they feel relieved, they tend to want to talk more about their world - experiences, feelings, and meanings; they feel impelled toward a new sense of liberty and become open to changes19.
Trust and the actualizing tendency
Another important factor of the interpersonal relationships elucidated by the nurses was trust.
Interpersonal relationships are very important for the person to trust in you and for you to see what is happening. Because if the people do not have trust […] they will never tell you what is happening. (E7)
Trust is crucial in the PCA from two perspectives. The trust of the professional in the person of the client, which is called the actualizing tendency, and is constituted in the belief that in every body a underlying flow exists for the constructive achievements of his/her intrinsic potential, because in man there is a natural tendency to grow and upgrade20. Even though the circumstances of the environment may alter the results of this growth, the human being has a positive and constructive body21,28. In this case, the role of the nurse is that of the facilitator of the environment, making it therapeutic so that the actualizing tendency can develop more fully. However, it is not in this context that the nurse illustrates the trust, but rather in the sense of the client towards the professional.
There are several possibilities to gain trust. In light of the PCA, it can be acquired more fully by the facilitating attitudes of the therapist - attitudes of empathy, congruence, and unconditional acceptance. Undoubtedly, when people encounter a therapeutic environment in which they are faced with a person who listens to them, comprehends them as they are presenting themselves, they feel accepted even though their behavior or experiences cause negative feelings, they feel secure enough to trust the professional with their inner experience21. Confidence placed in the professional creates the feeling of having a source of support and security in the client. This can cause discomfort when the professional feels overloaded and has limited availability.
They see support in us. So they end up draining us. There are some that come here every day waiting to talk and, every day, say the same thing. We [...] get worn out. I create a bond [...] but sometimes there are some that are too much. (E9)
The fact that the client feels supported by the nursing professional and creates emotional bonds that facilitate the communication between them and produce positive results in the treatment29. Conversely, this may provoke a sense of overload and an attitude of refusal and withdrawal in the professional, making the communication become inconsistent and superficial, generating an environment of exclusion rather than facilitation. In such cases, balance is paramount and beneficial, and can be achieved when the professional is able to delimit and organize the encounters through scheduling. In this context, the interpersonal relationship can assume the concept of the therapeutic interpersonal relationships as a process27.
The person as the center
To center on the person rather than the exclusive technical procedures can become an alternative to the hegemonic and technical model of care.
[...]There’s no way we can carry out a technique, dress a wound, and simply perform the technique... . On the other side there is the human being, a person. He does not want a mechanical thing. He wants to show his context, his life, his problems. Therefore, the interpersonal relationship is very important. (E1)
To have the person as the center and not the disease is the direction of the humanist-existentialist approaches5 because the person is considered in the social, psychological, spiritual and biological contexts, surpassing the health-disease relationship and the body as a instrument of care. In the PCA, the person is responsible and is able to produce changes, as a body worthy of trust where the direct aim is greater independence and integration, with the focus on the individual and not on the problem21.
Challenges in the pursuit of interpersonal relationship with mental disorder patients in the FHS
The inferences made with respect to the approaches to the PCA regarding the comprehension of the nurses about the interpersonal relationship terminate in opinions and not truly in a nursing praxis. It is clear, therefore, that such proximity is in the field of empiricism, as the difficulties presented by many of the nurses demonstrate the lack of specific knowledge related to how to approach the person with a mental disorder.
The approach, how to approach the patients. I don’t know what to do. [...] I don’t know to what extent I can counteract him or not, whether I agree with him or not. I’m too afraid of their responses, of their reactions [...] I’m afraid of their reactions to me, of them not liking the treatment, of them stopping the treatment because of something I said. (E2)
Some nurses commented that they had no content about interpersonal relationships in the university or when they had it had been superficial, conversely, they had not taken any graduate courses or courses that had a curriculum related to this theme.
I remember that we did have, but it was very superficial. (E7)
I had nothing about interpersonal relationship in the university, so I think it is flawed in that it does not prepare us adequately for this work. (E8)
It is worth considering the fact that these nurses completed their graduation courses at different times (6, 14 and 3 years previously, respectively) and in different schools. This indicates the need to revise the curriculum, because, as it is understood that interpersonal relationships are established in the everyday practice of nursing care and that this practice involves all the aspects and areas of this care, it is unacceptable for this topic to be rarely considered in the university.
Regarding the PCA theoretical framework, it is understandable that it is not yet being covered in the contents of graduation courses in Brazil, however, other theories that involve interpersonal relationships, the helping relationship, and the interpersonal relationships of nursing should be studied. This is because one of the characteristics the process of interpersonal relationships refers to is the requirement for knowledge, skills and specific competencies4,6, as facilitating attitudes that can be learned21,30.
Perhaps due to the lack of knowledge, some themes did not appear in the discourses, such as the therapeutic process of the interpersonal relationships, the helping relationship as a nursing practice, therapeutic communication, and the interpersonal responses of the professionals. It should be noted that the interpersonal relationship is constituted from the active participation of the interlocutors, which indicates the perception of the clients regarding the attitudes of the nurses as well as the perception of the nurses about their own attitudes and care. Faced with this, it can be perceived that the encounter between the researcher and a nurse awakened in the nurse a sense of going beyond, as illustrated by her statement.
You know I felt the difficulty after you came here. Because I kept thinking what more I could do to help them. I felt that... it seems like I do nothing... Do I have tools, as a nurse, to... not be only listening, if there is anything else, more than that... [...] Do I need to do something else? Am I doing it right? In addition to just listening... to move forward... (E4)
The quality of the encounter is highly valued in the PCA and approaches, in varying degrees, the encounter between two people from the Buberian concept, because through it the person finds him/herself, and is recognized and comprehended by another person; therefore, it is full confirmation of one’s existence transported to the world of words. The changes that can occur from these experiences and from new feelings or perceptions are developed and enriched by rational comprehension2,6.
CONCLUSION
Interpersonal relationships were designated by the nurses as being of fundamental importance in the practice of their profession, in a way very close to the guiding statements of the PCA. This demonstrates the possibilities of its use as a theoretical framework in mental health care nursing, not only for persons with a diagnosis of a mental disorder, but for all people who are in situations of mental distress and seeking help.
Based on the manifest content, it was possible to make inferences regarding empathy, congruence and unconditional positive regard, the actualizing tendency, the therapeutic encounter, and the person as the center. However, the approximations achieved involved evidence held by the authors, which implies the possibility of abstractions, since they consist of a duality: on one hand, the nurses expound contents about the interpersonal relationship in an almost empirical condition, however, they approach the theoretical framework; and, on the other, they protest that they have not had sufficient theoretical support, which is evident in the challenges to be overcome.
Although the present study was limited due to being carried out with a small group of nurses from one municipality, which prevents the generalization of the results, it indicates that the interpersonal relationships in the nursing of the FHS may have proximity to the concepts of the PCA. Thus, it is understood that there is the possibility for care, based on the humanists, existential, theoretical undercurrents, essential for mental disorder patients in these services.
It is hoped that this study will support actions that may contribute to the creation of strategies that facilitate the development, by nurses, of interpersonal relationships centered on the person, favoring a humanitarian praxis – of health promotion, prevention of suffering, and improvement in the care together with the mental disorder patients in the FHS.
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